26. A 70-year-old woman has been in long-standing poor health, with severe diabetes mellitus and rheumatoid arthritis.

Her physician notes that she appears pale and orders a hematocrit, which shows a result of 35%. Examination of the blood smear reveals a microcytic anemia. The physician is considering a differential diagnosis of iron deficiency anemia versus anemia of chronic disease. Which of the following laboratory determinations would be most helpful in distinguishing these conditions? a)Erythrocyte:granulocyte ratio in bone marrow b) Presence or absence of polychromatophilic target cells c)Presence or absence of stippled erythrocytes d)Serum ferritin e)Serum iron ________________________________________ 27. A 45-year-old patient on hemodialysis for one week has noted that his blood pressure is more difficult to control. He reports good compliance with his medications, which include erythropoietin, ferrous sulfate, vancomycin, and vitamin D. His blood pressure is 180/99 mm Hg. Which of the following is the most likely cause for the worsening control of his blood pressure? a)Erythropoietin b)Ferrous sulfate c)Vancomycin d)Vitamin D e) Uremia ________________________________________ 28. A 40-year-old man is brought to the emergency room by his friends. Apparently, he has ingested some unknown medication in a suicide attempt. The patient is disoriented to time. His temperature is 39.3 C (103 F), blood pressure is 120/85 mm Hg, pulse is 100/min and irregular, and respirations are 22/min. The skin is flushed and dry. Dilated pupils and muscle twitching are also noted on physical examination. ECG reveals prolonged QRS complexes. Hepatic transaminases are normal, and blood gas analysis shows a normal pH. These findings are most likely due to intoxication by which of the following substances? a)Acetaminophen b)Alcohol c)Benzodiazepines d)Clonidine e) Monoamine oxidase (MAO) inhibitors f)Tricyclic antidepressants

________________________________________ 29.A 72-year-old man comes to the physician because of a 3-day history of right-sided chest pain. He denies any shortness of breath, nausea or vomiting. Physical examination

shows a unilateral, erythematous, maculopapular rash extending from the anterior chest wall around to the back in a dermatomal pattern. The remainder of the examination is normal. In conversation, he states that is he is going to visit his grandchildren next week and that their mother "doesn't believe in immunizations". His grandchildren are at increased risk for which of the following rashes? a) Discrete maculopapular lesions that become confluent as they spread from "head to toe" b)Dome-shaped papules with central umbilication c)Expanding annular lesion with central clearing d) "Slapped-cheek" appearance and a lacy reticular rash e) Vesicles at various stages of evolution

________________________________________ 30. A 50-year-old man consults a physician because he has been having transient periods of rapid heart beat accompanied by sweating, flushing, and a sense of impending doom. Physical examination is unrevealing, with no evidence of arrhythmia at the time of the exam. However, the man's wife is a nurse, so the physician asks that she take vital signs the next time one of the episodes occurs. She does, and demonstrates a blood pressure of 195/140 mm Hg with heart rate 160/min during the episode. She promptly takes her husband to the emergency room, but the spell is over by the time that he is seen. Urinary measurement of which of the following would most likely be diagnostic in this case? a) Dehydroepiandrosterone (DHEA) b)Human chorionic gonadotropin (hCG) c)17-ketosteroids d)Vanillylmandelic acid VMA e) Zinc protoporphyrin ________________________________________ 31. A 35-year-old woman consults an ophthalmologist because of double vision and droopy eyelids. She also has complaints of generalized muscle weakness. IV injection of edrophonium dramatically, but only briefly, reverses her symptoms. This patient's probable disease has a pathophysiologic basis that is closest to that of which of the following conditions? a) Bullous pemphigoid b)Diabetes mellitus type 1 (some cases) c)Idiopathic Addison disease d)Insulin resistance e)Systemic lupus erythematosus

________________________________________ 32.A 34-year-old woman who is healthy without underlying medical problems presents to clinic with complaints of temperature up to 101 F and cough with greenish sputum

production for 2 days without any dyspnea. Her heart rate is 88/min, and her respiratory rate is 18/min. There is no accessory muscle use or conversational dyspnea, nor are there wheezes, bronchial breath sounds, rales, or egophony over the right lower lung fields. Chest x-ray film reveals a right lower lobe consolidation. A CBC shows a leukocyte count of 13,000/mm3. Which of the following is the most appropriate pharmacotherapy? a) Amoxicillin b)Ampicillin-sulbactam c)Ceftriaxone d)Erythromycin e) Erythromycin plus ceftriaxone

________________________________________ 33. A 23-year-old type 1 diabetic is brought to the emergency department after being found in a coma. The scent of acetone is present on the patient's breath. Urinary catheterization with subsequent dipstick analysis demonstrates marked positivity for glucose and ketones. Stat blood chemistries would most likely show which of the following values for the anion gap? a) 6 mEq/L b)11 mEq/L c)13 mEq/L d)15 mEq/L e) 20 mEq/L

________________________________________ 34. A 70-year-old man presents to the emergency department with a 3-day history of right temporal headache, fever, and profound malaise. He appears acutely ill. His temperature is 39.5 C (103.1 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 24/min. Tenderness over the right temporal region is appreciated on palpation. The right temporal artery is tender and slightly nodular. Neurologic examination is normal, including funduscopic examination. However, visual acuity is reduced. Laboratory studies show: Hematocrit 39.0% Hemoglobin 10.9 g/dL Leukocytes 8800/L (neutrophils 68%) Erythrocyte sedimentation rate 80 mm/hr Which of the following is the most appropriate next step in management? a)Measurement of intraocular pressure b)Visual field assessment c)Low-dose (10 mg/day) prednisone treatment d)High-dose (60 mg/day) prednisone treatment e) Temporal artery biopsy

________________________________________ 35.A 74-year-old woman presents to her physician for a postoperative medical visit. Three days ago, she underwent a left total knee replacement for severe osteoarthritis. She has a past medical history significant for type 1 diabetes mellitus and glaucoma. Her hospital course was uneventful. She continues to take daily NPH insulin and has good control of her blood glucose. She also takes oxycodone, which was given to her in the hospital for pain. She is involved in a physical therapy rehabilitation program at the local hospital. On review of her medications, which of the following is most acutely indicated at this time? a) An ACE inhibitor b)A nonsteroidal anti-inflammatory agent c)Oral aspirin d)Oral Coumadin e) Subcutaneous unfractionated heparin

________________________________________ 36. A 37-year-old woman presents with complaints of severe heartburn with or without meals. She has a history of hypertension, which has been treated with captopril. She also has a history of Raynaud disease, multiple facial telangiectasias, and very taut skin on the dorsum of both hands. She has failed to obtain relief for her heartburn with large doses of antacids, ranitidine, or omeprazole. Esophageal manometry is ordered. Which of the following would be the most likely results of this test? a) Decreased esophageal peristalsis and decreased LES pressure b)Decreased esophageal peristalsis and increased LES pressure c)Increased esophageal peristalsis and decreased LES pressure d)Increased esophageal peristalsis and increased LES pressure e) Normal esophageal peristalsis and normal LES pressure ________________________________________ 37. A 60-year-old woman consults a physician because of weakness, headaches, dizziness, and tingling in her hands and feet. Physical examination demonstrates multiple areas of bruising on the back of her forearms and shins. On specific questioning, she reports having had five nosebleeds in the past two months, which she had attributed to "dry air". Blood studies are drawn which show a platelet count of 1.2 106/L, a red cell count of 5.1 106/L, and a white count of 10,500/L with a normal differential count. Review of the peripheral smear demonstrates many abnormally large platelets, platelet aggregates, and megakaryocyte fragments. No abnormal red or white blood cells are seen. Philadelphia chromosome studies are negative. Which of the following is the most likely diagnosis? a)Chronic myelogenous leukemia b)Myelofibrosis c)Polycythemia vera

d)Primary thrombocythemia e) Secondary thrombocythemia ________________________________________ 38. A 23-year old-dancer presents with a chief complaint of weakness. She denies any other symptoms, including nausea or vomiting. She denies diarrhea. Her blood pressure is 80/40 mm Hg. There is no edema and the lungs are clear. Laboratory analysis of serum shows: Sodium 126 mEq/L Potassium 2.2 mEq/L Bicarbonate 29 mEq/L Magnesium 2.0 mg/dL Calcium 9.0 mg/dL The most likely cause of the patient's weakness is an abnormality in which of the following? a) Bicarbonate b)Calcium c)Magnesium d) Potassium e) Sodium ________________________________________

39. A 43-year-old woman is admitted for new-onset of seizures in the setting of hyponatremia. At baseline, she is well educated and works as a computer marketer. Her medical history is remarkable for a long history of depression and alcoholism, with multiple visits to the Emergency Department for trauma. She was initially found in her hot apartment by paramedics. At that time, she was postictal, incontinent of urine, and oriented only to name. She was last seen at work 3 days ago. In the Emergency Department her systolic blood pressure is 70 mm Hg and her pulse is 130/min. Upon physical examination, she has dry mucous membranes, a jugular venous pressure of less than 5 cm, and diffuse ecchymoses on her face, body, and breasts. She proceeds to have two addition seizures in the Emergency Department that are controlled with intravenous lorazepam. Laboratory studies reveal a serum sodium of 115 mEq/L, potassium of 2.8 mEq/L, and bicarbonate of 32 mEq/L. Which of the following is the most appropriate next test to obtain? a)Electroencephalogram (EEG) b)Magnetic resonance imaging (MRI) of the head c) Non-contrast computed tomography (CT) of the head d)X-ray films of the skull e)Lumbar puncture (LP) ________________________________________

40.A 65-year-old West Texas farmer of Swedish ancestry has an indolent, pale, raised, waxy, 1.2-cm skin mass over the bridge of the nose. The mass has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the neck. Other than a "weather-beaten" appearance for the rest of his exposed skin, the remainder of the physical examination is unremarkable. Which of the following is the most likely diagnosis? a)Basal cell carcinoma b)Invasive melanoma c)Keratoacanthoma d)Pyogenic granuloma e)Squamous cell carcinoma ________________________________________ 41.A 22-year-old woman goes to the emergency department because she feels very weak and is having muscle cramping and fasciculations. Blood chemistry studies demonstrate a plasma potassium of 1.5 mEq/L. On questioning, she admits to chronic use of laxatives and diuretics to control her weight. Which of the following ECG changes would be most characteristic of changes related to her K+ level? a)Increased U wave amplitude b)Prolongation of the P wave c)Shortening of the QT interval d)Tall, symmetric, peaked T waves e)Widening of the QRS complex

________________________________________ 42. A 34-year-old man presents with a swollen left knee of 2 days' duration. He denies any known trauma to that region and has no prior history of any musculoskeletal complaints. He is in otherwise excellent health. He is homosexual and practices safe sex with a single partner. On physical examination, his knee is swollen, tender to palpation, and erythematous and has a limited range of motion. An arthrocentesis is performed. Which of the following is most suggestive of a septic arthritis in this patient? a)A complete blood cell count with 14,300 white blood cells per mL b)A joint fluid aspirate with a white blood cell count of 28,000 per mL c)A joint fluid aspirate with a white blood cell count of 36,000 per mL d)A joint fluid aspirate with a white blood cell count of 48,000 per mL e) A joint fluid aspirate with a white blood cell count of 93,000 per mL ________________________________________ 43. A 59-year-old man presents to the hospital complaining of cough. The patient describes a cough that has progressively worsened over the past 3 days, becoming more productive of yellowish sputum. He also reports one episode of shaking chills 2 days ago. His past medical history is remarkable for rheumatoid arthritis, for which he takes a

nonsteroidal agent for pain control. On examination, his blood pressure is 140/90 mm Hg, and his pulse is 100/min. He has coarse breath sounds over his right base and a normal cardiac examination. Which of the following is the most appropriate diagnostic test for this patient? a)High-resolution chest CT b)Positron emission tomography (PET) scan of the lungs c)MRI of the chest d)Ventilation-perfusion scan e)X-ray films of the chest, posterior-anterior (PA) and lateral views ________________________________________ 44. A 52-year-old woman is seen by in clinic for advice on osteoporosis. She has been a patient there for a number of years. She has a past medical history significant for hypertension and diet-controlled diabetes mellitus. She smokes 1 pack of cigarettes per day. She was documented by previous LH and FSH levels to be in menopause within the last year. She is concerned about "breaking her hip when I'm old" and she is seeking advice on osteoporosis prevention. She should be told that independent of side effects, the best therapy currently available for prevention is which of the following? a)Bisphosphonates b) Calcitonin c)Calcium and vitamin D d) Conjugated estrogens e)Sodium fluoride

________________________________________ 45.A 22-year-old man comes to the emergency department with a 3-day history of fever, chills, a cough, pleuritic chest pain, and low-back pain. He says that the symptoms came on "out of the blue". He is the son of a wealthy local businesswoman and still lives at home, which he says "is cool because my parents are never around". His temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and respirations are 16/min. Physical examination shows oval, retinal hemorrhages with a clear, pale center and pinpoint lesions between his toes. Blood cultures are drawn. A chest x-ray film shows multiple patchy infiltrates. Laboratory studies show: Hemoglobin...................................11 g/dL Hematocrit....................................39% Erythrocyte sedimentation rate.......39 mm/hr Which of the following is the most likely pathogen? a)Candida albicans b)Pseudomonas aeruginosa c)Serratia marcescens d)Staphylococcus aureus e)Streptococcus viridans

________________________________________ 46. A 57-year-old man comes to his physician for his semi-annual visit. He has a medical history significant for long-standing chronic obstructive pulmonary disease (COPD). He has had a two to three pack per day smoking history for the past 40 years. He also has hypertension and diet-controlled type 2 diabetes mellitus. His medications include lisinopril once daily and thiazide. He has no allergies. He reports that he continues to smoke one to two packs of cigarettes per day and drinks one glass of whisky each night. He seems to be compliant with his medications. He walks one half mile per day at a fairly brisk pace but is limited by fatigue and shortness of breath. His home blood glucose log shows a range of values from 108 to 201 mg/dL. On physical examination, he is a fairly obese man with a large barrel chest. He is breathing comfortably. His blood pressure is 152/88 mm Hg, and pulse is 82/min and regular. His lungs are hyperresonant to percussion with scant bibasilar crackles. He has an S4 gallop and a grade one systolic ejection murmur radiating to the carotids bilaterally. His extremities are without edema or clubbing. Which of the following is the most appropriate preventative measure in this patient? a)Add an oral glucose control agent b)Encourage additional exercise c)Encourage rapid cessation of alcohol use d)Encourage rapid cessation of tobacco use e)Increase his dose of thiazide

________________________________________ 47. A 53-year-old woman presents complaining of fatigue over the past 6 months. During this time, she has also developed pruritus and lost 4 pounds. She is not sexually active, and her past medical history is significant only for Sjgren syndrome. On physical examination, she is afebrile and has mildly icteric sclera. There are excoriations noted on all four extremities and trunk and back. The liver edge is smooth and non-tender and measures 9 cm at the midclavicular line. There is no ascites, splenomegaly, or peripheral edema. Laboratory results reveal a normal complete blood count, normal electrolytes, and liver function tests with an alkaline phosphatase of 260 U/L (normal, <110 U/L), total bilirubin of 3.1 mg/dL, and normal transaminase levels. Which of the following is the most likely diagnosis? a) Acute cholecystitis b)Acute hepatitis A infection c)Bacterial cholangitis d)Primary biliary cirrhosis e)Primary sclerosing cholangitis

________________________________________

48. An elderly woman consults a physician because she is "feeling so tired all the time". Intraoffice hematocrit is 35%. Peripheral blood smear shows many macrocytic red cells. On questioning, the woman, whose finances are limited, admits that has been living on a "tea and toast" type diet. She has been drinking a powdered orange juice substitute (Tang). She has not been taking vitamin pills because she feels she can't afford them. A nutritional deficiency of which of the following is the most likely cause of this patient's anemia? a) Folate b)Iron c)Vitamin B12 d)Vitamin C e)Vitamin K

________________________________________ 49. A 65-year-old woman is admitted to the hospital for constant, severe abdominal pain that has worsened over the prior week. She has no other associated symptoms, such as nausea or vomiting, but has noticed that her daily urine output has sharply decreased. She has had a constant desire to urinate, but, when she tries, only a small amount of bloody urine is discharged. The patient is a long-time smoker, having smoked three packs per day for more than 45 years, although she claims to have quit 2 days ago. A bladder ultrasound in the emergency department reveals a mass consistent with bladder cancer, as well as significant urinary retention. Which of the following is most likely to be detected upon imaging the patient's genitourinary system? a)Bilateral hydronephrosis b)Bladder dilation c)Bladder dyskinesis d)Unilateral hydronephrosis e)Ureteral dilation

________________________________________ 50. A 29-year-old man is brought to the emergency department in a comatose state a few hours after complaining of sudden onset of excruciating headache. Neurologic examination reveals dilated pupils poorly responsive to light. A CT scan of the head without contrast demonstrates hyperdensity within the suprasellar cistern, while MRI is unremarkable. Lumbar puncture shows hemorrhagic cerebrospinal fluid. Which of the following is the most likely diagnosis? a)Amyloid angiopathy-related hemorrhage b)Cavernous sinus thrombosis c)Hemorrhagic infarction d)Pituitary apoplexy e)Ruptured berry aneurysm

Cardiovascular SECTION A: Read each question carefully and record the answer "TRUE" or "FALSE": The pain of myocardial ischemla: a) Is typically Induced by exercise and relieved by rest. b) Radiates to the neck and Jiw but not teeth. c) Rarely lasts longer than 10 seconds after resting. d) Is easily distinguished from oesophageal pain. e) Invariably worsens as exercise continues. The pulse characteristic listed below are typical features of the following disorders: f) Pulsus bisferiens-combinfed, mitral stenosis and regurgitation g) Pulsus paradoxus- aortic regurgitation. h) Collapsing pulse-severe anaemia. i) Pulsus altemans-extrasystoles every alternate beat. j) Slow rising pulse-mitral stenosis. The following statements about the jugular venous pressure (JVP) are true: k) The external jugular vein is a reliable guide to right atrial pressure. l) The JVP is conventionally measured from the suprastenal notch. m) The normal JVP, unlike the blood pressure, does not rise with anxiety. n) The normal JVP does not rise on abdominal compression. o) The normal JVP falls during inspiration.

The auscuitatory findings listed below are associated with the following phenomena: p) Third heart sound-opening of mitral valve. q) Varying intensity of first heart soupd-atrioventricular dissociation. r) Soft first heart sound-mitral stenosis. s) Reversed splitting of second heart sound-left bundle branch lock. t) Fourth heart sound-atrial fibrillation. The cardiac drugs listed below are associated with the following adverse effects: u) Digoxin-acute confusional state. v) Verapamil-constipation. w) Amiodarone-photosensitivity. x) Propafenone-comeal microdeposits. y) Lignocaine-convulsions. In the normal electrocardiogram z) the PR interval is measured from the end of the P wave to the beginning of the R wave aa) each small square represents 40 milliseconds at a standard paper speed of 25 mm/sec bb) the heart rate is 75 per minute if the R-R interval measuras by squares cc) Rwaves- become progressively larger from leads V1-V6 dd) the P wave represents sinoatrial node depolarization

The pulse characteristics listed below are typical features of the following disorders ee) pulsus bisferiens - combined mitral stenosis and regurgitation ff) pulsus paradoxus -aortic regurgitation gg) collapsing pulse - severe anaemia hh) pulsus altemans - extrasystoles every alternate beat ii) slow rising pulse -mitral stenosis The abnormalities of the jugular venous pulse listed below are associated with the following disorders jj) cannon waves - pulmonary hypertension kk) giant a waves - tricuspid stenosis ll) v waves - tricuspid regurgitation mm) inspiratory rise in jugular venous pressure - pericardia! Tamponade nn) absent a waves - atrioventricular dissociation The auscultatory findings listed below are associated with the following phenomena oo) third heart sound - opening of mitral valve pp) varying intensity of first heart sound - atrioventricular dissociation qq) soft first heart sound - mitral stenosis rr) reversed splitting of second heart sound - left bundle branch block ss) fourth heart sound--atrial fibrillation In patients with atrial fibrillation (AF) tt) aspirin therapy alone does not reduce the risk of stroke uu) the radial pulse is typically irregularly irregular vv) the response in cardiac output to exercise is reduced due to the absence of atrial systole ww) elective direct current (DC) cardioversion is contraindicated during anticoagulant therapy xx) alcohol abuse should be considered as a likely cause Digoxln yy) shortens the refractory period of conducting tissue zz) usually converts atrial flutter to sinus rhythm aaa) acts primarily on 'cell membrane Ionic pumps bbb) effects are potentiated by hyperkalaemia ccc) is a recognised cause of ventricular arrhythmias In a patient with central chest pain at rest ddd) intrascapular radiation suggests the possibility of aortic dissection eee) postural variation in pain suggests the possibility of pericarditis fff) chest wall tenderness is a typical feature of Tietze's syndrome ggg) relief of pain by nitrates excludes an oesophagealcause hhh) features of autonomic disturbance are specific to cardiac pain In a patient with cardiogenic shock due to acute myocardial Infarction iii) the absence of pulmonary oedema suggests right ventricular infarction

jjj) the central venous pressure is the best index of left ventricular filling pressure kkk) dopamine In low dose increases renal blood flow lll) high flow, high concentration oxygen Is Indicated mmm) colloid infusion Is Indicated if oligurla and pulmonary oedema develop In the treatment of cardiac failure associated with acute pulmonary oedema nnn) controlled oxygen therapy should be restricted to 28% oxygen In patients who smoke ooo) morphine reduces angor animi and dyspnoea ppp) frusemide therapy given intravenously reduces preload and afterload qqq) nitrates should be avoided if the systolic blood pressure < 140 mmHg rrr) ACE inhibitors decrease the afterload but increase the preload In patients with significant mitral stenosis sss) the mitral valve orifice is reduced from 5 cm2 to about 1 cm2 ttt) a history of rheumatic fever or chorea is elicited in over 90% of patients uuu) left atrial enlargement cannot be detected on the chest X-ray vvv) the risk of systemic emboli is trivial in sinus rhythm www) mitral balloon valvuloplasty is not advisable if there is also significant mitral regurgitation Disorders typically producing the sudden onset of symptomatic mitral regurgitation include xxx) Marian's syndrome yyy) acute myocardial infarction zzz) acute rheumatic fever aaaa) infective endocarditis bbbb) diphtheria Clinical features suggesting severe aortic stenosis Include , cccc) late systolic ejection click dddd) pulsus bisferiens eeee) heaving, displaced apex beat ffff) syncope associated with anginal pain gggg) loud second heart sound The typical features of congenital pulmonary stenosis Include hhhh) breathlessness and central cyanosis iiii) giant a waves in the jugular venous pressure jjjj) loud second heart sound preceded by an ejection systolic click kkkk) left parastemal heave and systolic thrill llll) enlargement of the pulmonary artery visible on chest X-ray In Infective endocarditis mmmm) streptococci and staphylococci account for over 80% of cases nnnn) left heart valves are more frequently involved than right heart valves oooo) normal cardiac valves are not affected pppp) glomerulonephritis usually occurs die to immune complex disease qqqq) a normal echocardiograram excludes the diagnosis The risks of developing clinical evidence of coronary artery disease are rrrr) increased by exogenous oestrogen use In postmenopausal female ssss) diminished by stopping smoking

tttt) reduced by the large consumption of alcohol uuuu) Increased in hyperfibrinogenaemia vvvv) Increased by hypercholesterolaemia not hypertriglyceridaemla The-clinical features of acute myocardial infarction inc-tide wwww) nausea and vomiting xxxx) breathlessness and angor animi yyyy) hypotension and peripheral cyanosis 4 zzzz) sinus tachycardia or sinus bradycardia aaaaa) absence of any symptoms or physical signs Findings consistent with an acute anterior myocardial Infarction Include bbbbb) hypertension and raised jugular venous pressure ccccc) rumbling low-pitched diastolic murmur at the cardiac apex ddddd) ST elevation > 2 mm in leads II, III and AVF on ECG eeeee) gallop rhythm and soft first heart sound fffff) an increased serum gamma-glutamyl transferase activity > 306 e* Drug therapies which improve the long-term prognosis after myocardial infarction include ggggg) aspirin hhhhh) nitrates iiiii) calcium antagonists jjjjj) ACE inhibitors kkkkk) B-blockers

Recognised causes of secondary hypertension include lllll) persistent ductus arteriosus mmmmm) primary hyperaldosteronismi nnnnn) acromegaly ooooo) oestrogen-containing oral contraceptives ppppp) thyrotoxicosis Complications of systemic hypertension include qqqqq) retinal microaneurysms rrrrr) dissecting aneurysm of the ascending aorta sssss) renal artery stenosis ttttt) lacunar strokes of the internal capsule uuuuu) subdural haemorrhage Accelerated phase or malignant hypertension Is suggested by hypertension and vvvvv) a loud second he art sound wwwww) a heaving apex beat xxxxx) headache yyyyy) retinal soft exudates or haemorrhages zzzzz) renal or cardiac failure Important explanations for hypertension refractory to medical therapy include aaaaaa) poor compliance with drug therapy

bbbbbb) inadequate drug therapy cccccc) phaeochromocytoma dddddd) primary hyperaldosteronism eeeeee) renal artery stenosis Clinical features compatible with .hypertrophic cardlomyopathy Include ffffff) family history of sudden death gggggg) angina pectoris and exertlonal syncope hhhhhh) jerky pulse and heaving apex beat iiiiii) murmurs suggesting both aortic stenosis and mitral regurgitation jjjjjj) soft or absent second heart sound Typical features of acute pericarditis include kkkkkk) chest pain identical to that of myocardial infarction llllll) a friction rub that is best heard in the axilla in mid-expiration mmmmmm) ST elevation on, the ECG with upward concavity nnnnnn) elevation of the serum creatine kinase oooooo) ECG changes that are only seen in the chest leads The typical features of constrictive pericarditis Include pppppp) severe breathlessness qqqqqq) a normal chest X-ray rrrrrr) a previous history of tuberculosis ssssss) tachycard'a and a loud third heart sound tttttt) marked elevation of the jugular venou pressure with a steep x and y descent In atrial septa) defect uuuuuu) the lesion is usually of secundum type vvvvvv) the initial shunt is right to left. wwwwww) splitting of the second heart sound Increases in expiration xxxxxx) the ECG typically shows right bundle branch block yyyyyy) surgery should be deferred until shunt reversal occurs

In right-to-left shunt reversals of congenital heart disease (Elsenmenger's syndrome) zzzzzz) pulmonary, arterial hypertension is usually present aaaaaaa) closure of the underlying lesion produces symptomatic relief bbbbbbb) the chest X-ray is typically normal ccccccc) central cyanosis and finger clubbing are often present ddddddd) physical signs of the underlying lesion parsist unchanged Typical clinical features of coarctation of the aorta include a) An association with bicuspid aortic valve b) Cardiac failure developing in male adolescents c) Palpable collateral arteries around scapulae d) Rib notching on chest X-ray associated with weak femoral pulses

e) ECG showing right ventlc-ular hypertrophy In Pallet's tetralogy eeeeeee) pulmonary and aortic stenosis arecombined with a ventricular septa) defect fffffff) both finger clubbing and bentral cyanosis are present at birtk ggggggg) the second heart sound is loud and widely split on inspiration hhhhhhh) the bhest X-ray and ECG are typically normal iiiiiii) cyanotic spells occur due to episodes of dysrhythmia Cardiovascular changes In normal pMgnancy Include. jjjjjjj) an increase in cardiac output of 150% by 12 weelys kkkkkkk) tachycardia, elevated jugular venous pressure and third heart sound lllllll) reduction in systemic diastolic pressure mmmmmmm) pulmonary systolic murmur nnnnnnn) increased blood coagulability The autoantibodies listed below are associated with the following diseasas ooooooo) antinuclear antibodies-rheumatoid arthritis ppppppp) anti-topoisomerase-progressive systemic sclerosis -(P$,S) qqqqqqq) anti-SSA (anti-Roy--Sjog.en's syndrome rrrrrrr) anti-centromere anti bodies--.dermatomyositis sssssss) antinuclear, cytoplasmic antibodies-CREST syndrome

The following features suggest a mechanical rather than Inflammatory cause of back pain ttttttt) radiation of pain down the back of one teg to the ankle uuuuuuu) an elevated C-reactive protein (CRP) vvvvvvv) localised tenderness over the greater sciatic notch wwwwwww) gradual mode of onset in an elderly patient xxxxxxx) back pain and stiffness exacerbated by resting Osteoarthritis is yyyyyyy) evident radiologically in at least 80% of patients > 65 years old zzzzzzz) more likely to be generalised and severe in males aaaaaaaa) characterised by degeneration of cartilage and synovial inflammation bbbbbbbb) associated with increased collagen synthesis in the affected cartilage cccccccc) best managed with anti-inflammatory doses of NSAIDs In the treatment of gout dddddddd) NSAID therapy increases urinary urate excretion eeeeeeee) salicylates control symptoms and accelerate resolution of the acute attack ffffffff) allopurinol inhibits xanthine oxidase and hence urate production gggggggg) tophi should resolve with control of hyperuricaemia hhhhhhhh) allopurinol or probenecid should be given within 24 hours of onset of the acute attack The following statements about shock syndromes are correct

iiiiiiii) in severe hypovolaemia, a source of blood/fluid loss is Invariably apparent clinically jjjjjjjj) in cardiogenic shock, the peripheries are characteristically warm kkkkkkkk) massive pulmonary embolism typically presents with shock llllllll) anaphylactic shock is associated with profound alleigen-induced systemic vasoconstriction mmmmmmmm) arteriovenous shunting is a significant contributory factor in septic shock Typical clinical features of acute circulatory failure due to anaphylactic shock include nnnnnnnn) elevated jugular venous pressure oooooooo) warm'dry skin pppppppp) stridor qqqqqqqq) confusion rrrrrrrr) polyuria Acute circulatory failure with an elevated central venous pressure are typical findings in ssssssss) acute pancreatitis tttttttt) massive pulmonary embolism uuuuuuuu) ruptured ectopic pregnancy vvvvvvvv) acute right ventricular infarction wwwwwwww) pericardial tamponade In a patient with suspected septic shock xxxxxxxx) the lower urinary tract is the commonest source of infection yyyyyyyy) a normal transthoracic electrocardiogram excludes endocarditis zzzzzzzz) intravenous access sites need only be changed if cutaneous evidence of infection is visible aaaaaaaaa) prior treatment with histamine receptor antagonists makes pneumonia a more likely cause bbbbbbbbb) corticosteroid therapy is of no proven benefit The expected effects of the following vasoactive drugs Include ccccccccc) sodium nitroprusside - reduction in systemic vascular resistance ddddddddd) prostacyclin - Increased pulmonary vascular resistance eeeeeeeee) isoprenaline - sin-is tachycardia fffffffff) dopamine - sinus bradycardia ggggggggg) adrenaline - increased splanchnic blood Echocardiography is the most sensitive method of diagnosing hhhhhhhhh) presence and degree of mitral stenosis iiiiiiiii) evaluation of left ventricular function jjjjjjjjj) detection of valvular vegetations kkkkkkkkk) detection of pericardial effusion lllllllll) assessing the degree of coronoray stenosis SECTION B: Only one Item appropriately applies to the Statement. All the following signs BUT ONE are suggestive of left ventricular hypertrophy: Slapping apex Apical displacement downwards and outwards Hyperkinetic apex Heaving apex

Localised apex Percussion of the heart may be useful in the diagnosis of the following conditions EXCEPT: a) Pulmonary hypertension b) Angina pectoris c) Pericardial effusion d) Right atrial enlargement e) Aortic aneurysm Splitting of the second heart sound occurs In: f) Mitral incompetence g) Left bundle branch block h) Severe aortic stenosis i) Atria[ septal defect j) All of the above The following signs are indicative of a massive pericardial effusion EXCEPT: k) Ewart's sign l) Kussmaul's sign m) Pulsus paradoxus n) Harsh pericardial rub o) Rotch's sign Stokes - Adams attack Is characterized by, except: a) Sudden fall to the ground. b) Loss of consciousness. c) Slow or absent pulse. d) Rapid week pulse. Orthostatic syncope is characterized by, except. a) Common in elderly. b) Change < 20 mmHg in systolic B.P in supine and standing. c) Change > 20 mmHg in systole in supine and standing. d) Vasodilators should be better avoided. An abnormal early diastolic sound heard at the apex and lower sternal border can be: e) Loud P2. f) S3 gallop. g) Opening snap. h) All of tho above. i) None of the above. 53. Graham Steell murmur is: An early diastolic murmur. A pansystolic murmur, An Austin Flint murmur. A subvalvular murmur. e) A pericardial murmur. In severe mitral stenosis , the following occurs except:

Pulmonary hypertenelon, Wider A2 -OS time Interval. Long mid-diastolic murmur. Low cardiac output, Valve area less than approximately 1.0 cm2/m2 body surface area. In aortic regurgitation , the following occur except: Quincke's sign. Duroziez's sign. Traube's area. Corrigan's sign. Austin Flint murmur. 56. Diastolic heart failure Is characterized by all the following except: a) Poor ventricular contractility. b) impaired compliance of the ventricle. c) High pulmonary venous pressure. d) High EDP. Cardiac transplantation Is absolutely contraindicated in: a. Patients with ejection fraction < 0.20. b. Patients with congestive cardiomyopathy. c. Patients with high pulmonary resistance. d. Patient with post infraction cardiomyopathy. ACEI Is regarded the first line of treatment in heart failure because It: a) decreases preload. b) decreased both pre and after load. c) increased contractility. d) potent loop diuretic. ACEIs are contraindicated in: a) Bilateral renal artery stenosis. b) Hypokalemia. c) Ejection fraction < 40%. d) Diastolic heart failure. Beta blockers in heart failure: a) Absolutely contrainedicated in CHF. b) Prescribed only in patients with class IV heart failure. c) Can be prescribed with ACEIs in class II & III heart failure. d) Safe and beneficial in corpuimonal with respiratory failure. The commonest clinical manifestation of MEN-1 is: e. Glucaigonoma. f. Hyperpttrathyroidism g. Cushing disease h. Medullary carcinoma thyroid 62. One of the following features is pathgnomonic to MEN-2B: a. Pheochrarnocytoma b. Hyperparathyroidism c. Insulinoma d. Mucosal neuromas

The followings are true about PAS- I except:* a. An autosornal recessive disorder b. Equally affects both sex c. Hypopuratityroidism is very common d. Autoimmune thyroid disease is more frequent than in type II APS The following features are present in APS- II except:* f) Addison's disease g) Typa-1 diabetes h) Mucocutanenus candidiasis i) Pernicious anaemia Pregnant lady In her last trimester presented to the emergency room with clinical,signs of acute deep venous thrombosis of her left leg ;initial treatment for this lady: j) Heparin followed immediately by oral anticoagulants. k) 13- Oral anticoagulants without heparin . l) Heparin during pregnancy followed by oral anticoagulants in the post-partum period. m) Thrombolysis Insertion of venacaval filter for patients with pulmonary embolism Is best suited in the following situation: a) Primary treatment in all patients with pulmonary embolism. b) Patients with recurrent pulmonary emboli Inspite of adequate anticoagulation . c) Young patient with Hypercoagulable state and extension of thrombosis to the IVC d) Deep venous thrombosis in patient with long period of Immobilization. Match each of the following Items marked by letters with those marked by numbers. Do not use any item more than once: a ] Late systolic mitral murmur b ] Early diastolic basal murmur c ] Short mid-diastolic mitral murmur d ] Short presystolic mitral murmur e ] Short mesosystolic pulmonary murmur

1.Austin Flint 2.Carry Coomb 3.Still's 4.Mitral Valve Prolapse 5.Graham Steel

answers
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28.TTTTF 29.FFTFF 30.FTFTT 31.TFFTF 32.TFFTF 34.FFFFF 35.FTTTT 36.TTTFF 37.TFTFF 38.TFFTF 39.FFTTF 40.FFTFT 41.FFTTF 42.FFFTT 44.TFTFF 45.TFTTF 46.A 47.B 48. 49,50 D 51.B 52.E 53.A 54.B 55.C 56.A 57.C 58.B 59.A 60.C 61.B 62.D 63.D 64.C 65. 66. 67.D 68.E 69.E 70.A 71.B