Internal Medicine Final Exam

6th Year 2014

Note: The exam was 100 questions in 100 minutes. Many questions were long cases, we are
giving you a summary of the pertinent positives/negatives, so expect to read a lot in the real
exam!

CARDIOLOGY
1. All of the following are true regarding chronic LBBB, EXCEPT:
A. QRS > 0.12 s
B. ST-T depression in leads I,aVL, V2-V6
C. ST-T elevation in V1,V2
D. +Septal Q-waves in V5,V6
2. Which of the following chemotherapeutic agents causes cardiomyopathy?
A. +Adriamycin
B. Chlorambucil
C. Melphalan
3. A young female presented with palpitations (more than 30 minutes). BP 80/60, HR 190 bpm.
She has recurrent similar episodes. What is the first step in management?
A. IV adenosine
B. IV verapamil
C. Carotid message
D. +DC shock
4. Which of the following congenital heart diseases causes cyanosis?
A. HOCM
B. +TOF
C. VSD
5. The earliest sign of cardiogenic pulmonary edema on CXR is
A. Alveolar infiltrates
B. Interstitial infiltrates
C. +Upper lobe diversion (increased pulmonary flow to the upper lobes)
D. Kerley B lines
E. Pleural effusion

6. All of the following are contraindications to thrombolytic therapy, EXCEPT

A. Pregnancy
B. BP 180/110
C. Proliferative diabetic retinopathy
D. +CVA (thrombotic infarct) at any time
E. Aortic dissection
7. Old male presented with retrosternal chest pain and diaphoresis. ECG showed ST
depression on leads II, III, aVF. All of the following are part of the management, EXCEPT
A. +Streptokinase
B. Aspirin
C. Heparin
D. Beta-blockers
E. Nitrates
8. All of the following medications can cause QT segment prolongation, EXCEPT
A. Organophosphates
B. Cisapride
C. Erythromycin
D. Hypokalemia
E. +Beta blockers
9. All of the following are ECG findings of hyperkalemia, EXCEPT
A. Flattened P wave
B. +Prominent U waves
C. Wide QRS complex
D. Hyperacute T waves
10. All of the following increase survival in patients of heart failure, EXCEPT
A. Spironolactone
B. ICD
C. ACE inhibitors
D. High atrial natriuretic peptide (ANP)
E. +High body mass index

RESPIRATORY
11. Regarding post-primary tuberculosis, which of the following is true?
A. The most common cause of resistance in Jordan is multi-drug resistance
B. +First line treatment is: isoniazid, rifampicin, pyrazinamide, ethambutol
C. Sputum remains infectious after 3 months of initiating therapy
D. Patient should be isolated for the whole treatment period
E. Treatment is at least for 12 months

12. Regarding chronic persistent asthma, which of the following is false?

A. +NSAIDs are contraindicated in all patients
B. Eosinophilic inflammation of the bronchi is found
C. Its a reversible obstruction
D. Inhaled steroids are the mainstay of treatment
13. A young female complaining of cough, shortness of breath almost everyday, with nocturnal
symptoms 2-3 nights/week. FEV1 65%. Which of the following is the best treatment?
A. Salbutamol as needed
B. Leukotriene modifier
C. Oral steroids
D. Low-dose inhaled corticosteroids with salbutamol as needed
E. +Medium-dose inhaled corticosteroids, long acting B2 agonist and salbutamol as
needed
14. A patient presented to the ER with acute-onset shortness of breath. All of the following
indicated a severe disease, EXCEPT
A. Unilateral silent chest
B. A-a gradient of 30 mmHg
C. +Diffuse expiratory wheezes
D. Cyanosis
E. Anion gap of 25
15. All of the following are used in the management of acute exacerbation of asthma, EXCEPT:
A. Inhaled corticosterods
B. +Antibiotics
C. Salbutamol
16. (Short case). Which of the following is not a feature of COPD:
A. Increased residual volume
B. Increased TLC
C. Low FEV
D. Low FEV1
E. +Increased diffusion capacity (DLCO)
17. Regarding COPD, which of the following is true?
A. The most common cause is alpha-1-antitrypsin deficiency
B. Smoking causes panacinar emphysema
C.+ Air pollution is known predisposing factor
D. Smoking cessation normalizes pulmonary function even in severe cases

18. Easy case, acute exacerbation of COPD, which of the following is false?
A. +Corticosteroids are contraindicated if bacterial infection is suspected
B. Oxygen therapy should be given to correct hypoxemia
C. Antibiotics are used
19. A patient with sarcoidosis and hypercalcemia, which of the following is true?
A. Normal chest x-ray
B. Normal urine calcium excretion
C. Increased PTH
D. Increased intestinal absorption of calcium
E. Hypogammaglobulinemia
20. (Long case) A 16-year old male, known diabetic, presented with abdominal pain and
nausea, vomiting, rapid breathing. Lab results: Na 130, K 6.3, Cl 95, HCO3 13, pH 7.21, Blood
glucose 430 mg/dL. Which of the following is not true?
A. He should be managed in the ICU
B. He should be started on insulin infusion
C. He has hyponatremia and hyperosmolarity
D. +The respiratory compensation is inappropriate
E. He has wide anion gap metabolic acidosis
21. Elderly, smoker, diabetic, ejection fraction <25%, diagnosed as having pneumonia. Chest xray showed a left-sided pleural effusion. Thoracentesis should be done because
A. This is a transudative effusion
B. The patient is a smoker and he is having lung cancer
C. +This is a new finding with unknown etiology
D. All pleural effusion should be drained
22. Pseudomonas aeroginosa is likely associated with
A. +Adult with cystic fibrosis
B. Meningitis in a diabetic
C. Following nail puncture
23. Regarding spontaneous pneumothorax, all of the following are true EXCEPT
A. Most commonly in ages 20-40 years
B. +If tension pneumothorax develops, the trachea will deviate to the collapsed lung
C. Can occur during menstruation
24. Which of the following findings on thoracentesis is the most helpful to diagnose empyema?
A.+ pH 7.1
B. Glucose 2.2 mmol/L
C. LDH 630
D. Protein 55 g/dL
E. WBC 11,000 with 95% neutrophils

25. (Long case) Patient presented with a picture of pneumonia, on exam he didnt have breath
sounds despite use of accessory muscles. pH 7.25, PaO2 60 mmHg, PaCO2 75 mmHg. The
most likely cause of hypoxemia is
A. Pneumonia
B. Intrapulmonary shunt
C. Pulmonary embolism
D. +Hypoventilation
E. Pneumothorax
26. ( Long useless case). pH 7.3, HCO3 12, PCO2 40, what is the acid-base disorder?
A. Lactic acidosis
B. +Mixed metabolic acidosis and respiratory acidosis
27. Which of the following is an indication for placing an inferior vena cava (IVC) filter?
A. +Active bleeding diathesis in a patient with history of DVT
B. Patient with right femur fracture
C. Patient with right heart thrombus
D. Recurrent PE on warfarin with INR of 1.5
E. Patient with upper limb DVT

GASTROENTEROLOGY
28. First line treatment of H.pylori
A. +PPI plus amoxicillin plus clarithromycin
29. A young female with history of dysphagia for solids and liquids, worsening over the last year,
with weight loss and cough. All of the following are part of initial management EXCEPT
A. Chest x-ray
B. Esophageal manometry
C.+ 24-hour pH monitoring
D. Barium swallow
E. Upper GI endoscopy
30. A patient complaining of post nasal discharge (PND) and hoarsness of voice, was referred
to the GI clinic from ENT. Which of the following is true?
A. +Symptoms may be related to GERD
B. PPI trial can be used to exclude reflux
C. PND can improve at a lower PPI dose than heartburn
D. PND may be related to GERD, but hoarseness is not related
31. Regarding reflux esophagitis, which of the following is false?
A. +Absence of heartburn excludes the diagnosis
B. PPI may be needed for more than 5 years
C. Severity of disease is not related to symptoms

32. 63 year old with recent onset dysphagia, scheduled for endoscopy. She has a history of
prosthetic knee joint placement. Which of the following is true regarding prophylaxis before the
procedure?
A. No need for prophylaxis
B. Prophylaxis is only needed if esophageal dilation is expected
C. Oral ampicillin 1 hour before procedure
D. Oral azithromycin 1 hour before procedure
E. IV gentamicin and vancomycin 1 hour before procedure
33. H.pylori is a gram-negative bacteria that lives in the antrum. It is associated with all of the
following EXCEPT
A. Gastric adenocarcinoma
B. +Esophageal adenocarcinoma
C. Intestinal metaplasia of the stomach
D. Gastric MALToma
E. Gastric lymphoma
34. Young male came complaining from diarrhea, stool difficult to flush, bloating, weight loss
and was found to have microcytic hypochromic anemia for 1 year, what is the most likely
diagnosis?
A. +Celiac disease
B. Acute pancreatitis
C. Lactose intolerance
35. An old male patient, known case of heart failure, presented complaining of chest pain,
dizziness and SOB and black tarry stool for 2 days, his blood pressure was 80/60 what is the
initial management?
A. Urgent endoscopy
B. Beta Blocker
C. +IV fluids administration
36. A young man, known case of ulcerative colitis on azathioprine and mesalamine
maintenance, presented complaining of itching. On physical examination liver span was 17 cm
and itching marks were noted. Labs: ALT and AST were normal, ALP and GGT were high, Antimitochondrial antibodies were negative. What is the most likely diagnosis?
A. Primary biliary cirrhosis.
B. +Primary sclerosing cholangitis.
C. Autoimmune hepatitis.
D. Azathioprine-induced hepatitis

37. 20-year-old female with liver cirrhosis, what is the least likely cause?
A. +Hereditary Hemochromatosis
B. Wilsons disease
C. Autoimmune hepatitis
D. Budd chiari syndrome
E. Hepatitis B
38. All of the followings may complicate treatment with anti-TNF drugs, except:
A. Reactivation of TB
B. Flare up of hepatitis B
C. +Increased risk of Colon cancer
D. Increased risk of lymphoma
E. Opportunistic infections
39. A female is concerned about being infected with hepatitis B as her sister has hepatitis B, her
serology results were: HBsAg -ve, HBcAb IgG +ve, HBsAb +ve. What is the explanation of
these results?
A. +Remote infection
C. Chronic carrier
D. Immunized
E. Immune tolerant
40. All of the following can be used in the management of esophageal varices, EXCEPT:
A. TIPS
B. Non-selective Beta blockers
C. Ethanolamine injection
D. +Adrenaline injection
E. Band ligation
41. An obese female was found to have high ALT level, US showed increased liver
echogenicity, all of the followings are true EXCEPT:
A. The most likely cause is non-alcoholic fatty liver disease (NAFLD)
B. NAFLD has equal incidence in males and females
C. +Progression to cirrhosis is extremely rare
42. All of the following are used to treat chronic hepatitis B infection EXCEPT:
A. Lamivudine
B. Tenofovir
C. Interferon alpha 2a
D. +Ribavirin

43. Which of the following causes fecal leukocytes?

A. Giardia lamblia
B. Toxigenic E.coli
C. +Campylobacter jejuni
D. Vibrio cholerae
E. Rotavirus

HEMATOLOGY
44. Which of the following is most likely seen with pernicious anemia?
A. Ileal resection
B. +Thyroid antibodies in the serum
C. Autoimmune hemolytic anemia
45. All of the following cause high ESR EXCEPT:
A. Multiple myeloma
B. +Polycythemia rubra vera
C. Polymyalgia rheumatica
46. Which of the following can cause DIC?
A. +Acute promyelocytic leukemia
B. chronic myeloid leukemia
47. An elderly male patient presented with fatigue, on examination, splenomegaly was found,
CBC showed WBC 16500 (40% segmented cells, 20% bands, 8% lymphocytes). What is the
most likely diagnosis?
A. Chronic lymphocytic leukemia
B. +Chronic myeloid leukemia
C. Aplastic anemia
48. 70-year-old asymptomatic male patient, CBC showed Hg=12, Plt= 145000 , WBC=26000
(mature lymphocytes 85%). What is the best management for this patient?
A. Fludarabine and rituximab
B. +Observation
C. CHOP
D. single purine analogue (chlorambucil)

49. A male teacher patient, previously healthy, now 5th day postop for exploratory laparotomy
after stab wound, he is bleeding from the cannula and the abdominal drain. He was on aspirin
for tendinitis and stopped 14 days before the operation. Platelets count, bleeding time were
normal. INR= 2, PTT=35 sec. What is the most likely cause of his bleeding?
A. Aspirin
B. thrombasthenia
C. Heparin-like anticoagulant
D. Congenital factor VIII deficiency
E. +Acquired Vitamin K deficiency
50. Which of the following is a cause of recurrent hemarthrosis?
A. +Hemophilia A
51. 71-year-old female presented with weight loss for 7 months, purple painful discoloration of
her fingers on cold exposure. On examination her tip of the spleen was palpable. Normal CBC,
Direct coombs test is positive at 4 degrees celsius and negative at 37. What is the most likely
diagnosis?
A. Burkitts lymphoma
B. Hodgkins lymphoma
C. SLE
D. Waldenstrom macrogammaglobulinemia
52. A young female presented with altered mental status, temperature 37.6, Heart rate 90,
palpable purpuric skin rash, kidney function (abnormal), CBC: Hg= 8 platelets:60000. What is
your management?
A. IVIG
B. +Plasma exchange
53. A female patient underwent open reduction and internal fixation of her left wrist after falling
down. CBC was normal on admission, she was started on prophylactic heparin. One week later
she couldnt move her right arm, CBC: platelets were 10000, what is your next step?
A. Give platelets
B. +Stop heparin
C. Cryoprecipitate
D. FFP

RHEUMATOLOGY
54. All of the following are common features in ankylosing spondylitis except:
A. Association with inflammatory bowel disease
B. Sacroillitis
C. Peripheral arthritis
D. Association with HLA-B27

55. Patient from Jarash presented with right lower limb DVT, all of the following support the
diagnosis of Behcets disease except:
A. Oral ulcers
B. Genital ulcer
C. Painful leg lesions
D. Photosensitivity
E. +Arthritis
56. All goes with FMF except:
A. Recurrent knee arthritis
B. Chest pain
C. Protein in urine
D. +Hypertension
57. Elderly patient hypertensive on thiazides with history of renal stones, presented to the ER
with left ankle pain and swelling. All can be used in the acute management except:
A. +Allopurinol
B. Colchicine
C. Oral prednisolone
58. 29 year old male patient complaining of low back pain and skin rash for 10 years, what is the
least likely cause?
A. Crohns disease
B. Ulcerative colitis
C. SLE
D. +Reactive arthritis
59. Which of the following is least associated with psoraitic arthritis:
A. Dactylitis
B. Uveitis
C. +Sparing of the sacroiliac joint
D. Nail pitting
60. 30 year old female diagnosed with early RA, all are possible findings except:
A. +Erosions on X-ray
B. Small and large joints involvement
C. High CRP and ESR
D. Positive RF
61. All are features of a flare-up of SLE except :
A. +Leukocytosis and thrombocytosis
B. Hematuria

62. Patient with high fever (40C) and arthritis, which of the following is wrong:
A. Infection and lymphoma should be ruled out
B. ANA and RF negative and very high ferritin goes with adult stills disease
C. +RA presents with high fever
63. Patient with proximal muscle weakness, was diagnosed with idiopathic polymyositis, all are
helpful investigations except:
A. +25-hydroxy vitamin D
B. LDH
C. Muscle biopsy
D. EMG
E. CK
64. Patient with recurrent nosebleeds, cavitary lesions on chest x-ray, hematuria and protein in
the urine, what investigation help you with the diagnosis (it was a very long case):
A. +ANCA
B. ANA
C. anti-topoisomerase
65. Patient with red eyes, (very very long case) on investigations there was eosinophilia, what is
the diagnosis?
A. Wegners granulomatosis
B. +Churg-Strauss disease
66. A 47-year-old man has had fever, weight loss, arthralgias, pleuritic chest pain, and midabdominal pain for the past 2 months. One week ago he noticed difficulty dorsi-flexing his right
great toe. Blood pressure is 150/95 mmHg (he has always been normotensive), and laboratory
studies reveal anemia of chronic disease, high erythrocyte sedimentation rate, and
polymorphonuclear leukocytosis. The chest x-ray is clear. The most likely diagnosis is
A. Giant cell arteritis
B. Allergic granulomatosis
C. Wegeners granulomatosis
D +Polyarteritis nodosa
E. Hypersensitivity vasculitis

67. All of the following are features of temporal arteritis (giant cell arteritis) except:
A. Vision loss on the same side
B. Tongue pain
C. Jaw pain on mastication
D. +Malar rash
E. High ESR

IMMUNOLOGY
68. HIV patient with CD4 count of 200-500, all can be present except:
A. +CMV retinitis
B. salmonellosis
C. Oral thrush
69. Which of the following eczemas is associated with high serum IgE?
A. Discoid dermatitis
B. +Atopic dermatitis
70. Most common cause of contact dermatitis in jewelers is:
A. +Nickel
B. Chrome

ENDOCRINE
71. All of the following are true about prolactinomas except:
A. Size can be more than 1 cm
B. Size can be less than 1 cm
C. Medical treatment is superior to surgical
D. +Dopamine antagonists are used in treatment
72. All of the following can cause hyperprolactinemia EXCEPT:
A. OCP
B. Pregnancy
C. Renal failure
D. +Bromocriptine
73. A hypothyroid patient on levothyroxine 100 microgram daily. On follow up, TSH was 0.2
(normal is 0.4-4.5), T4 and T3 were normal, what should be done next?
A. Increase the dose
B. Stop medication
C. +Decrease the dose
D. Continue on same dose
74. Graves disease can cause all of the following except:
A. Ophthalmopathy
B. Diffuse thyroid enlargement
C. +Decreased uptake on isotope scan
D. Pretibial myxedema

75. One is false about insulin hypoglycemia test:

A. It will cause increase in GH secretion
B. +Can be used safely in coronary artery disease patients
C. Normal response: cortisol rising to > 18 microgram/dL
D. It works on the principle of stimulation to diagnose a deficiency
E. It will activate the whole HPA axis
76. One of these is not part of MEN syndromes:
A. Hyperparathyroidism
B. Medullary thyroid cancer
C. +Carcinoid tumor
D. Multiple mucosal neuromas
77. Patient presented with new onset hypertension, on examination Cushingoid features were
present, whats the best screening test?
A. +Low-dose dexamethasone suppression test
B. Serum cortisol
C. Metyrapone
D. High-dose dexamethasone suppression test
78. All are features of primary adrenal insufficiency except:
A. +Hypokalemia
B. Hyponatremia
C. Hyperpigmentation
79. All are features of Conns syndrome except:
A. Hypokalemia
B. Hypertension
C. +Increased serum renin
80. All are features of diabetic neuropathy except
A. Erectile dysfunction
B. Third cranial nerve palsy
C. +Bradycardia
D. Charcots joint
E. Gastroparesis
81. The first clinical evidence of diabetic nephropathy is :
A. Elevated blood urea
C. Elevated creatinine
D. Hematuria
E. +Microalbuminuria

82. What is wrong about diabetic nephropathy?

A. It is the most common cause of end stage renal disease in adults
B. +Papillary necrosis is the most common finding
C. 95% have diabetic retinopathy
83. All of the following are true about primary hyperparathyroidism except:
A. Nephrocalcinosis
B. Osteitis fibrosa cystica
C. Long QT interval
D. Associated with MEN
84. All of the following are features of polycystic ovarian syndrome except:
A. Amenorrhea
B. +Increased FSH/LH ratio
C. Hirsutism and acne
D. Infertility

NEPHROLOGY
85. The most common cause of acute kidney injury in hospitalized patients is:
A. +Acute tubular necrosis
B. Atheroembolic disease
86. All of the following are true about minimal change disease except:
A. Good prognosis in children but not in adult
B. Allergens can trigger the condition
C. May present in the 5th decade
D. CD18 leads to effacement of the podocytes
E. Solubility factor (weird choice :P )
87. All are features of poststreptococcal glomerulonephritis EXCEPT:
A. +Low C3 and C4
B. Worse prognosis in adults
C. Occurs after 10-14 days of URTI
88. All of the following are features of nephrotic syndrome except:
A. +Red blood cell casts
B. Hypoalbuminemia
C. Renal vein thrombosis
D. Dyslipidemia

89. A male patient complains of bilateral flank pain, nausea, polyuria of 4 weeks duration. He is
known to have GERD and asthma, he is on omeprazole and over the counter analgesia
(paracetamol/aspirin) for flank pain. Labs: creatinine 3.5 mg, Urea: 59 .. Na: 140 , K=5.2
What is the most likely diagnosis?
A. Acute tubular necrosis
B. Acute interstitial nephritis
C. Acute papillary necrosis
D. Obstructive uropathy
90. 50-year-old female with history of recurrent renal stones and family history of kidney
problems (grandmother and father). Labs: K=2.9 HCO3= 16 Urine: pH=7.0 Calcium= 19
(upper normal)
What is the most likely diagnosis?
A. Proximal RTA
B. +Distal RTA
C. Bartters syndrome
D. Hyporeninemic hypoaldosteronism
E. Cystinurea
91. (Long case) A 20-year-old soldier presents to the ER with new onset hematuria after heavy
routine exercise (20 km walk). Labs showed elevated urea and creatinine, CPK was in
thousands. What is the most important next step?
A. +IV fluids
92. 20 year old male with bilateral high frequency sensorineural hearing loss, was found to have
stage V chronic kidney disease, no family history because he was adopted. What is the most
likely diagnosis?
A. Aminoglycosides toxicity
B. MPGN
C. +Hereditary nephritis
93. All are true about aminoglycosides toxicity EXCEPT:
A. Happens 8-14 days after taking the drug
B. Kidney biopsy will likely show ATN
C. +Plasmapheresis is the treatment of choice
D. Cephalosporins may potentiate toxicity
E. Associated with deafness
94. What is true about normal kidney function?
A. +Aldosterone increases the insertion of Enac channels in the cortical collecting ducts
B. HCO3 regeneration occurs in the proximal tubules
C. Fanconis syndrome diagnosis requires aminoaciduria and urine pH > 6.0
D. Loop diuretics work on the thick ascending loop of Henle

95. What is the least useful test to diagnose renal artery stenosis?
A. Renal duplex ultrasound
B. MRA
C. Plasma renin level
D. Selective adrenal vein sampling for renin
E. Captopril-enhanced renal scintigraphy
96. What is true about combining ACE inhibitors and ARBs?
A. It will increase the allergic reaction
B. It will increase the risk of hypotension and acute renal failure
C. It will decrease the mortality in heart failure

OTHERS
97. Which one of the following drugs cause osteoporosis after prolonged use?
A. +Heparin
C. NSAIDs
98. All of the following are matched correctly except:
A. Triamterene/ hyperkalemia
B. Spironolactone/ gynecomastia
C. +Thiazide/thrombocytosis
99. Regarding fever of unknown origin, which is true?
A. +Brucellosis occurs after contact with infected animals
B. Plasmodium malaria causes irregular fever
C. Typhoid fever causes sudden high fever and skin rash
D. Splenomegaly in the tropical areas, lymphoma should be ruled out

The End

Im not telling you its going to be easy. Im telling you its going to be worth it :)