UNIVERSITY OF MEDICINE, MANDALAY

DEPARTMENT OF MEDICINE

FINAL PART 2 (Problem & Data)

2023

Page 1 of 128
 CONTENT

Page

1. Cardiology 3
2. Hematology 14
3. Infection 26
4. Diabetes, Endocrine and Metabolism 42
5. Liver & GI 59
6. Therapeutic & toxicology
7. Renal 77
8. Respiration 84
9. Rheumatology 95
10. CNS & miscellaneous 107
11. Psychiatry 122
12. Poisoning 126

Page 2 of 128
 1. CARDIOLOGY

Q1. A 65-year-old female who come to visit outpatient clinic for general medical
checkup. Her BMI of 33.5 kg/m2 and blood pressure of 160/90 mmHg. ECG shown
below.

1. What ECG changes do you notice?

2. What tests would you like to do?

Page 3 of 128
Q2. A 40-year-old lady with DM is admitted with a 30-minute history of heavy central
chest pain associated with nausea and sweating. Her BP is 140/90 mmHg.
Her ECG has shown below:

1. Describe significant findings in ECG.

2. Which of the following coronary arteries is most likely to be occluded?

A. Circumflex artery
B. Left anterior descending artery
C. Obtuse marginal artery
D. Posterior descending artery
E. Right coronary artery

3. What is the definitive treatment for her problem?

A. Anticoagulants
B. Antiplatelets
C. primary PCI
D. lipid lowering agents
E. Antihypertensives

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Q3. A 35-year-old lady with hypertension which is difficult to control. She is currently
being treated with atenolol, amlodipine and ramipril but her blood pressure
remains consistently above 170/100. Examination reveals grade II hypertensive
retinopathy.
Her investigations result as following:

Sodium 144 mmol/L (137-144)

Potassium 2.1 mmol/L (3.5-4.9)
Urea 5.5 mmol/L (2.5-7.5)
Creatinine 100 mol/L (60-110)
Fasting Glucose 6.5 mmol/L (3.0-6.0)
HbA1c 6.1% (3.8-6.4)
ECG Left ventricular hypertrophy and U wave

1. Which diagnosis should be considered as a cause of his resistant hypertension?

A. Conn’s syndrome (primary hyperaldosteronism)
B. Cushing’s syndrome
C. Phaeochromocytoma
D. Primary hyperparathyroidism
E. Renal artery stenosis

2. What investigations would you like to do to confirm your diagnosis?

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Q4. A 66-year-old man with diabetes nephropathy presenting with palpitations and
fainting attack. Her BP is 150/90 mmHg. Investigations as follow:

Sodium 144 mmol/L

Potassium 6 mmol/L
Chloride 100 mmol/L
Bicarbonate 20 mmol/L
Creatinine 3 mg/dl
Fasting Glucose 5.2 mmol/L

ECG show:

1. Describe the abnormal findings in ECG.

The anesthetist is supporting airway and breathing.

2. Which of the following is the immediate next step in his management?
A. Adrenaline 1 mg
B. Amiodarone 300 mg
C. Cardiopulmonary resuscitation (CPR) 15:2 for two minutes
D. Defibrillation at 150 J biphasic
E. Precordial thump

3. After resuscitation process, patient is sinus rhythm and he survives. What is your next
step of treatment?
A. IV fluids
B. Treatment of hyperkalemia
C. Intracardiac defibrillator (ICD)
D. Antiarrhythmic agents
E. Insulin

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Q5. A 71-year-old lady with a history of previous myocardial infarction presents to the
Emergency department. She has sudden onset shortness of breath and palpitations
which happened after her dinner a couple of hours earlier. A previous ECG from
clinic a month earlier shows sinus rhythm. Medication includes simvastatin 10mg
daily, ramipril 10mg daily, amlodipine 10mg daily and aspirin 75mg. On
examination her blood pressure is 100/60 mmHg.

ECG has shown

1. Describe the ECG findings.

2. Which of the following is the most appropriate medication?

A. Digoxin
B. Amiodarone
C. Flecainide
D. Sotalol
E. Verapamil

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Q6. A 45-year-old lady is undergone surgery (TAH & BSO) for ovarium tumor. On 3rd
post operative day, she complains of sudden onset of shortness of the breath, severe
chest pain associated with sweating. HR is 140/min, BP is 100/70 mmHg and SPO2
is 88%

ECG shows:

1. Describe the ECG abnormalities.

2. What is the possible diagnosis?

A. AMI
B. Aortic dissection
C. Aspiration pneumonia
D. Pulmonary embolism
E. Pneumothorax
3. What is the standard investigation of choice for your diagnosis?
A. CT Pulmonary angiogram
B. CXR (PA)
C. Troponin T
D. D dimer
E. Coronary angiogram

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Q7. A 70-year-old lady presented with sudden onset of expressive dysphasia and a right
hemiparesis. She had a long-standing history of hypertension and history of TIA
five years ago. But she had no history of diabetes. On examination she had a heart
rate of 100 beats/min, irregularly irregular. Her BP was 170/100 mmHg. There was
clear evidence of an expressive dysphasia and left sided hemiparesis.

1. What is your provisional diagnosis?

A. ICH
B. SAH
C. cerebral thrombosis
D. cerebral embolism
E. hypertensive encephalopathy

2. What investigations would you like to do to confirm the diagnosis?

A. ECG
B. CXR
C. CT
D. MRI
E. ECHO

3. What is your immediate treatment?

A. antihypertensive
B. Mannitol
C. antiplatelet
D. anticoagulant
E. rate limiting drug

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Q8. A 60-year-old man attended the emergency OPD with central chest pain radiating
to the jaw. He had family history of ischemic heart disease.

ECG shown:

1. Describe ECG findings

Urgent blood tests are

Total cholesterol 250 mg/dl

HDL 36 mg/dl
Triglyceride 300 mg/dl
LDL 120 mg/dl
Troponin T 12 hour after admission 0.4 ng/l (N<0.1)
Fasting Glucose 12 mmol/L

2. Comments on his blood tests results

3. What is the diagnosis?

A. acute ST elevation myocardial infarction
B. musculoskeletal chest pain
C. stable angina
D. non-ST elevation myocardial infarction
E. unstable angina

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Q9. A 29-year-old woman presented with one week history of increasing dyspnea,
orthopnoea and PND. She had undergone normal vaginal delivery two weeks ago.
The blood pressure throughout pregnancy was normal. On examination Blood
pressure was100/60 mmHg, pulse rate was 120 beat/min and regular. Temperature
was 99·F. JVP was raised. Palpation of the precordium revealed a displaced and
prominent apex. On auscultation both heart sounds were normal with a third heart
sound. Auscultation of the lung revealed inspiratory crackles at both bases.

1. What is the most likely diagnosis?

A. Idiopathic dilated cardiomyopathy
B. infective endocarditis
C. anaemic heart failure
D. viral myocarditis
E. peri-partum cardiomyopathy

2. What appropriate investigation would you like to do?

A. ECG
B. blood culture
C. blood for complete picture
D. CXR
E. ECHO

3. What are the appropriate management for the patient?

A. ACEI
B. anticoagulation
C. diuretic
D. beta blocker
E. statin

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Q10. A 62-year-old male patient presented with fever and breathlessness four weeks
before admission. On examination he looks pale and temperature of 38· F. Blood
pressure was 90/60 mmHg, pulse rate was 110/min. Auscultation of heart revealed
pansystolic murmur at mitral area. Lung examination revealed inspiratory crackle
at both lung base.

1. What is the provisional diagnosis?

A. Chest infection
B. infective endocarditis
C. suppurative lung disease
D. acute viral infection
E. myocarditis

2. Which investigations will confirm the diagnosis?

A. CXR
B. blood culture
C. sputum culture
D. ECG
E. ECHO

3. Which organism is most likely in the blood culture?

A. streptococcus pneumonia
B. streptococcus viridian
C. staphylococcus aureus
D. Hemophilus influenza
E. Streptococcus faecalis

4. What is the most appropriate treatment?

A. IV Benzyl penicillin + gentamycin
B. IV Ampicillin + gentamycin
C. IV Flucloxacillin
D. IV Vancomycin
E. IV Benzyl penicillin alone

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 Cardiology (key)
Q1. 1. Sinus rhythm HR- 75/min Q6. 1. Sinus rhythm HR- 100/min
Deep S in V1,V2,V3/ Tall R in S1 Q3 T3 pattern
V5,V6 2. D
LVH 3. A

2. (i) Serum Creatinine / electrolyte Q7. 1. D

2. C/E
/UREME/lipid profile
3. C
(ii) CXR/ Ultrasound (abdomen
and pelvis) Q8. 1. T inversion in lead II ,III,aVF (Inferior
(iii) Echocardiogram ischemia)(arrow-headed T wave)
2. Total Cholesterol (raised)
HDL – normal
Q2. 1.Sinus rhythm 100/min LDL – normal
ST elevation at I ,aVL, V1,V2,V3 TG- raised
ST depression at II, III , aVF Fasting blood glucose – raised
(reciprocal changes) 3. D
2. B Q9. 1. E
3. C 2. E
3.C
Q3. 1. A
2. Renin : Aldosterone ratio, USS
(abd/pelvis) Q10. 1. B
2. B , E
3. B
Q4. 1.Ventricular tachycardia
2. D 4. A
3. B

Q5. 1. Left axis deviation

Atrial fibrillation HR – 80/Min
2. B

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 2. HAEMATOLOGY

Q1. A 45-year-old man, previously well, receives a unit of blood on a surgical ward.
Shortly after the transfusion commences you are bleeped to the ward and told that
he has had blood reaction.

1. What is your immediate action?

A. Inform to seniors
B. Look for signs and symptoms of possible acute transfusion reaction
C. Take the patient to ICU
D. Reassure the patient
E. Give IV fluid

2. If patient has hypotension, urticaria and feeling unwell, what will you do next?
A. Discard the blood
B. Stop transfusion
C. Rapid clinical assessment
D. Check identity of recipient details on the unit and compatibility form
E. Give IV antibiotics

3. Which of the following is the most common cause of this scenario?

A. Incorrect blood unit being given (i.e. for another patient)
B. Bacterial infection of blood
C. Reaction to HLA antibodies
D. Circulatory overload
E. Allergic reaction to white cells

4. What is your action if it is severe allergic reaction? What are

A. Discontinue transfusion
B. Give IV Chlorphenamine 10mg slowly
C. Give IV adrenaline
D. Give IM adrenaline 0.5 mg
E. Give Furosemide

Q2. A 26-year-old woman, who feels completely well, comes to the Accident and
Emergency department because she has developed spots. Examination reveals
widespread petechiae but nothing else abnormal.

1. What are the appropriate investigations?

A. Full Blood Count
B. Coagulation screen
C. CXR
D. ECG
E. Dengue antigen and antibody test

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 2. Hb= 9 gm%, WBC= 5.5* 109/L , Platelet = 60* 10 9 L and normal coagulation screen.
What is the most likely diagnosis?
A. Meningococcal septicaemia
B. Idiopathic thrombocytopenic purpura
C. Acute lymphatic leukaemia
D. Systemic lupus erythematosus
E. Haemolytic uraemic syndrome

3. What is the most appropriate treatment for this patient?

A. Platelet transfusion
B. Transfusion of whole blood
C. Packed cell transfusion
D. Corticosteroids
E. Vitamin C

4. If the patient suffers from frequent relapses, what are the treatment options?
A. Splenectomy
B. Bone marrow transplant
C. Thrombopoietin receptor agonist
D. Thalidomide
E. Immunosuppressants

Q3. A previously well 57-year-old lady with only a past history of allergy went to her GP
complaining of lethargy and recurrent ‘flu-like’ symptoms. There is no
organomegaly. Her complete blood count was Hb 13.1, WBC 279 x 10^9/l and
platelets 567 x 10^9/l. A blood film shows myelocytes, metamyelocytes, eosinophils
and basophils.

1. Which of the following statements is true?

A. She has developed chronic myeloid leukaemia.
B. She has developed a leukaemoid response to her bracelet.
C. She has developed acute lymphoblastic leukaemia.
D. She has developed primary thrombocythemia.
E. She has developed an infection and should respond to antibiotics.

2. What are the other appropriate tests for this patient?

A. LDH
B. Uric acid
C. CT (abdomen)
D. Viral screening
E. Sputum examination

3. What is the most appropriate treatment option?

A. Blood transfusion
B. Thalidomide
C. Imatinib
D. Botezomib
E. IV antibiotics

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 4. What are tyrosine kinase inhibitors used in CML?
A. Nilotinib
B. Rituximab
C. Eculizumab
D. Imatinib
E. Erlotinib

Q4. A 78-year-old lady presents with a 3-month history of worsening back pain. Her
FBC shows rouleaux with Hb of 10.2g/dl, and she has moderately impaired renal
function.

1. What is the most likely diagnosis?

A. Multiple myeloma
B. Renal stone
C. RA
D. OA
E. Ankylosing spondylitis

2. What are the appropriate investigations to get the definite diagnosis for this patient?
A. Urinary Bence- Jones protein
B. Liver function test
C. Viral screening
D. Serum protein electrophoresis
E. Sputum examination

3. What are the treatment options for this patient?

A. Calcium
B. Botezomib
C. Potassium
D. Bisphosphonate
E. Antibiotics

4. If dipstick testing of her urine is negative for protein and serum electrophoresis fails to
demonstrate a monoclonal band. Which one of the following statements is true?
A. She does not have myeloma.
B. Polymyalgia rheumatica is the most likely diagnosis.
C. She may have myeloma that produces only free light chains.
D. Bone pain is an unusual presentation of myeloma.
E. Negative protein on dipstick testing of urine rules out the presence of Bence-Jones
protein.

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Q5. A 22-year-old woman has had heavy periods ever since she can remember, certainly
for many years. Her FBC shows Hb= 7.8 gm/ dl, MCV= 68 FL, MCH= 26.6 pg,
MCHC= 29 g/dl, WBC- 5.5* 109, Platelets= 200* 109.

1. What is the diagnosis?

A. Normochromic normocytic anaemia
B. Hypochromic microcytic anaemia
C. Thrombocytopenia
D. Macrocytic anaemia
E. Megaloblastic anaemia

2. What further investigations would you like to get definite diagnosis?

A. Serum iron, TIBC, Ferritin
B. Creatinine
C. Electrolytes
D. Coagulation screen
E. CXR

3. What condition must be considered?

A. Haemophilia
B. Hypothyroidism
C. Disseminated intravascular coagulation (DI
D. Chronic liver disease
E. Idiopathic thrombocytopenic purpura (ITP)

4. Which test will you do to know the underlying cause?

A. Factor VIII and IX
B. Thyroid function test
C. Fibrinogen level
D. Liver function test
E. Platelet autoantibody

Q6. 35-year-old woman who has been dyspnoeic for a few months came to hospital. Her
full blood count has shown Hb= 8 gm/dl, MCV=110 FL, WBC= 5.5* 109L , Platelet=
170* 109 L.

1. So, she has

A. Hypochromic microcytic anaemia
B. Macrocytic anaemia
C. Thrombocytosis
D. Leucocytosis
E. Normocytic anaemia

2. Which is the least likely cause?

A. Liver disease
B. Hypothyroidism
C. B12 deficiency
D. Chronic obstructive pulmonary disease
E. Folate deficiency

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 3. Which investigation is least effective for this case?
A. Liver function test
B. Thyroid function test
C. Lipid profile
D. CXR
E. B12 and folate level

4. If bone marrow aspirate shows no megaloblastic changes, what are the least likely
causes of the macrocytosis?
A. Hypothyroidism
B. Liver disease
C. B12 deficiency
D. Pregnancy
E. Folate defi

Q7. A 15 years-old boy presenting with pallor and yellowish discoloration of sclera for 2
months.

1. What physical examination would you like to do?

A. Hepatosplenomegaly
B. Ascites
C. Lymphadenopathy
D. CVS examination
E. All of the above

2. On examination, he has mild hepatosplenomegaly. What will you consider?

A. COL
B. Chronic hemolytic anaemia, thalassaemia
C. CML
D. Aplastic anaemia
E. ITP

3. What investigations would you like to do to get the diagnosis?

A. Full blood count
B. Hb electrophoresis
C. Bone marrow examination
D. Lymph node examination
E. Iron study and ferritin

4. If he has hypochromic microcytic anemia, increased ferritin and increased HbA2 in Hb

electrophoresis, patient has
A. IDA
B. COL
C. CML
D. B thalassaemia trait
E. ITP

Page 18 of 128
Q8. A 15 years-old girl presenting with marked pallor since 5 years of age and she has
huge splenomegaly. She also has history of repeated blood transfusion.

1. What is your provisional diagnosis?

A. Aplastic anaemia
B. ITP
C. Thalassaemia major
D. Hemophilia
E. IE

2. What investigations would you like to do to confirm your diagnosis?

A. Full Blood Count
B. Bone marrow examination
C. Hb electrophoresis
D. Lymph node biopsy
E. Coagulation screen

3. What complications would you like to look for?

A. Cardiomyopathy
B. Growth retardation
C. Hypersplenism
D. Anaemic heart failure
E. All of the above

4. If Hb= 5 gm%, WBC = 2.2* 109L, Platelet= 50* 109L, what would you consider?
A. Hypopituitarism
B. Hypersplenism
C. Cardiomyopathy
D. Bone marrow infiltration
E. IE

Q9. A 25 years old lady presenting with fever and pallor for 2 weeks. She also noticed
red spots all over her body.

1. What would you like to look for?

A. Hepatomegaly
B. Splenomegaly
C. Lymphadenopathy
D. Other mucocutaneous bleeding
E. All of the above

2. If there is no hepatosplenomegaly and lymphadenopathy, what will you consider?

A. TB
B. Aplastic anaemia
C. Enteric fever
D. Hemophilia
E. Leukaemia

Page 19 of 128
 3. What investigations will you like to do to confirm the diagnosis?
A. Full blood count
B. Bone marrow examination
C. Iron study
D. CXR
E. Ultrasound abdomen

4. What are the treatment modalities for this patient?

A. Supportive therapy
B. Bone marrow transplant
C. Cyclosporin
D. Antithymocyte globulin
E. All of the above

5. What are the risk factors for his illness?

A. Viral hepatitis
B. Drugs or toxins
C. Radiation
D. SLE
E. All of the above

Q10. A 17 years-old boy came to the hospital with right knee joint swelling.

1. What are your differential diagnoses?

A. Septic arthritis
B. Hemearthrosis
C. Osteomyelitis
D. Polyarticular juvenile idiopathic arthritis
E. Reactive arthritis

2. What investigations would you like to do?

A. Knee X rays
B. Coagulation screen
C. Joint aspiration
D. ASO titre
E. Creatinine

3. If prolonged coagulation screen is found, what is the most likely diagnosis?

A. ITP
B. Leukaemia
C. Hemophilia
D. Aplastic anemia
E. Von-Willebrand disease

4. How will you manage this patient?

A. Joint aspiration
B. Antibiotic
C. Rest
D. Factor VIII concentrate
E. Cryoprecipitate

Page 20 of 128
 5. What type of inheritance it is?
A. Autosomal dominant
B. Autosomal recessive
C. X- link recessive
D. X- link dominant
E. Polygenic

6. Who have chance of similar attack among his relatives?

A. Uncles of his mother
B. His sister
C. His aunty
D. His father
E. His brothers

Q11. A 22 years-old boy presented with neck gland swelling for 3 months.
1. Which point will you emphasize on history taking?
A. Chronic cough
B. Sweating
C. Alcohol induced pain
D. Loss of appetite and loss of weight
E. All of the above

2. What will you look for in physical examination?

A. Hepatomegaly
B. Splenomegaly
C. Other Lymph node enlargement
D. Other mucocutaneous bleeding
E. All of the above

3. Which investigations would you like to do?

A. Lymph node biopsy
B. Full blood count
C. Urine culture
D. Bone marrow examination
E. Blood culture

4. Reed Sternberg Giant cell is found in lymph node biopsy, what is the most likely
diagnosis?
A. Non Hodgkin lymphoma
B. Hodgkin lymphoma
C. Acute myeloid leukaemia
D. Acute lymphoblastic leukaemia
E. Chronic myeloid leukaemia

5. What are the treatment options?

A. Chemotherapy
B. Radiotherapy
C. Broad spectrum antibiotics
D. Anti- TB
E. Antiviral

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Q12. A 22 years-old boy presenting with mass in abdomen, fever and weight loss for 4
months duration.

1. What are the differential diagnoses?

A. Leukaemia
B. Lymphoma
C. Aplastic anemia
D. ITP
E. Hemophilia

2. Which investigations would you like to do?

A. Lymph node biopsy
B. Full blood count
C. Urine culture
D. Bone marrow examination
E. Blood culture

3. Bone marrow examination shows lymphocyte predominant. What is your diagnosis?

A. Non Hodgkin lymphoma
B. Hodgkin lymphoma
C. Acute myeloid leukaemia
D. Acute lymphoblastic leukaemia
E. Chronic myeloid leukaemia

4. What are the treatment options?

A. Chemotherapy
B. Radiotherapy
C. Broad spectrum antibiotics
D. Anti- TB
E. Antiviral

Q13. A 14 years-old boy presenting with pallor and black urine.

1. What are the differential diagnoses?

A. Malaria
B. Enteric fever
C. G6PD deficiency
D. Thalassaemia
E. ITP

2. What investigations would you like to do?

A. Full blood count
B. G6PD assay
C. Hb electrophoresis
D. Bone marrow examination
E. Coagulation screen

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 3. He gave history of taking Feva Bean. What is the most likely diagnosis?
A. Hemophilia
B. G6PD deficiency
C. Thalassaemia
D. ITP
E. Malaria

4. How will you treat this patient?

A. Blood transfusion
B. BM transplant
C. Antibiotics
D. Antimalarial drugs
E. Cryoprecipitate

Q14. A 17 years old girl has experienced prolonged bleeding following a tooth extraction.

1. What investigations will you do?

A. Full blood count
B. PT, APTT
C. Bone marrow examination
D. Lymph node biopsy
E. CXR

2. According to blood results, Hb= 12 gm%, WBC= 5.5* 109 L, Platelet= 220*109 L,
APTT is prolonged, what is the most likely diagnosis?
A. Aplastic anemia
B. Leukaemia
C.Von Willibrand disease
D. Lymphoma
E. ITP

3. How will you treat this patient?

A. Packed red cell
B. Platelet concentrate
C. DDAVP
D. Antibiotics
E. Factor VIII concentrate

Q15. A 20 year old man presents to casualty with short history of malaise. Over the last
day, he has noticed a few bruises on his limbs. His full blood count reveals WBC=
34* 109/ L, platelet count = 25*109/ L and Hb = 7.8 gm%. The blood film shows
Auer rods.

1. What is the most likely diagnosis?

A. Acute lymphoblastic leukaemia
B. Acute myeloid leukaemia
C. Chronic myeloid leukaemia
D. Hemophilia A
E. Chronic lymphocytic leukaemia

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 2. His OSPT is 25 sec and APTT is 42 sec, what type is it?
A. FAb type M2
B. FAb type M3
C. FAb type M4
D. FAb type M5
E. FAb type M2

3. Treatment options for this disease include followings except

A. Systemic chemotherapy
B. Supportive care
C. Bone marrow transplant
D. ATRA
E. All of the above

Q16. A 16 years-old boy has been diagnosed with acute lymphoblastic leukaemia. His
WBC is 10*109/L, platelet count is 100*109/L and Hb is 14gm% at diagnosis.

1. Which of these factors is associated with the better outcome?

A. Age
B. Gender
C. Hemoglobin level
D. White cell count
E. Platelet count

2. What are the complications of this disease?

A. Anaemia
B. Infection
C. Thrombocytopenia
D. Tumour lysis syndrome
E. All of the above

3. What are the treatment options?

A. Chemotherapy
B. Stem cell transplant
C. Supportive therapy
D. Psychological support
E. All of the above

Page 24 of 128
 2. HAEMATOLOGY KEY

1. B, B/C/D, A, A/B/D
2. A/B, B, D, A/C/E
3. A, A/B, C, A/D
4. A, A/D, B/D, C
5. B, A/D, B, B
6. B, D, D, C/E
7. A, A/B, A/B/E, D
8. C, A/C, E, B
9. E, B, A/B, E , E
10.A/B/E,A/B,C,C/D/E,B,A/E
11. E, E, A/B/D, B,A/B
12. A/B, B/D, A, A/B
13. A/C, A/B, B, A
14. A/B, C, C/E
15. B, B, E
16. D, E, E

Page 25 of 128
 3. INFECTION

1. A 23- old man, beautician developed neck gland enlargement and low-grade fever over one
month. He was recently found to have HIV seropositive. CD4 count was 180 cells/mm3.

1. The most possible cause is

A. Seroconversion of HIV
B. PGL (persistent generalized lymphadenopathy)
C. Lymphoma
D. TB
E. Malignancy

2. The next step would be

A. Administration of antibiotics
B. Starting ART
C. Starting anti-TB
D. Neck gland biopsy
E. CT neck

3. If he has strong evidence of extra- pulmonary TB, he is in WHO stage

A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Seroconversion

2. A middle-aged trishaw driver, known RVI, presented with acute and severe dyspnea. On
Physical examination, he was cyanosed and had oral thrush. Respiratory rate was 40/min.
spO2 86% (on air).

1. The most likely cause is

A. Acute severe bronchial asthma
B. Acute exacerbation of COPD
C. Community acquired pneumonia.
D. PCP
E. Cardiac Asthma

Page 26 of 128
 2. The next step of management would be
A. Short action B2 agonist bronchodilator
B. Short acting anti-cholinergic bronchodilator
C. O2 (high flow/ concentration)
D. Empirical antibiotics
E. Corticosteroid

3. The next step of investigation would be

A. CT (chest)
B. CXR(PA)
C. Sputum C&S
D. Lung function test
E. Blood for complete picture

4. The patient's CD4 count would be

A. >500 cell/mm3
B. < 350 cell/mm3
C. >350 cell/mm3
D. <200 cell/mm3
>200 cell/mm3

Q3. A middle-aged woman, HIV seropositive, without evidence of active opportunistic

infection, was recently on sulphamethoxazole-trimethroprim.
1. For which infection prophylaxis is aimed?
A. Malaria
B. TB
C. Pneumocystis Carinii Pneumonia (PCP)
D. Cryptococcosis
E. Community Acquired Pneumonia

2. After one week later, she developed macular rashes over trunk and limbs. The next prompt
action is
A. Stop sulphamethoxazole- trimethroprim
B. Reduce the dose
C. Add antibiotic
D. Steroid therapy
E. Antihistamine

3.When she recovers from it, the following alternative drug can be given.
A. Clindamycin
B. Tetracycline
C. Dapsone
D. Pyrimethamine
E. ART
Page 27 of 128
Q4. A middle aged MSM developed chronic (watery) diarrhoea not accompanied by
abdominal pain and fever. HIV serology- reactive and CD4 count was 98 cells/mm3.

1. The most common cause is

A. Cryptosporiodiosis
B. Isosporiasis
C. Shigellosis
D. Salmonellosis
E. Traveler’s diarrhea

2. The next step would be

A. Stool for Cryptosporiodiosis
B. Stool for cholera
C. Stool for C & S
D. Stool for REME
E. Stool fecal immunochemical test (FIT)

3. The appropriate treatment would be

A. Anti- helminth
B. Quinolone
C. Metronidazole
D. Supportive treatment & Initiation of ART
E. Oral rehydration salt

Q5. A 24yr old nurse gave herself a needle stick injury while taking blood from HIV
seropositive patient.

1. The immediate action should be

A. Prompt administration of ART
B. Washing the wound with soap under running water
C. Immediately take the nurse's blood for HIV Ab test
D. Injection of anti-tetanus toxoid
E. Injection of antibiotics

2. What is the chance that the nurse will develop HIV?

A. 0.03%
B. 0.3%
C. 1%
D. 3%
E. 5%

Page 28 of 128
 3. Risk of transmission is low if
A. High viral load
B. Low CD4
C. Low viral load
D. Deep wound
E. Hollow needle injury

4. Antiretroviral drugs should be given within

A. 72 hours
B. 5 days
C. 1 week
D. 2 weeks
E. 1 month

5. PEP should not contain

A. Zidovudine
B. Nevirapine
C. Lamivudine
D. Tenofovir
E. Lopinavir

Q6. A HIV seropositive patient presents with fever, lymphadenopathy, hepatosplenomegaly,

and anemia. He also has papular lesions with central umblication on his face.

1. The most likely diagnosis is

A. Penicillosis
B. Tuberculosis
C. Viral warts
D. Molluscum contagiosum
E. Lymphoma

2. Skin scrapping was sent to laboratory. It should be stained with

A. Ziehl-Neelsen stain
B. Gram's stain
C. Giemsa' s stain
D. India ink stain
E. H & E stain

3. On microscopic examination there are oval yeasts with central septation. The following
treatment should be given.
A. Amphotericin B infusion followed by itraconazole.
B. ART
C. Acyclovir
D. Antibiotics
E. Steroid
Page 29 of 128
Q7. A dentist referred you a patient with white patches in the mouth. You noticed those
lesions were oral candidiasis.
1. The patient has HIV infection and according to WHO clinical staging of HIV, he is in the
stage
A. I
B. II
C. III
D. IV
E. None of above

2. Other possible clinical conditions in his clinical stage are the following, expect;
A. Pulmonary TB
B. Oral hairy leukoplakia
C. Unexplained chronic diarrhoea for >1 month
D. Chronic herpes simplex infection > 1 month
E. Unexplained anaemia (<8g/dl)

3. How do you treat his oral candidiasis,

A. Povidone iodine oral solution
B. Oral antiseptic mouth wash
C. Oral itraconazole
D. Clotrimazole cream
E. Oral nystatin solution

Q8. A 40-year-old male patient with HIV infection presented with maculopapular rashes after
taking TDF+3TC+EFV for 10days.You think these rashes are drug induced rashes.
1. Which drug is /are ART commonly associated with drug induced rashes.
A. TDF
B. 3TC
C. EFV
D. TDF + 3TC
E. TDF + 3TC + EFV

2. There is no mucosa involvement in this patient, what would you do?

A. Stop ART and restart when rashes fade out.
B. Stop ART and never restart.
C. Change to 2nd line ART.
D. Give antihistamine and closely monitor and continue ART.
E. Adjust ART doses.
Page 30 of 128
 3. His rashes faded out and 1 month later, he complained of fever, cough and CXR shows
military tuberculosis. What would you do?
A. Stop ART and treat TB first
B. Change EFV to LPV/r for anti TB.
C. Continue same ART and start anti TB.
D. Wait anti TB until ART reach 8th week.
E. Adjust ART doses.

Q9. A 35-year-old homosexual man known to have HIV seropositive, presents with right sided
weakness and a two-week history of fever and headache. CD4 lymphocyte count is 50
cells/ml. The CT scan of the brain demonstrates a large ring-enhancing lesion in the
parietopontal region of the left hemisphere and several small lesions in the right
hemisphere.

1. What is the most likely diagnosis?

A. HIV encephalopathy
B. Lymphoma
C. Progressive multifocal leucoencephalopathy
D. Cerebral toxoplasmosis
E. Tuberculosis

2. What immediate action do you like to do?

A. CXR (PA)
B. Lumber puncture
C. Brain biopsy
D. Empirical treatment for cerebral toxoplasmosis
E. Start ART

3. Which of the following medication is preferred.

A. Injection ceftriazone
B. Pyrimethamine and sulphadiazine
C. Fluconazole
D. Injection artesunate
E. Anti-TB trial

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Q10. A 32-year-old female known to have HIV seropositive, presents with cough, weight loss
and worsening lymphadenopathy. History of note is that he commenced antiretroviral
therapy for 3 weeks. She is diagnosed HIV and disseminated TB co-infection 5 months
ago and he is commenced on four-fixed-dose combination anti-TB drugs. Sputum and
lymph node aspirate gene X pert confirm fully sensitive Mycobacterium Tuberculosis.

1. What is the most likely explanation of lymph node enlargement?

A. Lymphoma
B. Multidrug-resistant TB
C. Immune reconstitution disease
D. Staphylococcal infection
E. Noncompliance

2. What do you do?

A. Omit antiretroviral drugs.
B. Omit anti-TB.
C. Give short course steroid.
D. Continue both ART, anti-TB and short course steroid.
E. Refer to HIV specialist

Q11. HIV seropositive patient should receive appropriate prophylaxis against Pneumocystic
jiroveci (formerly called Pneumocystic carinii)

1. What is the most appropriate medication?

A. Ampicillin
B. Erythromycin
C. Co-trimoxazole
D. Corticosteroid
E. Rifabutin

2. When to start appropriate prophylaxis agent for Pneumocystic jiroveci?

A. CD4 < 200 cell/mm3
B. CD4 < 100 cell/mm3
C. CD4 < 50 cell/mm3
D. CD4 < 500 cell/mm3
E. CD4 > 500 cell/mm3
Page 32 of 128
Q12. A 35-year-old with advanced HIV disease is admitted for confusion, headache and fever
for 2 weeks. He was diagnosed HIV infection 3 weeks prior and CD4 count – 23, started
on septrin for 3 weeks and planned to start ART in the next visit. On examination, T is
101°F, GCS (E-3, V-3, M-5), no focal deficit and CT (head) reveals normal.

1. What is the possible diagnosis?

A. Cerebral toxoplasmosis
B. PCNSL - extra-nodal non-Hodgkin lymphoma (NHL)
C. Cryptococcal meningitis
D. Pyogenic meningitis
E. Tuberculous meningitis

2. What immediate investigation would you like to do to confirm the diagnosis?

A. CT head
B. RBS
C. CXR (PA)
D. Lumber puncture
E. EEC

Investigation revealed; LP was performed,

Opening pressure – 21 (5-11 cm H₂O) Indian Ink – Cryptococcus neoformin
CSF protein – 40 mg/dL AFB – not seen
CSF Glucose – 2.4 mmol/l Gram stain – Gram (+) oval yeast cells +
CSF White cell count – 15 cell/ml CSF Cryptococcal Antigen +
Polymoph – 40% CSF Cryptococcal culture - pending
Lymphocytes – 60%

3. Which of the following should be recommended as first line regimen for initial induction
therapy in a HIV infected patient with Cryptococcal meningitis?

A. Flucytosine plus itraconazole

B. Flucytosine plus fluconazole
C. Amphotericin B plus fluconazole
D. Amphotericin B plus voriconazole

Page 33 of 128
 4. Which of the following medication is preferred as consolidation and maintenance therapy
for HIV infected patient with Cryptococcal meningitis
A. Amphotericin B
B. Fluconazole
C. voriconazole

5. In addition to providing antifungal therapy, what measures are the most likely to be
effective in the first several days in managing increased ICP.
A. Repeated LP with removal of 15-20 ml of CSF with each procedure
B. Antibiotics
C. Dexamethasone

Q13. A 38-year-old known HIV positive presents with cough with mucoid sputum production
for 2 weeks. CXR reveals pulmonary infiltrates in RMZ. CD4 was 100/mm³. There was
no history of previous use of anti TB.

1. Which of the following anti TB will be not used in this patient?

A. Streptomycin
B. Isoniazid
C. Rifampicin
D. Ethambutol
E. Pyrazinamide

2. When to start ART in this patient?

A. After completion of anti TB for 6 months
B. After completion of initial 2 months of anti TB
C. Within 2 to 8 weeks of anti TB
D. Start ART and Anti-TB at the same time

Page 34 of 128
Q14. A 37-year-old woman with HIV presents with headache, irritability, and confusion.
Funduscopic examination reveals bilateral papilledema.

1. What is the likely diagnosis?

A. Toxoplasmosis
B. Cryptococcal meningitis
C. Progressive multifocal leukoencephalopathy
D. TB meningitis
E. All of the above

2. What TWO investigations should be done to reach the diagnosis?

A. FBC
B. LP and CSF examination
C. CT Head
D. Blood for MP
E. CD4 count

CSF examination revealed Indian ink smear positive,

3. What is the diagnosis?
A. Toxoplasmosis
B. Cryptococcal meningitis
C. Progressive multifocal leukoencephalopathy
D. HIV dementia

4. Treatment
A. Sulphadiazine and pyrimethamine
B. Iv amphotericin
C. Iv ceftriazone
D. Iv dexamethasone
E. Iv acyclovir

Q15. A 47-year-old woman with HIV presents with new right-sided arm and leg weakness,

1. What investigation should be done to reach the diagnosis?

A. FBC
B. LP and CSF examination
C. CT Head
D. Blood for MP
E. CD4 count

CT scan of the head reveals multiple rings enhancing lesions located in both hemispheres.

Page 35 of 128
 2. What is the diagnosis?
A. Toxoplasmosis
B. Cryptococcal meningitis
C. Progressive multifocal leukoencephalopathy
D. HIV dementia

3. Treatment?
A. IV acyclovir
B. IV benzyl penicillin
C. sulphadiazine and pyrimethamine with folinic acid
D. IV amphotericin
E. IV ceftriaxone

Q16. A 54-year-old man presents with a 2-wk history of headache, fever, chills, and night
sweats. He complains of myalgia and easy fatigability. He has just returned from a
business trip to Kachin state. On physical examination, the patient has a temperature of
103.2ºF and is diaphoretic. There is no neck stiffness, photophobia, or lymphadenopathy.
Heart and lung examinations are normal. There is mild splenomegaly.

1. What investigation should be done to reach the diagnosis?

A. Blood for MP
B. CXR
C. FBC
D. Urine RE
E. ESR.

Investigations revealed.
Hemoglobin 9 g/dl
WBC 6
Platelets 132
ESR 22
RBS 5.6 mmol/l
Serum creatinine 2.1 mg/dl
Blood for MP Plasmodium falciparum +

Page 36 of 128
 2. Which of the following is the most likely diagnosis in this patient?
A. Malaria
B. Tuberculosis
C. Mononucleosis
D. Trypanosomiasis
E. Toxoplasmosis

3. How will you treat this patient?

A. IV levofloxacin
B. IV Ceftriazone
C. IV Artesunate followed by Oral Arthemether + lumefanthrene
D. IM diclofenac
E. Oral chloroquine

Q17. A 25-year-old male from Shwe Bo had been ill for 5 days with fever, chills, and
headache when he noted a macular rash that developed on his trunk spreading to limbs.
A black crusted necrotic papule is noted on the trunk.

1. Which of the following is the most important fact to be determined in the history?
A. Exposure to contaminated water
B. Exposure to raw pork
C. Exposure to mites
D. Exposure to prostitutes
E. Exposure to mosquitos

Investigations revealed - Urinalysis

Haemoglobin 12.3
WBC 4.3
Platelets 123
Serum creatinine 2.3 mg/dl
LFT serum bilirubin
ALP 89 U/L
ALT 123 U/L
AST 98 U/L

Page 37 of 128
 2. What is the most likely diagnosis?
A. Leptospirosis
B. Enteric fever
C. Malaria
D. Scrub typhus
E. Dengue fever

3. What treatment should be given?

A. IV Ceftriazone
B. IV artesunate
C. Oral Ciprofloxacin
D. Oral doxycycline
E. IV Benzyl penicillin

Q18. A 35-year-old man presents with fever, nausea, and right upper quadrant pain. He has
recently returned from Rakhine state. Physical examination reveals no jaundice. He has
point tenderness over the liver.

1. What investigation should be done to get the diagnosis?

A. Full blood count
B. Blood for MP
C. USG abdomen
D. Liver function tests
E. ESR

Investigations revealed
CXR (PA) raised Rt dome of diaphragm.
USG (Ab) revealed Large SOL in the Rt lobe of the liver

2. Which of the following is the most likely diagnosis in this patient?

A. Hepatitis A infection
B. Hepatocellular carcinoma
C. Entamoeba histolytica
D. Campylobacter jejuni
E. Salmonella

Page 38 of 128
 3. Which treatment will you give to treat the condition?
A. Chloramphenicol
B. Ciprofloxacin
C. Metronidazole and diloxanide furoate
D. Sorafinib
E. IV fluid and supportive management

Q19. A 46-year-old woman with a history of sinusitis presents with a severe headache. She
complains of neck stiffness and photophobia. On physical examination she has a
temperature of 103.4ºF. Blood pressure is normal and heart rate is 110/min. She has a
normal funduscopic examination and no focal neurologic deficit. She has nuchal rigidity
and Kernig signs is positive.

1. Which of the following is the most likely diagnosis?

A. Migraine headache
B. Cluster headache
C. Torticollis
D. Bacterial meningitis
E. Cysticercosis

2. What investigation should be done to reach the diagnosis?

A. Blood for MP
B. RBS
C. Lumber puncture
D. CXR
E. ESR

3. How will you treat this patient?

A. IV artesunate
B. IV glucose
C. IV Mannyl
D. IV Crystalline penicillin

Page 39 of 128
Q20. A 25-year –old farmer from Madaya was admitted to the Medical Unit with a history of
fever for 5 days and yellowish discoloration of the eyes. He has noticed darkening of urine
for 2 days and over the last 24 hours has developed red spots over the body. The fever is
high grade and continuous with the patient is mentally alert.

Prior to referral, GP carried out some routine blood tests.

WBC 16
Bilirubin 5 mg/dl
AST 120U/L
Creatinine 1.8mg/dl
Urine Albumin +
RBC +
Cast +

1. What are the TWO most likely diagnosis?

A. Falciparum malaria
B. Viral hepatitis
C. Enteric fever
D. Leptospirosis
E. Dengue

Investigations done at the hospital revealed

MP ICT (-)
ALT 270 U/L
AST 240U/L
Hb 9 g/dl
Platelet 150 × 10
Blood culture (-)
Dengue Duo (-)

2. What is the diagnosis?

A. Falciparum malaria
B. Viral hepatitis
C. Enteric fever
D. Leptospirosis
E. Dengue

3. Which treatment?
A. Iv Ciprofloxacin
B. IV Benzyl penicillin
C. IV Artesunate
D. Oral Coamoxiclav
E. IV Fluids and ORS
Page 40 of 128
 INFECTION & HIV (KEY)

1. DDD
2. DCBC
3. CAC
4. AAD
5. BBCAB
6. ACA
7. CDE
8. CDC
9. DDB
10. CD
11. CA
12. CDCBA
13. AC
14. E, B/C, B, B
15. C, A, C
16. A, A, C
17. C, D, D
18. C, C, C
19. D, C, D
20. A/D, D, B

Page 41 of 128
 4. Diabetes Mellitus

1. A 26-year-old female with no previous history of diabetes presents with a first episode
of diabetic ketoacidosis.
Blood gases on inspiring room air are shown,
pH 7.25
PaCO2 2.4 kPa
PaO2 15.5 kPa
Bicarbonate 12 mmol/l
O2 saturation 96%

1. What is the acid-base disturbance?

A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory acidosis
D. Respiratory alkalosis
E. Mixed metabolic alkalosis and respiratory acidosis

2. What is the management?

A. IV insulin
B. Metformin
C. Gliclazide
D. Thiazolidinedione
E. Acarbose

2. A 64-year-old man with type 2 DM is seen in the diabetic clinic. His blood pressure is
130/80 mmHg. HbA1c measures 9.6%. The creatinine is 130umol/l. Examination of his
eyes shows diabetic retinopathy changes.
1. Which of the following concerning diabetic retinopathy is correct?
A. It is unusual in type 2 diabetic patients.
B. Improved glycemic control is more effective than hypertensive control in reducing
progression of disease.
C. New vessel formations are seen in proliferative retinopathy.
D. Progression may be reduced with statin therapy.
E. Soft exudates are a feature of background retinopathy.
Page 42 of 128
 This patient’s lipid profile shows
Total cholesterol 6.9 mmol/L (<5.2)
Triglyceride 1.1 mmol/L (0.45-1.69)
HDL-Cholesterol 0.9 mmol/L (>1.55)
LDL-Cholesterol 4.3 mmol/L (<3.36)

2. Which is the most appropriate treatment for this man’s dyslipidemia?

A. Cholestyramine
B. Ezetimibe
C. Fenofibrate
D. No other treatment required
E. Rosuvastatin

3. An 81 years-old man with type 2 diabetes mellitus was found unconscious by his daughter.
Blood tests performed on admission to hospital are shown.
Sodium 153 mmol/l
Potassium 5.4 mmol/l
Urea 40 mmol/l
Creatinine 310 umol/l
Glucose 60 mmol/l

1. What is the diagnosis?

A. DKA
B. HONK
C. CVA
D. Lactic acidosis
E. Uraemic encephalopathy

2. What is the best combination of infusions in the management of the patient?

A. IV saline 0.45%, IV insulin and subcutaneous heparin
B. IV saline 0.9%, IV insulin and subcutaneous heparin
C. IV sodium bicarbonate, IV insulin and subcutaneous heparin
D. IV dextrose saline, IV insulin and subcutaneous heparin
E. IV dextrose 5%, IV insulin and subcutaneous heparin

Page 43 of 128
4. A 16-year-old male presents with a day history of malaise, weakness and vomiting. He was
diagnosed with type 1 diabetes mellitus three years previously.

1. Which one of the following supports a diagnosis of diabetic ketoacidosis?

A. Abdominal pain at onset
B. A serum standard bicarbonate of 15 mmol/l (Normal 22-26)
C. A random serum glucose 14 mmol/l (Normal 4.5-6-4)
D. Decreased appetite in the past few days
E. Shallow respiration

2. What is the mainstay of treatment in the management of DKA?

A. IV insulin infusion
B. IV sodium bicarbonate in every patient
C. IV furosemide
D. IV 0.9% saline
E. IV hydrocortisone

5. A 61 years-old woman comes to the clinic for medical checkup. She currently takes
metformin 1g twice daily and gliclazide 160 mg twice daily. On examination, blood pressure is
155/90 mmHg and BMI is 29.
Haemoglobin 11.9 g/dl (13.5-18)
White cell count 5.0 x 109/l (4-10)
Platelets 193 x 109/l (150-400)
Sodium 140 mmol/l (134-143)
Potassium 5.0 mmol/l (3.5-5)
Creatinine 142 µmol/l (60-120)
HbA1c 7.2% (<5.5)
Glomerular filtration rate38 ml/min (>90)

1. Which of the following is the correct course of action?

A. Continue metformin
B. Stop metformin and consider acarbose
C. Stop metformin and consider exenatide
D. Stop metformin and consider insulin
E. Stop metformin and continue gliclazide

Page 44 of 128
2. Which of the following is/are true regarding metformin?
A. It does not require any functioning pancreatic islet cells for its action.
B. It is contraindicated in patients suffering myocardial infarction.
C. It is safe in patients with renal impairment.
D. It may cause metabolic alkalosis.
E. It often causes hypoglycemia.

6. A 23-year-old woman with type 1 diabetes mellitus had experienced recurrent episodes of
cystitis for which she was taking trimethoprim. She smoked 15-20 cigarettes per day. Her
blood pressure measured 120/80 mmHg. Urinalysis did not reveal any evidence of
microalbuminuria.

1. What is the best method of preserving renal function?

A. Cessation of smoking
B. Strict glycemic control
C. ACE inhibitor therapy
D. Lifelong prophylactic antibiotics
E. Angiotensin II receptor blocker

2. What is the best treatment for reducing the rate of nephropathy?

A. Ramipril
B. Amlodipine
C. Insulin
D. Metformin
E. Atenolol

7. A 46-year-old obese woman was recently diagnosed as having diabetes mellitus.

Investigations on presentation are
Sodium 132 mmol/l
Potassium 4.6 mmol/l
Urea 12 mmol/l
Creatinine 190 umol/l
Fasting glucose 13mmol/l
HbA1c 9.4%
Urinalysis Protein ++
Glucose ++
Microscopy normal
Page 45 of 128
1. What is the best management for her diabetes?
A. Gliclazide
B. Insulin
C. Stringent diabetic diet
D. Metformin
E. Insulin and metformin

2. What is the best treatment for reducing the rate of nephropathy?

A. Ramipril
B. Amlodipine
C. Insulin
D. Metformin
E. Atenolol

8. A 45-year-old woman presents to the clinic with a three-month history of sweats and
weight gain of 7 kg. Her sweats tend to be worse in the morning and with exercise and she
often feels light headed. On examination she has a BMI of 30 kg/m2 but no abnormality is
noted. Urinalysis negative.

1. What is the likely diagnosis?

A. Acromegaly
B. Diabetes mellitus
C. Insulinoma
D. Phaeochromocytoma
E. Primary ovarian failure

2. What is the most appropriate investigation for this patient?

A. 24-hour ECG recording
B. 72 hours fast
C. Fasting insulin and C-peptide concentrations
D. MRI scan of pancreas
E. Short synacthen test

Page 46 of 128
 Diabetes Keys

1. AA
2. CE
3. BB
4. B, A/D
5. AB
6. BA
7. BA
8. CB

Page 47 of 128
 4. METABOLISM
1. A 70-year-old male with known history of bronchogenic carcinoma presented with a one-
week history of increasing confusion. He also complained of abdominal discomfort and felt
excessively thirsty. On examination he had reduced skin turgor. The heart rate was 110
beats/min. Heart sounds were normal. The chest was clear. Abdominal examination
revealed a palpable colon with hard faeces. Investigations are shown.
Hb 11 g/dl Sodium 139 mmol/l
WCC 11x 109/l Potassium 5 mmol/l
Platelets 100 x 109/l Urea 20 mmol/l
Creatinine 190 µmol/l Blood glucose 12mg/dl
Albumin 32 g/l
Calcium 3.2 mmol/l (2.2-2.7 mmol/l)
Phosphate 1.4 mmol/l (0.8-1.5 mmol/l)

1. The most likely cause of his confusion is

A. Infection
B. Electrolyte imbalance
C. Dehydration
D. DKA
E. Secondary metastasis to brain

2. The most likely cause of his electrolyte abnormalities is

A. Reduced intake
B. Bronchogenic carcinoma
C. Primary hyperparathyroidism
D. Vitamin D intoxication
E. Sarcoidosis

3. What is the immediate step in his management?

A. IV pamidronate.
B. IV furosemide
C. IV saline (0.9%)
D. IV hydrocortisone
E. IV calcitonin

Page 48 of 128
2. A 21-year-old young woman complained of sudden onset of right sided chest pain and
breathlessness. She has been bed-bound for 2 months because of fracture neck of femur. Her
blood gas results were
PH 7.35 (7.35 – 7.45)
PCO 2 4.0 kPa (4.7 – 6.0 kP)
PO2 8.6 kPa (11.2 – 14.0 kP)

1. What do the blood gases show?

A. Type I respiratory failure
B. Type II respiratory failure
C. Metabolic acidosis
D. Normal
E. Respiratory alkalosis

2. What is the most likely cause?

A. Acute asthma
B. COPD
C. Emphysema
D. Pneumonia
E. Pulmonary embolism

3. Possible abnormality on her ECG is

A. Sinus bradycardia
B. LBBB
C. S1Q3T3
D. LAD
E. ST depression

Page 49 of 128
3. A 62-year-old man was brought into causalty by the police after he was found unconscious.
He had a fit-on arrival. His results were as follow:
Sodium 101 mmol/l
Potassium 4.4 mmol/l
Random blood sugar 6.8 mmol/l
Urea 1.3 mmol/l
CXR cystic lesion left apex

1. The most likely cause of fit is

A. Epilepsy
B. Hyponatremia
C. Hypoglycemia
D. Alcohol withdrawal
E. Hyperthermia

2. The reason for electrolyte imbalance is

A. SIADH
B. Reduced intake
C. Cirrhosis of liver
D. Congested cardiac failure
E. Vomitting

3. Management would be
A. Treat underlying cause
B. Salt tablets
C. IV fluid
D. Conservative
E. Fluid restriction

Page 50 of 128
4. A 68-year-old woman known case of chronic renal failure presented with one-week history
of reduced urine output associated with marked generalized oedema. She has been taking on
ACEI and loop diuretics. On examination, she had puffy face with pallor and her chest showed
bilateral basal creptations. Her blood tests done 2 days ago showed as follow:
Sodium 138 mmol/l
Potassium 7.1 mmol/l
Bicarbonate 25 mmol/l
Blood glucose 5 mmol/l

1. The most expected finding on ECG at that time is

A. Tall T
B. Inverted T
C. ST elevation
D. ST depression
E. U wave

2. At emergency department, her ECG showed loss of P wave with widen QRS and her
potassium level was 8 mmol/l.

At this potassium level, the patient has risk of the followings EXCEPT
A. Cardiac arrest
B. Ventricular tachycardia
C. Ventricular fibrillation
D. Bradycardia
E. Hypoglycemia

3. The first step of management is

A. IV calaium glucoronate
B. Inhaled β2 agonist
C. IV furosemide
D. Ion-exchange resin
E. IV sodium bicarbonate
Page 51 of 128
5. A 70-year-old man is admitted to hospital with an infective exacerbation of COAD.
Investigations show: Arterial blood gases on air:
pH 7.31
PO2 6.5 kPa (11.2 – 14.0 kP)
PCO2 7.1 kPa (4.7 – 6.0 kP)
Bicarbonate 27 mmol/l
He is treated with nebulizers and transferred to the ward where he deteriorates over the following
two hours. Repeated arterial gases show:
pH 7.23
pO2 9.8 kPa
pCO2 9.3 kPa
Bicarbonate 28 mmol/l
A portable chest X-ray shows extensive right mid-zone consolidation.

1. What is the likely cause for the deterioration?

A. Aspiration
B. O2 administration
C. CO2 narcosis
D. ARDS
E. Septicaemia

2. What management would you recommend?

A. IV antibiotics
B. Intubation
C. IV Doxapram hydrochloride
D. High-dose O2 administration
E. Insertion of nasogastric tube

6. A 35-year-old woman presented with vomiting and epigastric discomfort after a weekend
of binge drinking. On examination she was alert. She had several spider naevi on the face and
chest wall. The heart rate was 100 beats/min and regular. The blood pressure was 160/96
mmHg. The respiratory rate was 20/min. Both heart sounds were normal. The abdomen was
soft. Inspection of the fundi was normal. Initial investigations are shown.

Sodium 132 mmol/l Urea 7 mmol/l

Page 52 of 128
Potassium 3.3 mmol/l Creatinine 80 µmol/l
Bicarbonate 11 mmol/l Bilirubin 18 mmol/l
Chloride 98 mmol/l AST 160 iu/l
Plasma osmolality 290 mOsm/l Blood glucose 5 mmol/l
Urinalysis Ketones ++++
1. What is the diagnosis?
A. Diabetic ketoacidosis
B. Methanol poisoning
C. Euglycaemic ketoacidosis
D. Renal tubular acidosis
E. Lactic acidosis

2. The most likely cause of acidosis is

A. Diabetes
B. Alcohol
C. Methanol
D. Salicylate poisoning
E. Renal failure

3. The initial management would be

A. IV dextrose and saline
B. IV insulin
C. Dialysis
D. IV antibiotic
E. Conservative

4. Before giving IV dextrose, which medication should be given first in case

of alcoholic?
A. Β blocker
B. IV thiamine
C. α blocker
D. Sedative
E. O2

Page 53 of 128
7. A 13-year-old female was admitted under the surgeons with acute abdominal pain. The
blood pressure was 100/60 mmHg. Investigations are shown.
PaO2 12 kPa (11.2 – 14.0 kP)
PaCO2 4.7 kPa (4.7 – 6.0 kP)
pH 7.3 (7.35 – 7.45)
Sodium 131 mmol/l
Potassium 7.2 mmol/l
Urea 13 mmol/l
Creatinine 121 μmol/l
Bicarbonate 8 mmol/l
Chloride 96 mmol/l
Abdominal X-ray Normal
Urinalysis Glucose +++

1. What is the acid-base disturbance?

A. Metabolic acidosis with a high anion gap
B. Metabolic alkalosis
C. Mixed metabolic acidosis and alkalosis
D. Respiratory alkalosis
E. Respiratory acidosis

2. What is the most likely cause for the abnormality?

A. DKA
B. Hyperventilation
C. Renal failure
D. Lactic acidosis
E. Starvation ketosis

3. The first therapeutic management step

A. O2
B. Rebreathing into closed bag
C. IV glucose
D. Dialysis
E. IV fluid and insulin therapy

Page 54 of 128
8. Following results are obtained from young adult male with generalized oedema.
Sodium 118 mmol/l
Potassium 4.3 mmol/l
Chloride 97 mmol/l
Bicarbonate 22 mmol/l
Urea 5.2 mmol/l
Blood glucose 4.8 mmol/l
Albumin 24 g/l
24-hour urinary protein 7.8 gm

1. What investigation is indicated to explain this patient hyponatraemia?

A. CXR
B. Measurement of plasma lipids
C. Skull X Ray
D. Plasma ADH level
E. Serum cortisol level

2. What is the possible diagnosis in this patient?

A. SIADH
B. Adrenocortical insufficiency
C. CNS disorder
D. Pseudohyponatremia due to nephrotic syndrome
E. Idiopathic

3. The above finding can be seen in

A. Paraproteinemia
B. SIADH
C. Primary polydipsia
D. Diuretic therapy
E. Adrenocortical failure

Page 55 of 128
9. A 46-year-old man is brought to the Accident and Emergency room complaining of severe
central abdominal pain radiating through to his back and associated with pronounced retching
and vomiting. He has been constipated for the past few months. Examination is normal apart
from some bruising around the umbilicus.
Na 144 mmol/l
K 5.8 mmol/l
Urea 14 mmol/l
Bicarbonate 18 mmol/l
Calcium 3.60mmol/l
Phosphate 0.55 mmol/l
Albumin 28 g/l
Bilirubin 7 umol/l (<17)
AST 33 iu/l
ALP 110 iu/l
Gamma GT 80 iu/lm (<40)

1. What additional acute investigation would you perform?

A. Troponin T
B. Serum amylase
C. OGD scopy
D. Plain X Ray (abdomen)
E. Barium meal

2. What is the likely cause of acute presentation?

A. Acute appendicitis
B. Acute pancreatitis secondary to hypercalcaemia
C. Bowel perforation
D. Acute gastrititis
E. Aortic dissection

3. What is immediate management?

A. IV 0.9% normal saline
B. Laprotomy
C. IV hydrocortisone
D. IV furosimide
E. Conservative

Page 56 of 128
10. 14-year-old girl received the first dose of chemotherapy for Hodgkin’s lymphoma.
Electrolytes taken 24 hours later were as follows. Her baseline renal function and electrolyte
results were normal.
Sodium 137 mmol/l
Potassium 6.8 mmol/l
Urea 23 mmol/l
Creatinine 524 µmol/l
Phosphate 3.9mmol/l (0.8-1.5)
Urate 1.0 mmol/l (0.12-0.14)

1. How would you explain the electrolyte abnormalities?

A. Acute renal injury (AKI)
B. Tumour lysis syndrome from chemotherapy
C. Diuretics therapy
D. Reduced oral intake
E. Haemolysis

2. List two preventive precautions which should have been taken.

A. Not treat with chemotherapy
B. Reduce dose of chemotherapy
C. Adequate rehydration
D. IV antibiotic
E. Prophylactic allopurinol
F. IV dexamethasone
G. IV mannitol
H. Prophylatic dialysis

Page 57 of 128
 METABOLISM KEYS

1. BBC
2. AEC
3. BAA
4. AEA
5. BC
6. CBAB
7. AAE
8. BDA
9. BBA
10. B,CE

Page 58 of 128
 5. HEPATOLOGY

Q1. A 63-year-old woman with an 18-year history of relapsing ulcerative colitis is admitted
with increasing malaise and jaundice for few weeks. On examination, there is scleral
icterus and she is mildly dehydrated. Scratch marks are present over her arms and legs,
and the tender liver is palpable under the costal margin. Her blood tests result shown:

Bilirubin 98 µmol/l
ALT 42 U/l
AST 51 U/l
ALP 230 U/l

1. What is the likely cause for her jaundice?

A. Drug side effect
B. Primary biliary cirrhosis
C. Primary sclerosing cholangitis
D. Autoimmune hepatitis
E. Viral hepatitis

2. What investigations would you like to do for diagnosis?

Q2. A 40-year-old lady developed right upper quadrant pain two weeks after a fall. She felt
nauseated but had not vomited, and she was passing dark urine and pale stools. On
examination she was overweight and jaundiced. Her temperature was 38.1°C, blood
pressure was 110/60mmHg and pulse was 100/min. Heart sounds were normal and her
chest was clear. Her right upper quadrant was tender, with 4-cm smooth hepatomegaly
and a soft hepatic bruit. No splenomegaly or ascites were detected.

Page 59 of 128
 Bilirubin 280 µmol/l
ALT 50 U/l
AST 122 U/l
ALP 320 U/l
GGT 430U/l
Creatinine 1.1 mg/dl
Na+ 143 mmol/L
K+ 4.3 mmol/L
Bicarbonate 25 mmol/L
Chloride 108 mmol/L

Ultrasound abdomen showed homogeneous hepatomegaly, Several gallstones in gallbladder,

Normal biliary tree.

1. What is the most likely diagnosis?

A. Acute cholecystitis
B. Ascending cholangitis
C. Infected hepatic haematoma
D. Non-alcoholic steatohepatitis
E. Alcohol-induced hepatitis

2. Select one test from the following to confirm your diagnosis:

A. Liver ultrasonography
B. Abdominal X-ray
C. ERCP
D. Liver biopsy
E. Surgery

Q3. A 21-year-old woman is referred from the Emergency department with a paracetamol
overdose. A paracetamol level is taken and is 75 mg/L.

1. What is the most appropriate treatment?

A. Doxycycline
B. Interferon and ribavirin
C. N-acetylcysteine
D. Penicillamine
E. Steroids

Page 60 of 128
2. Which of the following is an indication for liver transplantation in acute liver failure as a result of
paracetamol overdose?
A. Arterial pH < 7.35
B. Bilirubin > 200 µmol/L
C. Creatinine > 250 µmol/L
D. Grade I encephalopathy
E. Prothrombin time > 100 seconds (INR > 6.7)

3. Which of the following is a contraindication to liver transplantation?

A. Autoimmune chronic hepatitis
B. Cryptogenic cirrhosis
B. Postviral cirrhosis
C. Psychological factors that may impair compliance with immunosuppression
D. Refractory ascites

Q4. A patient is referred to hepatology department for possible treatment of hepatitis B.

He has stigmata of chronic liver disease. There is portal hypertension and ascites. His INR
is 2.2 (<1.4) and albumin 25 g/L (37-49). HBsAg and HBeAg positive. Hepatitis C screen
is negative.

1. What will you suggest for treatment?

A. Beta interferon
B. Tenofovir
C. Lamivudine plus interferon
D. Ribavirin alone
E. Ribavirin plus interferon

2. What are the complications of hepatitis B EXCEPT

A. E. HCC
B. F. cirrhosis of liver
C. G. Acute liver failure
D. H. Chronic hepatitis
E. Porphyria cutanea tarda

Page 61 of 128
Q5. A 35-year-old obese Afro-Caribbean lady presents with abnormal liver function tests. She
claims to be a teetotaler and her BMI is 30kg/m2.
Investigations reveal the following results.

Bilirubin 25 µmol/l
ALT (Alanine transaminase) 155 U/l
AST (Aspartate transaminase) 140 U/l
ALP (Alkaline phosphatase) 160 U/l
Random blood glucose 11.2 mmol/L
Creatinine 0.9 mg/dl
Na+ 140 mmol/L
K+ 3.3 mmol/L
Bicarbonate 23 mmol/L
Chloride 108 mmol/L
Haemoglobin 14 g/dL
Hepatitis B and C serology Negative

Ultrasound abdomen reveals hyperechogenic hepatic parenchyma.

1. Which of the following is the most likely diagnosis?

A. Alcoholic liver disease
B. Autoimmune hepatitis
C. Non-alcoholic steatohepatitis
D. Primary biliary cirrhosis
E. Viral hepatitis

2. Select one test from the following to confirm your diagnosis

A. Liver ultrasonography
B. Abdominal X-ray
C. ERCP
D. Liver biopsy
E. Surgery

3. What is the specific treatment in this case?

A. antiviral
B. steroid
C. Weight loss and reduce insulin resistnace
D. liver transplant
E. Desferrioxamine
Page 62 of 128
Q6. A 20-year-old male student was seen in the Emergency department. He complained of
nausea and he had noticed yellow discoloration of his eyes. He had recently been on an exchange
visit to Egypt where he had worked in a hospital. He recalled some traveller's diarrhea for
which he had taken ciprofloxacin that he had taken with him. Since that time he had generally
felt unwell but over the past few days had started to feel better. He denied history of alcohol
drinking. On examination he was clearly jaundiced, there were no signs of chronic liver disease;
he had a mildly tender liver edge but no other abnormal organ enlargement and no feature of
hepatic encephalopathy.

Bilirubin 90 µmol/l
ALT (Alanine transaminase) 1550 U/l
GGT (Gamma gluteryltransferase) 70 U/l
ALP (Alkaline phosphatase) 140 U/l
Haemoglobin 14 g/dL
MCV 90 fL
WBC 9.0 ×109/L
Platelets 300 ×109/L
C reactive protein 25 mg/L
Albumin 40 g/L
Globulin 20 g/L
Total Protein 60 gm/L

1. What disease process is likely to be causing this picture?

A. Alcoholic hepatitis
B. Autoimmune hepatitis
C. Drug induced hepatitis
D. Hepatitis A
E. Hepatitis B
2. How to spread the disease mostly?
A. Vertical
B. Fecal oral route
C. Blood
D. Sexual
E. Inoculation
3. The proper treatment for this patient
A. Interferon
B. Liver transplant
C. Mainly supportive and improvement sanitation
D. Azathioprine
E. Tenofovir

Page 63 of 128
Q7. A 30-year-old lady is found to be hepatitis B surface antigen positive. This positive result
has persisted for more than six months.

Hepatitis B surface antigen (HBsAg) positive

Hepatitis B surface antibody (anti-HBs) negative
Hepatitis B anti-core IgM (anti-HBc IgM) negative
Hepatitis B anti-core (anti-HBc IgG) positive
Hepatitis B envelope antigen (HBeAg) negative
HBV DNA negative
Bilirubin 10 µmol/l
ALT (Alanine transaminase) 20 U/l
AST (Aspartate transaminase) 30 U/l
ALP (Alkaline phosphatase) 90 U/l

1. What is the most appropriate interpretation of these serological results?

A. Acute hepatitis B infection, chronic hepatitis C infection
B. Chronic hepatitis B infection, acute hepatitis C infection
C. Chronic hepatitis B infection
D. Previous hepatitis B infection, chronic hepatitis C infection
E. Previous hepatitis B vaccination, acute hepatitis C infection

2. Which of the following options would be the best for further management?
A. Liver biopsy and antiviral therapy
B. Liver biopsy but no antiviral therapy
C. No antiviral therapy but monitor serology
D. No liver biopsy but antiviral therapy
E. Progress to antiviral therapy

Q8. A 50-year-old man with known alcoholic liver disease is noted by the nursing staff to be
confused on the ward. On examination he is tachycardic with a heart rate of 100 beats per
minute, his blood pressure is stable at 122/85 mmHg. He is alert, there is no asterixis but
his family who are also present report some change in his mood and behavior. Abdominal
examination reveals ascites with generalized abdominal tenderness.

Page 64 of 128
1. What is the severity of this patient's hepatic encephalopathy?
A. Grade 0 encephalopathy
B. Grade 1 encephalopathy
C. Grade 2 encephalopathy
D. Grade 3 encephalopathy
E. Grade 4 encephalopathy

2. What are the precipitation factors for hepatic encephalopathy EXCEPT

A. Constipation
B. Reduce protein load
C. Hypokalaemia
D. Sedative drugs
E. Spontaneous bacterial peritonitis

Q9. A 37-year-old homeless gentleman with a history of alcohol excess presents to hospital with
painless and progressive abdominal distension. Examination reveals a significantly
distended abdomen with shifting dullness. An ascitic tap is performed and the fluid sent
for analysis.
1. What is the best measurement to use in order to classify the nature of the ascitic fluid and
understand the possible cause?
A. Fluid albumin
B. Fluid amylase
C. Fluid lactate dehydrogenase
D. Fluid total protein
E. Serum ascites albumin gradient

2. The following are indicated exudative ascites EXCEPT

A. Malignancy
B. Pancreatic ascities
C. Heart failure
D. Pancreatitis
E. Spontaneous bacterial peritonitis

3. What is the most appropriate first-line treatment for his ascites?

A. Amiloride
B. Dietary salt restriction
C. Furosemide
D. Paracentesis
E. Spironolactone

Page 65 of 128
Q10. A 17-year-old male comes to see you with a three-day history of sore throat and lassitude.
He said that preceding these acute symptoms he has been feeling unwell for a week or so.
On examination he appeared well but anxious. His tonsils were mildly inflamed and there
were a few palpable cervical lymph nodes. Abdominal examination was unremarkable.
When he returns for review, you note from the blood tests that he is jaundiced.
Investigations show:

Bilirubin 60 µmol/l
ALT 20 U/l
AST 19 U/l
ALP 105 U/l
Albumin 42 g/L

1. What is the most likely explanation for the abnormal liver function tests?
A. Acute hepatitis A infection
B. Chronic hepatitis C infection
C. Epstein-Barr virus infection
D. Gilbert's syndrome
E. Primary biliary sclerosis

2. Which of the following investigations is appropriate next?

A. Unconjugated bilirubin levels
B. Serum electrophoresis
C. Liver biopsy
D. Liver ultrasound
E. Anti-hepatitis C Ig G
F. Anti-smooth muscle and liver/kidney microsomal antibodies

3. The proper treatment for this patient

A. Azathioprine
B. Desferrioxamine
C. Immunoglobulin
D. Interferon
E. Observation

Page 66 of 128
 HEPATOLOGY KEYS

1. CEBE
2. ED
3. CEC
4. BI
5. CDC
6. DBC
7. CC
8. BB
9. ECD
10. DAE

Page 67 of 128
 5. GASTEROENTEROLOGY

Q1. A 38-year-old alcoholic presents with abdominal pain, weight loss and bulky stools.
1. What is the most likely diagnosis?
A. Chronic pancreatitis
B. Coeliac disease
C. Bacterial overgrowth
D. Carcinoid syndrome
E. Carcinoma of head of pancreas

2. What is the most suitable investigation to confirm the diagnosis?

A. Endoscopic ultrasound
B. ERCP
C. Ultrasound abdomen
D. CT abdomen
E. Endoscopy with D2 biopsy

3. Which of the following treatment is helpful for malabsorption?

A. PPI
B. Dietary fat restriction with oral pancreatic enzyme supplement
C. Endoscopic therapy
D. Coeliac plexus neurolysis
E. Alcohol avoidance

Q2. A 28-year-old woman presents with intermittent episodes of diarrhea, constipation,

abdominal bloating, and flatulence. Clinical examination is unremarkable. Her BP is
110/70 mmHg, pulse is 65/min, and regular. BMI is 24 and her abdomen is soft and non-
tender. Fecal occult bloods are negative and hematological and biochemical investigations
are all normal.

1. Which of the following diagnosis fits best with this clinical picture?
A. Colonic carcinoma
B. Crohn’s disease
C. Coeliac disease
D. Ulcerative colitis
E. Irritable bowel syndrome

Page 68 of 128
2. Which of the following is least consistent with a diagnosis of irritable bowel syndrome?
A. Feeling of incomplete stool evacuation
B. Waking at night due to pain
C. Abdominal bloating
D. Fecal urgency
E. Passage of mucus with stool

3. If initial treatment with a combination of antispasmodics and laxatives and antimotility agents are
not helpful, next treatment that can be tried include
A. Low dose tricyclic antidepressant
B. CBT
C. Psychological therapy
D. Hypnotherapy
E. Acupuncture

Q3. A 67-year-old man present with hematemesis and melena, he had a long history of burning
epigastric pain off and on for 10 years sometimes relived by taking over the counter antacids.
He has recently taken some NSAID for his back pain. On examination, apart from marked
pallor and epigastric tenderness, there are no features of chronic liver insufficiency, he has
postural drop of BP 100/70 to 70/40mmHg, extremities are cold and clammy.

1. What is the most likely diagnosis?

A. Bleeding esophageal varices
B. Mallory Weiss tear
C. Bleeding peptic ulcer
D. Carcinoma of stomach
E. Vascular malformation

2. What is the most appropriate immediate management?

A. Blood transfusion
B. Intravenous omeprazole
C. Intravenous ranitidine
D. Intravenous crystalloid
E. Intravenous telipressin

Page 69 of 128
3. What is the next step of management after adequate resuscitation ideally within 24 hours?
A. Endoscopy
B. USG abdomen
C. IV octreotide
D. IV terlipressin
E. IV dobutamine

Q4. A 52-year-old man presents with hematamesis and melena, he had been diagnosed with
cirrhosis of liver when he presents with progressive abdominal distension and jaundice
last year and currently taking regular follow up with hepatologist. On admission, he is
severely shocked with a pulse rate of 105/min, and postural drop of 30mmHg. After fluid
resuscitation and blood transfusion she is endoscopied and there are oesophageal varices
which appear to have recently bled.

1. Which of the following is the most appropriate treatment for her varices?
A. Injection sclerotherapy and banding
B. Oral omeprazole 40mg daily
C. Oral propranolol 40mg daily
D. Oral omeprazole 20mg daily
E. Helicobacter eradication

2. Which of the following agent reduce portal hypertension and useful to prevent further
complication?
A. Propranolol
B. Verapamil
C. Nitrate
D. Nicorandil
E. Omeprazole

3. If patient present with diffuse abdominal pain, fever with raised white cell count, what is the next
step of management?
A. Ascitic fluid REME including absolute neutrophil count
B. USG abdomen
C. Plain X ray abdomen
D. KUB X ray
E. CT abdomen
Page 70 of 128
4. Treatment of choice in this condition is
A. IV cefotaxime
B. IV metronidazole
C. IV flucloxacillin
D. IV amipicillin
E. IV gentamycin

Q5. A 54-year-old man presents to his GP with symptoms of burning retrosternal pain. He
reports occasional sticking of food. There is a past history of asthma, but nothing else of note.
He smokes 20 cigarettes per day. Examination reveals some epigastric tenderness but only to
deep palpation.

1. Which of the following represents the likely diagnosis?

A. GERD
B. Carcinoma of esophagus
C. Peptic ulcer
D. Diffuse esophageal spasm
E. Achalasia

2. Which one of the following is associated condition?

A. Asthma
B. Squamous cell carcinoma of oesophagus
C. Peptic ulcer
D. Pharyngeal pouch
E. Diverticulosis

3. Which one of the following represents best clinical management?

A. Life style advice
B. Life style advice with proton pump inhibitor
C. Upper GI endoscopy
D. Life style advice with antacid
E. Life style advice with ranitidine

Page 71 of 128
Q6. A 75-year-old woman presents with increasing weight loss, but early satiety, and
progressive anorexia, she admits 2 to 3 episodes of vomiting of blood. Examination reveals
mass in epigastrium with left supraclavicular lymph node enlargement. Investigation
shows hypochromic microcytic anemia.

1. What is the likely diagnosis?

A. Carcinoma of stomach
B. Carcinoid syndrome
C. GIST
D. Colonic carcinoma
E. Peptic ulcer disease

2. What is the investigation of choice?

A. Upper GI endoscopy
B. CT abdomen
C. USG abdomen
D. Serum calcium level
E. Barium follow through

3. The following are risk factors for this condition except

A. H pylori infection
B. Pernicious anemia
C. Previous partial gastrectomy
D. Smoking
E. Coeliac disease

4. Cutaneous manifestation include

A. Acanthosis nigrican
B. Erythema multiforme
C. Pellagra
D. HPOA
E. Granuloma annulare

Page 72 of 128
Q7. A 32-year-old man presents with recurrent abdominal pain localized to epigastrium,
episodic in nature, occurs in relationship to food, anorexic and feeling fullness after meals.

1. What is the likely diagnosis?

A. Gastric outlet obstruction
B. Carcinoma of stomach
C. Peptic ulcer
D. Non ulcer dyspepsia
E. Reflux esophagitis

2. What is the appropriate next step of management?

A. Upper GI endoscopy and test for H.pylori
B. Ultrasound abdomen
C. CT abdomen
D. Oesophageal manometry
E. 24-hour pH monitoring

3. Which of the following is recommended treatment of choice to prevent relapse and complications?
A. H. pylori eradication
B. Long term PPI therapy
C. Dietary advice and stop smoking
D. Endoscopic balloon dilatation
E. Endoscopic injection sclerotherapy

4. The H.pylori eradication therapy is indicated in following conditions except

A. Peptic ulcer
B. MALToma
C. Previous history of gastric cancer
D. Family history of gastric cancer
E. GERD

Page 73 of 128
Q8. A 23-year-old student presents with 5-week history of bloody diarrhea, which has become
more severe in the past 48 hours. She feels tired and depressed. On examination, she has
heart rate of 120/min, BP 90/60mmHg, Temperature of 38.C, is tender to palpation over
left iliac fossa. Rectal examination reveals granular mucosa. Hb 9.4g/dl, WBC 12.3x109,
Albumin 29g/L, CRP 94mg/L.

1. What is the likely diagnosis?

A. Ulcerative colitis
B. Crohn’s disease
C. Diverticulitis
D. Ischemic colitis
E. Coeliac disease

2. What is the next step of management?

A. Sigmoidoscopy and biopsy
B. Plain X ray abdomen
C. Stool culture
D. IV hydrocortisone
E. Urgent surgical review

3. The treatment of choice for establish dilatation is

A. Colectomy
B. IV hydrocortisone
C. Mesalazine
D. Infliximab
E. Sulphasalazine

Q9. A 58-year-old alcoholic has a 6-month history of central abdominal pain accompanied by
5 kg weight loss. On further questioning, he admits that there is passage of oily offensive
stool, become anorexic and lethargic, investigation reveals Hb 13.8 g/dl, WBC 11.2x109/L,
platelets 145, CRP 54mg/L, amylase 79U/L, Albumin 29g/L, ultrasound abdomen is
unremarkable, and normal upper GI endoscope. Plain X ray abdomen shows pancreatic
calcification.

Page 74 of 128
1. What is the likely diagnosis?
A. Chronic pancreatitis
B. Carcinoma of head of pancreas
C. Acute cholecystitis
D. Peptic ulcer
E. Maltoma

2. Helpful symptomatic benefit would be gain from

A. Opiate
B. Paracetamol
C. PPI
D. H2 blocker
E. Distal pancreatectomy

3. For intractable pain, the following procedure is helpful.

A. Coeliac plexus neurolysis
B. Distal pancreatectomy
C. Injection of botulism toxin
D. Opiate injection
E. Steriod injection

Q10. A 39-year-old teacher has 3-month history of dyspepsia particularly at night, relieved by
taking some meal. She had a trial of PPI for one month ago but symptoms return shortly
after stopping treatment. On examination, there is slight epigastric tenderness.
1. What is the likely diagnosis?
A. Peptic ulcer
B. Irritable bowel syndrome
C. Carcinoma of stomach
D. Non ulcer dyspepsia
E. Reflux esophagitis

2. The most useful next management step would be

A. Test for H.pylori and eradicate if positive
B. Course of H2 antagonist
C. Upper GI endoscopy
D. C13 urea breath test and eradicate if positive
E. H.pylori eradication therapy should be started

3. The most life-threatening complication include

A. Upper GI bleeding resulting from bleeding ulcer
B. Gastric outlet obstruction
C. Peptic stricture
D. Hiatus hernia
E. Functional dyspepsia
Page 75 of 128
 GASTEROENTEROLOGY KEYS

1. ADB

2. EBA

3. CDA

4. AAAA

5. AAC

6. AAEA

7. CAAE

8. ABA

9. AAA

10. ADA

Page 76 of 128
 7. RENAL
Q1. 26-year-old lady presents with 2-month history of skin rashes, oral ulceration and
symmetrical polyarthritis of fingers and wrist joints with some morning stiffness. She had
puffy face, leg swelling and reduced urine output for 2 weeks duration. Her RBS is 5.6
mmol/l and BP 140/90 mmhg.
1. The most likely diagnosis is
A. Malignant Hypertension
B. Syphilis
C. Leptospirosis
D. Post streptococcal glomerulonephritis
E. Systemic lupus erythematosus

2. Investigation that should be done for diagnosis

A. ENA
B. TPHA
C. ASO (Antistreptolylsin)
D. Leptospiral antibody
E. ANCA

Investigations revealed;
WBC 6x109/L,
HB 9g/dl,
PLT 160x109/L,
Creatinine 210umol/L,
Urea 15mmol/L,
RBS 6.3mmol/L,
UREME RBS 3+, Protein 4+, Granular cast +

3. What investigation do you want to do for further management

A. Urine C&S
B. Completment
C. Renal biopsy
D. Urinary
E. Eosinophilia and urinary eosinophilia

Page 77 of 128
 4. What is definitive treatment
A. IV methylprednisolone
B. IV immunoglobulin
C. IV penicillin
D. Plasma Exchange
E. Renal transplant

Q2. A 56-year-old man, known to have type 2 DM and hypertension on irregular medication
for 5-year duration was admitted with pallor, DOE, fatigue, palpitation, puffy face and
reduced urine output. On examination, she has pallor, puffy face and leg swelling. BP
170/110mmHg, PR 100/min, RBS-10mmol/l, creatinine-900umol/l, urea 50mmol/l, Na-
144, CL-103, HCO3- 22mmol/l, Ca-1.6mmol/l, PO4-2.7 mmol/l
1. What is the most likely diagnosis
A. CKD
B. AKI
C. Renal stone
D. Chronic heart failure
E. Chronic hemolytic anemia

Hemogram showed Hb- 5.8 %

WBC 8x109 /L
PLT 112x 109 /L

2. The following are causes of reduced Hb% in this case except

A. Deficiency of erythropoietin
B. Reduced red cell survival
C. Increased blood loss due to capillary fragility and poor platelet function
D. Reduced intake, absorption and utilization of dietary iron
E. Haemolysis

3. What treatment should be given for his anemia

A. Oral iron
B. IV iron
C. Blood transfusion
D. S/C erythropoietin
E. IV steroid
Page 78 of 128
 4. The following are criteria for referral to nephrologist except
A. Age <40 year
B. Stage II CKD or worse
C. Rapid deterioration in renal function
D. Significant proteinuria (PCR >100mg/mmol, or ACR >70mg/mmol)
E. Significant Hematuria

Q3. A 63year old post-menopausal women present with 7 days history of chills and rigor, pain
during voiding. On physical examination, she is febrile & she has cloudy urine.
1. What is the most likely diagnosis
A. Malaria
B. Cholangiohepatitis
C. UTI
D. Pneumonia
E. Enteric fever

2. What is the most common organism

A. Plasmodium falciparum
B. Klebsiella
C. Salmonella
D. E. coli
E. Gonorrhea

3. The following are risk factor except

A. Diabetes Mellitus
B. Multiple sclerosis
C. Atrophic urethritis and vaginitis in post menopausal women
D. Urolithiasis
E. Previous history of travelling to malaria endemic area

4. What treatment will you give

A. Trimethoprim
B. Artesunate
C. Doxycycline
D. Cefixime
E. Quinine
Page 79 of 128
Q4. A 18-year-old man presented with generalize oedema and frothy urine for 3 months
duration. Investigation showed proteinuria >3.5G/24 hr. serum albumin <30g/L, elevated
cholesterol. Urea-7mmol/l, creatinine -90umol/l
Ultrasound abdomen and pelvis – unremarkable

1. What is the most likely diagnosis

A. Nephritis
B. Nephrotic syndrome
C. Acute interstitial nephritis
D. Glomerulonephritis
E. Reno vascular disease

2. The following investigations are helpful in the case of proteinuria except

A. 24-hour urinary protein
B. PCR
C. ACR
D. B2 microglobulin
E. CRP

3. The following consequences may be occurred except

A. Hyperalbuminaemia
B. Hypercholestrolaemia
C. Hypercoagulability
D. infection
E. sodium retention

4. what is the indication for renal biopsy

A. minimal change
B. children
C. normal blood pressure
D. normal renal function
E. patient fail to response to high dose corticosteroid therapy

Page 80 of 128
Q5. A 30-year-old female presented with malaise, nausea, vomiting and right upper quadrant
pain in the last week of her pregnancy. She had tolerated the pregnancy very well prior
to the event. Her blood pressure control throughout the pregnancy had been good, with
the last reading measuring 96/60 mmHg two weeks previously. There was no history of
headache or diarrhoea. On examination she appeared pale. There was no obvious
evidence of jaundice. There was marked right upper quadrant tenderness. The blood
pressure measured 130/86 mmHg.
Investigations are shown.
Hb 10 g/dl PT 12 sec
WCC 12 x109/l APTT 43 sec
Platelets 33 x 109/l Urea 12 mmol/l
Sodium 137 mmol/l Creatinine 223 umol/l
Potassium 3.4 mmol/l Albumin 33 g/l
Bilirubin 20 μmol/l Amylase 150 iu/l
AST 250 iu/l LDH 800 iu/l
ALT 298 iu/l
Alk Phos 200 iu/l
Urinalysis Protein +
Hepatobiliary ultrasound Normal

1. What is diagnosis?
A. Hemolytic Uremic Syndrome
B. Thrombotic thrombocytopenic purpura
C. Fatty Liver of pregnancy
D. HELLP
E. Biliary obstruction

2. What is the definitive treatment?

A. IV cefuroxime and metronidazole.
B. Start methyldopa.
C. Deliver the baby urgently.
D. Exploration laparoscopy.
E. IV hydrocortisone.

Page 81 of 128
Q6. A 64-year-old male presented with sudden onset of breathlessness. He had experienced a
transient ischaemic attack three months previously and had a history of intermittent
claudication. The chest X-ray on admission was consistent with pulmonary oedema. He
was taking nifedipine and atenolol for hypertension. He was treated with intravenous
diuretics and glyceryl trinitrate for 48 hours with good effect. He was subsequently
switched to oral furosemide 40 mg od. The atenolol was stopped and substituted with an
ACE inhibitor.

Blood tests on admission are shown.

Blood Tests On admission One week later
Sodium mmol/l 137 135
Potassium mmol/l 3.6 4.6
Urea mmol/l 8.2 15
Creatinine mmol/l 137 220

1. What is the most likely cause for the patient’s deterioration?

A. Initiation of furosemide.
B. Initiation of an ACE inhibitor.
C. Hypertensive nephropathy.
D. Relative hypotension.
E. Left ventricular dysfunction.

2. What is the next best investigation to ascertain the cause of the abnormal renal function?
A. Renal biopsy.
B. Renal angiography.
C. Renal isotope scan.
D. Captopril renogram.
E. Echocardiogram.

3. What is your diagnosis?

A. AKI
B. Ischaemic heart failure
C. Hypertensive heart failure
D. Chronic kidney disease
E. Renal artery stenosis
Page 82 of 128
 RENAL KEYS

1. EACA
2. AECB
3. CDEA
4. BEAE
5. DC
6. BBE

Page 83 of 128
 8. RESPIRATION

1. A 36-year-old man, a highway driver came to medical OPD with the chief complaint of low-
grade fever with evening rise in temperature, dry cough and night sweats for 2 weeks. He also
complained of right sided chest pain for 3 days. On examination, he is thin and emaciated, there
is oral thrush and many tattoo marks on his body. His chest revealed stony dullness on right
side of the chest from 7th intercostal space downwards from posteriorly.
1. What is the most likely diagnosis?
A. Tuberculosis
B. Pneumonia
C. Bronchogenic carcinoma
D. Bronchial Asthma
E. Empyema

2. What intial investigation would you like to do?

A. Sputum cup examination
B. ESR
C. Chest X ray
D. FBC
E. PEFR

3. What further investigation would you like to do to confirm the diagnosis?

A. Sputum for AFB and gene X-pert
B. Sputum for C& S
C. Sputum for cytology
D. Ultrasound chest
E. Pleural aspiration and biopsy

4. What additional test should be done to find out the associated disease?
A. hsCRP
B. Retro screening test
C. Renal function test
D. Blood culture
E. Spirometry

Page 84 of 128
2. A 65-year-old gentleman, a chronic smoker who experienced productive cough for 6 months
duration now presents with shortness of breath and blood streak sputum production for 2
weeks. He also had reduced appetite and loss of weight. On examination, he is thin and
emaciated and has clubbed nails and toes. His chest revealed crepitations.

1. What is the most likely diagnosis?

A. Asthma
B. Bronchiectasis
C. Bronchogenic carcinoma
D. COPD
E. Tuberculosis

2. His CXR shows no abnormality. What investigation would you like to do to confirm the
diagnosis?
A. PEFR
B. CT scan of the chest
C. Sputum for AFB and gene X-pert
D. Sputum for C&S
E. Lung function test

3. What treatment will you give?

A. Bronchodilators
B. Anti TB treatment
C. Corticosteroids
D. Surgery, radiation or chemotherapy according to staging
E. Antibiotics

4. What is the most important aetiological factor for this disease?

A. Male sex
B. Smoking
C. Old age
D. Chest infection
E. Reduced immunity

Page 85 of 128
3. A 67-year-old lady, a chronic smoker for 50 years duration, who has history of cough and
sputum production on most days for at least 3 months for 3 years. She came to medical OPD
with increased tightness of chest, breathlessness and purulent sputum production. She is so
breathless that she could only walk for a few minutes on level ground.

1. What is the most likely diagnosis?

A. Acute pulmonary oedema
B. Bronchogenic carcinoma
C. Bronchiectasis
D. Acute exacerbation of COPD
E. Tuberculosis

2. What grade of Modified MRC scale does this patient have?

A. 0
B. 1
C. 2
D. 3
E. 4

3. What investigation would you like to do except?

A. CXR
B. Sputum examination
C. Spirometry
D. Blood culture
E. FBC

4. What treatment will you give?

A. Bronchodilators
B. High flow oxygen
C. Diuretics
D. Anti TB agents
E. β-blockers

Page 86 of 128
4. A 76-year-old gentleman, known COPD came to hospital for 3 days history of increased
breathlessness, tightness of chest and sputum production which is yellow in colour. On
examination, he is dyspnoeic at rest and there is pitting oedema of both leg. RR- 36/min and
SpO2 – 76% on air. On auscultation of the chest, there is widespread ronchi and coarse
creptitations all over the lung field.

1. What is the most likely diagnosis?

A. Acute pulmonary oedema
B. Acute exacerbation of COPD
C. Acute pulmonary embolism
D. Acute severe asthma
E. Bronchogenic carcinoma

2. What initial investigation would you like to do except?

A. CXR
B. Sputum for C&S
C. FBC
D. ESR
E. CT chest

3. What treatments will you give except?

A. High flow O2 inhalation
B. Controlled O2 inhalation
C. IV Antibiotics
D. Nebulized salbutamol
E. IV Corticosteroids

4. What factor is associated with infective exacerbation of the disease?

A. RR- 36/min
B. SpO2- 76% on air
C. Pitting leg oedema
D. Increase in sputum production which is yellow in colour
E. Widespread ronchi

Page 87 of 128
5. A 30 years old man went to his GP for 1 month history of wheezing, tightness of chest and
cough especially at night and in the early morning and after exercise. He has similar complaint
since childhood. On examination, he has expiratory ronchi and prolonged expiration on
auscultation. He also has eczema on his feet.

1. What is the most likely diagnosis?

A. Heart failure
B. Bronchial asthma
C. Common cold
D. Pneumonia
E. COPD

2. What investigation would you like to do to confirm the diagnosis?

A. Echocardiogram
B. FBC
C. PEF meter readings at wakeup and before retiring in the evenings
D. Sputum for C&S
E. CXR

3. What treatment will you give?

A. Inhaled bronchodilators and/or corticosteroids
B. PO Amoxicillin 500mg tds for 7 days
C. High dose vitamin C
D. PO Lasix
E. Stop smoking

4. If the condition is not well controlled, what serious complication can be occurred?
A. Acute pulmonary oedema
B. Septic shock
C. Respiratory failure
D. Renal failure
E. Liver failure

Page 88 of 128
6. A 28-year-old lady with bronchial asthma came to hospital with increased tightness of chest
and dyspnoea for one day after a febrile illness. Her regular inhalers could not relieve her
symptoms. On examination, she was breathless at rest, RR- 38/min, SpO2- 70% on air, PR-
110/min and she could not speak complete sentence in one breath. Her chest revealed
widespread ronchi on auscultation.

1. What is the most likely diagnosis?

A. Acute pulmonary embolism
B. Acute pulmonary oedema
C. Acute severe asthma
D. Severe pneumonia
E. Anxiety disorder

2. What initial treatment will you give?

A. High concentration O2 to maintain SpO2 above 92%
B. Broad spectrum IV Antibiotics
C. IV furosemide
D. To try again with her regular inhalers
E. Montelukast 10mg

3. What further treatment you will give except?

A. High dose nebulized salbutamol
B. High dose nebulized ipratropium bromide
C. IV Hydrocortisone
D. IV Furosemide
E. IV Magnesium

But the patient failed to improve with the treatment and she became drowsy, cyanosed and her
chest became silent and her Arterial Blood Gas shows PaO2- 7 kPa, PaCO2- 6.6 kPa, pH- 7.1.
4. What is the most appropriate management for her?
A. Endotracheal intubation and intermittent positive pressure ventilation
B. IV Magnesium
C. IV Hydrocortisone
D. High dose nebulized salbutamol
E. High dose nebulized ipratropium bromide

Page 89 of 128
7. A 36-year-old thin lady, a non-smoker, a manual worker, suffered from low grade fever with
loss of appetite and loss of weight for about one month. She also suffered from productive cough
with white sputum production for 2 weeks. Last week, she had right sided sharp chest pain
which radiated to right shoulder tip. So she came to MGH.

1. What is the most likely diagnosis?

A. Pneumonia
B. Tuberculosis
C. Asthma
D. COPD
E. Bronchogenic carcinoma

2. What investigation would you like to do to confirm the diagnosis?

A. ESR
B. Sputum for AFB
C. CRP
D. FBC
E. Sputum for C&S
On respiratory system examination, there is reduced chest movement on right middle and
lower zones with stony dullness on percussion and reduced breath sounds on that area. So,
CXR was also taken.

3. What will be seen on the CXR?

A. Right lober pneumonia
B. Right lung collapse
C. Right sided pleural effusion
D. Left sided pleural effusion
E. Left lober pneumonia

4. What next investigation will you proceed?

A. CT chest
B. Bronchoscopy
C. Sputum for cytology
D. Pleural aspiration and biopsy
E. Lymph node biopsy

Page 90 of 128
 5. What treatment will you give?
A. IV Antibiotics
B. Anti TB treatment
C. Radiation therpy
D. Bronchodilators
E. IV Duretics

8. A 38-year-old lady came to hospital with high grade fever associated with rigors and malaise
for 3 days duration. She also suffered from sharp chest pain and cough with yellowish sputum
production. On examination, she is febrile with T˚- 100˚F, RR- 40/min, SpO2- 82% on air, BP-
90/60 mmHg, confusion (+), trachea – midline, dull percussion note on right middle zone of the
chest, and bronchial breath sound on that area.

1. What is the most likely diagnosis?

A. Tuberculosis
B. Acute severe asthma
C. Acute pulmonary oedema
D. Community acquired pneumonia
E. Acute exacerbation of COPD

2. Severity assessment include except-

A. Confusion
B. Urea > 7 mmol/L
C. RR > 30/min
D. BP = 90/60 mmHg
E. Age > 65 yr

3. What investigation will you do except?

A. FBC
B. CXR
C. Sputum for C&S
D. Echocardiogram
E. ESR & CRP

Page 91 of 128
 4. What is the most common causal organism?
A. Strep. pneumoniae
B. Mycoplasma pneumoniae
C. Chlamydia pneumoniae
D. Legionella pneumoniae
E. Haemophillus pneumonia

9. A 26-year-old man came to medical OPD with the chief complaint of 4 days history of high
fever, productive cough and severe breathlessness. The colour of the sputum was yellow. On
examination, he is dyspnoeic, drowsy, T˚ - 102˚F, RR-44/min, SpO2-70% on air, BP- 100/60
mmHg. On respiratory system examination, bilateral coarse creptitations are heard on both
lung fields. WBC- 22×109 /L, Hb- 13gm%, PLT- 330×109 /L, ESR- 40 mm1st hr, hsCRP- 110,
urea- 5.6 mmol/L, creatinine- 126µmol/L.

1. According to CURB-65, this patient's score is –

A. 0
B. 1
C. 2
D. 3
E. 4

2. What treatment will you give except?

A. Oxygen inhalation
B. IV Fluids
C. IV Antibiotics
D. NSAIDs
E. Diuretics

3. The followings are the indications for referral to Intensive Care Unit except.
A. CURB score 3
B. Progressive hypercapnia
C. Severe acidosis
D. Circulatory shock
E. Reduced conscious level

Page 92 of 128
10. A 56-year-old man, a chronic smoker for 40 years came to medical OPD with the chief
complaint of low-grade fever with evening rise in temperature, dry cough, loss of appetite and
loss of weight for 1 month. He also complained of right sided chest pain for 2 weeks. On
examination, he is thin and emaciated, there is right supraclavicular lymph node enlargement
which is hard in consistency and clubbing of nails and toes are seen. His chest revealed stony
dullness and reduced breath sound on right side of the chest from 8 th intercostal space
downwards.
1. What is the most likely diagnosis?
A. Tuberculosis
B. Bronchogenic carcinoma
C. Pneumonia
D. Infective endocarditis
E. Bronchiectasis

2. What investigations would you like to do for this patient except?

A. Echocardiogram
B. CXR
C. Sputum for AFB
D. Pleural aspiration and biopsy
E. ESR

3. What further investigations will you do if above investigations shows non-specific results
except?
A. Lymph node biopsy
B. CT scan of the chest
C. Sputum for cytology
D. Bronchoscopy
E. Blood culture

4. What treatment will you give?

A. Anti TB treatment
B. IV broad spectrum antibiotics for 1 month
C. Surgery, chemotherapy or radiotherapy according to the stage of the disease
D. IV antibiotics for 2 weeks
E. IV Diuretics

Page 93 of 128
 RESPIRATION KEYS
1.ACEB

2.CBDB

3.DDDA

4.BEAD

5.BCAC

6.CADA

7.BBCDB

8.DDDA

9.CBEA

10.BAEC

Page 94 of 128
 9. RHEUMATOLOGY

Q1. A middle age lady presented with pain in the small joints of both hands with sparing of
distal interphalangeal joints for three months duration. She also has morning stiffness.

1. Which of the following pathologic processes is most likely to be taking place in this patient?
A. Gout
B. Osteoarthritis
C. Osteomyelitis
D. Reactive arthritis
E. Rheumatoid arthritis

2. What is/are the appropriate investigation/s?

A. X’ray both hands
B. ANA
C. Full blood count
D. Blood culture
E. Rheumatoid factor

3. Which therapy plays a central role

A. Antibiotic
B. NSAID
C. Tramadol
D. Corticosteroid
E. DMARD

Page 95 of 128
Q2. A 45-year-old woman has had arthritis for 16 weeks. She has morning stiffness lasting two
hours. The hands, wrists, right elbow and knees are swollen. She also complains of
painful feet. The ESR is 41mm/hr and C reactive protein is 34 mg/L. The full blood count
is normal.

1. What is the most likely diagnosis?

A. Polymyalgia rheumatica (PMR)
B. Polymyositis
C. Reactive arthritis
D. Rheumatoid arthritis
E. Systemic lupus erythematosus

2. Which antibody test would you request?

A. Antinuclear antibodies (ANA)
B. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies)
C. Antineutrophil cytoplasmic antibodies (ANCA)
D. Antiphospholipid antibodies
E. Complement

3. Which of the following DMARDS would be most appropriate initial treatment?

A. Methotrexate
B. Leflunomide
C. Azathioprine
D. Penicillamine
E. Infliximab

4. Regarding her joint disease which of the following suggest an adverse prognosis?
A. Acuteness of presentation
B. Articular erosions on X’ray
C. Elevated C reactive protein
D. Enthesitis
E. Sero-negative for rheumatoid factor

Page 96 of 128
Q3. A 40 years old patient with long standing rheumatoid arthritis develop splenomegaly,
lymphadenopathy, skin pigmentation and leg ulcers

1. What is the likely diagnosis

A. Malaria
B. Felty’s syndrome
C. Sjogren syndrome
D. Cirrhosis
E. Tuberculosis
2. Possible laboratory finding in this patient is
A. Neutropenia
B. Leucocytosis
C. Thrombocytosis
D. Hypokalaemia
E. Increase creatinine

3. How will you treat this patient?

A. Antibiotic
B. Antimalaria
C. Anti-TB
D. High dose vitamin B complex
E. Treatment of rheumatoid arthritis

Q4. A 70-year-old man developed acute monoarthritis of his right ankle on the second
postoperative day following an elective inguinal hernia repair. He was on a diuretic for
hypertension. On examination his temperature was 38°C.

1. What is the most likely diagnosis?

A. Acute rheumatoid arthritis
B. Gout
C. Pseudogout
D. Septic arthritis
E. Traumatic synovitis

Page 97 of 128
 2. What of the followings are useful in the diagnosis except?
A. Serum uric acid
B. Joint aspiration
C. ANA
D. X ray of the joint
E. Inflammatory markers

3. Which of the following would be the best initial treatment for him if the patient has peptic
ulcer?
A. Allopurinol
B. Indomethacin
C. Febuxostat
D. Steroid
E. Colchicine

Q5. A middle age gentlemen came with low back pain and early morning stiffness with
radiation to buttocks with duration of 6 months. His symptoms are exacerbated by rest
and relieved by movements. His serum rheumatoid factor is negative.

1. What is the possible diagnosis?

A. Rheumatoid arthritis
B. Gouty arthritis
C. Lumbar spondylosis
D. Osteoarthritis
E. Ankylosing spondylitis

2. How will you investigate this patient?

A. Serum uric acid
B. Lumbar spine X’ray
C. Blood for complete picture
D. Inflammatory markers
E. MRI of sacroiliac spine

Page 98 of 128
 3. How will you treat this patient?
A. Antibiotic
B. Allopurinol
C. Tramadol
D. NSAID
E. Bed rest

Q6. A young boy came with arthritis of knees and ankles for 2 weeks duration. He has history
of diarrhea 2 weeks before arthritis.

1. What is the possible diagnosis?

A. Hepatitis C induced arthritis
B. OA knees
C. Rheumatoid arthritis
D. Haemarthrosis
E. Reiter’s disease

2. How will you investigate to get the diagnosis?

A. Viral serology
B. ESR
C. Aspiration
D. Rheumatoid factor
E. ANF

3. How will you treat?

A. Allopurinol
B. Plasma infusion
C. Tramadol
D. NSAID
E. Antibiotic

Page 99 of 128
Q7. A gentlemen come with the chief complaint of polyarthritis for 6 months duration. He also
complaint of low back pain. He has history of skin lesions which he described as silvery
white scaly lesion which come off and on

1. What is the possible diagnosis?

A. Rheumatoid arthritis
B. Haemarthrosis
C. Psoriatic arthritis
D. Septic arthritis
E. Gout

2. How will you treat this patient?

A. NSAID
B. IV antibiotic
C. Allopurinol
D. Bed rest
E. Hydroxychloroquine

Q8. A 35-year-old woman who was two months postpartum presented with a four-week
history of joint pain, facial rash and fever. Blood tests reveal an ESR of 40 mm/hour.

1. What is the most likely diagnosis?

A. Reactive arthritis
B. Rheumatoid arthritis
C. Sarcoidosis
D. Systemic lupus erythematosus (SLE)
E. Viral arthritis

2. The followings are ARA criteria for SLE except

A. Malar rash
B. Discoid rash
C. Uveitis
D. Oral ulcers
E. Photosensitivity
Page 100 of 128
 3. The followings Antibodies can be positive in SLE except
A. ANA
B. RF
C. Anti Smith Ab
D. Antiphospholipid Ab
E. Anti dsDNA

Q9. A middle age gentlemen come with red swollen painful big toe which he describes as he
has to wait up at night due to severe pain for one day duration. He has history of previous
attack which is worsened by beer drinking.

1. What is the diagnosis?

A. Gout
B. Ankylosing spondylitis
C. Rheumatoid arthritis
D. Osteoarthritis
E. SLE

2. Which test will you do for diagnosis?

A. Joint aspiration for uric acid crystal
B. RA test
C. Uric acid
D. ANF
E. ESR

3. How will you treat the acute attack?

A. Allopurinol
B. NSAID
C. Febuxostat
D. Antibiotics
E. DMARD

Page 101 of 128

Q10. A lady come with arthritis and photosensitive butterfly rash and oral ulcer
1. What is the diagnosis
A. SLE
B. Rheumatoid arthritis
C. Ankylosing spondylitis
D. Drug reaction
E. Psoriatic arthritis

2. How will you investigate this patient?

A. Serum uric acid
B. ANF
C. Rheumatoid factor
D. Blood culture
E. Joint X-ray

3. How will you treat this patient mild symptoms for long term?
A. Hydroxychloroquine
B. Allopurinol
C. Colchicine
D. Antibiotics
E. Topical NSAID

Q11. A 16-year-old girl presents with a three-month history of polyarthralgia and marked early
morning stiffness. Her symptoms respond well to diclofenac but she is becoming
increasingly concerned about her symptoms which appear to be progressing. She is
otherwise well apart from a history of acne which is well controlled on minocycline. Her
mother has severe rheumatoid arthritis.

Investigations:
ESR 50 mm/hr (0-20)
CRP 100 mg/L (<10)
Rheumatoid factor Negative
ANA Strongly positive (1:1600)
Anti-dsDNA antibodies Negative
IgG 25 g/L (<15)

Page 102 of 128

 1. What is the most likely cause?
A. Drug-induced SLE
B. Fibromyalgia
C. Rheumatoid arthritis
D. Sero-negative spondyloarthropathy
E. Systemic lupus erythematosus (SLE)

2. Which of the following antibodies is most likely to be detected in this patient?

A. Anti-endomysial antibodies
B. Anti-histones antibodies
C. Anti-Ro/SSA antibodies
D. Anti-SCL70 antibodies
E. Rheumatoid factor

3. Which of the following should be your first management step?

A. methotrexate
B. methylprednisolone
C. hydroxychloroquine
D. naproxen
E. Stop minocycline

Q12. 60 years old obese lady come with the chief complaint of knees pain which is worse on
walking and relieved by rest. She has been suffering it for 2 years duration.
1. What is the most possible diagnosis for this lady
A. Gout
B. RA
C. OA knees
D. SLE
E. Septic arthritis

2. How will you treat her initially?

A. Paracetamol orally
B. Colchicine
C. DMARD
D. High dose prednisolone
E. Antibiotics

Page 103 of 128

Q13. 60 years old man with no prior medical history had right hip pain for 6 years duration.
The pain is worse at the end of the day. There is sclerosis with narrowing of the joint space
at the right acetabulum seen on a radiograph of the pelvis.
1. Which of the following is mostly diagnosis?
A. Gout
B. Lyme disease
C. Rheumatoid arthritis
D. Osteomyelitis
E. Osteoarthritis

2. Which one of the following is the most appropriate initial treatment?

A. Tramadol
B. Dihydrocodeine
C. Injection diclofenac sodium
D. Paracetamol
E. Topical diclofenac

Q14. A 25-year-old lady presents with rapidly worsening Raynaud's phenomenon, and skin
tightness. On examination, there is sclerodactyly, skin thickening to the shoulders, and bi-
basal crepitations. Muscle strength is normal.
1. What is the diagnosis?
A. Dermatomyositis
B. Diffuse cutaneous systemic sclerosis
C. Limited cutaneous systemic sclerosis
D. Mixed connective tissue disease
E. Sjogren's syndrome

2. Which antibody is most likely associated with pulmonary fibrosis?

A. Anti-nuclear antibody
B. Anti-centromere antibody
C. Anti-Scl70 antibody
D. Anti-U1RNP
E. Anti-Ro/La antibod
Q15. A 40 years old man with asthma and allergic rhinitis came to you as he has been suffering
from tingling and numbness in upper limbs. He suffered weakness of right leg last 1 month
ago but now it is better. His blood film showed eosinophilia.

Page 104 of 128

 1. What is the diagnosis?
A. SLE
B. Churg-Strauss Syndrome
C. Drug allergy
D. Lyme disease
E. AIDS

2. How will you treat him?

A. High dose steroid
B. High dose IV antibiotics
C. IV colchicine
D. NSAID
E. ART

Q16. A 37-year-old woman presents with tightening of skin of her hands. She cannot open her
mouth very well. Respiratory examination reveals inspiratory crackles consistent with
pulmonary fibrosis.
CXR Interstitial shadowing consistent with fibrosis
1. What is the most likely diagnosis?
A. Systemic sclerosis
B. Reactive arthritis
C. Rheumatoid arthritis
D. Polymyalgia rheumatica
E. SLE

2. Which of the following autoantibodies can be found in her serum for the diagnosis?
A. Rheumatoid factor
B. Anti-PM/Scl antibodies
C.Anti-Scl-70 antibodies
D. Anti-smooth muscle antibodies
E. Anti-parietal cells antibodies

3. But things did not come out as we have expected and blood test showed anti RNP antibodies
and she said that she had photosensitive rash when she went under sunlight. What is the final
diagnosis?
A. Mixed connective tissue disease
B. Lyme disease
C. Scleroderma
D. SLE
E. Sjogren’s disease

Page 105 of 128

 Rheumatology (Answers)

1. EEE
2. DBAB
3. BAE
4. BCE
5. EED
6. EBD
7. CE
8. DCB
9. AAB
10. ABA
11. ABE
12. CA
13. ED
14. BC
15. BA
16. ACA

Page 106 of 128

 10. EMERGENCY

Q1. A 45-year-old chronic smoker came to emergency department with sudden onset of
breathlessness. On examination, blood pressure was 100/70 mmHg with basal crepitation on
auscultation.

1. What additional history would you like to look for?

A. Chest pain
B. Fever
C. Palpitation
D. Syncope
E. Tightness of chest

2. What immediate investigation would you do?

A. Blood for CP
B. ECG
C. Echocardiogram
D. Electrolyte
E. Urea

3. What treatment would you like to give first?

A. Aspirin
B. Blood transfusion
C. IV Antibiotic
D. IV Dopamine
E. IV Frusemide

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Q2. A 45-year-old chronic smoker came to emergency department with sudden onset central
chest pain, constricting in nature associated with breathlessness for 30 minutes. BP was 100/70
mmHg, normal heart sound and vesicular breath sound on auscultation. ECG shows ST
elevation in inferior leads.

1. Giving the diagnosis, what is your immediate action?

A. IV Frusemide
B. Oral aspirin
C. Oral aspirin and oral clopidogrel
D. Oral Carvedilol
E. Oral Warfarin

2. What is your definitive management?

A. ICD insertion
B. IV thrombolysis
C. Mitral Valvotomy
D. Oral Morphine
E. Primary PCI

Q3. A 63-year-old female presents with a one-day history of confusion with headaches.
On examination she is confused, with a Glasgow coma scale of 13 and a temperature of 39. 5°C.
She has nuchal rigidity and photophobia.

1. What investigation you would like to do?

A. Blood Sugar
B. Creatinine
C. CT head
D. LFT
E. Lumber Puncture

CSF examination reveals a glucose of 0.5 mmol/l (3.3-4.4), a white cell count of 2500 per mm

and Gram-positive cocci in pairs.

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2. What is your diagnosis?
A. Acute pyogenic meningitis
B. Cerebral malaria
C. Cryptococcal meningitis
D. Stroke
E. TB meningitis

3. What is your treatment?

A. Analgesic
B. Anti-TB
C. IV amphotericin B
D. IV antibiotics
E. IV mannitol

Q4. A 26-year-old woman presented at 35 weeks of pregnancy with profuse vaginal bleeding.
She had suffered two previous miscarriages. She had a pulse of 95 beats per minute, blood
pressure of 110/84 mmHg and no fetal heart sounds were audible.

Investigations revealed:
WBC 12.3 x 103/uL
Haemoglobin 98 g/L (115 ‐ 165)
Platelets 66 ×109/L (150 ‐ 400)
Prothrombin time 21 sec (11.5‐15.5)
APTT 52 sec (30‐40)
Fibrinogen 0.5 g/L (2‐4)

1. What is your diagnosis?

A. Acute leukaemia
B. Aplastic anaemia
C. Chronic myeloid leukaemia
D. DIC
E. ITP

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2. What is the most appropriate next step in management?
A. Antithrombin III infusion
B. Fibrinogen replacement by infusion cryoprecipitate
C. Intravenous heparin
D. Platelet transfusion
E. Transfusion of two units group O rhesus D negative blood

Q5. A 75-year-old man was admitted after being found collapsed in a garden shed
surrounded by a number of empty containers. On clinical examination the patient had small
pupils, a heart rate of 50 beats per minute, and was frothing at the mouth.

1. What is the most likely diagnosis?

A. Ethanol poisoning
B. Methanol poisoning
C. Organophosphorus poisoning
D. Paracetamol poisoning
E. Paraquat poisoning

2. What is your immediate management?

A. IV 50% Glucose
B. IV Atropine
C. IV N Acetyl Cysteine
D. IV Naloxone
E. IV Vitamin B1

3. After your management, what would you like to do?

A. Note Heart rate
B. Note Respiratory rate
C. Note Urine output
D. RBS
E. Serum Electrolyte

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Q6. A 44-year-old male with Child's grade C cirrhosis presented with hematemesis.

1. Which one of the following drugs, administered intravenously, would be the most appropriate
immediate treatment?
A. Isosorbide dinitrate
B. Omeprazole
C. Propranolol
D. Terlipressin
E. Tranexamic acid

2. What would you like to do next?

A. Barium meal
B. Fibroscan
C. OGD scopy
D. Surgery
E. USG abdomen

3. What underling problem is most likely?

A. Alcohol
B. Haemochromatosis
C. Hepatitis A
D. NSAID
E. Wilson disease

Q7. A 70-year-old man was admitted with pallor, light-headedness and loss of energy. On
the day prior to admission, he had reported loose dark stools.
Examination revealed a pulse of 110 per minute and a blood pressure of 91/60 mmHg.
Investigations revealed:
Haemoglobin 70 g/L (140‐180)
MCV 72 fL (80‐96)
WBC 11.3 ×109/L (4‐11)
Platelet count 480 ×109/L (150‐400)

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1. Presenting condition is called
A. ARDS.
B. fast atrial fibrillation.
C. impending shock.
D. megaloblastic anaemia.
E. thyroid crisis.

2. What clinical assessment should be performed?

A. One breath counting
B. PEFR
C. Postural hypotension
D. Respiratory rate
E. Valsalva maneuver

3. What is the most appropriate next step in his management?

A. Barium meal
B. Blood transfusion
C. Endoscopy
D. Parenteral iron infusion
E. Proton pump inhibitor therapy

Q8. A 59-year-old man who was active all his life develops sudden severe anterior chest pain
that radiates to his back. Within minutes, he is unconscious. He has a history of hypertension,
but a recent treadmill test had revealed no evidence for cardiac disease. On examination, he
has weaker pulse in the left radial artery with BP of 200/120 mmHg on right arm with 120/70
on the left arm.

1. Which of the following is the most likely diagnosis?

A. Acute myocardial infarct
B. Aortic dissection
C. Pulmonary embolism
D. Rupture Esophagus
E. Tension pneumothorax

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2. What investigation would you like to do next?
A. CXR
B. ECG
C. OGD scopy
D. RBS
E. Troponin T

3. What would be the underlying pathology?

A. Atherosclerosis
B. Bronchogenic carcinoma
C. Group A streptococcal infection
D. Pulmonary embolus
E. Tear in the aortic intima

Q9. A 55-year-old woman with a five-year history of knee pain, presented following an
episode of vomiting and collapse. She admitted that she was taking unknown medications from
a street vender to relive her knee pain and stopped taking those medications due to weight gain
and puffy face after taking them. On examination she had a blood pressure of 80/40 mmHg and
Cushing like appearance.

1. What is your diagnosis?

A. Addisonian crisis
B. Thyroid crisis
C. Septic shock
D. Cushing syndrome
E. Cardiac tamponade

2. What is your immediate treatment?

A. 10% dextrose infusion
B. Cefotaxime
C. Carbimazole
D. Hydrocortisone
E. Paracentesis

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3. What is the most likely underlying pathology?
A. TB
B. Malignancy
C. Autoimmune
D. Inheritence
E. Iatrogenic

Q10. A 41-year-old male presented to the ER with difficulty breathing, sweating, palpitations,
chest pain, discomfort in throat and numbness of mouth and extremities. Over the last 6
months, he has had several similar episodes which usually took 30 min each. At times, he
worried that might die. As a result, Dave has persistent worry about having another attack. In
addition, he has begun to avoid unfamiliar places and people where it may be difficult to get
help in the event of another attack.

1. What is the possible diagnosis?

A. Anxiety neurosis (AN)
B. Hypocalcaemia
C. Panic attack
D. Panic disorder
E. Unstable angina

2. What is the initial treatment?

A. Alprazolam
B. Bupropion
C. Calcium supplement
D. Haloperidol
E. Nitrate

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 10. ENVIRONMENT AND NUTRITION

Q1. An 84-year–old man is sent to the Emergency department. He is complaining of

weakness and general malaise. He has complained of general pain in the muscles and joints. He
lives alone in a second – floor flat. On examination, he has petechial rash prominent around
hair follicles, and tender over the muscles of his limb girdles. There are no other abnormalities
apart from a poorly healing wound on his right shin.
Investigations reveal: Haemoglobim 10.1 g/l
MCV 74 fl
WBC 7.9 × 10 9/l
Platelet count 334×10 9/l .

1. What is the most likely diagnosis?

A. Colonic carcinoma.
B. Idiopathic thrombocytopenic purpura
C. Peptic ulcer
D. Scurvy
E. Thalassemia

2. What is the cause?

A. Acute viral infection
B. Chromosome 16 defect
C. Familial adenomatous polyposis (FAP)
D. H. pylori infection
E. Vitamin C

3. The treatment should be.

A. antibiotics
B. antivirals
C. gene therapy
D. surgery
E. vitamin C

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 6. THERAPEUTIC AND TOXICILOGY

1. A 43-year-old woman with systemic lupus erythematosus is commenced on pulsed

Cyclophosphamide infusions, Methyl prednisolone, Hydroxychloroquine, Atorvastatin and
Enalapril due to involvement of nephropathy. A day after her most recent infusion she
complains of suprapubic discomfort and dysuria with a pink discoloration of her urine.

1. What is the most likely investigation for her?

A. APTT
B. Haemogram
C. OSPT
D. UREME
E. USG urinary tract

2. What would be the most culprit drug if the condition was associated with side effects of the
drug?
A. Atorvastatin
B. Cyclophosphamide
C. Enalapril
D. Hydroxychloroquine
E. Methyl prednisolone

3. Which medication, if administered alongside the culprit drug, reduces the risk of this
complication?
A. Alum
B. Mesna
C. Mycophenolate mofetil
D. Prednisolone
E. Trimethoprim

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2. A 30-year-old lady develops drooping of her eye lids especially in the evening for 2 months.
She also complains double vision at the same time and she is also having difficulties in combing
her hair and climbing stairs towards the end of the day. On examination, there is complex
ophthalmoplegia, fatigable muscle weakness in proximal muscles with intact tendon reflexes
without sensory impairment.

1. What would be your provisional diagnosis?

A. CVA
B. Guallain Barrie syndrome
C. Motor neurone disease
D. Myasthenia gravis
E. Peripheral neuropathy

4 days ago, she got high fever with chills associated with urinary symptoms and she was prescribed
with some drugs at OPD. She didn’t mention any of her problems to attending doctor. Now she is at
OPD again because of dyspnea and difficulties in swallowing.

2. What would be the most culprit drug she took 4 days ago that has worsened her underlying
condition?
A. Atorvastatin
B. Cephalexin
C. Ciprofloxacin
D. Linezolid acid
E. Rifampicin

3. What do you want to prescribe her at the initial presentation?

A. Azathioprine
B. Corticosteroid
C. Cyclophosphamide
D. Mycophenolate mofetil
E. Pyridostigmine

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3. A 30-year-old female with mitral stenosis and atrial fibrillation who was stable on digoxin
0.625 mg and warfarin 4 mg per day came to ERC for passing black tarry stool

1. What will be the very first investigation?

A. APTT
B. ECG
C. Echocardiogram
D. OSPT
E. Platelet count

In detail history, she was given a new drug from GP for her palpitation

2. What might be this new drug?

A. Amiodarone
B. Carvedilol
C. Metoprolol
D. Propranolol
E. Verapermil

3. What is the immediate management?

A. Correct INR with IV vit K
B. Giving a unit of PRP
C. Giving Antibiotic
D. Plan for USG for urinary pathology
E. Stop digoxin

4. A 55-year-old woman with known DM and hypertension for 5 years who has been taking
regularly of Metformin 1 G BD, Enalapril 5 mg BD, Aspirin 75 mg OD, Atorvastatin 20 mg
HS, Amlodipine 5 mg OD, vitamin B complex 1 tablet OD, was admitted to ERC medical with
complaints of dyspnea and palpitation. Her vitals are stable and RBS was 90 mg/dl and ECG
showed widen QRS with heightened T. by reviewing the detailed history, she had diarrhea for
20 times 2 days ago with reduced urine output for 1 day.

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1. What is your immediate plan?
A. Check HbA1c
B. Check serum potassium
C. Check trop T
D. Stool REME
E. USG abdomen

2. What drugs should be stopped for now?

A. Amlodipine
B. Aspirin
C. Atovastatin
D. Enalapril
E. Vitamin B complex

3. What is the immediate treatment?

A. IV calcium gluconate
B. IV glucose and insulin
C. IV glucose only
D. Nebulized salbutamol
E. Oral calcium resins

5. Daw Nu, 50-year-old lady, who has known Type 2 DM and hypertension for 15 years come
to hospital at night because she suffered sudden breathlessness. She couldn’t lay flat and
orthopnea. She denied fever, cough, chest pain, syncope and fit. On admission, her BP
was180/100 mmHg, Heart rate 122/min and bilateral coarse crepts are heard on both lungs
field. Her investigation results are;
Haemoglobin 11.3 g/dL (1.3-1.8)
White cells 9.0 ×109/L (4-11)
Platelets 300 ×109/L (150-400)
MCV 79 fL (80-96)
Albumin 40 g/L (37-49)
Creatinine 471µmol/l
Electrolytes normal
ECG LVH, No feature of ischemia
CXR Cardiomegaly

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1. What treatment would you recommend?
A. IM Morphine
B. IV Antibiotic
C. IV Frusemide
D. Oral Spironolactone
E. Oral Thiazide diuretic

2. What antihypertensive drugs are appropriate for this patient at this moment?
A. ACEI
B. ARB
C. B blocker
D. CCB
E. Thiazide like diuretic

3. What antihypertensive drugs are appropriate for long term if she refuses renal replacement
therapy?
A. ACEI
B. ARB
C. B blocker
D. CCB
E. Thiazide like diuretic

6. Daw Myint, 50 yr old lady, who has known Type 2 DM, stroke and hypertension for 15 years
come to hospital at night because she suffered unilateral left leg swelling. On admission, her BP
was 180/100 mmHg.
Her investigation results are;
Haemoglobin 11.3 g/dL (1.3-1.8)
White cells 9.0 ×109/L (4-11)
Platelets 300 ×109/L (150-400)
MCV 79 fL (80-96)
Albumin 40 g/L (37-49)
Urea 22 mmol/l
Creatinine 471µmol/l
Electrolytes normal
ECG LVH, No feature of ischaemia
CXR cardiomegaly
Doppler USG of LL Thrombus in left superficial femoral, deep femoral and popliteal vein

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1. What treatment would you recommend?
A. Factor Xa inhibitors
B. IV Antibiotic
C. Oral antiplatelet
D. Oral warfarin
E. SC Heparin

After taking appropriate medication, she got some purpuric spots on her body and her haemagram
result was
Haemoglobin 10.3 g/dL (1.3-1.8)
White cells 9.0 ×109/L (4-11)
Platelets 67 ×109/L (150-400)

2. What is the cause of problem if the condition is associated with one of the drugs listed?
A. Factor Xa inhibitors
B. IV Antibiotic
C. Oral antiplatelet
D. Oral warfarin
E. SC Heparin

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 11. PSYCHIATRY

Q1. 29-year-old school teacher who is working in remote rural area is brought to the clinic
by her relatives. She has been troubling with frequent wake up whole night since previous 6
months. She complaints of frequent attacks of cold peripheries, palpitation and sweating. She
cannot stay alone even at her home and always asks her family members to be with her. She
wakes up suddenly in the night due to nightmares. One of the family members commented that
those symptoms started only after an attempted rape 6 months ago. At that time, she was
assaulted by a stranger.

1. What physical sign is likely to see?

A. Cold extremities and tachycardia
B. Mid-systolic click and late-systolic murmur
C. Moon-face and parotid gland enlargement
D. Multiple intravenous injection marks
E. Tremor, sweating and goiter

2. One of the following treatments is most effective

A. Admission for detoxification of alcohol
B. Antithyroid
C. Beta blockers
D. CBT, stress management, antidepressants
E. Methadone replacement therapy

3. Diagnosis is
A. Alcohol withdrawal
B. Drug abuse
C. Mitral valve prolapses
D. Post-traumatic stress disorder
E. Thyrotoxicosis

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Q2. A 25-year-old carpenter is suffering from episodic attacks of chest pain, palpitations
and paranesthesia in lips and fingers. Current attack occurs after quarrelling with his
girlfriend. Whenever he suffers from the attack, he usually goes to his family doctor even at
late midnights with a feeling of impending doom. He sometime has cramps of hands during the
attacks.

1. Following sign is commonly seen in that condition.

A. Hallucination
B. High blood sugar
C. Hyperventilation
D. Unconsciousness
E. Urinary incontinence

2. Diagnosis is
A. Diabetic Ketoacidosis
B. Ischemic heart disease
C. Panic disorder
D. Paroxysmal arrhythmias
E. Temporal lobe epilepsy

3. Treatment is
A. IV Diazepam
B. Insulin infusion, fluid and potassium
C. prophylactic amiodarone
D. reassurance
E. thrombolysis or primary PCI

Q3. A 30-year-old male attends the outpatient clinic. He is obsessed with washing his hands
and spends up to one hour doing this each morning and evening. He says he feels that he is
dirty. He is also concerned about security and checks the doors at home a number of times
before leaving the house. On examination he was of low mood. He is slowed up in speech but
coherent. He sometimes is afraid of committing assault to someone whenever he sees a knife in
front of him. Once, he went to wedding but missed to attend it although he arrived at the
wedding. It was due to checking car lock repeatedly in the car parking.

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1. Diagnosis is
A. Acute schizophrenia
B. Adjustment disorder
C. Generalized Anxiety Disorder
D. Manic–depressive disorder
E. Obsessive compulsive disorder

2. Treatment is EXCEPT
A. Antidepressants
B. CBT
C. Deep brain stimulation
D. Desensitization
E. Psychosurgery

Q4. A 17-year-old Physics student came to ERC with sudden onset amnesia. She could not
unable to recall about her life and personal identity. She kept saying that she could not
remember anything. Her cousin was crying for her illness but she did not seem to be worry
about her amnesia. Her cousin said that she had been depressed for last 6 months because she
did not achieve entrance to medical schools.

1. What is the diagnosis?

A. Dementia
B. Dissociative disorder
C. Major depression
D. Malingering
E. Post-epileptic automatism

2. Following treatment is effective.

A. Antidepressant
B. Antipsychotics
C. ECT
D. Hypnotherapy
E. Reassurance

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Q5. A 42-year-old man is brought to the emergency department by his family after becoming
threatening when they confronted him about his excessive spending. He bought 250000 kyats
worth of clothing in the preceding week and then gave it away. He explains that this is a part
of his presidential campaign, which he has been working on night and day for several weeks.
On examination, he is talkative and wearing bright red coloured shirt and vivid yellow short.

1. What is the diagnosis?

A. Acute schizophrenia
B. Alcoholic dementia
C. Drug abuse
D. Hypomania
E. Mania

2. Following treatment is effective.

A. Antidepressant
B. Diazepam
C. ECT
D. Lithium
E. Reassurance

Q6. A 32-year-old man is brought to the emergency department by his family after doing
some strange behavior. He sometime seems to be in day-dreaming state and talking to an
imaginary person. He often hears speech which is not heard by other family members. After a
conversion with the patient, he admitted that he knows a secret of the US government who has
assassinated all of his family members and substituted with spies who are very similar to them.

1. What is the diagnosis?

A. Alcoholic dementia
B. Drug abuse
C. Hypomania
D. Manic depression
E. Schizophrenia

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2. Following treatment is effective.
A. Antidepressant
B. Diazepam
C. ECT
D. Olanzapine
E. Reassurance

12. POISONING

Q1. A 17-year-old girl presented with jaundice three days after having taken a paracetamol
and alcohol overdose during an argument with her boyfriend.

1. What investigations should be done in this patient Except?

A. D-dimers
B. Paracetamol level
C. Prothrombin time
D. Serum aspartate transaminase
E. Serum creatinine

2. What is the best marker of prognosis?

A. Paracetamol level
B. Prothrombin time
C. Serum alkaline phosphatase
D. Serum aspartate transaminase
E. Serum bilirubin

3. What is the most appropriate treatment?

A. Activated Charcoal
B. Gastric Lavage
C. Haemodialysis
D. Intravenous Insulin
E. Intravenous N acetylcysteine

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Q2. A farmer, on treatment for depression is admitted acutely 1 hour following an intentional
overdose of an unidentified substance. On examination he is bradycardic, hypotensive,
disorientated, hypersalivating, and has small pupils.

1. He has most likely ingested:

A. A tricyclic anti-depressant
B. An organophosphate insecticide
C. Cyanide
D. Paracetamol
E. Paraquat

2. What are the clinical features of anticholinesterase effects EXCEPT?

A. Diarrhea
B. Lacrimation
C. Mydriasis
D. Salivation
E. Urination

3. What is the treatment?

A. Adrenaline
B. Atropine
C. Dobutamine
D. Dopamine
E. Noradrenaline

Q3. An 18-year-old woman is admitted after taking drugs at a night club.

1. Which of the following features suggest she had taken Ecstasy?
A. A pyrexia of 40°C
B. Hypernatraemia
C. Hypokalaemia
D. Metabolic acidosis
E. Respiratory depression

2. Which one of the following would suggest substance abuse?

A. A history of attention deficit disorder.
B. A history of family conflict.
C. A history of low self-esteem.
D. A history of social isolation.
E. Deposits around the mouth.

Page 127 of 128

 Answer Keys

EMERGENCY
1. ABE
2. CE
3. EAD
4. DB
5. CBA
6. DCA
7. CCB
8. BAE
9. ADE
10. DA
ENVIRONMENT AND NUTRITION
1. DEE
THERAPEUTIC
1. DBB
2. DCE
3. AAA
4. BDA
5. CDD
6. EE
--------
PSYCHIATRY
1. ADD
2. CCD
3. ED
4. BD
5. DD
6. ED
POISONING
1. ABE
2. BCB
3. AE

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