ARAB BOARD IN INTERNAL MEDICINE

KEY ANSWERS
OF
PART 1
JUNE 2019
EXAM

December 2020

1 Page Key Answers of Part 1 June 2019 – Nabeel Ibrahim

These are NOT formal answers, and are NOT necessarily true.

1. C. Aspirate Synovial Fluid. Arthrocentesis with synovial fluid analysis

should be attempted in all patients with joint pain of unknown cause who
have an effusion or have signs suggestive of inflammation within the
joint.
2. D. Frontal Lobe. Patients with reckless gait ("careless gait") walk too
quickly and act impulsively (eg, a very rapid rise from a seated position:
the "rocket sign"). Typically, these patients have frontal-dysexecutive
impairment.
3. A. Behcet syndrome. There is a rule in neurology: Any acute, subacute,
or recurrent brain stem syndrome with CVT, consider NeuroBehçet.
4. B. 40%. See similar question from OnExam part 1 2017 neurology:
What is the likelihood of controlling seizures in a patient never
previously on anti-epileptic medication with a single first-line anti-
convulsant agent? Answer was 47%. A study of patients with previously
untreated epilepsy demonstrated that 47% achieved control of seizures
with the use of their first single drug. Fourteen per cent became seizure-
free during treatment with a second or third drug. An additional 3%
became seizure-free with the use of two drugs simultaneously.
(Reference: Kwan P, Brodie MJ. Early identification of refractory
epilepsy. N Engl J Med. 2000;342:314-9.).
5. E. Valproate.
6. A. Episodic memory.
7. C. Left posterior cerebral. When the left PCA territory is infarcted,
alexia without agraphia
8. B. Hypervariable regions in domains of B cells.
9. D. Intravenous tissue plasminogen activator, heparin, and aspirin.
10. C. Non-invasive ventilation.
11. C. Administration of metformin.
12. D. Hypochondriasis.
13. D. Increased protein catabolism.
14. B. Administer intravenous nicardipine. (Uncertain Answer).
15. E. Acute tubular necrosis.
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16. C. Spinal tap.
17. E. Von-Willebrand disease.
18. B. Start Ampicillin.
19. A. High blood levels during a rapid load could produce drug
toxicity. Drug metabolism consists of a distribution phase and an
elimination phase. After a single rapid intravenous bolus, all of the drug
is in the central or plasma compartment followed by transfer to an
extracellular compartment, termed the distribution phase. A phase of
slower decline, the equilibrium phase, then follows. During the initial
and distribution phases the drug levels can be quite high. In the case of
phenytoin, such high levels could lead to cardiovascular collapse.
Therefore, the loading dose needs to be given slowly to prevent high
levels. In certain situations, high initial levels may be desirable. For
example, high levels of certain benzodiazapines are required to induce
rapid brain uptake to produce quick sedation. On the other hand, if
potassium chloride is infused too quickly, cardiac arrest can result.
20. B. A systolic murmur heard at the upper right sterna border.
21. D. lymphocyte infiltration of the sub-villous margin. The main
histologic feature of celiac disease is increased intraepithelial
lymphocytes (IELs) with or without villous atrophy of the duodenal
mucosa. © American Society for Clinical Pathology
22. C. Low calorie diet. In England and Wales, 2.5% of pregnancies
involve women with diabetes. Approximately 87% of these are due to
gestational diabetes, 7.5% type 1 diabetes and 5% type 2 diabetes. There
are a number of risks to both mother and fetus, including miscarriage,
pre-eclampsia, preterm labour, stillbirth, congenital malformations,
macrosomia, birth injury, perinatal mortality, and neonatal
hypoglycaemia. Risk factors for gestational diabetes are: BMI >30
kg/m2, previous macrosomic baby (>4.5 kg), previous gestational
diabetes, first-degree relative with diabetes, and ethnic origin (South
Asian, Caribbean, Middle Eastern). Screening with fasting plasma
glucose, random blood glucose, glucose challenge tests, and urinalysis is
recommended for any women with one of these risk factors. The 2-hour
75 g oral glucose tolerance test is used to definitively diagnose
gestational diabetes. This is performed at 16-18 weeks in women who
3 Page Key Answers of Part 1 June 2019 – Nabeel Ibrahim
 have been affected in a previous pregnancy (with home BM monitoring
prior to this, and a repeat test at 28 weeks if this is normal) and 24-28
weeks for women with any other risk factor. If it is safely achievable,
women with gestational diabetes should aim to keep fasting blood
glucose between 3.5-5.9 mmol/L and one hour postprandial blood
glucose below 7.8 mmol/L during pregnancy. Reference:
OnExamination Part I 2017.
23. B. Analgesic nephropathy. Hypertension is commonly seen with
moderate to advanced disease. Patients usually have only mild
proteinuria (<1.5 g/day) urinalysis showing hematuria or sterile pyuria.
Anemia is commonly seen with moderate to advanced disease and may
be disproportionate to the degree of renal dysfunction. Patients may also
have polyuria due to impaired concentrating ability and non-anion-gap
metabolic acidosis from tubular damage. Shedding of a sloughed
necrotic papilla can cause gross hematuria Ring shadows is a sign of
papillary necrosis; it can develop in the medulla outlining detached
papilla within contrast material-filled cavity; Often in a triangular shape,
referred to as the ring sign.
24. A. Facial nerve. A number of cranial nerves are located in fibrous
sheaths along the lateral wall of each cavernous sinus: the oculomotor
nerve (cranial nerve III), the trochlear nerve (cranial nerve IV), and the
ophthalmic (V1) and maxillary branches (V2) of the trigeminal nerve.
The abducens nerve (cranial nerve VI) is located more medially, near the
internal carotid artery that also tracks through the cavernous sinus.
25. B. Chronic bronchitis.
26. A. Inhibition of membrane Na-K-ATPase. Digitalis compounds are
potent inhibitors of cellular Na+/K+-ATPase. This ion transport system
moves sodium ions out of the cell and brings potassium ions into the
cell.
27. B. is the most likely answer. ECG: Multifocal Atrial Tachycardia.
28. A. 24-hour urine free cortisol.
29. B. Spirometry before and after administration of bronchodilators.
Exercise-induced Asthma.

4 Page Key Answers of Part 1 June 2019 – Nabeel Ibrahim

30. C. the adult worm has a length of 4 centimeters. Enterobiasis is
observed most frequently among school children aged 5 to 10 years.
Adult male reaches 2.5 mm.
31. E. Trimethoprim/Sulfamethoxazole.
32. B. levofloxacin.
33. B. Hepatitis B Virus. HIV risk is 0.3%m HBV risk is 6%-30%, HCV
risk is 1.8%.
34. B. The HSV PCR in CSF is very specific test for diagnosis. Fever
is present in 90% of cases. Temporal lobe is involved. PCR is 94%-
100% specific.
35. D. Central sleep apnea. BMI >30 is a criterion for OHS. Elevated
serum bicarbonate (>27 mEq/L) is an association with OHS.
36. A. Phenytoin.
37. D. Unilateral vestibular neuritis. In an acute peripheral vestibular
lesion, the fast phase of the nystagmus is directed away from the lesion
(left here); also the caloric test indicates left sided lesion.
38. D. Hypervitaminosis E.
39. A. The usual age of presentation is between 20 and 40 years. Early
symptoms — In a systematic review of 27 eligible studies published by
May 2005 that evaluated patients with relapsing-remitting MS, bowel
and/or bladder symptoms at onset and incomplete recovery from a first
attack had the strongest and most consistent associations with poor
prognosis. Additional factors that predicted long-term disability in those
with relapsing-remitting MS were a short interval between the first and
second attack, and early accumulation of disability. Other MS symptoms
and signs at disease onset were once thought to predict a favorable
(sensory symptoms, optic neuritis) or unfavorable (pyramidal, brainstem,
and cerebellar symptoms) prognosis. However, subsequent data
suggested that none of these onset symptoms were independent
prognostic factors.
40. E. Extension of upper and lower limbs upon pressure over the
supraorbital ridge.
41. C. mononeuritis multiplex. Hyperemesis of pregnancy might lead to
Wernicke encephalopathy. Chorea from any cause beginning during
pregnancy has been called chorea gravidarum.
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42. A. Plasma aldosterone to plasma rennin ratio.
43. B. She has type 2 Diabetes and need to start on metformin.
Diagnosis of Diabetes Symptomatic hyperglycemia — The diagnosis of
diabetes mellitus is easily established when a patient presents with
classic symptoms of hyperglycemia (thirst, polyuria, weight loss, blurry
vision) and has a random blood glucose value of 200 mg/dL (11.1
mmol/L) or higher. Most patients with type 1 diabetes are symptomatic
and have plasma glucose concentrations well above ≥200 mg/dL. Some
patients with type 2 diabetes also present with symptomatic
hyperglycemia and blood glucose ≥200 mg/dL. Asymptomatic
hyperglycemia — The diagnosis of diabetes in an asymptomatic
individual (generally type 2 diabetes) can be established with any of the
following criteria: FPG values ≥126 mg/dL (7.0 mmol/L). ●Two-hour
plasma glucose values of ≥200 mg/dL (11.1 mmol/L) during a 75 g
OGTT. ●A1C values ≥6.5 percent (48 mmol/mol). In the absence of
unequivocal symptomatic hyperglycemia, the diagnosis of diabetes must
be confirmed on a subsequent day by repeat measurement, repeating the
same test for confirmation. However, if two different tests (eg, FPG and
A1C) are available and are concordant for the diagnosis of diabetes,
additional testing is not needed. If two different tests are discordant, the
test that is diagnostic of diabetes should be repeated to confirm the
diagnosis [American Diabetes Association. 2. Classification and
Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2020.
Diabetes Care 2020; 43:S14.].
44. D. Parathyroidectomy. Indications for surgery in this case: serum
calcium concentration of 1.0 mg/dL or more above the upper limit of
normal, elevated 24-hour calcium level.
45. C. Subacute Thyroiditis. Serum thyroglobulin Level is elevated
according to the reference range of the question, so this supports the
diagnosis of thyroiditis. The thyroid gland being non-tender is a point
against the diagnosis of thyroiditis. The patient being a pharmacist is
also a point for the diagnsosis of iatrogenic. So the most likely answer is
subacute thyroiditis (according to the elevated thyroglobulin).
46. Start dopamine agonist.
47. E. Beginning therapy with a calcium channel blocker.
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48. C. Acute Portal Vein Thrombosis. This lady has an acute portal vein
thrombosis after developing nephrotic syndrome due to her
Penicillamine treatment for rheumatoid arthritis. Acute portal vein
thrombosis often presents with RUQ pain, vomiting and can have fever.
It is unlikely to have any features of portal hypertension and the LFTS
are often only mildly deranged. The history of ankle swelling combined
with proteinuria, hypoalbuminaemia and abnormal renal function should
suggest proteinuria in this patient. Biliary colic is the main alternative
here but the presence of renal impairment and the clinical history should
make you think of nephrotic syndrome. Reference:
PASSMEDICINE/MRCP 2015.
49. E. Beginning therapy with a calcium-channel blocker. A scenario
of vasospastic angina (Prinzmetal or Variant angina).
50. B. Spironolactone.
51. C. The bone pain in sickle cell crisis is due to bone and bone
marrow infarction.
52. B. Anti-CCP antibodies. Difficulties with glucocorticoid tapering
make the diagnosis of PMR in doubt, especially with symptoms
bilaterally in wrists and hands. Anti-CCP antibodies test is part of the
work-up of PMR evaluation.
53. C. IV magnesium Sulfate.
54. C. Activated charcoal. (Uncertain Answer). Gastric lavage and
whole bowel irrigation are not recommended in patients with phenytoin
toxicity. Gastrointestinal decontamination and removal — Activated
charcoal (AC) may be useful in the setting of a recent ingestion (ie,
within several hours). Multiple doses may remove some unbound
phenytoin undergoing enterohepatic circulation, even if the phenytoin
was administered intravenously, or in cases of chronic phenytoin
toxicity. When considering treatment with AC, clinicians must weigh the
potential benefits of treatment with the risks of charcoal aspiration,
particularly because nausea, vomiting, and central nervous system
depression occur frequently with phenytoin intoxication. We suggest that
a single dose of activated charcoal be administered to patients with
phenytoin overdose, unless they manifest a depressed mental status. We
do not always use multidose activated charcoal (MDAC), but it appears
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 to be effective. MDAC has been used successfully when phenytoin
concentrations have remained persistently elevated secondary to
impaired metabolism. Charcoal should be withheld in patients who
cannot protect their airway, unless endotracheal intubation is performed
first. However, endotracheal intubation should not be performed solely
for the purpose of giving charcoal. (UpToDate 2020).
55. A. Do not exceed 6-8 mEq/L in any 24 hour period.
56. A. Gastric Adenocarcinoma.
57. A. Outpatient follow-up.
58. A. Normal Pressure Hydrocephalus.
59. B. Hemophilus influenza. Cellular immune dysfunction represents a
patient with AIDS, CMV, Mycobacteria, Pneumocystis, and
Histoplasma, are important pathogens in this regard. Encapsulated
bacteria, like Hemophilus, are important pathogen, in patients with
HYPOSPLENISM.
60. B. Obtain Chest X-Ray. The clinical picture suggests hypertrophic
osteoarthropathy. This process, the pathogenesis of which is unknown, is
characterized by clubbing of digits, periosteal new bone formation, and
arthritis. Hypertrophic osteoarthropathy is associated with intrathoracic
malignancy, suppurative lung disease, and congenital heart problems.
Treatment is directed at the underlying disease process. While x-rays
may suggest osteomyelitis, the process is usually bilateral and easily
distinguishable from osteomyelitis. The first step in evaluation of this
patient is to obtain a chest x-ray looking for lung infection and
carcinoma. The process is periarticular, not articular; so septic arthritis,
treated with parenteral antibiotics, would not be a consideration.
Although there is warmth over the wrists, the clubbing and periosteal
changes would not be seen in rheumatoid arthritis, so wrist aspiration
and methotrexate therapy would not address the underlying problem. An
elevated sedimentation rate could be seen in neoplasm, infection, and
inflammatory arthritis and would therefore be of little diagnostic value.
Reference: Pre-Test Medicine 14e.
61. C. Ciprofloxacin. Treatment for animal bites should cover
Pasteurella species and anaerobic organisms, as well as Capnocytophaga
canimorsus. A quinolone such as ciprofloxacin could be used if given
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 together with metronidazole or clindamycin for anaerobic coverage, but
ciprofloxacin alone is not adequate empiric treatment. Capnocytophaga
canimorsus is a gram-negative rod that is part of normal oral flora of
canines and other animals, including cats and rabbits. Those who are
asplenic and those with liver disease or other immune suppression are at
increased risk for severe disease and can develop shock, purpuric
lesions, and disseminated intravascular coagulopathy (DIC).
Capnocytophaga canimorsus can take up to 14 days to culture, so in
suspected cases treat empirically with amoxicillin/clavulanate or
imipenem for critical illness, or piperacillin-tazobactam would also be
acceptable. Reference: Brigham Intensive Review infectious diseases
Q19.
62. B. FEV1 1.0 L (33% of predicted), FVC 3.0 L (75% of predicted),
FEV1/FVC 0.33 (44% of predicted).
63. D. 20%. In the United States it has been determined to be cost
effective to treat if the 10-year fracture risk from FRAX is 20% or
higher, and/or the 10-year risk of hip fracture is 3% or higher.
64. C. B blockers.
65. C. Smoking Cessation. Smoking cessation can substantially reduce
the rate of decline in lung function (forced expiratory volume in one
second [FEV1]) that occurs in smokers with COPD. As an example, the
Lung Health Study reported a decline in postbronchodilator FEV1 of 54
and 66 mL/year in women and men, respectively, who continued to
smoke over an 11 year period. Women and men who were sustained
quitters of smoking had significantly lower declines in FEV1 of 22 and
30 mL per year, respectively.
66. A. He can be reassured that he is at no increased risk of
developing renal disease. Orthostatic (also referred to as postural)
proteinuria is characterized by an elevated protein excretion while in the
upright position and normal protein excretion in a supine or recumbent
position. It is the most frequent cause of isolated proteinuria in children,
especially adolescents. Individuals with orthostatic proteinuria are
generally asymptomatic and are diagnosed incidentally when a urinalysis
is done for an unrelated condition or as part of routine care.
DIAGNOSIS The diagnosis of orthostatic proteinuria is made by
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 demonstrating that urinary protein excretion is normal while in a
recumbent position, and increased while upright. The two approaches
generally used to make the diagnosis of orthostatic proteinuria are:
●Comparison of the protein-to-creatinine (Pr/Cr) ratio in urine samples
collected in recumbent and upright positions. This is the most convenient
standard method. ●24-hour urine collection divided into separate
daytime and nighttime collections. In view of the benign course of
orthostatic proteinuria, no intervention or further initial evaluation is
recommended. Since the long-term prognosis is excellent, the best
follow-up care remains unclear.
67. B. Sarcoidosis.
68. B. Airflow limitation by Spirometry with significant reversibility.
69. B. Low Forced Vital Capacity. In the worsening phase of GBS,
most patients require monitoring in a critical care setting, with particular
attention to vital capacity, heart rhythm, blood pressure, nutrition, deep-
vein thrombosis prophylaxis, cardiovascular status, early consideration
(after 2 weeks of intubation) of tracheotomy, and chest physiotherapy.
70. D. Hydrothorax.
71. C. Hypercalcemia.
72. C. AMA.
73. E. Amyloidosis. Restrictive lung disease occurs in AS (mainly due to
reduced chest wall and spinal mobility, and also due parenchymal lung
involvment) not obstructive pattern. Other involvement in AS: anterior
uveitis (not posterior uveitis); apical lung fibrosis (not basal); aortic
valve disease (rather than mitral).
74. B. Autosomal Dominant.
75. C. Creatine Phosphokinase. Rhabdomyolysis may occur with
hyperthermia associated with heat stroke.
76. A. infective endocarditis-associated GN.
77. C. Direct Thrombin Inhibition.
78. A. Oral Vitamin K.
79. B. Measure high-sensitivity C-reactive protein (hs-CRP) level.
80. D. Brucellosis. It is caused by a Gram-negative bacterium that is
transmitted by contact with infected livestock. The typical incubation
period is 1–3 weeks with an insidious onset. This patient’s symptoms of
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 malaise, fever, back pain and night sweats are typical. Back pain is
common, occurring in around 50% of patients. The findings of a
leucoerythroblastic blood film and raised transaminases fit with the
diagnosis. Diagnosis is via bone marrow culture or serum agglutination
testing. Acute myeloid leukaemia: Typically a patient with acute
myeloid leukaemia would either have a very high white cell count or
very low, but it would be unusual to have a normal white cell count.
Furthermore, you might expect bone marrow failure, with bleeding and
bruising, and pancytopenia. Lymphadenopathy is possible but not
common. Instead, this patient’s symptoms, signs and investigations
would be consistent with brucellosis through exposure to sheep. Chronic
myeloid leukaemia: You would expect a patient with chronic myeloid
leukaemia to have a raised basophil and eosinophil count, but these are
normal here. You might also expect a leucocytosis and teardrop
poikilocytes on the blood film. This patient’s signs and symptoms are
more consistent with brucellosis through exposure to infected sheep.
Hydatid disease: Hydatid disease can be caught from sheep. In 90% of
cases it causes liver dysfunction. However, that is characteristically
obstructive in nature, whereas this patient’s investigations fit with a
hepatitic cause. This patient’s symptoms and signs are more consistent
with brucellosis. Reference: PasTest Part II 2019 Infectious Diseases.
81. C. Flow-Volume Loop.
82. E. Karyotyping.
83. C. Home blood pressure diary, measure TSH, and repeat office
blood pressure in 3 months.
84. A. Serum BNP levels may be in the reference range in patients
with advanced heart failure.
85. D. hydrochlorothiazide 12.5 mg once daily. Regarding lisinopril,
losartan and aliskiren Pregnancy Consideration [US Boxed Warning]:
Drugs that act on the renin-angiotensin system can cause injury and
death to the developing fetus. Discontinue as soon as possible once
pregnancy is detected. The use of drugs which act on the renin-
angiotensin system are associated with oligohydramnios.
Oligohydramnios, due to decreased fetal renal function, may lead to fetal
lung hypoplasia and skeletal malformations. Use is also associated with
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 anuria, hypotension, renal failure, skull hypoplasia, and death in the
fetus/neonate. The exposed fetus should be monitored for fetal growth,
amniotic fluid volume, and organ formation. Infants exposed in utero
should be monitored for hyperkalemia, hypotension, and oliguria.
86. B. Upper endoscopy with small bowel biopsies. This woman has
iron deficiency without evidence of gastrointestinal tract or menstrual
blood loss, which suggests malabsorption of iron. The most common
manifestation of celiac disease is iron deficiency anemia. Iron is mainly
absorbed in the duodenum. Celiac disease preferentially affects the
proximal small bowel, interfering with iron uptake. Therefore, upper
endoscopy with small bowel biopsies should be performed to evaluate
for celiac disease. A small bowel series or capsule endoscopy may
suggest the diagnosis of celiac disease but does not provide tissue for
diagnosis. Positive serologic testing (tissue transglutaminase antibodies)
supports the diagnosis of celiac disease but, if negative, does not exclude
the diagnosis in this patient with a high pretest probability of celiac
disease. In a patient with iron deficiency and no gastrointestinal tract
symptoms, stool evaluation for ova and parasites would be low yield.
Furthermore, a parasitic infection (eg, strongyloidiasis) would likely be
detected on small bowel biopsy. Reference: Mayo Clinic Internal
Medicine Board Review 2013 Gastroenterology & Hepatology Q10.
87. B. Type III antiarrhythmic drugs.
88. C. Hyperthyroidism. Risk factors: statin characteristics: lowest with
fluvastatin, pravastatin and pitavastatin. Pre-existing neuromuscular
disorders like ALS. Hypothyroidism; hypovitaminosis D; Genetic factors
(SLCO1B1); Concurrent drug therapy (glucocorticoid, cyclosporine,
daptomycin, or zidovudine); Exercise.
89. E. Toxin assay for Botulism.
90. E. Vancomycin, Ceftriaxone and metronidazole.
91. C. is the mostly likely answer. Non lateralizing confusion with brain
atrophy in HIV patient, it is either HIV per se or CVM encephalitis, So
the logic next step to do is LP & CSF studies, (if pcr for CMV is
positive, it is diagnostic for CMV). For A and E , there must be signs of
mass clinically and radiologically to choose one of them. D would be
inconclusive here. B is not diagnostic even if it shows a lesion.
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92. E. Streptococcal Pneumonia. This is typical of community-acquired
pneumonia. One should think of common infections rather than any
opportunistic infections in HIV patients with good CD4 counts. (More
than 400 cells/mm3 is not immunocompromised.) It is not a typical
history for bronchial carcinoma as the history was short and radiographic
changes were not typical of bronchial carcinoma. Invasive pulmonary
aspergillosis is unlikely in a patient with good CD4 count. Pulmonary
tuberculosis typically causes cavitating lesions in a patient with a good
CD4 count. PCP commonly occurs in patients with CD4 count of less
than 200 cells/mm3 and chest radiograph shows bilateral infiltrates from
the hila without any effusion or lymphadenopathy. The history is too
short for tuberculosis, and apart from HIV there aren't any other risk
factors for this. Reference: OnExam Part I 2017.
93. C. Continue warfarin at the same dose as long as the INR in the
therapeutic range.
94. C. Measure serum transferring saturation.
95. D. A single, large nodule on chest radiograph. Paraneoplastic
phenomena (polymyositis).
96. D. Give blood transfusion, admit to hospital, and ensure adequate
hydration.
97. C. Hepatitis C polymerase chain reaction PCR.
98. B. 70/80. Positive predictive value = true positive (70) / total positive
(80).
99. D. Effectiveness. (Uncertain Answer).
100. D. Adduction and Elevation.

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Top References (found):
1. PasTest Part II 2019
2. OnExamination Part I 2017
3. Passmedicine 2015
4. Pre-Test Medicine 14e.
5. Brigham Intensive Review 2014.
6. Mayo Clinic Internal Medicine Board Review 2013.

==================THE END====================

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Note: Please write for me, if you find a certain answer or reference. (email:
nabeel_ibrahim_md@yahoo.com)

Nabeel Ibrahim Khaleel

M.B.Ch.B. Mosul College of Medicine.
SHO – Internal Medicine Arab Board.
Baghdad teaching Hospital

15 Page Key Answers of Part 1 June 2019 – Nabeel Ibrahim