1- A 23 year-old male is referred to you after developing “reddish brown” urine 1

day after playing football. He also notes that for the past two days he has had a
sore throat and cough. He has no PMHx, takes no medications and has a family
history of nephrolithiasis. Chemistries reveal a BUN of 16 mg/dL and creatinine
of 1.0 mg/dL. ANA is negative and C3 is normal. A 24 hour urine protein
excretion is 200 mg and creatinine clearance is 120 cc/m. Microscopic analysis
reveals many RBC with some dysmorphic cells. Renal U/S is normal. The most
likely diagnosis is:
a- Minimal change disease
b- Rhabdomyolysis
c- IgA nephropathy
d- Post-streptococcal glomerulonephritis

Answer: C

2- A 35-year-old man has chronic liver disease secondary to hepatitis. He comes on having had
a depressive episode, but also feels tired and unwell. He reveals that he has had a bottle of
wine a day for a week. On examination he has gross abdominal distension. A peritoneal tap is
done. Results from the tap show that it has albumin of 2.5 g/dL, LDH of 320 U/l, glucose 65
mg/dL (serum glucose 122 mg/dL) and a white cell count of 700 per mmᶾ (90%
neutrophils).What is the diagnosis?

A. Acute reactivation of hepatitis B

B. Tuberculous peritonitis
C. Alcoholic liver disease decompensation
D. Chylous ascites
E. Spontaneous bacterial peritonitis

Answer: E

3- A 40-year – old engineer has smoked a pack of cigarettes daily for 20 years presents with
chronic unproductive cough associated with a history of recurrent pneumothorax and a
chronic hepatitis .The most likely diagnosis is :
a- Immotile cilia syndrome
b- Cystic fibrosis
c- Chronic bronchitis
d- α-1 Antitrypsin deficiency
e- Marfan's syndrome

Answer: D

4- A 20-year-old man is referred for investigation of abnormal liver function tests. He has a
previous history of diabetes diagnosed 5 years ago. His albumin is 3.5 g/dL, bilirubin 15 μmol/l
(Normal 1.71 to 20.5 µmol/L), ALP is 390 U/l and ALT is 350 U/l. he has a serum copper of 30
μmol/l (Normal 12-26) and ceruloplasmin of 90 μmol/l (200-350). What is the most likely
diagnosis?
 A. Cholangiocarcinoma
B. Autoimmune hepatitis
C. Primary biliary cirrhosis
D. Hemochromatosis
E. Wilsons’s disease

Answer: E

5- A 63-year-old man develops pain and swelling in his knee. It appears warm, red, and
swollen with decreased range of movement. A diagnostic aspiration is performed. Which of
the following will most likely distinguish pseudogout from gout?

A. Involvement of large joints

B. Involvement of single joints
C. Acute onset
D. Positive birefringent crystals
E. Association with diabetes

Answer: D

6- A 35-year-old man presents with diarrhea for 10 days, characterized by frequent,

low-volume stools with the presence of mucus. He also complained of subjective fever and
lower abdominal pain. The presence of leukocytes in stool is consistent with which organism?

a) Clostridium perfringens

b) S. aureus

c) Giardia lamblia

d) Enterobius vermicularis

e) Entamoeba histolytica

Answer: e

7- Which statement about esophageal cancer is true?

a) Dysphagia is an early manifestation.

b) The most common type of esophageal cancer in the United States is adenocarcinoma.

c) Esophageal cancer is most commonly located in the proximal third of the esophagus.

d) Most esophageal cancers are not resectable at presentation.

e) Barrett's syndrome is associated with squamous carcinoma.

Answer: d
8- All of the following thyroid conditions are amenable to RAI treatment, except

a) Papillary cancer

b) Follicular cancer

c) Graves' disease

d) Thyroid lymphoma

e) Multinodular goiter

Answer: D

9- All of the following are characteristic patterns of joint involvement in rheumatoid arthritis,
except
a)Polyarticular involvement
b)Oligoarticular involvement
c)Symmetrical involvement
d)Involvement of the proximal interphalangeal (PIP), metacarpophalangeal (MCP) wrist, and
metatarsophalangeal (MTP) joints
e)Frequent cervical spine involvement

Answer: B

10- A 21-year-old man presents with painless haematuria which he has noticed in the last 3
days. He suffers from type 1 diabetes which is well controlled, but is otherwise fit and healthy.
The patient has recently recovered from a mild throat infection. Urine dipstick analysis reveals
blood and protein in the urine. The most likely diagnosis is:

A. Henoch–Schonlein purpura

B. Benign prostate hypertrophy

C. IgA nephropathy

D. Diabetic nephropathy

E. Urinary tract infection (UTI)

Answer: C

11- A 66-year-old woman with poorly controlled type 2 diabetes presents to accident and
emergency with a 2-day history of severe pain in the right flank, nausea and fevers that come
and go. On examination, the patient appears unwell, sweaty and has visible rigors with a
temperature of 38°C. The patient denies any recent travel. Urine dipstick is positive for
protein, blood, leukocytes and nitrates. A CT scan of the abdomen reveals gas in the renal
parenchyma area. The most likely diagnosis is:

A. Renal stones

B. Renal infarction

C. Diabetic nephropathy

D. Renal TB

E. Pyelonephritis

Answer: E

12- A 29-year-old man presents with a 4-week history of polyuria and extreme thirst. The
patient denies difficulty voiding, hesitancy or haematuria, although the urine is very dilute.
The patient does not believe he has lost any weight and maintains a good diet. No findings are
found on urine dipstick. The most appropriate investigation is:

A. Serum osmolality

B. Fasting plasma glucose

C. Urinary electrolytes

D. Magnetic resonance imaging (MRI) scan of the head

E. Water deprivation test

Answer: E

13-. A 43-year-old woman attends her GP with a 1-year history of progressive weight gain and
malaise. She bruises easily and has trouble climbing stairs. She also has increased facial hair.
On examination she has a body mass index of 32 kg/m2. Her abdomen is obese with visible
striae, although her arms and thighs appear wasted. What is the most likely diagnosis?

A) Conn's syndrome

B) Cushing's syndrome

C) Addison's disease

D) Phaeochromocytoma
E) Congenital adrenal hyperplasia

Answer: B

14- Which condition is characterised by the combination of microangiopathic haemolytic

anaemia, neurological signs and renal impairment?

A) Idiopathic thrombocytopenic purpura

B) Thrombotic thrombocytopenic purpura

C) Hereditary haemorrhagic telangiectasia

D) Primary thrombocythaemia

E) Henoch-Schönlein purpura

Answer: B

15- A 45-year-old male executive comes to your office complaining of epigastric pain for 2
months. His primary physician prescribed him H2-blockers 3 weeks ago, which have produced
only partial relief of his symptoms. His weight is stable. His physical exam is normal. An upper
endoscopy reveals a 1-cm duodenal ulcer. Which of the following risk factors is not associated
with the development of ulcer disease?

a) Daily use of nonsteroidal anti-inflammatory drugs (NSAIDs)

b) Gastric infection with H. pylori

c) Emotional stress

d) Cigarette smoking

e) Gastrin-secreting tumors

Answer: C

16-A 60-year-old smoker presents with chronic productive cough for over three months
annually for the past two years. This is most consistent with:
A. Bronchiectasis
B. Asthma
C. Chronic bronchitis
D. Interstitial lung disease

Answer: C
17-Which of the following organisms is most commonly associated with community-acquired
pneumonia in otherwise healthy adults?
A. Streptococcus pneumoniae
B. Mycoplasma pneumoniae
C. Klebsiella pneumoniae
D. Pseudomonas aeruginosa

Answer: A

18- A 70-year-old presents with progressive dyspnea and dry cough. HRCT shows
honeycombing without ground-glass opacities. What is the next step in treatment?
A. High-dose steroids
B. Lung transplantation evaluation
C. Antibiotics
D. Bronchodilators

Answer: B

19- A 30-year-old with a history of travel to Africa presents with fever, abdominal cramps, and
diarrhea. Stool cultures grow Salmonella enterica. What is the treatment of choice in a
non-complicated case?
A. Ciprofloxacin
B. Azithromycin
C. No antibiotic treatment
D. Metronidazole

Answer: C

20- A 19-year-old man is referred by his GP with a 3-month history of severe intermittent
bloody diarrhea. A barium enema shows multiple ulcers and evidence of inflammatory
changes extending from the rectum to the mid transverse colon. A colonoscopy is performed
and biopsies, taken from multiple sites, show acute and chronic inflammation restricted to the
mucosa. The most likely diagnosis is:

A. Ischemic colitis
B. Amoebiasis
C. Chrons disease
D. Ulcerative colitis
E. AIDS-associated diarrhea
Answer: D

21. A 45-year-old diabetic patient presents with fever, erythema, and swelling of the lower leg.
The lesion is warm to touch, with indistinct borders. What is the most likely diagnosis?
A. Erysipelas
B. Cellulitis
C. Necrotizing fasciitis
D. Contact dermatitis

Answer: B

22- A 38-year-old man presents with several episodes of severe chest pain that awoke him in
the early morning. He has no history of major physical illness or drug abuse, and does not
smoke. His temperature is 37 .0°C, blood pressure is 125/80 mm Hg, pulse is 78/min and
regular, and RR is 12/min. An ECG reveals no abnormalities and the physician tells the patient
that his pain is probably of psychological origin. After a few days, the patient comes to ER at 5
AM complaining of chest pain. An ECG reveals sinus rhythm with ST segment elevation. The
patient is admitted, and coronary arteriography is performed, revealing no stenotic lesions.
Intravenous administration of ergonovine during arteriography triggers chest pain
accompanied by ST elevation on ECG. Which of the following is the most likely diagnosis?

A. Myocardial Infarction
B. Prinzmetal angina
C. Psychological chest pain
D. Stable angina
E. Unstable angina

Answer: B

23-year-old female presents with a history of severe left temporal headache. She gives a
history of feeling generally unwell and also complaints of problems with eating. You arrange
investigation of this patient
Which one of the following drugs would you use in this patient whilst awaiting confirmation of
the diagnosis?
a) Steroids
b) Antiviral
c) Anticonvulsants
d) Sumatriptan

Answer: A

24-A 54-year-old man is admitted to the Emergency Department with a 15 minute history of
crushing central chest pain. Which one of the following rises first following a myocardial
infarction?
A. AST
B. Troponin I
C. CK
D. CK-MB

E. Myoglobin

Answer: E

25-Secretion of what of the following hormones does not increase at night :

(a) growth hormone.
(b) ACTH.
(c) melatonin.
(d) insulin.
(e) prolactin

Answer: D

26-A 55-year-old hospitalized white male with a history of rheumatic aortic and mitral valve
disease complains of fever, back pain, and myalgias for the past 3 days. On initial examination,
no definite focus of infection is found. The WBC count is 24,000/mm3 with 40%
polymorphonuclear leukocytes and 40% band forms. The following day, two blood cultures are
growing gram-positive cocci in clusters.
Until specific organism sensitivity is known, the most appropriate antibiotic treatment at this
time would be

a-vancomycin (Vancocin) and gentamicin (Garamycin)

b-ceftriaxone (Rocephin)

c-streptomycin and penicillin

d-nafcillin (Nafcil)

e-ciprofloxacin (Cipro)

Answer: A
27-A patient who has experienced recurrent urticaria comes to your office because the lesions
have persisted for 48 hours. The patient has individual wheals that are smooth, edematous,
and purpuric. They also itch and are painful.
Which one of the following is the most important diagnostic step at this time?
a-A trial of oral H1 antihistamines

b-A placebo-controlled food additive challenge

c-A WBC count with differential

d-A skin biopsy

e-A serum C4 complement level

Answer: D

28-A 25-year-old male visits your office concerned about a painless ulcer on the glans of his
penis. After appropriate examination and testing you diagnose primary syphilis and treat him
with 2.4 million units of benzathine penicillin intramuscularly in a single dose. Eight hours
later, while you are working the evening clinic, he returns because he has a fever of 100.6° F
and a bad headache, which he rarely gets. He says he "aches all over."
Which one of the following is the most appropriate action at this time?

a-Reassure and prescribe antipyretics

b-Add doxycycline (Vibramycin), 100 mg orally twice a day for 14 days

c-Perform a spinal tap

d-Order a CT scan of his head e-Obtain three blood cultures from different sites at 30-minute
intervals

Answer: A

29-An 81-year-old white female comes to your office complaining of being depressed. She also
complains of recurrent muscle cramping and tingling of her fingers. During your evaluation,
you discover that her serum calcium level is 6.8 mg/dL (N 8.5-10.8) and her serum
phosphorous level is 5.6 mg/dL (N 2.5-4.5).
Which one of the following additional findings would most suggest the diagnosis of primary
hypoparathyroidism?

a-Normal renal function

b-Intracranial calcifications

c-Papilledema

d-Prolongation of the QT interval on ECG

Answer: A

30- A 55-year-old construction worker with no history of health problems develops intense
flank pain with radiation into the groin. Urinalysis shows hematuria but is otherwise negative.
He subsequently passes a stone which is analyzed and shown to consist of calcium oxalate. A
CBC and chemistry profile are negative.
Which one of the following is true in this situation?

a-Daily ingestion of 3 L of fluid should be recommended

b-A 24-hour urine specimen should be checked for calcium

c-Dietary calcium should be restricted

d-Beverages such as beer and tea should be avoided

e-The patient should be started on triamterene (Dyrenium)

Answer: A

31- A 38-year-old white female who complains of abdominal pain insists that she be referred
for surgical evaluation. There is a history of multiple unexplained physical symptoms which
began in her late teenage years. She is vague concerning past medical evaluations, but a
review of her thick medical chart reveals multiple normal blood and imaging tests, several
surgical procedures which have failed to alleviate her symptoms, and frequent requests for
refills of narcotic analgesics.
This history is most compatible with which one of the following?

a-Somatization disorder

b-Generalized anxiety disorder

c-Panic disorder

d-Malingering

e-Hypochondriasis

Answer: A

32-A 42-year-old male presents to your office complaining of fatigue. His past medical history
is insignificant. He does not smoke or consume alcohol. His blood pressure is 120/70 mmHg
and heart rate is 85/min. Physical examination is insignificant. Laboratory values are:
Hemoglobin 7.7 g/dL MCV 72 fL MCHC 28% Leukocyte count8,000/cmm ESR 15 mm/hr Serum
iron and ferritin levels are decreased. What is the next best step in the management of this
patient?

A Iron supplementation

B. Dietary modifications
C. Test for occult blood in the stool

D. Work-up for malabsorption

E. Bone marrow sampling

Answer: C

33-A 38-year-old male presents to his physician with 4 to 6 months of weight loss and joint
complaints. He reports that his appetite is good, but he has had diarrhea with six to eight
loose, foul-smelling stools each day. He has also had migratory pain in the knees and
shoulders. Stool studies demonstrate steatorrhea. Which of the following diagnostic tests is
most likely to be positive in this patient?
A. Serum IgA antiendomysial antibodies
B. Serum IgA antigliadin antibodies
C. Serum PCR for Tropheryma whippelii
D. Small bowel biopsy showing reduced villous height and crypt hyperplasia
E. Stool Clostridium difficile toxin

Answer: C

34- A 28-year-old woman is 22 weeks pregnant with her first child. Over the last several weeks,
she has developed severe heartburn after eating meals and at bedtime. She wants to take
medication to improve her symptoms. Which of the following medications would be most
appropriate for first-line use in this patient?
a-Proton pump inhibitor (PPI)
b-Histamine type 2 receptor antagonist (H2RA)
c-Over-the-counter antacid
d-Promotility agent
e-Antispasmodics.

Answer: C

35-A 60 –year – old woman is noted to have small pupil which is non reactive to light but
constrict to accommodation .The most likely cause for the pupil abnormality is:
A. Syphilis
B. Posterior communicating artery aneurysm syndrome
C. Pancosts tumour
D. Pontine hemorrhage
E. Holmes

Answer: A
36-A 55 –year – old man presents with a six – month history of arthralgia and vasculitic skin
rash affecting the lower limbs .Further investigation reveals monoclonal and polyclonal
cryoglobulins. This condition is often associated with which one of the following infections ?
a - Hepatitis C virus (HCV )
b- Hepatitis B virus (HBV )
c- Cytomegalovirus (CMV )
d- Parvovirus
e- Epstein – Barr virus (EBV )
Answer: A

37-The following are possible causes of a goiter EXCEPT:

a- pregnancy
b- exogenous iodine
c- carbimazole
d- puberty
e- Graves' disease

Answer: B

38- A 56-year-old man has had sinsitis for a few months. Recently he complained of bloody
nasal discharge, cough, and shortness of breath. The chest X-ray shows a diffuse area of
consolidation and cavities in the right middle lobe and left upper lobe. Urinalysis shows red
blood casts and protein ++++. The most likely diagnosis is
a- Pulmonary tuberculosis
b- Sarcoidosis
c- Aspiration pneumonia
d- Wegerner's granulomatosis
e- Carcinoma of the bronchus

Answer: D

39- A 52 year old woman presents for follow-up. She has adult-onset DM for which she takes
glyburide. No other medical problems. On PE she is 152 cm tall, and weighs 90.7 kg. Liver is
mildly enlarged and non-tender. Labs show: AST 75 ALT 52 Alb 4.0 T.Protein 6.5 Alk Phos 110
T.bili 1.0 Glucose 254 Hep B/C neg. AMA/Anti-smooth muscle Ab neg. U/S shows decreased
echogenicity of liver but no ductal dilatation. The most likely diagnosis is:
a- Nonalcoholic steatohepatitis
b- Alcoholic steatosis
c- Autoimmune hepatitis
d- Biliary cirrhosis
e- Chronic cholecystitis

Answer: A
40- A 75-year-old lady presents with increasing tiredness for six months. On examination she is
pale and has 6 cm of splenomegaly. Her Hemoglobin is 7.2 gl/dl, MCV 85 fl, WCC 21.5 X 109/l
and platelets 45 X 109/l . Examination of her blood film reveals teardrop-shaped red cell and
occasional nucleated red cell A 24 year old man presents with a four – day history of a
worsening skin eruption preceded by symptoms of headache , fever and arthralgia . On
examination , there is evidence of a widespread purpuric rash affecting the extensor aspects of
her forearms , legs and buttocks . Investigations demonstrates a raised white cell count with a
neutrophilia , and a raised serum IgA level. Urinalysis reveals microscopic hematuria and
proteinuria . What is the most likely diagnosis ?
a- Rheumatic fever.
b- Erythema multiforme
c- Linear IgA disease.
d- Henoch – Schonlein purpura

Answer: D

41-A 40-year-old butcher complains of pain and paraesthesia in both hands. On examination
he has wasting of the right thenar muscles, and tapping the volar aspect of the right wrist
provoked a pins and needle sensation in the index and middle finger. Each of the following
disorders could be responsible for the clinical features, EXCEPT.
a- Hemochromatosis
b- Diabetes mellitus
c- Rheumatoid arthritis
d- Acromegaly

Answer: A

42- All of the following necessitate sending bacterial stool cultures in patients with diarrhea
for 2 days severe enough to keep them home from work except?
A. age >75
B. bloody stools
C. dehydration
D. recent lung transplantation
E. temperature >38.5°C

Answer: C

43- A 60-year-old right-handed woman is admitted with loss of power and sensation in the
right arm and leg, associated with word-finding difficulty. Physical examination confirms these
findings and reveals a right carotid bruit and normal heart sounds. The neurological signs
resolve over the two hours after admission. Her GP letter states that she has paroxysmal atrial
fibrillation and that she had a duodenal ulcer treated with triple therapy five years ago. She
takes no regular medication. Which one of the following treatments is the most appropriate
for secondary preventions of transient ischemic attacks?
a- Warfarin to an INR of 2-3.5
b- Aspirin and Omeprazole
c- Aspirin
d- Clopidogrel
e- Aspirin, dipyridamole, and omeprazole

Answer: A

44- Regarding systolic murmurs one of the following statements is False :

a- The murmur of a ventricular septal defect is pansystolic
b- Hypertrophic obstructive cardiomyopathy produces a murmur loudest on squatting
c- Aortic stenosis produces a mid-systolic murmur
d- Mitral valve prolapse produces a pansystolic murmur
e- An atrial septal defect produces an ejection systolic murmur

Answer: D

45- A 35-year-old teacher consults her GP. She gave birth to her second child five months ago.
When he was three months old, she returned to work and stopped breastfeeding. Since then,
she has been feeling anxious and irritable. On examination, the only abnormal finding was a
sinus tachycardia. Her GP checked her thyroid function tests, found that she was thyrotoxic
and referred her to the Endocrine Clinic. Which one of the following investigations would best
distinguish between Graves disease and postpartum thyroiditis?
a- FNA biopsy of the thyroid
b- Ultrasound scan of the thyroid
c- CT scan of the neck
d- Thyroid autoantibody titer
e- Isotope scan of the thyroid

Answer: D

46- A 60-year-old teacher is being investigated for increasing shortness of breath and diffuse
fibrotic changes found on plain chest X-rays. He was taking diuretics and anti-arrhythmic
treatment. The 12-lead ECG shows a prolonged QT interval. Each of the following clinical
situations could be responsible for this ECG abnormality, EXCEPT:
a- Heart failure
b- Hypokalemia
c- Hypercalcemia
d- Amiodarone therapy
e- Furosemide Therapy

Answer: C

47- Portosystemic Encephalopathy may be precipitated by all of the following EXCEPT:

a-Constipation
b- Gastrointestinal hemorrhage
c- Lactulose
d- Diuretics
e- Benzodiazepines

Answer: C

48- Which physical exam finding is most specific for pulmonary edema?
A. Dullness to percussion
B. Bilateral inspiratory crackles
C. Decreased breath sounds
D. Egophony

Answer: B

49- An autoantibody screen reveals that a patient is positive for anti-Jo 1 antibodies. What is
the most likely underlying diagnosis?

A. Limited cutaneous systemic sclerosis

B. Mixed connective tissue disease
C. SLE
D. Polymyositis
E. Diffuse cutaneous systemic sclerosis

Answer: D

50- A 16-year-old boy with sickle cell anemia (hemoglobin SS disease) comes to the emergency
department complaining of progressive exertional dyspnea, fatigue, and generalized
weakness. He has no fevers, chills, night sweats, or cough. His only medication is oxycodone
for chronic pain. His temperature is 36.7° C (98° F), blood pressure is 120/70 mm Hg, pulse is
76/min, and respirations are 18/min. The remainder of the examination is within normal
limits. Laboratory results are as follows: Hematocrit 20% Mean corpuscular volume 110 fL
Reticulocyte count 1.5%. Which of the following is the most likely underlying mechanism for
these findings?

A. Adverse drug reaction

B. Folate deficiency
C. Hyperhemolytic crisis

D. Iron overload

E. Malabsorption

F. Splenic sequestration

Answer: B