MEDICINE P5

1. A 65-year-old man presents with tiredness and has severe pallor. HB is 6g/dL., MCV
is 55fL and there is a lymph node in the left supraclavicular fossa. Which clinical sign
is consistent with the haematological diagnosis?

A. Beau's lines
B. white nails
C. koilonychia
D. onycholysis
E. hyperpigmented palms

2. An 80-year-old woman has been housebound for years and was admitted after a fall
which resulted in a fracture of her left hip. Previously she had a slow but distinctive
waddling gait and severe backache, using two sticks to get around. What is the likely
explanation for her mobility problems?

A. increased bone turnover

B. multiple bone cysts
C. reduced cortical bone density
D. severe osteomalacia
E. aseptic necrosis of the femoral head

3. A 70-year-old woman has had muscle cramps for the past 2 days. She also feels
rather weak and dizzy. She has been taking furosemide 80 mg orally twice daily for
an exacerbation of cardiac failure. Examination reveals decreased tone in all limbs,
temperature 36.5°C, pulse 120 beats/minute, BP 100/75 mmH. Which single
management option would improve her symptoms?

A. digoxin 0.5mg iv immediately

B. potassium chloride 10mmol/hour iv
C. quinine sulphate 300mg note
D. spironolactone 25mg orally bd
E. indomethacin 25mg tid

4. A 29-year-old woman has had tender swollen wrists for 3 weeks. A similar episode
occurred a year ago and resolved spontaneously. She has also noticed a reddish rash
on her face for 2 months. Which autoantibody is most consistent with the diagnosis?

A. anti-acetylcholine receptor
B. anti-ds DNA
C. anti-mitochondrial
D. antiScl-70
E. anti-smooth muscle
5. A 55-year-old woman has swollen painful joints. The pain is present all the time, but
is worse on movement and at the end of the day. Examination of the knees reveals
crepitus on passive movement, as well as swelling and mild warmth. Which of the
following clinical features would support the diagnosis?

A. onycholysis
B. bony nodules over DIP joints
C. ulnar deviation of the wrists
D. telescoping of the terminal phalanx
E. hyperextension of the PIP joints

6. A 35-year-old man has had painful wrists for 3 months; the pain is worse in the
mornings and he is stiff for the first 3 or 4 hours of the day. He is otherwise well,
except for a persistent itchy rash on the extensor surfaces of the arms and back.
Which additional finding would support the likely diagnosis?

A. early diastolic aortic murmur

B. elbow nodules
C. fingernail pitting
D. squaring of the thumbs
E. whitish nodule on the ears

7. A 33-year-old woman presents with breathlessness and mitral stenosis is suspected.

Which sign is useful in supporting the diagnosis?

A. low volume irregular pulse

B. sustained apical impulse
C. elevated JVP
D. loud third heat sound
E. loud systolic murmur

8. A doctor is examining a stable patient with a 12 year history of emphysema. The

physical finding most likely to be found is:

A. clubbing of fingers
B. Palmar and nailbed pallor
C. increased A-P chest diameter
D. pitting peripheral edema
E. sinus tachycardia
9. A 55-year-old man complains of haemoptysis, exertional dyspnea, joint pains and
weight loss. He smoked for 20 years and stopped 2 years ago. He is noted to have
marked finger clubbing. On chest X-ray there is unilateral nodular opacity on the
right middle lobe. The most likely diagnosis is:

A. Fibrosing alveolitis
B. bronchopneumonia.
C. bronchiectasis
D. bronchial carcinoma
E. Mesothelioma

10. A 60-year-old hypertensive presents with a headache and a painful right eye. On
examination he is noted to have right partial ptosis and the right pupil is fixed and
dilated. The eye is looking downwards and outwards. The most likely diagnosis is:

A. left trochlear nerve palsy

B. Argyll Robertson pupil
C. Cervical sympathetic compression
D. oculomotor nerve palsy
E. acute optic neuropathy

11. A 37-year-old man is admitted from the neurology clinic for work up for a suspected
spinal cord lesion. Which of the following clinical signs suggests a spinal cord lesion?

A. Bilateral paraesthesiae
B. Sensory level
C. Normal micturition control
D. Nystagmus on lateral gaze
E. Absent plantar response

12. A 23-year-old man is admitted with severe vomiting, diarrhea and abdominal pain.
He is being treated for a presumed gastroenteritis with several medications. Several
hours after admission, he becomes very anxious and is unable to prevent repeated,
involuntary movements of his neck and is unable to stop putting out his tongue.
Which drug is most likely to have caused this problem?

A. cyclizine
B. ciprofloxacin
C. metoclopramide
D. omeprazole
E. hyoscine
13. A patient who started TB treatment 3 weeks ago comes back to your clinic
complaining of passing orange-red urine. This is likely to be due to:

A. Inadequate fluid intake

B. thrombocytopenia
C. Ethambutol toxicity
D. Factitious complaint
E. Rifampicin side effect

14. A 42-year-old woman has been increasingly tired over the past 6 months. She has
felt faint on exercise and has occasional palpitations. She also feels rather irritable
and has pins and needles in her feet. Her conjunctivae and mucous membranes are
pale. FBC shows Hb 7.8g/dL, MCV 103fL, and peripheral film shows hypersegmented
neutrophils. What is the probable cause of her symptoms?

A. Megaloblastic anaemia
B. Iron deficiency anaemia
C. Anaemia of chronic infection
D. Sideroblastic anaemia
E. Haemolytic anaemia

15. A 68-year-old man has had a worsening tremor of his hands for 9 months. The
tremor is noticeable when his hands are still, and seems to improve when he moves
his hands, though he says that his writing seems smaller than it used to be. He is
asthmatic and uses two inhalers for this condition. What feature of his history is
consistent with the diagnosis?

A. The tremor is likely to improve with alcohol

B. He is likely to have a shuffling, small step gait
C. Stopping his inhalers will improve the tremor
D. B-blockers will improve this type of tremor
E. His speech has become difficult to understand

16. A 49-year-old woman has weakness in her right arm and right leg, and she has been
finding it increasingly difficult to find words. These symptoms have developed
gradually over about 2 weeks. Temperature is 36.5°C, pulse 84 beats/minute, BP
105/70 mmH. She has reduced power on the right side with brisk reflexes and
upgoing plantars. Which is the single most likely diagnosis?

A. Cerebral metastases
B. Cerebral infarct
C. Hemiplegic migraine
D. Transient ischaemic attack
E. Subarachnoid hemorrhage
17. A 26-year-old man was seen jerking on the floor at his workplace. He lost
consciousness for an hour and was brought into casualty where he was noticed to
have soiled himself. He had a similar episode a month ago. Temperature 36 °C, pulse
80 beats/minute, BP 140/85 mmg, SaOz 99% on air, GCS 12/15. A CT scan is reported
as 'normal'. What is the likely diagnosis?

A. Vasovagal syncope
B. Narcolepsy
C. Drop attacks
D. Primary generalized epilepsy
E. Pseudoseizure disorder

18. A 25-year-old man injured his head and neck in a road accident although he did not
lose consciousness at the time. He seems well in casualty and has normal vital signs.
He had been drinking excessively prior to the accident. What examination finding
would prompt you to request a CT scan?

A. Past pointing
B. Bruising behind the ears
C. Coarse tremor of the hands
D. Positive Romberg's test
E. Bleeding from the scalp

19. A 28-year-old woman has a 3-day history of a sore throat, malaise and fatigue
without cough or fever. She has no drug allergies and is on no medication.
Examination reveals a normal temperature and vital signs, and bilateral tonsillar
exudates. There are no cervical nodes. What is the best management step at this
time?

A. Monospot antibody test

B. Streptococcal antigen test
C. Immediate treatment with penicillin
D. Throat swab and culture
E. HIV test

20. A 64-year-old man presents with a day's history of a right-sided headache which is
getting worse. He also noticed some right eye discomfort and redness, and the eye is
sensitive to light. Examination reveals normal pupils and visual acuity though the
conjunctiva is diffusely red. The cornea is clear and there is a vesicular rash on the
forehead. What is the most likely diagnosis?

A. Herpes simplex virus keratitis

B. Episcleritis
 C. Trigeminal neuralgia
D. Herpes zoster ophthalmicus
E. Acute glaucoma

21. A 28-year-old man is admitted with a fever (temperature 39.2°C), and flu-like
symptoms after collapsing with a severe headache a week after returning from the
Honde Valley. BP is 100/60mm Hg, pulse is 100beats/min, regular. Which of the
following features would point to a likely diagnosis of malaria?

A. Basal crepitations
B. pallor and mild jaundice
C. Marked neck stiffness
D. Hepatomegaly of 6cm
E. Maculopapular rash

22. A 25-year-old woman has been passing minimal amounts of darkish urine for the
past three days. She feels tired but prior to this had been well except for a minor skin
infection for which she'd received a short course o antibiotics.. Examination shows
BP 140/95 mmHg, urea 14mmol/L, creatinine 240 mol/L, albumin 39g/L, urine
dipstick protein +, blood 2+. What is the most likely diagnosis?

A. Acute nephritic syndrome

B. Acute interstitial nephritis
C. Nephrotic syndrome
D. Renovascular disease
E. Acute tubular necrosis

23. A 25-year-old woman has had abdominal pain and nausea for 48 hours; there is no
vomiting and bowel movements are normal. Menses are normal, there is no
amenorrhoea or vaginal discharge. She has had a recent persistent coryzal illness.
Clinically she is apyrexial with BP 120/75mm Hg, pulse 65 beats/minute and
abdominal palpation reveals a soft abdomen with tenderness in the right iliac fossa
but no guarding or rebound tenderness. Which clinical finding would support the
likeliest diagnosis?

A. Cervical excitation tenderness

B. Right renal angle tenderness
C. right upper quadrant tenderness
D. Tender cervical lymphadenopathy
E. Tenderness on digital rectal examination

24. A 43-year-old man has frontal lobe lesionsconfirmed on MRI scan confirms this.
Which of the following signs may be are compatible with these lesions?
 A. hyperacusis
B. homonymous hemianopia
C. sustained blink response
D. persistent grasp reflex
E. constructional apraxia

25. A 70-year-old man complains of difficulty with walking. When he is seated the skin of
the lower leg seems discolored. After walking for about two minutes he complains of
pain. There is marked pallor evident over the ankle and foot. What is this most likely
to be due to?

A. Neurogenic claudication
B. Restless leg syndrome
C. Peripheral neuropathy
D. Vascular claudication
E. Venous insufficiency

26. A 40-year-old woman has received her second course of chemotherapy for recently
diagnosed acute myeloid leukaemia. She is a Jehovah's Witness and has stated
repeatedly that she will not accept supportive blood products at any stage of her
treatment. She has now become breathless, weak and confused and Hb is 3. 1g/dL.
The medical team feels that if she is not transfused with blood now, she will not
survive. What is the next appropriate step?

A. Apply to the medical superintendent to order that treatment can go through

B. Since she is now confused, the team can treat her in what they feel are her best
interests
C. Get consent for the proposed treatment from her next of kin
D. Reassess her capacity to decline the proposed treatment
E. Respect her earlier wishes and withhold treatment

27. An HIV-positive patient presents with a dry cough and breathlessness on mild
exertion.
He is not obviously cyanosed. You suspect Pneumocystis jroveci pneumonia. Which
one of the following is consistent with the diagnosis?

A. Being on cotrimoxazole prophylaxis

B. normal chest examination
C. Antiretroviral therapy for one year
D. Undetectable HIV viral load
E. high fever of 40°C
28. A 24-year-old man presents with a month's history of a swollen right knee. He was
started on antiretroviral therapy (ART) two months ago. He was also on treatment
for pulmonary tuberculosis, which predated the ART. Pus was aspirated from the
knee. What is the most likely cause?

A. Tuberculous arthritis
B. gouty arthritis
C. Staphylococcal arthritis
D. Rheumatoid arthritis
E. Reactive arthritis

29. A 30-year-old woman who has been on antiretroviral therapy (ART) for 6 months
presents with increasing shortness of breath and nausea for two weeks. She has
been losing weight but has no night sweats. She has been adherent to cotrimoxazole
prophylaxis. She has deep sighing breathing and tachypnoea but is not cyanosed. Her
pulse is 120beats/min. What is the most plausible explanation for her symptoms?

A. Pneumocystis pneumonia
B. Pulmonary oedema
C. Lactic acidosis
D. Lobar pneumonia
E. Renal impairment

30. A 19-year-old woman presents with left ventricular failure. She has been told that
she needs an operation to correct a congenital abnormality. There is no cyanosis, BP
is 160/115mm Hg and there are no murmurs on auscultation. What is the likely
underlying congenital lesion to cause the LVF?

A. Atrial septal defect

B. Patent ductus arteriosus
C. Mitral valve prolapse
D. Fallot's tetralogy
E. Coarctation of the aorta

31. Which of the following diseases is most likely to be prevalent as a result of longer
survival with treated HIV infection?

A. kidney disease
B. liver disease
C. cardiovascular disease
D. reactive arthritis
E. Dementia
32. Previous heavy asbestos exposure should be suspected when the following
radiological features are seen on a chest x-ray

A. lower lobe fibrosis

B. pleural plaques
C. cavitating lung lesions
D. a small pleural effusion
E. bilateral hilar nodes

33. A 48-year-old woman with Type I diabetes mellitus presents with nausea and
lethargy of six weeks' duration. Blood tests show creatinine 650 mol/L, urea 35
mol/L, alkaline phosphatase 150 |U/L, calcium 2.20 mol/L, phosphate 1.8 mmol/L,
Hb 10 g/dL. Which single investigation would support a diagnosis of chronic kidney
disease?

A. Bilateral shrunken kidneys on sonar scan

B. ECG showing left ventricular hypertrophy
C. Serum potassium of 6.5 mmol/L
D. Blood HbA1c of 8.5%
E. Granular casts on urine microscopy

34. A 12-year-old boy has been diagnosed with minimal change glomerulonephritis
having presented with a puffy face and ankle swelling. Which of the following
findings is most consistent with the diagnosis?

A. Haematuria
B. Impaired renal function
C. Bland urinary sediment
D. Selective proteinuria
E. Haemoglobin of 8g/ dL

35. A 45-year-old woman presents with hiccups, bone pain, and nausea. On
examination, she is pale, has blood pressure 110/80 and trace pedal oedema. On
dipstick examination, she has proteinuria 4+, blood 1+, serum creatinine is 713 mol/L
and potassium is 5.7mmol/L. Abdominal ultrasound shows bilaterally slightly
enlarged Kidheys. Which one of the following conditions could be the underlying
cause of the renal impairment?

A. reflux nephropathy
B. chronic glomerulonephritis
C. analgesic nephropathy
D. renal artery stenosis
E. chronic HIV infection
36. A 42-year-old man presents with a dizziness and easy fatigability. He also reports
passing dark, tarry, foul-smelling stool. Which one of the following is the most likely
diagnosis?

A. Amoebic dysentery
B. Colorectal carcinoma
C. Duodenal ulcer disease
D. Crohn's Disease
E. Vaso-vagal syncope

37. A 22-year-old cross-border trader presents with recent onset anorexia and weight
loss.
She recently completed treatment for TB. She has also been having pain on
swallowing food, to the extent that she has been afraid to eat. Which of the
following is the most likely diagnosis?

A. Achalasia of the oesophagus

B. Oesophageal candidiasis
C. Oesophageal carcinoma
D. Reflux oesophagitis
E. Mallory-Weiss tear

38. A 50-year-old man presents with severe upper abdominal pain, an enlarged liver and
worsening jaundice. He admits to being treated for polycythemia vera in the past.
Which one of the following is a cause of his post-hepatic portal hypertension?

A. Portal vein thrombosis

B. Schistosomiasis
C. Alcoholic hepatitis
D. Budd-Chiari syndrome
E. Splenic vein thrombosis

39. A 50-year-old man presents with a week's history of yellow eyes and pruritus. On
examination he is jaundiced and has a smooth, tender hepatomegaly. Which one of
the following signs would suggest liver failure?

A. Gynaecomastia
B. Encephalopathy
C. Spider naevi
D. Palmar erythema
E. Ascites
40. A 30-year old man presents with a 2-month history of nausea, thirst and abdominal
pain, in addition he admits to having loose stools and weight loss. On examination he
is thin, slightly pale with parotid enlargement, glove and stocking loss to pricking
sensation. Abdominal examination reveals mild epigastric guarding. What
complication of the condition has occurred?

A. Diabetes mellitus
B. Splenic vein thrombosis
C. Obstruction of common bile duct
D. Pancreatic pseudocyst formation
E. Vitamin B12 deficiency

41. A 72-year old man presents with skin lesions which have been present for over a
year and numbness of the fingers of one hand. There is an ulcer on the tip of the ring
finger. Which statement is correct about this condition?

A. The disease is highly contagious for household contacts

B. The causative organism cannot be grown on artificial lab media
C. The HIV pandemic has resulted in a worldwide increase in the condition
D. An inflammatory reaction reaction should be suspected with initiation of
therapying this patient

42. A 25-year-old woman complains of feeling increasingly ‘hot and bothered’ for the
past six months. She is sweating a lot and has lost 5kg. She smokes 20 cigarettes daily
and drinks 20 units of alcohol per week. What sign would be the most likely to
support the probable diagnosis?

A. Sinus bradycardia
B. Exophthalmos
C. Acneiform rash
D. Lymphadenopathy
E. Skin hyperpigmentation

43. A 56-year-old ex-smoker is investigated for symptoms of progressive dysphagia. He

can now swallow fluids and soft solid food only. He has lost 8kg in the past two
months. Which of the following conditions is most likely to have caused this
disorder?
A. Oesophageal achalasia
B. Barrett's oesophagus
C. Carcinoma esophagus
D. Gastro-oesophageal reflux
E. Sliding hiatus hernia
44. A 42-year-old woman has been increasingly tired over the past 6 months. She has
felt faint on exercise and has occasional palpitations. She also feels rather irritable
and has pins and needles in her feet. Her conjunctivae and mucous membranes are
pale. FBC shows Hb 7.8g/dL, MCV 103fL, peripheral film shows hypersegmented
neutrophils.What is the probable cause of her symptoms?

A. Megaloblastic anaemia
B. Iron deficiency anaemia
C. Anaemia of chronic infection
D. Sideroblastic anaemia
E. Haemolytic anaemia

45. A 67-year-old is recovering from a stroke and is on warfarin. During his rehabilitation
it is important to watch for?

A. Ankle oedema
B. Ecchymosis
C. Scratch marks
D. Skin blisters
E. Cellulitis of the weak limb

46. A 34 year old male nurse presents to casually after collapsing on night shift. On
evaluation, his blood glucose was 1.3mmol/L and BP - 130/67mmHg. Following
resuscitation, on arousal, he denied any palpitations and there was no report of
seizural activity from the co-workers present. He also said he has had three of these
episodes over the preceding two weeks. Bloods were sent off and showed a low
normal C-peptide level and markedly raised insulin level.Which of the following is
the most likely diagnosis of his multiple episodes of collapse?

A. Sulphonylurea abuse
B. Alcohol abuse
C. Insulin abuse
D. Insulinoma
E. Retroperitoneal sarcoma

47. A 78-year old woman is brought to casualty by her niece with a day's history of
confusion. ECG done in casualty as part of her workup showed a sinus tachycardia
and prolonged ORS duration of 130milliseconds. Her niece reports she had been
complaining of a 2-week history of dry mouth, constipation and blurring of vision.
She has long standing hypertension and is also being managed by her general
practitioner for depression. She is on the following drugs - losartan 50mg po daily,
sulpiride 50mg po daily, amitriptyline 25mg po daily and fluoxetine 20mg po daily.
What is the best treatment option for this patient?
 A. Intravenous sodium bicarbonate
B. Intravenous norepinephrine
C. Intravenous hypertonic saline
D. Intravenous physostigmine
E. Intravenous flumazenil

48. A 56-year-old man is evaluated in the hospital for paroxysmal episodes of atrial
fibrillation.The patient develops increasing shortness of breath during these
episodes. Five days ago, he was admitted for an acute myocardial infarction and
cardiogenic shock and received a drug-eluting stent in the left anterior descending
coronary artery. Medications are lisinopril digoxin, furosemide, aspirin, clopidogrel,
epterenone, simvastatin, and unfractionated heparin. On physical examination, the
patient is afebrile, blood pressure is 92/65 mm Hg and pulse rate is 75/min. Oxygen
saturation is 95% with 3 L oxygen by nasal cannula.Cardiac examination reveals
estimated central venous pressure of 12 cm H2O. Heart sounds are distant and
regular. There is a grade 2/6 holosystolic murmur at the cardiac apex. A summation
gallop is present. Crackles are auscultated bilaterally in lower lung fields.
Transthoracic echocardiogram shows left ventricular ejection fraction of 32%. Which
of the following is the most appropriate treatment for this patient's atrial fibrillation?

A. Amiodaron
B. Disopyramide
C. Dronedarone
D. Flecainide
E. Sotalol

49. A 76-year-old woman is evaluated in the emergency department for dizziness,

shortness of breath, and palpitations that began acutely 1 hour ago. She has a
history of hypertension and heart failure with preserved ejection fraction.
Medications are Hydrochlorothiazide, lisinopril, and aspirin. On physical
examination, she is afebrile, blood pressure is 80/60 mmHg, pulse rate is 155/min,
and respiration rate is 30/min. Oxygen saturation is 80% with 40% oxygen by face
mask. Cardiac auscultation reveals an irregularly irregular rhythm;tachycardia, and
some variability in S1 intensity Crackles are heard bilaterally one-third up in the
lower lung fields Electrocardiogram demonstrates atrial fibrillation with a rapid
ventricular rate.Which of the following is the most appropriate acute treatment?

A. Adenosine
B. Amiodarone
C. Cardioversion
D. Diltiazem
E. Metoprolol