Integrated Multi-System (IMS) MCQs Bank

2022-2023

Content:
Chapter 1: Headache
Chapter 2: Neck Swellings
Chapter 3: Cough
Chapter 4: Chest pain

Total bank MCQs is 56

 Chapter1: Headache
The total number of MCQs is 16

Question 1: A 32-year-old woman comes to the physician because of a 3-

month history of recurrent headaches and nausea. The headaches occur a
few times a month and alternately affect the right or left side. The
headaches are exacerbated by loud sounds or bright light. She is in graduate
school and has been under a lot of stress recently. She does not smoke or
drink alcohol but does drink 2-3 cups of coffee daily. Her only medication
is an oral contraceptive. Physical examination shows no abnormalities;
visual acuity is 20/20. Which of the following is the most likely diagnosis?

A. Migraine headache
B. Tension headache
C. Trigeminal neuralgia
D. Cluster headache

Question 2: A 33-year-old man comes to the emergency department

because of repeated episodes of severe headache for the past 3 days. He is
currently having his 2nd episode of the day. He usually has his first episode
in the mornings. The pain is severe and localized to his right forehead and
right eye. He had similar symptoms last summer. He works as an analyst
for a large hedge fund management company and spends the majority of
his time at the computer. He has been under a lot of stress because of
overdue paperwork. He also has chronic shoulder pain. He has been using
indomethacin every 6 hours for the past 3 days but has had no pain relief.
He has smoked one pack of cigarettes daily for 15 years. He appears
restless. Vital signs are within normal limits. Physical examination shows
drooping of the right eyelid, tearing of the right eye, and rhinorrhea. The
right pupil is 2 mm, and the left pupil is 4 mm. There is localized tenderness
to his right supraspinatus muscle. The remainder of the examination shows
no abnormalities. Which of the following is the most likely diagnosis?

A. Migraine headache
B. Subarachnoid hemorrhage
C. Cluster headache
D. Tension headache
Question 3: A 30-year-old woman comes to the office due to daily
headaches for the past few months. She describes the location to be all the
way around her head , and she feels like her head is under a lot of pressure
. She rates the pain as a 5 on a 10-point scale, and it often worsens in
severity throughout the day. She works as a secretary, and she states that
she has been under a lot of stress lately. Her medical history is significant
for bacterial sinusitis treated with antibiotics one month ago, and family
history is significant for migraines on her mother's side. Temperature is
37.0°C (98.6° F), pulse is 65/min, and blood pressure is 115/75 mm Hg.
Physical examination shows mild tenderness on palpation of her posterior
neck and occiput. Which of the following is the most likely diagnosis?

A. Cluster headache
B. Bacterial meningitis
C. Migraine headaches
D. Tension headache

Question 4: A 22-year-old man comes to the emergency department

because of a headache that feels “like a screwdriver” going through his
right temple and eye. He says that it has lasted for approximately 1 hour
thus far, and rates the pain as a 9 on a 10-point scale. He says this has
happened almost every morning this week, but he cannot identify a trigger.
He also describes “watering of his eyes” and difficulty seeing during these
episodes. Physical examination shows ipsilateral miosis of the right eye,
but the remainder of the ophthalmoscopic examination is normal. There is
no tenderness of the right temporal region on palpation. Which of the
following is the most likely diagnosis?

A. Cluster headache
B. Trigeminal neuralgia
C. Migraine headache
D. Tension headache
Question 5: A 35-year-old previously healthy woman suddenly develops
a severe headache while lifting weights. A minute later she has transient
loss of consciousness. She awakes with vomiting and a continued
headache. She describes the headache as “the worst headache of my life.”
She appears uncomfortable and vomits during your physical examination.
Blood pressure is 140/85, pulse rate is 100/minute, respirations are
18/minute, and temperature is 36.8°C (98.2°F). There is neck stiffness.
Physical examination, including careful cranial nerve and deep tendon
reflex testing, is otherwise normal.
Which of the following is the best next step in evaluation?

A. CT scan without contrast.

B. CT scan with contrast
C. Cerebral angiogram
D. Holter monitor.

Question 6: A 58-year-old man complains of the sudden onset of syncope.

It occurs without warning and with no sweating, dizziness, or light-
headedness. He believes episodes tend to occur when he turns his head too
quickly or sometimes when he is shaving. Physical examination is
unremarkable. He has no carotid bruits, and cardiac examination is normal.
Which of the following is the best way to make a definitive diagnosis in
this patient?

A. ECG
B. Carotid massage with ECG monitoring
C. Holter monitor
D. Electrophysiologic study to evaluate the AV node
Question 7: A 30-year-old man complains of unilateral headaches. He
was diagnosed with migraine headaches at age 24. The headaches did not
respond to triptan therapy at that time, but after 6 weeks the headaches
resolved. He has had three or four spells of severe headaches since then.
Currently his headaches have been present for the past 2 weeks. The
headaches start with a stabbing pain just below the right eye. Usually the
affected eye feels “irritated” (reddened with increased lacrimation). He saw
an optometrist during one of the episodes and a miotic pupil was noted.
Each pain lasts from 60 to 90 minutes, but he may have several discrete
episodes each day. The neurological examination, including cranial nerve
examination, is now normal.
What is your best approach to treatment at this time?

A. Prescribe oral sumatriptan for use at the onset of headache.

B. Prednisone 60 mg daily for 2 to 4 weeks
C. Obtain MRI scan of the head with gadolinium contrast.
D. Begin propranolol 20 mg bid.

Question 8: A 47-year-old dentist consults you because of tremor, which

is interfering with his work. The tremor has come on gradually over the
past several years and seems more prominent after the ingestion of
caffeine; he notices that, in the evening after work, an alcoholic beverage
will decrease the tremor. No one in his family has a similar tremor. He is
otherwise healthy and takes no medications. On examination his vital signs
are normal. Except for the tremor, his neurological examination is normal;
in particular there is no focal weakness, rigidity, or bradykinesia. When he
holds out his arms and extends his fingers, you detect a rapid fine tremor
of both hands; the tremor goes away when he rests his arms at his side.
What is the best next step in the management of this patient?

A. MRI scan to visualize the basal ganglia.

B.Electromyogram and nerve conduction studies to more fully characterize
the tremor.
C. Therapeutic trial of propranolol
D. Therapeutic trial of primidone
Question 9: A 35-year-old woman comes to the emergency department
because of a 3-day history of pain in the left cheek. The pain occurs every
few hours, lasts 30–60 seconds, and is aggravated by chewing and
brushing her teeth. She has a history of pain with a vesicular rash in the
right axillary area 1 year ago. She had an upper respiratory infection 2
weeks ago. Family history is unremarkable. Her vital signs are within
normal limits and physical examination shows no abnormalities. Which
of the following is the most likely diagnosis?

A. Cluster headache
B. Trigeminal neuralgia
C. Paroxysmal headache
D. Sinus headache

Question 10: A 72-year-old man is brought into the emergency

department after complaining of a severe headache that began suddenly a
few hours ago. Associated symptoms include nausea, vomiting, and neck
pain. He has a history of Marfan syndrome. His temperature is 37.1°C
(98.8°F), pulse is 96/min, respirations are 18/min, and blood pressure is
116/74 mm Hg. A lumbar puncture (LP) shows substantial erythrocytes
in the first tube and they do not clear on successive collection tubes.
Which of the following is the most likely diagnosis?

A. Meningitis
B. Migraine
C. Subarachnoid hemorrhage
D. Cluster headache
Question 11: A 22-year-old woman comes to the office because of
recurrent headaches. She also has neck stiffness and the symptoms have
been worsening for the past month. She initially thought it was due to
staring at a computer screen for most of the day, but the symptoms have
continued to progress despite reducing that activity and improving her
posture. Current medications include an oral contraceptive pill and
isotretinoin (retinoic acid) for acne. Her temperature is 37.0°C (98.6°F),
pulse is 65/min, respirations are 14/min, and blood pressure is 130/80 mm
Hg. She is 165cm (5ft 5in) tall, weighs 83.9-kg (185-lb); BMI is 30.8
kg/m2. Funduscopic examination shows bilateral bulging of the optic
disc. Which of the following is the next best step?

A. Corticosteroids
B. Discontinue oral contraceptive pills
C. Lumbar puncture
D. Head CT scan

Question 12: A 15-year-old girl is brought to the emergency department

by her parents because of a painful headache and acute visual changes.
She has had daily pulsatile headaches for several months, but the visual
changes, which include transient blurred vision in both eyes, are new.
Ophthalmoscopic examination shows bilateral papilledema. Magnetic
resonance imaging of the head shows ventricles of normal size, and there
are no obstructive masses occluding cerebrospinal fluid (CSF) flow. A
lumbar puncture is performed and shows a CSF opening pressure of
40mmHg that. Though the procedure itself was painful, the patient says
that her headache pain immediately improved after the fluid began to
drain. Which of the following combinations of tests is most likely to
show abnormal findings?

A. Cerebellar function test, vestibular function test

B. Complete blood count, liver function test
C. Visual perimetry, extra-ocular movement exam
D. Magnetic resonance imaging of the head, serum thiamine levels
Question 13: A 22-year-old woman comes to the emergency department
because of frontal throbbing headaches for 3 weeks. Yesterday, the patient
had blurry vision in both eyes and a brief episode of double vision. She has
been taking ibuprofen with only mild improvement of her symptoms. She
has not had any trauma, weakness, or changes in sensation. Medical history
is remarkable for polycystic ovarian syndrome, type 2 diabetes mellitus,
and facial acne. Her current medications include metformin and vitamin A.
She is 158 cm (5 ft 2 in) tall and weighs 89 kg (196 lb); BMI is 36 kg/m2.
Vital signs are within normal limits. Examination shows decreased
peripheral vision. Fundoscopic examination of both eyes is shown. An
MRI of the brain with contrast shows an empty sella but no other
abnormalities. Which of the following is the most appropriate next step in
management?

A. Emergency craniotomy
B. Acetazolamide therapy
C. Lumbar puncture
D. Cerebral shunt

Question 14: A 16-year-old boy presents with sudden onset of severe

headache, low-grade fever, and diplopia. A few days ago he had a
furuncle on his midface drained. Physical examination demonstrates a
sick-looking young male with periorbital edema, chemosis, lateral gaze
palsy, and ptosis on the right side. On fundoscopy, there is bilateral disc
edema. Lumbar puncture reveals elevated cerebrospinal fluid (CSF)
opening pressure. What is the most appropriate initial management?

A. Broad-spectrum antibiotics
B. Low molecular weight heparin
C. Corticosteroids
D. Immediate neurosurgical intervention
Question 15: A 31-year-old woman comes to the physician because of
headaches and nausea for 2 weeks. The headaches are worse on
awakening and she describes them as 7 out of 10 in intensity. During this
period, she has noticed brief episodes of visual loss in both eyes lasting
several seconds, especially when she suddenly stands up or bends over.
She is 165 cm (5 ft 5 in) tall and weighs 98 kg (216 lb); BMI is 36 kg/m2.
Vital signs are within normal limits. Examination shows a visual acuity of
20/20 in both eyes with mild peripheral vision loss. Fundoscopic
examination shows bilateral optic disc swelling. An MRI of the brain
shows no abnormalities. A lumbar puncture is performed; opening
pressure is 310 mm H2O. Cerebrospinal fluid analysis shows a leukocyte
count of 4/mm3 (75% lymphocytes), a protein concentration of 35
mg/dL, and a glucose concentration of 45 mg/dL. A diagnosis of
idiopathic intracranial hypertention is established. Which of the following
is the most appropriate next step in treatment?

A. Acetazolamide therapy
B. Prednisone therapy
C. Optic nerve sheath fenestration
D. Ventricular shunting

Question 16: A 66-year-old man is brought to the emergency department

20 minutes after being involved in a high-speed motor vehicle collision in
which he was the unrestrained passenger. His wife confirms that he has
hypertension, atrial fibrillation, and chronic lower back pain. Current
medications include metoprolol, warfarin, hydrochlorothiazide, and
oxycodone. On arrival, he is lethargic and confused. His pulse is 112/min,
respirations are 10/min, and blood pressure is 172/78 mm Hg. The eyes
open spontaneously. The pupils are equal and sluggish. He moves his
extremities in response to commands. There is a 3-cm scalp laceration.
There are multiple bruises over the right upper extremity.
Cardiopulmonary examination shows no abnormalities. The abdomen is
soft and nontender. Neurologic examination shows no focal findings. Two
large-bore peripheral intravenous catheters are inserted. A 0.9% saline
infusion is begun. A focused assessment with sonography in trauma is
negative. Plain CT of the brain shows a 5-mm right subdural hematoma
with no mass effect. Fresh frozen plasma is administered. Which of the
following is most likely to reduce this patient's cerebral blood flow?

A. Hyperventilation
B. Decompressive craniectomy
C. Lumbar puncture
D. Intravenous hypertonic saline
 Chapter2: Neck Swellings
The total number of MCQs is 8

Question 1: A 29-year-old lady presented to the clinic complaining of

tremorm abnormal menses, and weight loss. on examination: pulse rate
was 110, eye proptosis and diffuse swelling in the neck anteriorly was
observed. Laboratory: TSH level was undetectable. T4: 40 pmol/L
(normal 10-26 pmol/L). Thyroid scan showed diffuse homogenous
uptake. The most likely diagnosis of this patient is:

A. Grave’s Disease
B. Subacute Thyroiditis
C. Toxic Adenoma
D. Toxic Multinodular Goiter

Question 2:A 64-year-old man has inguinal, axillary and cervical

lymphadenopathy. The nodes are firm and non-tender A biopsy of the
cervical node shows a histologic pattern of nodular aggregates of small,
cleaved lymphoid cells (centrocytes) and larger cells with open
chromatin, several nucleoli, and moderate amount of cytoplasm
(centroblast). What is the most likely diagnosis?

A. Hodgkin lymphoma, nodular sclerosis subtype

B. Follicular lymphoma
C. Diffuse large B-cell lymphoma.
D. Burkitt lymphoma
Question 3: A healthy 29-year-old woman comes to the physician for a
health maintenance examination. Palpation of the neck reveals a firm,
0.5-cm nodule in the right thyroid lobe. The remainder of the gland is
normal. The physical examination is otherwise unremarkable. The patient
denies any symptoms attributable to hyperthyroidism. The results of
thyroxine and TSH immunoassays are within normal limits. Which of the
following is the most precise diagnostic screening procedure for
differentiating benign thyroid nodules from malignant ones?

A. MRI scan of the neck

B. CT scan of the neck
C. Radioactive iodine scan
D. Fine needle aspiration

Question 4: An 80 year old woman who was suspected for subclinical

hyperthyroidism. She has been complaining of intermittent palpitations,
being generally unwell, with low mood and some degree of weight loss (3
kg within the last 6 months). She had BP of 110/80 and her heart rate was
96 beats per minute with slightly increased respiratory rate. What is the
best test to do if there was no thyroid uptake scan in the center?

A. TSH receptor Ab
B. Anti TPO
C. Thyroglobulin
D. Thyroid uptake scan again
Question 5: A 46-year-old woman comes to the office because of a small
mass she found on palpation of her neck, more likely related to her
thyroid. A small nodule is found in the thyroid. There is no tenderness.
She is otherwise asymptomatic and uses no medications. What is the most
appropriate next step in the management of this patient?

A. Fine-needle aspiration.
B. Radionuclide iodine uptake scan.
C. T4 and TSH levels.
D. Thyroid ultrasound.
E. Surgical removal (excisional biopsy).

Question 6: A 46-year-old woman with a neck mass presented to the

clinic. A thyroid nodule is found after a neck examination. Her thyroid
was known to have normal thyroid function testing. The fine-needle
aspirate comes back as “indeterminant for follicular adenoma.” What is
the most appropriate next step in the management of this patient?
A. Neck CT.
B. Surgical removal (excisional biopsy).
C. Ultrasound.
D. Calcitonin levels.
Question 7: A 30-year-old male came to the emergency department
complaining of shortness of breath, unable to swallow, feeling warm and
loss of strength. He had unintentional weight loss over the last 6 months.
A clear central neck mass was detected during examination. A diagnosis
of Grave’s disease was confirmed after blood smear detection of elevated
Thyroid antibody (TRAbs) and Anti-TPO antibodies. Thyroid size was
estimated as (100 mL). What is the best management for this case?

A. Iodine supplementation
B. Scheduled follow ups and no need for intervention
C. Near-total thyroidectomy
D. Radioiodine therapy

Question 8: A 42-year-old patient known to have central painless neck

mass for months. Recently enlarged and complicated with unexplained
hoarseness and sour throat for more than 3 weeks. A diagnosis of
Follicular thyroid carcinoma was confirmed. He was given radioactive
Iodine to decrease his tumor size and planned to remove a part of his
thyroid. Which of the following drugs should be given after a month?

A. Potassium Iodide
B. Levothyroxine
C. Diiodotyrosine
D. Monoiodotyrosine
 Chapter3: Cough
The total number of MCQs is 16

Question 1: A 72-year-old woman complains of shortness of breath on

exertion as well as cough. She states that she also becomes short of breath
at night unless she uses three pillows (orthopnea). Physical examination
reveals mild obesity, bilateral pitting leg edema, and fine crackling
sounds on inspiration (rales). A chest X-ray shows cardiomegaly. What
are the most likely diagnoses in this patient?

A. Asthma
B. Emphysema
C. Left-sided heart failure.
D. Myocardial infarction

Question 2: A 40-year-old woman with a history of rheumatic fever

presents with shortness of breath, cough, weight loss, fatigue, and
abdominal distension. Physical examination shows rales in the lungs,
hepatosplenomegaly, and 2+ pitting edema of the legs. A chest X-ray
reveals only left atrial enlargement and pulmonary edema. What is the
most likely cause of pulmonary edema in this patient?

A. Aortic stenosis
B. Tricuspid insufficiency
C. Mitral stenosis
D. Pulmonic stenosis
Question 3: A 67-year-old woman comes to the clinic complaining of
shortness of breath during sleeping, cough, fatigue, weight gain, and
abdominal pain. Physical examination showed respiratory distress,
Ascites, and pitting edema in both legs. Her doctor is considering heart
failure. Which one of the following tests is used to diagnose heart failure?

A. BNP
B. Ck MB
C. Troponin
D. LFTs

Question 4: A 73-year-old man came to the hospital with severe

dyspnea, cough, orthopnea and bilateral edema, the doctor has done
physical examination and found the patient cyanosed, and heard rales in
lungs, what is the best method to confirm diastolic heart failure?

A. Chest X-ray
B. LDH
C. Cardiac MRI
D. Echocardiography
Question 5: A 35-year-old man presents to the emergency department
complaining of a cough and runny nose of 1-week duration. While being
evaluated, it is discovered that his blood pressure is 230/120 mm Hg. An
antihypertensive is immediately administered. Later, he develops lactic
acidosis, headache, vertigo, and confusion. Which antihypertensive was
given to him?

A. A Enalapril
B. B Labetalol
C. C Losartan
D. D Nitroprusside

Question 6: A 33-year-old Caucasian male comes to the clinic with a 4-

day history of chest pain. The pain radiates to the right side of the neck
and is worsened by deep inspiration and improved by leaning forward.
Several weeks ago, he had a fever and cough, which have both since
improved. He is afebrile, BP is 130/85, and pulse is 88. On examination,
there is a scratching sound heard over the left sternal border on
expiration. ECG shows ST elevation in leads I, II, III, avL, and V2 to V6.
The patient is offered treatment but refuses all medications. Which of the
following is the most common complication if this disease remains
untreated?

A. Cardiac tamponade
B. Recurrent pericarditis
C. Constrictive pericarditis
D. Ventricular free wall rupture
Question 7: A 48-year-old woman has been diagnosed with essential
hypertension and was commenced on treatment three months ago. She
presents you with a dry cough which has not been getting better despite
taking cough linctus and antibiotics. You assess the patient’s medication
history. Which of the following antihypertensive medications is
responsible for the patient’s symptoms?

A. Amlodipine
B. Lisinopril
C. Bendroflumethiazide
D. profen

Question 8: A 67-year-old man is hospitalized recovering from a left

wall myocardial infarction. He begins to show signs of fluid retention.
His doctors want to start a drug regimen for congestive heart failure,
including either an ACE inhibitor or an angiotensin receptor blocker
(ARB). ACE inhibitors and ARBs treat hypertension in a similar fashion
and have similar side effects. Which of the following is a side effect of
ACE inhibitors only?

A. Dizziness
B. Dry cough
C. Erectile dysfunction
D. Hypotension
Question 9: A 56-year-old man attends your clinic with a three-month
history of a productive cough with blood-tinged sputum, following his
return from India. Associated symptoms include lethargy, night sweats and
decreased appetite. He is normally fit and healthy with no past medical
history. On examination, the patient's chest has good air entry bilaterally
with no added sounds and his temperature is 37.3°C. A sputum sample sent
from the patient's general physician reveals a growth of acid fast bacilli.
From the list below, which is the most likely diagnosis?

A. Pulmonary embolism
B. Tuberculosis
C. Bronchitis
D. Pneumonia

Question 10: 68-year-old man in clinic, with a 40 (cigarette) pack year

history, who has been experiencing breathlessness on exertion and a
productive cough of white sputum over the last four months. You assess
his spirometry results which reveal an FEV1/FVC of 51% with minimal
reversibility after a 2-week trial of oral steroids. Cardiological
investigations are normal. Which of the following is the most likely
diagnosis?

A. Asthma
B. Chronic obstructive pulmonary disease (COPD)
C. Left ventricular failure
D. Chronic bronchitis
Question 11: A 45-year-old male is evaluated in the clinic for asthma. His
symptoms began 2 years ago and are characterized by an episodic cough
and wheezing that responded initially to inhaled bronchodilators and
inhaled corticosteroids but now require nearly constant prednisone tapers.
He notes that the symptoms are worst on weekdays but cannot pinpoint
specific triggers. The patient has no habits and works as a textile worker.
Physical examination is notable for mild diffuse polyphonic expiratory
wheezing but no other abnormality. Which of the following is the most
appropriate next step?

A. Exercise physiology testing

B. Measurement of FEV, before and after work
C. Methacholine challenge testing
D. Skin testing for allergies

Question 12: A 54-year-old woman presents complaining of a chronic

cough that has worsened over a period of 6-12 months. She reports the
cough to be present day and night, and productive of a thick green sputum.
Over the course of the day, she estimates that she produces as much as 100
mL of sputum daily. Bilateral coarse crackles are heard in the lower lung
zones. Pulmonary function tests demonstrate an FEV, of 1.68 L (53.3%
predicted), FVC of 3.00 L (75% predicted), and FEV /FVC ratio of 56%.
A chest radiograph is unre-markable. What would you recommend as the
next step in the evaluation of this patient?

A. Bronchoscopy with bronchoalveolar lavage

B. Chest CT with intravenous contrast
C. High-resolution chest CT
D. Serum immunoglobulin levels
Question 13: A 16-year-old girl is brought to the physician for recurrent
episodes of shortness of breath, nonproductive cough, and chest tightness
for 3 months. These episodes occur especially while playing sports and
resolve spontaneously with rest. She appears healthy. Her pulse is 63/min,
respirations are 15/min, and blood pressure is 102/70 mm Hg. Pulse
oximetry on room air shows an oxygen saturation of 98%. Physical
examination shows no abnormalities. An x-ray of the chest shows no
abnormalities. Spirometry shows a FEV1:FVC ratio of 85% and an FEV1
of 85% of predicted. Which of the following is the most appropriate next
step in management?

A. Albuterol before exercise

B. Physical conditioning
C. Echocardiography
D. Prednisone therapy

Question 14: A 22-year-old woman comes to the physician because of a

12-week history of persistent cough. The cough is nonproductive and
worse at night. She otherwise feels well. She has not had any changes in
appetite or exercise tolerance. For the past year, she has smoked cigarettes
occasionally when with friends. Use of herbal cough medications has not
provided any symptom relief. She has no history of serious illness but
reports getting a runny nose every morning during winter. Her temperature
is 37.0°C (98.6°F), pulse is 68/min, respirations are 12/min, and blood
pressure is 110/76 mm Hg. Cardiopulmonary examination and an x-ray of
the chest show no abnormalities. Her FEV1 is normal. Which of the
following is the most appropriate next step in management?

A. Smoking cessation
B. Oral amoxicillin-clavulanate
C. Oral pantoprazole
D. Oral diphenhydramine
Question 15: A 14-year-old girl is brought by her parents to the physician
because of recurrent episodes of shortness of breath and nonproductive
cough over the past 3 months. She has had two episodes per week, which
have resolved spontaneously with rest. Once a month, she wakes up at
night with shortness of breath. Spirometry shows an FVC of 95% and an
FEV1 of 85% of predicted. Treatment with inhaled budesonide-formoterol
as needed is begun. Two weeks later, she is brought to the physician with
acute onset of dyspnea and wheezing. Her pulse is 95/min and respirations
are 32/min. Which of the following is the most appropriate initial
pharmacotherapy?

A. Albuterol inhaler
B. Cromolyn sodium
C. Guaifenesin
D. Montelukast sodium

Question 16: 28-year-old man has been newly diagnosed with asthma. He
has never been admitted to hospital with asthma exacerbation and
experiences symptoms once or twice a week. You discuss the treatment
options with him. His peak expiratory flow reading is currently 85 per cent
of the normal predicted value expected for his age and height. Which of
the following is the most appropriate first step in treatment?

A. Short-acting beta-2 agonist inhaler

B. Low-dose steroid inhaler
C. Leukotriene receptor antagonists
D. High-dose steroid inhaler
 Chapter4: Chest pain
The total number of MCQs is 16

Question 1: A 56-year-old male patient presented with a history of

fever, malaise, and shortness of breath. His medical history was
significant for hypertension and smoking. Upon physical examination,
there was an audible murmur in the heart. Laboratory tests showed an
elevated white blood cell count and C-reactive protein. The chest X-ray
was normal, and an echocardiogram revealed vegetation on the mitral
valve. What is the most likely diagnosis for this patient?

A. Myocardial infarction
B. Endocarditis
C. Pericarditis
D. Cardiomyopathy

Question 2: A 55-year-old male with a history of IV drug use presents to

the emergency department with complaints of fever, chills, and chest pain
for the past week. On the physical exam, his temperature is 101°F, heart
rate is 110 bpm, and blood pressure is 130/80 mmHg. There is a grade
II/VI systolic murmur at the left sternal border and multiple petechial skin
lesions on the hands and feet.

Which of the following symptoms is most commonly associated with

cardiac infections?

A. Diarrhea
B. Shortness of breath
C. Abdominal pain
D. Skin rash
Question 3: A 62-year-old male patient presents to the emergency
department with chest pain, shortness of breath, and diaphoresis. His
electrocardiogram (ECG) shows ST-segment elevation in leads II, III, and
aVF. What are the appropriate investigations for diagnosing cardiac
infarction in this patient?
Which of the following cardiac biomarkers is the most sensitive and
specific for diagnosing acute myocardial infarction?

A. Troponin I
B. Creatine kinase-MB (CK-MB)
C. Myoglobin
D. LDH

Question 4: A 58-year-old male patient presents to the emergency

department with chest pain that radiates to his left arm. The patient has a
history of hypertension and hypercholesterolemia. ECG shows ST-
segment elevation in the anterior leads. Which of the following
investigations should be performed to confirm the diagnosis of acute
myocardial infarction?

A. Cardiac biomarkers
B. Chest X-ray
C. Echocardiogram
D. Coronary angiogram

Question 5: Which medication should be prescribed to all anginal

patients to treat an acute attack?

A. Isosorbide dinitrate
B. Nitroglycerin patch
C. Nitroglycerin sublingual tablet or spray
D. Ranolazine
Question 6: A 60-year-old woman had a myocardial infarction.
Which of the following should be used to prevent life-threatening
arrhythmias that can occur post-myocardial infarction in this patient?

A. Digoxin
B. Flecainide
C. Metoprolol
D. Procainamide

Question 7: Which of the following is most commonly recognized as an

absolute contraindication to fibrinolytic therapy in patients with STEMI?

A. Prior ischemic stroke within the past 6 months

B. Suspected aortic dissection.
C. Systolic blood pressure > 160 mm Hg or diastolic blood pressure >
100 mm Hg
D. Pregnancy

Question 8: An 85-year-old man comes to the emergency department

because of chest discomfort and shortness of breath that started two hours
ago while watching television. Past medical history includes hypertension
and hyperlipidemia. During the past 10 years, the patient has had similar
episodes of chest pain, which resolved with rest. The patient's pulse is
94/min, respirations are 22/min, and blood pressure is 134/86 mmHg. The
patient appears to be in distress and is diaphoretic. Physical examination
shows normal heart sounds with no murmurs or gallops on auscultation.
An ECG shows Inferior wall myocardial infarction. Treatment is
administered, and the patient suddenly reports feeling faint and loses
consciousness. Which of the following medications is most likely the
cause of the patient's worsened condition?

A. Nitrates
B. Clopidogrel
C. Warfarin
D. Aspirin
Question 9: A 55-year-old man was admitted to the hospital 2 weeks
ago for rapid onset of cough, fatigue, and pleuritic chest pain. He has
worked as a sandblaster for the past year. When first seen in the hospital,
he denied hemoptysis and smoking. Currently, the patient is intubated and
on assist-control ventilation. His temperature is 36.7°C (98°F), the pulse
is 96/min, blood pressure is 138/85 mm Hg, and respiratory rate is
18/min. A recent arterial blood gas study showed a pH of 7.42, partial
pressure of arterial carbon dioxide of 36 mm Hg, and partial pressure of
arterial oxygen of 110 mm Hg while on 100% fraction of inspired
oxygen. Physical examination is significant for diffuse crackles
throughout both lung fields, a loud pulmonic component of the second
heart sound, and jugular venous distention of 9 cm with a prominent A
wave, a left parasternal heave, and symmetric 3+ lower extremity pitting
edema. Which of the following is the correct diagnosis?

A. Asbestosis
B. Berylliosis
C. Silicosis
D. Coal worker’s pneumoconiosis

Question 10: A 35-year-old HIV-positive man (CD4+ count 150/mm3)

is seen in the ED with right-sided chest pain. The patient has become
progres- sively dyspneic over the past few days. Sud- denly, 30 minutes
ago he noticed a sharp pain in his chest associated with shortness of
breath. His temperature is 37.7° (99.9°F), blood pres- sure is 128/84 mm
Hg, pulse is 102/min and regular, respiratory rate is 25/min, and oxygen
saturation is 90% on room air. Physical exami- nation reveals diminished
right-sided breath sounds and hyperresonance. Jugular venous distention
is 5 cm and there is no tracheal de- viation. ECG shows sinus tachycardia.
X-ray of the chest shows a right-sided pneumothorax occupying
approximately 10% of the right tho- racic cavity. Which of the following
etiologies most likely caused this patient’s presentation?

A. Intravenous drug use

B. Kaposi’s sarcoma
C. Mycobacterium tuberculosis
D. Pneumocystis jiroveci (formerly carinii) pneumonia
Question 11: Differential diagnosis of PE is challenging. PE should be
considered in the differential diagnosis of patients suspected of having
cardiac ischemia, heart failure, COPD exacerbation, pneumothorax,
pneumonia, sepsis, acute chest syndrome (in patients with sickle cell
disease), and acute anxiety with hyperventilation. Which of the following
is the preferred imaging technique for diagnosing acute PE?

A. V/Q scans
B. Duplex ultrasonography
C. CT angiography
D. Echocardiography

Question 12: A 27-year-old woman is 7 months pregnant with her first

child. Her pregnancy has been uncomplicated to date. She presents to the
ED complaining of sudden-onset, right-sided chest pain that is
exacerbated with deep breathing, and shortness of breath, which began 1
hour ago. She denies leg pain and says the swelling that is apparent has
been unchanged since the sixth month of her pregnancy. Her tempera-
ture is 37.9°C (100.3°F), blood pressure is 130/87 mm Hg, pulse is
107/min and regular, respiratory rate is 24/min, and oxygen satura- tion is
90% on room air, increasing to 98% with 4 L oxygen via nasal cannula.
Physical ex- amination is significant for crackles at the lower right lung
field and a negative Homans’ sign bilaterally. X-ray of the chest appears
nor- mal, D-dimer is elevated, and ECG shows si- nus tachycardia, right-
axis deviation, S wave in lead I, Q wave in lead III, and an inverted T
wave in lead III. Which of the following is the most appropriate next step
in diagnosis?

A. Arterial blood gas analysis

B. MRI
C. C)Pulmonary angiography
D. Ventilation/perfusion scan
Question 13: A 23-year-old man is seen in the ED for sud- den-onset,
right-sided pleuritic chest pain that developed 30 minutes ago while he was
watching television. The patient also complains of difficulty breathing. He
has no prior medical history, denies smoking and intravenous drug use, and
does not take any medications. His temperature is 37.3°C (99.1°F), blood
pressure is 130/82 mm Hg, pulse is 92/min and regular, respiratory rate is
20/min and shallow, and oxy- gen saturation is 98% on room air. He is 196
cm (6 ft 5 in) tall with a body mass index of 18 kg/m2. Diminished breath
sounds, hyperresonance, and decreased tactile fremitus are prominent in
the right lung field. The trachea is midline. X-ray of the chest shows a 10%
pneumothorax on the right. Which of the following is the most appropriate
initial management?

A. Observation with supplemental oxygen

B. Open thoracotomy with oversewing of the
C. pleural blebs and scarification of the pleura
D. Needle decompression
E. Thoracoscopy with stapling of blebs

Question 14: A 62 year old man presented to the acute medical unit with
a three- day history of mild breathlessness on exertion, occasional right
sided chest pain and sweats. He looked well and was breathless at rest. He
had no significant past medical history. His temperature was 37.7 C. He
had a few crackles at the right base, dullness to percussion, and decreased
vocal resonance at the right base. What is the next step in management?

A. CT scan of chest with contrast timed for pleural enhancement.

B. Diuretics and monitoring of response with a chest x-ray.
C. Empirical antibiotics and monitoring of response with a chest
xray.
D. Pleural ultrasound and diagnostic aspiration.
Question 15: A 70-year-old man with a history of heavy smoking and
moderately severe chronic obstructive pulmonary disease COPD. has been
feeling poorly. He reports cough, chills, pleuritic chest pain, and low-grade
fever. Chest x ray reveals a small dense infiltrate in the right lower lobe.
Gram's stain of the patient's sputum reveals numerous gram-negative cocci,
many of which occur in pairs. The most appropriate therapy would be

A. No antimicrobial therapy is required.

B. Tetracycline
C. Ciprofloxacin
D. Trimethoprim/sulfamethoxazole TMP/SMZ.
E. Penicillin/clavulanic acid

Question 16: A 72-year-old male is admitted to the hospital from a

nursing home with severe pneumonia. He was recently discharged from the
hospital 1 week ago after open heart surgery. The patient has no known
allergies. Which of the following regimens is most appropriate for empiric
coverage of methicillin- resistant Staphylococcus aureus and Pseudomonas
aeruginosa in this patient?

A. Vancomycin + cefepime + ciprofloxacin

B. Vancomycin + cefazolin + ciprofloxacin
C. Telavancin + cefepime + ciprofloxacin.
D. Daptomycin + cefepime + ciprofloxacin