SplitPDFFile 1 To 200

PROMETRIC EXAM PRACTICE QUESTIONS
DHA,HAAD,MOH,OMAN,QATAR,SAUDI,BAHRAIN
Based on past papers questions collection

TABLE OF CONTENTS
1. Preface

2. Internal
medicine

3. Family medicine

4. Obstetrics and
gynecology

5. Psychiatry

6. Pediatrics

7. General surgery

8. Dermatology

9. Orthopedic

10.ENT

11.Ophthalmology

12.Abbreviations

13.PREVENTIVE
MEDICINE

14.EMERGENCY
MEDICINE

15.ASSORTED PAST
PAPERS

MEDICINE (MIXED QUESTIONS)
(1) Which of the following medications is contraindicated in hypertensive patients who are using
sildenafil?
(A) Calcium channel blockers.
(B) Beta-blockers.
(C) Nitrates.
(D) Diuretics.
(2) Which of the following is given as a prophylactic antiarrhythmic agent after my ocardial infarction?
(A) Procainamide.
(B) Lidocaine.
(C) Quinine.
(D) Metoproloi.
(3) Which of the following drugs will increase the chance of survival of patients with heart failure?
(A) Enalapril.
(B) Isosordil.
(C) Furosemide.
(D) Spironolactone.
(4) A patient presented with chest pain, fever and arthralgia. He suffered a myocardial infarction 5
weeks earlier. What is the most likely diagnosis?
(A) Dressler's syndrome.
(B) Meigs syndrome.
(D) Myocardial infarction.
(E) Pulmonary edema.
(5) What would you expect to see in the ECG reading of a patient with inferior myocardial infarction?
(A) Changes in leads II, ID and aVF.
(B) Changes in leads V1-V3.
(C) Changes in leads 1, II and III.
(D) Changes in leads II and aVF.
(6) Which of the following drugs interacts with carvedilol?

(A) Warfarin.
(B) Digoxin.
(C) Thiazide.
(D) All of the above.
(7) A patient presented with insomnia 2 months post myocardial infarction. What is the recommended
treatment for this patient?
(A) Zolpidem.
(B) Diazepam.
(C) Antihistamines.
(D) Nothing.
(8) A patient presented to the ER with atrial fibrillation and a blood pressure reading of 80/60 mmHg.
What is the recommended treatment for this patient?
(A) Synchronized cardioversion.
(B) Digoxin.
(C) Heparin.
(D) Warfarin.
(9) A patient with a known case of nephritic syndrome on angiotensin converting enzyme inhibitors.
His food is usually rich with protein. What would you expect to see in the results of a lab investigation
of the patient's blood?
(A) Decreased serum albumin.
(B) Decreased serum triglyceride.
(C) Increased serum albumin.
(D) Increased serum triglyceride.
(10) A middle-aged man presented to the ER with cyanosis. A chest x-ray showed prominent pulmonary
arteries and vascular marking. What is the most likely diagnosis?
(A) Ventricular septal defect.
(B) Atrial septal defect.
(C) Coarctation of the aorta.
(D) Truncus arteriosis.
(11) Which of following is an inappropriate method of managing a patient with myocardial infarction?
(A) Calcium channel blockers.
(B) Nitropaste (transdermal nitroglycerin ointment).
(C) IV morphine.
(D) Beta-blockers.
(12) A patient presented with chest pain persisting for 2 hours. ECG showed anterolateral lead ST
elevation. Providing there is no percutaneous coronary intervention in the hospital, what is the best
management plan for this patient?
(A) Streptokinase, nitroglycerin, aspirin and beta-blocker.
(B) Nitroglycerin, aspirin, heparin and beta-blocker.
(C) Nitroglycerin, aspirin and beta-blocker.
(D) Alteplase, nitroglycerin, heparin and beta-blocker.
(13) What type of edema occurs in congestive heart disease?

(A) Alveolar edema.
(B) Interstitial edema.
(C) Both A and B.
(D) None of the above.
(14) What is the most common embolic etiology that leads to cerebrovascular accident?
(A) Atrial fibrillation.
(B) Ventricular septal defect.
(C) Atrial septal defect.
(D) Cardiomyopathy.
(15) An elderly patient with a known history of hypertension and benign prostatic hyperplasia. Which
one of the following drugs may be recommended for the treatment of this patient?
(A) Atenolol.
(B) Terazosin.
(C) Losartan.
(D) Phentolamine
(16) A patient with a previous rheumatic episode has developed mitral stenosis with an orifice of
less than 1 cm. What are the complications?
(A) Left atrial hypertrophy and dilatation.
(B) Left atrial dilatation and decreased pulmonary wedge pressure.
(C) Right atrial hypertrophy and decreased pulmonary wedge pressure.
(D) Right atrial hypertrophy and chamber constriction.
(17) Which one of the following is a component of Tetralogy of Fallot?

(A) Atrial septal defect.
(C) Left ventricular hypertrophy.
(D) Aortic stenosis.
(18) Which of the following describes the Fick method of assessing cardiac output?
(A) Blood pressure.
(B) Oxygen uptake
(C) Carbon monoxide in blood.
(D) PC02.
(19) What is the predominant clinical effect of niacin?

(A) Decrease uric acid.
(B) Hypoglycemia.
(C) Increase LDL.
(D) Increase HDL.
(20) Which of the following diets is recommended for patients with ischemic heart disease?
(A) Decrease the intake of meat and dairy products.
(B) Decrease the intake of meat and bread.
(C) Increase the intake of fruit and vegetables.
(D) Decrease the intake of fruit and vegetables.
(21) Which of the following drugs is used for the treatment of congestive heart failure with systolic
dysfunction?
(A) Nifidepine.
(B) Deltiazm.
(C) Angiotensin converting enzyme inhibitors.
(D) Beta-blockers.
(22) A 15-year-old boy came for medical evaluation before participating in a team sport. His brother
died suddenly while walking to work due to a heart problem. On examination the boy appeared normal,
with no heart murmurs and equal pulses in all extremities. What condition should be definitively
excluded in this patient before he participates in any sporting activity?
(C) Bicuspid aortic valve.
(D) Hypertrophic cardiomyopathy.
(23) A female patient with a known case of rheumatic heart disease with diastolic murmur presented to
the ER with aphasia and hemiplegia. Which investigation should be carried out to determine the etiology
of this stroke?
(A) Magnetic resonance angiography.
(B) Non-contrast CT scan.
(C) Echocardiogram.
(D) ECG.
(24) A patient presented to the ER with chest pain that radiated to the jaw, increased with exercise and
decreased with rest. What is the most likely diagnosis?
(A) Stable angina.
(B) Unstable angina.
(C) Prinzmetal angina.
(D) Musculoskeletal pain.
(25) A 58-year-old male complained of shortness of breath that had persisted for 3 days. A chest x-ray
showed cardiomegaly and pleural effusion and the analysis of this effusion showed mild protein
< 30g/dl and moderate HDL< 200 IU/L contents. What is the most common cause of this effusion?
(A) TB.
(B) Bronchopneumonia.
(C) Congestive heart failure.
(D) Hypoproteinemia.
(26) Which of the following diseases will present with lower limb edema and neck vein congestion?
(A) Right heart failure (right ventricular failure).
(B) Left heart failure (left ventricular failure).
(C) Pulmonary hypertension.
(D) Systemic hypertension.
(27) Which technique could be used to differentiate between sinus tachycardia and atrial flutter?
(A) Carotid artery massage.
(B) Temporal artery massage.
(C) IV injection of adenosine.
(D) Both A and B.
(28) A patient who had been working outdoors in hot weather presented to the ER with clammy cold
skin, hypotension and tachycardia. What is the most likely cause of this presentation?
(A) Heat stroke.
(B) Heat exhaustion.
(C) Hypoglycemia.
(D) Heat cramps.
(29) Which of the following lab results represents the greatest risk factor for ischemic heart disease?
(A) Low serum LDL.
(B) High serum LDL.
(C) Low serum HDL.
(D) High serum HDL.
(30) Which prophylactic antibody should be given to a dental patient with a history of endocarditis?
(A) Amoxicillin 2 gm before the surgery.
(B) Amoxicillin 1 gm after the surgery.
(C) Clindamycin 2 gm before surgery.
(D) Clindamycin 1 gm after surgery.
(31) A patient presented with increased jugular venous pressure, a low volume pulse, low resting blood
pressure, pedal edema and no murmur on auscultation. What is the most likely diagnosis for this patient?
(A) Constrictive pericarditis.
(B) Tricuspid regurgitation.
(C) Tricuspid stenosis.
(D) Pulmonary hypertension.
(32) A 46-year-old male presented to the ER with moderate abdominal pain. The patient was known to
have hypertension and hyperlipidemia, was a smoker and did not follow his medication instructions well.
He was tall obese patient with stable vital signs and midline abdomen tenderness. What is the most likely
diagnosis for this patient?
(A) Marfan syndrome.
(B) Abdominal aortic aneurysm.
(C) Peptic ulcer.
(D) Gastroenteritis.
(33) An elderly patient who suffered a myocardial infarction 2 weeks previously and was discharged from
hospital within 24 hours presents with sudden left lower limb pain and numbness. On examination the
lower left limb is pale and cold, but the right limb is normal. What is the most likely diagnosis?
(A) Acute artery thrombosis.
(B) Acute artery embolism.
(C) DVT.
(D) Cellulitis.
(34) A patient with a known case of congestive heart failure likes to eat from restaurants 2-3 times weekly.
Which of the following is the correct advice for him?
(A) Do not add salt to your food.
(B) Eat no more than 4 gm salt per day.
(C) Eat a low fat and high protein diet.
(D) Eat a diet high in salt.
(35) Which of the following statements is correct regarding cardiac syncope?

(A) Gradual onset.
(B) Fast recovery.
(C) Neurological manifestations after it.
(36) An elderly man who regularly lifts weights presented to the ER with a severe headache. On
examination, his blood pressure was found to be 150/95 mmHg; otherwise his examination was normal.
While in the ER he became drowsy. What is the most likely diagnosis?
(A) Subarachnoid hemorrhage.
(B) Central hypertension.
(C) Tension headache.
(D) Migraine.
(37) An elderly patient with a known case of bronchial asthma and urine retention due to prostatic
enlargement had a blood pressure of 180/100 mmHg. What is the most appropriate drug to control
his hypertension?
(A) Labetalol.
(B) Phentolamine.
(C) Propanolol.
(D) Atenolol.
(38) A patient with left bundle branch block requires a dental procedure. When should the patient be
given prophylaxis for endocarditis?
(A) This is not necessary.
(B) Before procedure.
(C) After the procedure.
(D) Before and after the procedure.
(39) A teacher diagnosed with aortic stenosis, fainted in the classroom. What is the most probable cause?
(A) Cardiac syncope.
(B) Hypotension.
(C) Neurogenic syncope.
(D) Hypoglycemia.
(40) Which one of the following would you expect upon auscultation of a patient with mitral stenosis?
(A) Mid-diastolic low pitched rumbling murmur.
(B) Mid-systolic low pitched rumbling murmur.
(C) Holosystolic murmur.
(D) Mid-diastolic high pitched rumbling murmur.
(41) Which one of the following congenital heart diseases is most commonly associated with
endocarditis?
(C) Patent ductus arteriosus.
(D) Tetralogy of Fallot.
(42) Which type of exercise is recommended for patients with coronary artery disease?
(A) Isometric exercise.
(B) Isotonic exercise.
(C) Yoga exercise.
(D) Dynamic exercise.
(43) A young obese patient presented to the ER with a headache. He gave a history of high salt diet
intake. On examination; he was hypertensive and had a BMI = 33. What is the most probable cause of his
hypertension?
(A) High sodium intake.
(B) High potassium intake.
(C) High sodium and potassium intake.
(D) Obesity.
(44) Which of the following drugs is contraindicated in hypertrophic obstructive cardiomyopathy?

(A) Digoxin.
(B) Beta-blockers.
(C) Alpha-blockers.
(45) An elderly male patient presented to the ER with congestive heart failure and pulmonary edema.
What is the best initial therapy?
(A) Digoxin.
(B) Furosemide.
(C) Debutamine.
(D) Spironolactone.
(46) A young patient with a known case of rheumatic heart disease and atrial fibrillation presented to
the ER with dyspnea and productive, blood-tinged, frothy sputum. On examination, his cheeks were
found to have a dusky rash. What is the most likely diagnosis?
(A) Mitral stenosis.
(B) Aortic stenosis.
(C) Infective endocarditis.
(D) Congestive heart failure.
(47) Which of the following drugs is used in the treatment of congestive heart failure?
(A) Beta-blockers.
(B) Verapamil.
(C) Nitrates.
(D) Digoxin.
(48) All of the following are true about coarctation of the aorta except:
(A) A skeletal deformity will be seen on the chest x-ray.
(B) Upper limp hypertension occurs.
(C) Systolic murmur is present throughout the pericardium.
(D) Turner syndrome will be observed.
(49) A patient presented to the ER with presyncope and tachycardia. He has a history of myocardial
infarction. On examination, cannon a-waves associated with jugular venous pressure were observed.
ECG showed wide QRS complexes. What is the most likely diagnosis for this patient?
(A) Ventricular tachycardia.
(B) Pre-existing atrioventricular block.
(C) Anterograde atrioventricular block.
(D) Re-entrant atrioventricular nodal tachycardia.
(50) Which of the following is true regarding pericarditis?

(A) The patient will experience a sudden pain in the chest that increases with movement.
(B) The most effective diagnostic tool is ECG.
(C) The most effective diagnostic tool is the analysis of cardiac enzymes.
(D) The most effective diagnostic tool is chest x-ray.
(51) What is the greatest risk faced by patients with atrial fibrillation?
(A) Cerebrovascular accident.
(B) Myocardial infarction.
(C) Ventricular tachycardia.
(D) Ventricular fibrillation.
(52) What is the pathology of coronary artery disease?

(A) Fatty deposition with widening of arteries.
(B) Atherosclerosis with widening of arteries.
(C) Atherosclerosis with narrowing of arteries.
(D) Unknown.
(53) A patient taking an antihypertensive drug presented to the ER with a painful big toe. Which drug is
most likely to be responsible for this?
(A) Hydrochlorothiazide
(B) Furosemide.
(C) Both A and B.
(54) A 15-year-old patient presented with palpitations and fatigue. Investigation showed right
ventricular hypertrophy, right ventricular overload and right bundle branch block. What is the most likely
diagnosis for this patient?
(C) Coarctation of aorta.
(55) What is the best drug to prescribe a hypertensive patient who has liver cirrhosis, lower limb edema
and ascites?
(A) Hydrochlorothiazide
(B) Hydralazine
(C) Angiotensin converting enzyme inhibitors.
(D) Beta-blockers.
(56) What is the recommended short term management plan for a patient with supraventricular
tachycardia?
(A) Adenosine.
(B) Beta-blockers.
(C) Amiodarone.
(57) A 60-year-old patient, newly diagnosed with hypertension comes for treatment. He has no history
of diabetic mellitus, no history of coronary heart disease and no history of other diseases. What is the
best first line treatment for this patient?
(A) Angiotensin converting enzyme inhibitors.
(B) Angiotensin n receptor blockers.
(C) Diuretics.
(D) Beta-blockers.
(58) What is the pathophysiology of hypertension?

(A) Decreased sensitivity of baroreceptors.
(B) Increased peripheral vascular resistance.
(C) Decreased peripheral vascular resistance.
(D) Fibroid changes in blood vessels.
(59) Which of the following is a true about normal ECG readings?
(A) P waves are caused by atrial depolarization.
(B) P waves are caused by atrial repolarization.
(C) The QRS complex represents the time for ventricular repolarization.
(D) The T wave represents the period of ventricular depolarization.
(60) A patient with a known case of hypertrophic subaortic stenosis was referred by a dentist before a
dental procedure was carried out. Which of the following is true?
(A) The patient has a 50% risk of infective endocarditis.
(B) The patient has a 12 % risk of infective endocarditis.
(C) There is no need for prophylaxis in this patient.
(D) Post procedure antibiotic treatment is sufficient.
(61) A patient presented to ER with chest pain radiating to the back. On examination, decreased blood
pressure in the left arm and an absent left femoral pulse was found. A chest x-ray show left-sided pleural
effusion and an ECG show left ventricular hypertrophy. Which investigation should be carried out to help
diagnose this patient?
(A) Aortic angiogram.
(B) Amylase level measurement.
(C) CBC.
(D) Echocardiogram.
(62) How does the heart increase its blood supply?

(A) By increasing pulmonary resistance.
(B) By dilating coronary arteries.
(C) By constricting coronary arteries.
(D) By constricting the aortic artery.
(63) A patient suffered a sudden cardiac arrest. An ECG showed no electrical activity, with oscillation of
differently shaped QRS complexes. What is the underlying process for this ECG reading?
(A) Atrial dysfunction.
(B) Ventricular dysfunction.
(C) Toxin ingestion.
(D) Abnormal metabolism.
(64) Which of the following is true about unstable angina?

(A) The definition includes a lowest grade of II and a new onset of less than 2 months.
(B) Usually there is evidence of myocardial ischemia.
(C) Patients should be given the same treatment as stable angina.
(D) Patients should be discharged when the chest pain subsides.
(65) A patient presented with a blood pressure of 180/140 mmHg. Which of the following is true about
how quickly diastolic blood pressure should be lowered?
(A) 110-100 mmHg over 12 hours.
(B) 110-100 mmHg over 1-2 days.
(C) 90-80 mmHg over 12 hours.
(D) 90-80 mmHg over 1-2 days.
(66) Which one of the following is true about exercise?

(A) Exercise decreases HDL level.
(B) Exercise increases CRP level.
(C) Exercise is not useful in reducing central obesity.
(D) Exercise should be carried out daily to produce beneficial effects.
(67) A patient at risk of developing infective endocarditis is due to undergo urology surgery. The
patient is sensitive to penicillin. What is the best form of prophylaxis for him?
(A) IV vancomycin and IV gentamicin.
(B) Oral tetracycline.
(C) Augmentin.
(C) No needs to give prophylaxis.
(68) A patient with a known case of posterior inferior myocardial infarction presented with sudden
shortness of breath. What is the likely cause of this shortness of breath?
(A) Pulmonary embolism.
(B) Acute mitral regurgitation.
(C) Acute aortic stenosis.
(D) Arrhythmia.
(69) Which of the following is contraindicated in subaortic stenosis hypertrophy?

(A) Digoxin.
(B) Dobutamine.
(C) Both A and B.
(70) What is the best treatment for hypertension caused by hyperaldosteronism?

(A) Spironolactone.
(B) Angiotensin converting enzyme inhibitors.
(C) Beta-blockers.
(D) Amiloride.
(71) What is the best treatment for hypertension associated with migraine?
(A) Propranolol.
(B) Verapamil.
(C) Lisinopril.
(D) Furosemide.
(72) A 72-year-old carpenter visited the clinic for routine investigations. He gave history of death of one
member of his family due to heart attack and he denied any history of chest pain or shortness of breath.
On examination; he was well and fit and everything was normal, except a mid-systolic ejection murmur at
the left sternal area without radiation to carotid. What is the likely cause of this murmur?
(A) Aortic stenosis.
(B) Aortic sclerosis.
(C) Flow murmur.
(D) Hypertrophic sub-aortic stenosis.
(73) An elderly patient presented with shortness of breath, orthopnea, paroxysmal nocturnal dyspnea,
exertional dyspnea. Rales were found on auscultation. What is the main pathophysiology of these
symptoms?
(A) Left ventricular dilatation.
(B) Right ventricular dilatation.
(C) Aortic regurgitation.
(D) Tricuspid regurgitation.
(74) A male patient diagnosed with a prolapsed mitral valve prolapsed requires a dental procedure.
By investigation; Echo done for the patient with no abnormal finding. What is the recommended
prophylaxis for this patient?
(A) Give 2 gm amoxicillin one hour before the procedure.
(B) Give 1 gm amoxicillin one hour before the procedure.
(C) Give 2 gm clindamycin one hour before the procedure.
(D) No prophylaxis.
(75) What is the greatest risk factor for cerebrovascular accident?

(A) Diabetes mellitus.
(B) Hypertension.
(C) Family history of stroke.
(D) Hyperlipidemia.
(76) A patient suffering from stable angina for 2 years presented to the ER complaining of palpitations.
Hotter monitor investigation showed 1.2 mm ST depression for 1-2 of 5-10 minutes. What is the most
likely diagnosis?
(A) Myocardial ischemia.
(B) Sinus arrhythmia.
(C) Normal variation.
(D) Aortic stenosis.
(77) What is the first line of treatment for an overweight (BMI = 28) patient diagnosed with
hypertension stage I (BP = 140/85)?
(A) Exercise and weight reduction.
(B) Dietary pills.
(C) Antihypertensive medication.
(78) Which of the following is the recommended diet for the prevention of ischemic heart disease?
(A) Decrease the intake of meat and dairy.
(B) Decrease the meat and bread.
(D) Increase the intake of saturated fat diet.
(79) A patient presented to the ER with paroxysmal nocturnal dyspnea and orthopnea. On
examination he was found to have bilateral basal crepitation. A chest x-ray showed pulmonary edema.
What is the most likely diagnosis?
(A) Left heart failure.
(B) Right heart failure.
(C) Obesity and smoking.
(D) Obesity and hypertension.
(80) A patient taking digitalis developed a sudden disturbance in his vision, yellow discoloration and
light flashes. What is the likely diagnosis?
(A) Digitalis toxicity.
(B) Retinal detachment.
(C) Glaucoma.
(D) Cataract.
(81) Which one of the following conditions is least commonly associated with endocarditis?
(C) Patent ductus arteriosus.
(82) Which of the following is the correct about unstable angina?

(A) It should be treated with same drug as stable angina.
(B) It should be treated seriously as it might lead to myocardial infarction.
(C) It carries no risk of myocardial infarction or death.
(D) There is no need for treatment for this condition.
(83) A patient with diabetes mellitus, hypertension and myocardial infarction was taking metformin
and diltiazem and other medications, however, his creatinine clearance was high. What is the
recommended management plan for this patient?
(A) Add angiotensin n receptor blockers.
(B) Remove the metformin.
(C) Remove the diltiazem.
(D) Continue with the same medication.
(84) Which one of the following is not a risk factor for coronary heart disease?
(A) Increased HDL serum level.
(B) Hypertension.
(C) Diabetes mellitus.
(D) Hypercholesterolemia.
(85) What is the cause of premature ventricular contraction?

(A) Decreased oxygen supply to the heart
(B) Increased oxygen supply to the heart (C02 poisoning).
(C) Both A and B.
(86) Which enzyme should be investigated in a patient who has suffered a myocardial
infarction?
(A) Creatine phosphokinase.
(B) Alkaline phosphatase.
(C) Aspartate aminotransferase.
(D) Amylase.
(87) All of the following are correct about stable angina in the elderly except:
(A) Stable angina lasts less than 10 min.
(B) Stable angina occurs on exertion.
(C) No enzyme levels will be elevated.
(D) Stable angina is associated with loss of consciousness.
(88) What is the difference between stable and unstable angina?

(A) Unstable angina causes necrosis of the heart muscle but stable does not.
(B) Unstable angina appears to be independent of activity level but stable is not
(C) Unstable angina is associated with seizures but stable is not.
(89) What is the most prominent sign of severe hypokalemia?

(A) P-wave absence.
(B) Peak T-wave.
(C) Wide QRS complex.
(D) Seizure.
(90) Which one of the following is a manifestation of hypokalemia?

(A) Peaked T wave.
(B) Wide QRS complex.
(C) Absent P wave.
(D) Respiratory acidosis.
(91) A rheumatic fever patient has streptococcal pharyngitis. What is his risk of developing another
attack of rheumatic fever?
(A) 100%.
(B) 50%.
(C) 25%.
(D) 5%.
(92) A patient presented to the ER with chest pain and shortness of breath, which was decreased by the
patient leaning forward. On examination; friction rub and increased jugular venous pressure was
observed. What would you expect to see on an ECG of this patient?
(A) ST changes.
(B) Low voltage.
(C) Increased PR interval.
(D) T-wave inversions.
(93) What is the recommended management for a patient with carotid bruit with occlusion 60% of the
left carotid artery?
(A) Aspirin daily.
(B) Angiography.
(C) Carotid endarterectomy.
(94) A patient presented with pedal edema. On examination he also had a low volume pulse and low
resting blood pressure, with no murmur. What is the likely diagnosis?
(A) Constrictive pericarditis.
(B) Tricuspid regurgitation.
(C) Tricuspid stenosis.
(D) Pulmonary hypertension.
(95) Which one of the following should be avoided by a patient with hypercholesterolemia?
(A) Red meat.
(B) Avocado.
(C) Chicken.
(D) White egg.
(96) A 20-year-old patient presented to the ER with palpitations. On examination, his pulse was 300
bpm. ECG showed narrow QRS complexes. Which one of the following is true about his management?
(A) Amiodarone should be included in the management.
(B) The patient requires CPR.
(C) Beta-blockers are contraindicated.
(D) Diltiazem is the first line of management.
(97) A patient diagnosed with mitral valve prolapse by cardiologist had never been examined by
echocardiogram before. He now requires a dental procedure. What is the appropriate action?
(A) There is no need for prophylaxis.
(B) Ampicillin should be given as a prophylactic measure.
(C) Augmentin (amoxicillin davulanate) should be given as a prophylactic measure.
(D) An echocardiogram should be carried out.
(98) A 70-year-old male, newly diagnosed with hypertension, had a blood pressure of 170/105 mmgH.
He had suffered diabetes mellitus since he was 20-year-old, with no history of myocardial infarction
or any vascular disease. What is the most appropriate anti hypertensive drug to prescribe?
(B) Thiazide.
(C) Calcium channel blockers.
(D) Beta-blockers.
(99) Which drug will delay the need for surgery in aortic regurgitation?
(A) Digoxin.
(B) Verapamil.
(C) Nifedipine.
(D) Enalapril.
(100) What is the most common cause of death in patients with Ludwig's angina?
(A) Sepsis.
(B) Asphyxia.
(C) Pneumonia.
(D) Wall rupture.
(101) What is the most common cause of secondary hypertension in female adolescents?
(A) Cushing syndrome.
(B) Hyperthyroidism.
(C) Renal disease.
(D) Polycystic ovary disease.
(102) A patient presented to the ER with chest pain that was aggravated by coughing. On examination
added sound on left sternal border was found. What would you expect to find in an ECG of this patient?
(A) ST changes.
(B) PR prolongation.
(C) High voltage.
(D) Both A and C.
(103) Which of the following antihypertensive drugs is contraindicated in an uncontrolled diabetic
patient?
(A) Hydrochlorothiazide.
(B) Losartan.
(C) Hydralazine.
(D) Spironolactone.
(104) Which of the following drugs increase survival in patients with heart failure?
(A) Beta-blockers.
(C) Digoxin.
(D) Nitrites.
(105) An IV drug abuser presented to the ER with fever, arthralgia and conjunctival hemorrhage.
What is the most likely diagnosis?
(A) Bacterial endocarditis.
(B) Reactive arthritis.
(C) Polymyalgia rheumatica
(D) Systemic lupus erythematosus.
(106) Which of the following statements about systolic hypertension is true?

(A) It represents relatively little risk to the patient.
(B) It is defined as a systolic pressure >140 mmHg with a diastolic pressure >100 mmHg.
(C) It does not increase the risk of stroke.
(E) It is more dangerous in elderly patients than an elevated diastolic pressure.
(107) Regarding myocardial infarction all of the following are true except:
(A) Unstable angina and a longer duration of pain can occur even at rest.
(B) Stable angina and a shorter duration of pain occur with exertion.
(E) A Q wave should be observed in the ECG reading.
(D) Even if there is very painful unstable angina the cardiac enzymes will be normal.
(108) A child was asystolic following CPR. Which drug should be given?
(A) Atropine.
(B) Epinephrine.
(C) Lidocaine.
(D) Both A and C.
(109) What ECG finding would you expect to see in a patient with acute pericarditis?
(A) ST segment elevation in all leads.
(B) ST segment depression in all leads.
(C) Inversion of the T waves.
(D) The presence of normal Q waves.
(110) To which of the following patients would you prescribe aspirin and dopidogrel?
(A) A patient with a history of myocardial infarction.
(B) A patient with a history of previous ischemic stroke.
(C) A patient with a history of peripheral artery disease.
(D) A patient who has undergone cardiac catheterization.
(111) A patient with chronic atrial fibrillation who was taking 5 mg of warfarin daily came to the clinic
for a follow up investigation. The patient's INR was 7, but there were no signs of bleeding. How would
you treat this patient?
(A) Decrease the warfarin dose to 2.5 mg.
(B) Stop the warfarin treatment and repeat INR next day.
(C) Stop the warfarin treatment.
(D) Continue the patient on the same warfarin dose and repeat INR next day.
(112) An elderly patient felt dizzy and fell down one day ago. He has a history of epigastric
discomfort. On examination, he was found to be tachycardic (HR= 130-140 bpm) and his blood
pressure = 100/60mmHg. What is the likely diagnosis?
(A) Peptic ulcer.
(B) Gastroesophageal reflux disease.
(C) Leaking aortic aneurysm.
(D) Gastritis.
(113) An elderly patient presented with abdominal and back pain. On examination he was found to
have a pulsatile abdomen. What procedure should be used to confirm the diagnosis for this patient?
(A) Abdominal US.
(B) Abdominal CT.
(C) Abdominal MRI.
(D) Endoscopy.
(114) Which of the following criteria would suggest a diagnosis of right bundle branch block?
(A) A wide S wave in lead 1 and V6 and a wide R wave in VI.
(B) No Q wave in lead 1.
(C) A small R wave in lead 1 and aVL and a small Q wave in lead II, in and aVF.
(D) Right axis deviation.
(115) Which of the following treatments is contraindicated in asthmatic patients?

(A) Non-selectivebeta-blockers.
(B) Nitrates.
(C) Anticholinergic.
(D) Beta-2 agonist.
(116) A 30-year-old male patient with no known medical illness presented to the ER with a sudden
attack of shortness of breath and left side chest pain. On chest percussion, was hyperresonance was
detected on the left side. What is the likely diagnosis?
(A) Spontaneous pneumothorax.
(B) Pulmonary embolism.
(C) Pneumonia.
(D) Ischemic heart disease.
(117) How can allergic symptoms caused by dust mites be prevented?

(A) Wash clothes with hot water.
(B) Keep the house humid.
(C) Give the patient antihistamines.
(D) Give the patient glucocorticoids.
(118) Where is the genetic defect in cystic fibrosis?

(A) The short arm of chromosome 7.
(B) The long arm of chromosome 7.
(C) The short arm of chromosome 17.
(D) The long arm of chromosome 17.
(119) A male patient has acute respiratory distress syndrome. On ventilation, manifestations of
pneumothorax occur. What is the likely cause?
(A) Negative pressure ventilation.
(B) Lung damage.
(C) Central line insertion.
(D) 100% Oxygen.
(120) In which lobe of the lung does pneumonia usually occur?

(A) Right upper.
(B) Right middle.
(C) Right lower.
(E) Both B and C.
(121) What is the most specific diagnostic investigation used to diagnose pulmonary embolism?
(A) Ventilation-perfusion scan (V/Q scan).
(B) Pulmonary angiography.
(C) Chest x-ray.
(D) ECG.
(122) Regarding right lung anatomy, which one of the following is true?
(A) It has one fissure.
(B) It has 8 pulmonary segments.
(C) It has no relationship with the azygos vein.
(D) It has 2 pulmonary veins.
(123) A patient presents with a history of recurrent pneumonia, productive cough with foul smelling
sputum, hemoptysis and nail clubbing. What is diagnosis?
(A) Bronchiectasis.
(B) Pneumonia.
(C) Lung Abscess.
(D) Chronic obstructive pulmonary disease.
(124) An elderly patient was diagnosed with myocardial infarction and admitted to hospital. After 5
days of treatment, the patient developed shortness of breath and crepitation on both lungs. What is the
likely cause?
(A) Pulmonary embolism.
(B) Pneumonia.
(C) Mitral regurgitation.
(D) Aortic regurgitation.
(125) An elderly bedridden patient suffered from confusion and fever. His blood culture showed
enterococcus faecalis. What is the source this of infection?
(A) Pneumonia.
(B) Urinary tract infection.
(C) Gastrointesinal tract.
(D) Bed sores.
(126) A male patient with a known case of bronchial asthma that is well controlled by a salbutamol
inhaler presented with a cough, dyspnea, chest tightness and wheezing with no response to salbutamol.
What medication could be added to this patient's prescription?
(A) Corticosteroid inhaler.
(B) Short acting beta-agonist.
(C) Oral corticosteroid.
(D) Theophylline.
(127) A young patient with an unremarkable medical history presented with shortness of breath,
wheezing and a long expiratory phase. What is the recommended initial management for this patient?
(A) Short acting beta-agonist inhaler.
(B) Ipratropium.
(C) Steroids.
(D) Diuretics.
(128) An 18-year-old patient with a known case of bronchial asthma was on a daily low dose of inhaled
corticosteroids and a short acting beta2-agonist. What is the classification of this patient's state?
(A) Mild intermittent.
(B) Mild persistent.
(C) Moderate persistent.
(D) Sever persistent.
(129) An elderly patient who stopped smoking 10 years earlier was suffering from shortness of
breath after exercise with no cough. The results of investigations were: FEV1 = 71%, FVC = 61%,
FEV1/FVC = 95%, TLC = 58%. What is the likely diagnosis?
(A) Restrictive lung disease.
(B) Obstructive with restrictive.
(C) Bronchial asthma.
(D) Emphysema.
(130) A patient with a known case of chronic obstructive pulmonary disease presented with coughing
up greenish sputum. What is the responsible organism?
(A) Staphylococcus aurous.
(B) Streptococcus pneumonia.
(C) Mycoplasma.
(E) Haemophilus Influenzae.
(131) A patient was diagnosed with pulmonary embolism, which was confirmed via a CT scan. What
is the recommended initial therapy?
(A) Heparin IV.
(B) Warfarin IV.
(C) Streptokinase.
(D) Embolectomy.
(132) An elderly male patient presented to the ER with sudden chest pain and coughing up of blood.
On examination, are decreased in chest wall movements were observed. An ECG showed SI Q3 T3. What
is the most common diagnosis?
(A) Acute MI.
(C) Severe pneumonia.
(D) Chronic obstructive pulmonary disease.
(133) A young patient on anti TB medication presented with vertigo. Which of the following drugs is
commonly responsible for this side effect?
(A) Streptomycin.
(B) Ethambutol.
(C) Rifampicin.
(D) Penicillin.
(134) A patient presented to the hospital with a cough, hemoptysis, dyspnea, weight loss, fever and
chest pain. Chest x-ray revealed infiltration of the upper lobe of the right lung with pleural effusion.
What is the diagnosis?
(A) TB.
(B) Congestive heart failure.
(C) Hypothyroidism.
(D) Hypoproteinemia.
(135) What is the characteristic symptom of miliary TB?
(A) Spare lung apical.
(B) Septal lines.
(C) Multiple lung nodules.
(D) One large cavity in the upper lobe of the lung.
(136) What is the most common cause of community acquired pneumonia in adults?
(A) Haemophilus influenzae.
(B) Streptococcus pneumonia.
(C) Mycoplasma.
(D) Klebsiella.
(137) A 17-year-old patient presented with dyspnea. Chest x-ray, blood P02 and blood PC02 were
normal, while blood pH was increased. What is the likely diagnosis?
(A) Acute attack of bronchial asthma.
(C) Pneumonia.
(D) Pneumothorax.
(138) A patient on treatment for TB started to develop numbness in hands and feet. In which vitamin
does the patient have a deficiency?
(A) Vitamin B1 (thiamine).
(B) Vitamin B3 (niacin or nicotinic acid).
(C) Vitamin B6 (pyridoxine).
(D) Vitamin C (ascorbic acid).
(139) Which of the following factors is most important to reduce the mortality rate in chronic obstructive
pulmonary disease patients?
(A) Home oxygen therapy.
(B) Enalapril.
(C) Smoking cessation.
(D) Oral steroid.
(140) What is the most common cause of cough in adults?

(A) Bronchial asthma.
(B) Gastroesophageal reflux disease.
(C) Postnasal drip.
(D) Pneumonia.
(141) What is the term used to describe difficulty in breathing?

(A) Dyspnea.
(B) Tachycardia.
(C) Bradypnea.
(D) Tachypnea.
(142) An elderly patient with a history of ischemic heart disease presents with a pattern of breathing
described as: a period of apnea followed by slow breathing which accelerates to become rapid breathing
with hyperpnoea, tachycardia, followed by apnea again. What is this type of breathing known as?
(A) Hippocratic breathing.
(B) Cheyne-stokes respiration.
(C) Kussmaul breathing.
(D) Paradoxical breathing.
(143) Which of the following shifts the hemogiobin-02 dissociation curve to the right?
(A) Respiratory alkalosis.
(B) Hypoxia.
(C) Hypothermia.
(D) Decrease 2,3-diphosphoglycerate.
(144) What is the most common treatment regimen for a patient with community acquired
pneumonia who is healthy and without risk factors?
(A) Azithromycin.
(B) Fluoroquinolone.
(C) Penicillin.
(D) Gentamicin.
(145) An elderly patient was diagnosed with pneumonia caused by Haemophilus influenzae. Which of
the following antibiotics is the best treatment for this patient?
(A) Cefuroxime.
(B) Penicillin.
(C) Ciprofloxacin.
(D) Ceftriaxone.
(146) All of the following are side effects of prolonged 100% oxygen treatment, except:
(A) Retrosternal chest pain.
(B) Seizure.
(C) Depression.
(D) Dyspnea.
(147) A young male patient has known case of uncontrolled moderate persistent bronchial asthma and
is on a beta-agonist inhaler. What is the recommended management for this patient?
(A) Add a corticosteroidinhaler.
(B) Continue on the beta-agonist inhaler only.
(C) Switch to a leukotriene inhaler only.
(148) What is the recommended treatment for erosive gastritis?

(A) Antibiotics.
(B) H2-blockers.
(C) Total gastrectomy.
(D) Sucralfate.
(149) All of the following should be avoided in celiac disease except:
(A) Wheat.
(B) Oats.
(C) Rice.
(D) Gluten.
(150) A TB patient presented with painful red eyes and photophobia. What is the likely diagnosis?
(A) Glaucoma.
(B) Uveitis.
(C) Bacterial conjunctivitis.
(D) Viral conjunctivitis.
(151) Which of the following is correct regarding Barrett's esophagitis?

(A) It carries an increased risk of adenocarcinoma.
(B) It carries an increased risk of squamous cell carcinoma.
(C) It carries no risk of malignancy.
(D) It is not related to gastroesophageal reflux disease.
(152) A patient presented with bloody diarrhea. Stool analysis showed occult blood, colonoscopy showed
friable mucosa and biopsy showed a crypt abscess. What is the likely diagnosis?
(A) Crohn's disease.
(B) Ulcerative colitis.
(C) Diverticulosis.
(D) Fissure.
(153) Which of the following is true about ulcerative colitis?

(A) It carries an increased risk of malignancy.
(B) Fistula is a common complication.
(C) It spans the full thickness of the gastrointestinal wall.
(D) It features skip lesions.
(154) A female patient presented with jaundice and pruritus. On examination, clubbing was observed.
Investigation revealed elevated liver enzymes (alkaline phosphatase), high bilirubin levels, hyperlipidemia
and positive antimitochondorial antibodies. What is the most likely diagnosis?
(A) Primary sclerosing cholangitis.
(B) Primary biliary cirrhosis.
(C) Obstructive jaundice.
(D) Ascending cholangitis.
(155) What is the empirical treatment of Helicobacter pylori peptic ulcers?

(A) Omeprazole.
(B) Clindamycin.
(C) Metronidazole.
(D) Cimetidine.
(156) What is the recommended treatment for Helicobacter pylori infection?
(A) Omeprazole for 2 weeks and clarithromycin and amoxicillin for one week.
(B) Ranitidine, erythromycin and metronidazole for 2 weeks.
(C) A bismuth compound alone.
(D) Surgery.
(157) Which of the following should be taken with NSAIDs analgesics to decrease the side effects of
these drugs?
(A) Cimetidine.
(B) Pseudoephedrine.
(C) Ceftriaxone.
(D) Doxycydine.
(158) What is the organism responsible for pseudomembranous colitis?

(A) Pseudomonas.
(B) Clostridium difficile.
(C) E. coli.
(D) Enterococcus fecalis.
(159) A group of people presented with diarrhea and vomiting after eating a meal. What is the likely
diagnosis?
(A) Staphylococcus aureus poisoning.
(B) Salmonella poisoning.
(C) E. colipoisoning
(D) Clostridium difficilepoisoning.
(160) A patient presented with jaundice. He gave a history of received blood transfusion. What is the
likely diagnosis?
(A) Hepatitis A.
(B) Hepatitis C.
(C) Hepatitis D.
(D) Hepatitis E.
(161) In which of the following is ibuprofen contraindicated?

(A) Peptic ulcer.
(B) Seizures.
(C) Diabetes meliitus.
(D) Irritable bowel syndrome.
(162) Which of the following features is related to Crohn's disease?
(A) Fistula formation.
(B) Superficial layer involvement.
(C) Decreased risk of colon cancer.
(D) Continuous mucosal areas of ulceration that affect the anus.
(163) A patient develops diarrhea at the end of a course of antibiotics. What is the likely cause?
(A) Salmonella bacteria.
(B) Clostridium difficile.
(C) E. coli.
(D) Vibrio cholerae.
(164) A patient presented with dysphagia to solids and liquids and regurgitation. Investigations; with
barium uncovered non-peristalsis dilatation of the esophagus, air fluid level and tapering end. What is
the diagnosis?
(A) Esophageal spasm.
(B) Achalasia cardia.
(C) Esophageal cancer.
(D) Gastroesophageal reflux disease.
(165) A patient who had recently travelled abroad presented with bloody diarrhea. Stool examination
showed trophozoites with RBCs inclusion. What is the likely diagnosis?
(A) Syphilis.
(B) Amoebic dysentery (entameba histolytica).
(C) E. coli.
(D) AIDS.
(166) What is the recommended treatment for pseudomembranous colitis?

(A) Metronidazole and vancomycin.
(B) Chloroquine.
(C) Clindamycin.
(D) Amoxicillin.
(167) An elderly patient known to have atrial fibrillation presented with abdominal pain and bloody
stools. What is the likely diagnosis?
(A) Ischemic mesentery.
(B) Hemorrhoid.
(C) Ulcerative colitis.
(D) Crohn's disease.
(168) A 40-year-old Crohn's disease patient presented with fevers, hip and back pain and brown stools
containing blood. On examination, a soft abdomen, normal bowel sounds and a normal range of motion of
the hips were observed. What is the best radiological diagnostic tool to proceed with for this patient?
(A) Abdominal US.
(B) Abdominal CT.
(C) Hip US.
(D) Hip CT.
(169) What are the two most useful tests for screening for hepatocellular carcinoma?
(A) Liver biopsy and alpha-fetoprotein blood test.
(B) Liver US and alpha-fetoprotein blood test.
(C) Abdominal CT and alpha fetoprotein blood test.
(D) Liver biopsy and liver enzyme assay.
(170) A teacher presented with malaise, fever and eye icterus. Two of his students had also developed
the same condition. On examination he was found to have right upper abdominal tenderness. Which
investigation should be used to confirm the diagnosis?
(A) Positive for hepatitis A IgG.
(B) Positive hepatitis A IgM.
(C) Positive hepatitis B anti-body.
(D) Positive hepatitis B core.
(171) Which of the following is correct about the symptoms of reflux esophagitis?
(A) They are not affected by alkaline conditions.
(B) They increase with standing.
(C) They can be distinguished between it and duodenal ulcer.
(172) An obese elderly patient who is a smoker, presented with intermittent diarrhea and bleeding of
the rectum. A stool guaiac test was positive. What is the diagnosis?
(A) Iron deficiency anemia.
(B) Colorectal cancer.
(C) Hemorrhoid.
(D) Diverticulosis.
(173) A patient presented with acute diarrhea. Investigation revealed epithelial infiltration with
polymorphonuclear cells. Which organism is likely causing this diarrhea?
(A) E. coli.
(B) Salmonella.
(C) Vibrio Cholerae.
(E) Shigella.
(174) Which one of the following medications increases reflux esophagitis?

(A) Theophylline.
(B) Ranitidine.
(C) Metodopramide.
(D) Ampicillin.
(175) A patient presented with retrosternal chest pain. A barium swallow showed a corkscrew
appearance. What is the most likely diagnosis?
(A) Achalasia.
(B) Esophagitis.
(C) Gastroesophageal reflux disease.
(D) Diffuse esophageal spasm.
(176) All of the following can cause gastric ulcers, except:
(A) Tricyclic antidepressants.
(B) Delay gastric emptying.
(C) Sepsis.
(D) Salicylates.
(177) The blood work of a patient with a history of illegal drug abuse showed the presence of an RNA
virus. Which type of hepatitis is it likely that he has?
(A) Hepatitis A.
(B) Hepatitis B.
(C) Hepatitis C.
(D) Hepatitis D.
(178) Which of the following is ibuprofen contraindicated in?
(A) Hypertension.
(B) Diabetes mellitus.
(C) Peptic ulcer.
(D) Dysmenorrhea.
(179) What is the best prophylaxis for patient with a known case of sickle cell anemia?
(A) Penicillin.
(B) Iron.
(C) Anticoagulants.
(D) Multivitamins.
(180) Which of the following is associated with Polycythemia vera?

(A) Muscle weakness.
(B) Splenomegaly.
(C) Venous engorgement.
(D) Hypertension.
(181) A 35-year-old patient presented with symptoms of anemia (shortness of breath and fatigue) and
chronic diarrhea.. He had a surgery to resect part of the distal small intestine and proximal large intestine
4 years previously further surgery to anastomose them 6 months previously due to a blunt abdominal
trauma caused by RTA. His CBC showed megaloblastic anemia. What is the most likely diagnosis?
(A) Folic acid deficiency.
(B) Vitamin B12 deficiency.
(C) Anemia of chronic disease.
(D) Iron deficiency.
(182) What is the most common complication of central nervous system in adult patients with sickle cell
anemia?
(A) Cerebral infarction.
(B) Ataxia.
(C) Seizure.
(D) Cerebral hemorrhage.
(183) Which one of the following leukemias will characteristic with Blast cell?
(A) Acute myeloid leukemia.
(B) Acute lymphoblastic leukemia.
(C) Chronic myeloid leukemia.
(D) Chronic lymphocytic leukemia.
(184) A sickle cell anemia patient was admitted to hospital many times due to crisis attacks and now
presents with pain of the abdominal, neck, arm and body. What is the recommended management plan
for this patient?
(A) Hospitalization and pain management as well as observation.
(B) Outpatient hydration management.
(C) Outpatient pain management and observation.
(D) Outpatient pain management.
(185) Which one of the following is the most important prognostic factor in chronic myeloid leukemia?
(A) Stage.
(B) Age.
(C) Lymphocytic doubling time.
(D) Degree of involvement of bone marrow.
(186) An elderly patient is complaining of pruritus and weakness that started after taking a warm bath.
Investigations revealed polycythemia. What is the mechanism of this pruritus?
(A) Increased histamine sensitivity.
(B) Abnormal release of histamine.
(C) Decreased histamine sensitivity.
(D) Both A and B.
(187) A female patient has typical signs of DVT. Which one of the following will exacerbate her
condition?
(A) DIC.
(B) Hemophilia A.
(C) Hemophilia B (Christmas disease)
(D) Anticoagulant agent.
(188) A 65-year-old patient presented with hepatosplenomegaly and lymphadenopathy.

Bone marrow biopsy confirmed a diagnosis of chronic lymphocytic leukemia. The patient gave
a history of breast cancer 5 years ago and was treated with chemotherapy. The patient is also a smoker.
What is the greatest risk factor for the development of chronic lymphocytic leukemia?
(A) History of radiation.
(B) Smoking.
(C) Previous cancer.
(D) Age.
(189) A patient presented with DVT and inferior venous obstruction. What is a possible diagnosis for this
patient?
(A) Christmas disease.
(B) Lung cancer.
(C) Nephrotic syndrome.
(190) What would you expect to find in a patient with anemia of chronic disease?
(A) Increased serum iron and increased TIBC.
(B) Decreased serum iron and increased TIBC.
(C) Decreased serum iron and decreased TIBC.
(D) Increased serum iron and decreased TIBC.
(191) A patient presented with symptoms of anemia. Investigations revealed a low MCV, decreased
serum iron and increased TIBC. What is the diagnosis?
(A) Iron deficiency anemia.
(B) Pernicious anemia.
(D) Hemolytic anemia.
(192) How can a diagnosis of anemia be confirmed in a patient with a family history of thalassemia?
(A) Hemoglobin electrophoresis.
(B) Genetic testing.
(C) Histopathoiogical analysis.
(D) Blood smear.
(193) What is the recommended treatment for Von Willebrand disease?

(A) Fresh frozen plasma.
(B) Factor Vm replacement.
(C) Blood transfusion.
(D) Oral iron.
(194) Which one of the following diseases is commonly treated with fresh frozen plasma?
(A) Hemophilia A.
(B) Hemophilia B.
(C) Von Willebrand disease.
(D) DIC.
(195) What is the defect in hemophilia?

(A) Clotting factors.
(B) Platelet dysfunction.
(C) Blood vessels dysfunction.
(196) Laboratory results from the blood of a leukemia patient show pancytopenia, leukocytosis and
positive myeloperoxidase. Which type of leukemia does he have?
(A) Acute myeloid leukemia.
(B) Acute lymphoblastic leukemia.
(C) Chronic myeloid leukemia.
(D) Chronic lymphocytic leukemia.
(197) A patient presented with a painless neck mass and a 5 weeks history of fatigue,
generalized pruritus and mild cough. Which one of the following is the most likely diagnosis?
(A) Hodgkin's lymphoma.
(B) Non-Hodgkin's lymphoma.
(C) Lyme disease.
(D) Infectious mononucleosis.
(198) A young female presented with a 6 months history of night sweats and weight loss. On
examination splenomegaly was uncovered. Investigation showed reed Sternberg cells in the blood. What
is
the diagnosis?
(A) Hodgkin's lymphoma.
(B) Lyme disease.
(C) Infectious mononucleosis.
(D) Non-Hodgkin's lymphoma.
(199) A patient presented with a sore red tongue. Investigations showed low vitamin B12 levels in his
blood. What is the diagnosis?
(A) Pernicious anemia.
(B) Hemolytic anemia.
(D) Iron deficiency anemia.
(200) What is true about pneumococcal vaccination in sickle cell disease patients of 11-month-old?
(A) 23-valent should be taken.
(B) 32-valent should be taken.
(C) The patient requires a prophylactic antibiotic even if they have been vaccinated.
(D) There is no need for antibiotics if the patient has been vaccinated.
(201) A child with leukemia suffered from septicemia caused by a venous line. What is the most likely
organism to have caused this septicemia?
(A) E. coli.
(B) Gram-negative streptococci.
(C) Gram-positive streptococci.
(D) Pseudomonas.
(202) All of the following are recommended for the primary prevention of iron deficiency anemia
except:
(A) Health education about food rich in iron.
(B) Iron-fortified food in childhood.
(C) Limitation of cow milk before 12-month-old.
(D) Genetic screening for hereditary anemia.
(203) An adult patient with sickle cell anemia suffered from an upper respiratory tract infection then
suddenly developed chest pain, fever and tachypnea. On examination RR = 30/min. His oxygen
saturation was 90% and he had lobar infiltration, observed by chest x-ray. His WBCs count was
18,000/md and hemoglobin was 7 gm/dl. What is the likely cause of his condition?
(A) Pulmonary edema.
(B) Pulmonary hypertension.
(C) Acute chest syndrome.
(D) Vaso-occlusive crisis.
(204) A child who eats little meat presented with pallor. He was found to have microcytic hypochromic
anemia. What is the recommended treatment for him?
(A) Trial of iron therapy.
(B) Multivitamin with iron daily.
(C) Folic acid.
(D) Multivitamins.
(205) For what duration should anticoagulant agents be prescribed?

(A) 1 month.
(B) 6 months.
(C) 6 weeks.
(D) 1 year.
(206) A sickle cell anemia patient presented with asymptomatic unilateral hip pain. What is the most
likely diagnosis?
(A) Septic arthritis.
(B) Avascular necrosis.
(C) Aseptic arthritis.
(D) Gout disease.
(207) What is the therapeutic range of the INR for warfarin?

(A) 1.5 - 2.5
(B) 2.0 - 3.0
(C) 2.5 - 3.5
(D) 3.0 - 4.0
(208) A case of Hodgkin's lymphoma (mediastinal mass) treated with radiotherapy, but not on
regular follow up, presented with gradual painless difficulty in swallowing and shortness of breath.
On examination, facial swelling and redness was found. What is the diagnosis?
(A) Superior vena cava obstruction.
(B) Inferior vena cava obstruction.
(C) Thoracic aortic aneurysm.
(D) Abdominal aortic aneurysm.
(209) What is the investigation of choice in iron deficiency anemia?

(A) Serum iron.
(B) Ferritin.
(C) TIBC.
(D) MCV.
(210) A 65-year-old man had a hemoglobin level of 9 gm/dl. What is the next step in his treatment?
(A) Assess his iron levels.
(B) Assess his lactate dehydrogenase levels.
(C) Arrange for an endoscopy.
(D) Electrophoresis.
(211) A patient presented with a knee swelling with bloody content due to trauma to the knee. What
is the probable mechanism of this bleeding?
(A) Platelet deficiency.
(B) Clotting factor deficiency.
(C) Platelet dysfunction.
(D) Blood vessels dysfunction.
(212) A 56-year-old patient presented with symptoms of anemia. His CBC showed a hemoglobin
level of 11 gm/dl, MCV of 93 fl and a reticulocyte count of 0.25%. What is the likely cause of this
anemia?
(A) Chronic renal failure.
(B) Liver disease.
(C) Sickle cell anemia.
(D) G6PD deficiency.
(213) A male patient presented with excessive fluid intake and polyuria. His FBS level was 122
mg/dl. What is the likely diagnosis?
(B) Diabetes insipidus.
(C) Impaired FBS.
(D) Normal.
(214) A diabetic patient presented with abdominal pain, vomiting and the smell of ketones from his
mouth. What is the most frequent pathophysiology of these symptoms?
(A) Insulin overdose.
(B) Insulin missed.
(C) Oral drugs overdose.
(D) Oral drugs missed.
(215) A diabetes mellitus type 1 patient, presented with Kussmaul breathing and an acetone smell. What is
the pathophysiology of the acetone smell?
(A) Insulin deficiency which leads to fatty acid utilization and the production of ketones.
(B) Missed hypoglycemic medications which lead to protein utilization and the production of ketones.
(C) Both A and B.
(216) A patient newly diagnosed with diabetes mellitus type 1 has a normal vision. How often should he
be checked for any complications or changes in his eyes?
(A) Now and then annually.
(B) Now and after 3 years.
(C) Now and after 3 years.
(D) If there is a complaint.
(217) A 15-year-old boy presented with unilateral gynecomastia. What is the recommended management
plan for this patient?
(A) His condition may resolve spontaneously so no management is necessary.
(B) Hormonal therapy.
(C) Decreased use of soda oil or fish oil.
(D) Immediate surgical removal.
(218) Which of thef ollowing is true regarding metformin?

(A) The main complication is hypoglycemia.
(B) Its use can lead to weight gain.
(C) It suppresses hepatic gluconeogenesis.
(D) It stimulates hepatic gluconeogenesis.
(219) A 49-year-old man who smokes 2 packs of cigarettes per day presents with weight gain. A chest
x-ray shows a lung mass and laboratory tests reveal hyponatremia with hyperosmolar urine. What is the
most likely diagnosis?
(A) Inappropriate secretion of antidiuretic hormone.
(B) Pituitary failure.
(C) Renal failure.
(D) Conn's syndrome.
(220) A diabetes meilitus patient presented to the ER with drowsiness. The patient's blood sugar level
was 400 mg/dl and pH was 7.05. What is the recommended management for this patient?
(A) 10 units of insulin and 400 ml of dextrose.
(B) 0.1 unit/kg of insulin administered SC.
(C) NaHC03.
(D) Give one liter of normal saline solution.
(221) An elderly patient with diabetes meilitus type 2 presented to the ER with sweating and
dizziness. The patient's blood sugar level was 60 mg/dl. Which drug is likely to be causing these
manifestations?
(A) Thiazolidinediones.
(B) Sulfonylurea drugs.
(C) Insulin.
(D) Alpha-glucosidase inhibitors.
(222) Which hormone causes large hands and jaws, obesity and a large body?
(A) Thyroid hormone.
(B) Adrenocorticotropic hormone.
(C) Human growth hormone.
(D) Anti-diuretic hormone.
(223) A diabetic patient presented with exudates from a wound in his leg with poor healing and no
sign of inflammation. What is the cause of the poor wound healing in this diabetes meilitus patient?
(A) Decreased phagocytosis process.
(B) Stimulated bacterial growth.
(C) Decreased immunity.
(D) Increased blood supply to the wound.
(224) A patient was diagnosed with osteopenia. Investigations revealed increased serum alkaline
phosphatase and normal serum calcium, phosphate and vitamin D levels. What is the recommended
(A) Selective estrogen receptor modulators.
(B) Calcium regulator.
(C) Bisphosophnates.
(D) Multivitamins.
(225) What is the pathophysiology of diabetic ketoacidosis?

(A) Missing insulin leads to the release of free fatty acids and the formation of ketone bodies.
(B) Increased insulin resistance.
(C) Decreased hepatic gluconeogenesis.
(D) Both B and C.
(226) An elderly patient with diabetes mellitus and no previous significant medical problem was found to
have repeated blood pressure measurements in of 138/85mmHg. What is the first line of management for
this abnormality?
(A) Diuretics.
(C) Lifestyle and behavioral therapy.
(D) Nothing.
(227) What is the mechanism of action of propylthiouracil?

(A) Inhibits the action of thyroid peroxidase (thyroperoxidase).
(B) Inhibits the action of the sodium-dependent iodide transporter.
(C) Decreases the efficacy of TSH binding to the TSH receptors.
(D) Decreases the rate of proteolysis by thyroglobulin.
(228) What is the recommended treatment for asymptomatic hyperthyroidism in pregnancy?

(A) Beta-blockers.
(B) Propylthiouracil.
(C) Methimazole.
(D) Nothing.
(229) An 18-year-old boy presented to the ER with abdominal pain, vomiting and leg cramp. His RBS
was 414 mg/dl. What is the most important next step of the investigation into his condition?
(A) Abdominal US.
(B) ABG.
(C) Urine analysis by dipstick.
(D) Chest x- ray.
(230) What is the recommended treatment for albuminuriain diabetes mellitus patients?
(B) Diuretics.
(C) Calcium channel blockers.
(D) Hemodialysis.
(231) A patient was found to have the following blood test results: high parathyroid hormone, low
calcium, high creatinine and normal vitamin D levels. What is the likely diagnosis?
(A) Vitamin D deficiency.
(B) Chronic renal failure.
(C) Iron deficiency anemia.
(D) Polycystic kidney disease.
(232) A 40-year-old male presented to the clinic complaining of central obesity, acne, weakness
and buffalo hump. He is not known to have any medical illness. On examination, he was found to
have hypertension. What is the likely diagnosis?
(A) Cushing's disease.
(B) Psuedo-cushing syndrome induced by alcohol intake.
(C) Adrenal adenoma.
(D) Adrenal carcinoma.
(233) A diabetic patient presented with diabetic ketoacidosis, hypokalemia, hypotension. What
is the best initial treatment for this patient?
(A) Give 2 liters normal saline with insulin infusion at a rate of 0.1/kg.
(B) Give 2 liters normal saline with KCI at 20 mEq.
(C) Dextrose with insulin.
(D) NaHC03.
(234) What is human leukocyte antigen (HLA) type of diabetes mellitus type 1?
(A) DR3.
(B) DR4.
(C) DR5.
(D) Both A and B.
(235) Which of the following diseases most occurs due to Candida infection?
(B) Systemic lupus erythematosus.
(C) Gastroenteritis.
(D) Endocarditis.
(236) A comatose patient was brought to the ER by his family. He did not respond to painful stimuli.
He had high TSH levels, sever hypothyroidism and hyponatremia (Na = 108). What is the recommended
management?
(A) Intubate, give 3% sodium,hydrocortisone and treat the hypothyroidism.
(B) Intubate, give 3% sodium then treat the hypothyroidism.
(C) Treat the hypothyroidism and monitor serum sodium level every 6 hours.
(D) Give thyroid and fluid replacements only.
(237) What is the most common cause of renal failure?

(B) Nephritis.
(C) Smoking.
(D) Hyperlipidemia.
(238) What are the factors most related to retinopathy in diabetic patients?
(A) Hypertension and obesity.
(B) Hypertension and smoking.
(C) Smoking and obesity.
(D) Smoking.
(239) A 24-year-old female with newly diagnosed diabetes mellitus type 2 has been wearing glasses for
10 years. What is the recommended follow up period for the ophthalmic clinic?
(A) 6 Months.
(B) 12 Months.
(C) 5 years.
(D) 10 years.
(240) Thethyroid function test of a pregnant woman was completely normal, with the exception of
high TSH levels. What is the diagnosis?
(A) Normal due to pregnancy.
(B) Pituitary disorder.
(C) Thyroid disorder.
(D) Adrenal disorder.
(241) What is the recommended treatment for thyroid carcinoma?

(A) Surgical resection.
(B) Radiotherapy.
(C) Anti-thyroid drug.
(D) Chemotherapy.
(242) What is the diagnosis of a patient with the following blood test results: high Na, low K and high
HC03?
(A) Primary hyperaldosteronism.
(B) Secondary hyperaldosteronism.
(C) Addison disease.
(D) Pheochromocytoma.
(243) A 22-year-old patient has been newly diagnosed with diabetes mellitus type 1. What is the
erommended follow up period for the ophthalmic clinic?
(A) Upon diagnosis, then annually.
(B) After 3 years, then annually.
(C) After 5 years, then annually.
(D) After 10 years, then annually.
(244) A 35-year-old lady presented to the clinic with swelling in the neck. The swelling is firm, large and
lobulated. The patient also complains of psychosis, weight gain, depression, sensitivity to heat and cold,
fatigue, bradycardia, constipation, migraines, muscle weakness, muscle cramps and hair loss. Blood tests
revealed increased TSH and decreased T4 levels. What is the likely diagnosis?
(A) Addison disease.
(B) Hashimoto's thyroiditis.
(C) Idiopathic hypoparathyroidism.
(D) Hypopituitarism.
(245) All of the following can cause hypokalemia, except:
(A) Acute tubular necrosis.
(B) Metabolic acidosis.
(C) Chronic diarrhea.
(D) Addison disease.
(246) Which one of the following is not normally palpable in a head and neck examination?
(A) Thyroid gland.
(B) Submandibular gland.
(C) Parotid gland.
(D) Lymphnodes.
(247) What is the pathophysiology of Cushing's syndrome?

(A) Increased adrenocorticotropic hormone from a pituitary adenoma.
(B) Decreased adrenocorticotropic hormone from a pituitary adenoma.
(C) Increased adrenocorticotropic hormone from the adrenal gland.
(D) Decreased adrenocorticotropic hormone from the adrenal gland.
(248) A newly dianosed child with diabetes mellitus, found in his home unconscious. What is the
advice for his family first thing to do?
(A) Bring him as soon as possible to the ER or call an ambulance.
(B) Give him sugar in fluid orally.
(C) Give him his usual dose of insulin.
(D) Give him IM glucagon.
(249) What is the target glycosylated haemoglobin (HbAlc) level in a diabetic patient?
(A) 2-3%.
(B) 4-5%.
(C) 6-7%.
(D) 8-9%.
(250) What is the goal of blood pressure in patients with hypertension and diabetes mellitus?
(A) SBP less than 140 mmHg and DBP less than 90 mmHg.
(B) SBP less than 130 mmHg and DBP less than 90 mmHg.
(C) SBP less than 130 mmHg and DBP less than 80 mmHg.
(D) SBP less than 120 mmHg and DBP less than 80 mmHg.
(251) A 40-year-old male presented to the clinic with large hands. On examination, he was also found
to have hepatomegaly. Which of the following is the most likely diagnosis?
(A) Acromegaly.
(B) Gigantism.
(C) Hyperthyroidism.
(D) Hypothyroidism.
(252) What is the best non-pharmacological method of lowering hypertension?
(A) Cessation of smoking.
(B) Decrease lipid level.
(C) Reduce weight.
(D) High sodium diet.
(253) What is the most active form of thyroid hormone?

(A) T3.
(B) T4.
(C) TSH.
(D) TRH.
(254) A pregnant lady presented with neck swelling and multiple nodular non-tender goiter. What is
the best approach to manage this condition?
(A) Thyroid biopsy.
(B) Anti-thyroid medication.
(C) Radioactive iodine therapy.
(D) Evaluation of TSH and free T4 and follow up.
(255) Which of the following is associated with primary hyperaldosteronism?

(A) Hypernatremia.
(B) Hypomagnesemia.
(C) Hypokalemia.
(D) Hyperkalemia.
(256) What is the recommended initial treatment of symptomatic hyperthyroidism?

(A) Surgery.
(B) Radioactive iodine therapy.
(C) Beta-blockers and propylthiouracil.
(D) Rituximab.
(257) A patient with a known case of diabetes mellitus presented with a spastic tongue, dysarthria
and spontenous crying. What is the most likely diagnosis?
(A) Parkinson's disease.
(B) Bulbar palsy.
(C) Pseudobulbar palsy.
(D) Myasthenia gravis.
(258) A 59-year-old patient presented with new onset supraventricular tachycardia with palpitation
and had no history of shortness of breath or chest pain. On examination his chest was normal with no
peripheral edema. Investigation showed his oxygen saturation in room air as 98%. What is the next
investigation that should be performed?
(A) ECG stress test.
(B) Pulmonary arteriography.
(C) CT scan.
(D) TSH.
(259) A patient presented with a history of neck discomfort, palpitation and sweating. On examination
he had a tender neck. Blood investigations revealed low TSH and high T4 levels. What is the likely
diagnosis?
(A) Hyperthyroidism.
(B) Subacute thyroiditis.
(C) Hemangioma.
(D) Lipoma.
(260) What is the best single test to confirm Cushing's syndrome?

(A) Plasma cortisone level.
(B) Adrenocorticotropic hormone.
(C) Dexamethasone suppression test.
(D) Renal function test.
(261) A 50-year-old patient with uncontrolled diabetes mellitus presented with brown to black nasal
discharge. What is the most likely diagnosis?
(A) Mucormycosis.
(B) Aspergillosis.
(C) Foreign body.
(D) Epistaxis.
(262) A 25-year-old woman presented with weight loss, heat intolerance and irritability. What is the
likely diagnosis?
(A) Hyperthyroidism.
(B) Hypothyroidism.
(C) Hyperparathyroidisim.
(D) Hypoparathyroidisim.
(263) A young male with diabetes mellitus presented with abdominal pain, vomiting and the smell of
ketones from his mouth. What is the frequent cause of these symptoms?
(A) Insulin mismanagement.
(B) Diet mismanagement.
(C) Renal failure.
(264) Which of these is the earliest sign of puberty in males?

(A) The appearance of pubic hair.
(B) Increase in testicular size.
(C) Increase in penis size.
(D) Increase in prostate size.
(265) A female patient with diabetes mellitus type 1 is advised to make schedule for glucose level for
monitoring his insulin dose; FBS = 283 mg/dl, after lunch = 95 mg/dl and at 3 pm = 184 mg/dl. What is
the modification of insulin dose?
(A) Increase in short acting insulin dose.
(B) Decrease in short acting insulin dose.
(C) Increase in long acting insulin dose.
(D) Decrease in long acting insulin dose.
(266) A young female patient complaining of severe headaches over a long period is starting to avoid
alcohol and smoking to improve her health. She notes that she had improved over her last pregnancy.
Which treatment has she used?
(A) Biofeedback.
(B) Beta-blockers.
(C) Alcohol cessation.
(D) Tobacco withdrawal.
(267) What is the most effective treatment of cluster headaches?

(A) Ergotamine nebulizer.
(B) Sumatriptan SC.
(C) 100% oxygen.
(D) Verapamil IV.
(268) Which one of the following will increase IgG levels in CSF?
(A) Multiple sclerosis.
(B) Duchenne dystrophy.
(C) Down syndrome.
(D) Epilepsy.
(269) What is the first sign of increase intracranial pressure?

(A) Nausea.
(B) Vomiting.
(D) Bilateral pupil constrict.
(E) Decreased level of consciousness.
(270) A patient presented to the hospital 6 hours after a cerebral ischemic stroke. What is the best
treatment?
(A) Aspirin.
(B) Tissue plasminogen activator.
(C) Clopidogrel.
(D) Heparin IV.
(271) A patient presented with neck stiffness, high fever, headache and petechial rash. Lumber puncture
showed a high CSF pressure and CSF analysis showed a decrease in glucose level. What would be the
cause?
(A) Neisseria meningitides.
(B) Neisseria gonorrhea.
(C) Haemophilus influenza.
(D) Streptococcus pneumonia.
(272) A male patient presented with pain near the right eye preceded by tinglin gand parenthesis.
The pain occurs many times a week in the same side. The patient also complains of nasal congestion and
eyelid edema. What is the diagnosis?
(A) Cluster headache.
(B) Migraine with aura.
(D) Withdrawal headache.
(273) A 19-year-old patient had a closed head injury and now presents with an inability to bring a
spoon in front of his mouth to eat. Where is the most likely site of lesion?
(A) Temporal lobe.
(B) Occipital lobe.
(C) Parietal lobe.
(D) Cerebellum.
(274) A female patient presented with a band-like headache which occurred twice/week and increased
in intensity with stress. What is the likely diagnosis?
(A) Cluster headache.
(B) Migraine.
(275) Which one of the following is closely associated with Guillain-Barre syndrome?
(A) Descending paralysis starting from the upper limbs.
(B) Ascending paralysis starting from the lower limbs.
(C) Normal CSF.
(D) Need ECG to confirm the diagnosis.
(276) What is the initial ER management of grand mal seizure?

(A) ABC of CPR to secure airway.
(B) Physical splint or protection.
(C) Anticonvulsants.
(D) ECG monitoring.
(277) An elderly male patient admitted to the hospital due to cerebrovascular accident lost the vision in
his left eye 9 days later. Where is the site of lesion?
(A) Frontal lobe.
(B) Occipital lobe.
(C) Parietal lobe.
(D) Temporal lobe.
(278) What is the common CSF finding in the initial 24 hours of aseptic meningitis?
(A) Decreased protein level.
(B) Increased glucose level.
(C) Lymphocytosis.
(D) Eosinophil polyneuropathy.
(279) What is most important sign of pure autonomic failure?

(A) Orthostatic hypotension.
(B) Sinus arrhythmia.
(C) Horner syndrome.
(D) Muscle wasting.
(280) A young male patient who works out doors in hot weather presents with clammy cold skin. On
examination he has hypotension and tachycardia. What is the diagnosis?
(A) Heat stroke.
(B) Heat exhaustion.
(C) Fever.
(D) Volume shock.
(281) A 17-year-old female patient complained of unilateral headache, nausea and vomiting. The pain
was exacerbated by movement and aggravated by light. What is the most likely diagnosis?
(A) Migraine.
(B) Cluster headache.
(282) What are the symptoms of L4/L5 disc prolapse?

(A) Loss of ankle jerk reflex.
(B) Fasciculation of posterior calf muscles.
(C) Loss of dorsiflexion compartment of the foot (foot drop).
(D) Loss of the sensation in the groin and anterior aspect of the thigh.
(283) A patient presented to the ER with a deep laceration in the anterior aspect of the wrist. What is
the result of this injury?
(A) Radial nerve injury and wrist drop.
(C) Ulnar nerve injury and claw hand.
(D) Median nerve injury and loss of thumb opposition.
(B) Sensory loss only.
(284) What is the normal site of lumbar puncture?
(A) Between L1-L2.
(B) Between L2-L3.
(C) Between L3-L4.
(D) Between L4-L5.
(285) What is the most common reversible risk factor of stroke?

(B) Elevated blood pressure.
(C) Family history of stroke.
(D) Hyperlipidemia.
(286) Which of the following is false about emergency management of stroke?

(A) Giving IV fluid and avoid glucose containing (dextrose).
(B) Diazepam should be given for convulsions.
(C) Anticonvulsant drugs are not needed if the patient has seizures.
(D) Managing elevated blood pressure.
(287) Romberg's sign indicates a lesion in the:

(A) Dorsal column.
(B) Cerebellum.
(C) Visual cortex.
(D) Brain stem.
(288) An elderly male patient presented with difficulty in walking, resting tremors, sleep disturbance
and rigidity. What is the most common symptom of the disease suffered by this patient?
(A) Rigidity.
(B) Tremors.
(C) Unsteady gait.
(D) Hypotension.
(289) Which of the following antiepileptic drugs has a side effect of alopecia?
(A) Phenytoin.
(B) Carbamazepine.
(C) Sodium valproate.
(D) Diazepam.
(290) A 33-year-old male patient presented with pain in his lip and right cheek. The pain was stabbing
and triggered with touch. On examination, his cranial nerves were intact. What is the recommended
(A) Carbamazepine.
(B) Phenobarbital.
(C) Ergotamine.
(D) Lithium.
(291) All of the following are extrapyramidal lesion symptoms except:
(A) Dyskinesia.
(B) Akathisia.
(C) Dystonia.
(D) Tonic-clonic convulsion.
(292) What is the most common cause of intra-cerebral hemorrhage?

(A) Ruptured aneurysm.
(B) Hypertension.
(C) Trauma.
(D) Vascular malformation.
(293) What is the most common cause of non-traumatic subarachnoid hemorrhage?

(A) Middle meningeal artery hemorrhage.
(B) Bridging vein hemorrhage.
(C) Rupture of a cerebral aneurysm.
(D) Non-aneurysmal perimesencephalic hemorrhage.
(294) A female patient presented with dysuria, urination urgency, increase urination frequency and
suprapubic pain. She is allergic to sulfa and penicillin. What is the treatment?
(A) Nitrofurantoin.
(B) Cephalexin.
(C) Trimethoprim-sulfamethoxazole.
(D) Amoxicillin.
(295) A female patient complaining of urinary symptoms that have persisted for one year took
several different antibiotics with no improvement. On examination there was a mild tenderness on the
base of the bladder and CT and MRI scans were normal. What is the diagnosis for this patient?
(A) Interstitial cystitis.
(B) Diabetes mellitus.
(C) Candida albican.
(D) Urethral injury.
(296) What is the gold standard test of renal function?

(A) Creatinine clearance.
(B) 24 hours urine collection.
(C) BUN to creatinine ratio.
(D) BUN serum level.
(297) What is the most reliable laboratory test to establish a diagnosis of acute glomerulonephritis?
(A) RBCs cast in urine.
(B) Increased WBCs in urine.
(C) Low hemoglobin with normal RBCs.
(D) Small shrunk kidney identified by US.
(298) A patient presented with abdominal pain and hematuria. On examination hypertension and
palpable bilateral flank masses were observed. Genetic testing showed an abnormality in chromosome
16. What is the diagnosis?
(A) Amyloidosis.
(B) Sarcoidosis.
(C) Polycystic kidney disease.
(D) Metastatic hypernephroma.
(299) Which of the following is found in chickpeas, kidney beans and lentils?
(A) Bromide.
(B) Chromium.
(C) Iron.
(D) Selenium.
(300) Which one of the following is associated with Goodpasture's syndrome?

(A) Osteoporosis.
(B) Multiple fractures and nephrolithiasis.
(C) Lung hemorrhage and glomerulonephritis.
(D) Lung hemorrhage only.
(301) A 60-year-old female patient with a known case of hypertension presents to the hospital with
edema. She has azotemia and a glomerular filtration rate of 44 ml/min. What is the cause of this
kidney disease?
(A) Bilateral renal artery stenosis.
(B) Diabetic nephropathy.
(C) Renal tubular acidosis.
(302) What is the mechanism of rheumatic fever development from group A streptococcus infection?
(A) Blood dissemination.
(B) The development of pharyngitis/tonsillitis.
(C) Joint invasion.
(303) Which of the following is a minor criterion for the diagnosis of rheumatic fever?
(A) Arthritis.
(B) Erythema marginatum.
(C) Chorea.
(D) Fever.
(304) Which drug is used to treat Leishmania?

(A) Amphotericin B.
(B) Metronidazole.
(C) Doxycydine.
(D) Penicillin.
(305) Which of the following is a treatment for giardiasis?
(A) Praziquantel.
(B) Mebendazole.
(C) Metronidazole.
(D) Albendazole.
(306) A patient presented with neck swelling. On examination the patient had cervical
lymphadenopathy with hepatosplenomegaly. He had evidence of Epstein Barrvirus antibodies. What is
the diagnosis?
(A) Infectious mononucleosis.
(B) Toxoplasmosis.
(C) Malaria.
(D) Lymphoma.
(307) A HIV patient presented with a hemorrhagic lesion in the mouth and papules in the face. Skin
biopsy showed spindle cells and vascular structures. What is the diagnosis?
(A) Kaposi sarcoma.
(B) Melanoma.
(C) Squamous cell carcinoma.
(D) Basal cell carcinoma.
(308) Which of the following is the most common cause of malaria?

(A) Plasmodium falciparum.
(B) Plasmodium vivax.
(C) Plasmodium ovale.
(D) Plasmodium malariae.
(309) What is the most specific test for syphilis?

(A) Blood culture and sensitivity.
(B) CBC.
(C) Fluorescent treponemal antibody absorption.
(D) Microhemagglutination assay for antibodies to Treponema.
(310) What is the recommended chemoprophylaxis for vibrio cholera?

(A) Penicillin V.
(B) Gentamicin.
(C) Tetracycline.
(D) Amoxicillin.
(311) Which of the following is true about aspirin overdose?

(A) Liver enzyme levels will peak within 3-4 hours.
(B) First signs include peripheral neuropathy and loss of reflexes.
(C) 150 mg/kg of aspirin will not result in aspirin toxicity.
(D) There is no effect on acid base status.
(312) Which of the following is the most cost-effective drug to prescribe DVT patients?
(A) Low molecular weight heparin.
(B) Unfractionated heparin.
(C) Warfarin.
(D) Aspirin.
(313) What is the recommended treatment for anaphylaxis?

(A) Epinephrine.
(B) Antihistamine.
(C) Corticosteroid.
(D) Analgesic.
(314) What is the antidote for organophosphorus?

(A) Atropine.
(B) Deferoxamine.
(C) Ethanol.
(D) Vitamin K.
(315) What is the result of vitamin B1 (thiamine) deficiency?

(A) Beriberi.
(B) Pernicious anemia.
(C) Scurvy.
(D) Pellagra.
(316) A patient was diagnosed with infectious mononucleosis which confirmed by monospot test.
The patient had a palpable tip of the spleen. What is the recommended management for this patient?
(A) Empiric antibiotics.
(B) Antivirals.
(C) Observation.
(D) Supportive treatment.
(317) An elderly patient presented with fever. A blood culture showed the presence of
enterococcus faecalis. What is the probable source of these bacteria?
(A) Skin.
(B) Urinary tract.
(C) Upper respiratory tract.
(D) Mouth.
(318) How can factitious fever be confirmed?

(A) CBC.
(B) Blood pressure.
(C) Chest x-ray.
(D) Heart rate.
(319) What is the recommended treatment for peritonitis?
(A) Clindamycin.
(B) Metronidazole.
(C) Amoxicillin.
(D) Doxycydine.
(320) A patient presented with leg pain which was aggravated by walking and relieved by rest. On
examination hair loss and coldness in the leg was observed. What is the diagnosis?
(A) Chronic leg ischemia.
(B) DVT.
(C) Venous insufficiency.
(D) Cellulitis.
(321) A hypertensive patient using lisinopril presented to the ER with a cough due to an
antihypertensive drug.Which drug will give the same antihypertensive effect but with less risk of a
cough?
(A) Losartan.
(B) Captopril.
(C) Enalapril.
(D) Benazepril.
(322) A patient presented to the hospital with a history of right back pain for one day which was
not relieved by analgesics. He noticed a skin rash forming a tight chain like pattern from the back to
the abdomen. What is the likely diagnosis?
(A) Herpes zoster virus infection.
(B) Measles.
(C) Epstein Barr virus infection.
(D) Allergy to drug.
(323) Which one of the following drugs combinations should be avoided?

(A) Digoxin and levodopa.
(B) Tetracycline and aluminum hydroxide.
(C) Penicillin and probenecid.
(D) Cephaloridine and acetaminophen.
(324) What is the best method of eradicating entameba histolytica?

(A) Boiling of water.
(B) Freezing.
(C) Iodine treatment.
(D) Add chlorine to water.
(325) What is the best investigation for the diagnosis of giant cell arteritis?
(A) Biopsy from temporal arteritis.
(B) Raised ESR.
(C) CBC.
(D) Angiogram.
(326) Which of the following drugs is taken twice a day?

(A) Ibu profen.
(B) Piroxicam.
(C) Indomethacin.
(D) Naproxen.
(327) What is the most effective method to prevent brucellosis infection?

(A) Treat infected people.
(B) Immunize farmers and those whom deal with the animals.
(C) Dispose of all the infected animals.
(D) Pasturization of dairy products.
(328) What is the recommended treatment of Neisseria gonorrhoeae?

(A) Ceftriaxone.
(B) Amoxicillin.
(C) Penicillin.
(D) Gentamicin.
(329) Which of following drugs is not used in the treatment of leprosy?

(A) Dapsone.
(B) Clofazimine.
(C) Rifampicin.
(D) Haloperidol.
(330) A comatose patient was brought to the ER by his family after the ingestion of many sleeping pills.
The patient is gasping for breath and application of a mask leads to no response. What is the next course
of action?
(A) Continue one breath every 5 seconds.
(B) Continue one breath every 15 seconds.
(C) Intubation.
(D) Put him in the recovery position.
(331) Where does the fluid accumulate in grade-1 pitting edema?

(A) Arteriole.
(B) Venule.
(C) Interstitial fluid.
(D) Capillary.
(332) What is the mode of transmission and vector of Flavivirus?
(A) Sand fly.
(B) Mosquito.
(C) Airborne transmission.
(D) Fecal-oral transmission.
(333) What is the best method to prevent Lyme disease?

(A) Killing the vector.
(B) Wearing clothes of natural fibers.
(C) Using antibacterial soap.
(D) Application of corticosteroid cream.
(334) What is the recommended treatment for pyoderma gangrenosum?
(A) Steroids.
(B) Topical antibiotics.
(C) Oral antibiotics.
(D) Methotrexate.
(335) What is the recommended treatment for molluscum contagiosum?

(A) Acyclovir.
(D) Broad spectrum antibiotics.
(C) It will resolve without treatment.
(B) Steroids.
(336) A patient presented with penile discharge and gave a history of unprotected sex. Urethral
discharge culture revealed a Gram-negative diplococcus. What is the diagnosis?
(A) Chlamydia.
(B) Neisseria Gonorrheae.
(C) Streptococcus.
(D) Staphylococcus.
(337) Which organism causes skin infection due to a cat bite?

(A) Staphylococcus.
(B) Streptococcus.
(C) Pasteurella multocida.
(D) Fungus.
(338) What is the antidote to acetaminophen toxicity?

(A) Pendlinemia.
(B) N-acetylcysteine.
(C) Potassium.
(D) Dexamine.
(339) An elderly patient presented with leg pain after walking. On examination there was no
edema. What is the most likely diagnosis?
(A) Claudication.
(B) Compartment syndrome.
(C) Bone pain.
(D) DVT.
(340) A patient presented with arthritis and urethral discharge. A culture of discharge was negative
for gonorrhea and chlamydia. What is the most likely diagnosis?
(A) Reiter's syndrome.
(B) Gonorrhea.
(C) Rheumatoid arthritis.
(341) A patient presented with a skin rash, diarrhea and dementia. What is the most likely diagnosis?
(A) Pellagra.
(B) Dermatitis.
(C) Vitamin A deficiency.
(D) Beriberi.
(342) What is the sodium content in normal saline (sodium chloride 0.9%)?
(A) 50 mEq/L.
(B) 70 mEq/L.
(C) 90 mEq/L.
(D) 154 mEq/L.
(343) Which of the following is a feature of polymyalgia rheumatica?

(A) Proximal muscle weakness.
(B) Proximal muscle tenderness.
(C) Inability to walk.
(D) Osteophytes observable on joint radiography.
(344) What is the antidote to opioid toxicity?

(A) Naloxone.
(B) Aspirin.
(C) Atropine.
(D) Vitamin K.
(345) Which of the following is true about Raynaud's phenomenon?

(A) Pallor is seen, then cyanosis then red finger without other clinical features.
(B) It is due to exposure to heat.
(C) It is due to vasodilatation.
(346) Aluminum salt will decrease the absorption of:
(A) Tetracycline.
(B) Penicillin.
(C) Benzodiazepine.
(D) Omeprazole.
(347) What is the chief complaint of patients with genital herpes?

(A) Painful vesicular and ulcers.
(B) Bleeding.
(C) Difficulty in urination.
(D) Multiple large swellings.
(348) A young adult presented with a painless penile ulcer with rolled edges. Which
investigation should be used to confirm the diagnosis?
(A) CBC.
(B) Dark field microscopy.
(C) Culture.
(349) What is the antiviral drug that can cause fever, chills and muscle pain?
(A) Interferon.
(B) Acyclovir.
(C) Amantadine.
(D) Combivir.
(350) What is the recommended treatment of scabies?

(A) Permethrin.
(B) Amoxicillin.
(C) Metronidazole.
(D) Morphine.
(351) Which drug causes a systemic lupus erythematosus like syndrome?
(A) Hydralazine.
(B) Propranolol.
(C) Amoxicillin.
(D) Aspirin.
(352) A patient presented with hand cellulitis, red streaks in the hand and tender axillary
lymphadenopathy. This condition is more likely to be associated with:
(A) Malignancy.
(B) Pyoderma.
(C) Neuropathy.
(D) Lymphangitis.
(353) The separation of chromatids occurs in:
(A) Anaphase.
(B) Metaphase.
(C) Telophase.
(D) Prophase.
(354) Investigation of a 70-year-old patient showed an osteolytic lesion in the skull, monoclonal spike
and rouleaux formation. What is the diagnosis?
(A) Multiple myeloma.
(B) Breast cancer.
(C) Anemia.
(D) Chronic myeloid leukemia.
(355) A female patient presented with weight loss and erosion of tooth enamel. She also has
hypokalemia. What is the likely diagnosis?
(A) Bulimia nervosa.
(B) Anorexia nervosa.
(C) Diabetes mellitus.
(D) Thyrotoxicosis.
(356) A 20-year-old female diagnosed with anorexia nervosa presented with multiple fractures due to
fragile bones. On examination, her BMI =16. What is the cause of the fragility of her bones?
(A) Osteoporosis.
(B) Hypovitaminosis osteopenia.
(C) Osteogenesis imperfect.
(D) Osteomalacia.
(357) Which of the following is most likely to be seen in patient with bulimia nervosa?
(A) Hypokalemia.
(B) Metabolic acidosis.
(C) Elevated liver enzyme.
(D) Hypernatremia.
(358) A young female patient is diagnosed with osteoporosis due to an eating disorder. What is the
recommended management?
(A) Weight gain.
(B) Vitamin D supplementation.
(C) Bisphosphonates.
(D) Weight loss.
(359) A young female patient presented with the effects of poor nutrition and excessive exercise.
On examination, her BMI = 18 and she had fine hair all over her body. What is the likely diagnosis?
(A) Anorexia nervosa.
(B) Body dysmorphic disorder.
(C) Bulimia nervosa.
(D) Generalized anxiety disorder.
(360) What is the best treatment for bacteroid fragilis?

(A) Clindamycin.
(B) Antifungals.
(C) Steroids.
(361) A 20-year-old male was found to have hepatitis B surface antibodies. What does this indicate?
(A) Previous vaccination against hepatitis B.
(B) Previous hepatitis B infection.
(C) Active hepatitis B infection.
(D) Hepatitis B carrier.
(362) An 85-year-old male complained of waking many times because of leg pain. This pain is
relieved by moving his foot, but recurs at rest. What is the best choice of treatment for this patient?
(A) Clozapine.
(B) Haloperidol.
(C) Lorazepam.
(D) Ropinirole.
ANSWERS
(1) (C) Nitrates.
- Concomitant (regular/intermittent) use of sildenafil with any nitrate is contraindicated.
- It is not known when nitrates can be safely administered following the use of sildenafil; one set of
guidelines supports the administration of nitrates after only 24 hours.
(2) (D) Metoprolol.

- Antiarrhythmic drugs as prophylactic agents for sudden cardiac death have been studied in post
-myocardial infarction patients with high risk features other than ventricular arrhythmias.
- Beta-blockers improve survival in patients who have had a myocardial infarction in part by reducing
the incidence of sudden cardiac death.
- The efficacy of beta-blockers persists in patients treated with certain other anti-arrhythmic drugs,
including amiodarone and the class I antiarrhythmic drugs.
(3) (A) Enalapril.

- Enalapril is an angiotensin converting enzyme inhibitors.
- Angiotensin converting enzyme inhibitors prevent the conversion of angiotensin I to angiotensin
II, which reduces aldosterone secretion.
- The use of angiotensin converting enzyme inhibitors increases survival, improves symptoms and
decreases repeat hospitalizations in heart failure patients.
- The addition of enalapril to conventional therapy in patients with severe congestive heart failure
can reduce the risk of mortality by slowing the progression of heart failure and improve symptoms.
(4) (A) Dressler's syndrome.

- Dressler's syndrome occurs in 5-6% of patients with acute myocardial infarction.
- Characteristic symptoms include fever, malaise and pleuropericardial chest pain; the onset of which
is
2- 3 weeks after the acute event.
- About 28% of patients develop pleural or pericardial effusion.
- The acute event can also be anything causing inflammation or penetration of the pericardium,
cardiac surgery, a stab wound, a non-penetrating blow to the chest, perforation of the heart with a
heart catheter, or post-operative cytomegalovirus infection. In these cases it is called post
- pericardotomy or post cardiac injury syndrome.
(5) (A) Changes in leads n, HI and aVF.

- In inferior myocardial infarction there are:
1- Pathologic Q waves and evolving ST-T changes in leads II, HI and aVF.
2- Q waves are usually largest in lead m, then in lead aVF and smallest in lead II.
(6) (B)Digoxin.
- Digoxin may enhance the bradycardic effect of carvedilol.
- Carvedilol may increase the serum concentration of digoxin.
(7) (A) Zolpidem.
- Selective serotonin re-uptake inhibitors have emerged as effective agents for the treatment of mild
to moderate depression.
- Unlike their tricyclic antidepressants predecessors, selective serotonin re-uptake inhibitors have
repeatedly been demonstrated to be safe and to have a negligible effect on the cardiovascular system,
even in cases of overdose.
- Selective serotonin re-uptake inhibitors have virtually no effect on fast sodium
channels or conduction and are not noted to have any proarrhythmic or
anti-arrhythmic effects.
- The extended release form of zolpidem has a half-life of 1.5-2.4 hours, but its effects can last longer.
- Zolpidem extended release was developed to improve both sleep-onset insomnia and
sleep-maintenance insomnia while avoiding hangover effects, although it has never been directly
compared to regular zolpidem.
- Zolpidem extended release has relatively few side effects, with the most common being
headache, somnolence and dizziness.
• The duration of deep sleep may be reduced during the first night following discontinuation of
Zolpidem.
(8) (A) Synchronized cardioversion.

- Urgent or emergent cardioversion should be considered for patients with active ischemia, significant
hypotension, severe heart failure, or the presence of a preexcitation syndrome associated with rapid
conduction using the accessory pathway.
(9) (C) Increased serum albumin.

- Nephrotic syndrome is characterized by increased urinary excretion of albumin and other serum
proteins, accompanied by hypoproteinemia and edema formation.
- Nephrotic patients have lower serum albumin concentrations than do patients undergoing
continuous ambulatory peritoneal dialysis when albumin and protein losses are the same in both
groups, suggesting that nephrotic patients may not maximally adapt to the loss of protein.
• The fractional rate of albumin catabolism is increased in nephrotic patients, possibly as a
result of increased albumin catabolism by the kidney, but the absolute albumin catabolic rate
is decreased in nephrotic patients.
- The rate of albumin synthesis may be increased, but not sufficiently to maintain normal serum
albumin concentration or albumin pools.
- Augmentation of dietary protein in nephrotic rats directly stimulates albumin synthesis by increasing
albumin mRNA content in the liver, but also causes an increase in glomerular permeability to
macromolecules so that much, if not all, of the excess albumin synthesized is lost in the urine.
- When dietary protein is restricted, the rate of albumin synthesis is not increased in either nephrotic
patients or in rats, despite severe hypoalbuminemia.
- Although dietary protein supplementation may lead to a positive nitrogen balance, dietary protein
supplementation alone does not cause an increase in serum albumin concentration or body albumin
pools and may instead cause further albumin pool depletion because of the changes induced in
glomerular permselectivity.
- The use of angiotensin-converting enzyme inhibitors may blunt the increased albuminuria caused by
dietary protein supplementation and allow albumin stores to be increased.
• In practice, the recommended protein intake is 0.8-1 gm/kg/day, with a preference for vegetable and
fish proteins.
(10) (A) Ventricular septal defect.
Most patients with large ventricular septal defect have early, large, left to right shunting with
the development of heart failure during infancy.
- In rare cases, the pulmonary vascular resistance does not fall postnatally, left to right shunting is less
marked and presentation with Eisenmenger syndrome occurs sometime during late childhood to early
adulthood.
- The right to left shunt causes cyanosis.
- Chest x-ray in patients with uncomplicated small ventricular septal defect normally shows a normal
cardiac shadow and pulmonary vascular markings.
- With larger ventricular septal defect, the chest x-ray may show cardiomegaly with prominent left
ventricular contour and left atrial and pulmonary artery enlargement due to volume overload directly
related to the magnitude of the shunt.
- The chest x-ray may also show evidence of shunt vascularity.
- In Eisenmenger syndrome, chest x-ray usually shows dilatation of the central pulmonary arteries,
peripheral pulmonary artery (pruning; abrupt attenuation and/or termination of peripheral pulmonary
artery branches) and neovascularity.
(11) (A) Calcium channel blockers.

- Acute coronary syndromes result from the acute obstruction of a coronary artery.
- Consequences depend on the degree and location of the obstruction and range from unstable
angina to non-ST-segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial
infarction STEMI) and sudden cardiac death.
- Symptoms are similar in each of these syndromes (except sudden death) and include chest
discomfort with or without dyspnea, nausea and diaphoresis.
- Diagnosis is achieved by ECG and detecting the presence or absence of serologic markers.
- Treatments include antiplatelet drugs, anticoagulants, nitrates, beta-blockers and for ST-segment
elevation myocardial infarction (STEMI), emergency reperfusion via fibrinolytic drugs, percutaneous
intervention, or, occasionally, coronary artery bypass graft surgery.
Calcium channel blockers have not been shown to be beneficial in acute myocardial infarction
and they may exert deleterious adverse effects alone or when given with other medications,
therefore, calcium channel blockers should generally be avoided.
(12) (A) Streptokinase, nitroglycerin, aspirin and beta-blocker.

Myocardial infarction occurs when cardiac myocytes die due to prolonged myocardial ischemia.
- The rapid triage procedure for chest pain is:
1- Aspirin 1S0-300 mg chewed and ctopidogrel 300 mg oral gel.
2- Sublingual glyceryl trinitrate 0.3-1 mg. oxygen-nasal cannula 2-4 L/min.
3- Brief assessment of the patient's history and risk factors.
4- Physical examination.
5- IV access to allow the assessment of blood markers (plus CBC, biochemistry, lipids, glucose).
6- 12-lead ECG.
7- IV administration of an opiate, e.g. diamorphine (or morphine) 2.5-5 mg and an antiemetic, e.g.
metoclopramide 10 mg.
8- Prescription of a beta-blocker (if no contraindication) for ongoing chest pain, hypertension and
tachycardia.
9- If primary percutaneous coronary intervention is available, a glycoprotein Ilb/ma inhibitor should be
given, alternatively give thrombolysis.
- Fibrinolytic agents enhance the breakdown of occlusive thromboses through the activation of
plasminogen to form plasmin.
- The initial thrombolytic agent used in clinical trials was streptokinase.
- This agent is derived from bacteria, which can lead to the development of neutralizing antibodies that
limit its repeated use.
- The combination of streptokinase and aspirin is significant y more effective than either agent alone.
(13) (B) Interstitial edema.

- Heart failure is a common clinical syndrome characterized by dyspnea, fatigue and signs of volume
overload, which may include peripheral edema and pulmonary rales.
- Heart failure has high morbidity and mortality rates, especially in older persons.
- Many conditions, such as coronary artery disease, hypertension, valvular heart disease and diabetes
mellitus, can lead to decompensation of chronic heart failure.
- Up to 40-50% of patients with heart failure have diastolic heart failure with preserved left ventricular
function and the overall mortality rate is similar to that of systolic heart failure.
- The initial evaluation includes a history and physical examination, chest radiography,
electrocardiography and laboratory assessment to identify causes or precipitating factors.
- A displaced cardiac apex, a third heart sound and chest radiography findings of venous congestion or
interstitial edema are useful in identifying heart failure.
(14) (A) Atrial fibrillation.

- Cardiogenic emboli are a common source of recurrent stroke.
- They may account for up to 20% of acute strokes and have been reported to have the highest
one-month mortality rate.
- Cardioembolic strokes may be isolated, multiple and in a single hemisphere, or scattered and bilateral;
the latter two types indicate multiple vascular distributions and are more commonly found in
cardioembolism.
- Multiple and bilateral infarcts can be the result of embolic showers or recurrent emboli.
- Other possible causes of single and bilateral hemispheric infarctions include emboli originating from the
aortic arch and diffuse thrombotic or inflammatory processes that can lead to multiple small-vessel
occlusions.
(15) (B) Terazosin.

- Terazosin is a quinazoline compound that counteracts alphal-induced adrenergic contractions of the
bladder neck, facilitating urinary flow in the presence of benign prostatic hyperplasia.
- It is indicated for the treatment of symptomatic benign prostatic hyperplasia and hypertension.
- Its effect on voiding symptoms and flow rates is dose-dependent.
- It improves irritative and obstructive voiding symptoms.
- Improvement in flow rate is objective.
(16) (A) Left atrial hypertrophy and dilatation.
Mitral stenosis is the narrowing of the mitral orifice that impedes blood flow from the left atrium to
the left ventricle.
- A mitral orifice of less than 1 cm indicates severe stenosis.
- Almost invariably, the cause is rheumatic fever.
The left atrial size and pressure increase progressively to compensate for mitral stenosis; pulmonary
enous and capillary pressures also increase and may cause secondary pulmonary hypertension, leading
to right ventricular heart failure and tricuspid and pulmonic regurgitation.
(17) (B) Ventricular septal defect.

Tetralogy of Fallot consists of 4 features:
1- A large ventricular septal defect.
2- Right ventricular outflow tract and pulmonary valve obstruction.
3- Right ventricular hypertrophy.
4- Over-riding of the aorta.
- Symptoms include cyanosis, dyspnea with feeding, poor growth and Tet spells (sudden, potentially
lethal ep sodes of severe cyanosis).
- A harsh systolic murmur at the left upper sternal border with a single second heart sound (S2) is
common. Diagnosis is achieved by echocardiography or cardiac catheterization.
- The definitive treatment is surgical repair.
(18) (B) Oxygen uptake

- The Fick method for cardiac output determination is a form of indicator dilution in which exogenous
ndicators are not required, but instead, transported oxygen serves this purpose.
- This method describes a means of determining blood flow by measuring overall oxygen uptake and
content in the blood.
The Fick equation relates cardiac output to oxygen consumption and blood oxygen content and is
recognizable as a special form of the generalized indicator dilution equation.
(19) (D) Increase HDL

Niacin is the most effective lipid-regulating agent clinically available to raise HDL Nicotinic acid
(niacin) is the most effective therapy for high risk patients who have low HDL levels without any other
lipid abnormality.
- Nicotinic acid was found to raise serum HDL by 30% versus only 10% with gemfibrozil.
ie combination of gemfibrozil and nicotinic acid is more effective than monotherapy, raising
HDL by as much as 45%.
(20) (C) Increase the intake of fruit and vegetables.

Soluble fiber increases the excretion of fecal bile acid and the removal of cholesterol.
Good sources of soluble fiber include oat products, barley, fruits and vegetables.
One daily serving of oat bran or oatmeal decreases total cholesterol levels by up to 3%.
Pectin, a soluble fiber found in fruit, also decreases LDL levels.
Exchanging soluble fiber for fat intake produces even greater reductions in LDL levels.
(21) (C) Angiotensin converting enzyme inhibitors.
- The management of heart failure due to systolic dysfunction involves the correction of systemic
factors, lifestyle modification, treatment of the underlying cardiac diseases, device (implantable
cardioverter-defibrillator and cardiac resynchronization) therapy as indicated, as well as pharmacologic
therapy to relieve symptoms and prolong survival.
- For patients with systolic heart failure and volume overload, diuretics are recommended.
- For patients with heart failure with left ventricular systolic dysfunction (left ventricular ejection
fraction <40%), angiotensin converting enzyme inhibitors therapy is recommended.
- For patients with systolic heart failure who do not tolerate angiotensin converting enzyme inhibitors,
an angiotensin II receptor blocker is recommended as an alternative that provides a similar survival
benefit.
- For patients with current or prior heart failure and left ventricular ejection fraction <40%, therapy
withi a beta-blocker is recommended.
(22) (D) Hypertrophic cardiomyopathy.

- Hypertrophic cardiomyopathy is a genetic disorder that is typically inherited in an autosomal
dominant fashion with variable penetrance and variable expressivity.
• The disease has complex symptomatology and potentially devastating consequences for patients and
their families.
- Children and adolescents with hypertrophic cardiomyopathy are often asymptomatic and diagnosed
during family screening.
- However, since echocardiography may be normal during childhood, a single negative screening
examination may not exclude the disease.
- The disorder has a variable presentation and carries a high incidence of sudden death.
- In fact, hypertrophic cardiomyopathy is the leading cause of sudden cardiac death in preadolescent
and adolescent children.
- The hallmark of the disorder is myocardial hypertrophy that is inappropriate, often asymmetrical and
occurs in the absence of an obvious inciting hypertrophy stimulus.
*23) (C) Echocardiogram.

- An echocardiogram, often referred to as a cardiac echo, or simply an echo, is a sonogram of the heart.
- Among the acquired heart valve lesions, mitral stenosis is associated with the highest risk of systemic
thromboembolism.
- The risk increases markedly following the onset of atrial fibrillation and is considerably higher for
patients with mitral stenosis compared to those with isolated mitral regurgitation.
- Patients who suffer a first embolus are at increased risk of repeat embolization, particularly over the
ensuing 6 months.
- Not infrequently, the first presentation of mitral stenosis is an embolic event; most commonly
cerebral.
- Prior to surgical treatment and the widespread use of warfarin as an anticoagulant, as many as 30% of
patients with mitral stenosis experienced an embolic event during the course of the disease.
- There are three major clinical and echocardiographic predictors of embolism: left atrial thrombus, the
degree of reduction in mitral valve area and significant aortic regurgitation.
(24) (A) Stable angina.
Angina may be a vague, barely troublesome ache or may rapidly become a severe, intense precordial
crushing sensation.
It is rarely described as a pain.
Discomfort is most commonly felt beneath the sternum, although the location varies.
Discomfort may radiate to the left shoulder and down the inside of the left arm, even to the fingers;
< aight through to the back; into the throat, jaws and teeth; and, occasionally, down the inside of the
right arm.
may also be felt in the upper abdomen.
The discomfort of angina is never above the ears or below the umbilicus.
Angina pectoris is typically triggered by exertion or strong emotion, usually persists no more than a
few minutes and subsides with rest.
Response to exertion is usually predictable, but in some patients, exercise that is tolerated one day
may precipitate angina the next because of variations in arterial tone.
(25) (C) Congestive heart failure.

Congestive heart failure is one of the most common causes of transudative pleural effusion.
The most important diagnostic step in the evaluation of a pleural effusion is a
thoracocentesis, he accurate classification of pleural fluid into transudates and exudates is
clinically significant.
The usual criteria for categorization as an exudate are: a pleural fluid-to-serum protein ratio greater
han 0.5; a pleural fluid lactate dehydrogenase concentration greater than 200 units/liter and a pleural
uid-to-serum lactate dehydrogenase ratio greater than 0.6.
An exudative process usually requires more extensive evaluation to exclude occult malignancy or
infection.
- ransudative effusions are caused by a combination of increased hydrostatic pressure and decreased
plasma oncotic pressure.
Heart failure is the most common cause, followed by cirrhosis with ascites and then by
hypoalbuminemia, usually due to nephrotic syndrome.
(26) (A) Right heart failure (right ventricular failure).

- In right ventricular failure, the most common symptoms are ankle swelling and fatigue.
Sometimes patients feel a sensation of fullness in the abdomen or neck.
Hepatic congestion can cause right upper abdominal quadrant discomfort and stomach and intestinal
iigestion can cause anorexia and abdominal bloating.
Signs of right ventricular failure include non-tender peripheral pitting edema (digital pressure leaves
visible and palpable imprints, sometimes quite deep) in the feet and ankles; an enlarged and sometimes
ulsatile liver palpable below the right costal margin; abdominal swelling and ascites; and visible evation
of the jugular venous pressure, sometimes with large a or v waves that are visible even hen the patient is
seated or standing.
(27) (A) Carotid artery massage.

Carotid sinus massage is a simple bedside maneuver that helps to clarify the type and sometimes also
the mechanism of different rhythm disturbances.
- fie major indication for carotid sinus massage is the diagnosis of tachyarrhythmias in which the
atrial ivity is either absent or intermittently present.
- Carotid sinus massage is also useful in some patients with normal heart rate; increased vagal tone may
normalize a bundle branch block or localize the site of type I second-degree atrioventricular
block and can be used to evaluate the sensing function of permanent pacemakers.
- Carotid sinus massage is also an important diagnostic procedure in patients with suspected
hypersensitivity of the carotid sinus.
- Massage of the carotid sinus is contraindicated in patients with diseased carotid arteries because of the
risk of cerebrovascular accident.
- In rare instances, carotid sinus massage may initiate ventricular tachycardia.
(28) (B) Heat exhaustion.

- Heat exhaustion is characterized by the inability to maintain adequate cardiac output due to strenuous
physical exercise and environmental heat stress.
- Acute dehydration may be present, but is not required for the diagnosis.
- Heat exhaustion is caused by a water and electrolyte imbalance due to heat exposure, with or without
exertion.
- Symptoms are often vague and patients may not realize that heat is the cause.
- Symptoms may include weakness, dizziness, headache, nausea and sometimes vomiting.
- Syncope due to standing for long periods in the heat (heat syncope) is common and may mimic
cardiovascular disorders.
- On examination, patients appear tired and are usually sweaty and tachycardic.
- Mental status is typically normal, unlike in heat stroke.
- The core body temperature is usually normal and, when elevated, usually does not exceed 40°C.
(29) (B) High serum LDL.

- High concentrations of LDL in the blood are a particularly important risk factor for atherosclerosis.
- The oxidative modification of LDL appears to be one mechanism by which LDL promotes
atherosclerosis; oxidized LDL may lead to atherogenesis via a number of mechanisms.
- Higher LDL concentrations have been associated with an increased incidence of coronary heart disease.
- Elevated plasma concentrations of oxidized LDL also are associated with coronary heart disease.
- Many investigators believe that the single most atherogenic agent is LDL.
(30) (A) Amoxicillin 2 gm before the surgery.

- The risk of infective endocarditis is generally considered to be the highest for dental procedures
that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the
oral mucosa; this does not include routine cleaning.
- All individuals at risk of developing infective endocarditis should establish and maintain a program of
oral health care including regular professional care, the regular use of manual or powered toothbrushes,
dental floss and other plaque removing devices.
- The primary antibiotic regimen for most patients, including those with prosthetic valves, is amoxicillin 2
gm orally 30-60 minutes before the procedure: a second dose is not necessary.
(31) (A) Constrictive pericarditis.
signs and symptoms of constrictive pericarditis, sud as iussmau s sig e rei s sign pulsus doxus, occur
due to reduced ventricular filling as also occurs in cardiac tarn nade Systemic venous co ngest on
(ascites dependent edema hepatomegaly and raised jugular venous pressure) Imonary venous Di
gestion dyspnea, cough orthopnea, paroxysmal noctur yspnea) 'ess commonly duced cardiac ou>
fatigue, hypotension and reflex tachycardia).
p d ventricular g ^pericardia knock) heard in ea lastole a; the lowe eft sternal border ial
dilatation 30% of cases have atrial fibrillation!
(32) (B) Abdominal aortic aneurysm.

eurysms are ab nai dilations of arteries caused by weakening ot the arterial wall usually associated ith
atherosclerosis
er ses i rauma vasculitis, cystic medial necrosis and postsurg.cal an stomotic disruption,
common es are syphilis n localizes bacterial or funga' infection, v really due to sepsis or
infective endocarditis, which weaken the arterial wall and lead to infected (mycotic)
aneurysms ng is the st lgest ns: factor
ictors nclude hypertension older age (the peak ncidence is between 70-80-year-old), family
SK
race (mo mmon es than in blacks) and male sex

m aortic aneurysm prese s lically in a variel of ways
ials bdominai aortic aneurysm have no symptoms sy
do occu paii is ue mos common compla n
na or ma not be associ ted /ith abdominal aortic aneurysm r pture or other associated symptoms.
(33) (B) Acute artery embolism.

a e la embol original - he heart and travel to the extremities the tower extremities are ed
nuch more frequently than the upper extremi es. l lie tnajori o thes< embol o r i patients v i
significant underlying cardiac d sease.
seve ity of the patient s under ying cardiac condition may ncrease the o: surgery and limit
the options available for restoring b ood flow to the ischemic extremity.
Potentia soi ce, of emboli fro m the heart incl ude left ventri cular thrombus formation following
myocardial infarction and atrial thrombus in patients with atrial fibrillation.
Up tc 75 i of patients w th embol in the lower extremities have a history of recent myocardial
infarction o' atria fi mllation.
(34) (B) Eat no more than 4 gm salt per day.

ents with heart failure can benefit from paying attention to exercise diet nd nutrition.
Restricted act ity romotes physical decond tion ng, so physica activ ty shou d be encouraged
Restriction of dietary sodium to 2-3 gm/day is recommended
Restr ct on of fluid intake to 2 tters/day is recommended for patients with evidence of
hyponatremia 13 ) mEq/dl) and or those wnose fluid status is d'ff cult to control despite
sodium restriction and
the use of high-dose diuretics
ic supplemen a o s recommended for patients with evidence of card a cachexia
(35) (B) Fast recovery.
- Cardiac syncope can occur in any posture.
- There is usually little warning and recovery is rapid.
- Frequently, syncope due to tachyarrhythmia occurs wi 1 no perception of palpitations.
Syncope should always be investigated due to the risk o hreatening ventricular tachyarrhythmia in any
patient with a histo v of myocardial infarction or he rt failure, or a family history of sudden, unexpected
death at a young age (<40-year-old).
- Such cases require urgent cardiological assessment
- Mechanical obstruction should always be excluded in patients with exertional syncope; however,
the majority of patients with conditions such as aortic stenosis or hypertrophic cardiomyopathy
experience syncope either at rest or during low-level activity.
- Finally, a detailed drug history should be obtained to determine whether the patient is taking
any drug associated with an acquired form of long QT syndrome.
(36) (A) Subarachnoid hemorrhage.

- Subarachnoid hemorrhage is sudden bleeding into the subarachnoid space.
- The most common cause of spontaneous bleeding is a ruptured aneurysm.
- Symptoms include sudden, severe headache, usually with loss or impairment of consciousness.
- High blood pressure is the leading cause of subarachnoid hemorrhage.
- Heavy lifting or straining can cause pressure to rise in the brain and may lead to rupture of an
aneurysm.
- Strong emotions, such as being upset or angry, can raise blood pressure and can subsequently
cause aneurysms to rupture.
- Blood thinners (such as warfarin), some medications and prescription drugs (including diet pills
that act as stimulants such as ephedrine and amphetamines) and harmful drugs like cocaine can
cause aneurysms to rupture and bleed.
- Diagnosis is achieved by CT or MRI. If the results of neuroimaging are normal, diagnosis is
achieved by CSF analysis.
- Treatments include supportive measures and neurosurgery or endovascular measures, preferably
in a referral center.
(37) (B) Phentolamine.

- Phentolamine is a potent competitive antagonist at both alphal and alpha2 receptors.
- Alphal-receptor antagonists have been used successfully in patients with benign prostatic hyperplasia.
- These drugs are particularly useful in patients who also have hypertension.
- It causes a reduction in peripheral resistance through the blockade of alphal receptors and possibly
alpha2 receptors on vascular smooth muscles.
- Since phentolamine potently blocks both alpha receptors, antagonism of presynaptic alpha2 receptors
may lead to enhanced release of norepinephrine from sympathetic nerves which may contribute to marked
cardiac stimulation via unblocked alpha adrenoceptors.
- Phentolamine is an agonist at muscarinic and HI and H2 histamine receptors.
(38) (A) This is not necessary.

- In the past, patients with nearly every type of congenital heart defect needed to receive antibiotics
one hour before dental procedures or operations on the mouth, throat, gastrointestinal tract, genital
organs, or urinary tract.
- Today, antibiotics before dental procedures are only recommended for patients with the highest risk of
infective endocarditis; e.g. those who have:
1- An artificial heart valve or who have had a heart valve repaired with artificial material.
2- A history of endocarditis.
3- Had a heart transplant due to abnormal heart valve function.
4- Certain congenital heart defects, including cyanotic congenital heart disease (birth defects with
oxygen levels lower than normal) that has not been fully repaired, including children who have had
surgical shunts and conduits.
5- A congenital heart defect that has been completely repaired with artificial material or a device within 6
months.
6- Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at
or adjacent to a prosthetic patch or prosthetic device.
(39) (A) Cardiac syncope.

- Syncope in patients with aortic stenosis is often associated with exertion.
In most such cases, syncope results from an inability to produce a compensatory increase in cardiac
output (due to the obstruction), which normally occurs in response to exercise-induced peripheral
i/asodilation.
- In others, the most probable cause of syncope is an exaggerated, more malignant form of a vasovagal
response.
This may have the same mechanism as vasovagal syncope, which is due to the stimulation of ventricular
mechanoreceptors.
- « bradyarrhythmia or ventricular tachyarrhythmia may also be a cause for syncope in some of these
oatients.
(40) (A) Mid-diastolic low pitched rumbling murmur.

Mitral stenosis is a narrowing of the mitral orifice that impedes blood flow from the left atrium to the eft
ventricle.
The almost invariable cause is rheumatic fever.
Common complications are pulmonary hypertension, atrial fibrillation and thromboembolism.
Symptoms are those of heart failure; signs include an opening snap and a diastolic murmur.
The diastolic murmur of mitral stenosis is of a low pitch, is rumbling in character and is best heard at the
apex of the heart with the patient in the left lateral position.
The murmur commences after the opening snap of the mitral valve and the duration of the murmur
correlates with the severity of the stenosis.
(41) (D) Tetralogy of Fallot.
- Infective endocarditis is a problem in patients with adult congenital heart disease.
- Tetralogy of Fallot is one of the most common manifestations of congenital heart disease, which
carries a high risk for the development of infective endocarditis.
- Certain subtypes of congenital heart diseases are known to increase the risk for infective endocarditis.
- Tetralogy of Fallot represents the largest proportion of infective endocarditis cases, followed by
bicuspid aortic valve problems.
- Repaired Tetralogy of Fallot often has residual aortic regurgitation; a subtype for aortic valve infective
endocarditis.
(42) (B) Isotonic exercise.

- Three types of muscular contraction or exercise can be applied as a stress to the cardiovascular system:
isometric (static), isotonic (dynamic or locomotory) and resistive (a combination of isometric and isotonic).
- Isometric exercise, defined as a muscular contraction without movement (e.g. handgrip), imposes
a greater pressure than volume load on the left ventricle in relation to the body's ability to supply oxygen.
- The cardiovascular response to isometric exercise is difficult to grade.
- Cardiac output is not increased to the same extent as in isotonic exercise because increased resistance in
active muscle groups limits blood flow.
- Isotonic exercise, defined as muscular contraction resulting in movement, primarily provides a
volume load to the left ventricle and the cardiovascular response is proportional to the size of the
muscle mass and the intensity of the exercise.
- Resistive exercise combines both isometric and isotonic exercises by using muscular contraction with
movement, as in free weight lifting.
(43) (D) Obesity.

- Obesity and hypertension are on the rise in the world.
- Hypertension seems to be the most common obesity-related health problem and visceral
obesity seems to be the major cause.
- In addition, the risk of dyslipidemia is increased with rising blood pressure and BMI.
(44) (A) Digoxin.

- In hypertrophic obstructive cardiomyopathy inotropic drugs should be avoided if possible.
- Nitrates and sympathomimetic amines should also be avoided, except in patients with concomitant
coronary artery disease.
- Digitalis should be avoided because glycosides are contraindicated, except in patients with uncontrolled
atrial fibrillation.
- Caution should be exercised with diuretics because of their potential adverse effects on the left
ventricular outflow gradient and ventricular volume.
- Appropriate medications include beta-blocker, calcium channel blocker and, rarely, diltiazem,
amiodarone and disopyramide.
- Antitussives may be administered as needed to prevent coughing.
(45) (B) Furosemide.
lents oensated heart failure are US' illy volume overloads
the tuation .n whic ? cardiogenic pulmonary edema develops wit ho significant
volume overload (e.g. with hypertensive emergency, acute aortic or mitral valvular insufficiency), fluid
oval e cs n leve symptoms and improve oxygenation
atients w th acut ecompensated heart failure and evidence voiume ov erload, regardless o the >gy,
sh eated ith V diuretics as part of their initial therapy; rare exceptions include
tents with se\ e ypotension or cardiogenic shock.
such ases the underlying cause for hemodynamic instability should be oughi and the patient
req re nemo namic and mechanical ventilatory support.
lents .in ao c stenosis with volume overload should be managed with diuretics but caution
ould be applied.
tients admitted with significant fluid overload should receive diuretic therapy without delay in
the £R or outpatient clinic; as early intervention may produce better outcomes.
rather than orai administration of diuretics is recommended because of the greater and more
sisterr drug bioavailability associated with this method.
(46) (A) Mitral stenosis.

volvement of the mitral valve is present in approximately 90% of individuals with rheumatic
irt disease
trial fibrillation is common in patients with mitral stenosis due to the elevation of left
atrial ssure and consequent left atrial enlargement.
he most common and often only symptom of mitral stenosis is dyspnea, which occurs in up to
70% o symptomatic patients
yspnea often results from the elevation in left atrial pressure, leading to reduced compliance of
the lungs and a decrease in vital capacity due to vascular congestion and interstitial edema.
he increased pulmonary pressures and vascular congestion can lead to hemoptysis as
blood-tinged sputum induced by the severe coughing associated with paroxysmal nocturnal dyspnea
or bronchitis, o as pink frothy sputum resulting from pulmonary edema.
ransient atrial fibrillation and infective endocarditis should also be considered when embolization
curs in patients with mitral stenosis who are in sinus rhythm.
W hen mitral stenosis is severe and the cardiac output is diminished, there is
vasoconstriction, esulting in pinkish-purple patches on the cheeks (mitral facies).
(47) (A) Beta-blockers.

heart failure, beta-adrenergic blockers are used for neurohormonal modification,
improvement o symptoms and left ventricular ejection fraction, the prevention of arrhythmia and
the control of ventricular rate.
T eatment with carvedilol, metoprolol succinate (controlled release) or bisoprolol decreases
mortality by at least 34% in patients with heart failure.
hese agents differ pharmacologically; however, they have all demonstrated benefits
and ny of the three can be used.
(48) (C) Systolic murmur is present throughout the pericardium.
- Coarctation of the aorta s a localized narrowing of the aortic lumen
»>ical physical examination findings include hypertension in the upper extremities, diminished or
delayed femoral pulses and low or unobtainable arterial blood pressure in the lower extremities.
An ejection systolic murmur of grade 2-3 of 6 is often present at the upper left sternal border.
It ft axilla and sometimes, most prominently, in the left nterscapular area.
- An apical ejectio1 click is present if a bicuspid aortic alv is also present
- Dilated intercostal collateral arteries may cause a cont nu us murmur in the intercostal spaces.
- Affected females may have Turner syndrome; a congen al disorder causing lymphedema of
the feet a webbed neck squa ely shaped chest, cubitus valgus and widely spaced n pples.
- leart size is normal unless heart failure supervenes
- Dilated intercostal collateral arteries may erode the 3rd-8 th ribs, causing rib notching, but
this is seldom seen before 5-year-old
(49) (A) Ventricular tachycardia.

Cannon waves are very large a-waves that occur when the right atrium contracts against a closed
tricuspid valve.
-They occur irregularly in complete heart block and ven'ric lar tachycardia; conditions that are
characterized by atrioventricular dissociation with random occasional simultaneous atrial and
entricular contractions
- Ventricular tachycardia may be reflected in symptoms such as syncope, palpitations and dyspnea
- With some exceptions, ventricular tachycardia is assoc'at d with an increased risk of sudden death.
(50) (B) The most effective diagnostic tool is ECG.

- The diagnosis of acute pericarditis is usually suspected ba ed on a history of characteristic pleuritic
chest pain and confirmed if a pericardial friction rub is present.
- Pericarditis should also be suspected In a atient with ersistent fever and pericardial effusion or
new unexplained cardiomegaly.
- Additional testing, which typically includes blood worl chest radiography, electrocardiography
and echocardiography, car support the diagnosis but s fr uently normal or unrevealing.
- The electrocardiogram is usually the most helpft 1 test n e evaluation of patients with suspected acute
pericarditis.
- Echocardiography is often normal, but can be an essential part of the evaluation if there is evidence of
an associated pericardial effusion and/or signs of cardiac tamponade.
(51) (A) Cerebrovascular accident.
- Atrial fibrillation is the most common cardiac arrhythmia that can have adverse
consequences related to a reduction in cardiac output and to atrial and a: iai appendage
thrombus formation (stroke and peripheral embolization)
In addition, affected patients may be at increased risk A ortality.
- The risk of stroke from atrial fibrillation that lasts longer than 24 hours is a major concern
and is usually addressed by prescribing a blood thinner (warfar n or dabigatran).
-The risk of embolic stroke is increased in patients older tha 75-year-old; so it is recommended that all
patients older than 75-year-old should be treated, unless a compelling contraindication is noted.
- Isrhemic stroke is a risk, not only for patients with a histoi of atrial fibrillation, but also for
patients without atrial fibrillation who have a history of coronary heart disease.
(52) (C) Atherosclerosis with narrowing of arteries.
Coronary atherosclerosis is often irregularly distributed in different vessels but typically occurs at
points turbulence (e.g. vessel bifurcations).
the atheromatous plaque grows, the arterial lumen progressively narrows, resulting in
ischemia often causing angina pectoris).
The degree of stenosis required to cause ischemia varies with oxygen demand.
The consequences of acute ischemia, collectively referred to as acute coronary syndromes, depend on
tie location and degree of obstruction and range from unstable angina to transmural infarction and
sudden death.
coronary artery spasm is a transient, focal increase in vascular tone, markedly narrowing the lumen id
reducing blood flow: symptomatic ischemia may result.
Marked narrowing can trigger thrombus formation, causing infarction or life-threatening arrhythmia.
(53) (A) Hydrochlorothiazide

Hyperuricemia is a relatively common finding in patients treated with a loop or thiazide diuretic and
may, over a period of time, lead to gouty arthritis.
Diuretics reduce urate excretion by both directly and indirectly increasing urate reabsorption and
decreasing urate secretion: the effect is dose dependent.
Treatment of asymptomatic hyperuricemia is not necessary.
If diuretic-induced gout occurs, it is usually treated with a urate lowering drug such as allopurinol.
Thiazide diuretics selectively enhance urate reabsorption.
(54) (B) Ventricular septal defect.

- In the case of a large ventricular septal defect that persists into late childhood without
intervention, the increase in pulmonary artery blood flow from persistent left-to-right shunting
results in the development of pulmonary vascular remodeling and histological evidence of
pulmonary arteriolar intimal and medial hypertrophy.
- The resulting elevated pulmonary artery vascular resistance leads to right ventricular pressure
overload and right ventricular hypertrophy.
When pulmonary vascular resistance exceeds systemic vascular resistance, the ultimate reversal of flow
with right-to-left shunting causes cyanosis: this condition is called Eisenmenger syndrome.
Dyspnea and fatigue in patients with ventricular septal defect result from either progressive left
ventricular overload due to the ventricular septal defect or from significant aortic regurgitation,
pulmonary hypertension or a double-chambered right ventricle.
Syncope is often exertional and caused by severe pulmonary hypertension, right ventricular outflow
obstruction due to a large prolapsing aortic valve cusp, or a large aneurysm of the membranous septum
or double-chambered right ventricle.
- Patients with ventricular septal defect may also present with arrhythmias or sudden death.
(55) (A) Hydrochlorothiazide.

Most patients with cirrhosis and ascites require both dietary sodium restriction and diuretics.
- When given the option of a more restrictive diet without diuretics or less restrictive diet with
diuretics, most patients choose the latter.
- The approach is to prescribe diuretics in combination with sodium restriction to all patients with
cirrhosis and clinically detectable ascites.
- The diuretic doses can be tapered or temporarily discontinued if weight loss is rapid.
Diuretic therapy typically consists of treatment with spironolactone and furosemide.
(56) (A) Adenosine.
- Short-term management treatment options can involve both pharmacologic and nonpharmacologic
measures.
- In most patients, the drug of choice for acute therapy is either adenosine or verapamil.
-The use of IV adenosine or the calcium channel blockers, verapamil, are considered safe and effective
therapies for controlling supraventricular tachycardia.
- The advantages of adenosine include a rapid onset of action
(typically within 10-25 seconds via a peripheral vein), short half-life (less than 10 seconds) and a high
degree of efficacy.
- The short half-life of this agent minimizes the severity of adverse effects, which include facial
flushing, chest tightness, dyspnea and transient sinus arrest and/or atrioventricular block.
- The use of adenosine is contraindicated in patients with sinus node dysfunction or second or third
degree block and should be used with caution in patients with severe obstructive lung diseases.
(57) (C) Diuretics.

- In general, three classes of drugs are considered first-line therapy for the treatment of hypertension in
elderly patients: low-dose thiazide diuretics (e.g. 12.5-25 mg/day of chlorthalidone), long-acting calcium
channel blockers (most often dihydropyridines) and angiotensin converting enzyme inhibitors or
angiotensin n receptor blockers.
- A long-acting dihydropyridine or a thiazide diuretic is generally preferred in elderly patients because
of their high efficacy in blood pressure lowering.
(58) (B) Increased peripheral vascular resistance.

- Because blood pressure= cardiac output x total peripheral vascular resistance, pathogenic
mechanisms must involve: increased cardiac output, increased total peripheral vascular resistance, or
both.
- In most patients with hypertension, cardiac output is normal or slightly increased and total peripheral
vascular resistance is increased.
- This pattern is typical of primary hypertension and hypertension due to primary aldosteronism,
pheochromocytoma, renovascular disease and renal parenchymal disease.
- The progression of essential hypertension begins with prehypertension in persons between
10-30-year-old (due to increased cardiac output) and then advances to early hypertension in persons
between 20-40-year-old (in which increased peripheral resistance is prominent), then to established
hypertension in persons 30-50-year-old and finally to complicated hypertension in persons
40-60-year-old.
(59) (A) P waves are caused by atrial depolarization.

- In a normal ECG:
- The P wave represents atrial depolarization.
- The PR interval includes the P wave as well as the PR segment; it is measured from the beginning of
the P wave to the first part of the QRS complex (which may be a Q wave or R wave).
- It includes time for atrial depolarization (the P wave) and conduction through the AV node and the
His-Purkinje system (which constitutes the PR segment).
- The QRS complex represents the duration of ventricular depolarization.
- The ST segment occurs after ventricular depolarization has ended and before repolarization has
begun; it is a time of electrocardiographic silence.
- The T wave represents the period of ventricular repolarization.
- The QT interval is primarily a measure of ventricular repolarization.
(60) (C) There is no need for prophylaxis in this patient.
Antibiotic prophylaxis to prevent bacterial endocarditis is no longer recommended in
patients with subvalvar aortic stenosis, except in those with a history of endocarditis or with a
repair that required prosthetic material or a device.
- In the latter, antibiotic prophylaxis is recommended for the first 6 months after the repair unless a
residual defect is present, in which case prophylactic antibiotics are continued beyond the six-month
period.
(61) (A) Aortic angiogram.

- This is a case of aortic dissection.
- The distinctive symptoms of an aortic dissection usually make the diagnosis obvious to doctors,
although the disorder produces a variety of symptoms that sometimes resemble those of other
disorders.
- In about 2/3 of people with aortic dissection, pulses in the arms and legs are diminished or absent.
- A dissection that is moving backward toward the heart may cause a murmur that can be heard
through a stethoscope.
- Aortic dissection is usually diagnosed using imaging techniques before the results of blood work are
interpreted.
- The choice of imaging techniques depends, in part, on whether or not the patient is
hemodynamicaliy stable.
- Aortography is still considered by some as the standard diagnostic test for aortic dissection.
(62) (B) By dilating coronary arteries.

- The heart is the pump that supplies blood, oxygen and other nutrients to the entire body.
- However, the heart itself is an organ that requires its own blood supply to maintain proper function.
- The coronary arteries supply blood, oxygen and nutrients to the heart muscle and the conduction
system.
- Because the left ventricle muscle mass exceeds that of the right ventricle and has a greater blood
and oxygen requirement, the coronary arteries supply more blood to the left ventricle.
- Coronary veins remove waste and oxygen poor blood from the myocardium, dumping blood back to
the coronary sinus.
- In the normal resting heart, unlike other organs, almost all the oxygen is extracted from the blood
during its passage through the arterioles and the capillary beds.
- Therefore, when faced with increased oxygen demand during exercise or stress, the heart is
dependent upon the coronary arteries to increase their diameter through dilatation.
(63) (B) Ventricular dysfunction.

- Sudden cardiac arrest and sudden cardiac death refer to the sudden cessation of organized cardiac
electrical activity with hemodynamic collapse, typically due to sustained ventricular
tachycardia/ventricular fibrillation.
- These events generally occur in patients with a structural heart disease (that may not
have been previously diagnosed), particularly coronary heart disease.
- The events is referred to as sudden cardiac arrest (or aborted sudden cardiac death) if an
intervention (e.g. defibrillation, cardioversion, antiarrhythmic drug) or spontaneous reversion restores
circulation.
- The event is called sudden cardiac death if the patient dies; however, the use of (sudden cardiac
death) to describe both fatal and nonfatal cardiac arrest persists by convention.
other structural cardiac disease, arrhythmias in the absence of structural heart disease
and noncardiac causes responsible for the remaining deaths.
(64) (B) Usually there is evidence of myocardial ischemia.

- Unstable angina belongs to the spectrum of clinical presentations referred to collectively as acute
coronary syndromes, which range from ST-segment elevation myocardial infarction (STEMI) to non-ST
elevation myocardial infarction (NSTEMI).
- Unstable angina is considered to be an acute coronary syndrome in which there is no detectable
release of the enzymes and biomarkers of myocardial necrosis.
- The term angina is typically reserved for pain syndromes arising from presumed myocardial ischemia.
(65) (B) 110-100 mmHg over 1-2 days.

- Severe hypertension (systolic blood pressure 2:180 mmHg or diastolic blood pressure >120 mmHg),
with no acute signs of end-organ damage, is often called hypertensive urgency.
- There is no proven benefit from rapid reduction of the blood pressure in patients with severe
asymptomatic hypertension and myocardial or cerebral ischemia can be precipitated by overly rapid
blood pressure lowering.
- The initial goal of reducing the blood pressure to <160/100 mmHg over several hours to days with
conventional oral therapy.
- The optimal rapidity with which blood pressure is lowered is controversial and must take into
consideration the individual patient's risk of an ischemic event.
(66) (D) Exercise should be carried out daily to produce beneficial effects.
- Aerobic training has beneficial effects on serum lipoprotein concentrations, body composition and
aerobic capacity and improves hemostatic factors associated with thrombosis.
- The effect of aerobic training in serum lipoprotein is to lower serum levels of total cholesterol, LDL,
VLDL and triglycerides and a higher concentration of HDL.
- The use of combined aerobic and resistance training to reduce the risk of cardiovascular disease
development, as defined by a decrease in serum CRP concentration in healthy humans, is encouraged.
- Long-term exercise programs cause a greater decrease in abdominal fat than lower-body fat and help
maintain these lower levels.
- Physical activity should be performed for approximately 30 minutes, 5-7 days/week, to prevent weight
gain and to improve cardiovascular health.
- There appears to be a dose-dependent effect of physical activity on weight loss and substantially
greater amounts of exercise are necessary to produce significant weight loss in the absence of a
calorically-restricted diet.
(67) (C) No needs to give prophylaxis.

- Antibiotics are no longer recommended for endocarditis prophylaxis for patients undergoing
genitourinary or gastrointestinal tract procedures.
- For high risk patients who undergo gastrointestinal or genitourinary procedures at a time of ongoing
gastrointestinal or genitourinary infection, antibiotic coverage for enterococcal bacteremia should be
provided with amoxicillin or ampicillin or, in the patient unable to tolerate these drugs, vancomycin.
(68) (B) Acute mitral regurgitation.
- Severe mitral regurgitation can occur early in the course of ST elevation myocardial infarction (STEMI).
- Three mechanisms may be responsible for the mitral regurgitation and a transesophageal
echocardiogram may be necessary to confirm the etiology:
1- Severe left ventricular dysfunction and dilatation, causing annular dilatation of the valve and
subsequent regurgitation.
2- Myocardial infarction of the inferior wall, producing dysfunction of the papillary muscle that may
normally respond to coronary intervention.
- The posteromedial papillary muscle is most frequently involved because of its single blood
supply through the posterior descending coronary artery.
• Complete transection of the papillary muscles is rare and usually results in immediate pulmonary
edema, cardiogenic shock and death.
- Patients with pulmonary edema most commonly complain of shortness of breath and profuse
diaphoresis.
3- Myocardial infarction of the papillary muscles, producing sudden severe pulmonary edema and
cardiogenic shock (intra-aortic balloon pump, coronary angiography and early surgery may improve
patient survival rate).
The incidence of clinically evident systemic embolism after myocardial infarction is lower than 2%.
- This incidence increases in patients with anterior wall myocardial infarction.
- The overall incidence of mural thrombus after myocardial infarctionis approximately 20%.
Large anterior myocardial infarction may be associated with mural thrombus in as many as 60% of
patients.
- Most emboli arise from the left ventricle as a result of wall motion abnormalities or aneurysms.
Atrial fibrillation in the setting of ischemia may also contribute to systemic embolization.
The most common clinical manifestation of embolic complications is stroke, although patients may
have ' ischemia, renal infarction, or intestinal ischemia.
- Most episodes of systemic emboli occur in the first 10 days after acute myocardial infarction.
(69) (B) Dobutamine.

- Dobutamine concentrate is indicated in adults who require inotropic support in the treatment of low
jutput cardiac failure associated with myocardial infarction, open heart surgery, cardiomyopathies, septic
shock or cardiogenic shock.
- Dobutamine concentrate can also increase or maintain cardiac output during positive end expiratory
pressure ventilation.
Inotropic agents, including dobutamine, do not improve hemodynamics in most patients with a
mechanical obstruction that hinders either ventricular filling or outflow, or both.
The inotropic response may be inadequate in patients with markedly reduced ventricular
compliance: sucn conditions are present in cardiac tamponade, valvular aortic stenosis and
idiopathic hypertrophic subaortic stenosis.
Dobutamine is contraindicated in patients with idiopathic hypertrophic subaortic stenosis.
(70) (A) Spironolactone.
- The optimal treatment of idiopathic adrenal hyperplasia consists of mineralocorticoid receptor
blockade with spironolactone, or eplerenone for medical therapy of a unilateral adrenal adenoma.
- The goals of therapy are the same as for unilateral adenoma: normalization of the serum potassium leve
I in hypokalemic patients, normalization of the blood pressure and reversal of the effects of
hyperaldosteronism on the heart.
- The recommendation for patients with bilateral adrenal hyperplasia is treatment with drug therapy, not
adrenalectomy.
- Blood pressure control is often inadequate with subtotal adrenalectomy and the risks associated with
bilateral adrenalectomy (including the need for lifelong glucocorticoid and mineralocorticoid
replacement) outweigh the potential benefits.
(71) (A) Propranolol.

- Blood pressure treatment appears to reduce the overall prevalence of headache in general.
- Beta-blockers, particularly metoprolol, propranolol and timolol, are effective for migraine prevention.
- Lower quality evidence suggests, but does not establish that calcium channel blockers, angiotensin
converting enzyme inhibitors and angiotensin D receptor blockers are effective for migraine prevention.
- There are no clinical trial data for the use of thiazide diuretics in migraine prevention.
(72) (B) Aortic sclerosis.

- Aortic valve thickening (sclerosis) without stenosis is common in elderly adults.
- Aortic valve sclerosis is important clinically because it can progress to aortic stenosis and is a marker for
increased risk of cardiovascular conditions.
- Aortic sclerosis is an asymptomatic condition that is generally detected either as a systolic ejection
murmur on physical examination or as an incidental finding on ECG.
- Aortic sclerosis found on physical examination, in the absence of stenosis, may be associated with a
mid-systolic ejection murmur, which is usually best heard over the right second interspace.
- In general, the murmur is brief and not very loud.
- A normal carotid pulse and normal heart sound S2 suggest the absence of aortic stenosis.
(73) (A) Left ventricular dilatation.

- The first symptoms of dilated cardiomyopathy are becoming short of breath during exertion and
tiring easily.
- They result from a weakening of the heart's pumping action, which is called heart failure.
- Heart failure is a syndrome of ventricular dysfunction.
- Left ventricular failure causes shortness of breath and fatigue, orthopnea and paroxysmal nocturnal
dyspnea.
- Right ventricular failure causes peripheral and abdominal fluid accumulation, ankle swelling and
fatigue. Sometimes patients also feel a sensation of fullness in the abdomen or neck, hepatic congestion
causing right upper quadrant abdominal discomfort and stomach and intestinal congestion causing
anorexia and abdominal bloating.
- The ventricles can be involved together or separately.
(74) (D) No prophylaxis.
- Endocarditis prophylaxis is no longer recommended for patients with a prolapsed mitral valve.
although mitral valve prolapse is associated with an increased risk of endocarditis, there are no
convincing data that antibiotic prophylaxis is effective in preventing episodes of endocarditis.
In ective endocarditis can occur in spite of antibiotic prophylaxis and many cases of failure of
prophylaxis have been reported with bacteria sensitive to the antibiotic given preventively.
rthermore, transient everyday episodes of bacteremia account for a large proportion of cases of
endocarditis.
(75) (B) Hypertension.

H pertension, which promotes the formation of atherosclerotic lesions, is the single most important
treatable risk factor for stroke.
pproximately 60% of strokes in men and women of all ages are attributed to hypertension, pertension
is associated with an increased likelihood of subclinical or silent stroke, which in turn has linked with an
elevated risk of vascular dementia and recurrent stroke, addition to mean blood pressure elevation,
there is mounting evidence that visit-to-visit variability in /stolic blood pressure is itself an independent
risk factor for stroke.
(76) (A) Myocardial ischemia.

isodes of transient ischemia during Holter monitoring are diagnosed by a sequence of ECG changes la
include a flat or downward sloping ST depression of at least 1 mm, with a gradual onset and offset tna
lasts for at least one minute.
Although ST segment depression during Holter monitoring has not always been accepted as
unequivocal dence of myocardial ischemia, recent studies have shown an excellent correlation between ST
ession recorded during Holter monitoring and other simultaneous objective evidence of ischemia
oerfusion scintigraphy, radionuclide cardioangiography and hemodynamic monitoring.
(77) (A) Exercise and weight reduction.

iie treatment of hypertension should involve nonpharmacologic therapy (also called lifestyle
odification) alone or in concert with anti hypertensive drug therapy.
eight loss in obese individuals can lead to a significant fall in blood pressure.
The decline in blood pressure induced by weight loss can occur in the absence of dietary sodium
estriction, but even modest sodium restriction may produce an additive antihypertensive effect. IUS, an
increase in physical activity should always be added to dietary changes in order to provide mon sustained
weight loss
R gular aerobic exercise and resistance training are usually accompanied by a fall in blood pressure, ich
can be beneficial in the treatment of hypertension.
addition, regular exercise can delay, if not stop, the development of hypertension.
All individuals should be advised to gradually increase their levels of physical activity.
- Nutritional education should continue to promote the existing recommendations for a
heart-healthy diet, which emphasize eating a variety of fruits and vegetables, increasing unsaturated
fatty acid and fiber intake and reducing saturated fat intake.
- This type of dietary pattern has been shown to help prevent ischemic heart disease by favorably
affecting several coronary risk factors.
(79) (A) Left heart failure.

- In heart failure due to left ventricle dysfunction, cardiac output decreases and pulmonary venous
pressure increases.
- When pulmonary capillary pressure exceeds the oncotic pressure of plasma proteins (about 24
mmHg), fluid extravasates from the capillaries into the interstitial space and alveoli, reducing pulmonary
compliance and increasing the effort of breathing.
- Possible symptoms: exertional dyspnea, which precedes orthopnea and paroxysmal nocturnal
dyspnea, fatigue and symptoms secondary to pulmonary edema, including cough (sometimes with pink
froth), hemoptysis and wheeze (cardiac asthma).
- Most common signs: tachycardia, basal crackles (the worse the heart failure the more widespread the
crackles) and a gallop heart rhythm (a 3rd heart sound and/or a 4th heart sound).
(80) (A) Digitalis toxicity.

- Clinical digoxin toxicity represents a complex interaction between digoxin and various electrolyte and
renal abnormalities.
- A patient with normal digoxin levels (0.5-2 ng/ml) but renal insufficiency or severe hypokalemia may
have more serious cardiotoxicity than a patient with high digoxin levels and no renal or electrolyte
disturbances.
- The most common precipitating cause of digitalis intoxication is depletion of potassium stores, which
often occurs in patients with heart failure as a result of diuretic therapy and secondary
hyperaldosteronism.
- Visual aberration often is an early indication of digitalis toxicity.
- Yellow-green distortion is most common, but red, brown, blue and white distortion also occurs.
- Drug intoxication also may cause snowy vision, photophobia, photopsia, decreased visual acuity,
yellow halos around lights (xanthopsia) and transient amblyopia or scotomata.
(81) (B) Atrial septal defect.

- Bacterial endocarditis can occur with many heart defects but is most common in aortic valve lesions,
patent ductus arteriosus (unrepaired). Tetralogy of Fallot, ventricular septal defects, coarctation of the
aorta and mitral valve prolapse with mitral regurgitation.
- Endocarditis rarely occurs in isolated secundum atrial septal defects or pulmonic stenosis.
- Endocarditis may occur in most congenital heart lesions after surgical repair with the exception of
completely repaired ventricular septal defects and patent ductus arteriosus 6 months after the surgery.
(82) (B) It should be treated seriously as it might lead to myocardial infarction.
Unstable angina and acute non-ST elevation myocardial infarction (NSTEMI) are medical emergencies
requiring the simultaneous application of multiple therapies.
• After the emergent period, other therapies may need to be started.
Treatment is designed to relieve distress, interrupt thrombosis, reverse ischemia, limit infarct size,
reduce cardiac workload and prevent and treat complications.
- Acute coronary syndrome is a medical emergency; its outcome is greatly influenced by rapid
diagnosis and treatment.
- 50% of people with unstable angina have evidence of myocardial necrosis based on elevated cardiac
serum markers such as creatine phosphokinase-MB and troponin T or I and thus have a diagnosis of
non-ST elevation myocardial infarction.
(83) (B) Remove the metformin.

- Biguanide therapy with metformin in patients with diabetes mellitustype 2 can lead to lactic acidosis.
Despite its rarity, lactic acidosis related to metformin use remains a concern because of the high
fatality
rate of the condition.
- Most cases have occurred in patients with shock, tissue hypoxia, or in the presence of several other
predisposing conditions: all are relative or absolute contraindications to metformin therapy.
- Of these factors, impaired renal function is of greatest concern and heart failure the least worrisome.
- Symptoms of lactic acidosis are nonspecific and may include anorexia, nausea, vomiting, abdominal
pain, lethargy, hyperventilation and hypotension.
- More serious lactic acid accumulation occurs with superimposed shock or in the presence of
conditions that predispose metformin toxicity.
(84) (A) Increased HDL serum level.

- HDL is positively associated with a decreased risk of coronary heart disease.
- An HDL of 60 mg/dl or greater is a negative (protective) risk factor.
- On the other hand, a high-risk HDL level is described as one that is below 40 mg/dl.
- Randomized, controlled clinical trials have demonstrated that interventions to raise HDL levels are
associated with reduced coronary heart disease events.
(85) (A) Decreased oxygen supply to the heart

- Premature ventricular contractions may be associated with stress, fatigue, excess caffeine, alcohol or
nicotine consumption, lack of oxygen to tissues or organs (ischemia), low blood oxygen levels (hypoxia),
electrolyte imbalance, or, in particular, low potassium levels in the blood (hypokalemia).
- Both prescription and illicit drugs may be associated with premature ventricular contraction.
- The arrhythmia may also be a symptom of a heart attack or other cardiac disease.
(86) (A) Creatine phosphokinase.
- Elevations in total serum creatine phosphokinase lack specificity for cardiac damage, but can be
approved with measurement of the MB fraction
- The normal creatine phosphokinase level range varies considerably; a two fold or greater increase in
the creatine phosphokinase concentration is required for a positive myocardial infarction diagnosis.
• When cardiac troponin data are available, creatine phosphokinase -MB should not be used for the
diagnosis of acute myocardial infarction.
- Assays to determine creatine phosphokinase-MB level can be performed easily and rapidly.
- Since creatine phosphokinase levels return to baseline 36-48 hours after infarction, resampling can be
used to detect reinfarction and because cardiac troponin does not normalize as rapidly, it was initially
suggested that monitoring creatine phosphokinase-MB might be of value in this area.
- It is now clear that cardiac troponin increases rapidly, albeit from an abnormal baseline in patients
with reinfarction.
- Therefore, the use of cardiac troponin monitoring has been recommended for all acute myocardial
infarction diagnosis, including reinfarction.
(87) (D) Stable angina is associated with loss of consciousness.

- Stable angina pectoris, or stable angina, refers to chest discomfort that occurs predictably and
reproducibly at a certain level of exertion, usually persists no more than a few minutes and is relieved
with rest or nitroglycerin.
- Most patients with ischemic heart disease will experience angina as part of the clinical
manifestations of the disease.
- Symptoms are exaggerated when exertion follows a meal or occurs in cold weather; for example
walking into the wind or first contact with cold air after leaving a warm room may precipitate an attack.
- Symptom severity is often classified by the degree of exertion resulting in angina.
(88) (B) Unstable angina appears to be independent of activity level but stable is not.
- Unstable angina differs from stable angina in that the discomfort is usually more intense and easily
provoked and ST-segment depression or elevation may be seen on an ECG.
- Otherwise, the manifestations of unstable angina are similar to those of other conditions of
myocardial ischemia, such as chronic stable angina and myocardial infarction.
- Symptoms that occur at rest and suddenly become more frequent, severe, or prolonged are a change
from the usual pattern of angina and usually do not respond to rest or nitroglycerin.
(89) (D) Seizure.

- Severe hypokalemia is defined as a level less than 2.5 mEq/L
- Severe hypokalemia is not linked with any specific symptoms, but may cause:
1- Muscle myalgia or muscle pain.
2- Disturbed heart rhythm including ectopy (disturbance of the electrical conduction system of the
heart where beats arise from the wrong part of the heart muscle).
3- Serious arrhythmias (electrical activity faster or slower than normal).
4- Greater risk of hyponatremia (an electrolyte disturbance in humans when the sodium concentration
in the plasma decreases below 135 mmol/L) with confusion and seizures.
ECG changes in hypokalemia:
1 T-wave flattening.
2- U-wave: (additional wave after the T wave).
3- ST segment depression.
ECG changes in hyperkalemia:
1- Peak T wave.
2 Wide QRS complex (in severe case).
3- Prolonged PR interval (in severe case).
4- Loss of P wave.
(90) (D) Respiratory acidosis.

Hypokalemia is frequently encountered in clinical medicine and has been estimated to occur in
approximately 20% of patients admitted to general internal medicine services.
- Symptoms may be absent, identified only on routine electrolyte screening, or may range from
neuromuscular weakness, rarely progressing to frank paralysis or sudden cardiac death.
Usually, correction of hypokalemia is not difficult, but if therapy is not appropriate,
symptoms may worsen with potentially severe, even lethal, consequences.
Hypokalemia can profoundly affect systemic acid-base homeostasis through its effects on multiple
components of renal acid-base regulation.
- The most common abnormality is metabolic alkalosis.
In rare cases, severe hypokalemia leads to respiratory muscle weakness and the development of
respiratory acidosis.
- In patients with hypokalemia as a result of renal tubular acidosis, the concomitant development of
respiratory acidosis can be life-threatening.
Hypokalemia produces characteristic changes in ECG readings, although these changes are not seen in
all patients.
There is depression of the ST segment, a decrease in the amplitude of the T wave and an increase in
the amplitude of U waves, which occur at the end of the T wave (waveform 1).
U waves are often seen in the lateral precordial leads V4-V6.
Hypokalemia also prolongs the QT interval.
(91) (B) 50%.

An individual who has had a previous attack of rheumatic fever and in whom group A beta-hemolytic
streptococcus pharyngitis develops, is at high risk of a recurrent attack of rheumatic fever.
- A recurrent attack can be associated with worsening of the severity of any rheumatic heart disease
that developed after a first attack, or less frequently with the new onset of rheumatic heart disease in
individuals who did not develop cardiac manifestations during the first attack.
Prevention of recurrent episodes of group A beta-hemolytic streptococcus pharyngitis is the most
effective method of preventing the development of severe rheumatic heart disease.
The proportion of patients with a primary episode of acute rheumatic fever that have recurrent
attacks varies depending upon compliance with secondary prophylaxis; in areas where compliance is
poor, up to 45% of cases of rheumatic fever are recurrent episodes.
(92) (B) Low voltage.
- This is a case of pericardial effusion.
- ECG findings suggestive of pericardial effusion are low QR5 voltage and electrical alternans.
- Low voltage is usually defined as a QRS complex <5 mm (0.5 mV) in all of the limb leads.
- This may or may not be accompanied by low voltage in the precordial leads, defined as total QRS
amplitude of <10 mm in V1-V6.
- It has been suggested that low QRS voltage may be a manifestation of cardiac tamponade and
pericardial inflammation, rather than pericardial effusion alone.
- ECG changes during pericarditis include: diffuse ST elevation, PR depression followed by T-wave
intervention and low voltage.
(93) (A) Aspirin daily.
- The low prevalence of asymptomatic carotid stenosis, low risk of stroke in patients with asymptomatic
carotid stenosis and the variability of surgical outcomes dependent upon surgeon and center, are factors
that influence recommendations for population screening for carotid stenosis.
- Patients with evidence of carotid artery atherosclerosis benefit from risk factor intervention,
including management of hypertension, smoking cessation and the use of statin drugs.
- Low-dose aspirin therapy may be beneficial for high-risk individuals.
- It is reasonable to perform carotid endarterectomy in asymptomatic patients who have more than 70%
stenosis of the internal carotid artery if the risk of perioperative stroke, myocardial infarction and death
during the procedure is low.
(94) (A) Constrictive pericarditis.

- Patients with constrictive pericarditis typically present with one or both of the following
constellations of symptoms:
- Symptoms related to fluid overload, ranging from peripheral edema to anasarca.
- Symptoms related to diminished cardiac output in response to exertion, such as fatigability and
dyspnea on exertion.
- The vast majority of patients with constrictive pericarditis display elevated jugular venous pressure on
physical examination.
- Other important but less common features observed during physical examination include pulsus
paradoxus, Kussmaul's sign, a pericardial knock, edema, ascites and/or cachexia.
(95) (A) Red meat.

- A diet low in fats and cholesterol can lower the LDL cholesterol level.
- Experts recommend limiting calories from fat to no more than 25-35% of the total calories consumed
over several days.
- The type of fat consumed is also important.
Fats may be saturated, polyunsaturated or monounsaturated.
Saturated fats increase cholestero e /e1s more that othe f rms of at
- Saturated tats should pro vide no more than 7-10% of total calories consumed each day.
- Polyunsaturated fats and monounsaturated fats m <y help decrease levels of triglycerides and LDL
cholesterol in the blood
- Large amounts of saturated fats occur in meats egg yolk full-ât dairy products some nuts
(such as macadamia nuts) and coconut.
egetable oils contain smaller amounts of saturated fat, but only some vegetabl oils are truly low in
saturated fats.
Eating lots of fruits, vegetables and grams, which are naturally low in at and contain no cholesterol, is
recommended.
Also recommended are foods rich in soluble fiber, which binds fats in the intes* ne and helps
lower he cholesterol level in blood. Such foods include oat bran, oatmeal, beans peas rice bran
barley, citrus fruits, strawberries and apple pulp.
(96) (A) Amiodarone should be included in the management.

iniodarone has emerged as the leading antiarrhythrnic therapy for the termination and prevention
ventricular arrhythmia in different climca^ settings because of its proven efficac, and safety, in patients
with shock-refractory out-of-hospital cardiac arrest and hemody namically destabilizing entricular
arrhythmia, amiodarone is the most effective drug available to ass st in resuscitation though the superior
ty of the transvenous implantable cardioverter defibr la tor over amiodarone as been well established in
the preventive treatment of patients at high risk of life-threatening tricular arrhythmias amiodaron (if
used with beta-blockers) s the most effective antiarrhythrnic in preventin mp antable cardioverter
defibrillator shocks and treat electrical storm, the pharma okmetics and lie electrophysiologk profile of
amiodarone are complex and its p imal and sat use requires careful patient surveillance with respect to
potential adverse effects.
(97) (D) An echocardiogram should be carried out.
ifective endocardi s is a potential complication ot mitral valve prolapse.
tients with mitra. valve prolapse syndrome whom have mur rs and/or thickened redundant leaflets
on echocardiograpn should receive antibiotic prophylaxis against endocarditis
(98) (A) Angiotensin converting enzyme inhibitors.

lgiotensin conver ing enzyme inhibitors prevent or delay niicrovascular and macrovascular plications
of iabe.es and are recommended as first-1 ne antihypertens ve agents n pat ents i diabetes
giotensin conver ng enzyme inhibitors elay the progress on of diabetic kidney disease and ore
elective tha other medications in delaying the onset of dney failure patients who e hypertensioi and
diabetes mellitus typel with macroalbununuria
(99) (C) Nifedipine.

g-te m vasodilator he. apy with nifedipine reduces or delays the nee for aortic-valve replacemen
nptO'iiatic itients with severe aortic regurgitation and normal left /ei tricular systol e functio yea
lagnos s o* . tien with severe aortic .egj gitation e . eplacement was no red n y pa lent treated witl
redipne compare to those treated w digoxin 6 e rs s determined by actuarial analysis valve
replacement was equ ed significantly less n pa s reated with nifedipine
lent un vent valve replacement independent of which drug was used had a fall in left icular ejection
âction from b2% at baseline to 46% before surgery.
(100) (B) Asphyxia.
- Ludwig's angina is a bilateral infection of the submandibular space that begins in the floor of the
mouth, most commonly related to the second or third mandibular molar teeth.
It is an aggressive, rapidly spreading (woody) or brawny cellulitis without lymphadenopathy.
- Airway compromise is a potential complication and requires careful monitoring and rapid
intervention to prevent asphyxia and aspiration pneumonia.
- Various aerobic and anaerobic microorganisms and less often fungi, have been implicated in the
etiology of Ludwig s angina, including oral flora such as streptococci and staphylococci.
- Early recognition and the use of parenteral antibiotics can prevent mortality and morbidity.
- Ludwig's angina s a progressive cellulitis that often results in death by asphyxia.
Ludwig s angina can be complicated by subsequent deep neck infection.
(101) (C) Renal disease.

- Secondary hypertension is potentially curable because it s most commonly caused by the stenosis
(narrowing) of the renal arteries.
- Less often, secondary hypertension can be caused by tumors of the adrenal gland that secrete
hormones acting to increase the blood pressure.
- Renal parenchymal disease is the most common cause ot secondary hypertension.
- Hypertension associated with renal parenchymal disease occurs as a complication of a wide
variety of glomerular and interstitial renal diseases and may accelerate the decline in renal function
if inadequately controlled.
- Renal parenchymal hypertension probably represents th< combined interactions of multiple
independent mechanisms: potential factors include impai ed sodium handling leading to volume
expansion, perturbations of the renin-angiotensin system alterations in endogenous vasodepressor
compounds and the increased activity of vasoactive substances.
(102) (A) ST changes.

- Chest pain is the cardinal symptom of pericarditis It is usually precordial or retrosternal with referral to
the trapezius ridge, neck, left shoulder, or arm.
- The quality of the pain is usually pleuritic, but it ranges from sharp to dull, aching,
burning, or pressing and the intensity varies from barely perceptib e to severe.
- The pain is worse during inspiration, when lying flat, dur ng swallowing, or with body motion and it
may be re ieved by leaning forward while seated.
The typical progression of ECG changes in patients with acute pericarditis is:
Stage 1 is seen in the first hours to 4 days and is characterized by diffuse ST elevation with reciprocal
ST depression in leads aVR and VI (waveform 1). There is Iso an atrial current of injury, reflected by elevat
on of the PR segment in lead aVR and depressio of the PR segment in other limb leads and in the left
chest leads; primarily V5 and V6.
Stage 2 is typically seen n from day 5 and is characterized by normalization of the ST and PR segments
Stage 3 is characterized by the development of diffuse T wave inversions, generally after the ST
segments have become isoelectric.
- Stage 4 is represented by the normalization of the ECG or indefinite persistence of T wave inversions
(chronic pericarditis).
(103) (A) Hydrochlorothiazide.
The special advantage of using diuretics includes a reduction in the edema and expanded plasma
volume that are often associated with hypertension and cardiovascular disease.
Diuretics are one of the 5 major classes of antihypertensive agents recommended for the initial drug
therapy of hypertension.
However, treatment of hypertension with diuretics is currently controversial, because of their
potentially adverse effects on the cardiovascular risk profile, including deterioration in glucose control,
especially in patients with impaired glucose tolerance.
Additionally there is concern about the high rate of mortality associated with diuretic therapy and
diabetes mellitus.
- The metabolic side effects on glucose metabolism and lipid profile are related to the type of
diuretic and its dosage.
The adverse effects of thiazides on insulin action, glycemia and lipid profile are dose dependent and
can be minimized by using low doses.
In contrast, indapamide does not seem to alter glucose metabolism or lipid profile.
The choice of diuretic depends on concomitant diseases.
(104) (B) Angiotensin converting enzyme inhibitors.

- Angiotensin converting enzyme inhibitors therapy leads to symptomatic improvement, reduced
hospitalization and enhanced survival in patients with heart failure and systolic dysfunction.
Therefore, angiotensin converting enzyme inhibitors are an important component of standard heart
failure therapy in patients with current or prior symptoms of heart failure and depressed left ventricular
systolic function.
Angiotensin converting enzyme inhibitors inhibits aldosterone which, if present in high concentrations,
causes modification of the cardiac myocytes in the long term.
(105) (A) Bacterial endocarditis.

Infective endocarditis is an infection of the endocardium, usually with bacteria (commonly, streptococci
and staphylococci) or fungi.
- It causes fever, heart murmurs, petechiae, anemia, embolic phenomena and endocardial vegetations.
Vegetations may result in valvular incompetence or obstruction, myocardial abscess, or mycotic
aneurysm. Endocarditis can occur at any age.
- Men are affected about twice as often.
- IV drug abusers and immunocompromised patients are at highest risk.
Specific drugs of abuse may also be risk factors for the development of endocarditis, which often
involves the right side of the heart.
- The pathogenic mechanisms accounting for an apparent association between injection drug use and
right-sided endocarditis remain to be elucidated.
- Diagnosis requires demonstration of microorganisms in blood and usually echocardiography.
- Treatment consists of prolonged antimicrobial treatment and sometimes surgery.
(106) (E) It is more dangerous in elderly patients than an elevated diastolic pressure.
- Systolic hypertension is a major health and economic problem within our aging society.
- Increased arterial stiffness, especially of the large arteries, is the vascular phenotype of
systolic hypertension.
- Elevated systolic blood pressure has a greater association with cardiovascular morbidity and mortality
than diastolic blood pressure.
- The treatment of systolic hypertension in the elderly should be based on
non-pharmacological measures and medical therapy if the systolic hypertension cannot be
controlled by conservative therapy alone.
- In the very elderly, lowering blood pressure to a level of 150/80 mmHg is still very beneficial.
- Antihypertensive therapy needs to be tailored in the elderly because of comorbid conditions, such as
ischemic heart disease, heart failure, atrial fibrillation, renal insufficiency and diabetes.
- Angiotensin converting enzyme inhibitors or angiotensin II receptor blockers should be considered in
combination with diuretics or with a dihydropyridine calcium antagonist.
- Beta-blockers seem to be less effective for cardiovascular disease protection in comparison with other
antihypertensive drug classes, such as diuretics, dihydropyridines, angiotensin converting enzyme
inhibitors or angiotensin II receptor blockers.
- A major effort is required to reduce the therapeutic inertia and increase therapeutic adherence for
better blood pressure control in the elderly with systolic hypertension.
(107) (E) A Q wave should be observed in the ECG reading.

- When myocardial blood supply to a region of the heart is abruptly reduced or cut off, a sequence of
injurious events occur, beginning with subendocardial or transmural ischemia, followed by necrosis and
eventual fibrosis (scarring), if the blood supply is not restored in an appropriate period of time.
- Rupture of an atherosclerotic plaque followed by acute coronary thrombosis is the most common
mechanism of acute myocardial infarction.
- The ECG changes reflecting this sequence usually follow a well-known pattern depending
on the location and size of the myocardial infarction.
- Myocardial infarction resulting from total coronary occlusion results in more homogeneous tissue
damage and is usually reflected by a Q-wave myocardial infarction pattern on the ECG.
- Myocardial infarction resulting from subtotal occlusion lead to more heterogeneous
damage, which may be evidenced by a non Q-wave myocardial infarction pattern on the ECG.
- A 2/3 of myocardial infarction presentations to ER evolve to non-Q wave myocardial infarctions; most
having ST segment depression or T wave inversion.
(108) (B) Epinephrine.

- In pediatrics resuscitation: patients in asystole or with pulseless electrical activity should receive CPR
and epinephrine (IV / intraosseous administration is preferred over endotracheal administration).
- The administration of epinephrine is the intervention most likely to be of benefit when basic life
support and volume resuscitation do not restore effective circulation.
- Atropine is no longer routinely recommended in patients with cardiac arrest and is primarily indicated
for vasovagal induced bradycardia or the treatment of primary atrioventricular block.
- For adults in asystole the only 3 drugs recommended are epinephrine, vasopressin and atropine.
- In spite of full vagolytic doses of atropine (0.03 mg/kg) and high-dose epinephrine (0.20 mg/kg), or
the use of vasopressin 40 units, few patients survive to leave the hospital neurologically intact.
(109) (A) ST segment elevation in all leads.
acute pericarditis, the ECG typically shows ST segment elevation in all leads with an upwa d
concavity of the elevation (so called smiling face), e PR segment is depressed
Hike my oca rd a infarction, there is no reciprocal change and T waves a e ot inverted, e pattern
of ST segment elevation is important in the diagnosis of ac ite pericarditis Ti e ST segment e evation
that occurs during acute pericarditis is usually concave compared with the ex appearanc ot the ST
segment that occurs during the acute injury stage or a myocardial infarction lother .mportan feature
of ac te pericarditis is the widespread ST-segmen e evation no esponding to any specific arterial
territory, which usually occurs n associati n ith acute ocardial infarctior
i addition, reciprocal changes are absent in acute pericarditis, although they are frequently
found acute myocardial infarction.
(110) (D) A patient who has undergone cardiac catheterization.

almost all patients who receive an intracoronary stent, the combination of aspirin and a second
platelet agent, eterred to as dual antiplatelet therapy is used for a period of time after stenting, hile
the optimal duration of dual antiplatelet therapy after stenting is not known, most of the Jence
suggests that 12 months is a reasonable goal.
al antiplatelet therapy is typically the combination of aspirin plus dopidogrel, tidopidine,
prasugrel, ticagrelor, all of which are referred to as platelet P2Y12 receptor blockers
ie risk of coronary artery stent thrombosis and its consequences of myocardial infarction or death
are minished by the use of dual antiplatelet therapy with aspirin and a platelet P2Y12 receptor
blockers mpared to the use of aspirin alone
(111) (B) Stop the warfarin treatment and repeat INR next day.
• ri INR between 2.0 and 3.0 is recommended for most patients with nonvalvular atrial fibrillation
who eceive warfarin.
This is based on the increased risk of stroke observed with INR values significantly lower than 2.0
and e increased risk of bleeding associated with higher intensities of anticoagulation.
Recommended management of a supra-therapeutic INR

Bleeding Recommended action
INR
- Lower warfarin dose, or
> - Omit one dose of warfarin and resume therapy at a lower dose when INR is
No within the therapeutic range, or
Therapeutic
- No dose reduction needed if INR is minimally prolonged.
range to 5.0 - Omit the next 1-2 doses of warfarin, monitor INR more frequently and
resume treatment at a lower dose when INR is within the therapeutic
range, or
No
> 5.0 - 9.0 - Omit one dose of warfarin and administer 1 - 2.5 mg oral vitamin K.
- Stop warfarin administration and administer 2.5 - 5 mg oral vitamin K.

- Monitor INR more frequently and administer more vitamin K as needed.
>9.0 No - Resume warfarin treatment at a lower dose when INR is within the therapeutic
range.
- Stop warfarin administration and administer 10 mg vitamin K by slow IV infusion;
supplement with four-factor prothrombin complex concentrate or fresh frozen
Serious or
Any plasma, depending on clinical urgency. Monitor and repeat as needed.
life-threatenin
g
(112) (C) Leaking aortic aneurysm.
- Abdominal aortic aneurysms are relatively common and are potentially life threatening.
- Individuals at greatest risk of abdominal aortic aneurysms are men older than 65-year-old who have
peripheral atherosclerotic vascular disease.
- Aneurysms are usually asymptomatic but can cause pain and lead to ischemia, thromboembolism,
spontaneous dissection and rupture, which may be fatal.
- Syncope may be the chief complaint, however, with pain less prominent.
- If an abdominal aortic aneurysms ruptures, patients who do not die immediately typically present
with abdominal or back pain, hypotension and tachycardia.
- They may have a history of recent, often minimal, upper abdominal trauma or isometric straining.
(113) (B) Abdominal CT.

- For symptomatic patients suspected of having abdominal aortic aneurysm who are hemodynamically
stable, an urgent abdominal CT scan is recommended rather than a US.
- An abdominal CT scan has the advantage of evaluating the abdomen in more detail, which is
necessary for differentiating ruptured from nonruptured aneurysm.
- CT scans are better than US for evaluating suprarenal aneurysms.
- Abdominal CT scans also readily identify other abdominal pathologies as potential causes of symptoms.
- Abdominal CT scans define the extent of the aneurysm, providing important anatomical information by
which to plan urgent abdominal aortic aneurysm repair and determines whether the aneurysm is suited to
endovascular aneurysm repair.
(114) (A) A wide S wave in lead 1 and V6 and a wide R wave in VI.
- A small R wave in lead 1 and aVL, a small Q wave in leads II, m and aVF and right axis deviation are
criteria used to diagnose left posterior fascicular block.
(115) (A) Non-selective beta-blockers.

- Bronchoconstriction can occur when non-selective beta-blockers are administered to asthmatic
patients.
- Therefore, non-selective beta-blockers are contraindicated in patients with bronchial asthma or
chronic obstructive pulmonary disease.
(116) (A) Spontaneous pneumothorax.

- A primary spontaneous pneumothorax tends to occur in a young adult without underlying lung
problems and usually causes limited symptoms.
- Chest pain and sometimes mild breathlessness are the usual predominant presenting features.
- It is rare for spontaneous pneumothorax to cause tension pneumothorax.
(117) (A) Wash clothes with hot water.

- Dust mite debris is the major source of allergens in house dust.
- These microscopic arthropods primarily feed on human skin scales.
- They lack an organized respiratory system, their water supply is derived from the ambient air and
acaricides are not effective to control their presence and numbers.
- Seasonal changes in relative humidity can affect the concentrations of dust mite allergens and these
fluctuations can contribute to allergic symptoms in the sensitized individual.
- Washing linens in hot water (55°C) at least once/week is recommended to kill the mites and remove
most of the associated allergens.
(118) (B) The long arm of chromosome 7.
vstic fibrosis is an autosomal-recessive disorder caused by mutations in the cystic fibrosis
ansmembrane conductance regulator gene (chloride channel) on the long arm of chromosome 7 and
is characterized by widespread exocrine gland dysfunction
(119) (B) Lung damage.

atients with acute respiratory distress syndrome often require high-intensity mechanical ventilation,
eluding high levels of positive end expiratory pressure or continuous positive airway pressure and,
ossibly. high mean airway pressures; thus, barotrauma may occur Patients present with
pneumomediastinum, pneumothorax, or both.
neumothorax is a frequent and potentially fatal complication of mechanical entilation in patients ith
acute respiratory distress syndrome.
Lung damage (such as pneumothorax) can occur due to injury from the breath ng machine needed
treat acute respiratory distress syndrome.
Other potential complications that may occur in these mechanically ventilated patients include
accidental extubation and right mainstem intubation.
(120) (E) Both B and C.

Generally, the right middle and lower lung lobes are the most common sites of nfiltrate formation
due the larger caliber and more vertical orientation of the right mainstem bronchus Patients who
aspirate while standing can have bilateral lower lung lobe infiltrates
right upper lobe is a common area of consolidation in alcoholics who aspi ate in the prone position.
(121) (B) Pulmonary angiography.
The gold standard or the diagnosis of pulmonary embolus is a pulmonary angiogram n which a
catheter threaded into the p nonary arteries, usually from ve ns n the <eg.
Dye is injected and a ciot or clots can be identified on imaging studies.
- This is considered an invasive test and is rarely performed due to the wider acceptance of CT
scans, i ch are non-invasive
pulmonary ang ography is the recommended first line diagnostic imaging test i most people.
(122) (D) It has 2 pulmonary veins.

There are 2 complete fissures in the right lung and 1 complete fissure and 1 incomplete fissure in the
left lung.
The right lung comprises 10 segments while the left comprises 8 segments Here are 2 pulmonary
veins superior and inferior that are formed on each lung, ese 4 veins typ cally join it or near their
junction w.th the left atrium and usually this common area rapericardially a h over the right main
bronchus posteriorly a i the root of the right lung to join the erior vena cava
s arch of the a . gos vein is an nportant anatomical landmark
(123) (A) Bronchiectasis.
- Patients with mild bronchiectasis only produce yellow or green sputum after an infection.
- Localized areas of the lung may be particularly affected; in which case sputum production will depend
on position
- As the condition worsens, the patient suffers from persistent halitosis, recurrent febrile episodes with
malaise and episodes of pneumonia.
- Clubbing occurs and coarse crackles can be heard over the infected areas; usually the bases of the
lungs.
- When the condition is severe there is a continuous production of foul-smelling, thick, khaki-colored
sputum.
- Hemoptysis can occur either as bloodstained sputum or as a massive hemorrhage.
- Breathlessness may result from airflow limitation.
(124) (C) Mitral regurgitation.

- Acute mitral regurgitation occurs in association with coronary artery disease and acute myocardial
infarction (typically, inferior myocardial infarction, which may lead to papillary muscle dysfunction).
- Significant acute mitral regurgitation is accompanied by symptoms of impaired left ventricular
function, such as dyspnea, fatigue and orthopnea.
- In these cases, pulmonary edema is often the initial manifestation because of the rapid
volume overload on the left atrium and the pulmonary venous system.
(125) (B) Urinary tract infection.

- The most common type of infection caused by enterococci is usually nosocomial (associated with
urinary tract catheterization or instrumentation).
- Sources of enterococcal bacteremia include the urinary tract, intra-abdominal foci, wounds and
intravascular catheters, especially catheters in femoral locations.
(126) (A) Corticosteroid inhaler.
(127) (A) Short acting beta-agonist inhaler.

- Bronchial asthma is a common chronic inflammatory condition of the lung airways.
- Symptoms include a cough, wheezing, chest tightness and shortness of breath that is often
worse at night.
- Mild asthmatics with intermittent attacks have a condition known as intermittent bronchial
asthma and a controller medication is not indicated.
- The reliever medication for these patients is a short-acting beta-agonist as needed for symptoms.
- Short-acting beta-agonists, such as salbutamol or terbutaline, should be prescribed as 2 puffs as
required.
(128) (B) Mild persistent.
- Treatment of bronchial asthma:
1- Step 1 - Intermittent bronchial asthma:
- A controller medication is not indicated.
- The reliever medication is a short-acting beta-agonist as needed for symptoms.
2- Step 2 • Mild persistent bronchial asthma:
- The preferred controller medication is a low-dose inhaled corticosteroid.
- Alternatives include sodium cromolyn, nedocromil, or a leukotriene receptor antagonist.
3- Step 3 - Moderate persistent bronchial asthma:
- The preferred controller medication is either a low-dose inhaled corticosteroid plus a long-acting
beta-agonist (combination medication is the preferred choice to improve compliance), or an inhaled
medium-dose corticosteroid.
- Alternatives include a low-dose inhaled corticosteroid plus either a leukotriene receptor agonist, such
as theophylline, or zileuton.
4- Step 4 - Moderate-to-severe persistent bronchial asthma:
- The preferred controller medication is an inhaled medium-dose corticosteroid plus a leukotriene
receptor antagonist (combination therapy).
- Alternatives include an inhaled medium-dose corticosteroid plus either a leukotriene receptor
antagonist, such as theophylline, or zileuton.
5- Step 5 - Severe persistent bronchial asthma:
- The preferred controller medication is an inhaled high-dose corticosteroid plus a leukotriene receptor
antagonist.
- Omalizumab should be considered for patients who have allergies.
6- Step 6 Severe persistent bronchial asthma:
- The preferred controller medication is a high-dose inhaled corticosteroid plus a leukotriene receptor
antagonist and an oral corticosteroid.
- Omalizumab should be considered for patients who have allergies.
(129) (A) Restrictive lung disease.

- In restrictive lung disease, both FEV1 and FVC are reduced, however, the decline in FVC is greater than
that of FEV1; resulting in a FEV1/FVC ratio of higher than 80%.
- In obstructive lung disease, however, FEV1 is reduced while FVC remains stable; consequentially
depicting a lower FEV1/FVC ratio.
(130) (E) Haemophilus Influenzae.

- After Streptococcus pneumoniae, non-typeable haemophilus influenzae is the most common cause in
adults.
- It is common in patients with chronic obstructive pulmonary disease and AIDS and exacerbates
chronic obstructive pulmonary disease, the symptoms of which include low-grade fever, increased
cough and purulent sputum production and dyspnea.
- Non-typeable haemophilus influenzae invasive diseases are frequently associated with underlying
medical conditions, including prematurity, advanced age, alcoholism, malignancy, cystic fibrosis,
bronchial asthma, CSF leak, central nervous system shunts, congenital heart disease and
immunoglobulin deficiency.
- People with chronic obstructive pulmonary disease have diseased airways, which impairs the normal
protective responses.
- Thus Haemophilus influenzae is present in the lower airways of people with chronic obstructive
pulmonary disease.
- It is also the most important bacterial cause of the exacerbation of chronic obstructive pulmonary
disease symptoms and can lead to serious complications.
(131) (A) Heparin IV.
- Heparin augments the activity of antithrombin m and prevents the conversion of fibrinogen to fibrin.
- Full-dose low molecular weight heparin or full-dose unfractionated IV heparin should be initiated at the
first suspicion of DVT or pulmonary embolism.
(132) (B) Pulmonary embolism.
- The most common ECG abnormalities in the setting of pulmonary embolism are tachycardia and
nonspecific ST-T wave abnormalities.
- The classic findings of right heart strain and acute corpulmonale are tall, peaked P waves in lead n
(P pulmonale); right axis deviation; right bundle-branch block; and SI Q3 T3 pattern or atrial fibrillation.
- Unfortunately, only 20% of patients with proven pulmonary embolism have any of these classic
electrocardiographic abnormalities.
- If electrocardiographic abnormalities are present, they may be suggestive of pulmonary
embolism, but the absence of such abnormalities has no significant predictive value.
(133) (A) Streptomycin.

- Streptomycin is an antibiotic (antimycobacterial) drug, the first of a class of drugs called
aminoglycoside to be discovered and it was the first antibiotic remedy for TB.
- Fever and rashes often result from persistent use of this drug.
- The vestibular portion of cranial nerve vm (the vestibulococlear nerve) can be affected, resulting
intinitus, vertigo and ataxia.
- Other adverse effects of this medicine areototoxicity, nephrotoxicity, fetal auditory toxicity and
neuromuscular paralysis.
(134) (A) TB.

- TB a multisystemic disease with myriad presentations and manifestations, is the most
common cause of infectious disease-related mortality worldwide.
- The classic clinical features associated with active pulmonary TB are cough, weight
loss/anorexia, fever, night sweats, hemoptysis, chest pain and fatigue.
- Chest pain in patients with TB can also result from tuberculous.
- Pericardial TB can lead to cardiac tamponade or constriction.
- Chest radiographs may show a patchy or nodular infiltrate.
- TB may be found in any part of the lung, but upper lobe involvement is most common.
- The lordotic view may better demonstrate apical abnormalities.
(135) (C) Multiple lung nodules.

- Multiple fine nodular densities distributed throughout both lungs that represent hematologic or
lymphatic dissemination are typical of miliary TB.
(136) (B) Streptococcus pneumonia.

- Pneumonia is defined as an inflammation of the lung tissue.
- It is usually caused by bacteria.
- Clinically it usually presents as an acute illness with cough, purulent sputum and fever together with
physical signs or radiological changes compatible with consolidation of the lung.
- The clinical presentation varies according to the immune state of the patient and the infecting agent.
he most common type of pneumonia (caused by Streptococcus pneumonia) there is often a
preceding history of a viral infection.
With Streptococcus pneumonia infection, the patient rapidly becomes more il with a high temperature
(up to 39.5 C), pleuritic pain and a dry cough.
e day or two days later, rusty-colored sputum is produced and at about the same time the
patient may develop labial herpes simplex
The | atient breathes rapidly and shallowly, the affected side of the chest moves less and signs of cons
lidation may be present together with a pleural rub.
(137) (A) Acute attack of bronchial asthma.

onchiai asthma is common and it can be serious.
About 1 in 7 teenagers and 1 in 10 adults have bronchial asthma.
Ir most patients with bronchial asthma, chest radiography findings are normal or may indicate
hyperinflation.
• P tients with acute severe bronchial asthma typically
have: liability to complete a sentence in one breath. e.
Respiratory rate <25/min.
3- achycardia <110 bpm
EFR > 50% of predicted normal or best.
bG provides important information in acute bronchial asthma.
his test may reveal dangerous levels of hypoxemia or hypercarbia secondary to
hypoventilation; cally, results are consistent with respiratory alkalosis.
(138) (C) Vitamin B6 (pyridoxine).

- ridoxine deficiency can occur in treatment with isoniazid.
(139) (C) Smoking cessation.

noking cessation continues to be the most important therapeutic intervention for chronic
obstructive pulmonary disease
ost patients with chronic obstructive pulmonary disease have a history of smoking or are currently
noking tobacco products.
smoking cessation plan is an essential part of a comprehensive management plan.
(140) (C) Postnasal drip.

1 le most common cause of an acute or subacute cough is a viral respiratory tract infection.
adults with a chronic cough, e.g. a cough that lasts longer than 8 weeks, more than 90% of cases are
to,post-nasal drip bronchial asthma, eosinophilic bronchitis and gastroesophageal reflux disease. ie
causes of chronic cough are similar in children with the addition of bronchitis.
(141) (A) Dyspnea.

Dyspnea: difficult or labored breathing; shortness of breath.
Tachycardia: abnormally rapid heart rate.
adycardia: slowness of the heartbeat, as evidenced by a slowing of the pulse rate to less than 60
bpm. Tachypnea: very rapid respiration.
(142) (B) Cheyne-stokes respiration.
- Cheyne-stokes respiration is also known as periodic respiration, with cycles of respiration that are
increasingly deeper then shallower with possible periods of apnea.
- Typically, over a period of 1 minute, a 10-20 second episode of apnea or hypopnea occurs followed
by breaths of increasing depth and frequency.
- The cycle then repeats itself.
- It may be caused by damage to respiratory center or by physiological abnormalities in chronic heart
failure and is also seen in newborns with immature respiratory systems and in visitors new to high
altitudes.
(143) (B) Hypoxia.

- Factors that move the hemoglobin-oxygen dissociation curve to the right are those physiological
states where tissues need more oxygen.
- For example, during exercise muscles have a higher metabolic rate and consequently need more
oxygen, produce more carbon dioxide and lactic acid and their temperature rise.
- So, the standard curve is shifted to the right by an increase in temperature,
2,3-diphosphoglycerate or PC02 or a decrease in pH.
(144) (A) Azithromycin.

- The primary microorganisms causing this group of diseases are viruses, atypical bacteria,
penicillin-sensitive Streptococcus pneumoniae and Haemophilus influenzae.
- Recommended management is with a macrolide antibiotic such as azithromycin or clarithromycin
for 7-1 days.
(145) (D) Ceftriaxone.

- Initially, invasive and serious Hib infections are best treated with an IV third-generation cephalosporin
until antibiotic sensitivity data become available.
(146) (C) Depression.

- The effects of oxygen toxicity may be classified by the organs affected, producing three principal
forms:
1- Central nervous system: characterized by convulsions followed by unconsciousness, occurring under
hyperbaric conditions.
2- Pulmonary characterized by difficulty In breathing and pain within the chest, occurring when
breathing elevated pressures of oxygen for extended periods.
3- Ocular (retinopathic conditions), characterized by alterations to the eyes when breathing elevated
pressures of oxygen for extended periods.
(147) (A) Add a corticosteroid inhaler.

- Bronchial asthma is classified as moderate persistent if symptoms occur daily.
- Flare-ups occur and usually last several days.
- Patients with moderate persistent bronchial asthma are generally treated with a combination of
medications. - The treatment: medium-dose inhaled corticosteroids alone and with cromolyn sodium or
nedocromil, a leukotriene modifier, a long-acting bronchodilator such as theophylline or long-acting
beta2-agonist.
(148) (B) H2-blockers.
- Acute gastritis can be broken down into 2 categories:
Erosive (e.g. superficial erosions, deep erosions, hemorrhagic erosions).
2- Non erosive (generally caused by Helicobacter pylori).
Surgical intervention is not necessary, except in the case of phlegmonous gastritis. With this entity,
urgical intervention with resection of the affected area may be the most effective form of treatment.
(149) (C) Rice.

Celiac disease is an immune reaction to eating gluten, a protein found in wheat, barley and rye.
- Rice does not contain gluten.
(150) (B) Uveitis.

veitis is defined as inflammation of the uveal tract, which includes the iris, ciliary body and choroid.
- Medical histories that increase the likelihood that uveitis is the cause of ocular pain include:
autoimmune diseases, sexually transmitted diseases, particularly syphilis and chlamydia, TB and AIDS.
Symptoms include pain, redness, photophobia, excessive tearing and decreased vision.
(151) (A) It carries an increased risk of adenocarcinoma.

Barrett's esophagus is a complication of chronic gastroesophageal reflux disease.
The reason for the great interest in Barrett's esophagus is that it is associated with an increased risk
of cancer of the esophagus.
- The type of cancer that occurs in patients with Barrett's is adenocarcinoma, which arises
from the metaplastic intestinal tissue.
(152) (B) Ulcerative colitis.

Bloody diarrhea is a hallmark for ulcerative colitis.
- Crypt abscesses and a friable mucosa are also commonly found in this condition.
(153) (A) It carries an increased risk of malignancy.
- In ulcerative colitis there is a risk of developing colon cancer.
- Options B, C and D are associated with Crohn's disease.
(154) (B) Primary biliary cirrhosis.

- Primary biliary cirrhosis is a chronic disease of the liver, presumably autoimmune in nature, which
leads to progressive cholestasis and often end-stage liver disease.
The main signs and symptoms include fatigue, pruritus, right upper quadrant discomfort,
hepatomegaly, hyperpigmentation, splenomegaly, jaundice, xanthoma, xanthelasmata and
kayser-Fleischer rings.
Complications of cirrhosis and portal hypertension include fluid retention in the abdomen (ascites),
esophageal varices, hepatic encephalopathy, including coma in extreme cases.
Association with an extrahepatic autoimmune disorder such as rheumatoid arthritis or Sjogren's
yndrome occurs in up to 80% of cases.
Lab findings include significant elevations of alkaline phosphatase levels, increased lipid and
cholesterol evels and an increased HDL fraction, alanine aminotransferase, aspartate aminotransferase
and bilirubin, he hallmark of primary biliary cirrhosis is the presence of antimitochondrial antibodies in
the serum.
(155) (A) Omeprazole.
- Omeprazole is proton pump inhibitor, it decreases the amount of acid produced in the stomach.
(156) (A) Omeprazole for 2 weeks and clarithromycin and amoxicillin for one week.
- Standard eradication therapies are successful in approximately 90% of patients.
- Metronidazole, clarithromycin, amoxicillin, tetracycline and bismuth are the most widely used
agents to eradicate Helicobacter pylori infection.
- Resistance to amoxicillin (1-2%) and tetracycline (>1%) is low except in countries where these
antibiotics are available without prescription and resistance may exceed 50%.
- Quinolones, such as ciprofloxacin, furazolidone and rifabutin, are also used when standard
regimens have failed (rescue therapy).
- Bismuth suppresses Helicobacter pylori effectively.
- None of these drugs is effective alone.
- Eradication regimens usually comprise 2 antibiotics given with powerful acid suppression in the
form of a proton pump inhibitor, all given for 7 days.
- Example regimes are:
1- omeprazole 20 mg and clarithromycin 500 mg and amoxicillin 1 gm - all twice daily
2- omeprazole 20 mg and metronidazole 400 mg and clarithromycin 500 mg - all twice daily.
(157) (A) Cimetidine.

- Cimetidine competitively inhibits the action of histamine at H2 receptors and thus represents a
new class of pharmacological agents; the histamine H2 receptor antagonists.
- Cimetidine is not an anticholinergic agent
- Cimetidine inhibits both daytime and nocturnal basal gastric acid secretion.
- Cimetidine also inhibits gastric acid secretion stimulated by food, histamine, pentagastrin,
caffeine and insulin.
- Its ability to inhibit gastric acid secretion via this unique mechanism of action permits a new
approach to the treatment of acid-related gastrointestinal disorders.
- In addition to its antisecretory effects, cimetidine also has cytoprotective properties.
- In therapeutic studies, patients with NSAID-induced lesions or ulcers had symptomatic
relief and healing when cimetidine was co-administered with the existing NSAIDs therapy.
- Indications and clinical uses:
- Primary therapy for conditions where the inhibition of gastric acid secretion is likely to be beneficial
such
1- Duodenal ulcer therapy.
2- Non-malignant gastric ulcer therapy.
3- Prophylaxis of recurrent duodenal or gastric ulcer.
4- Gastroesophageal reflux disease.
5- Management of upper gastrointestinal hemorrhage.
6- Pathological hypersecretion associated with Zollinger-Ellison syndrome, systemic mastocytosis and
multiple endocrine adenomas.
7- Prophylaxis of stress ulceration.
8- Prophylaxis of acid aspiration pneumonitis.
9- Adjunctive therapy in the management of cystic fibrosis in children.
10- Treatment of NSAID-induced lesions (ulcers, erosions) and gastrointestinal symptoms
and prevention of their recurrence.
(158) (B) Clostridium difficile.
- Pseudomembranous colitis is caused by Clostridium difficile, which releases strong toxins that
irritate the colon.
(159) (B) Salmonella poisoning.

- This is a case of food poisoning.
- Salmonellosis is a type of food poisoning caused by the Salmonella bacteria.
- Symptoms of salmonellosis include diarrhea, fever and abdominal cramps.
- They develop 12-72 hours after infection and the illness usually lasts 4-7 days.
(160) (B) Hepatitis C.

- Hepatitis C is transmitted sexually and by blood transfusion.
(161) (A) Peptic ulcer.

- Ibuprofen is a NSAID.
- Aspirin and other NSAIDs deplete mucosal prostaglandins by inhibiting the cyclo-oxygenase
pathway, which leads to mucosal damage.
- 50% of patients taking regular NSAIDs will develop gastric mucosal damage and approximately 30%
will have ulcers on endoscopy.
- Only a small proportion of patients have symptoms (about 5%) and only 1-2% have a major
problem, e.g. gastrointestinal bleed.
- Because of the large number of patients on NSAIDs, including low-dose aspirin for vascular
prophylaxis, this is a significant problem, particularly in the elderly.
- Helicobacter pylori and NSAIDs are independent and synergistic risk factors for the development of
ulcers.
(162) (A) Fistula formation.

- Fistula is a one complication of Crohn's disease, a disease that involves the full thickness of the
gastrointestinal wall and skips lesions.
(163) (B) Clostridium difficile.

- Clostridium difficile causes antibiotic-associated diarrhea, colitis and pseudomembranous colitis.
- It is a Gram-positive, anaerobic, spore-forming bacillus and is found as part of the normal
bowel flora in 3-5% of the population and even more commonly (up to 20%) in hospitalized
people.
-Diagnosis is made by detecting A (enterotoxin) or B (cytotoxic) toxins in the stools by ELISA
techniques.
- Treatment is with metronidazole 400 mg 3 times daily or oral vancomycin 125 mg 4 times daily.
- Causative antibiotics should be discontinued if possible.
(164) (B) Achalasia cardia.
• Achalasia is a primary esophageal motility disorder characterized by the absence of
esophageal peristalsis
and impaired relaxation of the lower esophageal sphincter in response to swallowing.
- The lower esophageal sphincter is hypertensive in about 50% of patients.
• These abnormalities cause a functional obstruction at the gastroesophageal junction.
- It is characterized by the following signs and symptoms: dysphagia (most common),
regurgitation, chest pain, heartburn and weight loss.
- Laboratory studies are noncontributory.
- Studies that may be helpful include:
1- Barium swallow: bird's beak appearance, esophageal dilatation.
2- Esophageal manometry (the criterion standard): incomplete lower esophageal sphincter relaxation
in response to swallowing, high resting lower esophageal sphincter pressure, absent esophageal
peristalsis.
3- Prolonged esophageal pH monitoring to rule out gastroesophageal reflux disease and determine
whether the abnormal reflux is being caused by treatment.
4- Esophagogastroduodenoscopy to rule out cancer of the gastroesophageal junction or fundus
5- Concomitant endoscopic US if a tumor is suspected.
(165) (B) Amoebic dysentery (entameba histolytica).

• Diarrhea is the most common symptom of amoebic dysentery.
• Patients with amebic colitis typically present with cramping abdominal pain, watery or bloody diarrhea
and weight loss or anorexia.
- Fever is noted inl0-30% of patients.
- Microscopic examination of fresh stool smears for trophozoites that contain ingested RBCs.
(166) (A) Metronidazole and vancomycin.

- Oral metronidazole and oral vancomycin have similar efficacy in the treatment of mild to moderate
Clostridium difficile-associated with diarrhea.
- However, metronidazole is the empiric treatment of choice because of its cost and the risk of selection
for vancomycin-resistant enterococci in the stool with oral vancomycin.
(167) (A) Ischemic mesentery.

- Mesenteric ischemia is caused by decreased intestinal blood flow that can be caused by a
number of mechanisms.
- The blood supply to the intestine is derived predominantly from 3 major gastrointestinal
arteries that arise from the abdominal aorta.
- The vast majority of cases are secondary to arterial causes.
- The classic picture of a patient with acute mesenteric ischemia involves severe abdominal pain, bloody
stools and a history of risk factors like atrial fibrillation.
(168) (D) Hip CT.

- In adults, a musculoskeletal complication (commonly arthritis) often occurs with the attacks
of Crohn's disease.
- Commonly affects large joints of lower extremity.
(169) (B) Liver US and alpha-fetoprotein blood test.
- Low alpha-l-antitrypsin levels and increased alpha fetoprotein levels to above 400 ng/ml are
considered diagnostic of hepatocellular carcinoma with appropriate imaging studies.
- Accurate diagnosis and surgical planning require adequate cross-sectional imaging studies.
- While US is commonly used for screening, it does not provide sufficient anatomical detail for planning
surgical resection or ablation.
(170) (B) Positive hepatitis A IgM.

- This is a case of hepatitis A.
- Blood tests may show raised IgM and IgG antibodies to hepatitis A.
- IgM is usually positive before IgG.
(171) (C) They can be distinguished between it and duodenal ulcer.

- Inflammation of the lower esophagus from regurgitation of acid gastric contents is
characterized by substernal pain, usually due to malfunction of the lower esophageal sphincter.
(172) (B) Colorectal cancer.
The stool guaiac test or guaiac fecal occult blood test is one of several methods that detect the presence
of fecal occult blood, which is defined as blood in the feces that cannot be seen.
- One major reason for testing for blood in stools is the detection of colorectal cancer.
- Smoking, obesity, intermittent diarrhea and bleeding per rectum are associated with colorectal cancer.
(173) (E) Shigella.

The host response to primary Shigella infection is characterized by the induction of an acute
inflammation, which is accompanied by polymorphonuclear cell infiltration, resulting in massive
destruction of the colonic mucosa.
Apoptotic destruction of macrophages in subepithelial tissue allows survival of the invading shigella and
inflammation facilitates further bacterial entry.
(174) (A) Theophylline.

Certain medications and dietary supplements can irritate the lining of the esophagus, causing heartburn
pain and others can increase the severity of gastroesophageal reflux disease.
Examples include narcotics, progesterone, theophylline and quinidine.
(175) (D) Diffuse esophageal spasm.

Corkscrew appearance is characteristic of esophageal spasm.
(176) (A) Tricyclic antidepressants.

- Tricyclic antidepressants are used in the treatment of peptic ulcer.
Gastric ulcers are not considered side effects of tricyclic antidepressants.
(177) (C) Hepatitis C.

- Hepatitis C is often passed through contact with contaminated blood, most commonly through needles
shared during illegal drug use.
(178) (C) Peptic ulcer.
- Ibuprofen, which is a NS AID, may increase the risk of gastrointestinal irritation, inflammation,
ulceration, bleeding and perforation.
- These events can be fatal and may occur at any time during therapy and without warning.
- NSAIDs should be used with caution in patients with a history of gastrointestinal disease
(such as bleeding or ulcers), as concurrent therapy with aspirin, anticoagulants and/or corticosteroids, in
patients who smoke tobacco or drink alcohol and in elderly or debilitated patients.
- The lowest effective dose should be used for the shortest duration of time, consistent with individual
patient goals, to reduce the risk of adverse gastrointestinal events
-. Alternative therapies should be considered for patients at high risk.
• When used concomitantly with aspirin, a substantial increase in the risk of gastrointestinal
complications
(e.g. ulcer) occurs: concomitant gastroprotective therapy (e.g. proton pump inhibitors) is recommended.
(179) (A) Penicillin.

- Penicillin prophylaxis and vaccines against various serotypes of Streptococcus pneumonia have been
used to prevent infection with Streptococcus pneumonia in sickle cell anemia patients.
■ Over the years, penicillin prophylaxis has proven to be more effective than vaccination.
(180) (B) Splenomegaly.

- Polycythemia vera is a stem cell disorder characterized as a panhyperplastic, malignant and neoplastic
marrow disorder.
• The most prominent feature of this disease is an elevated absolute RBCs mass because of
uncontrolled
RBCs production.
- This is accompanied by increased white blood cell (myeloid) and platelet (megakaryocytic) production,
which is due to an abnormal cloning of the hematopoietic stem cells with increased sensitivity to
the different growth factors for maturation.
- Polycythemia vera, itself, is often asymptomatic.
- Occasionally, increased red cell volume and viscosity produce weakness, headache, light-headedness,
visual disturbances, fatigue and dyspnea.
- Pruritus often occurs, particularly after a hot bath.
- The face may be red and the retinal veins engorged.
- The palms and feet may be red, warm and painful, sometimes with digital ischemia (erythromelalgia).
- Hepatomegaly is common and more than 75% of patients have splenomegaly which may be massive.
(181) (B)Vitamin B12 deficiency.

- Vitamin B12 deficiency may occur in blind loop syndrome or after extensive resection of the distal ileum.
- Patients with extensive small bowel resection are at risk of nutrient, mineral and vitamin deficiencies
because of the loss of the absorptive surface.
- The risk of nutrient deficiency is greatest during and after the transition to enteral feeding, since the
degree of intestinal adaptation and the absorption of nutrients are unpredictable.
- Serum levels of calcium, magnesium, zinc, selenium and the fat soluble vitamins (A, D, E and K) should
be monitored every 3 months.
- In addition, patients who have had more than 60 cm of ileum resected may become deficient in vitamin
B12, despite adequate calorie and protein absorption and supplementation may be required.
(182) (A) Cerebral infarction.
The cerebrovascular complications associated with sickle cell disease are cerebral infarction, intracranial
hemorrhage and cognitive and behavioral changes.
- Cerebrovascular accident is a leading cause of death in both children and adults with sickle cell disease.
- The type of stroke varies with age.
An ischemic infarct is most common in children between 2-9-year-old, is uncommon between
20-29-year-old and has a second peak in adults over 29-year-old.
Hemorrhagic stroke can occur in children but is most frequent in individuals between 20-29-year-old.
A cooperative study of sickle cell disease found that of the first cerebrovascular accident in patients
with sickle cell disease, 54% were caused by cerebral infarction, 11% by transient ischemic attack, 34% by
ntracranial hemorrhage and 1% had features of both infarction and hemorrhage.
Cerebral infarction is defined clinically by the presence of typical symptoms that last for at least 24
hours. The symptoms of infarction stroke include hemiparesis, dysphasia, gait disturbance and a change
in the level of consciousness.
These findings are associated with a corresponding radiographic lesion.
Stroke is usually associated with narrowing or occlusion of the large cerebral arteries.
(183) (A) Acute myeloid leukemia.

- Bone marrow aspiration and biopsy (usually unilateral) is a key component in the diagnosis of acute
myeloid leukemia.
- The bone marrow is usually hypercellular due to a partial or almost total replacement of the normal
cellular components of the marrow by immature or undifferentiated cells, although acute myeloid
eukemia can sometimes present with a hypocellular marrow.
The bone marrow biopsy gives a general overview of the degree of involvement and specific
histological features associated with the process (e.g. fibrosis, necrosis).
- The aspirate provides material for a 500-cell differential count to determine the percentage of blasts in
the marrow; it also provides for detailed cytologic evaluation of the blasts and other cells that may
be residual normal hematopoietic elements or abnormal cells maturing from the blasts.
(184) (A) Hospitalization and pain management as well as observation.

- Treatment of sickle cell anemia includes:
ydroxyurea to increase the amount of fetal hemoglobin.
Haemophilus influenzae and pneumococcal vaccines.
Prophylactic penicillin for children under 5-year-old.
- Acute crisis: analgesia and hydration.
Patients with sickle cell anemia at home and in the hospital use a range of pain medications depending
on the severity of their pain.
- In the majority of cases a moderate to severe painful crisis warrants hospitalization and medical
'ntervention.
Management often includes IV fluid to prevent or correct dehydration, pain relief (often opiates), ea
rest and an investigation of the cause of the crisis and its management where applicable; for example,
treating a precipitating infection.
(185) (B) Age.
- The median age of chronic myeloid leukemia patients is approximately 60-year-old and the age is still
considered an important prognostic factor.
- However, older age is a consistently poor prognostic factor in patients with chronic myeloid leukemia.
- The negative effect of age on long-term survival has been consistently observed with most effective
therapeutic modalities: including both pharmacological therapy (busulfan, hydroxyurea and interferon)
and allogeneic transplantation.
- Their poor prognosis may have been due, at least in part, to poorer tolerability and inadequate
treatment delivery.
(186) (B) Abnormal release of histamine.

- Pruritus results from increased histamine levels released due to increased numbers of basophils and
mast cells and can be exacerbated by a warm bath or shower.
- This occurs in up to 40% of patients with polycythemia vera.
(187) (A) DIC.

- DIC involves abnormal, excessive generation of thrombin and fibrin in the circulating blood.
- During the process, increased platelet aggregation and coagulation factor-consumption occur.
- DIC that evolves slowly over weeks or months primarily causes venous thrombotic and embolic
manifestations (for example, DVT, thrombosis and pulmonary embolism).
- DIC that evolves rapidly (over hours or days) causes primarily bleeding.
(188) (D) Age.

- Chronic lymphocytic leukemia is more common among the elderly, so age is considered a major risk
factor.
- Chronic lymphocytic leukemia is not known to be associated with viral infection, radiation exposure or
carcinogenic chemicals, like benzene.
- The incidence of chronic lymphocytic leukemia varies markedly between different ethnic groups.
Asians show a very low incidence of chronic lymphocytic leukemia wherever they live in the world.
This suggests that there is a genetic influence on the risk of contracting this condition.
- Close relatives of chronic lymphocytic leukemia patients appear more likely than other people to have
some form of cancer of the lymphatic system but it is important to stress that these cancers are still rare
in this group.
(189) (C) Nephrotic syndrome.

- Patients with nephrotic syndrome have a higher risk of venous and arterial thrombosis; mainly DVT
and renal vein thrombosis.
- The prevalence is estimated at 5% and 60%, respectively, mainly in patients with membranous
nephropathy.
(190) (C) Decreased serum iron and decreased TIBC.

- The serum iron concentration and transferrin level (also measured as TIBC) are both low and the
percentage of transferrin saturation is usually normal, which should distinguish anemia of chronic disease
from iron deficiency anemia, in which transferrin saturation is low.
However, approximately 20% of patients with anemia of chronic disease have low transferrin
saturations n the iron deficiency range (as low as 10%), even though only about 25% of such patients are
truly iron deficient.
- In the remaining patients, the reduced ability to release iron from macrophages is presumably
responsible for the low serum iron levels and low transferrin saturation.
(191) (A) Iron deficiency anemia.

The classic presentation of iron deficiency anemia is:
1- Low hemoglobin level, at 8 gm/dl.
2- MCV is low at 75 fl.
3- MCH is low.
4- A blood smear shows microcytic, hypochromic red cells.
5- Serum iron is low (10 mcg/dl).
6- TIBC is elevated (400 mcg/dl), resulting in a low transferrin saturation of 2.5%.
7- The plasma ferritin concentration is markedly reduced (10 ng/ml).
8 - Iron stores are absent in the patient's bone marrow as judged by microscopic examination of a bone
marrow aspirate; the gold standard test for estimating iron stores.
- Finally, the patient responds quickly to a therapeutic trial of oral iron, with a reticulocytosis, followed
by elevations in the hemoglobin concentration and hematocrit.
(192) (A) Hemoglobin electrophoresis.

- Hemoglobin electrophoresis will show increased levels of hemoglobin A2 in anemic patients.
- The diagnosis of beta-thalassemia major is normally made in all patients at around 6-12-month-old
due to the presence of pallor, irritability, growth retardation, abdominal swelling due to
hepatosplenomegaly and jaundice.
The laboratory examination at that time will show severe anemia with markedly abnormal
hypochromic, microcytic red cells and with all of the classical findings of severe hemolytic anemia (e.g.
increased indirect bilirubin and lactate dehydrogenase and reduced or absent haptoglobin).
The diagnosis is confirmed by hemoglobin electrophoresis.
- Hemoglobin A is absent or severely reduced; only hemoglobins F and A2 are present.
- Variable amounts of hemoglobin A will be present in those who are subsequently treated with red cell
transfusions, but levels of hemoglobins F and A2 will remain elevated.
(193) (A) Fresh frozen plasma.

- The two main treatment options for patients with Von Willebrand disease are desmopressin and
transfusion therapy.
Platelet transfusions may be helpful in some patients with Von Willebrand disease whose disease is
refractory to other therapies.
Cryoprecipitate and fresh frozen plasma contain functional von Willebrand factor but should be
avoided whenever possible because of the potential transmission of viral disease.
(194) (C) Von Willebrand disease.
- The two main treatment options for patients w ith V on Willebrand disease are desmopressin and
transfusion therapy
- w t- regard to the iatter therapy p ate et trans us ns may be helpfu in some patients with Von
llebrand disease whose disease s refractory to or e- therapies Cryoprec pitate and res ôzen p
ma con: n functional von . llebrand * ctor bur should be avo ded whene /e- poss b e because of
the pote tia a smiss on of vira d sease
- At addi ona drawback of :rozen plasma s t e arge infusior volume ost often required
(195) (A) Clotting factors.

- Hemoph as are common : ereditary bleedin diso : e caused b defic encies of either clotting factor r m
or IX.
- The extent o e facto deficiency deterrr nes the probability a sever ‘ o bleeding B eed ig
into deep : sues or o its usual develops v\ : n hours of trauma
-T e agnos - s suspected in a patient with ar eievated partial thromboplastin time PTT and norma
prothrombin time (PT) and platelet count: it is confirmed by specific factor assays.
Treatme nc udes replacement of the defic en factor if acute bleeding is suspected confirmed o-
kely to develop e.g before surgery
Hemopl la A (factor Vm deficiency) affects abo patients with hemophilia.
- Hemopi aB acto I def cie c> nas : en ical c ca manifesta tions sc een g test abnormalities and X-
in<ed genetic transmiss on as nemophu a A.
Specific factor assays are required to distingu sh them
(196) (A) Acute myeloid leukemia.

- In acute myeloid leukemia, laboratory studies usually reveal pancytopenia although any combination
of anemia, thrombocytopenia and leukopenia or leukocytosis may exist.
• Blasts and other immature WBCs may be present in the peripheral blood and because of rapid cell
turnover, serum lactic dehydrogenase and uric acid levels may be elevated.
- Acute myeloid leukemia can usually be diagnosed from a peripheral blood smear, but bone marrow
aspirate and biopsy should always be performed to determine the proper classification.
- Bone marrow aspirate from these patients has more than 30% blasts (< 5% blasts is normal) of which
>3% are positive for myeloperoxidase stain.
- Patients whose blood is negative for all stains (acute undifferentiated leukemia) are usually treated as
acute myeloid leukemia patients if immunophenotyping demonstrates myeloid markers.
(197) (A) Hodgkin's lymphoma.

- Hodgkin's lymphoma is a localized or disseminated mal gnant proliferation of cells of the
lymphoreticular system, primarily involving lymph node tissue, the spleen, liver and bone marrow.
- Symptoms include painless lymphadenopathy, sometimes with fever, night sweats, unintentional
weight loss, pruritus, splenomegaly and hepatomegaly.
- Diagnosis is based on lymph node biopsy.
- Treatment is curative in about 75% of cases and consists of chemotherapy with or without radiation
therapy.
(198) (A) Hodgkin's lymphoma.
- Hodgkin s lymphoma is a neoplasm characterized by the presence of clonal malignant
Hodgkin/Reed-Sternberg cells in a reactive cellular background comprised of variable numbers of
ocytes, pias na cells and lymphocytes.
Historically, Hodgkin/Reed-Sternberg cells have been enigmatic and difficult to study, as they often
institute less than 1% of the ce s in involved tissues.
The central pathogenic issues in Hodgkin's ymphoma are: the origin of Hodgkin/Reed-Stc nbe g ce s the
identity of the events underlying the transformation of Hodgkin/Reed-Sternberg cells and the nature of
the signals that produce the intense, characteristic tissue response.
(199) (A) Pernicious anemia.

- Pernicious anemia refers specifically to vitamin B-12 deficiency resulting from a lack of production of
intrinsic factor in the stomach.
T e onset of perniciou: anemia is usually insidious and vague.
classic triad of weakness sore tongue and paresthesia may be elicited but is not sually the c ef
symptom comple
icall), medical attention is sought because of symptoms suggestive of cardiac, renal, genitourinary,
gastrointestinal, infectious, mental, or neurological disorders and the patient is found to be anemic
macrocytic :eli ar ndices.
(200) (C) The patient requires a prophylactic antibiotic even if they have been vaccinated.
Children with sickle ce disease snould receive all routine childhood mmumzations The new 7-valent
pneumococcal conjugate vaccine decreases the incidence of invasive pneumococcal infection in children
younger than 2-year-old and should be given to infants with sickle cell disease on the same schedule as
other hi dren.
- However, because children with sickle cell disease remain susceptible to life-threatening
pneumococcal infections, they should receive the 23-valent polysaccharide pneumococcal vaccine if
2-year-old or older;
ifthepatien year-old or younger evacc na n shorn e onsi ears
These immunizations do not negate the need for penicil in prophylaxis which should continue until 5
year-old
(201) (C) Gram-positive streptococci.

One hundred and nine consecutive episodes of septicemia were retrospectively evaluated in 61 children
with malignancy
In addition, the records of all pediatrics oncology patients who received high-dose cytarabine
motherapy wer ^viewed.
am-positive or s ns accounted for 82.6% of e se tice e >isodes
- In the total group, coagulase negative staphylococci and viridans streptococci
accounted lor 35.8% and 28.4% of the episodes, lespectively
(202) (D) Genetic screening for hereditary anemia.
- In thi first year of life measi es to prevent iron deficiency include completely avoiding cow s milk,
st j iron supplementatic at 4-6 month-old eastfed infa and us ig an ron-fon fied form la en ot
breastfeeding: a low-iron formula should o used.
the second ear of life, iro deficiency can be preven ed by a diversified lei that is rich in sources
of iron a vitamin C, I miting cow s milk consumnti and providing a dail iron-fortified vitamin.
A infants and toddlers who did not receive primary prevention methods si d be screened for iron
deficiency.
(203) (C) Acute chest syndrome.

Acute chest syndrome, characterized by respiratory or chest symptoms, fever and a new
pulmonary nfii ate on chest radiography.
- Acute cl est syndrome may complicate any painful episode or other acute medical condition in a
patient with sickle cell disease.
- For example 30% of all patients with hemoglob n SS disease will have one episode of acute
chest synd om - 50% of these patients will have recurrent episodes.
Because survival is improved with aggressive treatment, urgent consul tatio with a hematologist
or pulmonologist is advised
For persistent hypoxemia or respiratory deterioration in the face of conservative
measures, the transfusion of RBCs is indicated.
(204) (A) Trial of iron therapy.

- This a case of iron deficiency anemia.
- The most common presentation of iron deficiency anemia is an otherwise asymptomatic,
well-nourished infant or child who has a mild to moderate microcytic hypochromic anemia.
- Much less frequent are infants with severe anemia, who present with lethargy, pallor, irritability,
cardiomegaly, poor feeding and tachypnea.
- For infants and young children presenting with a mild microcytic anemia and a presumptive
diagnosis of iron deficiency anemia, the most cost effective strategy is a therapeutic trial of iron.
- For infants and young children with confirmed iron deficiency anemia, ferrous sulfate remains the
most cost-effective treatment.
- For maximal absorption, the iron supplement should be given between meals and with juice.
- Iron absorption is increased if the ferrous sulfate is given with juice rather than milk.
(205) (B) 6 months.

- Anticoagulant medications work by inhibiting or altering steps in the coagulation cascade.
- Medications such as warfarin are available in oral forms, whereas heparin and the
low-molecular-weight heparins require either IV or SC routes for treatment.
- Warfarin is used in patients that have had DVT in order to prevent recurrence or progression.
- Warfarin is generally continued for 3-6 months.
- Continuation of warfarin in this setting depends on other risk factors.
- Warfarin is also used in some settings for patients with strokes, heart attacks and peripheral vascular
disease.
(206) (B) Avascular necrosis.
oscular necrosis * the femo a ead is characterized by hip pair w th uveighi bear ng ascular
ecrosis he femora, head is found in individuals o' al ages , ith ckle cell disease iding
children as oung as 5- ea old prevalence o* s complication ncreases with age
irst symptom o pain has been noted at an average age of 12-year-old range 7-15-year-old
(207) (B) 2.0-3.0

INR is used to monitor warfarin therapy.
T e INR is calculated from the ollowing formula: INR = patient PT control PT
e therapeutic range for the INR var es with the clinical indication most
indications the recommended range is 2.0-3.0. higher or ower INR range
may be recommended in certain clinical settings.
(208) (A) Superior vena cava obstruction.

Superior vena cava obstruction or superior vena cava syndrome is caused by compression or nvasion
nediastinal masses tumors and/or lymphadenopathy stenosis ot the superior vena cava or thrombosis.
Vlalignancy accounts for 90% of cases of superior vena cava syndrome.
Lung cancer and non-Hodgkin lymphoma together cause about 95% of cancer-related superior vena
cava syndrome.
Puzzlingly, Hodgkin lymphoma rarely causes superior vena cava syndrome, despite its common effect
on the mediastinal lymph nodes.
Patients often complain of a variety of symptoms, the most common of which are facial or neck
swelling 82%), arm swelling (68%), dyspnea (66%), cough (50%) and dilated chest veins 38%
- Patients may also report chest pain, dysphagia, hoarseness, headache, confusion, dizziness and
syncope.
(209) (B) Ferritin.

- The assessment of serum or plasma ferritin has replaced the assessment of bone marrow iron stores
as he gold standard for the diagnosis of iron deficiency in most patients.
- irtually all patients with serum ferritin concentrations less than 10-15 ng/ml are iron deficient, with a
sensitivity of 59% and a specificity of 99%.
(210) (A) Assess his iron levels.

- Anemia is a common problem with serious consequences in older persons.
Approximately one third of persons with anemia have a nutritional deficiency; one third have anemia
due to chronic inflammation, chronic kidney disease, or both; and one third have unexplained anemia.
- Once anemia is confirmed, a CBC is helpful.
- If bleeding or iron deficiency anemia is clinically suspected, the measurement of serum ferritin is also
warranted.
- Iron deficiency anemia often is caused by gastrointestinal bleeding arid requires further investigation
in c der persons
- Even in asymptomatic patients, more than one ha t of ndividuals with anemia are found to have a
bleeding-related lesion on endoscopic evaluation with esophagogastroduodenoscopy and colonoscopy
Al anemi participants undergo a clinical hematologic evaluation, including history and physical
exam natior CBC vith red cell indices ro indices serum ron, transferrin, ferritin), levels of vitamin B12 and
folate and a review of a peripheral blood smear.
(211) (B) Clotting factor deficiency.
- This is a case of hemophilia
- Depending on the levei of factor Vm activity, patients w th hemophilia may present with easy bruising,
nadequate dotting of traumatic injuries or in the case of severe hemophilia, spontaneous hemorrhage.
- Hemarthrosis or bleed ng into the joints is a clinical hallmark of hemophilia.
(212) (A) Chronic renal failure.

- A low reticulocyte count usually points to decreased RBCs production as the primary mechanism
responsible for the anemia whereas an elevated reticulocyte count points to increased RBCs destruction
or hemolysis as the most likely cause.
- Although decreased RBCs production is the main mechanism in both anemia of chronic illness and
anemia of chronic kidney disease, often the anemia is due to a combination of factors, nduding
concomitant
b ood loss.
- Therefore, a reticulocyte count should always be interpreted with caution.
(213) (C) ImpairedFBS.

- In asymptomatic patients whose random serum glucose level suggests diabetes (>140 mg/dl), an FBS
or glycosylated haemoglob n HbAlc) level should be measured.
- An FBS level of 100-125 mg/dl is considered as impaired fasting glucose and an FBS level of less than
100 mg/dl is considered as normal fasting glucose.
- However an FBS of 91-99 mg/ dl is a strong independent predictor of future diabetes mellitus type 2.
Diabetes diagnostic criteria
Condition HbAlc
Fasting glucose mg/dl
2 hour glucose mg/dl
%
Normal < 140 < 110 < 6.0
Impaired fasting
< 140 k 110 and < 126 6.0 - 6.4
glycaemia
Impaired glucose & 140 < 126 6.0 - 6.4

tolerance
k 126 k 6.5
k 200
Diabetes mellitus
(214) (B) Insulin missed.
- This is case of diabetes mellitus type 1 presented with diabetic ketoacidosis.
- Insulin is always indicated in a patient who has been in ketoacidosis.
- The most common early symptoms of diabetic ketoacidosis are insidious polydipsia and polyuria.
- The following are other signs and symptoms of diab tic ketoacidosis:
laise gent I weakn s atigability.
- Nausea and vomiting that may be associated with diffuse abdominal pain, decreased appetite
and ia
3- Rapid weight loss in patients newly diagnosed with diabetes type 1.
4- A history of failure to comply with insulin therapy or missed insulin injections due to vomitii g o
'logical teas,
5 Decreased perspiration.
>- Altered consciousness (e.g. mild disorientation, confusion); frank coma is uncommon but may occur
he cor d egiec d or witl severe dehydration/ aci os ^
- The most common scenarios for diabetic ketoacidosis are underlying or concomitant infection (40%).
fussed insulin trt a er (25% ewi diagnosed previously unki own diabetes (15%)
er associate us / jp ighly 20% of the various scenarios.
(215) (A) Insulin deficiency which leads to fatty acid utilization and the production of ketones.
toacdo is the bo s producing iarge qua ti es o Ketone odies via the metabolism
of fatty acids sis ie bo s producing insuffic e suli to s production,
e oacidosis ca e smelled on a person's breath.
r his is due to th presence of acetone; a direct byproduct of the spontaneous decomposition acetoacetic
acid.
(216) (A) Now and then annually.

T ie risk of diabetic retinopathy varies with the type and duration of diabetes and with other life events
s, the screening guidelines differ from one person to another Diabetes mellitus type 1:
ople with diabetes type 1 should have eye examinations by an ophthalmologist or optometrist
ginning 5 years after they are diagnosed with diabetes, although screening is usually not necessary
before puberty.
eople who have difficulty with their vision or who require glasses or contacts may need to be seen
sooner.
tie frequency of subsequent examinations will depend upon the results of the initial exam.
eye exam is usually recommended every 1-2 years after the initial examination.
Diabetes mellitus type 2:
eople with diabetes mellitus type 2 should have an eye examination by an ophthalmologist or
optometrist when they are first diagnosed with diabetes.
The reason tor this s that blood sugar levels often increase over a period or several years before
th< person is diagnosed
Eye complications can develop during this time and often have no symptoms.
Having an eye exaruination soon after diagnosis can help to determine if there are eye complications,
the extent or severity of the complications and whether treatment is needed.
The frequency of subsequent exams will depend upon the results of the initial
examination, eye exam is u sually recommended every 1-2 years after the initial
examination.
(217) (A) His condition may resolve spontaneously so no management is necessary.
g ea iy to mid-puberty, pproxim ?ly 2/3 of b y develop various degrees of subareolar
hyperplasia of the breasts
• Physiologic pubertal gynecomastia may involve only one breast and it is not unusual for both breasts
to irge it disproportionate rates or it different times
(218) (C) It suppresses hepatic gluconeogenesis.

- Metformin inhibits hepatic gluconeogenesis through adenosine 5'-monophosphate activated protein
kinase-dependent regulation of the small heterodimer partner.
- Metformin is effective only in the presence of insulin and its major effect is to decrease hepatic
glucose output.
- In addition, metformin increases insulin-mediated glucose utilization in peripheral tissues (such as
muscL and liver tissue), particularly after meals and has an antilipolytic effect that lowers serum free
fatty acid concentrations, thereby reducing substrate availability for gluconeogenesis.
- As a result of the improvement in glycemic control, serum insulin concentrations decline slightly.
- Metformin, which decreases hepatic glucose output and sensitizes peripheral tissues to insulin, has
been shown to decrease mortality rates in patients with diabetes mellitus type 2 and is considered a
first-line agent.
(219) (A) Inappropriate secretion of antidiuretic hormone.
- The syndrome of inappropriate secretion of antidiuretic hormone is a disorder of impaired water
excretion caused by the inability to suppress the secretion of antidiuretic hormone.
- If water intake exceeds the reduced urine output, the ensuing water retention leads to the
development of hyponatremia.
- The syndrome of inappropriate secretion of antidiuretic hormone is an important cause of dilutional
hyponatremia that has been identified in tumors of the thymus gland, malignant lymphoma and
pancreatic neoplasms.
- It occurs predominantly, however, as a result of ectopic secretion of antidiuretic hormone by small cell
carcinomas of the lung.
- Since the tumor cells per se are autonomously producing antidiuretic hormone, there is no feedback
inhibition from the hypothalamic osmoreceptors and the persistent antidiuretic hormone effect on the
renal tubules causes water retention even with concentrated urine; hence the term inappropriate
antidiuretic hormorn secretion.
- Laboratory findings include low plasma sodium levels (dilutional hyponatremia), low plasma
osmolality and high urine osmolality caused by disproportionate solute excretion without water.
(220) (D) Give one liter of normal saline solution.

- Patients with diabetic ketoacidosis classically present with the triad of uncontrolled hyperglycemia,
metabolic acidosis and increased total body ketone concentration.
- Critically ill patients with severe hyperglycemia resulting from diabetic ketoacidosis or hyperglycemic
hyperosmolar syndrome should be treated immediately with a bolus of normal saline.
- The average fluid deficit for patients with diabetic ketoacidosis is 3-5 liters.
- Fluid resuscitation in young, otherwise healthy, patients should begin with a rapid bolus of 1
liter of normal saline followed by an infusion of normal saline at 500 ml/hour for several hours.
- These patients should then be given a loading dose of regular insulin at 0.1 units/kg body weight to a
maximum of 10 units, followed by an infusion of regular insulin at 0.1 units/kg body weight/hour, to a
maximum of 10 units/hour.
(221) (B) Sulfonylurea drugs.
These symptoms are due to hypog ycemia Sulfonylurea drugs are usually
well-tcuerated.
- Hypoglycemia is the most common side effect of these drugs and is more common with long-acting
sulfonylurea drugs (e.g. chlorpropamide, glyburide and glimepiride).
Thus, the use of long-acting sulfonylureas should be avoided in the elderly.
- A short-acting sulfonylurea, such as glipizide, is preferred.
- In patients who are using sulfonylurea drugs, the presence and frequency of hypoglycemia
should be evaluated at each clinic visit.
(222) (C) Human growth hormone.

Growth hormone is produced and released by the pituitary gland.
- When growth hormone is released into the blood, it stimulates the liver to produce another
hormone, insulin like growth factor 1. which causes growth of muscle, bones and cartilage throughout
the body.
- The characteristic findings in a patient with excessive growth hormone release are an enlarged jaw
(macrognathia) and enlarged, swollen hands and feet.
Manifestations of soft tissue overgrowth include macroglossia, deepening of the voice and paresthesia
of the hands (e.g. carpal tunnel syndrome in around 20% of patients).
- Macroglossia and enlargement of the soft tissues of the pharynx and larynx lead to obstructive sleep
apnea in about 50% of patients.
The skin thickens, making it hard to puncture and skin tags may appear, ert a ng the pa en o
grov cre. se and some women have irsutis
(223) (A) Decreased phagocytosis process.

pergiccemia-related impairment of the immune response involves neutrophil chemotaxis adherence
o ascuiar endothelium, phagocytosis, ntracellular bactericidal activity; opsonization cell-mediated
munity are ail depressed in diabetics with hyperglycem a
perglycemia caused by decreased insulin availability and increased resistance to insulin can affect
cellular esponse to tissue injury.
re is a delayed esponse to injury and impaired functioning of immune cells in diabetes mellitus.
(224) (C) Bisphosophnates.

agents current; available for osteoporosis treatment include bisphosphonates the selective >gen
recep: modulators raloxifene calcitonin, denosumab and an anabolic agent teriparatide
man recombrianT parathyroid hormone)
All therapies should be given with calcium and vitamin D supplementatio sphosphonates . re the most
commonly used agents for osteoporosis, ey have been employed for both treatment and prevention, al
and IV options are available.
ral bisphosphonates are considered as an initial therapy because of their efficacy, favorable cost and
availability of long-term safety data.
(225) (A) Missing insulin leads to the release of free fatty acids and the formation of ketone bodies.
- Diabetic ketoacidosis representing the metabolic consequences of insulin deficiency, glucagon excess
and counter regulatory hormonal responses to stressful triggers in patients with diabetes.
- Diabetic ketoacidosis is more common in younger patients with diabetes mellitus type 1, though it
can occur in diabetes mellitus type 2.
- Glucose concentrations in diabetic ketoacidosis are often usually < 800 mg/dl.
- In states of insulin deficiency, the combination of increased free fatty acid delivery and glucagon
excess promotes ketogenesis.
- Ketoacidosis results from lipolysis, with synthesis of ketones from free fatty acids in the liver
mitochondria.
(226) (C) Lifestyle and behavioral therapy.

- Diabetic patients with a systolic blood pressure of 130-139 mmHg or a diastolic blood pressure of
80-89 mmHg should be given lifestyle and behavioral therapy alone for a maximum of 3 months and
then,
if targets are not achieved, in addition, be treated with pharmacological agents that
block the renin-angiotensin system.
- A target blood pressure of <130/80 mmHg is reasonable if it can be safely achieved.
(227) (A) Inhibits the action of thyroid peroxidase (thyroperoxidase).

- Propylthiouracil is used for the treatment of hyperthyroidism.
- Propylthiouracil binds to thyroid peroxidase and thereby inhibits the conversion of iodide to iodine.
- Thyroid peroxidase normally converts iodide to iodine (via hydrogen peroxide as a cofactor)
and also catalyzes the incorporation of the resulting iodide molecule onto both the 3 and/or 5 positions
of the phenol rings of tyrosines found in thyroglobulin.
- Thyroglobulin is degraded to produce thyroxine (T4) and triiodothyronine (T3), which are the main
hormones produced by the thyroid gland.
- Therefore propylthiouracil effectively inhibits the production of new thyroid hormones.
(228) (D) Nothing.

- In early pregnancy, physiological changes can mimic biochemical hyperthyroidism that does not
require therapy.
- True subdinical hyperthyroidism may occur in pregnant women, but it is not typically
associated with adverse outcomes during pregnancy and does not require therapy.
-10-20% of normal pregnancies have subdinical hyperthyroidism during peak hCG activity.
- 60% of women with hyperemesis have subdinical or mild overt hyperthyroidism, which resolves
without treatment.
(229) (B) ABG.
>ie most widely used diagnostic criteria for diabetic ketoacidosis includes a blood glucose level 2 0
mg/dl, a moderate degree of ketonemia, serum bicarbonate <15 mEq/l, arterial pH <7.5 and an
ncreased anion gap metabolic acidosis.
The severity of diabetic ketoacidosis is determined primarily by the venous pH level, serum
bicarbonate level and mental status of the patient and not by the blood glucose measurement. A though
the bicarbonate level typically is low, it may be normal or high in patients with vomiting, etic use, or
alkali ingestion.
If the serum osmolality is less than 320 mOsm/kg (520 mmol/kg), etiologies other than diabetic
toacidosis should be considered.
(230) (A) Angiotensin converting enzyme inhibitors.

abetes mellitus and microalbuminuria revert to normal urine albumin excretion without treatment.
T lu mainstays of treatment to prevent the progression of diabetic nephropathy have traditionally
uded achieving adequate glycemic control and lowering blood pressure with angiotensin converting
enzyme inhibitors or angiotensin n receptor blockers
eight loss smoking cessation and decreased dietary protein have also been recommended.
The primary treatment goal is the prevention of end stage renal disease, because micro-
and rna roaibumnuria alone are asymptomatic conditions.
A giotensir converting enzyme inhibitors and angiotensin II receptor blockers are equally effective
reventing the progression of diabetic nephropathy, owever, the combination of an angiotensin
converting enzyme inhibitors and angiotensin II receptor ockers is not recommended because it provides
no additional benefit and actually leads to higher m creatinine .eveis and an increased rate of dialysis.
derately increased albuminuria (the new term for what was formerly called microalbuminuria)
is ned as persistent urinary albumin excretion between 30-300 mg/day (20-200 meg/min). erely
increased albuminuria (the new term for what was formerly called macroalbuminuria) ers to
albumin excretion above 300 mg/day (200 meg/min).
(231) (B) Chronic renal failure.

chronic kidney disease, plasma concentrations of creatinine and urea (which are highly dependent
on glomerular filtration) begin a nonlinear rise as glomerular filtration rate diminishes.
normalities of calcium, phosphate, parathyroid hormone, vitamin D metabolism and renal
sêodystrophy can occur.
Decreased renal production of calcitriol contributes to hypocalcemia,
ecreased rena excretion of phosphate results in
hyperphosphatemia.
econdary hyperparathyroidism is common and can develop into renal failure before abnormalities
Icium or phosphate concentrations occur.
For this reason, monitoring parathyroid hormone in patients with moderate chronic renal disease, even
be ore hyperphosphatemia occurs has been recommended.
(232) (A) Cushing's disease.
- Cushing's syndrome is a constellation of clinical abnormalities caused by chronic high blood levels of
cortisol or related corticosteroids.
- Cushing’s disease is Cushing’s syndrome that results from excess pituitary production of
adrenocorticotropic hormone, usually secondary to a pituitary adenoma.
- Clinical manifestations include moon face with a plethoric appearance, truncal obesity with
prominent supraclavicular and dorsal cervical fat pads (buffalo hump) and, usually, very slender
distal extremities and fingers.
- Muscle wasting and weakness are present.
- The skin is thin and atrophic, with poor wound healing and easy bruising.
- Purple striae may appear on the abdomen.
- Hypertension, renal calculi, osteoporosis, glucose intolerance, reduced resistance to infection and
mental disturbances are common.
- Cessation of linear growth is characteristic in children.
• Females usually have menstrual irregularities.
- In females with adrenal tumors, increased production of androgens may lead to hypertrichosis,
temporal balding and other signs of virilism.
(233) (B) Give 2 liters normal saline with KCI at 20 mEq.
- The primary goal in the initial management of diabetic ketoacidosis ns to restore intravascular
volume and improve tissue perfusion.
- This will decrease insulin counter-regulatory hormone levels and glucose concentration in the blood.
- One approach is to start with 0.9% NaCI 1 to 2 liters bolus, followed by an infusion rate of 0.9%
NaCI 500 ml/hour until the patient is hemodynamically stable.
- The rate is then decreased to 250 ml/hour and can be sw tched to half-normal saline to replace the
large free water deficit.
- To prevent hypokalemia, it recommended that potassium replacement occurs once serum levels fall
below 5.5 mEq/L.
- Generally, 20-30 mEq potassium in each liter of fluid is sufficient to maintain the serum potassium
within the range of 4.0-5.0 mEq/L
(234) (D) Both A and B.

- In the general population, only 50% of people inherit a copy (allele) of the DR gene called DR3 and
DR4 and less than 3% of the people have 2 alleles.
- However, at least one allele of DR3 or DR4 is found in 95% of Caucasians with diabetes mellitus
type 1 and individuals with both DR3 and DR4 are particularly susceptible to diabetes mellitus
typel.
- 90-95% of young children with diabetes mellitus type 1 carry HLA-DR3, HLA-DR4, or both.
- Carriage of both haplotypes (e.g. DR3/DR4 heterozygotes) confers the highest susceptibility.
- Types of human leukocyte antigen:
- DR2: Goodpasture's syndrome and multiple myeloma.
- DR3: diabetes mellitus, systemic lupus erythematosus and graves' disease.
- DR27: Ankylosing spondylitis and Reiter's syndrome.
- B51: Behcet's disease.
- Dll: Hashimoto's disease.
(235) (A) Diabetes mellitus.
- A weakened or undeveloped immune system or metabolic illnesses such as diabetes are significant
predisposing factors of candidiasis.
- There are several organism-specific factors that predispose diabetics to infection.
- Glucose-inducible proteins promote the adhesion of Candida albicans to buccal or vaginal epithelia.
This adhesion, in turn, impairs phagocytosis, giving the organism an advantage over the host.
- Vulvovaginal candidiasis is the most common form of mucosal candidiasis, it most often occurs in
situations associated with increased estrogen levels, such as oral contraceptive use and pregnancy.
- Antibiotics, glucocorticoids, diabetes mellitus, HIV infection, intrauterine devices and diaphragm use
are also risk factors.
(236) (A) Intubate, give 3% sodium, hydrocortisone and treat the hypothyroidism.
- Patients with hypothyroidism typically have a history of fatigue, weight gain, constipation and cold
intolerance.
- Physicians should include hypothyroidism in the differential diagnosis of every patient with
hyponatremia.
- Patients in a myxedema coma should be admitted to the intensive care unit and hypovolemia and
electrolyte abnormalities corrected.
- Mechanical ventilation may be necessary.
- Cardiovascular status should be monitored carefully, especially after IV thyroid hormone replacement.
Myocardial infarction must be ruled out and blood pressure stabilized.
- Because of the possibility of secondary hypothyroidism and associated hypopituitarism,
hydrocortisone should be administered until adrenal insufficiency has been ruled out.
(237) (A) Diabetes mellitus.

- Diabetes is the most common cause of kidney failure.
- Even when diabetes is controlled, the disease can lead to chronic kidney disease and kidney failure.
- Most people with diabetes do not develop a chronic kidney disease that is severe enough to progress
to kidney failure.
- People with kidney failure either undergo dialysis, an artificial blood-cleaning process, or
transplantation to receive a healthy kidney from a donor.
- Hypertension, is a major factor in the development of kidney problems in people with diabetes.
- Both a family history of hypertension and the presence of hypertension appear to increase the risk of
developing kidney disease.
- Hypertension also accelerates the progress of kidney disease when it already exists.
(238) (A) Hypertension andobesity.

- Systemic hypertension in the setting of diabetic nephropathy correlates well with the presence of
retinopathy.
- Independently, hypertension also may complicate diabetes, in that it may result in hypertensive retinal
vascular changes superimposed on the preexisting diabetic retinopathy, further compromising retinal
blood flow.
- Proper management of hyperlipidemia (elevated serum lipids) may result in less retinal vessel leakage
and hard exudate formation, but the reason behind this is unclear.
(239) (B) 12Months.
Ophthalmologic examination schedule for diabetes mellitus
Recommended first examination Minimum routine follow-up

Patient group
■ Within 5 years of diagnosis of diabetes once

DM 1 - Yearly.
the patient is 10-year-old or older.
- Yearly.
At the time of diagnosis of diabetes.
DM-2
Pregnancy in • Prior to conception and during the first trimester, - Close follow-up
preexisting - Counsel on the risk of development and/or throughout pregnancy and
diabetes progression of retinopathy. for one year postpartum.
(240) (A) Normal due to pregnancy.

- To meet the increased metabolic needs of a normal pregnancy, there are changes in thyroid
physiology that are reflected in altered thyroid function tests.
- The major changes in thyroid function during pregnancy are an increase in serum
thyroxine-binding globulin concentrations and stimulation of the TSH receptor by hCG.
(241) (A) Surgical resection.

- Surgery is the primary mode of therapy for patients with differentiated thyroid cancer.
- Total thyroidectomy is recommended if the primary tumor is at least 1-2 cm in diameter, or if
extrathyroidal extension or metastases are present.
- This operation should be performed by an experienced thyroid surgeon to minimize the risk of
hypoparathyroidism and recurrent laryngeal nerve injury.
- This more aggressive initial surgical approach is associated with lower rates of local and regional
recurrence in most patients and overall mortality in high risk patients.
(242) (A) Primary hyperaldosteronism.
- Individuals with primary aldosteronism may present with hypokalemic metabolic alkalosis;
however, as many as 38% of patients with aldosteronism may be normokalemic at presentation.
- Routine laboratory studies can show hypernatremia, hypokalemia and metabolic alkalosis
resulting from the action of aldosterone on the distal tubule of the kidney (e.g. enhancing sodium
reabsorption and potassium and hydrogen ion excretion).
(243) (C) After 5 years, then annually.
It is unusua far patients with diabetes mellitus type 1 under 30-year-old to develop retinopathy
that requres spec fie ophthalmologic therapy earlier than 5 years after the onset of diabetes
mellitus. patients with diabetes mellitus type 1, no clinically significant retinopathy can be seen in
the first ears after the nitial diagnosis of diabetes mellitus is made, ter 10-15 years, 25-50% of
patients show some signs of retinopathy.
rus prevalence ncreases to 75-95% after 15 years and approaches 100% after 30 years of diabetes
teuitus.
Proliferative diabetic retinopathy is rare within the first decade of diabetes mellitus type 1 diagnosis
ncreases to 14-17% within 15 years, rising steadily thereafter.
patients with diabetes mellitus type 2, an initial comprehensive examination by an ophthalmologist
optometrist is recommended shortly after the diagnosis of diabetes is made.
(244) (B) Hashimoto's thyroiditis.

ashimoto s thyroiditis is chronic autoimmune inflammation of the thyroid with lymphocytic
infiltration. Pat ents complain of painless enlargement of the thyroid or fullness in the throat.
E animation reveals a nontender goiter that is smooth or nodular, firm and more rubbery than the
normal thyroid.
any patients present with symptoms of hypothyroidism, but some present with hyperthyroidism,
estigations consist of measuring T4, TSH and thyroid autoantibodies. Early in the disease, T4 and levels
are normal and there are high levels of thyroid peroxidase antibodies and less commonly
antithyroglobulin antibodies.
tients later develop hypothyroidism with decreased T4, decreased thyroid radioactive iodine uptake
increased TSH.
(245) (D) Addison disease.

pokalemia is a common clinical problem that can result from decreased intake, increased nsiocation
into the cells, or, most often, increased losses of potassium from the gastrointestinal track n the
urine.
oss of gastric or intestinal secretions from any cause (vomiting, diarrhea, laxatives, or tube drainage)
ssociated with potassium losses and possibly hypokalemia.
pokalemia due to lower gastrointestinal tract losses (usually from diarrhea) is typically associated
bicarbonate wasting and metabolic acidosis rather than the metabolic alkalosis observed with per
gastrointestinal losses.
Addison disease, abnormalities in serum electrolyte levels are observed, including low Na '5 mEq/L),
high K (>5 mEq/L), low HC03 (15-20 mEq/L) and high BUN.
(246) (C) Parotid gland.

e major salivary glands are best examined by palpation and by observation of the salivary effluent
ng palpation.
y the parotic: gland and the submandibular glands can be examined in this way.
parotid gland ies on the lateral surface of the mandibular ramus and folds itself around
posterior border of the mandible.
- It is generally soft and is not usually palpable as a discrete gland.
- The anterior border of the gland may be better defined by having the patient clench his or her teeth
together, which tenses the masseter muscle.
- Around 40-100 lymph nodes are demonstrable in the dissection of the normal human neck; a few are
always palpable through the skin in normal living adults.
- Normally the thyroid gland is palpable and rises along with thyroid and cricoid cartilage during
swallowing, in persons with a slender neck.
(247) (C) Increased adrenocorticotropic hormone from the adrenal gland.
- The hallmark biochemical feature of adrenocorticotropic hormone dependent Cushing's syndrome is a
normal or elevated adrenocorticotropic hormone level, which reflects tumoral secretion.
- The tumor secretion of adrenocorticotropic hormone causes bilateral adrenocortical hyperplasia and
hyperfunction.
- The increased serum cortisol concentrations inhibit both hypothalamic corticotropin releasing hormone
and vasopressin secretion, as well as adrenocorticotropic hormone secretion by normal pituitary
corticotrophs.
- While the term Cushing's syndrome denotes the clinical picture resulting from cortisol excess from any
cause, Cushing's disease refers to hyperfunction of the adrenal cortex from pituitary adrenocorticotropic
hormone excess.
- Patients with Cushing's disease usually have a small adenoma of the pituitary gland.
(248) (D) Give him IM glucagon.

- As the main counter-regulatory hormone to insulin, glucagon is the first-line treatment for severe
hypoglycemia in insulin-treated patients with diabetes
- Unlike dextrose, which must be administered IV by a qua ified health care professional, glucagon can be
administered by SC or IM injection by trained parents o caregivers.
- This can prevent the delay in commencing treatment that is otherwise experienced while waiting for the
arrival of emergency personnel, reducing the need for hospitalization and providing reassurance for
patients and their caregivers.
(249) (C) 6-7%.

- The recommended target glycosylated haemoglobin value should be lower than 7% for most patients.
- The goal should be set somewhat higher for older patients and those with comorbid conditions or a
limited life expectancy in which the risk of hypoglycemia may outweigh the potential benefit.
(250) (C) SBP less than 130 mmHg and DBP less than 80 mmHg.
- Most guidelines for the treatment of hypertension recommend a blood pressure goal of <140/90 mmHg
and a more aggressive goal of <130/80 mmHg for patients with diabetes mellitus.
(251) (A) Acromegaly.
- Gigantism and acromegaly are syndromes of excessive secretion of growth hormone
(hypersomatotropism) that are nearly always due to a pituitary adenoma.
- Before closure of the epiphyses, the result is gigantism.
Later, the result is acromegaly, which causes distinctive facial and other features.
- Diagnosis is clinical and by skull and hand x-rays and the measurement of growth hormone levels.
- Treatment involves removal or destruction of the responsible adenoma.
- Acromegaly is the clinical syndrome that results from the excessive secretion of growth hormone.
The mean age at diagnosis is 40-45-year-old.
iie earliest clinical manifestations are coarsening of the facial features and soft tissue swelling of the
hands and feet.
he patient's appearance changes and larger rings, gloves and shoes are needed.
The heart, liver, kidneys, spleen, thyroid, parathyroid glands and pancreas are larger than normal.
(252) (C) Reduce weight.

Evaluation of a patient with difficult-to-control hypertension should begin with an assessment of
adherence to the prescribed management plan, including recommended lifestyle modifications. Patients
may not appreciate the value of lifestyle modifications such as the dietary approaches to stop
ypertension.
xplaining that the combination of the dietary approaches and low sodium intake can be as effective
single antihypertensive medication may help motivate patients, addition, a low sodium diet has been
shown to reduce cardiovascular events, e importance of weight loss for overweight patients should also
be stressed, ther lifestyle modification recommendations include daily aerobic exercise (which has the
added e efit of promoting weight loss) and moderation of alcohol intake.
(253) (A) T3.

T3 is 4 times more active than the more abundant T4.
le half-life of T3 is only 1 day, while the half-life of T4 is 5-7 days.
Approximately 99% of circulating thyroid hormone is bound to plasma protein and is metabolized
rimarily by the liver.
le main hormone secreted from the thyroid gland is T4, which is converted to T3 by deiodinase in the
peripheral organs.
(254) (D) Evaluation of TSH and free T4 and follow up.

areas of mild to moderate iodine deficiency, the prevalence of thyroid nodules during pregnancy a
les between 3-21%.
pregnant woman found to have a thyroid nodule should be evaluated in the same way as
if sue were not pregnant.
yroid function tests (TSH and free T4) and US analysis should be performed,
hyroid radionuclide scanning is contraindicated during pregnancy.
The indications for fine needle aspiration of the nodule are the same as in nonpregnant patients.
- Fine needle aspiration is safe to perform during pregnancy.
Subsequent management varies according to the biopsy results.
(255) (C) Hypokalemia.
• Nonsuppressible primary hypersecretion of aldosterone is an underdiagnosed cause of hypertension.
- The classic presenting signs of primary aldosteronism are hypertension and hypokalemia.
-Hypokalemia is present in many patients with primary aldosteronism who are on an adequate sodium
intake.
- Two factors contribute to the urinary potassium wasting in this setting: the hypersecretion of
aldosterone, which directly promotes potassium secretion in the cortical collecting tubule and the
adequate delivery
of sodium and water to the distal secretory site.
- As an example, increasing sodium intake and, therefore, distal delivery will exacerbate the
hypokalemia in this setting, since aldosterone secretion will not be appropriately suppressed by the
volume expansion.
(256) (C) Beta-blockers and propylthiouracil.

- In many tissues, hyperthyroidism is associated with an increased number of beta-adrenergic
receptors.
- The ensuing increase in beta-adrenergic activity is responsible for many of the symptoms
associated with this disorder.
- It also explains the ability of beta-blockers to rapidly ameliorate many of the symptoms,
including palpitations, tachycardia, tremulousness, anxiety and heat intolerance.
- Many of the neurologic and cardiovascular symptoms of thyrotoxicosis are relieved by
beta-blockers therapy.
- Before such therapy is initiated, the patient should be examined for signs of dehydration that
often occur with hyperthyroidism.
- After oral rehydration, beta-blockers therapy can be started.
- Beta-blockers therapy should not be administered to patients with a significant history of bronchial
asthma.
- Anti-thyroid drugs (e.g. methimazole and propylthiouracil) have been used for hyperthyroidism.
- These medications are employed for the long term control of hyperthyroidism in children,
adolescents and pregnant women.
- In adult men and non-pregnant women, they are used to control hyperthyroidism before definitive
therapy with radioactive iodine.
(257) (C) Pseudobulbar palsy.

- Progressive pseudobulbar palsy affects mainly the muscles of the face, jaw and throat.
- Emotions may be changeable: people with progressive pseudobulbar palsy may switch from
happiness to sadness quickly and without reason.
- Inappropriate emotional outbursts are common.
- Many years later, muscles begin to twitch and waste away.
- The disorders usually progress for several years before total disability results.
(258) (D) TSH.
Thyroid hormone has important effects on cardiac muscle, the peripheral circulation and the
sympathetic nervous system that alter cardiovascular hemodynamics in a predictable way in patients
with , perthyroidism.
- Cardiovascular symptoms are common in patients with hyperthyroidism.
- Some actions of T3 on the heart produce clinical findings similar to those of beta-adrenergic
stimulation. Hyperthyroidism predictably increases heart rate and cardiac contractility.
- Virtually all measures of cardiac function, including left ventricular ejection fraction, the rate of
ventricular pressure development, diastolic relaxation and cardiac output, are increased.
(259) (B) Subacute thyroiditis.

Subacute thyroiditis (subacute granulomatous thyroiditis) is characterized by neck pain or discomfort ,
a tender diffuse goiter and a predictable course of thyroid function evolution.
Thyroiditis is defined as inflammation of the thyroid gland.
Common types are subacute granulomatous, radiation, lymphocytic, postpartum and drug-induced
amiodarone hyroiditis.
Signs and symptoms in subacute and radiation, presents with tender thyroid, malaise and upper
respiratory tract infection symptoms.
- Diagnosis of this condition is dependent on thyroid dysfunction (typically hyperthyroidism
followed by hypothyroidism), with decreased uptake on a radioactive iodine uptake test.
- Treatment involves the administration of beta-blockers for hyperthyroidism; levothyroxine for
hypothyroidism and anti-inflammatory medication.
(260) (C) Dexamethasone suppression test.

rhe possible presence of Cushing s syndrome is suggested by certain signs and symptoms.
- Unfortunately, none of these are pathognomonic and many are nonspecific (e.g. obesity,
hypertension, menstrual irregularity and glucose intolerance).
- As a result, the diagnosis must be confirmed by biochemical tests.
Biochemical confirmation of Cushing's syndrome has relied upon the measurement of urinary free
cortisol over a 24 hours period and low dose dexamethasone suppression testing.
Low-dose dexamethasone suppression testing, especially the 1 mg overnight test, has been the
mainstay of biochemical screening and is recommended in most standard texts.
(261) (A) Mucormycosis.

Immunocompromising conditions are the main risk factor for mucormycosis.
■ Patients with uncontrolled diabetes mellitus, especially with ketoacidosis, are at high risk.
When spores are deposited in the nasal turbinates, rhinocerebral disease develops.
Most patients with rhinocerebral disease have diabetes mellitus (especially with ketoacidosis).
Rhinocerebral mucormycosis may manifest as unilateral, retro-orbital headache, facial pain, numbness,
fever, hyposmia and nasal stuffiness, which progresses to black discharge, initially, mucormycosis may
mimic sinusitis.
(262) (A) Hyperthyroidism.
- Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free
thyroid hormone
- There are many symptoms, including tachycardia, fatigue, weight loss, nervousness and tremor.
- Diagnosis is made by clinical signs and symptoms and with thyroid function tests.
- Treatment depends on the cause
(263) (A) Insulin mismanagement
- The absence of insulin, the prima y anabolic hormone m ns that issues such as muscle, fat and liver
do
not take up glucose.
- Counter regulatory hormones, such as glucagon, growth hormone and catecholamines, enhance
triglyceride breakdown nto fee fatty acids and gluconeogenesis, which is the main cause for the
elevation in serum c; ucose level in diabetic ketoacidosis.
- Beta-oxidation of these free fatty ac ds ads to 'ncre sed formation of ketone bodies
The n o common scenarios foi liabetic ketoa sis inderiymg or concomitant infection
(40%), missed insulin treatments (25%) a d new diagnosed previously unknow d abetes
(15%).
(264) (B) Increase in testicular size.

- The earliest stage of male maturatio which has a mean duration of 6 months is an
increase in testicular size.
- Almost al boys have an increase I test cu a olume (> c) prior to the appearance of penile growth
and pubic hair.
Thus if o le considers oniy pub hair in the assessmer early male puberty, misdassification
and unnecessary testing may resu t.
- The appearance of sperm in the urine and the onset oi nocturnal sperm emissions occur shortly
after the attainment of peak height velocity, many consider e events the male equivalent of menarche.
(265) (C) Increase in longacting insulindose.

- An elevated blood glucose level before breakfast needs t< ncrease pre-dinner oi pre-bed
intermediate or long-acting insuhn.
- Blood glucose tests dur ng the night might ensure that this change does not result in nocturnal
hypoglycemia.
(266) (A) Biofeedback.

Biofeedback is a treatment technique n which people are trained to improve their health by using
signals from their own bodies.
It may be used to improve health, performance and the physiological changes that often occur in
conjunction with changes to thoughts, emotions and behavior.
It has been found to be effective in the treatment of headaches and migraines
(267) (C) 100%oxygen.
- During the onset of a cluster headache, many people respond to the inhalation of 100% oxygen therapy
12-15 liters/min in a non-re-breathing mask).
- Some people have found better results with 25 liters/min.
- When oxygen is used at the onset the attack can be aborted in as little as 1 minute or as long
as 10 minutes.
- Once an attack is at its peak, oxygen therapy appears to have little effect so many people
keep an oxygen tank close at hand to use at the very first sign of an attack.
Hyperbaric oxygen therapy has been used successfully in treating cluster headaches though it was not
shown to be more successful than surface-pressure oxygen.
(268) (A) Multiple sclerosis.

multiple sclerosis, patients present with multiple neurologic complaints that are separated in time
and space and are not explained by a single lesion, fts the disease progresses, permanent deficits may
accumulate.
Limb weakness, optic neuritis, paresthesia, diplopia, vertigo, nystagmus, gait unsteadiness, urinary
etention, sexual and bowel dysfunction, depression and cognitive impairment are also seen.
CSF reveals mononuclear pleocytosis (>5 cells/pl) and an increase IgG index, or oligoclonal bands
(nonspecific).
(269) (E) Decreased level of consciousness.
The earliest sign of increased intracranial pressure is a change in the level of consciousness symptoms
include restlessness, confusion and drowsiness).
ther early signs are headache, nausea, vomiting and pupil diameter changes.
Late signs of intracranial pressure are bradycardia, hypertension and bradypnea (Cushing's triad).
(270) (B) Tissue plasminogen activator.

stroke, or cerebrovascular accident, is characterized by the sudden loss of blood circulation to an area
the brain, resulting in a corresponding loss of neurologic function, trokes are classified as either
hemorrhagic or ischemic.
- -cute ischemic stroke refers to strokes caused by thrombosis or embolism and is more
common than hemorrhagic stroke.
urrent treatments for acute ischemic stroke include IV thrombolytic therapy with tissue-type
lasminogen activator and endovascular therapies, including intra-arterial thrombolytic therapy and ne
use of clot retrieval devices.
surgical management with hemispheric decompression in patients with middle cerebral artery erritory
infarction and associated life-threatening parenchymal edema has also been supported.
T ssue plasminogen activator is administered within 3 hours of symptoms onset (if no contraindication).
Aspirin: use within 48 hours of ischemic stroke to reduce risk of death.
- Clopidogrel: can be used in acute ischemic stroke.
- Heparin and other anticoagulants: can be used in patient has high risk of DVT or atrial fibrillation.
(271) (A) Neisseria meningitides.
- Bacterial meningitis classically presents with the triad of headache, high fever and nuchal rigidity.
- Meningitis caused by the bacteria Neisseria meningitidis can be differentiated from meningitis of
other causes by a rapidly spreading petechial rash, which may precede other symptoms.
- The rash consists of numerous small, irregular purple or red spots (petechiae) on the trunk, lower
extremities, mucous membranes, conjuctiva and (occasionally) the palms of the hands or soles of the
feet.
- CSF glucose is low in bacterial, mycobacterial and fungal infections.
- The three most common etiologic agents of bacterial meningitis are Haemophilus influenzae at 6% of
cases, Neisseria meningitis at 10% and streptococcus pneumonia at 26%.
(272) (A) Cluster headache.

- Males are affected by cluster headaches more often than females and the average age of onset is
25-year-old.
- Patients present with a brief, excruciating, unilateral periorbital headache that lasts 30
minutes to 3 hours, during which the patient tends to be extremely restless.
- Attacks tend to occur in clusters, affecting the same part of the head at the same time of
day (commonly during sleep) and in a certain season of the year.
- Associated symptoms include ipsilateral lacrimation of the eye, conjunctival injection, Homer's
syndrome and nasal stuffiness.
- Diagnosis: classic presentations with a history of repeated attacks over an extended period of time
require no evaluation.
- First episodes require a workup to exclude disorders associated with Horner's
syndrome (e.g. carotid artery dissection or cavernous sinus infection).
- Treatment: acute therapy: high-flow oxygen (100% non-rebreather), dihydroergotamine,
octreotide, sumatriptan or zolmitriptan.
- Prophylactic therapy: transitional therapy includes prednisone and ergotamine and
maintenance therapy includes verapamil, methysergide, lithium, valproic acid and topiramate.
(273) (D) Cerebellum.

- The cerebellum coordinates voluntary movements such as posture, balance, coordination and speech,
resulting in smooth, balanced muscular activity.
- It is also important for learning motor behaviors.
- It is a relatively small portion of the brain, about 10% of the total weight, but it contains half the
brain's neurons.
- Damage to the cerebellum, while not causing paralysis or intellectual impairment, would contribute to
a lack of balance, slower movements and tremors.
- Complex physical tasks would become unsteady and halting.
(274) (C) Tension headache.
Tension headaches are considered by some to be a milder form of migraine headache.
- They are more common in females than in males.
Patients usually present with a tight, band-like pain that is not associated with sensory phobia, nausea,
vomiting, or auras and is brought on by fatigue or stress.
- Nonspecific symptoms (e.g. anxiety, poor concentration, difficulty sleeping) may also be seen.
- May be generalized or most intense in the frontal, occipital and neck regions.
Ir
- It is diagnosed by exclusion other differential diagnosis.
Treatment is: relaxation, massage, hot baths and avoidance of exacerbating factors.
- NSAIDs and acetaminophen are first-line abortive therapies, but triptans may also be considered.
(275) (B) Ascending paralysis starting from the lower limbs.

- Guillain-Barre syndrome is an acute polyneuropathy affecting theperipheral nervous system.
Ascending paralysis and weakness beginning in the feet and hands and migrating towards the trunk, is
the most typical symptom and some subtypes cause changes in sensation or pain as well as dysautonomia.
- It can cause life-threatening complications, in particular if the muscles of respiration are affected or if
isau o iom ystem involvement.
(276) (A) ABC of CPR to secure airway.

- When an individual is brought to the ER during or following a grand mal seizure, the airway and
circulation must first be protected and then any associated injuries or medical problems (e.g. stroke, drug
overdose or withdrawal, infection, or complications of diabetes) must be treated.
individual rom self-injury
- CPR may be needed in some cases.
- If the seizure is ongoing, a thiamine and sugar solution (glucose) should be given IV.
- Both vitamin Bl-deficiency and low blood sugar (hypoglycemia) can cause grand mal seizure and are
easily treated with no side effects.
- An individual with ongoing grand mal seizures is treated with anticonvulsant drugs, either individually
or in combination.
(277) (B) Occipital lobe.

he occipital i perception of the mamma: brain containing most of the Visual cortex,
e an o ta es visual symptom .vhi can ange fron v uai hallucinations to
aiete blindne
(278) (C) Lymphocytosis.

tic mening is i also o te reft red to as viral m ningitis
r tseptic meningitis i es a clinical syndrome th edominan f lymphocytes CSF i no m teria
agen > identified in the CSF
ana is! a g es a pro e of lymphocytic pleocytosis usually less than 000 cells/cc
yeli pro in level and normal glucose level.
es 20-75% of patients with viral meningitis have neutrophil predominance in the
CSF spe men obtain d especially in enterovirus mumps and arbovirus nfections.
A repeat lumbar puncture wit in 8 12 hours frequently shows a change from neutrophil to lymphocyte
predominance, with the emainder taking place in 24 48 hours.
(279) (A) Orthostatic hypotension.
- Pure autonomic failure, also known as Bradbury-Eggleston syndrome or idiopathic orthostatic
hypotension, is a form of dysautonomia that first occurs in middle-aged patients or later in life:
men are affected more often than women.
- it is one of three diseases classified as primary autonomic failure.
- It is a degenerative disease of the autonomic nervous system and symptoms include dizziness and
fainting (caused by orthostatic hypotension), visual disturbances and neck pain.
- Chest pain, fatigue (physical) and sexual dysfunction are less common symptoms that may also occur.
- Symptoms are worse when standing; sometimes one may relieve symptoms by lying down.
(280) (B) Heat exhaustion.

ex USt ion:
- Heat exhaustion is one part of the spectrum of heat related illness that begin with heat cramps,
progress to heat exhaustion and finally to heat stroke.
- Heat exhaustion often occurs when people are exposed to high temperatures, especially when
combined with strenuous physical activities and humidity.
- Body fluids are lost through sweating, causing dehydration in adults and overheating of the body.
- The temperature may be elevated, but not above 403C.
2- Heat stroke:
- Heat stroke, also referred to as sun stroke, is a life-threatening medical condition in which the body
temperature may reach 40.5‘C or greater within minutes.
- Heat stroke symptoms include heavy sweating, rapid breathing, rapid and weak pulse, dry skin and
dizziness.
- The od s cooling system, which is controlled by the brain, stops working and the internal body
temperature rises to the point at which brain damage or damage to other internal organs may result.
- Heat rash due to skin irritation from excessive sweating.
(281) (A) Migraine.

- Migraine headaches affect females more often than males and may be familial.
- Auras may occur with or without the pain of migraine headache.
- Onset usually occurs when the patient is in their early 20s.
- Patients usually present with a throbbing headache (>2 hours but usually <24 hours and almost
always < 72 hours in duration) that is associated with nausea, vomiting, photophobia and noise
sensitivity.
- Headache is usual y relieved by sleep and darkness.
(282) (C) Loss of dorsiflexion compartment of the foot (foot drop).
Lumbar nerve root entrapment - signs and symptoms
Nerve root Sensory changes Reflex loss Weakness Usual disc prolapsed
- Hip flexion and

L2 - Front of thigh. - None. -L2/3.
adduction.
L3 - Inner thigh and knee. - Knee. - Knee extension.
L4 - Inner calf. - Knee. - Knee extension. - L3/4.
- Outer calf. - Inversion of foot.

L5 - None. - L4/5.
- Upper and inner foot - Dorsiflexion of toes.
- Posterior calf.
SI - Ankle. • Plantar flexion of foot. - L5/S1.
- Lateral border of foot.
(283) (D) Median nerve injury and loss of thumb opposition.

Lacerations of the wrist often cause median nerve injury because this nerve is relatively close to the
suface.
(284) (C) Between L3-L4.

Lumbar puncture is a procedure that is often performed in the ER to obtain information about CSF.
Although usually used for diagnostic purposes to rule out potentially life-threatening conditions (e.g.
pediatrics bacterial meningitis or subarachnoid Hemorrhage), it is also sometimes used for
therapeutic purposes (e.g. treatment of idiopathic intracranial hypertension).
CSF fluid analysis can also aid in the diagnosis of various other conditions (e.g. demyelinating
diseases and carcinomatous meningitis).
- This procedure is done between L3-L4 because in about 94% of individuals the spinal cord ends at
the evel of the LI vertebra.
The L3-L4 interspace or below is therefore the safest position for this procedure.
(285) (B) Elevated blood pressure.

- Hypertension is the most important modifiable risk factor for stroke and intracerebral
hemorrhage and the risk of stroke increases progressively with increasing blood pressure,
independent of other factors.
Modifiable risk factors include: obesity, atrial fibrillation, carotid stenosis, hypercholesterolemia,
smoking, hypertension, diabetes mellitus and drug use (cocaine or IV drugs).
- Non modifiable risk factors are: family history of myocardial infarction or stroke, age over
60-year-old, male gender and African-American, Hispanic, or Asian ethnicity.
(286) (C) Anticonvulsant drugs are not needed if the patient has seizures.
- Anticonvulsants prevent seizure recurrence and terminate clinical and electrical seizure activity.
- These agents are used routinely to avoid seizures that may be induced by cortical damage.
- Guidelines for management of spontaneous intracranial hemorrhage and treatment with
antiepileptic drugs are indicated for those patients with clinical seizures or with EEG seizure
activity accompanied by a change in mental status.
- Prophylactic use of anticonvulsants is controversial and should be used judiciously, if at all.
(287) (A) Dorsal column.
- The Romberg test is a test of the body's sense of positioning (proprioception), which requires
healthy functioning of the dorsal columns of the spinal cord.
(288) (B) Tremors.

- This is a case of Parkinson's disease.
- Clinical diagnosis requires the presence of 2 of 3 cardinal signs: resting tremor, rigidity, or
bradykinesia.
- The most common initial finding is an asymmetric resting tremor in an upper extremity.
(289) (C) Sodium valproate.

- Sodium valproate is a type of anticonvulsant.
- It belongs to category of valproic acid drugs.
- It is a broad spectrum anticonvulsant, producing little sedation or other central effects.
- Its chief side effects are weight gain, edema, fulminate hepatitis, anorexia, vomiting,
drowsiness, ataxia, tremor, transient loss of hair, increased blood ammonia, rashes and
thrombocytopenia.
- Phenytoin side effects: gingival hyperplasia, hirsutism and ataxia.
- Carbamazepine side effects: agranulocytosis, hepatotoxicity and aplastic anemia.
(290) (A) Carbamazepine.

• This is a case of trigeminal neuralgia.
- The goal of pharmacologic therapy is to reduce pain.
- Carbamazepine is regarded by most as the medical treatment of choice.
• Some advocate a trial of baclofen since it has fewer adverse effects.
- Oxcarbazepine may be better tolerated.
- The synergistic combination of carbamazepine and baclofen may provide relief from episodic pain
though convincing clinical evidence is weak at best.
- The anticonvulsant carbamazepine is the first line treatment.
- Second line medications include baclofen, lamotrigine, oxcarbazepine, phenytoin, gabapentin,
pregabalin and sodium valproate.
- Uncontrolled trials have suggested that clonazepam and lidocaine may be effective.
(291) (D) Tonic-clonic convulsion.
- Extrapyramidal symptoms, such as akathisia, dystonia, psuedoparkinsonism and dyskinesia, are
drug-induced side effects that can be problematic for persons who receive antipsychotic medications
or other dopamine-blocking agents.
- The clinical manifestations include a number of atypical involuntary muscle contractions that
influence gait, movement and posture.
(292) (B) Hypertension.
The most common cause of spontaneous intracerebral hemorrhage is hypertension.
Chronically high blood pressure can weaken the walls of arteries, particularly deep in the brain where
small vessels branch off of larger arteries.
When high pressure pushes against those weak blood vessel walls, the artery can burst.
nee hypertension by itself often causes no symptoms, many people with intracranial hemorrhage are
< o aware that they have high blood pressure, or that it needs to be treated.
- Less common causes of intracerebral hemorrhage include trauma, infections, tumors, blood clotting
deficiencies and abnormalities in blood vessels (such as arteriovenous malformations).
(293) (C) Rupture of a cerebral aneurysm.

subarachnoid hemorrhage is bleeding into the subarachnoid space.
e subarachnoid spaceis the area between the arachnoid (brain) and the pia mater surrounding the
man brain.
his may occur spontaneously, usually from a ruptured cerebral aneurysm, or may result from head
lji igy.
85% of cases of spontaneous subarachnoid hemorrhage, the cause is rupture of a cerebral aneurysm,
rebral aneurysm is a weakness in the wall of one of the artery in the brain that becomes enlarged,
hey tend to be located in the circle of Willis and its branches.
hile most cases of subarachnoid hemorrhage are due to bleeding from small aneurysms, larger .
eurysms which are less common are more likely to rupture.
(294) (A) Nitrofurantoin

ms is a case of urinary tract infection.
ternative therapies in the presence of sulfa allergy or where E. coli Trimethoprim-sulfamethoxazole
es stance rates exceed 20% is a fluoroquinolone or nitrofurantoin.
(295) (A) Interstitial cystitis.

terstitial cystitis is a syndrome characterized by urinary urgency and frequency, usually with pelvic a
n and nocturia, in the absence of bacterial infection or any other identifiable pathology.
is a diagnosis of exclusion of unknown cause characterized by bladder pain.
It may be associated with urinary urgency, urinary frequency, nocturia and sterile urine cultures.
nose with interstitial cystitis may have symptoms that overlap with other urinary bladder disorders
uch as urinary tract infection, overactive bladder, urethritis, urethral syndrome and prostatitis.
(296) (A) Creatinine clearance.

Renal function, in nephrology, is an indication of the state of the kidney and its role in renal
physiology, ne creatinine clearance test compares the level of creatinine in urine with the creatinine level
in the lood.
eatinine is a breakdown product of creatine, which is an important part of muscle.
The test helps provide information on kidney function.
(297) (A) RBCs cast in urine.
- Urinalysis and sediment examination are crucial in the evaluation of patients with acute nephritic
syndrome.
- In some instances, marked sterile pyuria is present.
- The presence of RBCs casts is almost pathognomonic of glomerulonephritis.
(298) (C) Polycystic kidney disease.
- Autosomal dominant polycystic kidney disease is a multisystem and progressive disorder characterized
by cyst formation and enlargement of the kidney and other organs (e.g. liver, pancreas and spleen).
- Signs and symptoms: pain in the abdomen, flank, or back is the most common initial complaint and
it is almost universally present in patients with autosomal dominant polycystic kidney disease.
- Dull aching and an uncomfortable sensation of heaviness may result from a large polycystic liver.
- Examination in patients with autosomal dominant polycystic kidney disease may demonstrate the
following: hypertension, palpable, bilateral flank masses, nodular hepatomegaly and, rarely, symptoms
related to renal failure (e.g. pallor, uremic fetor, dry skin and edema).
(299) (C) Iron.

- Iron can be obtained from chickpeas (e.g. in hummus), lentils, navy beans, pinto beans, kidney beans,
soybeans, quinoa, tofu, raisins, goji berries, fortified vegan burgers, soy products, pumpkin seeds,
cashews, figs, sunflower seeds, sesame tahini, prunes, whole wheat parsley and pine nuts.
(300) (C) Lung hemorrhage and glomerulonephritis.

- Goodpasture's syndrome is an uncommon and life-threatening hypersensitivity disorder believed to be
an autoimmune disorder process related to antibody formation in the body.
- Goodpasture's syndrome is characterized by glomerulonephritis and lung hemorrhage.
- The exact cause is unknown.
- Sometimes the disorder is triggered by a viral infection or by the inhalation of gasoline or other
hydrocarbon solvents.
- An association also exists between cigarette smoking and the syndrome.
- The target antigen of the Goodpasture's antibodies has been localized to type IV collagen.
(301) (A) Bilateral renal artery stenosis.

In renal artery stenosis, renal perfusion pressure is reduced and nephron transit time is prolonged
on the side of the stenosis; salt and water reabsorption is therefore increased.
- As a result, urine from the ischaemic kidney is more concentrated and has a lower sodium
concentration than urine from the contralateral kidney.
- Creatinine clearance is decreased on the ischaemic side.
- Patients with documented or possible renovascular hypertension may experience progressive azotemia
as a consequence of the renal ischemia and/or the persistence of significant hypertension.
- Refractory hypertension (e.g. poor control of blood pressure despite treatment with 3 or more
antihypertensive agents) may occur.
(302) (B) The development of pharyngitis/tonsillitis.
- Acute rheumatic fever is an autoimmune inflammatory process that develops as a consequence of
streptococcal infection.
• Acute rheumatic fever has extremely variable manifestations and remains a clinical syndrome for
which no specific diagnostic test exists.
- Persons who have experienced an episode of acute rheumatic fever are predisposed to recurrence
following subsequent (rheumatogenic) group A streptococcal infections.
- Acute rheumatic fever is characterized by nonsuppurative inflammatory lesions of the joints, heart,
subcutaneous tissue and central nervous system.
- Rheumatic fever follows pharyngeal infection with rheumatogenic group A streptococcus.
-The risk of developing rheumatic fever after an episode of streptococcal pharyngitis has
been estimated at 0.3-3%.
(303) (D) Fever.

Modified Jones criteria for a first episode of acute rheumatic fever:
1- Major criteria: carditis, chorea, erythema marginatum, polyarthritis and subcutaneous nodules.
2- Minor criteria: arthralgia, elevated ESR or CRP, fever and prolonged PR interval on ECG.
- Diagnosis of acute rheumatic fever requires 2 major or 1 major and 2 minor manifestations and
evidence of group A streptococcal infection; e.g. elevated or rising antistreptococca! antibody titer (e.g.
antistreptolysin O, anti-DNase B), positive throat culture, or positive rapid antigen test.
(304) (A) Amphotericin B.

- A compound of pentamidine and amphotericin B is used as a second line for treatment of
Leishmania.
(305) (C) Metronidazole.

- Giardia intestinalis is a flagellate that is found world-wide.
- It causes small intestinal disease (giardiasis), with diarrhea and malabsorption.
- A 2 gm of metronidazole given as a single dose on 3 successive days will cure the majority of
infections, although sometimes a second or third course is necessary.
- Alternative drugs include tinidazole, mepacrine and albendazole.
(306) (A) Infectious mononucleosis.

- Tests for Epstein Barr virus antibodies are used to help diagnose infectious mononucleosis.
- Cervical lymphadenopathy and hepatosplenomegaly are signs of infectious mononucleosis.
(307) (A) Kaposi sarcoma.

- Kaposi sarcoma is a spindle cell tumor thought to be derived from endothelial cell lineage.
- AIDS-related Kaposi sarcoma, unlike other forms of the disease, tends to have an aggressive clinical
course.
- Lesions in Kaposi sarcoma may involve the skin, oral mucosa, lymph nodes and visceral organs.
- Most patients present with cutaneous disease.
(308) (A) Plasmodium falciparum.
- In humans, malaria is caused by Plasmodium falciparum, Plasmodium malariae, Plasmodium ovale,
Plasmodium vivax and Plasmodium knowlesi.
- Plasmodium falciparum is the most common species identified among infected individuals (~75%),
followed by Plasmodium vivax (~20%).
1- In Plasmodium vivax or Plasmodium ovale infection:
- The illness is relatively mild.
- Anemia develops slowly and there may be tender hepatosplenomegaly.
- Spontaneous recovery usually occurs within 2-6 weeks, but hypnozoites in the liver can cause
relapses for many years after infection.
- Repeated infections often cause chronic ill health due to anemia and hyperreactive splenomegaly.
2- Plasmodium malariae infection:
- This also causes a relatively mild illness, but tends to run a more chronic course.
- Parasitaemia may persist for years, with or without symptoms.
- In children. Plasmodium malariae infection is associated with glomerulonephritis and nephrotic
syndrome.
3- Plasmodium falciparum infection:
- This causes, in many cases, a seif-limiting illness similar to the other types of malaria, although the
paroxysms of fever are usually less marked.
- However it may also cause serious complications and the vast majority of malaria deaths are due to
Plasmodium falciparum.
- Patients can deteriorate rapidly and children, in particular, progress from reasonable health to
coma and death within hours.
- A high parasitaemia (1% of red cells infected) is an indicator of severe disease, although patients
with apparently low parasite levels may also develop complications.
- Cerebral malaria is marked by diminished consciousness, confusion and convulsions, often
progressing to coma and death.
- If untreated, malaria is universally fatal.
- Black water fever is due to widespread intravascular hemolysis, affecting both parasitized and
unparasitized red cells, giving rise to dark urine.
(309) (C) Fluorescent treponemal antibody absorption.

-A fluorescent treponemal antibody absorption test checks for antibodies to the bacteria that cause
syphilis and can be used to detect syphilis after the first 3-4 weeks following exposure to syphilis
bacteria.
- The test can be done on a sample of blood or spinal fluid.
(310) (C) Tetracycline.

- Vibrio cholera can be life threatening, but it is easily prevented and treated.
- Prevention is achieved by advanced water and sanitation systems and chemoprophylaxis by
tetracycline.
(311) (C) 150 mg/kg of aspirin will not result in aspirin toxicity.
T xicity dose of aspirin:
Dose < 125mg/kg minimal risk of toxicity, ose > 150mg/kg
will mild toxicity.
3 ose 150-300 mg kg moderate toxicity.
Dose 300-500 mg/kg severe and prolonged.
5 ose > 500 mg/kg potentially lethal.
(312) (A) Low molecular weight heparin.

Low molecular veight heparin is prepared by selectively treating unfractionated heparin to isolate the lov
molecular weight (< 9,000 dalton) fragments.
activity s measured in units of factor x inactivation and monitoring of the aPTT is not required.
(313) (A) Epinephrine.

pinephrine ma ntains blood pressure, antagonizes the effects of the released mediators and inhibits
ther release of mediators.
Th< standard treatment for anaphylaxis should also include antihistamines and corticosteroids.
However ant siamines have a much slower onset of action than epinephrine; they exert a minimal effect
on blood pressure and they should not be administered alone as treatment A tihistamine h rapy is thus
considered adjunctive to epinephrine, ticosteroids have no immediate effect on anaphylaxis.
vever they should be administered early to prevent a potential late phase reaction.
(314) (A) Atropine.

.Id cases of organophosphorus insecticide toxicity require no specific treatment other then the val
of soiled clothing
taminated skin should be washed with soap and water to prevent further absorption.
2 mg of atropine should be given IV to reduce bronchorrhoea.
addition a e (e.g. pralidoxime mesilate 30 mg/kg by slow IV injection 4-hourly or an infusion
alidoxime mesi ate 8-10 mg/kg/hour), which react vates phosphorylated acetylcholinesterase, should
ven in symptomatic patients where the diagnosis has been confirmed.
opine is initiated in patients with organophosphorus insecticide toxicity who present with muscarinic
symptoms.
peti e in hi tors at autonomic postganglionic cholinergic receptors, including receptors found
astrointesti d pulmonary smooth muscle, exocrine glands, heart and eye le endpoint for atropinization
is dried pulmonary secretions and adequate oxygenation.
Tachycardia and mydrias s must not be used to limit or to stop subsequent doses of atropine.
main conce n with organophosphorus toxicity is respiratory failure from excessive airway secretions.
(315) (A) Beriberi.
Vitamin B12 (col alamin ) deficiency leads to pernicious anemia.
> amin C (ascorb c acid) deficiency leads to scurvy, itamin B3 (niacin) deficiency leads to pellagra.
(316) (D) Supportive treatment.
- A monospot test used for the diagnosis of infectious mononucleosis.
- Infectious mononucleosis is often called the kissing disease.
- The virus that causes mono is transmitted through saliva.
- The cause of mononucleosis is the Epstein Barr virus.
- Enlargement of spleen is a serious complication of mononucleosis.
- There is no specific therapy available to treat infectious mononucleosis.
- Antibiotics do not work against viral infections such as mono.
- Treatment mainly involves bed rest and drinking plenty of fluids (supportive treatment).
(317) (B) Urinary tract.

- These infections may be local or systemic and include urinary tract infection, abdominal infections,
wound infections, bacteremia and endocarditis.
(318) (D) Heart rate.

- Factitious fever is produced artificially by a patient.
- This is done by artificially heating the thermometer or by self-administered pyrogenic substances.
- An artificial fever may be suspected if the pulse rate is much less than expected for the degree
of fever noted.
This diagnosis should be considered in all patients in whom there is no other plausible explanation for
the fever.
- Patients who pretend to have fevers may have serious psychiatric problems.
(319) (B) Metronidazole.

- The organism which causes peritonitis is bacteroides fragilis.
- Metronidazole is broad spectrum antibiotic for bacteroides fragilis.
(320) (A) Chronic leg ischemia.

- Leg pain aggravated by walking and relieved by rest (claudication), hair loss and coldness are signs of
limb ischemia.
(321) (A) Losartan.

- Losartan and lisinopril caused similar hypotensive effects.
- Lisinopril, but not losartan, was found to increase a cough response induced by both mechanical and
chemical stimulation.
- The specific selective angiotensin □ receptor blockers losartan does not cause cough in patients with a
previous angiotensin converting enzyme inhibitors cough.
- Angiotensin converting enzyme inhibitors cough is likely to be related to kininase II inhibiting action.
(322) (A) Herpes zoster virus infection.

- Skin changes over the back (vesicles) forming a tight chain like pattern from the back to the abdomen
is characteristic of herpes zoster virus infection.
(323) (B) Tetracycline and aluminum hydroxide.
- Using aluminum hydroxide together with tetracycline may decrease the effects of tetracycline.
- Administration of tetracycline and aluminum hydroxide should be separated by 2-3 hours.
(324) (A) Boiling of water.

- Entamoeba histolytica is a protozoan which causes a disease known as amoebic dysentery.
- This protozoan can also cause abscesses in the liver.
- The organism exists both as a motile trophozoite and as a cyst that can survive outside the body.
Cysts are transmitted by the ingestion of contaminated food or water, or are spread directly by
person-to-person contact.
Trophozoites emerge from the cysts in the small intestine and then pass on to the colon, where they
multiply.
Amoebiasis is difficult to eradicate because of the substantial human reservoir of infection.
- The only progress will be through improved standards of hygiene, sanitation and better access
to clean water.
Cysts are destroyed by boiling, but chlorine and iodine sterilizing tablets are not always effective.
(325) (A) Biopsy from temporal arteritis.

- A temporal artery biopsy from the affected side is the definitive diagnostic test for giant cell arthritis.
- The lesions are patchy and the whole length of the biopsy (> 1 cm long) must be examined; even so,
negative biopsies occur.
- The histological features of giant cell arthritis include intimal hypertrophy.
- Inflammation of the intima and sub-intima breaking up of the internal elastic lamina.
- Presence of giant cells, lymphocytes and plasma cells in the internal elastic lamina.
(326) (A) Ibuprofen.

- Usually, ibuprofen can be used every 12 hours while the other three drugs used every 4-6 hours.
(327) (D) Pasturization of dairy products.

- Avoid unpasteurized dairy foods, cook meat thoroughly and vaccinate domestic animals.
(328) (A) Ceftriaxone.

- Single-dose oral therapy with cefixime (400 mg), ceftriaxone IM (250 mg) or 2 gm of spectinomycin
IM successfully treats uncomplicated anogenital infection.
- Single-dose oral amoxicillin 3 gm with probenecid 1 g, ciprofloxacin (500 mg) or ofloxacin (400 mg)
may be used in areas with a low prevalence of antibiotic resistance.
- Longer courses of antibiotics are required for complicated infections.
- There should be at least one follow-up assessment and culture tests should be repeated at
least 72 hours after treatment is complete.
- All sexual contacts should be notified and then examined and treated as necessary.
(329) (D) Haloperidol.
- Multidrug therapy is essential to treat leprosy because of developing drug resistance.
- Much shorter courses of treatment are now being used but longer therapy may be required in severe
cases.
- Follow up including skin smears is obligatory.
- Leprosy should be treated in specialist centers with adequate physiotherapy and occupational
therapy support
- Surgery and physiotherapy also play a role in the management of trophic ulcers and deformities of
the hands, feet and face.
Recommended treatment regimens for leprosy in adults
- Rifampidn 600 mg once-monthly,

supervised.
Multibacillary leprosy
- Clofazimine 300 mg once-monthly,
(lepromatous, borderline lepromatous,
borderline) supervised.
- Clofazimine 50 mg daily, self-administered.
- Dapsone 100 mg daily, self-administered.
- Treatment continued for 12 months.
Paudbacillaiy leprosy
(borderline tuberculoid, - Rifampicin 600 mg once-monthly,
tuberculoid) supervised.
- Dapsone 100 mg daily, self-administered.
- Treatment continued for 6 months.
Single lesion paucibadllary leprosy
- Rifampicin 600 migas a single dose.
- Ofloxacin400 mg as a single dose.
(330) (C) Intubation.
- Minocycline 100 mgas a single dose.
- Damage to the brain may result in a altered level of consciousness.
- When this becomes severe to the point of stupor or coma (defined as a score on the Glasgow coma
scale of less than 8), dynamic collapse of the extrinsic muscle associated with the larynx can obstruct
the airway, impeding the free flow of air into the lungs.
- Furthermore, protective airway reflexes such as cough and swallowing may be diminished or absent.
- Tracheal intubation is often required to restore patency of the airway and protect the
tracheobronchial tree from pulmonary aspiration of gastric contents.
- Indications of intubation:
1- Failure to maintain airway tone.
2- Swelling of upper airway as in anaphylaxis or infection.
3- Facial or neck trauma with oropharyngeal bleeding or hematoma.
4- Decreased consciousness and loss of airway reflexes.
5- Failure to protect airway against aspiration.
6 - Decreased consciousness that leads to regurgitation of vomit secretions, or blood.
7- Failure to ventilate.
8- End result of failure to maintain and protect airway.
9- Prolonged respiratory effort that results in fatigue or failure, as in status asthmaticus or severe
chronic obstructive pulmonary disease.
10- Failure to oxygenate (e.g. transport oxygen to pulmonary capillary blood).
11- End result of failure to maintain and protect airway or failure to ventilate.
12- Diffuse pulmonary edema.
13- Acute respiratory distress syndrome
4- Large pneumonia or air-space disease.
15- Pulmonary embolism.
6- Cyanide toxicity, carbon monoxide toxicity, methemoglobinemia, i - Anticipated clinical course
or deterioration (e.g. need for situation contro , tests, or procedures).
18- Uncooperative trauma patient with life-threatening injuries who needs
procedures e.g. tube thoracostomy) or immediate CT scanning.
19- Stab wound to neck with expanding hematoma.
20- Septic shock with high minute-ventilation and poor peripheral perfusion.
21- Intracranial hemorrhage with altered mental status and need for close blood pressure control.
22- Cervical spinal fracture with concern for edema and loss of airway patency.
(331) (C) Interstitial fluid.

Edema is an abnormal accumulation of fluid in the interstitium, which are locations beneath the skin
i one or more cavities of the body, ib clinically shown as swelling.
Generally the amount of interstitial fluid is determined by the balance of fluid homeostasis and
creased secretion of fluid into the interstitium or impaired removal of this fluid may cause edema.
tting edema is graded on a scale from 1 to 4, which is based on both the depth the (pit) leaves and
iow long the pit remains.
A patient with a score of 1 has edema that is slight (roughly 2mm in depth) and disappears rapidly,
score of 2 is deeper (4mm) and disappears within 15 seconds.
score of 3 is deeper yet (6mm) and can last longer than a minute: in stage 3 pitting edema the
; remity also looks grossly swollen.
nally, stage 4 is the most severe with deep pitting (8mm or greater in depth) that may last more n
2 minutes.
(332) (B) Mosquito.

- Most of these viruses are transmitted by the bite from an infected arthropod (mosquito or tick).
(333) (A) Killing the vector

.yme disease is caused by Borrelia burgdorferi bacteria.
Symptoms: rash, flu-like symptoms, later; joint pain, neurological problems.
He best way to prevent Lyme disease is to avoid areas where deer ticks live, especially wooded,
bushy areas with long grass.
Ticks should be removed as soon as possible with tweezers.
(334) (A) Steroids.

pyoderma gangrenosum is an uncommon, ulcerative cutaneous condition of uncertain etiology.
It is associated with systemic diseases in at least 50% of patients who are affected.
T eatment typically includes high doses of corticosteroids, such as prednisone, along with other
rugs designed to suppress the immune system.
(335) (C) It will resolve without treatment.
- Moliuscum contagiosum is a relatively common vira infection of the skin that results in round, firm,
painless bumps ranging in size from a pinhead to a penc eraser.
- If the bumps are scratched or injured, the infection can spread to surrounding skin.
- In adults, moliuscum contagiosum involving the genitals is considered a sexually transmitted
infection.
- Moliuscum contagiosum usually resolves without treatment within 6-12 months.
(336) (B) Neisseria Gonorrheae. males and

- Gonorrhea is an infect on caused by a sexually transmitted bacterium that can infect
both
females. pain or
- Gonorrhea is caused by Neisseria gonorrhoeae bacteria (a Gram-negative
diplococcus).
- Symptoms in males include painful urination, pus like d scharge from the tip of the
penis,
swelling in one testicle
(337) (C) Pasteurella multocida.

- Pasteurella multocida is a small. Gram-negative, non-motile, non-spore-forming coccobacillus with
bipolar staining features.
- Pasteurella multocida often exists as a commensal organism in the upper respiratory tracts of many
livestock, poultry and domestic pet species, especially car and dogs.
- Pasteurella multocida infection in humans is often assoc ated with an animal bite, scratch, or lick, but
infection without epidemiologic evidence of animal contact may occur.
(338) (B) N-acetylcysteine.

- N-acetylcysteine works to reduce acetaminophen toxici , by replenishing body stores of the
antioxidant glutathione.
- Glutathione reacts with the toxic N-acetyl-p-benzoquinone imine metabolite so that it does not
damage cells and can be safely excreted.
(339) (A) Claudication.

- These characteristics are likely to be evidence of claudication.
(340) (A) Reiter's syndrome.

- Reiter's syndrome is a form of reactive arthritis.
- Presentation of Reiter's syndrome is arthritis of large joints, conjunctivitis or uveitis and urethritis in
men or cervicitis in women.
(341) (A) Pellagra.

- The classic triad is dermatitis, diarrhea and dementia for pellagra.
- Pellagra is due to vitamin B3 deficiency.
(342) (D) 154 mEq/L

- Normal saline contains 9 gm/L of sodium chloride with an osmolarity of 308 mOsmol/L.
- It contains 154 mEq/L sodium and chloride ions.
(343) (B) Proximal muscle tenderness.
• Polymyalgia rheumatica is characterized by proximal myalgia of the hip and shoulder girdles with
accompanying morning stiffness that lasts for more than one hour.
- Muscle weakness is not a feature of polymyalgia rheumatic.
(344) (A) Naloxone.

- Naloxone is a pure opioid receptor antagonist.
- Unlike other opioid receptor antagonists it has no concomitant agonist properties.
• Naloxone is a medication used to counter the effects of opioid drug overdose, such as heroin or
morphine, specifically the life-threatening depression of the central nervous system, respiratory system
and hypotension secondary to opiate overdose.
- Mechanism of action: a competitive opioid antagonist; synthetic congener of oxymorphone.
(345) (A) Pallor is seen, then cyanosis then red finger without other clinical features.
- Raynaud's phenomenon manifests as recurrent vasospasm of the fingers and toes and usually occurs
in response to stress or cold exposure.
- It is characterized by pallor, cyanosis, suffusion and a sense of fullness or tautness, which may be
painful.
(346) (A) Tetracycline.

- Aluminum hydroxide decreases levels of tetracycline by inhibiting gastrointestinal absorption.
- Prevention of interactions is achieved by monitoring the patient closely, using alternatives if available
and separate intake of the drugs by 2 hours.
(347) (A) Painful vesicular and ulcers.

- When present, the initial symptom of genital herpes usually is pain or itching, beginning within a few
weeks of exposure to an infected sexual partner.
- After several days, small red bumps or tiny white blisters may appear.
- The blisters then rupture, becoming ulcers that ooze or bleed.
(348) (B) Dark field microscopy.

- This is a case of syphilis.
- A primary syphilis lesion is an ulcer known as a chancre.
- It is typically indurated, with a clean base and rolled edges and develops an average of 3 weeks after
infection (10-90 days).
- The lesion may occur on any area of skin or mucous membrane but usually appears on or near the
genitals.
- Syphilis, also known as great imitator, is a sexually transmitted disease caused by the spirochete
bacterium. Treponema pallidum.
- It classically presents as single painless non-itchy skin ulceration with sharp borders.
- Treponema pallidum is too small to be seen under the light microscope so dark field
microscopy is necessary when sores are present.
- Blood tests can confirm the presence of antibodies.
- The antibodies remain in the patient's body for years, so the test can be used to determine a
current or past infection.
- Syphilis presents with painless ulcer in the penis.
- Gonorrhea is sexually transmitted disease caused by bacterial infection cause pain and
discharge, but there is no ulcer.
• Choncroid is sexually transmitted disease caused by bacterial infection cause pain and
discharge, but there is no ulcer.
• Herpes simplex virus is sexually transmitted disease caused by virus that cause painful ulcer with
discharge.
(349) (A) Interferon.

- Flu-like symptoms following each injection (fever, chills, headache, muscle ache, pains and
malaise) occur with all interferons.
(350) (A) Permethrin.

- Permethrin contains chemicals that kill scabies mites and their eggs.
(351) (A) Hydralazine.

- Drug-induced systemic lupus erythematosus causes include chlorpromazine, hydralazine, isoniazid,
methyldopa, penicillamine, procainamide, quinidine and sulfasalazine.
(352) (D) Lymphangitis.

- Red streaks in the hand are due to lymphangitis.
(353) (A) Anaphase.

- Anaphase begins when the duplicated centromeres of each pair of sister chromatids separate and
the daughter chromosomes begin moving toward opposite poles of the cell due to the action of the
spindle.
(354) (A) Multiple myeloma.

- Rouleax formation is the arrangement of RBCs in fluid blood (or in diluted suspensions) with their
biconcave surfaces in opposition, thereby forming groups that resemble stacks of coins.
- In multiple myeloma, peripheral blood smears may show Rouleax formation.
- Conventional plain radiography can usually depict lytic lesions.
- Such lesions appear as multiple, rounded, punched out areas found in the skull, vertebral
column, ribs and pelvis.
(355) (B) Anorexia nervosa.
Anorer a nervosa complications include electrolyte imbalance (hypokalemia) weight loss and osteopen a
ma- caus sio of tooti' enema.
(356) (B) Hypovitaminosis osteopenia.

<pe la S" he most; evere complications of anorexia nervosa a 1 t is difficult to reverst eated w
tarn ns
(357) (A) Hypokalemia.

Bulin la nervosa is a so known as b nge eating, which means the patient eats a arege amount then forces
vomiting; leading to a oss of acids and electrolytes which leads to hypokalen ia and metabolic alkalosis.
It s associated with fluid and electrolyte imbalances me iding hypokalemia, hyponatremia and
hypochloremic ilkalosis
(358) (A) Weight gain.

\A ight gam is recom mend >d n order to ma ntain a norma we ght and dec ease the development
of osteoporosi
(359) (A) Anorexia nervosa.

- These symptoms are associated with aneroxia nervosa (BMI =18, fine hair all over the body,
feeling of iinnc obese eat excessive exerc se
a n ?rvos presents th dec rease body weight amenorr ea and an o hair ia ervosa esents with
normal or increase body weight, restrict eating following by overeating
then guilt.
(360) (A) Clindamycin.

iamycin is the antimicrobial agents most commonly used againsi anaerobes
(361) (A) Previous vaccination against hepatitis B.

anti-hepa is i - surface are present in persons immunized with hepatitis B vaccine, whereas both
iepat’ is B s rface and anti -NBc are detected in persons with a resolved infection.
(362) (D) Ropinirole.

amine agonist e the most commonly used medicines to treat restless leg syndrome.
Ropini n am pexole are approved for the treatment of restless leg syndrome, dose dopam ne
agonists are largely replacing levodopa as first line treatment for restless leg omc.
FAMILY MEDICINE
(1) Which of the following is true regarding chickenpox (varicella) vaccine in adult?
(A) 2 doses, 2 weeks apart.
(B) 2 doses, 6 weeks apart.
(C) 2 doses, 6 months apart.
(D) 3 doses, during 6 months.
(2) Which of the following is an example of secondary prevention?

(A) Measles vaccine.
(B) Rubella vaccine.
(C) Detection of asymptomatic diabetic patient.
(D) Coronary bypass graft.
(3) Which of the following is not alive vaccine?

(A) BCG.
(B) Hepatitis B vaccine.
(C) Oral polio virus vaccine.
(D) Varicella vaccine.
(4) What is the definition of epidemic curve?

(A) A graph in which the number of new cases of a disease is plotted against an interval of time to
describe a specific epidemic or outbreak.
(B) The curve which demonstrates the straight line relationship between 2 variables when both of them
are scaled as logarithms.
(C) A curve representing graphically the probabilities of different numbers of occurrences of an event.
(D) A graphic presentation of a life table.
(5) What is the most common problem present in primary care?

(A) Coryza.
(B) Congenital heart diseases.
(D) Diabetes mellitus.
(6) What is the most important factor for a smoker to quit?

(A) Patient desire.
(B) Nicotinepills.
(C) Programplan.
(D) Change in life style.
(7) What does it mean if the likelihood ratio of a disease incidence is 0.3?
(A) Large increase.
(B) Small increase.
(C) Small decrease.
(D) Large decrease.
(8) If you face difficulty getting accurate information from a patient, what is the best course of action?
(A) Ask direct questions (dose-ended).
(B) Ask open questions.
(C) Control the discussion.
(D) Use medical terms.
(9) What is the meaning of endemic?

(A) Spread of disease in incidence, which is virtually constant all the time.
(B) Spread of disease from country to country by carrier.
(C) Rapid spread of disease.
(D) Very low incidence of disease.
(10) What is the proper way to reduce weight in patient diagnosed with diabetes mellitus type2?
(A) Decrease calories intake by 1500 kcal/day.
(B) Decrease calories intake and increase fat.
(C) Decrease calories intake by 500 kcal/kg/week.
(D) Decrease calories intake by 800 kcal/day.
(11) In a primary health care center, of 50 children, 10 of them got the disease in the first week,
another B0 on the subsequent 2 weeks. What is the incidence of the disease in that primary health care
center?
(A) 20%.
(B) 40%.
(C) 60%.
(D) 80%.
(12) During a TB outbreak, what should be given as a prophylaxis?

(A) BCG.
(B) Isoniazid.
(C) Ethambutol.
(D) Rifampicin.
(IB) What is the weight classification of a 15-year-old girl with BMI = 24?
(A) Under weight.
(B) Normal weight.
(C) Over weight.
(D) Obese.
(14) Regarding smoking cessation, the peak of withdrawal symptoms occurs after:
(A) 1-2 days.
(B) 2-4 days.
(C) 1 week.
(D) 2 weeks.
(15) What is an attributable risk?
(A) Number of new cases of a disease occurring in a specified time period divided by the number of
individuals at risk of developing the disease during the same time.
(B) A number of cases of a disease attributable to one risk factor.
(C) A measure of the strength of association based on prospective studies (cohort studies).
(16) What is the contraindication of buprione used in smoking cessation?

(A) Seizure.
(B) Arrhythmia.
(C) Xerostomia.
(D) Headache.
(17) What is the most effective way to disseminate health education?
(A) Mass media.
(B) Group discussion.
(C) Individual approach.
(D) No difference.
(18) A male patient has a known case of congestive heart failure and likes to eat out 2-3 times weekly.
What is the advice for him?
(A) Eat without any salt.
(B) Eat 4 gm salt.
(C) Low fat and high protein.
(D) Take a lot of fluids.
(19) In a city with 1,500 persons, out of 105 births, there are 5 still births, 4 neonatal deaths and
2 deaths before 1-year-old. What is the perinatal mortality?
(A) 4.
(B) 5.
(C) 6.
(D) 9.
(20) What is the nutritional supplement given for an adolescent female who is eating mostly fast food?
(A) Calcium and folic acid.
(B) Vitamin C and folic acid.
(C) Zinc and folic acid.
(D) Zinc and Vitamin C.
(21) A study was performed on a population of 10,000. They found 2,000 to have diabetes mellitus and
at end of the study that had increased by l.OOO.What is the incidence of diabetes mellitus?
(A) 10%.
(B) 12%.
(C) 24%.
(D) 30%.
(22) Which of the following is an example of close ended question?
(A) Where is the pain in your chest?
(B) Can I help you?
(C) Could you be more specific?
(D) Any other/further complaints?
(23) What is the most common cause of immediate death in a burn victim?
(A) Inhalational injury.
(B) Septic shock.
(C) Hypovolemic shock.
(D) Associated injury.
(24) What does perinatal mortality mean?

(A) Number of stillbirths 20 weeks of gestational age.
(B) Number of stillbirths + neonatal deaths.
(C) Number of deaths/1,000 live babies.
(D) Death of a live born baby within the first 28 days of life.
(25) What is the best method for eradication of Entamoeba histolytica?
(A) Boiling ofwater.
(B) Freezing.
(C) Using chlorine.
(D) Filtration.
(26) Which of the following is correct about case control study?

(A) Both groups should be randomized.
(B) Both groups must be equal in numbers.
(C) This study must look for backward risk factors.
(D) This study must look for forward risk factors.
(27) Which one of the fallowing is a characteristic of randomized control study?

(A) It is always expensive.
(B) It gives un-useful information about adverse effects.
(C) It is the gold standard for a clinical trial.
(28) A study show, there are 100 patients on carbamazepine and after 2 years they check how many
of them have hyperlipidemia. What is the type of this study?
(A) Case control study.
(B) Retrospective cohort study.
(C) Prospective cohort study.
(D) Cross sectional study.
(29) What is the best method for prevention diseases?
(A) Immunization.
(B) Teaching individuals how to protect themselves.
(C) Diet and nutrition.
(D) Physical activity.
(30) What is the best way to promote health in populations?

(A) Environment modification.
(B) Promote personal hygiene.
(C) Social support networks.
(D) Family planning.
(31) A female is planning to become pregnant. What should she be informed about the varicella
vaccine?
(A) Tell her that it is alive vaccine.
(B) Tell her that it is safe.
(C) Tell her that, if she takes the vaccine, she should delay pregnancy 1-3 months.
(D) Just give her the vaccine.
(32) What is the advice for a patient who is over weight (BMI =28) and has a known case of ischemic
heart disease?
(A) Decrease weight and do exercises.
(B) Eat 4 gm salt per day.
(C) Eat a diet that is high in salt and saturated fat.
(33) If there is outbreak of diphtheria and tetanus in community, which one of the following is correct
regarding vaccination of pregnant woman?
(A) Contraindicated to give DT vaccine.
(B) If exposed.terminate pregnancy immediately.
(C) If exposed.terminate after 72 hours.
(D) Give DT vaccine anyway.
(34) Which one of the following is correct regarding pneumococcal vaccine?

(A) It is not recommended in healthy child.
(B) It cannot be given with MMR vaccine.
(C) It can be given to child less than 2-year-old.
(D) If given to sickle cell patient who is then exposed to infection, he has to take penicillin.
(35) What is the best method for history taking?

(A) Yes or no questions.
(B) Open ended questions.
(C) Close ended questions.
(36) What is the best method to prevent plague?
(A) Rodent eradication.
(B) Spray insecticide.
(C) Give prophylactic antibiotic.
(D) Hand wash.
(37) Which of the following is true about case control studies?

(A) It divides intogroups and compares results.
(B) A study that follows a group of healthy people with different levels of exposure and assesses what
happens to their health over time.
(C) A study that compares groups in terms of their current health and exposure status and assesses their
similarities.
(D) It determines the number of cases of a disease attributable to one risk factor.
(38) All of the following are primary preventions of anemia except:

(A) Iron and folic acid given in pregnancy and postnatal.
(B) Limitation of cow milk before 12-month-old.
(C) Genetic screening for hereditary anemia.
(D) Health education about food rich in iron.
(39) What is the specificity of test?

(A) When the person does have the disease with positive test.
(B) When the person does have the disease with negative test.
(C) When the person does not have the disease with positive test.
(D) When the person does not have the disease with negative test.
(40) What is the best way to prevent house mites?

(A) Cover the pillows with impermeable cover.
(B) Wash the clothes in hot water.
(C) Remove the old carpets.
(D) Buy washable stuffed toys.
(41) Which of the following is true regarding screening for cancer?
(A) Screening for cervical cancer has decreased in recent years.
(B) Screening for breast cancer has decreased in recent years.
(C) Screening for colorectal cancer is inadequate for the high risk groups.
(D) Screening for lung cancer has reduced the mortality rate of lung cancer.
(42) What are the antimalarial prevention methods in addition to pharmacological measures?
(A) Vector eradication with protection from vector bite.
(B) Vector eradication with inspection of vector bite.
(C) Clothing disinfection with protection from vector bite.
(D) Clothing disinfection with inspection of vector bite.
(43) An obese cardiac patient with hypertension and hyperlipidemia eats unhealthy food. What are
the three most correctable risk factors?
(A) Hypertension, obesity andlow HDL.
(B) High triglyceride, unhealthy food and sedentary life.
(C) High cholesterol, unhealthy food and sedentary life.
(D) High cholesterol, hypertension andobesity.
(44) A 45-year-old female patient is newly diagnosed with diabetes mellitus type 2 just 2 weeks ago.
She has an appointment today to discuss the next step of managing her chronic disease. She was on
time for her appointment at 10:00 morning, but because of a complicated patient you did not get into
her room until 11:15 morning. When you walk in, she appears extremely angry. How should you
approach this situation?
(A) Acknowledge her anger with a statement like, you seem furious.
(B) Be empathetic, understanding that her anger is likely displaced and a reaction to her new chronic
illness.
(C) Explain the situation with a statement like, my last patient was very complex and he really needed
my attention.
(D) Help the patient understand that her anger should be directed at the illness not at you.
(45) Which one of the following is true regarding the null hypothesis?
(A) The effect is not attributed to chance.
(B) There is significant difference between the tested populations.
(C) There is no significant difference between the tested populations.
(D) The concept in which three approaches is used differently in to statistical inference.
(46) Which one of the following is true regarding diabetes mellitusin the Kingdom of Saudi Arabia?
(A) The prevalence is about < 10%.
(B) Most of the patients are diabetes mellitus type 1.
(C) Female patients are more affected with diabetes mellitus type 2.
(D) Most of patients with diabetes mellitus type 2 are obese.
(47) What is the most effective measure to prevent spread of infection among health care workers
and patients in a nursery?
(A) Wash hand before and after examining for each patient.
(B) Wear gown and gloves before entering the nursery.
(C) Wear shoe covers.
(48) A 17-year-old female patient missed her second dose of varicella vaccine. She had the first dose
about 1 year ago. What is the action now?
(A) Give her double dose vaccine.
(B) Give her the second dose only.
(C) Revaccinate from the start.
(D) See if she has antibody and act accordingly.
(49) Other than lung cancer, what cancer does smoking increases its risk?
(A) Colon cancer.
(B) Bladder cancer.
(C) Liver cancer.
(D) Intestine cancer.
(50) What is the epidemic disease in poor sanitation areas that affect children and young
adults?
(A) Hepatitis A.
(B) Hepatitis B.
(C) Hepatitis C.
(D) Hepatitis D.
(51) What type of allergy should be excluded before giving a child the flu vaccine?
(A) Chicken.
(B) Egg.
(C) Fish.
(D) Banana.
(52) What is the percent of water in adult human body?

(A) 40%.
(B) Differs depending on age and sex.
(C) Less in infant than adult.
(53) One liter of fluid deficit is equal to:

(A) 0.5 kg.
(B) 1 kg.
(C) 2 kg.
(54) What is most important in counseling?

(A) Exclude physical illness.
(B) Establishing rapport.
(C) Family history.
(D) Schedule appointment.
(55) All of the following will increase patient compliance except:

(A) Involve the patient in the plan.
(B) Make a simplified regimen.
(C) Give easy written instructions.
(D) Warn the patient about the danger of missing a pill.
(56) What is the best source of water for patient in travelling?

(A) Boiled water.
(B) Iced water.
(D) Tap water.
(C) River water.
(57) What should be added to water to prevent dental caries in developing countries?
(A) Fluoride.
(B) Zinc.
(C) Copper.
(D) Iodide.
(58) What is true about CPR in a child?

(A) 30 chest compression 2 ventilation.
(B) 30 chest compression 1 ventilation.
(C) 15 chest compression 2 ventilation.
(D) 15 chest compression 1 ventilation.
(59) Which of the following is the recommended diet to prevent ischemic heart disease?
(A) Decrease the intake of meat and dairy.
(B) Decrease the intake of meat and bread.
(60) Which of the following is proven to reduce the incidence of cancer?

(A) Salt.
(B) Mineral water.
(C) Vitamin D.
(D) Fiber.
(61) A patient presented with scoliosis. At which degree should the patient be referred to the
orthopedic?
(A) 5%.
(B) 10%.
(C) 15%.
(D) 20%.
(62) What is vitamin deficiency cause Beriberi disease?

(A) Vitamin B1 (thiamine).
(B) Vitamin B2 (riboflavin).
(C) Vitamin B3 (niacin/nicotinic acid).
(D) Vitamin C (ascorbic acid).
(63) What is the most common cause of precocious puberty in girl?

(A) Idiopathic.
(B) Functional ovarian cysts.
(C) Ovary tumor.
(D) Brain tumor.
(64) How to break a bad news to patient who is newly diagnosed with cancer?
(A) Inform his family.
(B) Find out how much the patient knows about it.
(C) Let social service informs him.
(D) Do not tell him.
(65) What is the most common chromosomal abnormality?
(A) Trisomy 13.
(B) Trisomy 21.
(C) Trisomy 18.
(D) Turner syndrome.
(66) What is the first step to reduce weight in a very obese girl?
(A) Increase water intake.
(B) Decrease calorie intake.
(C) Switch dairy milk for non-dairy milk.
(D) Replace some animal products with plant-based foods.
(67) What is the first thing to do regarding epidemiological study or investigation?
(A) Good sampling.
(B) Count those who have the disease.
(C) Verifying the diagnosis.
(D) Implement control and prevention measures.
(68) What are the most factors that increase the chance to have diabetes mellitus in a healthy male
with a family history of diabetes mellitus type 2?
(A) Hypertension and Obesity.
(B) Smoking and Obesity.
(C) Pregnancy and hypertension.
(D) Pregnancy and Smoking.
(69) The way to determine the accuracy of occult blood test for 11,000 elderly patients is by
measuring:
(A) Sensitivity.
(B) Specificity.
(C) Positive predictive value.
(D) Negative predictive value.
(70) Using the following chart, relative risk

of those with the risk factor to those without
risk factor is: Risk factor Disease Normal Total
the
(A) [A/(A+B)] / [C/(C+D)]. Present A B A+B
Absent C D C+D
(B) [A/(A+C)]/[B(B+D)1.
Total A+C B+D
(C) A/(A+B).
(D) C/(C+D).
(71) What is the management of eating disorder?

(A) Cognitive and behavioral
therapy.
(B) Pharmacology.
(C) Hospitalization.
(1) (B) 2 doses, 6 weeks apart.
• Chickenpox is a common illness caused by the varicella -zoster virus.
- Symptoms of chickenpox include fever and itchy spots or blisters all over the body.
- People who have not been vaccinated by 13-year-old should get 2 doses of the vaccine, 4-8 weeks
apart.
(2) (C) Detection of asymptomatic diabetic patient

- Secondary prevention means methods to diagnose and treat existent disease in early stages before it
causes significant morbidity.
- Illness is absent and disease is present.
(3) (B) Hepatitis B vaccine.

- Examples of live attenuated vaccines include MMR combined vaccine, varicella (chickenpox) and oral
poliovirus vaccines.
- Live attenuated strains of bacteria include BCG and oral typhoid vaccines.
- Hepatitis B vaccine is an example of vaccines that produced by genetic engineering.
(4) (A) A graph in which the number of new cases of a disease is plotted against an interval of time to
describe a specific epidemic or outbreak.
- The classical epidemiological curve is drawn when the number of new cases of an infection is plotted
against time.
- It can provide information on the following characteristics of an outbreak: pattern of spread,
magnitude, outliers, time trend, exposure and/or disease incubation period.
(5) (A) Coryza.

- Coryza is a word describing the symptoms of a cold.
- It describes the inflammation of the mucous membranes lining the nasal cavity, which usually
gives rise to the symptoms of nasal congestion and loss of smell, among other symptoms.
(6) (A) Patient desire.

- The clinician should first assess the patient's tobacco use, the desire to stop smoking and the
history of previous quit attempts, including methods used and their effectiveness.
- Many behavioral methods have been advocated to encourage patients to work toward quitting.
-Most people who give up cigarettes do so on their own, without joining a formal stop smoking
program.
- The single most important factor for people who successfully quit smoking is the belief and
confidence that they could do it.
(7) (C) Small decrease.

- The likelihood ratio is the likelihood that a given test result would be expected in a patient with
the target disorder compared to the likelihood that same result would be expected in a patient
without the target disorder.
- A likelihood ratio greater than 1 produces a post-test probability which is higher than the pre-test
probability.
- A likelihood ratio less than 1 produces a post-test probability which is lower than the pre-test
probability.
- When the pre-test probability lies between 30-70%, test results with a very high likelihood ratio (say,
above 10) rules in the chance that the patient has the disease.
- A likelihood ratio below 1 produces a post-test probability less than the pre-test probability.
- A very low likelihood ratio (say, below 0.1) virtually rules out the chance that the patient has the
(8) (A) Ask direct questions (dose-ended).
- Closed ended questions are just that: direct questions that ask for specific pieces of information from
a patient.
- Closed questions have their greatest value when we need to obtain facts and specific pieces of
information, especially if you face difficulty in getting specific information.
- By their nature they limit the patient's field of choice and length of response.
(9) (A) Spread of disease in incidence, which is virtually constant all the time.
- Endemic means the constant presence of a disease or infectious agent in a certain geographic area or
population group (usual rate of disease).
- Epidemic means the rapid spread of a disease in a specific area or among a certain population group
(excessive rate of disease).
- Pandemic means a worldwide epidemic; an epidemic occurring over a wide geographic area and
affecting a large number of people.
(10) (D) Decrease calories intake by 800 kcal/day

- To lose 0.5-1 kg/week (a safe rate of weight loss), subtract 500-1,000 calories from the total number
of calories needed to maintain weight.
- As an example, an overweight man who weighs 120 kg would need to eat 2,500 cal/day to maintain
his weight, to lose 0.5-1 kg/week; he should eat 1,500-2,000 cal/day.
- As weight is lost, the recommended calorie intake should be recalculated.
(11) (D) 80%.

- Incidence is a measure of the risk of developing some new condition within a specified period of
time.
- Within 3 weeks, there are 40 children affected out of 50.
- The percent will be 80%.
(12) (B) Isoniazid.

- Three strategies may be used in the prevention of clinical TB:
1- Biologic prophylaxis of uninfected persons with BCG vaccine.
2- Chemoprophylaxis of newly or recently infected persons with isoniazid.
3- Isoniazid chemoprophylaxis of selected persons with latent TB infection.
- Isoniazid is used alone or with other drugs to treat TB and to prevent it in people who have had
contact with TB bacteria.
(13) (B) Normal weight

- BMI < 16: severe under weight.
- BMI 16-18: under weight.
- BMI 18-25: normal weight
- BMI 25-30: over weight.
- BMI 30-35: obese class I (moderately obese).
- BMI 35-40: obese class II (severely obese).
- BMI > 40: obese class m (very severely obese or morbidly obese).
(14) (B) 2-4days.
ithdrawal symptoms begin as soon as 4 hours after the last cigarette, generally peak in intensity
after ours and disappear after 2 weeks.
(15) (B) A number of cases of a disease attributable to one risk factor.

ttributable risk s a measure of how much disease risk is attributed to a certain exposure, s useful in
determining how much disease can be prevented for public health guidelines and planning.
(16) (A) Seizure.

uprione is contraindicated in patients with a history of significant head trauma, seizure disorder, eating
disorder and in those who have used monoamine oxidase inhibitors in the past 14 days.
(17) (A) Mass media.

using mass media, a large number of people from all socioeconomic statuses can be reached.
(18) (A) Eat without any salt.

hen eating out, the patient with congestive heart failure is advice torequest that the cook prepare
foods without adding salt and think about hidden sources of salt and sodium, such as salad dressings a id
soups.
general, for people with heart failure, the daily recommended amount of dietary sodium is no iore
than 2 gm/day.
(19) (D) 9.
Stillbirth is the death of a fetus 22 weeks gestation or more.
- Neonatal death is the death of a live newborn in the first 28 days.
T he perinatal mortality = still births + neonatal deaths, he
perinatal mortality = 5 (still births) + 4 (neonatal deaths) = 9.
(20) (A) Calcium and folic acid.

olate plays an integral role in DNA. RNA and protein synthesis.
nus, adolescents have increased requirements for folate during puberty.
dequate calcium intake is essential also for development of strong and dense bones during the
adolescent growth spurt.
nadequate calcium intake may increase fracture risk during adolescence and the risk of developing
osteoporosis in later life.
(21) (A) 10%.

cidence is a measure of the risk of developing some new condition within a specified period of time, o
the incidence is measured by new cases divided by total population and finally multiplies by 100.
ncidence of diabetes mellitus = (1,000/10,000) x 100 = 10%.
(22) (A) Where is the pain in your chest?
- Open-ended questions are those questions that will solicit additional information from the
inquirer.
- Sometimes called infinite response or unsaturated type questions.
- By definition, they are broad and require more than 1-2 word responses.
(23) (A) Inhalational injury.

- Asphyxiation and carbon monoxide poisoning (inhaiational injuries) are the most common cause
of early death associated with burn injury.
(24) (B) Number of stillbirths + neonatal deaths.

- Perinatal mortality = number of stillbirth + neonatal death.
- Perinatal mortality rate = [(number of stillbirth + neonatal death)/ live birth]x 1,000.
(25) (A) Boiling of water.

- No vaccine is available to prevent amebiasis and there is no recommended chemoprophylaxis.
- When traveling n tropical countries where poor sanitation exists drink purified or boiled water and
do not eat uncooked vegetables or unpeeled fruit.
- Public health measures include water purification, water chlorination and sewage treatment
programs.
(26) (B) Both groups must be equal in numbers.

- A case control study is a type of study design used wide y, often in epidemiology.
- It is a type of observational study in which two existing groups differing in outcome are identified
and compared on the basis of some supposed causal attribute
- After clearly defining cases and controls, decide on data to be collected; the same data must be
collected in the same way from both groups.
- Matching in a case control study involves sampling of controls to parallel selected characteristics of
cases in order to reduce the likelihood of confounding the matched features.
(27) (C) It is the gold standard for a clinical trial.

- A randomized controlled trial is a specific type of scientific experiment and ne gold standard for a
clinical trial.
- It is often used to test the efficacy and/or effectiveness of various types of medical intervention
within a patient population.
(28) (C) Prospective cohort study.

• A prospective cohort study is a cohort study that follows over time a group of similar individuals
(cohorts) who differ with respect to certain factors unde study, to determine how these factors affect
rates of a certain outcome.
- It is important for research on the etiology of diseases and disorders in humans because for ethical
reasons people cannot be deliberately exposed to suspected risk factors in controlled experiments.
(29) (B) Teaching individuals how to protect themselves.
- Preventing any disease can be grouped into three levels.
- The levels are named for the stages of disease they target.
- The three levels of prevention are primary, secondary and tertiary.
- We use primary prevention methods before the person gets the disease.
• Primary prevention aims to prevent the disease from occurring.
- So primary prevention reduces both the incidence and prevalence of a disease.
- Encouraging people to protect themselves from the sun's ultraviolet rays is an example of primary
prevention of skin cancer.
(30) (B) Promote personal hygiene.

- Personal hygiene refers to keeping physically and mentally healthy to avoid sickness or disease and
to be able to live in normal social life.
- All persons are required to pay attention to their own cleanliness, eating, drinking, discharge of
excrement, dressing, sleeping, work and rest, including proper sexual intercourse in accordance with
the principles of hygiene.
- Hygienic behavior is the first important role in the prevention of diseases related to water and
sanitation.
- Washing hands is the most effective behavior for the prevention of diarrhea as well as for the
prevention of roundworm and whipworm.
(31) (C) Tell her that, if she takes the vaccine, she should delay pregnancy 1-3 months.
- If a pregnant woman gets varicella in her first or early second trimester, her baby has a small risk
(0.4-2.0%) of being born with congenital varicella syndrome, the baby may have scarring on the skin,
abnormalities in limbs, brain and eyes and low birth weight.
- Non-pregnant women who are vaccinated should avoid becoming pregnant for 1 month after each
injection.
- It is not given to pregnant women.
- Susceptible women who are exposed to varicella (or shingles, which is caused by the same virus)
should receive varicella-zoster immune globulin within 96 hours, which may prevent or modify
infection.
(32) (A) Decrease weight and do exercises.

- Any patient with ischemic heart disease must maintain a healthy weight, because being overweight
increases the risk of heart disease and increases the likelihood of developing diabetes also.
- Exercise helps achieve and maintain a healthy weight and control diabetes, elevated cholesterol and
high blood pressure. All of which are risk factors for heart disease.
(33) (D) Give DT vaccine anyway.

- Both tetanus and diphtheria toxoids and tetanus toxoid vaccines have been used extensively in
pregnant women worldwide since the 1960s to prevent neonatal tetanus.
- Tetanus and diphtheria toxoids and tetanus toxoid vaccines administered during pregnancy have
not been shown to harm either the mother or baby/fetus.
- Ideally, the vaccine should be given between 27-36 weeks of pregnancy.
(34) (D) If given to sickle cell patient who is then exposed to infection, he has to take penicillin.
- Children who have sickle cell disease and are under 5-year-old are at increased risk of
life-threatening pneumococcal infection due to absent or non-functional spleens and a decreased
immune response.
- To prevent pneumococcal infection, use of penicillin prophylaxis in children with sickle cell disease
under 5-year-old and in older children who have had a previous severe pneumococcal infection or
have functional/surgical asplenia.
(35) (B) Open ended questions.

- First we have to use open-ended questions so the patient feels free to provide additional
information.
- Then we use dose-ended questions that seek very specific, often yes or no, responses from the
patient and do not encourage the patient to provide any additional information.
- Good interviews are a mixture of both kinds ofquestions.
(36) (A) Rodent eradication.

- In general, to prevent contracting plague, people should avoid contact with wild animals.
- Controlling rat and flea populations where plague is found is also important.
- This is accomplished by application of chemicals by trained professionals to kill fleas and rodents.
(37) (A) It divides into groups and compares results.

- A case control study is a type of study design used widely, often in epidemiology.
- It is a type of observational study in which two existing groups differing in outcome are identified
and compared on the basis of some supposed causal attribute.
(38) (C) Genetic screening for hereditary anemia.

- Genetic screening for hereditary anemia can be used only to determine one type of anemia.
- The best laboratory tests for the diagnosis of anemia involve measuring the packed volume of red
cells (hematocrit) or the concentration of hemoglobin in circulating blood.
- Because most pregnant women eventually become anemic, it makes sense as a preventive measure
to give all women supplementation with medicinal iron during the second half of pregnancy.
- Breast milk appears to be adequate to cover the dietary iron requirements of normal birth weight
infants up to 6-month-old.
- Iron supplementation of preschool children is also important andrequires special planning.
- Weaning foods rich in iron and/or vitamin C, such aspurees of cooked vegetables and raw fruits,
are not difficult to preparein the home.
- However, parents need to be motivated and taught howto do so.
(39) (D) When the person does not have the disease with negative test.
- The specificity is the ability of the test to correctly identify those without the disease (true
negative rate).
- If 100 with no disease are tested and 96 return a negative result, then the test has 96% specificity.
(40) (C) Remove the old carpets.
- Experts say homes with bare floors have up to 90% less dust in them than homes with carpets.
Dust mite numbers can be reduced by replacing carpets with flat surfaces that are easier to vacuum
and maintaining relative humidity below 50%.
(41) (C) Screening for colorectal cancer is inadequate for the high risk groups.
- Colorectal screening intervals were chosen to distinguish those who underwent screening at least
annually or every 1-3 years from those who underwent screening at less frequent intervals, which was
considered inadequate for high-risk syndromes.
(42) (C) Clothing disinfection with protection from vector bite.

- Prevention requires A. 6, C and D: Awareness of risk + Bite avoidance + Chemoprophylaxis
taking preventive medicines if they are travelling to or living in a malaria region) +
Diagnosis made promptly with early treatment of an infected case).
(43) (D) High cholesterol, hypertension and obesity.

- The most important modifiable risk factors for heart disease are high blood pressure, high blood
cholesterol, cigarette smoking, diabetes mellitus, physical inactivity, unhealthy diet and obesity.
(44) (A) Acknowledge her anger with a statement like, you seem furious.
Dealing with the angry patient is challenging for any health care provider.
The natural reaction to anger is defensiveness, but a defensive response will often escalate the
situation. The best approach is for the physician to first recognize the anger, then acknowledge it, try
to inderstand it and respond to it.
it a physician senses that a patient is angry, but the patient has not volunteered this information, it is
mportant to explore the anger.
If the patient seems very upset, it may make him/her angrier if you minimize the situation by saying
something like, you seem a little upset.
- If a patient is extremely angry, choose words that seem to match the intensity of his/her feelings.
In some instances anger is displaced and may be truly directed at the disease process or illness.
In that case, the appropriate response is empathy.
However, in this setting, the anger is likely a response to the wait time that the patient has endured
and is less likely to be displaced.
Placing the blame on your previous patient should be avoided.
(45) (C) There is no significant difference between the tested populations.

The null hypothesis refers to a general or default position: that there is no relationship between two
measured phenomena, or that a potential medical treatment has no effect.
(46) (D) Most of patients with diabetes mellitus type 2 are obese.
- Diabetes mellitus type 2 is closely linked to obesity and sedentary lifestyle.
- BMI has been proved to be a useful index for large scale epidemiological work.
- In the study of hypertensive and diabetic patients attending the primary health care clinics in
Riyadh, only 19% of patients were found to have ideal weight (BMI < 25). while 35% were overweight
(BMI = 25-29.9), 41% were moderately obese (BMI = 30-40) and 5% were morbidly obese (BMI > 40).
- In general, the prevalence of diabetes mellitus type 2 tended to be higher in males than in females
in the majority of age groups.
(47) (A) Wash hand before and after examining for each patient.
- The first and most important step to infection control is hand washing.
(48) (B) Give her the second dose only.

- Any teenager or adult who has not had chickenpox or the chickenpox vaccine should receive the
vaccine.
- Adults are 10 times more likely than children to be hospitalized with the severe consequences of
chickenpox.
- These consequences include pneumonia and encephalitis.
- For people 13-year-old and older, the minimum interva1 is 4 weeks.
- If the patient forgets the second dose, just give it.
(49) (B) Bladder cancer.

- The primary risks of tobacco usage include many forms of cancer, particularly lung cancer, kidney
cancer, cancer of the larynx and head and neck, breast cancer, bladder cancer, cancer of the
esophagus, cancer of the pancreasand stomach cancer.
(50) (A) Hepatitis A.

- Hepatitis A is associated with a lack of safe water and poor sanitation.
- It is transmitted through ingestion of contaminated food and water or through direct contact with
an infectious person.
(51) (B) Egg.

- The majority of the IM inactivated influenza vaccines and the intranasal live-attenuated influenza
vaccines are cultured in fluid from chicken embryos.
- As a result, there is a small amount of egg protein in these vaccines.
- Thus, there is a potential risk of inducing an allergic reaction when administering the influenza
vaccine to an individual with egg allergy.
(52) (B) Differs depending on age and sex.

- The percentage of water varies according to age and gender.
- The amount of water in the human body ranges from 50-75%.
- The average adult human body is 50-65% water, averag ng around 57-60%.
- The percentage of water in infants is much higher, typically around 75-78% water, dropping to
65% by 1-year-old.
(53) (B) 1 kg.
- Each kilogram of weight loss is equal to 1 liter of fluid deficit.
(54) (B) Establishing rapport.

Rapport is the single most important aspect of a counseling relationship.
- It has been found to increase patient interest, motivation and comfort, all which contribute to
clinical efficacy.
(55) (D) Warn the patient about the danger of missing a pill.
Two randomized clinical trials have shown that simplified dosing schedules have improved patient
adherence to medication as prescribed.
Some, but not all, randomized controlled trials show multidimensional interventions can also improve
adherence.
- These interventions include combinations of patient and family education, home monitoring of isease
status and increased convenience of care, such as workplace access.
s recommended to provide patients with simple written instructions to enhance compliance with
medications.
(56) (A) Boiled water.

ood and water in developing countries may not be as clean as they are at home.
These items might contain bacteria, viruses, or parasites that could make you sick, o be safe boil
water before drinking, u can also drink commercially available bottled water when possible.
(57) (A) Fluoride.

ental decay occurs when acid destroys or demineralizes the outer surface of the tooth (the enamel),
acteria in the mouth from food and drinks containing sugar produce acid and fluoride repairs
mineralization before it becomes permanent.
does this by encouraging repair of enamel surface and discouraging demineralization.
Fluoride also helps strengthen the mineral structure of developing teeth.
(58) (C) 15 chest compression 2 ventilation.

egarding CPR, it is always 30/2 except in child it becomes 15/2.

<arge observational study suggests that a higher intake of fruits and vegetables is associated with
educed risk of ischemic heart disease mortality.
hether this association is causal and if so the biological mechanisms by which fruits and vegetables
erate to lower ischemic heart disease risks remains unclear
(60) (D) Fiber.

Yidence consistently suggests that eating plenty of fiber can reduce the nsk of bowel cancer, ets hig
in fiber can help keep bowel healthy and prevent constipation, ber-rich foods include wholegrain
pasta, bread, breakfast cereals and rice ulses, fruit and vegetables are also good sources of fiber.
(61) (D) 20%.
- Orthosis is effective in preventing significant curve progression in patients with 20-39% curves.
- Patients with Cobb angles of <20% at the time of presentation may be observed.
- Patients with substantial growth remaining with Cobb angles between 40-50% may be managed
with bracing or surgery.
- Patients with substantial growth remaining with Cobb angles of > 50% at the time of diagnosis
usually require surgical intervention.
(62) (A) Vitamin B1 (thiamine).

- Beriberi refers to a cluster of symptoms caused primarily by a nutritional deficit in Vitamin B1
(thiamine).
- Symptoms of beriberi include weight loss, emotional disturbances, impaired sensory perception,
weakness and pain in the limbs and periods of irregular heart rate.
- Edema is common.
- It may increase the amount of lactic acid and pyruvic acid within the blood.
- In advanced cases, the disease may cause high output cardiac failure and death.
- Symptoms may occur concurrently with those of Wernicke's encephalopathy, a primarily
neurological thiamine-deficiency related condition.
(63) (A) Idiopathic.

- In girls, the cause of precocious puberty 90-95% of the time is idiopathic, or unknown.
- Boys are more likely to have an underlying identifiable cause.
(64) (B) Find out how much the patient knows about it.
- Physician is ultimately responsible for telling the patient bad news.
- Nurses and social services help, educate and support.
- The patient may want a member of their family with them; however, this must be established prior
to the interview.
- Arrange some privacy, ideally an interview room. Where a patient is confined to bed, pull the
curtains around the bed.
- It is important to gain a rapport with your patient.
- The mechanisms by which you do this will depend very much on the patient, their condition, cultural
background and age.
• It is important before you begin breaking bad news that you assess the patient's understanding of
their condition.
- At this stage you can correct any misunderstandings and it will enable you to assess if the patient is
engaging in either denial, wishful thinking or unrealistic expectations of treatment.
- One mechanism to help you is to assess the level of information the patient wants.
- Offer to speak to family members or caregivers should the patient wish.
- If patient is in surgery then most likely physician will inform family first.
- If patient is in a clinic setting, then it is recommended patient and family are informed together.
- Robert Buckman’s six step protocol for breaking bad news:
1- Getting started.
2- Finding out how much the patient knows.
3- Finding out how much the patient wants to know.
4- Sharing the information.
5- Responding to the patients feelings.
6- Planning and follow-through.
(65) (B) Trisomy 21.
Down syndrome < trisomy 21) is the most common chromosomal abnormality, affecting about 1 in
800
babies.
he risk of Down syndrome increases with the mother's age.
(66) (B) Decrease calorie intake.

The most effective way to lose weight is to adopt healthy eating habits, exercise routines and stress
iianagement techniques.
Regular exercise and healthy eating are important and even modest weight loss will improve your
health. It is also important to learn stress management tools that can be used in place of overeating or
snacking during stressful times.
(67) (C) Verifying the diagnosis.

investigating an outbreak, speed is essential, but getting the right answer is essential, too.
To satisfy both requirements, epidemiologists approach investigations systematically, using the
following 10 steps:
Prepare for field work.
2- Establish the existence of an outbreak.
- Verify the diagnosis.
Define and identify cases.
- Describe and orient the data in terms of time, place and person.
6- Develop hypotheses.
Evaluate hypotheses.
3- Refine hypotheses and carry out additional studies.
- Implement control and prevention measures.
10- Communicate findings.
(68) (A) Hypertension and Obesity.

- Diabetes has long been linked to obesity and being overweight.
Research showed that the single best predictor of diabetes mellitus type 2 is being obese or
overweight. Note that hypertension, or high blood pressure a significant risk factor in the development
of diabetes mellitus type 2.
any factors like obesity, diet, stress, occupation, which are considered more important in the western
and urban studies, were not found to be significant in this rural area, whereas strong genetic factors,
tobacco use, less physical activity and systolic hypertension emerged as strong risk factors.
(69) (A) Sensitivity.

- A Sensitivity (also called the true positive rate, or there call rate in some fields) measures
he proportion of actual positives which are correctly identified as such (e.g. the percentage of
sick people who are correctly identified as having the condition).
(70) (A) [A/(A+B)J / [C/(C+D)].
- Relative risk: is an epidemiological indicator resulting from Cohort study and it is the ratio of
incidence of a health outcome among exposed population to the incidence of the health outcome in the
non-exposed population.
(1) Incidence among exposed = A / A+B.
A - Exposed patient who developed disease.
A+B = All exposed population.
(2) Incidence among non-exposed = C / C+D.
C = Non-exposed with the disease.
C+D = All non-exposed population.
(71) (A) Cognitive and behavioral therapy.

- Cognitive behavioral therapy is effective in these cases.
- Pharmacotherapy has high success rates.
OBG
(1) Pregnant female is HIV positive, what is the most likely mode of transmission to the baby?
(A) Through the placenta.
(B) Through the blood cord.
(C) Through hand contamination of mother.
(D) By breastfeeding.
(2) A female patient presented to the clinic with tremors, fatigue, irritability, nervousness, palpitations
and heat intolerance. She has a 6-month-old baby. Which of the following is most likely the diagnosis?
(A) Postpartum thyroiditis.
(B) Hyperthyroidism.
(C) Subacute thyroiditis.
(D) Hypothyroidism.
(3) A pregnant woman at 36 weeks gestational age presented with 7 cm cervical width at 0 station.
During birth CTG shows late deceleration. What is the management?
(A) Give oxytocin.
(B) Give oxygen and change the mother's position.
(C) Give magnesium sulfate.
(D) Cesarean section.
(4) Which one of the following conditions is not associated with increased alpha-fetoprotein?
(A) Neural tube defects.
(B) Down syndrome.
(C) Gastroschisis.
(D) Multiple gestations.
(5) A pregnant woman presented with low back pain and all gynecologic causes are ruled out. What is
the treatment?
(A) Acetaminophen.
(B) Ibuprofen.
(C) Diclofenac.
(D) Aspirin.
(6) A pregnant woman with 34 weeks gestational age presented with breech presentation. What is the
management?
(A) Wait until 36 weeks.
(B) Do external cephalic version.
(C) Cesarean section.
(D) Induce labor.
(7) A mother delivered her first baby with cleft lip and palate. What is the percentage of
recurrence for her next pregnancy?
(A) 1%.
(B) 4%.
(C) 15%.
(D) 20%.
(8) A mother delivered her first baby with anencephaly. What is the chance of having the same
condition in her second baby?
(A) 2%.
(B) 10%.
(C) 25%.
(D) 50%.
(9) A female patient suffered from a postpartum hemorrhage. After massage, oxytocin and
ergometrine, she still bleeds. What is the next step in management?
(A) Hysterectomy.
(B) Ligate internal iliac artery.
(C) Brace suturing of uterus.
(D) Blood transfusion.
(10) What is the treatment of hyperthyroidism in pregnant women?

(A) Propylthiouracil.
(B) Methimazole.
(C) Beta-blockers.
(D) Radioactive iodine.
(11) A 48-year-old female has not menstrated for 2 cycles. The method of contraception used is
condoms. On examination, everything is normal except for dusky discoloration of the cervix. What is
the next step of investigation?
(A) Progesterone challenge.
(B) Beta-hCG.
(C) Pelvic US.
(D) Urine pregnancy test.
(12) Which heart condition is tolerable during pregnancy?

(A) Eisenmenger syndrome.
(B) Aortic stenosis.
(E) Mitral stenosis.
(13) What is the most accurate method to determine the gestational age?
(A) US.
(B) Last menstrual period.
(C) Beta hCG.
(D) Mother's weight.
(14) What is the treatment of scabies in pregnant women?

(A) Permethrin 5% dermal cream.
(B) Benzyl benzoate.
(C) Crotamiton.
(D) Malathion.
(15) A female presents with positive urine pregnancy test at home. What is the next step?
(A) Serum hCG.
(B) Abdominal US.
(C) CBC.
(D) Repeat urine pregnancy test.
(16) Which of following is true regarding pregnancy?

(A) Use of anti-thyroid drugs increases the incidence of congenital anomalies.
(B) Gastroesophageal reflux disease increases the incidence of iron deficiency anemia.
(C) 15 % of pregnant women will have depression at some time, pre- or postpartum.
(D) Serum hCG can be demonstrated in maternal plasma by 8-9 days after ovulation.
(17) A pregnant women in labor suffers from severe pain and dilated cervix bu tall of the
manifestations are within normal parameters. What is the type of analgesia should be used?
(A) Epidural analgesia.
(B) Spinal analgesia.
(C) Systemic analgesia.
(D) General anesthesia.
(18) What is the effect of drinking alcohol during pregnancy?

(A) It can cause fetal alcohol syndrome.
(B) There is no effect on the baby.
(C) It only causes problems if combined with smoking.
(19) Which one of the following changes will occur during pregnancy?
(A) Increase tidalvolume.
(B) Decrease tidal volume.
(C) Increase total lung capacity.
(D) Increase functional residual capacity.
(20) A pregnant woman with 18 weeks of gestational age presented with tachycardia and severe
vomiting. On examination, she has increased blood pressure. On investigations, her thyroid function test
showed increased thyroxine binding globulin, increased total thyroid hormone, normal free thyroid
hormone and TSH and an increased beta-hCG. What is the most common cause of this result?
(A) Pregnancy.
(B) Compensated euthyroidism.
(C) Subacute thyroiditis.
(D) Hyperthyroidism.
(21) A pregnant woman presented with signs and symptoms of suspected DVT. What is the best initial
investigation?
(A) Duplex US.
(B) D-dimer.
(C) CT scan.
(D) Venogram.
(22) A pregnant woman with 2 months gestational age presented with severe vomiting (hyperemesis)
and vaginal bleeding with pelvic pain. On examination, the uterus is larger than suspected. On
investigations, beta-hCG is very high. What is the most likely diagnosis?
(A) Endometrial cancer.
(B) Gestational trophoblastic disease.
(C) Cervical cancer.
(D) Ovarian cancer.
(23) During the third trimester of pregnancy, all of the following changes occur normally except
(A) Decrease in WBCs.
(B) Reduced gastric emptying rate.
(C) Diminished residual lung volume.
(D) Diminished pelvic ligament tension.
(24) A pregnant woman presented to the ER with blood gushing from the vagina due to abdominal
trauma. What is the most likely diagnosis?
(A) Abrupto placenta.
(B) Placenta brevia.
(C) Contusion of uterus.
(D) Injury to fetus.
(25) Which one of the following can lead to polyhydramnios?
(A) Duodenal atresia.
(B) Renal agenesis.
(C) Postterm pregnancy.
(D) Intrauterine growth restriction.
(26) A 42-year-old pregnant woman visits the clinic during her second trimester asking to do
screening to detect Down syndrome. What is the best method?
(A) Amniocentesis.
(B) Choriocentesis (chorionic villous sampling).
(C) Cordocentesis (umbilical cord blood sampling).
(D) Triple screen.
(27) A female patient complains of severe migraines that affect her work. She mentioned that her
migraines improved during her last pregnancy. What it the best thing to prevent her migraine?
(A) Biofeedback.
(B) Acetaaminophen.
(C) Propranolol.
(D) Ibuprofen.
(28) A pregnant woman with 41 weeks of gestational age did not complain of anything. On
examination, she had mild hypertension and her biophysical profile showed oligohydroamnios. What
is the appropriate management?
(A) Wait for spontaneous vaginal delivery to occur.
(B) Induce labor after 42 weeks.
(C) Induce labor now.
(D) Do biophysical profile twice weekly.
(29) A pregnant woman underwent US which showed anteriolateral placenta. On vaginal
examination, the examiner's finger cannot reach the placenta. What is the type of this placenta?
(A) Placenta previa totalis.
(B) Placenta previa marginalis.
(C) Placenta previa partialis.
(D) Normal placenta.
(30) Which drug is contraindicated for treatment of urinary tract infectionin pregnant women?
(A) Ampicillin.
(B) Nitrofurantoin.
(C) Fluoroquinolone.
(D) Cephalexin.
(31) Which antibiotic is safe for a pregnant woman who has no known sensitivity to any drug?
(A) Tetracycline.
(B) Ampicillin.
(C) Chloramphenicol.
(D) Sulfonamide.
(32) What is a contraindication of methylergonevine (Methergine)?

(A) Maternal hypertension.
(B) Pulmonary edema.
(D) DVT.
(33) What is the best diagnostic test for endometriosis?

(A) US.
(B) Laparoscopy.
(C) Laparotomy.
(D) MRI.
(34) A young female patient presented by pain during the first 2 days of menses. Her menarche was
2 years back. What is the initial treatment?
(A) Oral contraceptive pills.
(B) NSAIDs.
(C) Aspirin.
(D) Self-limited, no medication is required.
(35) A 19-year-old woman complains of abdominal pain within the first two days of her
menstruation cycle. There is no finding in her full examination and investigations. What is the
diagnosis?
(A) Primary dysmenorrheal.
(B) Secondary dysmenorrheal.
(C) Endometriosis.
(D) Polycystic ovary syndrome.
(36) An elderly female presented with itching of the vulva with no discharge. On examination her
vagina is pale and thin. What is the management?
(A) Estrogen cream.
(B) Progesterone cream.
(C) Corticosteroid cream.
(D) Fluconazole cream.
(37) A female patient was diagnosed recently with epilepsy and phenobarbitone was prescribed for
her. She lactates her child 3 times/day. Which of the following is true?
(A) Stop lactation immediately.
(B) Stop lactation after 3 weeks.
(C) Lactate 8 hours after each dose.
(D) Continue the feeding.
(38) Which statement is true regarding MMR vaccine in a lactating mother?

(A) MMR vaccine has live attenuated bacteria.
(B) Discontinue breast feeding for 72 hours after the vaccination.
(C) MMR vaccine can be taken safely while breastfeeding
(D) MMR vaccine is contraindicated in a lactating mother.
(39) A 52-year-old woman complains of hot flushes, dry vagina, loss of libido, loss of concentration
and weight gain. What is the treatment?
(A) Estrogen.
(B) Progesterone.
(C) Fluoxetine.
(D) Steroid.
(40) Which one of following is contraindication of breastfeeding?

(A) Chemotherapy.
(B) Anti-convulsion drugs.
(C) After DT vaccine.
(D) Smoking.
(41) What is the absolute contraindication of breastfeeding?

(A) Asymptomatic HIV infection.
(B) Active hepatitis C.
(C) Veneral wart.
(D) TB treated for 3 months.
(42) A lactating woman presented with breast engorgement and tenderness. What is the
management?
(A) Warm compressor and continue breastfeeding.
(B) Didoxacillin and continue breastfeeding.
(C) Didoxacillin and milk expression.
(D) Discontinue breastfeeding and cold compressor.
(43) What is the best stimulant for breast milk secretion?
(A) Breast feeding.
(B) Oxytocin.
(C) Visual stimulation.
(D) Psychogenic stimulation.
(44) A 30-year-old woman is para 3 with a history of dilatation and curettage after her second delivery.
She is complaining of amenorrhea. Investigation showed high follicle stimulating hormone and
luteinizing hormone with low estrogen. What is the diagnosis?
(B) Asherman's syndrome.
(C) Primary ovarian failure.
(D) Premature ovarianfailure.
(E) Polycystic ovary syndrome.
(45) Patient complains of irregular menstruation with excessive facial hair. She is obese with a BMI =36.
Her mother has the same condition. Investigation showed normal estrogen, increased testosterone,
increased luteinizing hormone, decreased follicle stimulating hormone.
Her urine showed 17-hydroxysteroid. What is the diagnosis?
(A) Cushing syndrome.
(B) Polycystic ovary syndrome.
(C) Adrenal adenoma.
(D) Hypothyroidism.
(46) What is true regarding female puberty comparing with male puberty?
(A) Female puberty is 6-12 months earlier than male puberty.
(B) Female puberty is 2-3 years earlier than male puberty.
(C) Female puberty and male puberty occurs at the same age.
(D) Male puberty is earlier than female puberty.
(47) What is the most common cause of precocious puberty of female?

(A) Idiopathic.
(B) Adrenal tumor.
(C) Brain tumor.
(D) Ovarian tumor.
(48) A 34-year-old woman presented with pelvic pain and menorrhagia. Also she has a history of
infertility. On examination, the uterus was of normal size and retroverted. She had multiple small tender
nodules palpable in the uterosacral ligament.What is the mostlikely diagnsosis?
(A) Endometritis.
(B) Endometriosis.
(C) Adenomyosis.
(D) Pelvic inflammatory disease.
(49) A pregnant woman with a known case of uterine fibroids presented with abdominal pain with
no other symptoms. On investigation, US showed a live fetus. What is the management?
(A) Myomectomy.
(B) Hysterectomy.
(C) Pain management.
(D) Pregnancy termination.
(50) Which one of the following is true about uterine fibroid in pregnancy?
(A) It presents with severe anemia.
(B) It is likely to regress after pregnancy.
(C) It needs immediate surgery.
(D) It presents with antepartum hemorrhage.
(51) How long after menarche does the spinal length stop growing?
(A) 6 months.
(B) 1 years.
(C) 2 years.
(D) 3 years.
(52) A female patient has primary amenorrhea, short stature, webbed neck and low hairline. What
is the most likely diagnosis?
(A) Turner syndrome.
(B) Cushing syndrome.
(C) Down syndrome.
(D) Klinefelter syndrome.
(53) What is the major health problem in menopause?

(A) Depression.
(B) Osteoperosis.
(C) Endometrial carcinoma.
(D) Breast cancer.
(54) A young woman presented with history of cyclical metromenorrhagia. She has never used any
kind of contraceptives before. What is the management?
(A) Ibuprofen.
(B) Oral contraceptive pills.
(C) Danazol.
(D) Acetaminophen.
(55) What is the non-hormonal drug is used to decrease hot flush in postmenopausal women?
(A) Paroxetine.
(B) Captopril.
(C) Ibuprofen.
(D) Only hormonal treatment is effective.
(56) Which of the following is true about secondary dysmenorrhea?
(A) It is due to anovulation.
(B) It is due to gonadal agenesis.
(C) It is always pathological.
(D) It is a part of Sheehan syndrome.
(57) CA-125 is a tumor marker. Which cancer it is mostly used for it?
(A) Ovarian cancer.
(B) Cervical cinder.
(C) Breast cancer.
(D) Uterine cancer.
(58) A postpartum woman complains of passage of flatus and stool through the vagina.
(A) Anal fistula.
(B) Rectovaginal fistula.
(C) Ureterovaginal Fistula.
(D) Vesicovaginal fistula.
(59) What is the drug that comparable to laparoscopy in ectopic pregnancy?

(A) Methotrexate.
(B) Hydroxyurea.
(C) Mefipristone.
(D) Oral contraceptive pills agents.
(60) A patient presented with abdominal pain. She gave history of 3 weeks amenorrhea. On examination,
laparoscopy found blood in the pouch of Douglas. What is the cause of this bleeding?
(A) Rupture of ectopic pregnancy.
(B) Ovarian cyst.
(C) Spontaneous or threatened abortion.
(D) Appendicitis.
(61) What is the management of ectopic pregnancy in the fallopian tube?

(A) Wait andobserve.
(B) Laparotomy.
(C) Laparoscopy.
(D) Dilatation and curettage.
(62) What is the most common site of ectopic pregnancy?

(A) Fallopian tubes.
(B) Ovaries.
(C) Cervix.
(D) Abdomen.
(63) What is the likeliest cause of bleeding after dilatation and curettage?
(A) Asherman syndrome.
(B) Missed disease.
(C) Perforated uterus.
(D) Infection.
(64) A young woman presented with history of heavy vaginal bleeding. She is diagnosed as having
dysfunctional uterine bleeding. What is the management?
(A) Combined oral contraceptive pills.
(B) Hospitalization and blood transfusion.
(C) Hysterectomy.
(D) Dilatation and curettage.
(65) A female patient presented with history of cyclic abdominal pain, inability to conceive and
heavy menses. On examination, there is tenderness and nodularity in the uterosacral ligaments. What
is the diagnosis?
(A) Endometriosis.
(B) Ovarian cysts.
(C) Pelvic inflammatory disease.
(D) Mullerian anomalies.
(66) What is the most common symptom in placenta abruption?

(A) Vaginal bleeding.
(B) Uterine tenderness.
(C) Uterine contractions.
(D) Fetal distress.
(67) A female patient complains of irregular menstrual cycle. It comes every other month and lasts
7-8 days with a very heavy bleeding. What is the best description for her menstrual cycle?
(A) Menorrhagia.
(B) Polymenorrhea.
(C) Metrorrhagia.
(D) Menometrorrhagia.
(68) A female patient complains of increase frequency of menstrual cycle. What is the best
description for her menstrual cycle?
(A) Polymenorrhea.
(B) Hypermenorrhea.
(C) Menorrhagia.
(D) Dysmenorrhea.
(69) A pregnant woman with 16 weeks gestational age presented with vaginal bleeding, enlarged
abdomen and vomiting. Her uterus is smaller than expected for the gestational age. The US has
a snowstorm appearance. What is the diagnosis?
(A) Complete hydatiform mole.
(B) Partial hydatiform mole.
(C) Endometriosis.
(D) Fibroids imaging findings.
(70) A menopausal woman complains of bleeding not associated with intercourse. What is the
treatment?
(A) Estrogen.
(B) Progesterone.
(C) Dilatation and curettage.
(D) Hysterectomy.
(71) Dysfunctional uterine bleeding is most common in:

(A) Post menopausal women.
(B) Adolescents.
(C) Women of reproductive age.
(D) All ages have the same chance of dysfunctional uterine bleeding.
(72) A 54-year-old female presented with chronic pelvic pain. By investigation, she is found to
have a right-sided ovarian mass. Surgery is planned to remove the mass and to avoid excessive
bleeding during the surgery, which ligament should be ligated?
(A) Round ligament.
(B) Suspensory ligament.
(C) Ovarian ligament.
(D) Transverse cervical ligament.
(73) What is the most common cause of bleeding for postmenopausal women?
(A) Cervical polyp.
(B) Endometrial atrophy.
(C) Cervicitis.
(D) Nutritional deficiency.
(74) Which one of them following is true about antepartum hemorrhage?

(A) Antepartum hemorrhage is an indication to perform laparoscopy.
(B) Antepartum hemorrhage remains a direct cause of maternal death in nearly 50% of cases.
(C) Second trimester bleeding is most often associated with placental abnormalities.
(D) Placenta previa increases with an increasing number of cesarean sections.
(75) A pregnant woman with 8 weeks gestation age presented with vaginal bleeding for the last 12
hours with lower abdominal pain. She passed tissue. On examination, the internal os was 1 cm
dilated. What is the diagnosis?
(A) Complete abortion.
(B) Incomplete abortion.
(C) Missed abortion.
(D) Threatened abortion
(76) A pregnant woman with 34 weeks of gestational age presented wilh vaginal bleeding.
Which of the following is relevant to ask about?
(A) Smoking.
(B) The result of last Pap smear.
(C) History of vaginal irritation.
(D) Recent sexual intercourse.
(77) A pregnant woman in her 8th month presented with vaginal bleeding and abdominal pain.
She has a known case of hypertension. What is the most common cause of her bleeding?
(A) Placenta previa.
(B) Ectopic pregnancy.
(C) Abrubtio placenta.
(D) Nutritional deficiency.
(78) Which type of contraceptive is contraindicated in lactation?

(A) Oral contraceptive pills.
(B) Mini pills.
(C) Depo-Provera.
(D) Intra uterine device.
(79) Which of the following is true regarding infertility?

(A) It is failure to conceive within 6 months.
(B) Male factors are more common than female factors.
(C) It could be due to high prolactin levels.
(D) It is rarely due to anovulation.
(80) What is an absolute contraindication of combined oral contraceptive pills?

(A) History of previous DVT.
(B) Ovarian cancer.
(C) Cervical cancer.
(D) Diabetes mellitus type 2.
(81) Oral contraceptive pills can cause changes in:
(A) Cervical mucosa.
(B) Vaginal acidity.
(C) Tubal thickness.
(D) Ovum released structure.
(82) What is true about the actionof oral contraceptive pills?

(A) It inhibits estrogen then ovulation.
(B) It inhibits prolactin then ovulation.
(C) It inhibits mid-cycle gonadotropin then ovulation.
(D) It increases vaginal acidity.
(83) What is the drug used for induce ovulation?

(A) Clomiphene.
(B) Estrogen.
(C) Progesterone.
(84) A 23-year-old woman, married for 3 months, presented to the clinic complaining of not getting
pregnant. They have intercourse 3-4 times/week. She has a normal gynecologic history. Her husband is
25-year-old with a healthy weight. What is the management?
(A) Continue trying to one year.
(B) Obtain sperm analysis.
(C) Study tubes patency.
(0) Perform full female hormonal essay.
(85) A female patient complains of frothy vaginal discharge, musty odor and vaginal itching. Her
partner also complains of urethral discharge. Examination shows strawberry cervix. What is the
treatment?
(A) Meconazole cream.
(B) Estrogen cream.
(C) Progesteron cream.
(0) Metronidazole.
(86) What is the treatment of trichomoniasis?

(A) Metronidazole.
(B) Ampicillin.
(C) Rifampicin.
(D) Ceftriaxone.
(87) A male patient presented with joints pain. He gives history of unprotected coitus. On investigation,
culture showed Gram-negative diplococcus. What is the diagnosis?
(A) Gonorrheal arthritis.
(B) Nongonorrheal arthritis.
(C) Rheumatoid arthritis.
(D) Syphilis.
(88) What is the most common site of gonorrhea infection in women?
(A) Cervix.
(B) Urethra.
(C) Rectum.
(D) Pharynx.
(89) A female patient presented with cord-like, cheesy, whitish, adherent, odorless vaginal discharge.
She gives history of using an antibiotic course. What is the diagnosis?
(A) Vulvovaginal candidiasis.
(B) Trichomoniasis.
(C) Bacterial vaginosis.
(D) Gonorrhea.
(90) What is the drug of choice in treating gonorrhea?

(A) Ceftrixone.
(B) Doxycydine.
(C) Azithromycin.
(D) Metronidazole.
(91) A 20-year-old female patient presented with vaginal discharge, dysuria, intermenstrual bleeding,
dyspareunia (painful intercourse) and mild lower abdominal pain. On investigation, urethral culture show
Gram-negative intracellular diplococci. What is the diagnosis?
(A) Gonorrhea.
(B) Syphilis.
(C) Herpes simplex virus.
(D) Chancroid.
(92) A female patient was diagnosed with salpingitis and managed by antibiotics. After 3 days there is
no improvement. On examination, there is swelling in the pelvis in the posterior fornix, which is
fluctuant. What is the treatment now?
(A) Colpotomy.
(B) Laparoscopy.
(C) Laparotomy.
(D) Continue antibiotic.
(93) A 34-year-old female was diagnosed with HIV. Her cervical Pap smear was negative. When you will
repeat cervical Pap smear for her?
(A) After 3 months, if negative repeat it after 6 months.
(B) After 6 months, if negative repeat it annually.
(C) After 1 year, if negative repeat it annually.
(94) Trichomoniasis classically has:
(A) Clue cells.
(B) Greenish frothy discharge.
(C) Odorless discharge.
(D) Pelvic pain.
(95) What is the usual treatment of mastitis for a lactating mother?

(A) Doxycydine.
(B) Ceftriaxone.
(C) Cefixime.
(D) Dicloxaciliin.
(96) What is the usual treatment of mastitis for a lactating mother?

(A) Doxycydine or dicloxaciliin.
(B) Ceftriaxone.
(C) Cefoxine.
(D) Metronidazole.
(97) A female presented with monilial vaginal discharge. What is the treatment?
(A) Miconazole cream for 7 days.
(B) Fluconazole orally as a single dose.
(C) Metronidazole orally for 7 days.
(D) Nystatin cream for 7 days.
(98) A female patient presented with a thin, grey vaginal discharge with fishy odor, especially after
sexual intercourse. She has no history of dyspareunia or abdominal pain. On investigation, KOH test is
positive for whiff test with a pH of 5.5. What is the most likely diagnosis?
(A) Bacterial vaginosis.
(B) Trichomonas vaginalis.
(C) Vaginal candidiasis.
(99) A diabetic mother has elevated blood sugar despite insulin injections. Which one of the following
will be a complication?
(A) Maternal hyperglycemia.
(B) Maternal hypoglycemia.
(C) Neonatal hypoglycemia.
(D) Neonatal hyperglycemia.
(100) A 28-year-old diabetic female is planning to become pregnant; her blood glucose is well
controlled. When must she control her metabolic state to decrease the risk of having congenital
anomalies?
(A) Before conception.
(B) First trimester.
(C) Second trimester.
(D) Third trimester.
(101) What is true regarding diabetes mellitus in pregnancy?

(A) The prevalence of diabetes mellitus in pregnancy is 10%.
(B) Glucose screening is best done at 24-28 weeks of gestation age.
(C) Diabetic and non-diabetic mothers have the same perinatal mortality rate.
(D) Gestational diabetes can be diagnosed by abnormal fasting glucose serum test.
(102) What is the best medication for gestational diabetes mellitus?

(A) Sulfonylureas.
(B) Metformin.
(C) Thiazolidinediones.
(D) Insulin.
(103) After delivery, what risk for the mother is associated with gestational diabetes?
(A) Diabetes mellitus type 1.
(B) Diabetes mellitus type 2.
(C) Impaired fasting glucose.
(D) There is no risk after delivery.
(104) What is the drug used for seizures of eclamptic origin (preeclampsia)?
(A) Magnesium sulfate.
(B) Diazepam.
(C) Phenytoin.
(D) Phenobarbital.
(105) What is the drug of choice for hypertension in pregnancy?

(A) Methyldopa.
(B) La beta I ol.
(C) Nifedipine.
(D) Captopril.
(106) A pregnant woman with 36 weeks gestational age visits the clinic for routine antenatal care. Her
blood pressure is 150/95 mmHg, with no lower limp edema. She denied any previous abnormal reading
of blood pressure. What is the next step?
(A) Repeat measuring of blood pressure.
(B) Investigate for protein urea.
(C) Give magnesium sulfate.
(D) Give anti-hypertension medication.
(107) A primigravida (G1 P0+0) at 13 weeks gestational age presented to the clinic with a blood
pressure of 145/100 mmHg. She does not know if she has previous hypertension. The next visit, her
blood pressure is 145/95 mmHg with no protein urea. She exercises regularly 3-4 times/week. What is
the most likely diagnosis?
(A) Pre-eclampsia.
(B) Eclampsia.
(C) Chronic hypertension.
(D) Gestational hypertension (pregnancy induced hypertension).
ANSWERS
(1) (D) By breastfeeding.

- HIV is transmitted from one person to another through specific body fluids: blood, semen,
genital fluids and breast milk.
- Having unprotected sex or sharing needles with an HIV-infected person are the most common
ways HIV is transmitted.
- An HIV-infected mother can transmit HIV to her baby during pregnancy, during labor and
delivery, or by breastfeeding.
- Anti-HIV medications help prevent mother-to-child transmission of HIV.
- Because HIV can be transmitted through breast milk, HIV-infected mothers should not
breastfeed their babies.
(2) (A) Postpartum thyroiditis.

- Postpartum thyroiditis is a phenomenon observed following pregnancy and may involve
hyperthyroidism, hypothyroidism, or the two sequentially.
- It affects about 5% of all women within a year after giving birth.
- The initial phase of hyperthyroid symptoms occurs transiently about 2-6 months postpartum.
(3) (B) Give oxygen and change the mother's position.

- Management of late deceleration:
1- Move mother to left or right lateral position.
2- Give supplemental oxygen.
3- Stop oxytocin (and potentially start tocolytics).
4- Increase IV hydration.
5- Monitor maternal blood pressure to ensure maternal hypotension is not the cause.
6- Perform fetal blood sampling to assess for acidosis (if available).
Type of
Management
Etiology
deceleration
- Head compression from . NG treatment,
Early
uterine contraction (normal).
- Place patient on side, discontinue oxytocin,

correct any hypotension, increase IV hydration.
- If decelerations are associated with
tachysystole consider terbutaline.
- Administer oxygen.
- Uteroplacenta - If late decelerations persist for more than
Late
30 minutes. Despite the above maneuvers, fetal
insufficiency and fetal
scalp pH is indicated.
hypoxima.
- Scalp pH > 7.25 is reassuring; pH 7.2 - 7.25
may be repeated in 30 minutes; deliver for pH
< 7.2 or minimal baseline variability with late
or prolonged decelerations and inability to
obtain fetal scalp pH.
- Change position to where fetal heart rate
pattern is most improved.
- Trendelenburg may be helpful.
Variable - Umbilical cord compression. ’ Disc0",,nue

- Check for cord prolapse or imminent
delivery
by vaginal examination.
- Consider amnioinfusion.
- Administer oxygen.
(4) (B) Down syndrome.
- Elevated serum alpha-fetoprotein indicates the following conditions:
1- Neural tube defects: anencephaly and spina bifida.
2- Gastroschisis: abdominal wall defect, often lateral to the rectus on the right.
3- Omphalocele: midline umbilical hernia covered by peritoneum.
4- Multiple gestations, when there is placental abruption.
5- Ovarian tumor.
- Decreased serum alpha-fetoprotein indicates the following conditions:
1- Down syndrome.
2- Trisomy 18.
3- Diabetic patients.
(5) (A) Acetaminophen.

- Acetaminophen is considered safe during pregnancy; it can be used during all three trimesters of
pregnancy.
- NSAIDs are not recommended during pregnancy, particularly during the third trimester, while
NSAIDs as a class are not direct teratogens, they may cause premature closure of the fetal ductus
arteriosus and renal adverse drug reactions in the fetus, additionally; they are linked with premature
birth and miscarriage.
(6) (A) Wait until 36 weeks.

- External cephalic version is done after 36 weeks.
-Though it can be done at 34 weeks, it is less safe because of the tendency for the premature fetus to
revert spontaneously to a breech presentation.
(7) (B) 4%.

- If this is first child with cleft, the overall risk for another sibling or offspring is 4%.
- If more than one family member is affected, the overall risk for another sibling or offspring is
10-16%.
(8) (A) 2%.

- If a previous baby was affected, the recurrence rate is 4%.
- If 2 previous babies were affected, the recurrence rate is 10%.
(9) (B) Ligate internal iliac artery.
- The sequence of surgical interventions is:
1 - Repair trauma if any.
2 - Uterine artery ligation.
3 - Utero ovarian artery ligation.
4 - Internal iliac artery ligation.
5 - Brace suturing of uterus.
6 - Hysterectomy.
7 - Angiographic embolisation.
(10) (A) Propylthiouracil.

Treatment of hyperthyroidism in pregnancy is propylthiouracil 50 mg twice daily.
Methimazole readily crosses the placental membranes and can induce goiter and cretinism in the
developing fetus.
Beta-blockers may be given to ameliorate the symptoms of moderate to severe hyperthyroidism in
pregnant women. Low-dose atenolol may be appropriate to begin.
Radioactive iodine is absolutely contraindicated as it can cause fetal goiter.
Thyroidectomy during pregnancy may be necessary in women who cannot tolerate thionamides
because of allergy or agranulocytosis.
(11) (B) Beta-hCG.

There are 2 common types of hCG tests.
1 A qualitative hCG test detects if hCG is present in the blood.
2- A quantitative hCG test (or beta-hCG) measures the amount of hCG actually present in the blood.
(12) (C) Mitral regurgitation.

Mitral regurgitation is a well-tolerated heart disease during pregnancy unless the regurgitation is
severe.
(13) (A) US.

- The most accurate test is the US, which measures the size of the gestational sac and the length
between crown and rump to determine the age of the fetus in weeks
US are most accurate for dating purposes before 12 weeks of pregnancy.
(14) (A) Permethrin 5% dermal cream.

Permethrin is the treatment of choice of scabies in pregnancy.
Only a small amount is absorbed through the skin and this is rapidly detoxified without retention in
the body.
(15) (A) Serum hCG.

- Detection of hCG in the serum or urine is the basis of contemporary pregnancy tests.
serum hCG assays are the most sensitive test and are able to detect pregnancy within 8-12 days of
ovulation (after the embryo has implanted.
U me hCG assays are not as sensitive, but can still detect hCG within 14 days of ovulation.
(16) (D) Serum hCG can be demonstrated in maternal plasma by 8-9 days after ovulation.
- A hCG is produced in the earliest stages of pregnancy.
- During early pregnancy it plays a role in survival of the corpus luteum and in stimulating the thyroid
gland and it also appears to have a significant role in the implantation of the blastocyst and protection
of the embryo against immune attack at the fetal/matemal boundary.
- The serum hCG test is the most sensitive and specific and the hormone can be detected in both blood
and urine by about 8-9 days after conception.
- This test can be performed quantitatively or qualitatively.
- Urine pregnancy tests differ in their sensitivity and specificity, which are based on the hCG units set
as the cutoff for a positive test result, usually 2-5 mlU/ml.
(17) (A) Epidural analgesia.

- Epidural analgesia, sometimes called an epidural block, causes some loss of feeling in the lower areas
of the body, though the patient remains awake and alert. An epidural block may be given soon after the
contractions start or later as the labor progresses.
- Spinal analgesia is like an epidural analgesia, but it lasts only 1-2 hours.
- Systemic analgesics are not given right before delivery because they may slow the baby's reflexes
and breathing at birth.
- General anesthesia often is used when regional analgesia in not possible or is not the best choice for
medical or other reasons. It can be started quickly and causes a rapid loss of consciousness. Therefore it
is often used when an urgent cesarean section is needed.
(18) (A) It can cause fetal alcohol syndrome.
- Fetal alcohol syndrome is a pattern of mental and physical defects that can develop in a fetus in
association with high levels of maternal alcohol consumption during pregnancy.
(19) (A) Increase tidal volume.

- Tidal volume increases by 45% during pregnancy, with approximately half of the change occurring
during the first trimester.
- Functional residual capacity begins to decrease by the 5th month of the pregnancy; this is due to
elevation of the relaxed diaphragm, which occurs as the enlarging uterus enters the abdominal cavity.
(20) (A) Pregnancy.

- Effects of pregnancy on thyroid function:
1- Increased total T3 and T4.
2- Normal free T3, free T4 and TSH.
3- Increased serum thyroglobulin.
4- Increased renal iodide clearance.
- Furthermore, hCG has mild thyroid stimulating activity.
- Pregnancy produces an overall increase in thyroid activity, which allows the healthy individual to
remain in a net euthyroid state.
(21) (A) Duplex US.
- US with duplex and color Doppler US is the procedure of choice to detect proximal DVT,
although it is highly sensitive and specific for femoral and popliteal thrombosis.
- US does not detect pelvic vein thrombosis, which may be responsible for pulmonary embolism.
(22) (B) Gestational trophoblastic disease.

- Gestational trophoblastic disease is a term used for a group of pregnancy-related tumors.
- Gestational trophoblastic disease is divided into 5 tumors: benign (hydatidiform mole), malignant
(invasive mole, choriocarcinoma, placenta site trophoblastic tumor and epithelioid trophoblastic
tumor).
- Gestational trophoblastic disease can simulate pregnancy because the uterus may contain fetal
tissue, albeit abnormal.
This tissue may grow at the same rate as a normal pregnancy and produce hCG, a hormone
which is measured to monitor fetal well-being.
- Invasive mole and choriocarcinoma are chemo-sensitive.
(23) (A) Decrease in WBCs.

- Changes occur normally in pregnancy are increased tidal volume with respiratory rate unchanged,
ncreased RBCs mass, increased WBCs count (especially neutrophils) and increased glomerular
filtration rate.
(24) (A) Abrupto placenta.

- Symptoms of abrupt placenta may include vaginal bleeding, contractions, abdominal tenderness
and decreased fetal movement.
Eliciting any history of trauma, such as assault, abuse, or motor vehicle accident, is important.
(25) (A) Duodenal atresia.

- Polyhydramnios is the presence of excess amniotic fluid in the uterus.
- Causes of polyhydramnios include maternal diabetes, multiple gestations, neural tube defects
(anencephaly, spina bifida), gastrointestinal anomalies (omphalocele, esophageal atresia and
duodenal atresia) and hydrops fetalis.
- Oligohydramnios means a deficiency of amniotic fluid.
- Causes of oligohydramnios include intrauterine growth restriction, premature rupture of the
membranes, post-maturity and renal agenesis.
(26) (A) Amniocentesis.

- During amniocentesis, a sample of the amniotic fluid surrounding the fetus is withdrawn through a
needle inserted into the mother's uterus. This sample is then used to analyze the chromosomes of the
fetus. This test is usually performed after 15 weeks of gestation. This test carries a 1 in 200 risk of
miscarriage.
- Choriocentesis is usually performed at 10-12 weeks. This test carries a 1 in 100 risk of miscarriage.
- Cordocentesis is used when information cannot be obtained through amniocentesis or
choriocentesis. This test carries significant risk of complications so it is typically reserved for
pregnancies determined tobe at high risk for genetic defect. This test carries 1-2 in 100 risk of
miscarriage.
- Triple screen is a maternal blood test that measures three things called alpha-fetoprotein, hCG and
accurate.
unconjugated estriol. If this test shows abnormality then perform an amniocentesis, which it is more
(27) (C) Propranolol.
- Propranolol (beta-blocker) decreases the frequency f graines.
- Calci m channel blockers decrease the ntensity of n g ines.
- Antiepileptics decrease both the intensity and frequenc of migraines.
(28) (C) Induce labor now.

- Post-term pregnancy is defined as more than 42 weeks of gestation
- Both prematurity and post-maturity increase perinatal morbidity and mortality rates.
- With post-maturity, dystocia (difficult delivery) becomes more common because of the increased
size of the fetus.
- If the gestational age is known to be accurate and the cervix is favorable, labor is induced (with
oxytocin, for example).
- If the cervix is not favorable or the dates are uncertain, twice weekly biophysical profiles are done.
- At 41 weeks, most obstetricians advise induction of labor.
(29) (D) Normal placenta.

- Scan of placenta position can be done at 20 weeks of gestational age by US.
- The normal positions of placenta could be: anterior, posterior, fundal and lateral (right or left).
(30) (C) Fluoroquinolone.

- Fluoroquinolone studies have not been done in humans; however, use is not recommended during
pregnancy since fluoroquinolones have been reported to cause bone development problems in young
animals.
(31) (B) Ampicillin.

- Some antibiotics are considered safe in pregnancy: Amoxicillin, Ampicillin, Cephalosporin,
Erythromycin, Clindamycin, Penicillin and Gentamicin.
- Tetracycline can damage a pregnant woman's liver and discolor a developing baby's teeth.
- Sulfonamide has been associated with rare birth defects. Although there's no direct proof that these
antibiotics cause birth defects, additional research is needed.
- Chloramphenicol using late in pregnancy has been associated with gray baby syndrome.
(32) (A) Maternal hypertension.

- Contranindication of common uterotonics includes:
- Methylergonovine: preeciampsia, gestational hypertension, or chronic hypertension.
- Oxytocin: pulmonary edema.
- Carboprost: bronchial asthma.
(33) (B) Laparoscopy.

- Endometriosis is confirmed by laparoscopy.
- US and MRI can be used, but if normal, they cannot exclude endometriosis.
(34) (B) NSAIDs.
- is is a case of dysmenorrhea.
AIDs is the best initial reatmen! for dysmenorrhea.
(35) (A) Primary dysmenorrheal.

mary dysmenorrhea
et within 6 months after menarche
wer abdomnal/peivic pain begins with onset of menses and lasts 8-72 hours.
pain is suprapub c, sharp and colicky, usea,
diarrhea an-:: headache may accompany the pain.
.nding n exami ation or nvestigations. ondary
dysmenorrhea:
re is a; underlying disease which leads to dysmenorrhea so there are findings : either examination
estgatic s.
(36) (A) Estrogen cream.

nal itching and dryness are secondary to hormonal deficiency in perimenapausai women,
they go through menopause, the most common prescription includes o.mone replacement
therapy or anti-depressants to minimize hot flashes
endroi te or sedronate (non-hormona medications) to educe bone loss and reduce the risk
of ures.
e ective estrogen receptor modulators, which mimic estrogen s beneficial effects on bone
density, ginal estrogen administered locally, to relieve vaginal itching dryness and discomfort
during sexual intt course
(37) (D) Continue the feeding.

hough a iticonvu sants are excreted in breast milk in small amounts breastfeeding s not a
indicated.
(38) (C) MMR vaccine can be taken safely while breastfeeding

MIVR vaccine has live-attenuated viruses.
It should b given to women who are not pregnant and who do not have evidence of immunity to
rubella cinated women are advised to avoid conception for 28 days after administration.
The vaccine can be gi.ei safely to postpartum women who are breastfeeding Brea stfeeding does
not interfere with the response to MMR vaccine and the baby will not be affected by the vaccine
through breast mi k.
(39) (A) Estrogen.

tor postme, opausal women w th moderate to severe vasomotor symptoms (and no history of
breast or card ovasc ar disease; short-term estrogen therapy is the treatment of cho ce
(40) (A) Chemotherapy.

Contraindications of breastfeeding include ga actosaemia in baby, active untreatec TB n mother,
y, iphotr phi virus type or 1 1 .n mother, mother receiving diagnostic or th rapeutic radioactive
T-c I 1
isotopes >r exposure to adioac; ve materials mother receiving antimetabolites ot other

chemotherapeutic s abusing drugs erpes ^ lex esions on mother s breast (thoug; ebaby may feed
from
he eas i free from lesions or HIV positive mother.
(41) (A) Asymptomatic HIV infection.
- Maternal infection with hepatitis B and C virus is not a contraindication to breastfeeding, as opposed
to HIV infection and galactosemia.
- Transmission of HIV by breastfeeding is well documented
-Thus, if safe alternatives are available, breastfeeding by IV infected mothers is not recommended.
H
(42) (A) Warm compressor and continue breastfeeding.

- This is a case of engorgement of the breast, which is ma aged by warm compressor.
- If there is redness, swelling and fever, this would be a case of mastitis, which is managed by
antibiotics (dicloxacilhn)
(4B) (A) Breastfeeding.

- Because of this, it is recommended to begin feeding as soon as possible after birth.
- Even if there is no milk at initiation of feeding, it will come due to the stimulation of feeding.
(44) (D) Premature ovarian failure.

- Premature ovarian failure presents with menstrual irregularity.
- Typical symptoms of premature ovarian failure include hot flushes arid night sweats.
- Diagnosis of premature ovarian failure is made by elevated follicle st mulating hormone and low
estrogen in the setting of amenorrhea.
- In primary ovarian failure, the girl never begins menstruation.
- In polycystic ovary syndrome, there is infertility due to lack of ovulation.
(45) (B) Polycystic ovary syndrome.

- Women with polycystic ovarian syndrome have abnormalities in the metabolism of androgens and
estrogen and in the control of androgen production.
- The major features of polycystic ovary syndrome include menstrual dysfunction, anovulation and
signs of hyperandrogenism.
- Other signs and symptoms of polycystic ovary syndrome may include the following: hirsutism,
infertility, obesity and metabolic syndrome, diabetes and obstructive sleep apnea.
- The follicle stimulating hormone level should be checked to rule out primary ovarian failure.
- In patients with polycystic ovary syndrome follicle stimulating hormone levels are within the
reference range or low.
- Luteinizing hormone levels are elevated for Tanner stage, sex and age.
- The luteinizing hormone -to- follicle stimulating hormone ratio is usually greater than 3.
- Stimulation testing with a long-acting gonadotropin-releasing hormone agonist induces a
characteristic rise in ovarian-derived 17-hydroxyprogesterone after 24 hours.
- This is thought to be a result of excessive 17-hydroxylase activity.
(46) (B) Female puberty is 2-3 years earlier than male puberty.
- The average age of onset of puberty in female is 9-year-old.
- Once female puberty is initiated, it proceeds over an average of 4-5 years and culminates in the
onset of menses.
- Increasing production of luteinizing hormone and follicle-stimulating hormone, as well as other
factors (such as leptin), is responsible for the initiation of the pubertal process.
(47) (A) Idiopathic.
Precocious puberty is typically c; fined as the appearance of any sign of secon ary s< xual ma ura ion
in
boys younger than 9-year-old, in white girls younger than 7-year-old and in black girls younger than
ear-old
Most cases of prec c ous puberty are idiopa ic
(48) (B) Endometriosis.

A patient nay have endometriosis without the presence of any symptoms
sicai findings or < ndomet os s nay inc ude multiple tender od lies pal ab e along the terosacra
ent a* he time of v I rectal exam.nation \ ostenor y nxed terus an . possin y enlarged cystic
ovarie-
(49) (C) Pain management.

mei i or fib as during pregnancy is not necessary
mo co:up cation of fibroids during pregnancy s localized pain typ cal et .veen the first and t
nest
usually eas reated vith pain relievers.
(50) (B) It is likely to regress after pregnancy.

oids ca dram, caily lcrease it. size durin pregnancy
t ght o ecause o he inciease n estrogen levels during pregnancy
ga ibro ns usually shrink back to thei pie-pregnancy s ze.
I impn e a* te menopause wnei toe level of estroge n decreases d amatically. eve
menopausal women who ar taking supplemental estrogen may not ex perience reliei of
symptoms
(51) (C) 2 years.

r sp us a lly occui s a 1 5-2 ears afte rnenarc; n gi Is a I 18-year-old in boys
(52) (A) Turner syndrome.

It is important to note that an individual may have any combination of symptoms but would be
unlikely have all symptoms.
Approximately 95' of indi duals wit I Turne s drome na e bo shore sat and s gns o ovarian
failure.
■ a IO ofTui e s ndrome lcludes short staturi ymphedema (swetingj o he hands and feet broad
chest s ith wideh spaced nipples. Io airline ow-set ears reproductive sternity
rudimentary ova ies gonad snea (under developed gonadal str. ures tha er become fibrosed)
anenorrhoea or absence of a erv trua period and a ign arched pa ate.
(53) (B) Osteoperosis.

O teoporc sis may be a pri nary d sease state resulting irom estrogen def en y or aging or may oe coi
dary to otl e seases conditions, or med catior s that affec: calcium and bom metabo ism - It .s i silent
disease e oming symptomatic only when fractures have occurred.
(54) (B) Oral contraceptive pills.
- Metromenorrhagia can be treated via conventional med al or surgical methods
- The selection of treatment often depends on the cause a d severity of the metromenorrhagia.
1- If metromenorrhagia s the result of conditions amenab e to medical treatment (such as a thyroid
disorder), then contra of these conditions may decrease the bleeding.
2- If the patient has irregular cycles (for example, because of lack of ovulation), then hormones such as
oral contraceptive pills or medroxyprogesterone may be u ed to regulate the cycles and decrease
menstrual flow.
3- A patient who is nearing the menopause can receive hormone ejections that place her into an earlier
artificial menopause eliminating menstrual bleeding altogether.
4- If the patient encounters acute and profuse bleeding then high-dose estrogens may be given
5- If metromenorrhagia :s resistant to medical manageme t, then surgical treatment may be necessary.
Examples of procedural Treatments for metromenorrhagia are di ation and curettage, for acute profuse
bleeding; thermal ablation of the endometrial lining* hyst roscopic resection of endometrial polyps or
fibroids; and placement of a progesterone-impregnated intrauterine device. Hysterectomy is the
definitive surgery for metromenorrhagia no matter what the cause, ince menstrual bleeding cannot
occur without the uterus
(55) (A) Paroxetine.

- Paroxetine is an antidepressants drug of the selective serotonin re-uptake inhibitors type
- It is most commonly used in the treatment of depress o and some personality disorders.
- It nas been found effic ent in alleviating hot flashes w dose paroxetine mesylate is used for the
treatment of moderate o severe vasomotor symptoms (e.g hot flashes and night sweats) associated with
menopause.
(56) (C) It is always pathological.

- Secondary dysmenorrhea may present at any time after nenarche, but it most commonly arises when
a woman is in her 20s o; 30s, after years of normal re ati> ely painless cycles
- Elevated prostaglandins may also play a role in seconda dysmenorrhea but, by definition,
concomitant pelvic pathology must also be present
- Common causes nclude endometriosis, leiomyomata (f i raids), adenomyosis pelvic inflammatory
disease and intrauterine device use.
(57) (A) Ovarian cancer.

- CA-125 is the most frequently used biomarker for ova ian cancer detection.
- Around 90% of women with advanced ovarian cancer ta e elevated levels of CA-125 in their blood
serum making CA-125 a useful tool for detecting ovarian cancer fter the onset of symptoms.
(58) (B) Rectovaginal fistula.

- A rectovaginal fistula is a medical condition where there s a fistula or abnormal connection between
the rectum and the vagina.
- Rectovaginal fistulae are often the result of trauma during childbirth.
a■
(59) (A) Methotrexate.
lethotre ate emotherape tic ayer, that has been used successfully to treat small, nruptured ectopic
pregnar c es
s approach as the advantage of avoiding surgery but the pat ent niust be counseled that it may
take 3-4 weeks for th* ectopi preg ancy to resolv> with methotrexate therapy.
(60) (A) Rupture of ectopic pregnancy.

The classic clinical triad of ectopic pregnancy is as follows abdom nai pain amenorrhea, ag na
bleeding. Unfortunately, onl; about 50% of patients present with all 3 symptoms, t ents n pa a t lose
who a e hemodynamically unstable should proceed to laparoscopy proximately 20 o ot patients th
ectopic pregnancies are hemodynamicall compromised at initial mentation, which s highly suggestive
of rupture
(61) (C) Laparoscopy.

erative laparosco y may be performed to confirm the diagnosis of ectopic pregnancy and to
remove e abnormal gestati n via salpingectomy or salpingostomy
(62) (A) Fallopian tubes.
■/o of ectopi g mcie ot r n the Fallopian tube 80% of these occur i h ampulla region of ube About
10% or cur in the isthmus region and about 5% in the infundibu um region. Only about occu: in
the i terstitial portion of the Fallopian tube % occurs on ovaries % occurs in the cervix.
1% occurs in the abdome with possible adherence to the peritoneum, viscera surfaces, or
omentum.
(63) (C) Perforated uterus.

Heavy bleeding nay occur do to a perforation of the uterus during surgery e metal instruments can
puncture the uterus or other internal organs some cases, bie :dir i occurs after dilatation and
curettage due to hemorrhage or infection
(64) (A) Combined oral contraceptive pills.

cause of the abnor mal bleeding should determine the treatment options available to the patient.
Hoi monal or m. dica conditions causing the bleeding should be addresse r;
ctural caus s re often addressed surgically (as in the case of fibroids polyps, or cancers) but
conservative therapies may also be appropriate.
rtese treatment optio s are discussed elsewhere Patients with structura arid hoi monal causes of
their abnormal bleeding may need multiple or seq uential therapies
(65) (A) Endometriosis.

Endometriosis usually presented with dysmenorrhea, pain with ovulation, chronic pelvic pain,
spareunia and infertility.
can be associated with urinary and gastrointesinal symptoms.
(66) (A) Vaginal bleeding.
- The clinical presentation of abruption includes vaginal bleeding, abdominal pain and uterine
contractions.
- The severity of the clinical presentation is variable.
- In partial placental abruption, there is no maternal or fetal compromise.
- In complete placental abruption with profuse bleeding, expect signs of maternal DIC and a stillbirth.
(67) (D) Menometrorrhagia.
(68) (A) Polymenorrhea.

- Polymenorrhea is frequent menestration (< 21 day cycle)
- Hypermenorrhea or menorrhagia is abnormally heavy and prolonged menstruations at regular
intervals with more than 80 ml of blood loss per cycle or prolonged bleeding, more than 8 days.
- Oligomenorrhea is an increased time between menses (35-90 days between cycles).
- Metrorrhagia is bleeding between periods.
- Menometrorrhagia is excessive and irregular bleeding.
(69) (A) Complete hydatiform mole.

- US is primarily used to rule out an intrauterine pregnancy.
- The classic US finding of a complete mole is the snowstorm or granular appearance, central
heterogenous mass with numerous anechoic (cystic) spaces, low resistance arterial and venous flow
and absence
of embryo or fetus.
When US finding and hCG levels are suspicious for hydatidiform mole, the d agnosis should be
confirmed by histology.
(70) (B) Progesterone.

- Most common cause of postmenupusal bleeding is atrophic vaginitis, which is treated by
estrogen, but it is related to sexual intercourse.
- This is a case of dysfunctional uterine bleeding, which is not related to sexual intercourse,
caused by unopposed estrogen due to anovulation, so the treatment is progesterone or
combined oral contraceptive pills.
- Treatment depends on what is causing the bleeding:
- Polyps mean surgery may beneeded to remove them.
- Endometrial atrophy can be treated with medication alone.
- Endometrial hyperplasia may be treated with medication, such as progestin or progesterone therapy
and/or surgery to remove thickened areas of the endometrium.
(71) (A) Postmenopausal women.

- Dysfunctional uterine bleeding has a negative impact on he quality of life of affected women
whether young or old.
- It occurs in approximately 10-30% of reproductive-aged women,
20% in adolescence and 40% in patients over age 40-year-old.
(72) (B) Suspensory ligament.

- The suspensory ligament contains ovarian vessels and nerves.
(73) (B) Endometrial atrophy.
- The most common cause of p menopausa bleeding is vagina a metrial atrophy but
endomei noma must be uied out irs
ther le po yps, ce . ica caner, h'r ■ ai repiaceme : : ?ap> endometrial
perplas a m tria'cancer endometrial poi ps terine tumors, o a an cancel and
estrogen-set reting tumors n other parts of the bt d/.
(74) (D) Placenta previa increases with an increasing number of cesarean sections.
Placenta previa is an obstetric complication that occurs in the second and third trimesters of pregnancy.
This condition is generally defined as the implantation of the placenta over or near the internal os of the
cervix and it is one of the eading causes of vaginal bleeding in this time period.
The exact etiology of placenta previa is unknown.
The condition may be multifactorial and is postulated to be related to the following risk factors:
Multiple gestations (larger surface area of the placenta), short interpregnancy interval, prior uterine
surgery, uterine insuit or injury previous cesarean delivery including first subsequent pregnancy following
a cesarean delivery, advancing maternal age (> 35-year-old), infertility treatment, multiparity 5% in grand
multiparous patients), previous or recurrent abortions, prior placenta previa (4-8%), placental abruption
from preeclampsia, chronic hypertension, erythroblastosis, nonwhite ethnicity, low socioeconomic status,
smoking, cocaine use, digital examination and trauma (e.g. postcoital trauma).
- A study showed that the risk of placenta previa is 0.26% with an unscarred uterus and increased
almost inearly with the number of prior cesarean sections to 10% in patients with 4 or more.
(75) (B) Incomplete abortion.

- Most incomplete abortions occur in women whose pregnancies have reached 8 weeks or more
from the time of conception, or 10 weeks from last menstrual period.
The fetus has giown to an inch and length and may be too large to pass through the cervix on its own.
(76) (A) Smoking.

Smoking is an important risk factor for antepartum hemorrhage.
(77) (C) Abrubtio placenta.

- Causes of antepartum hemorrhage:
1- Abruptio placentae 30%.
2- Placenta previa 20%.
3- Uterine rupture
4- Vasa previa.
(78) (A) Oral contraceptive pills.
- Oral contraceptive pills, also called combined oral contraceptive pills, contain estrogen and
progesterone. Combined oi ai contraceptive pills decrease milk volume and impair a woman's ability to
breast feed
exclusively.
Thus, hormonal contraceptives can be used immediately postpartum, but progestin-only contraceptives
are preferable during the first 6 months because they have no apparent deleterious effect on breast
feeding.
Mini pills are progesterone-only birth control pills.
Depo-proveia is a progesterone-only birth control injection.
(79) (C) It could be due to high prolactin levels.
- Infertility is the failure to conceive (regardless of cause) after 1 year of unprotected intercourse.
- Female factors are more common than male factors.
- Anovulation is a common cause of infertility.
(80) (A) History of previous DVT.

- Absolute contraindications for the combined oral contraceptive pills include: active thrombophlebitis
or venous thrombo-embolism disorder, acute or chronic obstructive liver disease with elevated liver
enzyme levels or compromised liver function, known or suspected breast cancer, undiagnosed genital
bleeding, smoking in women over 35-year-old and known or suspected pregnancy.
(81) (A) Cervical mucosa.

- Mode of oral contraceptive pills action:
1- The primary mechanism is inhibition of the luteinizing hormone surge, which leads to suppression
of ovulation.
2- Thickening of the cervical mucosa decreases the water content and increases the viscosity of the
cervical mucosa, resulting in ineffective sperm migration.
3- Slowing tubal motility and ova transport may interfere with fertilization.
4- Alteration of endometrium, to make it thin and inactive, hampers implantation.
(82) (C) It inhibits mid-cycle gonadotropin then ovulation.

- Oral contraceptive pills acts primarily by inhibiting the mid-cycle surge of gonadotropin secretion
and there by inhibiting ovulation.
-They also alter the endometrium and cervical mucus to decrease sperm transport and implantation and
decrease tubal motility.
(83) (A) Clomiphene.

- Clomiphene is the most commonly prescribed fertility drug and is indicated for the treatment of
anovulation.
- Clomiphene citrate is an estrogen antagonist and works best in women with a functioning
hypothalamic-pituitary-ovarian axis (e.g. women with normal estrogen levels and oligo- or anovulation
such as those with polycystic ovarian syndrome).
(84) (A) Continue trying to one year.

- Infertility is the failure to conceive (regardless of cause) after 1 year of unprotected intercourse.
(85) (D) Metronidazole.

- This is a case of trichomoniasis.
- Treatment of trichomoniasis is metronidazole.
- Sexual partners must be treated (even if asymptomatic) to prevent reinfection.
(86) (A) Metronidazole.
- Trichomonas vaginalis is a flagellated protozoon which is predominantly sexually transmitted.
- It is able to attach to squamous epithelium and can infect the vagina and urethra.
- Trichomonas may be acquired perinatally in babies born to infected mothers.
- Metronidazole is the treatment of choice for trichomoniasis, either 2 gm orally as a single dose or
400 mg twicedaily for 7 days.
- There is some evidence of metronidazole resistance and nimorazole may be effective in these cases.
- Topical therapy with intravaginal tinidazole can be effective, but if extravaginal infection exist.s
this may not be eradicated and vaginal infection reoccurs.
- Male partners should be treated, especially as they are likely to be asymptomatic and more
difficult to detect.
(87) (A) Gonorrheal arthritis.

- Gonococcal arthritis is caused by infection with the Gram-negative diplococcus (Neisseria
gonorrhea).
- Exact diagnosis depends on identification of Neisseria gonorrhea by one of several methods; one
of these is Gram stain, looking for Gram-negative diplococcus in polymorphonuclear leukocytes.
(88) (A) Cervix.

- The most common site of gonorrhea infection in women is the endocervix, followed by the urethra,
then the rectum and then the pharynx.
- The most common site for infection in man is the urethra.
(89) (A) Vulvovaginal candidiasis.

- Candida infection is common in women who take antibiotics.
- Broad-spectrum antibiotics are effective against a wide range of bacteria but kill healthy
bacteria in the vagina, which can lead to the overgrowth of Candida.
- Factors that increase the risk of developing a Candida infection include antibiotic use, increased
estrogen levels, uncontrolled diabetes mellitus and impaired immune system.
(90) (A) Ceftrixone.

- Ceftriaxone is the drug of choice in treating gonorrhea because of the attainment of high,
sustained bactericidal levels in the blood.
- Negative considerations include possibly higher drug cost, discomfort because of injection and
additional expense due to injection administration.
(91) (A) Gonorrhea.

- Neisseria gonorrhoeae is a Gram-negative intracellular diplococcus which infects epithelium
particularly of the urogenital tract, rectum, pharynx and conjunctivae.
In women, the primary site of infection is usually the endocervical canal.
- Symptoms include an increased or altered vaginal discharge, pelvic pain due to ascending
infection, dysuria and intermenstrual bleeding.
- Complications include Bartholin's abscesses and in rare cases, perihepatitis (Fitzhugh-Curtis
syndrome) can develop.
- On a global basis. Neisseria gonorrhoeae is one of the most common causes of female infertility.
- Rectal infection, due to local spread, occurs in women and is usually asymptomatic, as is
pharyngeal infection.
- Conjunctival infection is seen in neonates born to infected mothers and is one cause of ophthalmia
neonatorum.
- Treatment is indicated in those patients who have a positive culture for Neisseria gonorrhoeae.
- Single-dose oral therapy with cefixime (400 mg), ceftriaxone IM (250 mg) or spectinomycin 2 gm
IM successfully treats uncomplicated anogenital infection.
- Longer courses of antibiotics are required for complicated infections.
- There should be at least one follow-up assessment and culture tests should be repeated at least 72
hours after treatment is complete.
- All sexual contacts should be notified and then examined and treated as necessary.
(92) (A) Colpotomy.

- Unresolved abscesses may be drained percutaneously via posterior colpotomy (under CT or US
guidance), laparoscopically, or through laparotomy.
- In this case the management will be by colpotomy.
- Posterior colpotomy is preserved for abscesses in the cul-de-sac.
- The 3 requirements for colpotomy drainage are as follows:
1- Abscess must be in the midline.
2- Abscess should be adherent to the peritoneum of the cul-de-sac and dissect into the rectovaginal
septum to ensure extraperitoneal drainage of pus.
3- Abscess should be cystic or fluctuant for adequate drainage.
- Cases that do not meet the above criteria can be managed by percutaneous drainage or
laparotomy.
- Colpotomy also known as a vaginotomy is a procedure by which an incision is made in the vagina.
(93) (B) After 6 months, if negative repeat it annually.

- Cervical Pap smear is used for screening for cervical cancer
- Women with HIV are advised to have screening more frequently.
- HIV-positive women should have a cervical smear when they are first diagnosed with HIV if
negative repeat after 6 months and if negative repeat it every year.
(94) (B) Greenish frothy discharge.

- Trichomonas vaginalis usually presents with frothy yellow-green vaginal discharge,
strong-unpleasant odor and pain during urination and sexual intercourse.
(95) (D) Didoxacillin.

- Empirical antibiotic therapy for mastitis for a lactating mother should include activity against
Staphylococcus aureus.
- For non-severe infections in the absence of risk factors for methicillin-resistant Staphylococcus
aureus, outpatient therapy may be initiated with didoxacillin or cephalexin.
- For beta lactam hypersensitivity, clindamycin may be used.
- For non-severe infections with risk for methicillin-resistant Staphylococcus aureus, outpatient
therapy with trimethoprim-sulfamethoxazole or clindamycin may be initiated, Linezolid is also
acceptable.
- For severe infections (e.g. hemodynamic instability or progressive erythema), inpatient therapy
with vancomycin should be initiated.
(96) (A) Doxycycline or didoxacillin.
- For simple mastitis without an abscess, oral antibiotics are prescribed. Cephalexin and
didoxacillin are 2 of the most common antibiotics chosen.
- Oral antibiotics for mastitis:
- Amoxicillin/davulanate (augmentin) 875 mg twice daily.
- Cephalexin 500 mg 4 times daily.
- Ciprofloxacin 500 mg 2 times daily.
- Clindamycin 300 mg 4 times daily.
- Didoxacillin 500 mg 4 times daily.
- Trimethoprim/sulfamethoxazole, 160 mg/800 mg twice daily, which is often effective against
methicillin-resistant Staphylococcus aureus.
- However, avoid in women breastfeeding healthy infants 2-month-old or younger and
compromised infants.
(97) (B) Fluconazole orally as a single dose.

- This is case of vulvovaginal candidiasis
- Vulvovaginal candidiasis can be managed with either topical antifungal agents or a single dose
of oral fluconazole.
> A single dose of oral fluconazole (150 mg) in acute episodes of vulvovaginal candidiasis has been
shown to yield clinical and microbiological efficacy as good as or better than topical antifungal
agents.
(98) (A) Bacterial vaginosis.
- Vaginal odor is the most common and often initial symptom of bacterial vaginosis.
- Odor may be recognized only after sexual intercourse.
- The alkalinity of semen may cause a release of volatile amines from the vaginal discharge and
cause a fishy odor.
- The amines are products of anaerobic bacterial metabolism.
- Increased vaginal discharge is typically mild to moderate.
- Vulvar irritation is less common.
- Dysuria or dyspareunia occur rarely.
- The whiff test may be positive in up to 70% of bacterial vaginosis patients. This test is performed
by placing a drop of 10% KOH on the speculum after the vaginal examination or mixing vaginal
fluid with a drop of KOH on a microscope slide. The potassium hydroxide, by virtue of its alkaline
properties, causes the release of volatile amines from the vaginal fluid. The amines are products of
anaerobic bacterial metabolism.
- A pH > 4.5 indicates infection.
Bacterial Trichomonas Vaginal
Clinical Elements vaginosis vaginalis candidiasis
Vaginal odor +/- -

+
Green-yellow
Vaginal discharge Vulvar
Symptoms White, curdlike +
Thin, gray, homogenous +/-
+
irritation
Dyspareunia - + -
Vulvar erythema - +/- +/-
Signs Bubbles in vaginal fluid + +/- -
Strawberry cervix - +/- -
Saline wet mount
Clue cells -
+ -
Motile protozoa -
- +
KOH test
Microscopy
Pseudohyphae - - +
Whiff test + +/- -

PH >4.5 >4.5 <4.5
(99) (C) Neonatal hypoglycemia.

- Insulin will cross placenta which lead to neonatal hypoglycemia.
- Infants bom to diabetic mothers are at increasing risk of morbidity and mortality related to the
following: respiratory distress, growth abnormalities (large for gestational age, small for gestational
age), hyperviscosity secondary to polycythemia, hypoglycemia, congenital malformations,
hypocalcemia, hypomagnesemia and iron abnormalities.
(100) (A) Before conception.
- The congenital anomaly of diabetes mellitus mother occurs in first trimester so you should to control
it before conception.
- In women with overt diabetes and suboptimal glycemic control before conception, the likelihood of a
structural anomaly is increased.
- Patients who have received more aggressive preconception and first trimester management, report
decreased anomaly rates.
- It is notable that no increase in birth defects occurs among the offspring of fathers who have
diabetes or the offspring of women who develop gestational diabetes after the first trimester. This
suggests that periconceptional glycemic control is the main determinant of abnormal fetal
development in diabetic women.
(101) (B) Glucose screening is best done at 24-28 weeks of gestation age.
- Prevalence of diabetes mellitus in pregnancy is 2-3%; approximately 90% are cases of gestational
diabetes.
- There are several tests intended to identify gestational diabetes in pregnant women.
- The first, called the glucose challenge screening, is a preliminary screening test performed between
24-28 weeks.
(102) (D) Insulin.
- Treatment for gestational diabetes always includes special meal plans and scheduled physical activity.
It may also include daily blood glucose testing and insulin injections.
(103) (B) Diabetes mellitus type 2.

- If a woman develops gestational diabetes, there is a very good chance that diabetes will go away
mmediately after the delivery.
This is especially true if diabetes was controlled with only a meal plan and exercise during pregnancy,
he mother should continue to check blood glucose levels for at least several days to make sure her
diabetes is actually gone.
Women with a history of gestational diabetes frequently develop diabetes mellitus type 2 later.
(104) (A) Magnesium sulfate.

Because there are no signs that accurately predict seizures, prophylaxis is most effective for all women
ith preeclampsia.
Magnesium sulfate is superior to other antiepileptic medications for preventing eclampsia-related
zures and seizure-related morbidity and mortality.
(105) (A) Methyldopa.

Methyldopa is most used frequently and has been studied the most. There is no evidence of fetal
maternal adverse events
betalol a l p h - d beta-blocker) is associated with a possible increase in growth restriction, fed
pine ca c uni channel biocker) has limited data, but it rapidly reduces blood pressure, ptopril
angiotensin-converting enzyme inhibitor) is contraindicated in pregnancy because i erse
effects on fetal renal function.
(106) (A) Repeat measuring of blood pressure.

estationai hypertension is usually defined as having a blood pressure higher than 140/90 mmHg t
out the presence of protein in the urine and diagnosed after 20 weeks of gestation measured on
parate occasions more than 6 hours apart.
gestational hypertension the blood pressure will return to normal before 12 weeks postpartum.
(107) (C) Chronic hypertension.

hronic hypertens on is persistent blood pressure greater than 140/90 mmHg before 20 weeks
of gestation
ironic hypertension, initially diagnosed any time during pregnancy, is also any elevated
blood essure that persists for more than 12 weeks postpartum.
PSYCHIATRY
(1) A man walking along the street and saying bad words to stranger and he is unaware of his
surroundings. What is the description of this behavior?
(A) Flight ofidea.
(B) Perseveration.
(C) Insertion ofidea.
(D) Loosening of association.
(2) A 46-year-old male presented with complaining of early ejaculation and inability to sustain
erection. He believes his 26 years of marriage is alright, his wife is healthy but unorganized and obese.
On examination and investigations confirms that there is no organic cause, he looks thin and sad.
What is the treatment?
(A) Selective serotonin re-uptake inhibitors.
(B) Sublingual nitrate 6 hours before sexual interaction.
(C) Testosterone injection.
(D) Pindolol.
(3) A 25-year-old teacher presented with sweating, tachycardia and tightness with complaining of
panic, after be made a mistake in the classroom. What is the diagnosis?
(A) Achluophobia.
(B) Agoraphobia.
(C) Social Phobia.
(D) Aviophobia.
(4) A patient told doctor that the refrigerator told him that all food inside is poisoning. What is the
description of this behavior?
(A) Auditory hallucination.
(B) Delusion.
(C) Illusion.
(D) Compulsion.
(5) A young girl who became very stressed out during exams and she pull her hair till a patch of
alopecia appears. What is the best treatment for her?
(B) Behavior change therapy with emotional support.
(C) Tricyclic antidepressants.
(D) Olanzapine.
(6) Which one of the following is true about antipsychotics?

(A) Predominantly metabolized in the liver.
(B) Carbamazepine as a single dose is better than divided doses.
(C) Do not associated with prolonged QT interval in ECG.
(D) Olanzapine is one of the first generation antipsychotics.
(7) A female patient presented with thirst and polyuria. She gave a history of being diagnosed as
bipolar and she is now on lithium. Her laboratory tests indicate that creatine level and BUN tests are
normal. What is the diagnosis?
(A) Nephrogenic diabetes insipidus.
(B) Central diabetes insipidus.
(C) Dipsogenic diabetes insipidus.
(D) Gestational diabetes insipidus.
(8) Which of the following feature of schizophrenia suggest good prognosis?

(A) Family history of schizophrenia.
(B) No precipitating factors.
(C) Presence of affecting symptoms.
(D) Early onset.
(9) Which of the following is a good prognosis for schizophrenia?

(A) Young age at onset.
(B) Late onset.
(C) Many relapses.
(D) Family history of schizophrenia.
(10) What is the best treatment for binge eating disorder?

(A) Cognitive behavioral therapy.
(B) Problem solving therapy.
(C) Interpersonal therapy.
(D) Pharmacological (drug) therapy.
(11) A man is thinking that there are aliens in his yard, although he knows that aliens do not exist, he is
still having these thoughts. When he is out in the yard, he is afraid of dying due to alien attack.
(A) Obsession.
(B) Delusion.
(C) Hallucination.
(D) Illusion.
(12) What is the most common side effect of antipsychotics?

(A) Alopecia.
(B) Weight gain.
(C) Hypotension.
(D) Weight loss.
(13) A 26-year-old male patient with known case of depression became unconscious with toxicity
of unknown substance. He was taking citalopram. By investigation: metabolic acidosis and anion
gap of 18 were found. What is the cause?
(A) Citalopram toxicity.
(B) Aspirin toxicity.
(C) Acetaminophen toxicity.
(D) Diclofenac toxicity.
(14) A male patient presented with acute onset of disorientation, changein the level of consciousness,
decreased metal focus and tremor and reports that he was well before. What is the diagnosis?
(A) Parkinson dementia.
(B) Schizophrenia.
(C) Delirium.
(D) Delusional disorder.
(15) Why selective serotonin re-uptake inhibitors are the first line of treatment for major depression?
(A) Less expensive.
(B) Most tolerable and effective.
(C) To differentiate between psychosis and depression.
(D) Selective serotonin re-uptake inhibitors do not increase uterine bleeding.
(16) What is the most common cause of sleeping in daytime?

(A) Narcolepsy.
(B) Mood disturbance.
(C) General anxiety disorder.
(D) Sleep apnea.
(17) A patient has known case of chronic depression. Which of the following is true about treatment
with paroxetine?
(A) May take up to 4 weeks before symptoms improve.
(B) Initial dose: 20 mg orally once a day with or without food, usually in the morning and not
stopping the treatment suddenly.
(C) Paroxetine may also be contraindicated in many adult men due to sexual and reproductive side
effects.
(18) A patient whose symptoms are exaggerated when he is around other people. What is the
diagnosis?
(A) Somatization.
(B) Malingering.
(C) Factitious disorder.
(D) Conversion disorder.
(19) Which one of the following is secondary presenting complaint in patient with panic attack
disorder?
(A) Dizziness.
(B) Epigastric pain.
(C) Tachycardia.
(20) Main difference between dementia and delirium?
(A) Memory impairment.
(B) Level of consciousness.
(C) Aphasia.
(D) Apraxia.
(21) What are the differences between dementia and delirium?

(A) Delirium is acute reversible global cognitive impairment, but dementia is chronic irreversible global
impairment of cognitive functions.
(B) Delirium is transitory, has quick onset and its symptoms will remit with proper treatment;
dementia
is a long term disorder, usually slow progressing and characterized by a gradual decline from baseline.
(C) There is a fluctuation in the level of consciousness in delirium, but in case of dementia the level of
consciousness is generally steady.
(22) What is the drug of choice in general anxiety disorder?

(A) Benzodiazepines.
(B) Buspirone.
(C) Venlafaxine.
(D) Selective serotonin re-uptake inhibitors.
(23) A partner lost his wife before 6 months ago and presented with loss of appetite, low mood and
sense of guilt because he did not take her to the doctor before her sudden death and thinking that he is
the responsible for her death. What is the diagnosis?
(A) Bereavement.
(B) Major depression.
(C) Adjustment disorder with depression.
(D) Mourning.
(24) Which of the following is an early warning sign for hopelessness?

(A) Choosing suicide.
(B) Bipolar disorders.
(C) Depression.
(D) Dysthymia.
(25) What is the half-life of fluoxetine after acute administration?

(A) 2 hours.
(B) 18 hours.
(C) 1-3 days.
(D) 7-9days.
(26) A child becomes inactive and depressed after changing his school due to moving to another place.
(A) Adjustment disorder.
(B) Anxiety disorder.
(C) Major depression disorder.
(D) Conduct disorder.
(27) Which of the following drugs is best to be given as maintenance for bipolar disorder?
(A) Sodium valproate.
(B) Lithium.
(C) Olanzapine.
(28) A patient was diagnosed with severe depression and now he shows some improvement with
antidepressant therapy. How that may affect his risk of suicide?
(A) No risk.
(B) Become greater.
(C) Become lower.
(D) No change.
(29) A 12-year-old boy is mocked at school because he is obese; he desires to die by taking pills. What
is the best line of treatment?
(A) Cognitive behavioral therapy.
(B) Pharmacological (drug) therapy.
(C) Advice healthy food.
(30) An elderly patient was diagnosed with depression. What is time the antidepressants drugs need
to work properly?
(A) 2 weeks.
(B) 3-4weeks.
(C) 2 months.
(31) What is the best line of treatment for major depressive disorder?
(A) Escitalopram.
(B) Selegiline.
(C) Trazodone.
(D) Bupropion.
(32) What is the best initial treatment for depression?
(B) Bupropion.
(C) Venlafaxine.
(D) Sceletium tortuosum.
(33) Which of the following is secondary to depression?

(A) Dizziness.
(B) Anxiety.
(C) Abdominal pain.
(D) Tachycardia.
(34) What is the most common line of treatment for alcohol withdrawal syndrome?
(B) Antipsychotics.
(C) Clomethiazole.
(D) Trazodone.
(35) Which of the following is true regarding depression?

(A) Selective serotonin re-uptake inhibitors are leading to sexual dysfunction in 17-41% of patients.
(B) Venlafaxine can be used safely in sever hypertension.
(C) Cardiovascular side effects are very common with selective serotonin re-uptake inhibitors use.
(D) Tricyclic antidepressants have fewer side effects than selective serotonin re-uptake inhibitors.
(36) A 45-year-old male patient presented with increased alcohol intake during last few weeks,
increased activity and phone calls and getting not more than 2 hours sleep at a time. What is the
diagnosis?
(A) Alcohol abuse.
(B) Mania.
(C) Depression.
(D) Attention deficit hyperactivity disorder.
(37) A 50-year-old female patient with known case of anxiety became stressed and anxious with
tachycardia and dyspnea during an interview about one month ago. She had to cancel it and always try
to avoid that room where the interview in it. What is the diagnosis?
(A) Generalized anxiety disorder.
(B) Specific anxiety disorder.
(C) Panic disorder.
(D) Social phobia.
(38) What it the mechanism of action of the tricyclic antidepressants?

(A) Inhibiting reuptake of norepinephrine and serotonin leading to increased concentration of these
neurotransmitters.
(B) Increase reuptake of serotonin.
(C) Block or delay the re-absorption of serotonin.
(D) Unknown.
(39) A patient with refractory depression and psychotic features took drug that causes neutropenia.
Which drug did he use?
(B) Clozapine.
(C) Bupropion.
(D) Venlafaxine.
(40) A female patient was diagnosed with anxiety. What isthe drug of choice for rapid relief of her
symptoms?
(B) Barbiturates.
(C) Selective serotonin re-uptake inhibitors.
(D) Bupropion.
(41) A female patient was diagnosed with major depression and after being treated she presented with
complains of insomnia and irritability. Which line of treatment she is taking?
(B) Tricyclic antidepressants.
(C) Monoamine oxidase inhibitors.
(D) Serotonin norepinephrine reuptake inhibitors.
(42) A male patient was diagnosed with depression and medications were prescribed for him. Next day,
he told that he have planned a suicide plan. What is the action now?
(A) Counseling.
(B) Admit to hospital.
(C) Call to police.
(D) Take it as a joke.
(43) What is delusion?

(A) Presence of a fluctuating level of consciousness or impaired cognitive abilities.
(B) False fixed beliefs not in alignment with the culture or surroundings.
(C) State of abnormally elevated or irritable mood, arousal and/or energy levels.
(D) An error in perception.
(44) What is the peak of withdrawal symptoms of tobacco?

(A) 2-4 days.
(B) 5-7 days.
(C) 14 days.
(D) 21 days.
(45) Which of the following medication can be used for the treatment of moderate to severe
depression?
(A) Amitriptyline.
(B) Droperidol.
(C) Haloperidol.
(D) Chlorpromazine.
(46) Which one of the following is might be a risk for committing suicide?
(A) A 20-year-old college boy who had big conflict with his girlfriend.
(B) A 60-year-old woman who is taking antidepressant and newly diagnosed to have osteoporosis.
(C) Old man retired from community newly diagnosed with herpes zoster and start taking medication.
(47) Which of the following is the most common side effect of bupropion?
(A) Weight loss.
(B) Seizure.
(C) Xerostomia.
(0) Headache.
(48) Which of the following is correct about chronic fatigue syndrome?

(A) Antidepressants treatment can help in reducing the symptoms.
(B) Can be relieved by rest.
(C) There is a cure for chronic fatigue syndrome.
(D) The exact causes of chronic fatigue syndrome are known.
(49) A postpartum woman presented with hallucination, delusion, disorganized thinking and speech
and social and emotional difficulty experienced during last 6 months. She has also experienced her
child's death 3 months ago. All of the following could be the possible diagnosis except
(A) Schizophrenia.
(B) Schizophreniform disorder.
(C) Brief psychotic disorder.
(D) Schizoaffective disorder.
(50) A patient presented with elevated mood state characterized by inappropriate elation, increased
irritability, severe insomnia, increased speed and volume of speech, disconnected and racing thoughts,
increased sexual desire, markedly increased energy and activity level, poor judgment and
inappropriate social behavior. Which of the following is associated this condition?
(A) Hallucination.
(B) Delusion.
(C) Grandiosity.
(D) Delirium.
(51) A patient presented with history of diarrhea, abdominal pain, agitation, headache, dizziness,
weakness, pulsatile thyroid, unsteady gate. On examination; everything was normal. What is the
diagnosis?
(A) Hypochondriasis.
(B) Somatization disorder.
(C) Thyroid cancer.
(D) Anxiety.
(52) An elderly psychiatric patient presented with hallucination, aggressive behavior, loss of memory,
living without care and urinate on himself. What is next step to do for him?
(A) Give antipsychotic.
(B) Admit him at a care center for elderly.
(C) Give mood stabilizers.
(D) Give methylphenidate.
(53) What is the antidepressantthat is associated with hypertensive crisis?
(C) Monoamine oxidase inhibitors.
(54) What is the alternative therapy for severe depression which no longer be treated with
antidepressant medications?
(C) Electroconvulsive therapy.
(55) What is the mechanism of drugs used in treatment of obsessive compulsive disorder?
(A) Increase availability of serotonin.
(B) Decrease production of serotonin.
(C) Increase production of serotonin.
(D) Serotonin depletion.
(56) A 30-year-old male presented with the following behavior: he is covering the television because
he believes that the government is spying on him and God talks to him through the lamp and has
special power. What is the diagnosis?
(A) Schizophrenia.
(B) Bipolar affective disorder.
(C) Mental disorders secondary to general medical conditions.
(D) Shared psychotic disorder.
(57) A patient who is taking anti-psychiatric medication, presented with tachycardia, dry mouth,
hyper-reflexia, dilated pupils and strabismus due to drug toxicity. What is the medication he is taking?
(B) Selective serotonin re-uptake inhibitors.
(C) Ephedrine.
(D) Aspirin.
(58) A newly married wife noticed her husband check the closed door many times; also when he takes
a shower for long time, while repeating his prayer many times. What is the diagnosis?
(A) Obsessive compulsive disorder.
(B) Schizophrenia.
(C) Attention deficit hyperactivity disorder.
(D) Major depressive disorder.
(59) An elderly retired man presented with insomnia, with no symptoms related to anxiety or
depression. What is the best drug for him?
(A) Zolpidem.
(D) Diazepam.
(60) Which of the following drugs is not available as emergency tranquilizer in psychiatric clinics?
(A) Haloperidol.
(B) Phenobarbital.
(C) Lorazepam.
(D) Diazepam.
(61) A female patient was in the lecture room, suddenly had an attack of anxiety with palpitation
and shortness of breath. After this episode, she fears going back to the same place to avoid an other
attack. What is the diagnosis?
(A) Panic attack.
(B) Anxiety attack.
(C) Generalized anxiety disorder.
(D) Cardiac dysrhythmias.
(62) Which of the following disease in children can be treated by Clozapine?

(A) Schizophrenia.
(B) Depression.
(C) Enuresis.
(63) A child started to talk to himself and walk in the street naked, after his father's death. He said
that his father asked him to do that. A 3 days after this incidence, he seemed completely normal and
does not remember much about the past events. What is the diagnosis?
(A) Schizophrenia.
(B) Schizoaffective.
(C) Schizophreniform.
(D) Brief psychotic disorder.
(64) What is the best drug used for treating schizophrenia, mania and schizophreniform disorders?
(A) Risperidone.
(B) Amitriptyline.
(C) Olanzapine.
(D) Paroxetine.
(65) Which one of the following is correct regarding obsessive neurosis?
(A) Treatment is easy.
(B) Clomipramine is not a line of treatment.
(C) Mostly associated with severe depression.
(D) Can be cured spontaneously.
(66) A patient presented with fear to go to park, zoo and sport stadium. What is the diagnosis?
(A) Agoraphobia.
(B) Schizophrenia.
(C) Social phobia.
(D) Panic disorders.
(67) A patient presented with echolalia, echopraxia, poor hygiene, insomnia and weird postures. What
is the treatment?
(A) Paroxetine.
(B) Lithium.
(C) Risperidone.
(D) Benzodiazepines.
(68) Which one of the following is correct regarding postpartum psychosis?

(A) Recurrences are common in subsequent pregnancies.
(B) It often progresses to frank schizophrenia.
(C) It has good prognosis.
(D) It has insidious onset.
(69) An 80-year-old man living in a nursing home for the past 3 months. His wife died 6 months ago
and he has been diagnosed with a coronary artery disease within the past month. He is now forgetful
especially of short term memory and has decreased eye contact with loss of interest. What is
the diagnosis?
(A) Alzheimer's disease.
(B) Depression.
(C) Hypothyroidism.
(D) Hyperthyroidism.
(70) A female patient is on her third week postpartum and complains that she frequently
visualizes snakes crawling to her baby's bed; although she knows that it is impossible but she
cannot remove the idea from her mind and said that she wakes up around 50 times at night to
check on her baby.
This problem prevents her from getting good sleep and it started to affect her marriage. What is the
diagnosis?
(A) Postpartum obsessive compulsive disorder.
(B) Hallucination.
(C) Postpartum psychosis.
(D) Delusion.
(71) An elderly man presented with the feeling that he is forced to count the things and he
does not want to perform that task. What it the diagnosis?
(B) Depression.
(C) Delusion.
(D) Illusion.
(72) A 45-year-old female patient presented with irritability, excessive worry for 8 months
with low appetite and decreased concentration. What is the diagnosis?
(A) Generalized anxiety disorder.
(B) Specific phobia.
(C) Social anxiety disorder.
(D) Panic disorder.
(73) A 61-year-old man diagnosed with irritable bowel syndrome, after 6 months he
presented with low appetite, low weight, trouble sleeping and less concentration. What is the
diagnosis?
(A) Late life depression.
(B) Generalized anxiety disorder.
(C) Bipolar disorder.
(D) Dysthymia.
(74) A female patient told that she hears someone is talking to her, when in fact no one is
talking. What is the description of this behavior?
(A) Auditory hallucination.
(B) Delusion.
(C) Schizophrenia.
(D) Illusion.
(75) What is the first line treatment for moderate to severe depressive disorder in children?
(A) Electroconvulsive therapy.
(D) Bupropion.
(76) A male patient with known case of Alzheimer's disease with psychotic manifestations.
What is the treatment?
(A) Haloperidol.
(B) Paroxetine.
(C) Fluoxetine.
(D) Fluvoxamine.
(77) A patient presented with complains of fear, shortness of breath and sweating when he is
within an automobile. What is the diagnosis?
(A) Specific phobia.
(B) Panic disorder.
(C) Generalize anxiety disorder.
(D) Post traumatic stress disorder.
(78) What is the treatment of hallucination and delusion?
(A) Antipsychotics.
(B) Cognitive behavioral therapy.
(79) A patient comes to ER daily with different complaints, but nothing can be clinically diagnosed.
(A) Somatization.
(B) Malingering.
(C) Depression.
(D) Mania.
(80) A male patient presented with complains of loss of association and circumstantiality, neologism
and flight of idea. What is the defect?
(A) Form.
(B) Content.
(C) Quality.
(81) A 38-year-old male complaining of fear from going outside and fear from seeing the front door.
He also does not sit in a room which has a front door. What is the most likely diagnosis?
(A) Depression.
(B) Agoraphobia.
(C) Malingering.
(D) Anti-social personality.
(82) What is the mechanism of the drug that is prescribed for patients with depression?
(A) Increased availability of serotonin.
(B) Decreased production of serotonin.
(C) Increased production of serotonin.
(D) Serotonin depletion.
(83) A patient presented with complaining of hearing voices, later he started to complain about the
thought in his mind which cannot be taken out. What is the diagnosis?
(A) Schizophrenia.
(B) Depression.
(C) Mania.
(D) Agoraphobia.
(84) Electroconvulsive therapy is a good management for:

(A) Severe agoraphobia.
(B) Severe or major depression.
(C) Mania.
(D) General anxiety disorder.
(85) Which of the following is correct about management of major depression disorder?
(A) Initially start with monotherapy even in severe depression.
(B) The treatment should be changed if no response is seen within 2 weeks.
(C) Psychotherapy, medication and electroconvulsive therapy.
(D) No need for hospital admission in severe depression.
(86) A 40-year-old man becomes sweaty with palpitation before giving a speech in public;
however, he does very well at his job. What is the diagnosis?
(A) Generalizes anxiety disorder.
(B) Performance anxiety.
(C) Agoraphobia.
(D) Depression.
(87) Which of the following antipsychotic medication has rapid onset of action?
(A) Sublingual.
(B) Oral.
(C) IM.
(D) IV.
(88) A patient thinks that he has a brain tumor, but actually it is not true. What is the diagnosis?
(A) Somatization disorder.
(B) Hypochondriasis.
(D) Depression.
(89) A 14-year-old girl presented with palpitation, tachypnea and paraesthesia after failing in her
school examination. What is the diagnosis?
(A) Hyperventilation syndrome.
(B) Depression.
(C) Acute respiratory distress syndrome.
(D) Panic disorder.
(90) A 29-year-old female teacher has recurrent attacks of intense fear before the beginning of
her classes in the secondary school. She thinks that, it is only a matter of time before she will
make some mistakes. What is the diagnosis?
(B) Social phobia.
(C) Mixed phobia.
(D) Panic attacks with agoraphobia.
(91) A parent is complaining about his 6-year-old boy who eats paper and clay. What is the
management?
(A) Behavioral therapy.
(B) Fluoxetine.
(C) Bupropion.
(D) Mirtazapine.
(92) The antidepressant used for secondary depression and cause sexual dysfunction is:
(A) Sertraline.
(B) Imipramine.
(C) Levofluxine.
(D) Bupropion.
(93) Before giving lithium to a patient with bipolar disorder, you will do all of the following except:
(A) Thyroid function test.
(B) Liver function test.
(C) Renal function test.
(D) Pregnancy test.
(94) A man has excessive worry getting ill from the germs on his hand. What is the diagnosis?
(B) Agoraphobia.
(C) Obsessive compulsive disorder.
(D) General anxiety disorder.
(95) A 27-year-old female patient having mood changes during and after menses. This bad mood is
affecting her personality and the same symptoms regain each cycle. What is the diagnosis?
(A) Premenstrual dysphoric disorder.
(B) Major depression disorder.
(C) Postpartum blues.
(D) Postpartum depression.
(96) A man changed his job and in his new job, he has to talk in front of 50 people. He feels that he
cannot do this and he send his friend instead. What is the management?
(A) Propranolol.
(B) Biofeedback.
(D) Cognitive behavior therapy.
(97) A 44-year-old female, mother of 3 boys, presented with bouts of shortness of breath, fatigue,
dizziness and chest discomfort. She is doing well at her job, but she thinks a lot about her job and
children. What is the diagnosis?
(B) Panic attack.
(D) Social phobia.
(98) Which personality disorder is associated with inflexibility and perfectionism?

(A) Narcissistic personality disorder.
(B) Borderline personality disorder.
(C) Obsessive compulsive personality disorder.
(D) Histrionic personality disorder.
(99) Which of the following antipsychotic is associated with weight gain?
(A) Risperidone.
(B) Quetiapine.
(C) Olanzapine.
(D) Ziprasidone.
(100) Which drug is contraindicated to use in people with Migraine?

(A) Bupropion.
(B) Lithium.
(C) Diazepam.
(D) Acetaminophen.
(101) A female patient presented with being tearful and irritable after delivery, with otherwise normal
mood. What is the diagnosis?
(A) Postpartum blues.
(B) Postpartum psychosis.
(C) Postpartum depression.
(D) Anxiety disorder.
(102) Which of the following is considered as an indication of electroconvulsive therapy?

(A) Major depression with psychomotor symptoms.
(B) Patients without suicidal thoughts.
(C) Patient with chronic schizophrenia.
(103) A middle-aged patient is presented with abdominal pain and he thinks he has gastric cancer; he
went to 6 gastroenterologists and did one CT scan, one barium enema and series of investigation, but all
are normal. What is the diagnosis?
(A) Hypochondriasis.
(B) Conversion disorder.
(C) Somatization disorder.
(D) Malingering.
(104) A 33-year-old female patient has myocardial infarction and complication of ventricular
tachycardia and from that time she started taking buspirone and now she has fatigue. On examination;
BP = 120/80 mmHg andHR = 65/min. Which of the following investigation must to be done?
(A) Thyroid function.
(B) Liver and renal function tests.
(C) Pregnancy test.
(105) A young patient diagnosed with major depressive disorder. What is the finding during
communication with the patient?
(A) Hypomania.
(B) Late morning awake.
(C) Loss of eye contact.
(D) Mania.
(106) Which one of the following anti-psychotic drug causes ECG changes, leukopenia and drooling?
(A) Risperidone.
(B) Clozapine.
(C) Amisulpride.
(D) Haloperidol.
(107) Which of the following antidepressant medications cause insomnia, restlessness and anxiety?
(B) Monoamine oxidase inhibitors.
(108) An elderly patient is suspected to have cognitive dysfunction, what test should be
done before sending the patient home?
(A) Do brief intelligence quotient test.
(B) Do Assessment for hearing loss.
(C) Clock drawing test.
(109) Regarding postpartum depression, what is the most appropriate intervention which can reduce
the symptoms?
(A) Include family in the therapy.
(B) Isolation therapy.
(C) Add very low doses of imipramine.
(D) Encourage breastfeeding.
(110) A 87-year-old male patient brought by his daughter and she said that he is forgetting his
things the room and not paying attention. What is the diagnosis?
(B) Multi infarct dementia.
(C) Depression.
(D) Delirium.
(111) Which of the following disease manifested with hallucinations and paranoia?
(A) Schizophrenia.
(B) Depression.
(C) Mania.
(D) Phobia.
(112) A patient presented with alcohol withdrawal manifestations such as headache, hyperactivity,
agitation and dilated pupil. What is the management?
(A) Diazepam.
(B) Naxtrol.
(C) Haloperidol.
(D) Clozapine.
(113) A 73-year-old patient is complaining of progressive loss of memory (progressive dementia) with
decrease in cognitive function, but no personality changes. Neurological examination was normal
however, visuodeficit was found. CT scan revealed ventricular dilatations and cortical atrophy. What is
the diagnosis?
(B) Multi-infarct dementia.
(C) Multiple sclerosis.
(D) Parkinsonism dementia.
(114) A Female patient developed sudden loss of vision in both eyes while she was walking down
the street, along with numbness and tingling in her feet; there is discrepancy between the complaint
and the finding. On examination reveals that reflexes and ankle jerks are preserved, however, there is
decreased sensation and weakness in the lower muscles. What is the management?
(A) Referral to ophthalmologist.
(B) Referral to neurologist.
(C) Start with anti-psychotic medication.
(D) Reassure her and ask her about the stressors.
(115) What is the best drug to treat depression in children and adolescent?
(A) Fluoxetine.
(B) Diazepam.
(C) Lithium.
(116) A male patient with known case of pancreatic cancer was treated with chemotherapy and has
improved significantly. He now came to the doctor with concern about recurrence of his cancer and
visited many hospitals. What is the diagnosis?
(A) Malingering.
(B) Hypochondriasis.
(C) Factitious disorder.
(D) Conversion disorder.
(117) A Patient presented with symptoms of anxiety including palpitation, agitation and worry. What is
the first best line for treatment?
(C) Beta-blockers.
(D) Monoamine oxidase inhibitors.
(118) A patient presented with a history of low interest in live, not sleep well and not finding any joy in
his life for last 2 years. What is the most likely diagnosis?
(A) Dysthymia.
(B) Major depressive disorder.
(C) Bipolar disorder.
(119) What is the best drug used for treatment dementia?
(A) Haioperidol.
(B) Galantamine.
(C) Memantine.
(D) Omega-3 fatty acids.
(120) A 70-year-old patient presented with progressive dementia. By using brain microscopy, amyloid
plaques and neurofibrillary tangles were clearly visible. What is the diagnosis?
(A) Dementia with Lewy bodies.
(B) Parkinsonism.
(C) Alzheimer’s disease.
(121) Which of the following is correct regarding antidepressants?

(A) Start treating with a single agent even if the patient has severe depression.
(B) Start any one of them; they all have the same efficacy.
(C) Stop the medication after 2 weeks if no improvement.
(D) Contraindicated to use in combination with other medications.
(122) A young male patient who has undergone nasoplasty and blepharoplasty, was presented with
deformity of his jaw. On examination nothing was found abnormal. What is the diagnosis?
(A) Body dysmorphic syndrome.
(B) Obsessive compulsive disorder.
(C) Major depressive episode.
(D) Dermatillomania.
(123) An elderly patient presented with diffuse hair thinning and loss of eye lashes, the patient
is admitted because he was pulling out his hair in stress. What is the diagnosis?
(A) Trichotillomania.
(B) Tinea capitis.
(C) Monilethrix.
(D) Traction Alopecia.
(124) A 65-year-old lady presented with history of insomnia and crying since her husband died 5 days
ago. What is the best treatment?
(A) Lorazepam.
(B) Fluoxetine.
(C) Chlorpromazine.
(D) Haioperidol.
(125) Which of the following is true regarding battered women?

(A) Mostly they come from poor socioeconomic area.
(B) Usually they marry a second violent man.
(C) Mostly they come to the ER complaining of the symptoms.
(D) Mostly they think that the family responds like this.
(126) What is the management of somatization?
(A) Antidepressant.
(B) Multiple clinic appointment.
(C) Referral to pain clinic.
(D) Reassurance.
(127) A female patient is presented with complain of poor feeding of the baby with hallucinations,
after 2 weeks of delivery. What is the diagnosis?
(B) Post-partumpsychosis.
(C) Depression.
(D) Schizophrenia.
(128) Which of the following is the side effect of amitriptyline?

(A) Diarrhea.
(B) Hypertension.
(C) Weight loss.
(D) Postural hypotension.
ANSWERS
(1) (D) Loosening of association.

- Loosening of association (asyndesis) is a disorder in which separate ideas or thoughts cannot be joined
into a coherent concept.
(2) (A) Selective serotonin re-uptake inhibitors.

- Prescribe one of selective serotonin re-uptake inhibitors, such as sertraline, paroxetine or fluoxetine
which can be used to help delay ejaculation.
- It may take up to 10 days for these drugs to take effect.
- If timing of early ejaculation does not improve, prescribe the tricyclic antidepressant clomipramine.
(3) (C) Social Phobia.

- Social Phobia is characterized by intense fear in social situations causing considerable distress and
impaired ability to function in at least some parts of daily life.
(4) (A) Auditory hallucination.

- Auditory hallucination is a form of hallucination that involves perceiving sounds without auditory
stimulus.
- A common form of this disorder involves hearing one or more talking voices.
(5) (B) Behavior change therapy with emotional support.

- The diagnosis is trichotillomania.
- The most successful treatment for hair pulling disorder (trichotillomania) is behavior change therapy.
- Supportive therapies and psychoanalysis without the behavioral therapy aspect are not effective in
treating this disorder.
(6) (A) Predominantly metabolized in the liver.

- The metabolism of antipsychotics occurs mostly in the liver although extrahepatic metabolism in the
lung and kidneys may also take place.
(7) (A) Nephrogenic diabetes insipidus.

- Nephrogenic diabetes insipidus is characterized by a decreased ability to concentrate urine in the body
because of resistance to antidiuretic hormone action in the kidney.
- It can be observed in chronic renal insufficiency, lithium toxicity, hypercalcemia, hypokalemia,
glucosuria and tubulointerstitial disease.
(8) (C) Presence of affecting symptoms.
(9) (B) Late onset.

- Good prognostic factors for schizophrenia are: late onset, acute onset, obvious precipitating factors,
good premorbid personality, presence of mood symptoms (especially depression), presence of positive
symptoms and good support (married with stable family).
- Bad prognostic factors for schizophrenia are: young age at onset, insidious onset, no precipitating
factors, poor premorbid personality, low intelligence quotient, many relapses, poor compliance, negative
symptoms, poor system support, family history of schizophrenia and high emotion expressing family.
(10) (A) Cognitive behavioral therapy.
- Bulimia nervosa is an eating disorder characterized by frequent episodes of binge eating, followed by
frantic efforts to avoid gaining weight, which affects women and men of all ages.
- Cognitive behavioral therapy is evidence based effective treatment for bulimia nervosa.
- Cognitive behavioral therapy is the preferred psychotherapeutic approach for binge eating disorder
(anorexia nervosa).
- Cognitive behavioral therapy teaches the patient how to keep track of what they eating and how they
can change unhealthy are eating habits.
- It also teaches how to change the way they act in difficult situations.
- If the patient is overweight, he/she may need weight loss counseling in addition to cognitive
behavioral therapy.
- Bulimia nervosa is treated with a combination of psychotherapy and medication.
(11) (A) Obsession.

- Obsessions are thoughts that recur and persist despite efforts to ignore or confront them.
(12) (B) Weight gain.

- 40-62% of people with schizophrenia are overweight or obese.
- Some atypical antipsychotics (especially olanzapine and clozapine) are associated with body weight
gain and have been hypothesized to be partially due to occupancy of the histamine receptor and changes
in neurochemical signaling in regions of the brain that regulate appetite.
(13) (B) Aspirin toxicity.

- Citalopram when mixed with aspirin lead to bleeding, bruising, loss of consciousness, convulsions,
swelling, vomiting, headache, dizziness and blood in urine or stools.
- This interaction is more likely to happen if the patient is elderly or have kidney or liver disease.
(14) (C) Delirium.

- Delirium has clouded consciousness or decreased level of alertness, disorientation, acuity of onset and
course and presence of risk factors for it.
- Dementia has an insidious onset with chronic memory loss and executive function disturbance which
do not fluctuate.
- In schizophrenia, auditory hallucinations are much more common compared to visual hallucinations,
memory is grossly intact and disorientation is rare and speech is not dysarthric.
- Delusional disorder is chronic and often lasts lifelong; these patients generally do not show any
disturbance of behavior; if disturbed behavior does occur, it is directly related to the delusional beliefs.
- Patients with delusional disorder mostly remain coherent, sensible and reasonable.
(15) (B) Most tolerable and effective.

- Selective serotonin re-uptake inhibitors are now considered the first line treatment for major
depression.
- Previously, fluoxetine and escitalopram were the only antidepressants approved for the treatment of
major depressive disorder in adolescents (12-17-year-old).
- Fluoxetine is also approved for children 8-year-old and older.
- Because they act specifically on serotonin, selective serotonin re-uptake inhibitors have fewer side
effects than the previous agents.
(16) (A) Narcolepsy.
Mctrcolepsy is an actual sleep disorder and chronic condition with no cure and is characterized
by whelming feelings of sleepiness and fatigue, often during daytime, i the second cause of
excessive daytime sleepiness after behavioral sleep deprivation
(17) (D) All of the above.

paroxetine is an antidepressant drug of the selective serotonin re-uptake inhibitors type.
e onset of action is within a week; however, individual response varies greatly and full response may o
be seen until 8-12 weeks after initiation of treatment.
initial: 20 mg once daily, preferably in the morning; increase if needed by 10 mg/day increments at
ervals of at least 1 week; maximum dose: 50 mg/day.
shares the common side effects and contraindications of other selective serotonin re-uptake inhibitors,
th high rates of nausea, sleepiness and sexual side effects.
(18) (B) Malingering.

alingering is the act of intentionally feigning or exaggerating physical or psychological symptoms
personal gain, for example, patient may be exaggerating the pain for insurance claims or lawsuits,
omatization disorder is a long term (chronic) condition in which a person has physical symptoms that
involve more than one part of the body, but no physical cause can be found.
factitious disorder is a condition in which a person acts as if he or she has a physical or mental illness
when he or she is not really sick.
nversion disorde is a condition in which a person has blindness, paralysis, or other nervous system
eurologic) disorders that cannot be explained by medical evaluation.
(19) (D) Phobias.

nic attacks and panic disorder can result in severe complications that affect daily life.
One of them can develop into specific phobias, such as fear of driving or leaving the home.
(20) (B) Level of consciousness.
(21) (D) All of the above.

elirium is usually a sudden change in a condition.
s triggered by a specific illness, such as a urinary tract infection, pneumonia, dehydration, illicit drug
or withdrawal from drugs or alcohol, can last for a couple of days to even a couple of months.
may significantly and uncharacteristically impair someone's ability to speak coherently or
ppropriately.
eople with deliriur are often either overly active (hyper and restless) or under-active (lethargic and less
responsive) compared to usual functioning
ementia typically begins slowly and is gradually noticed over time.
causes of dementia may be certain disease such as Alzheimer's, vascular dementia, lewy body
dementia, frontotemporal dementia or a related disorder.
generally a chronic, progressive disease that is incurable.
pie with dementia may have difficulty finding the right words and the ability to express themselves
ually deteriorates as the disease progresses
isuaily does n o ffe t a person s activity level until at the later stages.
(22) (A) Benzodiazepines.
- Benzodiazepines can be prescribed on an as needed basis and are rapidly acting.
- Buspirone takes 2-3 weeks to become fully effective.
- Venlafaxine is effective in treating the insomnia, poor concentration, restlessness, irritability and
excessive muscle tension associated with generalized anxiety disorder.
- Selective serotonin re-uptake inhibitors may be effective, especially for patients with comorbid
depression.
(23) (A) Bereavement.

- Bereavement is the period of grief and mourning after a death.
- It is a part of the normal process of reacting to a loss.
- A person may experience grief as a mental, physical, soc'al or emotional reaction.
- Mental reactions can include anger, guilt, anxiety, sadness and despair.
- Physical reactions can include sleeping problems, changes in appetite, physical problems or illness.
(24) (A) Choosing suicide.

- The common emotion in suicide is hopelessness-helplessness.
- A pervasive sense of hopelessness, defined in terms of pessimistic expectations about the future, is
even more important than other forms of negative emotion, such as anger and depression, in predicting
suicidal behavior.
- The suicidal person is convinced that absolutely nothing can be done to improve his or her situation;
no one else can help.
(25) (C) 1-3 days.

- Half-life of fluoxetine is 1-3 days after acute administration and 4-6 days after chronic
administration.
(26) (A) Adjustment disorder.

- Adjustment disorder is a stress related, short term, nonpsychotic disturbance
- It happens for a limited time, usually beginning within 3 months of the stressful event.
- It can be acute (if the disturbance lasts less than 6 months) or chronic (if the disturbance lasts for 6
months or longer).
- The symptoms may involve anxious or depressive affect or may present with a disturbance of
conduct.
- Stressors may be single or multiple.
(27) (B) Lithium.

- Lithium is the only drug approved for both acute and maintenance treatment, it continues to be the
gold standard of maintenance therapy in bipolar disorder, periodic blood tests are required, since
lithium can cause thyroid and kidney problems.
- The greatest advantage of sodium valproate may be tha it is both well tolerated and effective in
patients who do not respond to lithium.
- Olanzapine is effective in preventing relapses, although the evidence is not as solid as it is for lithium.
(28) (B) Become greater.
The link between antidepressants and suicidal thinking is not clear and not taking an antidepressant
when it is needed also increases the risk of suicide.
(29) (A) Cognitive behavioral therapy.

Children and adolescents who are depressed and express suicidal thoughts or behaviors are in need of
an extended evaluation in the hospital to provide maximal protection against the patient's own self
destructive impulses and behavior.
- Cognitive behavioral therapy is widely recognized as an effective intervention for the treatment of
moderate to severe depression in children and adolescents.
- Cognitive behavioral therapy aims to challenge maladaptive beliefs and enhance problem solving
abilities and social competence.
(30) (B) 3-4weeks.

- It is important to remember that the maximal effects of a particular dosage may not be evident for
4-6 weeks.
(31) (A) Escitalopram.

Selective serotonin re-uptake inhibitors are now the first line treatment for major depression.
Selective serotonin re-uptake inhibitors include fluoxetine, sertraline, paroxetine, fluvoxamine,
citalopram and escitalopram.
Escitalopram is safer and generally causes fewer serious side effects compared to other types of
antidepressants.

- Selective serotonin re-uptake inhibitors are the primary medications considered for depression.
They have relatively mild side effects (except on the sexual life) and reduced risk of overdose, compared
to their older tricyclic alternatives.
- Bupropion is possibly more effective if added to selective serotonin re-uptake inhibitors.
- Venlafaxine may be slightly more effective than selective serotonin re-uptake inhibitors; however, it is
not recommended as a first line of treatment because of the higher rate of side effects.
Sceletium tortuosum is being used in treating withdrawal symptoms from antidepressants.
(33) (B) Anxiety.

- Complications associated with depression can include: alcohol abuse, substance abuse, anxiety, work
or school problems, family conflicts, relationship difficulties, social isolation and suicide and self-
mutilation. such as cutting and premature death from other medical conditions.

Benzodiazepines are the most commonly used drug for the treatment of alcohol withdrawal and are
generally safe to use and effective.
Antipsychotic agents are sometimes used as an add-on to first line therapies such as benzodiazepines
for controlling agitation or psychosis.
Clomethiazole also inhibits the enzyme alcohol dehydrogenase, which is responsible for breaking
down a cohol in the body, leading to slow rate of elimination of alcohol from the body, helping to
relieve the sudden effects of alcohol withdrawal in alcoholics.
- Trazodone have particular use for treating withdrawal symptoms, especially
insomnia, which is persisting beyond the acute withdrawal phase.
(35) (A) Selective serotonin re-uptake inhibitors are leading to sexual dysfunction in 17-41% of
patients.
- Release of extracellular serotonin in the brain decreases dopamine and norepinephrine leading
to erectile and/or sexual dysfunction.
- Although the lack of placebo control in these studies means they are likely underestimates.
(36) (B) Mania.

- Mania is most often associated with bipolar disorder, characterized by presence of disturbed
mood, grand or extravagant style, or expanded self-esteem; pressured speech; reduced need of
sleep; talks more often and feels the urge to talk longer; ideas flit through the mind in quick
succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors
with high risk of negative outcome (e.g. extravagant shopping, sexual adventures or improbable
commercial schemes).
- Bipolar disorder and alcoholism commonly co-occur.
(37) (B) Specific anxiety disorder.

- Specific anxiety disorder is a generic term for any kind of anxiety disorder that leads to an
unreasonable or irrational fear related to exposure to specific objects or situations.
(38) (A) Inhibiting reuptake of norepinephrine and serotonin leading to increased concentration
of these neurotransmitters.
- Tricyclic antidepressants act by inhibiting reuptake of norepinephrine and serotonin by
blocking the transporters responsible for reuptake of these neurotransmitters.
- This inhibition elevates the concentration of neurotransmitters in the synapses and triggers
further neurotransmission.
(39) (B) Clozapine.

- One possible side effect of clozapine is neutropenia, which causes a reduction in the number of
WBCs in the blood.
- It is uncommon but if it happens patient should stop taking clozapine completely.

- Because benzodiazepines have a rapid anxiolytic sedative effect, they are most commonly used
for immediate treatment of insomnia, acute anxiety and agitation or anxiety associated with any
psychiatric disorder.
- Before the introduction of benzodiazepines, barbiturates were frequently prescribed,
but because of their high abuse potential, their use is much rare now.
- Selective serotonin re-uptake inhibitors work less rapidly compared to the benzodiazepines.

- Side effects of selective serotonin re-uptake inhibitors include fatigue, nausea, dry mouth,
diarrhea, rash, weight loss or weight gain, drowsiness, insomnia, headaches, increased sweating,
agitation, decreased sexual desire, difficulty reaching orgasm and erectile dysfunction.
(42) (B) Admit to hospital.
Ti eatment of suicidal ideation can be puzzling due to the fact that several medications have
actually been linked to ncreased suicidal ideation in patients, especially who might have taken
antidepressant medications
T iie main treatment is hospitalization, which allows the patient to be in a secure, supervised
environment to prevent their suicidal ideation and from turning into suicide attempts.
(43) (B) False fixed beliefs not in alignment with the culture or surroundings.
elusion is a false belief based on incorrect inference about external reality that is firmly sustained
despite what almost everyone else believes and despite what constitutes incontrovertible and obvious
proof of evidence to the contrary.
e belief is not ordinarily accepted by other members of the person's culture or subculture.
(44) (A) 2-4 days.

ymptoms of tobacco withdrawal will peak about 2-4 days later after last use of tobacco.
C mmon symptoms include, an intense craving for nicotine, anxiety, depression, drowsiness or trouble
sleeping, feeling tense, restless or frustrated, headaches, increased appetite, weight gain and problem
oncentrating.
(45) (A) Amitriptyline.

Amitriptyline is a tricyclic antidepressant drug.
Droperidol, haloperidol and chlorpromazine are typical antipsychotics and are not approved for the
reatment of depression.
- Depression may result from long term use of haloperidol as antipsychotics.
(46) (C) Old man retired from community newly diagnosed with herpes zoster and start taking
medication. Herpes zoster, more commonly known as shingles, is a potentially painful, disfiguring
disease. Post-herpetic neuralgia may lead to suicide.
(47) (B) Seizure.

- Bupropion is used when someone is trying to quit smoking.
The most common side effects of bupropion included: agitation (32%), weight loss (28%), xerostomia
28%), constipation (26 %), headaches (26 %), nausea or vomiting (23%) and dizziness (22%).
(48) (A) Antidepressants treatment can help in reducing the symptoms.

- Chronic fatigue syndrome is characterized by profound mental and physical exhaustion associated with
neuropsychiatric and several other symptoms that are lasting at least for 6 months.
- Must be new (not lifelong), must not be relieved by rest and must result in greater than 50% reduction n
previous activity.
resentation with 4 or more of the following: poor memory/concentration, myalgia, arthralgia, sore ti n
oat, tender lymph node, recent onset headache, unrefreshing sleep, excessive tiredness with exercise.
Treatment by: cognitive and exercise therapy, also, diet, physiotherapy, dietary supplement and
Antidepressant.
(49) (C) Brief psychotic disorder.
- Brief psychotic disorder is a period of psychosis whose duration is generally shorter,
non-re-occurring and not caused by another condition.
- Symptoms generally last at least one day, but not more than one month.
(50) (C) Grandiosity.

- This is a case of mania.
- To be classed as a manic episode, while the disturbed mood is present at least three (or four if only
irritability is present) of the following must have been consistently prominent: grand or extravagant
style, or expanded self-esteem; pressured speech; reduced need of sleep (e.g. three hours may be
sufficient); talks more often and feels the urge to talk longer; ideas flit through the mind in quick
succession, or thoughts race and preoccupy the person; over indulgence in enjoyable behaviors with
high risk of a negative outcome (e.g. extravagant shopping, sexual adventures or improbable
commercial schemes).
(51) (B) Somatization disorder.

- Somatization disorder (also Briquet's syndrome or hysteria) is characterized by recurring, multiple,
clinically significant complaints about pain, gastrointestinal, sexual and pseudoneurological symptoms.
- The symptoms involve several different organs and body systems.
- The patient may report a combination of: pain, neurologic problems, gastrointestinal complaints
and sexual symptoms.
(52) (B) Admit him at a care center for elderly.

- Elderly patients with dementia are at high risk for the development of psychotic symptoms and
behavioral disturbance during the course of this illness.
- Somatic and visual hallucinations may be more common in elderly than in younger patients,
particularly when the psychosis is secondary to a medical condition (e.g. Parkinson's disease).
- Seriously ill elderly patients who cannot be appropriately cared for elsewhere should be
hospitalized.
(53) (C) Monoamine oxidase inhibitors.

- The most worrisome side effect of monoamine oxidase inhibitors is the tyramine induced
hypertensive
crisis.
- Tyramine is produced from the natural breakdown of the amino acid tyrosine present in food.
- Monoamine oxidase inhibitors, however, inactivate gastrointestinal metabolism of dietary tyramine,
thus allowing intact tyramine to enter the circulation, leading to a hypertensive crisis.
- Adequate concentration of monoamine oxidase inhibitors systhesis should be allowed by avoiding
tyramine containing foods for at least 2 weeks, after the ast dose of monoamine oxidase inhibitors.
(54) (C) Electroconvulsive therapy.

- Electroconvulsive therapy is typically used in people with serious or life threatening
depression that cannot be resolved by other treatments.
- It uses electric impulses to trigger controlled seizures in the brain.
- This treatment can rapidly relieve depression, although it is not dea r how long the effects last.
(55) (A) Increase availability of serotonin.
The mechanism of action of the obsessive compulsive disorder drugs is to prevent excess serotonin
from being pumped back into the original neuron that released it.
(56) (A) Schizophrenia.

- A person diagnosed with schizophrenia may experience hallucinations
most reported are hearing voices), paranoid, bizarre delusions or persecutory in nature (government
spy m through television), also he has grandiose delusion (as he believe that he has a special power)
and disorganized thinking and speech.
Social withdrawal, sloppiness of dress and hygiene and loss of motivation and judgment are all
common in schizophrenia.
(57) (A) Tricyclic antidepressants.

Many of the initial signs are those associated with the anticholinergic effects of tricyclic
antidepressants such as dry mouth, blurred vision, urinary retention, constipation, dizziness and
vomiting.
This symptoms are caused by the location of norepinephrine receptors in our body; many physical
signs are also associated with a tricyclic antidepressants overdose.
(58) (A) Obsessive compulsive disorder.

Obsessive compulsive disorder is an anxiety disorder characterized by intrusive thoughts that produce
uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated
anxiety; or by a combination of such obsessions and compulsions.
Symptoms of the disorder include excessive washing or cleaning; repeated checking; extreme
hoarding; preoccupation with sexual, violent or religious thoughts; relationship related obsessions;
aversion to particular numbers; and nervous rituals, such as opening and closing a door a certain
number of times before entering or leaving a room.
(59) (A) Zolpidem.

on-Benzodiazepines medications such as zolpidem and zaleplon are most commonly used for
insomnia, because they do not alter sleep architecture and have no hangover effect, tolerance, or
rebound insomnia. Benzodiazepines, such as diazepam and flurazepam improve insomnia by reducing
rapid eye movement eep, decreasing sleep latency and decreasing nocturnal awakenings.
se of benzodiazepines has been correlated with an increased risk of falling.
Tricyclic antidepressants (trazodone) often used to treat depressed patients with significant insomnia.
(60) (B) Phenobarbital.

Phenobarbital is long acting drug with a half-life of 12-24 hours.
(61) (A) Panic attack.

A panic attack is a sudden episode of intense fear that triggers severe physical reactions when there is
no real danger or apparent cause; it can be very frightening and it can be associated with the presence
or absence of agoraphobia.
- Agoraphobia is defined as anxiety toward places or situations in which escape may be difficult
embarrassing.
- Effective and safe use of clozapine in children with schizophrenia has been reported.
(63) (D) Brief psychotic disorder.

- Brief psychotic disorder is characterized by the presence of delusions, hallucinations, disorganized
speech, grossly disorganized behavior or catatonic behavior for at least one day but no more than one
month.
- The individual returns to his or her usual level of functioning after this brief period.
(64) (A) Risperidone.

- Atypical antipsychotics (e.g. risperidone, olanzapine) are the first choice in schizophrenia and in
schizophreniform disorder and can be used also in mania
- According to side effects, risperidone is fewer side effects than olanzapine.
(65) (C) Mostly associated with severe depression.

- Obsessive neurosis tendencies are common and may manifest themselves as depression, acute or
chronic anxiety, obsessive compulsive tendencies, specific phobias (such as social phobia, arachnophobia
or any number of other phobias) and some personality disorders (paranoia, schizotypal, borderline,
histrionic, avoidant, dependent and obsessive compulsive).
(66) (A) Agoraphobia.

- Agoraphobia is an anxiety disorder characterized by anxiety in situations where the sufferer
perceives certain environments as dangerous or uncomfortable, often due the environment's vast
openness
or crowdedness.
- These situations include, but are not limited to wide open spaces, as well as uncontrollable social
situations such as in shopping malls, airports and on bridges.
(67) (D) Benzodiazepines.

- This is a case of catatonic schizophrenia.
- Benzodiazepines are generally the medication of choice to treat catatonic schizophrenia.
- They are typically fast acting, helping relieve catatonic symptoms quickly.
- Echolalia is the automatic speech repetition made by another person.
- Echopraxia is the automatic repetition of movements made by another person.
(68) (A) Recurrences are common in subsequent pregnancies.

- Subsequent pregnancies are associated with an increased risk of another episode, sometimes as high
as 50%.
- The symptoms of postpartum psychosis can often begin within days of the delivery, although the
mean time to onset is within 2-3 weeks and almost always within 8 weeks of delivery.
(69) (B) Depression.

- In order to differentiate between depression and Alzheimer's disease in elderly, note that symptoms
of depression in elderly patients are as follows: mental decline is relatively rapid, knows the correct time,
date and where he or she is. difficulty concentrating, language and motor skills are slow, but normal and
notices or worries about memory problems.
(70) (A) Postpartum obsessive compulsive disorder.
part mobs compulsive disorder is characterized by presence of obsessions (persistent, itive oug
r menta mages related to the baby), compu s ons (mother may do certain things er agaii to i her ears
and obsessions), sense of h r or abou the obsessions, fear of left alone wi : ! infant hyper vigilance in
protecting the nfant. Since the mother with artu obsess compulsive disorder know that their
thoughts are bizarre, they are very unlikely to ever aci on them
(71) (A) Obsessive compulsive disorder.

se s omp is e so s an anxiety disorder in which people have un nted and repeated thoughts,
feelings deas, se isations (obsessions), or behaviors tha make them feel driven to do
etiiing (compuls ons
(72) (A) Generalized anxiety disorder.

eraiiz am disorder or overanxious disorder is an excessive anxiety and worry about a number
nts or activities fu ire oriented), occurring more thank days for at least 6 months, rry s ssocate vith at
least three of the following s, mpton s estless less r feeling keyed up or ..n edge easily fa difficu ty
concentrat ng 'rritabiTiy, muscle tension an sleep disturbance.
(73) (A) Late life depression.

Ciinical depress >n is common in the
elderly, be elated tc a physical Iness.
ess oi that firs develops n la er li e usually after 60-year-old is more commonly associated with
phyi ca ealth problems associated with aging
(74) (A) Auditory hallucination.

i auditory hallucinations (also known as Paracusia) hea ne or more oices; symptoms are la
ly sso ed with psychotic disorders such as schizophren a or mar a nd hold special
i mce in the diagnosis of these conditions
Although many , < ot suffering from mental 'llness nay sometimes ear voices as well
(75) (B) Selective serotonin re-uptake inhibitors.

i e serotonir - take n; ’bitors are widely accepted as first ine pharmacological intervention
odera e to severe depressive disorders irt children and adolescents
n acute randomized clinical trials have demonstrated efficacy of fluoxet ine, citalopram and n
npar i placebo in the treatment of major depression in childrer a d adolescents
(76) (A) Haloperidol.

- About 2/3 of agitated, elderly patients with various forms of dementia improve when they are given
mine eceptor antagonists typical antipsy chotics). dose of high potency drugs e g. 0 5-1 mg/day of <
operidol aie used.
(77) (A) Specific phobia.
- A specific phobia is a strong, persisting fear of an object or situation
- Situational phobias involve a fear of specific situations, such as flying, riding in a car or on public
transportation, driving, going over bridges or in tunnels, or of being in a closed place (such as an
elevator).
(78) (A) Antipsychotics.

- Common conditions in which antipsychotics might be used include schizophrenia, bipolar
disorder and delusional disorder.
- These medications were developed originally to treat symptoms associated with schizophrenia
(such as hallucinations and delusions), but they are widely used to treat similar symptoms in
Alzheimer's disease.
- These are very effective in treating hallucinations and delusions.
(79) (A) Somatization.

- Somatization disorder is an illness of multiple somatic complaints in multiple organ systems that
occur over a period of several years and results in significant impairment or treatment seeking, or both.
(80) (A) Form.

- Thought disorder or formal thought disorder refers to disorganized thinking as evidenced by
disorganized speech.
- Specific thought disorders include derailment, poverty of speech, tangentially, illogicality,
perseveration, neologism and thought blocking.
(81) (B) Agoraphobia.

- Agoraphobia is a generalized fear of open spaces, social situations, crowds, etc and is associated with
avoidance of these stimuli.
(82) (A) Increased availability of serotonin.

- Selective serotonin re-uptake inhibitors block or delay the re-absorption of the neurotransmitter,
serotonin, by the original (presynaptic) nerves it was released from.
- This effect increases the levels of serotonin within the synapses.

• Schizophrenia is a mental disorder characterized by a breakdown of thought processes and by a
deficit of typical emotional responses.
- Common symptoms include auditory hallucinations, paranoid or bizarre delusions, or disorganized
speech and thinking; and it is accompanied by significant social or occupational dysfunction.
(84) (B) Severe or majordepression.

- Electroconvulsive therapy may be considered as the first line therapy for severe or major depression.
- It is sometimes used when the patient is at high risk of harming themselves or others (where there is
clear evidence of repeated suicide attempts or significantly aggressive behavior) or where psychotic
features are prominent
(85) (A) Initially start with monotherapy even in severe depression.
Management of major depression disorder.
1 Pharmacotherapy t is the pr mary therapy for major depression effective in 50-70%, allow for 2-6
weeks taking effect, treating more than 6 months (selective serotonin re-uptake inhibitors tricyclic
antidepressants and monoamine oxidase inhibitors).
2 Psycotherapy: It is he treatmen of hoice In those under 18-year-old; psychotherapy combined with
antidepressant is more effect than either treatment alone.
Electroconvulsive therapy may improve mood n peop e with severe depression or suicidal
3-
thoughts who do not get better with other treatments
f hototherapy it is effective for patient who has a seasonal pattern.
4-
(86) (B) Performance anxiety.

age fright or performance anxiety is the anxiety, fear, or persistent phobia which may occur in an
(dual before performing in f oni of an audience, whether actually or potentially (for example,
performing before a camera)
(87) (D) IV.

eneral injec ions act rapidly with onset of action in 15-30 seconds for IV 10 20 minutes for IM
15-30 minutes tor SC.
(88) (B) Hypochondriasis.

pochondriasis or hypochondria (sometimes referred to as health phobia or health anxiety) refers
cesswe worry about having a serious illness.
s debilitating condition is the result of an inaccurate perception of the bod s condition despite
absence of an actual medical condition.
(89) (A) Hyperventilation syndrome.

perventnation syndrome or chron c hyperventilation syndrome is a respiratory disorder, which is
psychological or physiological origin, involves breathing too deeply or too rapidly (hyperventilation)
It nay present with chest pain and a tingling sensation in the fingertips and around the mouth
aresthesia) and may accompany a panic attack.
Many people with panic disorder or agoraphobia will experience hyperventilation syndrome.
(90) (B) Social phobia.

Social anxiety disorder (also known as social phobia) is an anxiety disorder which is one of the most
ci nmon psychiatric disorders
s characterized by intense fear in social situations, causing considerable distress and impaired
ability to perform certain daily tasks.
(91) (A) Behavioral therapy.

tie diagnosis is called pica disorder.
Currently, behavioral strategies are considered to be the most effective in the treatment of pica.
(92) (A) Sertraline.
- Sertraline is an antidepressants drug ol the selective se otomr re-uptake inhibitors.
- Like other selective serotonin re uptake inhibitors sert aline is associated v.ith certain side effects
which ndude sexual arousal disorder and difficulty achieving o gasm
(93) (B) Liver function test.

Side effects of lithium:
1- Thyroid: goiter, hypothyroidism, exophthalmos and hyperthyroidism.
2- Renal: inability to concentrate, morphologic changes polyuria (nephrogenic diabetes insipidus),
reduced glomerular filtration rate, nephrotic syndrome and renal tubular acidosis.
3- Pregnant women: causes birth defects in first trimester, most common malformations involve the
cardiovascular system, most commonly Ebstein's anomaly of the tricuspid valves.
4 - The only gastrointestinal tract associated adverse effects for lithium are nausea, decreased appetite,
vomiting and diarrhea; however, there is no known side effect of this agent is on the liver.
(94) (C) Obsessive compulsive disorder.

- Obsessive compulsive disorder is an anxiety disorder characterized by intrusive thoughts leading to
uneasiness, apprehension, fear, or worry and by repetitive behavior in an attempt of reducing anxiety.
(95) (A) Premenstrual dysphoric disorder.

- Premenstrual dysphoric disorder is characterized by depressed or labile mood, anxiety, irritability,
anger and other symptoms occurring exclusively during the 2 weeks preceding menses.
(96) (A) Propranolol.

- Propranolol falls into the broad pharmacologic category known as beta-blockers.
- Beta-blockers block beta-adrenergic receptors leading to reduced heart rate and control blood
pressure so that the patient becomes less anxious.
- It is very helpful for performance anxiety, such as giving presentations or speeches.
(97) (C) Generalized anxiety disorder.

- Generalized anxiety disorder is characterized by persistent, excessive and unrealistic worry about
everyday things.
- People with this disorder experience exaggerated worry and tension, often expecting the worst, even
when there is no apparent reason for concern.
- They anticipate disaster and are often overly concerned about money, health, family, work, or other
issues.
(98) (C) Obsessive compulsive personality disorder.

- Obsessive compulsive personality disorder is a disorder characterized by a pervasive pattern of
preoccupation with orderliness, perfectionism, mental and interpersonal control at the expense of
flexibility, openness and efficiency.
- In contrast to people with obsessive compulsive disorder, behaviors are rational and desirable in
people with obsessive compulsive personality disorder..
- Obsessive compulsive personality disorder is different from obsessive compulsive disorder and is
characterized mainly by perfectionism while obsessive compulsive disorder.is characterized by
repetitive actions due to compulsion.
(99) (A) Risperidone.
Weight gain is a common side effect of risperidone.
- It occurs in up to 5% of people and associated with an increase in appetite, a rise in blood
cholesterol levels that may increase the risk of developing heart disease or diabetes.
(100) (A) Bupropion.

- One of the side effects of bupropion is migraine.
- It affects 1-4% of patients using bupropion.
(101) (A) Postpartum blues.

- After the baby is born, many new mothers have the postpartum blues or the baby blues.
- The new mother is more irritable, cries more easily, feels sad and feels confused.
- The postpartum blues peak 3-5 days after delivery.
They usually end within 10 days of the baby's birth.
(102) (A) Major depression with psychomotor symptoms.
ectroconvulsive therapy should be considered for patients who are in the acute phase of major
depressive disorder and have a high degree of symptom severity and functional impairment or
who ha i/e psychotic symptoms or catatonia.
ectroconvulsive therapy may also be the treatment of choice for patients for whom the treatment
onse is urgently needed, such as patients who are suicidal.
(103) (A) Hypochondriasis.

ypochondriasis is a mental disorder characterized by excessive fear of or preoccupation with a
serious less, despite medical testing and reassurance to the contrary, was formerly called
hypochondriacal neurosis.
(104) (B) Liver and renal function tests.

uspirone is metabolized by the liver and excreted by the kidneys.
harmacokinetic study in patients with impaired hepatic or renal function demonstrated increased
asma levels and a lengthened half-life of buspirone. erefore, the administration of buspirone to
patients with severe hepatic or renal impairment cannot recommended.
(105) (C) Loss of eye contact.

le mood states can also exhibit the mood through physical complaints, such as showing sad facial
essions (frowning) and poor eye contact.
e patient will avoid eye contact, moving eyes downwards or away, with slow eye blinking
rate less any of these could be considered normal behavior in any individual).
(106) (B) Clozapine.

lere are many side effects for clozapine; they include leukopenia, drooling (especially at night) and
^/cardiac abnormalities (1%).
st marketing clinical experience has included ventricular tachycardia, cardiac arrest, QT
prolongation d Torsades de Pointes.
(107) (C) Selective serotonin re-uptake inhibitors.
- General side effects of selective serotonin re-uptake inhibitors are mostly present during the first
1-4 weeks while the body adapts to the drug.
- Almost all selective serotonin re-uptake inhibitors are known to cause one or more of these
symptoms: insomnia and/or changes in sleep pattern, feeling agitated or shaky and anxiety.
(108) (C) Clock drawing test.

- Clock drawing test is a simple test that can be used as a part of a neurological test or as a screening
tool for Alzheimer's and other types of dementia.
(109) (A) Include family in the therapy.

- The most important first step in managing postpartum depression is recognizing the problem and
taking action to deal with it.
- The support and understanding of the partner, family and friends play important rule in recovery.
(110) (A) Alzheimer's disease.

- Alzheimer's disease is the most common form of dementia, a general term for memory loss and
other intellectual abilities serious enough to interfere with daily life.
- It begins slowly and involves the parts of the brain that control thought, memory and language.
- People with Alzheimer's disease may have trouble remembering things that happened recently or
names of people they know.

- Schizophrenia causes alterations in the brain and the way it perceives reality, resulting in the
hallmark symptoms of hallucinations and delusions.
(112) (A) Diazepam.

- Benzodiazepines, such as diazepam or lorazepam, are the most commonly used drug for the
treatment of alcohol withdrawal.
- Antipsychotic agents, such as haloperidol, are sometimes used for alcohol withdrawal as an add-on
to first-line treatments such as benzodiazepines for controlling agitation or psychosis.
- Clozapine is particularly risky (induces myocarditis); if used, extreme caution is required.
(113) (A) Alzheimer's disease.

- Most common causes of dementia for Alzheimer's disease are age and family history are risk factors.
- Etiology unknown but toxic beta-amyloid deposit in brai .
- New patients usually present with amnesia, followed by language deficit, acaluia, depression,
agitation and finally apraxia (inability to perform skilled movement)
- Diagnosis by exclusion: suggested by clinical feature and by progressive cognitive course without
substantial motor impairment.
- The definitive diagnosis of Alzheimer's disease can be made only through autopsy after death.
- MRI and CT may show atrophy, ventricle enlargement and can rule out other causes.
- On brain microscopy amyloid plaques and neurofibrillary Tangles.
- Death usually occurring secondary to aspiration pneumonia.
- Treatment is does by cholinesterase inhibitor.
- A good family support is needed for the patients.
(114) (D) Reassure her and ask her about the
stressors, is is a case of co ersio disor
- Conversion disorder causes patients to suffer from neurological symptoms, such as numbness,
blindness, ralysis or Tits . u a de inab e organ c cause
s thought t syniptoms a: ise in esponse to stressful situations effecting a patient s menta health
ute onset, dearl identi able s ss at th s time and short time between onset and treatment are
associated witn favorable pro nosis.
e diagnosis > es wee elements: the exclusion of neurological disease the exclusion of feigning the
determina of a psychological mechan sm
(115) (A) Fluoxetine.

uoxetme is an antidepressants drug of the selective serotonin re-uptake inhibitors, ective sero om
re-uptake nhibitors remain a first line pharmacological treatment for depression in i ren and
adolescents for whom psychotherapy has failed or is unavailable, icidal ideation and behaviors
merit close monitoring.
uoxetine is the only antidepressant specifically approved for the treatment of depression in
children 8-year-O‘d
(116) (B) Hypochondriasis.

pochondnasis is characterized primarily by physical symptoms for which no demonstrable organic
anations or physical findings exist.
fear or idea s based on the misinterpretation of bodily signs and sensations as evidence of
disease, illness persists despite appropriate medical evaluations and reassurance.

ective serotoni re-uptake .nhibitors are generally recommended as first line agents to treat
anxiety order
ecause beta-blockers do not affect the emotional symptoms of anxiety such as worry, they are
most helpful for phobias, particularly social phobia and performance anxiety.
ome people tolerate beta-blockers well and find that those are successful in managing
anxiety sy nptoms
But others find that the side effects increase their overall anxiety, escription of
beta-blockers is (off-label), meaning that they are not approved for use; however, sometimes
those are used anyway.
(118) (A) Dysthymia.

sthymia is a mood disorder consisting of the same cognitive and physical problems as in
depression, less severe but longer lasting symptoms, which persists for at least 2 years.
(119) (B) Galantamine.
olinesterase inhibitors include donepezil, rivastigmine and galantamine which are primarily used
in the treatment of dementia.
G, antammt reduces the action of acetylcholinesterase and therefore tends to increase the
concentration of acetylcholine in the brain.
(120) (C) Alzheimer's disease.
- In Alzheimer s disease a number of microscopic changes occur within the brain.
- The 2 major findings in the Alzheimer's brain are amyloid plaques and neurofibrillary tangles.
(121) (A) Start treating with a single agent even if the patient has severe depression.
- Tradit ona! guidelines call a sequence of single antidepressants, for the treatment of major
depression.
- Augmentation with a second agent generally oniy happens when the first agent is well tolerated and
provides some symptomatic mprovement.
- Most skilled clinicians who treat severe depression and treatment resistant depression with
inadequate responses to single agents have seen patients respond to combinations of drugs, as well as
to single drugs with more than one mechanism of action.
(122) (A) Body dysmorphic syndrome.

- Body dysmorphic disorder is a type of mental illness, a somatoform disorder, where the affected
person is concerned with body image, manifested as excessive concern about and preoccupation with a
perceived defect of their physical features.
- The person thinks they have a defect in either one feature or several features of their body, which
causes psychological distress leading to clinically significant distress or impairs occupational or social
functioning.
(123) (A) Trichotillomania.

- Trichotillomania is a compulsive disorder resulting in alopecia from repetitive hair manipulations by
the patient's own hand.
- Trichotillomania is one of the self-induced primary psychiatric disorders.
- Regardless of its pathogenesis, trichotillomania is a kind of alopecia or loss of hair from skin that
must be differentiated from other kinds of alopecia which are diagnosed by a dermatologist (e.g.
alopecia areata, traction alopecia androgenetic alopecia, alopecia mucinosa).
(124) (A) Lorazepam.

- Lorazepam has strong sedative/hypnotic effects and the duration of clinical effects from a single dose
makes it an appropriate choice for the short term treatment of insomnia, in particular when severe
anxiety is present.
- It is not recommended for use in patients with a primary depressive disorder or psychosis.
- This case to be diagnosed as a major depression; it must have 5 or more symptoms of depression
over 2 weeks period.
- One of the very common side effects of fluoxetine is difficulty sleeping.
(125) (D) Mostly they think that the family responds like this.
- Battered woman syndrome occur at ail socioeconomic levels.
- Most battered women report that they thought that the assaults would stop; unfortunately, studies
show that the longer the women stay in the relationship the more likely they are to be seriously injured.
(126) (B) Multiple clinic appointment.
- Somatization disorder is a somatoform disorder characterized by recurring, multiple, clinically
significant complaints about pain, gastrointestinal, sexual and pseudoneurological symptoms.
- Cognitive behavioral therapy is the best established treatment for a variety of somatoform disorders
including somatization disorder.
(127) (B) Post-partumpsychosis.
- Psychosis can be manifested through one or more of the following:
1- Delusion is a fixed false belief.
2- Hallucination is a false perception (e.g. visual, auditory, or olfactory).
3- Thought disorganization.
(128) (D) Postural hypotension.

- Cautions: cardiac abnormalities may occur, monitor ECG.
- Do not discontinue amitriptyline abruptly because withdrawal symptoms may occur.
- Side effects: dry mouth, constipation, weight gain, postural hypotension, drowsiness, confusion,
headache and visual disturbance.
PEDIATRICS
(1) An 8-year-old child presented with this auscultation: late systolic murmur best heard over the sternal
border, high pitch, crescendo, decrescendo. What is the diagnosis?
(A) Physiological murmur.
(B) Innocent murmur.
(C) Ejection systolic murmur.
(D) Systolic regurgitation murmur.
(2) A 10-year-old child was diagnosed with rheumatic fever without any defect of the heart. How
many years are needed for his treatment with prophylactic antibiotics?
(A) 1 years.
(B) 3 years.
(C) 6 years.
(D) 15 years.
(3) A 6-month-old child presented with difficulty breathing and sweating. Clinical examination shows
hyperactive precordium with loud S2 and pansystolic murmur grade 3/6 best heard in the left 3rd
parasternal region. What is the diagnosis?
(B) Large ventricular septal defect.
(D) Aortic regurgitation.
(4) A child presented with hypertrophic right atrium. What is the congenital anomalies which can lead
to this condition?
(C) Tetralogy of Fallot.
(D) dextro-transposition of the great arteries.
(5) All of the following are true about Tetralogy of Fallot except?
(A) Pulmonary stenosis.
(C) Right atrium hypertrophy.
(D) Aortic Stenosis.
(6) A 12-year-old boy brought by his parent for routine evaluation, he is obese but otherwise healthy;
his parents want to measure his cholesterol level. What is the best indicator of measuring this child
cholesterol?
(A) Hisparent desire.
(B) Family history of early cerebrovascular accident.
(C) High BMI.
(D) Family history of obesity.
(7) A 15-year-old boy came for clinical evaluation to participate in sport activity; his brother died
suddenly while he is walking to his work because of heart disease. On examination; everything is
normal, no murmurs and equal pulses in all extremities. What should be excluding in this patient
before he participates in sport activity?
(6) Bicuspid valve.
(C) Ventricular septal defect.
(D) Hypertrophic cardiomyopathy.
(8) What is the cause of cardiac arrest in children?

(A) Primary respiratory arrest.
(B) Hypovolemic shock.
(C) Neurogenic shock.
(D) Congenital heart disease.
(9) What it is the most common congenital heart disease associated with rheumatic heart disease?
(C) Coarctation of aorta.
(D) Valvular heart disease.
(10) A 15-year-old patient presented with palpitation and fatigue. On investigation right ventricular
hypertrophy, right ventricular overload and right branch blockage were identified. What is the
diagnosis?
(C) Coartaction of aorta.
(D) Pulmonary stenosis.
(11) A 9-month-old child with known case of congenital heart disease presented with central and
peripheral cyanosis. What is the diagnosis?
(A) Tetralogy of Fallot.
(B) Coarctation of aorta.
(C) Truncus arteriosus.
(D) Atrial septal defect.
(12) A child presented with congestive heart failure and several hemangioma on the body.
What is the most likely internal place for the hemangioma?
(A) Liver.
(B) Spleen.
(C) Intestine.
(D) Pancreas.
(13) What is true about rheumatic fever in children?
(A) Antibiotic prophylaxis before future dental procedures.
(B) 2 Blood cultures and presence of Osier nodes are diagnostic according to Duke's criteria.
(C) Duke's criteria are not dependable for the diagnosis.
(D) 1 blood culture + new murmur are diagnostic.
(14) A child presented with night sweating, myalgia, arthralgia and pericarditis. What is the most
likely diagnosis?
(A) Kawasaki disease.
(B) Still's disease.
(C) Scarlet fever.
(D) Lyme Disease.
(15) What is the best way to decrease the allergy in asthmatic child?
(A) Cover pillow and bed with impermeable material.
(B) Keep pets a way.
(C) Prophylactic medication.
(16) A child presented with drooling saliva and stridor and hyperextended neck. What is the diagnosis?
(A) Croup.
(B) Pertussis.
(C) Laryngitis.
(D) Epiglottitis.
(17) A child presented to ER with wheezing, dyspnea and muscle contraction. What is the best initial
treatment?
(A) Theophylline.
(B) Salbutamol nebulizer.
(C) Oralsteroid.
(D) Magnesium Sulphate.
(18) A 4-year-old child wakes up from sleep because of a croup. Which one of the following a
differential diagnosis?
(A) Foreign body.
(B) Bronchiolitis.
(C) Cystic fibrosis.
(D) Congenital heart disease.
(19) A young patient with mild intermittent bronchial asthma attacks once to twice a week. What
is the best treatment?
(A) Inhaled short actingbeta-agonist as needed.
(B) Inhaled steroid.
(C) Long acting beta-agonist as needed.
(D) Ask him to come to ER as required.
(20) A 3-month-old infant presented with tachypnea and respiratory distress. X-ray shows lower and
mid lobe infiltration, opaque right lung and shifted trachea to left. What is the responsible organism?
(A) Haemophilus influenza.
(B) Streptococcus pneumonia (pneumococcus).
(C) Mycoplasma pneumonia.
(D) Respiratory syncytial virus.
(21) A child presented to ER with shortness of breath, anxiety and wheezing after bee sting. On
examination: vital signs; BP = 75/55 mmHg, HR = 120/min and RR =20/min. What is the
management?
(A) Start IV fluid, IM epinephrine and antihistamine.
(B) Antihistamine injection and reassure the patient.
(C) Ventilation.
(D) Antihistamine then IM Epinephrine.

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PROMETRIC EXAM PRACTICE QUESTIONS

Based on past papers questions collection

(6) Which of the following drugs interacts with carvedilol?

(13) What type of edema occurs in congestive heart disease?

(17) Which one of the following is a component of Tetralogy of Fallot?

(19) What is the predominant clinical effect of niacin?

(35) Which of the following statements is correct regarding cardiac syncope?

(44) Which of the following drugs is contraindicated in hypertrophic obstructive cardiomyopathy?

(50) Which of the following is true regarding pericarditis?

(52) What is the pathology of coronary artery disease?

(58) What is the pathophysiology of hypertension?

(62) How does the heart increase its blood supply?

(64) Which of the following is true about unstable angina?

(66) Which one of the following is true about exercise?

(69) Which of the following is contraindicated in subaortic stenosis hypertrophy?

(70) What is the best treatment for hypertension caused by hyperaldosteronism?

(75) What is the greatest risk factor for cerebrovascular accident?

(82) Which of the following is the correct about unstable angina?

(85) What is the cause of premature ventricular contraction?

(88) What is the difference between stable and unstable angina?

(89) What is the most prominent sign of severe hypokalemia?

(90) Which one of the following is a manifestation of hypokalemia?

(106) Which of the following statements about systolic hypertension is true?

(115) Which of the following treatments is contraindicated in asthmatic patients?

(117) How can allergic symptoms caused by dust mites be prevented?

(118) Where is the genetic defect in cystic fibrosis?

(120) In which lobe of the lung does pneumonia usually occur?

(140) What is the most common cause of cough in adults?

(141) What is the term used to describe difficulty in breathing?

(148) What is the recommended treatment for erosive gastritis?

(151) Which of the following is correct regarding Barrett's esophagitis?

(153) Which of the following is true about ulcerative colitis?

(155) What is the empirical treatment of Helicobacter pylori peptic ulcers?

(158) What is the organism responsible for pseudomembranous colitis?

(161) In which of the following is ibuprofen contraindicated?

(166) What is the recommended treatment for pseudomembranous colitis?

(174) Which one of the following medications increases reflux esophagitis?

(180) Which of the following is associated with Polycythemia vera?

(188) A 65-year-old patient presented with hepatosplenomegaly and lymphadenopathy.

(193) What is the recommended treatment for Von Willebrand disease?

(195) What is the defect in hemophilia?

(205) For what duration should anticoagulant agents be prescribed?

(207) What is the therapeutic range of the INR for warfarin?

(209) What is the investigation of choice in iron deficiency anemia?

(218) Which of thef ollowing is true regarding metformin?

(225) What is the pathophysiology of diabetic ketoacidosis?

(227) What is the mechanism of action of propylthiouracil?

(228) What is the recommended treatment for asymptomatic hyperthyroidism in pregnancy?

(237) What is the most common cause of renal failure?

(241) What is the recommended treatment for thyroid carcinoma?

(247) What is the pathophysiology of Cushing's syndrome?

(253) What is the most active form of thyroid hormone?

(255) Which of the following is associated with primary hyperaldosteronism?

(256) What is the recommended initial treatment of symptomatic hyperthyroidism?

(260) What is the best single test to confirm Cushing's syndrome?

(264) Which of these is the earliest sign of puberty in males?

(267) What is the most effective treatment of cluster headaches?

(269) What is the first sign of increase intracranial pressure?

(276) What is the initial ER management of grand mal seizure?