Internal Medicine Midterm G ( A+B )

1. A 45-year-old African American woman with systemic lupus erythematosus (SLE) presents to the emergency
department with complaints of headache and fatigue. Her prior manifestations of SLE have been arthralgias,
hemolytic anemia, malar rash, and mouth ulcers, and she is known to have high titers of antibodies to double-
stranded DNA. She currently is taking prednisone, 5 mg daily, and hydroxychloroquine, 200 mg daily. On
presentation, she is found to have a blood pressure of 190/110 mmHg with a heart rate of 98 bpm. A urinalysis
shows 25 red blood cells (RBCs) per highpower field with 2+ proteinuria. No RBC casts are identified. Her blood
urea nitrogen is 88 mg/dL, and creatinine is 2.6 mg/dL (baseline 0.8 mg/dL). She has not previously had renal
disease related to SLE and is not taking nonsteroidal anti-inflammatory drugs. She denies any recent illness,
decreased oral intake, or diarrhea. What is the most appropriate next step in the management of this patient?

A. Initiate cyclophosphamide, 500 mg/m 2 body surface area intravenously (IV), and plan to repeat monthly for 3–
6 months.
B. Initiate hemodialysis.
C. Initiate high-dose steroid therapy (IV methylprednisolone, 1000 mg daily for 3 doses, followed by oral
prednisone, 1 mg/kg daily) and mycophenolate mofetil, 2 g daily.
D. Initiate plasmapheresis.
E. Withhold all therapy until renal biopsy is performed.

2. A 56-year-old man has had sinusitis for a few months. Recently, he complained of bloody nasal discharge,
cough, and shortness of breath. The chest X-ray shows diffuse area of consolidation cavities in the right middle
lobe and left upper lobe. Urinalysis shows red blood casts and +4 protein. The most likely diagnosis is:
A. pulmonary tuberculosis
B. Sarcoidosis
C. Aspiration pneumonia
D. Wegener's granulomatosis
F. Carcinoma of the bronchus

3. Which of the following patients is appropriately diagnosed with asthma?

A. A 24-year-old woman treated with inhaled corticosteroids for cough and wheezing that has persisted for 6
weeks following a viral upper respiratory infection
B. A 26-year-old man who coughs and occasionally wheezes following exercise in cold weather
C. A 34-year-old woman evaluated for chronic cough with an FEV 1 /FVC ratio of 68% with an FEV 1 that
increases from 1.68 L (52% predicted) to 1.98 L (61% predicted) after albuterol (18% change in FEV 1 )
D. A 44-year-old man who works as a technician caring for the mice in a medical research laboratory and
complains of wheezing, shortness of breath, and cough that are most severe at the end of the week
E. A 60-year-old man who has smoked two packs of cigarettes per day for 40 years who has dyspnea and cough
and who has airway hyperreactivity in response to methacholine

4. -A 64-year-old woman was diagnosed 1 year ago with small cell carcinoma of the lung. She was doing well until
she became confused and lethargic and subsequently had a tonic-clonic seizure. On arrival to the emergency room,
she had a normal heart rate and blood pressure, and on examination, her lungs were clear and no edema was
present. Blood work revealed Na+ 112 mEq/L, serum osmolality 230 mOsm/kg, and urine osmolality 650 mOsm/
kg. which one of the following is the best initial intervention?
A. Administer a vasopressin receptor antagonist
B. Place on fluid restriction and administer phenytoin
C. Administer 3% sodium chloride intravenously
D. Administer a loop diuretic and normal saline intravenously to increase free water excretion
E. Observation
5. A patient is diagnosed with Anterior STEMI. His Blood pressure is 130/80. His heart rate is 69 bpm, and O2
saturation is 96%. Which of the following is the initial treatment for his condition?
A. Aspirin, Clopidogrel, Heparin, metoprolol, O2, Nitrates
B. Aspirin, Clopidogrel, Heparin, metoprolol, Nitrates
C. Aspirin, Clopidogrel, metoprolol, O2
D. Aspirin, metoprolol, O2, Nitrates
E. Aspirin, Clopidogrel, Heparin, O2, Nitrates

6. Which one of the following organisms causes cellulitis?

A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Staphylococcus epidermidis
D. Streptococcus pyogenes
E. Streptococcus viridans

7. Heinz bodies in hemolytic anemia are present in:

A. G6PD deficiency
B. Post splenectomy
C. Cold agglutinin disease
D. Paroxysmal nocturnal haemoglobinuria
E. Clostridium welchii septicaemia

8. You review a 48-year-old man after an episode of variceal hematemesis. He received injection sclerotherapy
and is already on spironolactone. Which of the following would be the most appropriate to reduce portal blood
pressure in this man?
A. Atenolol
B. Propranolol
C. Isosorbide dinitrate
D. Furosemide
E. Lactulose

9. A 72-year-old woman with poorly controlled type 2 diabetes mellitus presents to your clinic
one week after being discharged from the hospital. She had been admitted with pyelonephritis
secondary to a multi-drug resistant organism, and received several days of intravenous antibiotics.
Her serum creatinine on admission had been 2.1mg/dl. Today it is found to be 4.9 mg/dl.
Urinalysis reveals rare epithelial casts and no white blood cells. FENa is greater than 2%. What
antibiotic did she most likely receive during her hospitalization?
A. Nafcillin
B. Vancomycin
C. Levofloxacin
D. Amikacin
E. Doxycycline
F. Azithromycin

10. A 40-year-old lady was admitted to the hospital with fever and a productive cough. CXR shows diffuse patchy
consolidation around the left lung. She had a flu-like illness 4 weeks ago, and has a past medical history of
asthma. She also smokes. Which organism is likely to be responsible?
A. Mycoplasma
B. B. Pseudomonas
C. C. Klebsiella
D. Staphylococcus
E. Tuberculosis
11. A 60-year-old lady with a history of diabetes mellitus, essential hypertension and ischemic heart disease with
a myocardial infarct, is noted to have platelet count of 700 × 10 /L (150-400). Bone marrow biopsy shows
increased megakaryocytes with lobulated nuclei and abnormal localization. JAK-2 mutation is positive. What is
the correct management of this patient with essential thrombocythemia?
A. Interferon
B. Anagrelide
C. Aspirin + hydroxycarbamide
D. Aspirin
E. Hydroxycarbamide

12. Which of the following statements is true of sickle cell disease?

A. The spleen is frequently enlarged
B. There is often an inability to concentrate urine
C. Symptoms of anemia are usually limiting when Hb equals 8 g/dl
D. Oral iron supplements are required
E. A painful shoulder joint will respond to an intra- articular corticosteroid injection

13. A 25-year-old woman presents to the General Practitioner with complaints of severe earache on the left side
for the past two days. She also complains of inferolateral deviation of the left angle of the mouth for the past 24
hours. On examination, her blood pressure is 120/78 mmHg and her heart rate is 76 bpm. Neurological
examination does not reveal any weakness of the extremities. She has a deviation of the angle of the mouth to the
right side and is unable to close her left eyelid or wrinkle her forehead on the left side. Local examination of her
left ear reveals vesicular lesions on an erythematous base in her external ear canal. Which of the following is the
best line of management for this patient?
A. Oral aciclovir and prednisolone
B. Oral valaciclovir alone
C. Physiotherapy and facial nerve stimulation
D. Prednisolone alone
E. Topical aciclovir cream in the external ear canal

14. Which of the following would most likely cause a transudate?

A. Tuberculosis
B. Chest trauma
C. CABG with a left internal mammary artery
D. Constrictive pericarditis
E. Bacterial pneumonia

15. A 64 year old male presents with general malaise, weight loss and night sweats. He also
complains of abdominal discomfort in the left upper quadrant . On examination there is
evidence of massive splenomegaly. Bloods revealed a low haemoglobin and neutropenia. A
blood film reveals leukoerythroblastosis with tear drop, poikilocytosis, and megakaryocyte
fragments. What is the most likely diagnosis?
A. CML
B. Myelofibrosis
C. Myelodysplasia
D. AML
E. Non Hodgkin’s lymphoma

16. Which one of the following is most characteristic of type 1 renal tubular acidosis?
A. Hyperkalemia
B. Osteomalacia
C. Decreased bicarbonate reabsorption in the proximal tubule
D. Renal stones
E. Raised anion gap metabolic acidosis
17. Arterial blood gas results on room air from a patient newly admitted to the intensive care unit are as follows: pH:
7.42 PaCO2: 25, PaO2: 100, Bicarbonate: 14 mEq/L. Which of the following patients is most likely to have these
laboratory values?
A. 36-year-old patient with stridor after an allergic reaction
B. 42-year-old patient with acute asthma exacerbation
C. 42-year-old patient with aspirin toxicity
D. 52-year-old patient with persistent vomiting
E. 64-year-old patient with excessive diuresis

18. A 27-year-old Zimbabwean woman presents following two episodes of hematemesis. She gives a 4-week history
of increasing heartburn and dysphagia for both solids and liquids. She has been treated with anti-reflux medication,
with only partial relief. She has lost 2 kg in the last 6 weeks. On examination, there is cervical lymphadenopathy and
mild epigastric tenderness on palpation. Abdominal examination is otherwise unremarkable. Gastroscopy reveals
widespread shallow ulceration of the esophagus with adherent white patches. What is the likely underlying etiology
of her complaints?
A. Scleroderma
B. neurological condition
C. HIV infection
D. Esophageal neoplasia
E. Barrett’s esophagus

19. The following investigations (TSH = 0.2 mU/l, Free T4 = 7.1 ng/dl (high), Free T3 (high), ESR = 54 mm/hr,
Anti-TSH receptor stimulating antibodies: Negative) are compatible with:
A- Hashimoto thyroiditis
B- Grave’s disease
C- Post-viral thyroiditis
D- Primary hypoparathyroidism
E- Primary hyperparathyroidism

20. Which of the following haematological disorders is inherited as an autosomal recessive condition
A. Antithrombin III deficiency
B. Protein C deficiency
C. Glucose-6-phosphate dehydrogenase deficiency
D. Pyruvate kinase deficiency
E. Acute intermittent porphyria

21. A 65-year-old woman is evaluated for dyspnea on exertion and chronic cough. She has a long history of tobacco
use, smoking 1.5 packs of cigarettes daily since the age of 20. She is a thin woman in no obvious distress. Her
oxygen saturation on room air is 93% with a respiratory rate of 22 breaths/min. The lungs are hyperexpanded on
percussion with decreased breath sounds in the upper lung fields. You suspect COPD. What are the expected
findings on pulmonary function testing?
22. You are told by your registrar that one of the clinic patients has been admitted with a ‘flare up’ of ulcerative
colitis (UC) which he reports as being severe. From the list of answers below, select the parameters which are likely
to reflect a severe flare up of ulcerative colitis:
A. Fewer than four bowel motions per day with large amounts of rectal bleeding
B. Between four and six bowel motions per day with large amounts of rectal bleeding
C. More than four bowel motions per day with large amounts of rectal bleeding
D. More than five bowel motions per day with large amounts of rectal bleeding
E. More than six bowel motions per day with large amounts of rectal bleeding

23. In patients with established rheumatoid arthritis, all of the following pulmonary radiographic findings may be
explained by their rheumatologic condition EXCEPT:
A. Bilateral interstitial infiltrates
B. Bronchiectasis
C. Lobar infiltrate
D. Solitary pulmonary nodule
E. Unilateral pleural effusion

24. You read a report which was handwritten in a patient’s medical notes who you suspect has inflammatory bowel
disease. The report reads, ‘… there is cobblestoning of the terminal ileum with the appearance of rose thorn ulcers.
These findings are suggestive of Crohn’s disease’. Select the most likely investigation that this report was derived
from:
A. Colonoscopy
B. Sigmoidoscopy
C. Barium follow through
D. Abdominal CT
E. Abdominal ultrasound

25. Chronic silicosis is related to an increased risk of which of the following conditions?
A. Infection with invasive Aspergillus
B. Infection with Mycobacterium tuberculosis
C. Lung cancer
D. Rheumatoid arthritis
E. All of the above
F. B+C

26. Check ECG, which of the following arteries mostly occluded?

A. RCA
B. LAD
C. Left circumflex artery
D. Left coronary artery

Photo not identical but similar

27. A 53-year-old man presents to the clinic for evaluation of persistent diarrhea lasting more than 1 month. He has
also noticed symptoms of facial flushing lasting minutes at a time with no clear precipitant. On physical
examination, his blood pressure is 124/74 mm Hg, heart rate is 84 and regular, and there are facial telangiectasias
on head and neck examination. He also has a systolic heart murmur that was not present 2 years before. This
murmur is accentuated by deep breathing. Which of the following is the most appropriate initial diagnostic test?
(A) urinary vanillylmandelic acid (VMA)
(B) serum noradrenaline levels
(C) barium enema
(D) serum serotonin levels
(E) urinary 5-hydroxyindolacetic acid (5-HIAA)