6th year internal medicine exam 2016 – by Kinana AbuRayyan, Malek Zahran & Amjad Elmashala
1. Which of the following is a contraindication to thrombolysis  Pregnancy
2. Which one of the following is not related to IBD activity 
Sacroiliitis (axial skeleton involvement)
3. All of the following are causes of uveitis except 
Ankylosis spondylitis
Lymphoma
Inflammatory bowel disease
Behcet’s disease
4. Feature of RA  Marginal erosion
5. Which of the following physical findings favor emphysema over chronic
bronchitis 
Barrel chest
Obesity
6. Nothing in the history except diabetes. Picture of fundoscopy. Most likely
diagnosis is (difficult to tell) 
Papilledema
Optic atrophy
Normal disc
7. Which of the following causes odynophagia (esophagitis)  Tetracycline
8. Patient was on warfarin, developed subdural hematoma 
Give oral vitamin K and FFP
Give IV vitamin K
Give FFP
9. Intoxication + dilated pupil. Most likely abused 
Cocaine
Heroin
Opioid
10. Ejection systolic murmur at left sternal border in Turner patient, you would
expect to find  Bicuspid aortic valve (associated with coarctation)
11. Which of the following is proven to prolong survival in MI patients 
Captopril or enalapril (ACE- inhibitors are proven to prolong survival
regardless of the ejection fraction post-MI)
12. Mode of transmission of hemophilia B  X-linked
13. Patient was hypoventilating, his ABGs – pCO2 60 & pO2 40. His A-a
gradient:
Increased (A-a gradient = 150 – 1.25 * pO2 – pO2 = 150 – (1.25 * 60) – 40 = 35)
Normal
Decreased
Cannot be calculated
14. Patient (smoker) with longstanding HTN and peripheral arterial disease,
presenting with worsening HTN over a 6 month period. He has
claudication. Most likely diagnosis  Renal artery stenosis
15. Case of Takayasu, you would expect:
Low BP in arms and high BP in legs
High BP in arms and low BP in legs
16. Case of sudden collapse, patient became apneic and pulseless, rhythm
analysis revealed V. fibrillation 
Defibrillation
ET intubation
17. Which of the following is not a risk factor for squamous cell cancer of the
esophagus 
Barrett’s esophagus (since it predisposes to adenocarcinoma)
Tylosis
Achalasia
18. Which of the following medical management does not improve survival in
CHF patients 
Synchronization of biventricular contraction or activity
Controlling tachycardia
Optimization of preload
Reduction of afterload
Aggressive diuresis
19. Case of TTP, presented with bleeding, platelet count < 10,000. Best next step
in management 
Plasmapheresis (never give platelets to patients with HUS/TTP)
Give platelets
Give FFP
20. Which of the following antibiotics does not need dose adjustment in renal
failure 
Clarithromycin
Imipenem or meropenem
Piperacillin
Vancomycin
Clindamycin
21. Case of PAN, Tx should be 
Steroids + cyclophosphamide
Steroids only
22. Case of 60 year patient with lung mass, on exam he has Gottron papules,
most likely diagnosis  Dermatomyositis
23. Patient after removal of pheochromocytoma. The drug with alpha-blocking
activity used would be 
Phenoxybenzamine
Nebivolol
Propranolol
24. Case of Hypothyroidism, low FSH, LH & estrogen. Has hypokalemia (?) and
hypoglycemia. Most likely diagnosis  panhypopituitarism
25. Which of the following is least useful in ABG analysis 
pO2
pCO2
pH
HCO326. Patient with a history of rheumatic fever presented with a new murmur and
fever. Most likely organism causing IE is  Streptococcus viridans
27. Regarding irritable bowel syndrome
Only 1% have underlying psychiatric
Diarrhea predominant, you need to exclude microscopic colitis, lactose
intolerance and one more thing
Abdominal pain is most likely presentation
28. Patient presents with episodes of hypoglycemia (or symptoms suggesting
hypoglycemia). Most appropriate next step 
72 hour fast
Insulin level and C-peptide
29. ICU patient, TSH slightly decreased, T3 low and normal T4  sick
euthyroid syndrome
30. CKD patient with anemia, hemoglobin was 8. He was given erythropoietin,
and his recent hemoglobin 9.2. His MCV is now 77, you would give  Iron
31. Which of the following is a treatment with proven benefit for achalasia 
Botulinum toxin injection
32. Which of the following is a poor prognostic factor for patients with mitral
regurgitation 
Displaced apex beat
Soft S1
Split S2
33. Which of the following drugs causes prolongation of the QT interval 
Erythromycin
34. 70 year old patient presenting with pneumonia  Admission and treatment
with fluoroquinolone or azithromycin and …
35. Poor prognosis in pneumonia (mortality increased)  Resp. rate > 35
36. 70 year old female, known case of atrial fibrillation, presented with two
episodes of numbness on the right side of face and arm, she has poor
coordination of the right arm on exam  Anticoagulation
37. Chest x-ray showing right upper consolidation, you would expect on exam
 bronchial breathing over that area
38. Chest x-ray with right-sided effusion, you would expect on exam 
dullness to percussion
39. Which of the following would not be expected in patients with adrenal
insufficiency (Addison’s)  Metabolic alkalosis
40.ABGs pH 7.30, pCO2 60, HCO3- 26  Acute respiratory acidosis
41. Patient with recurrent pneumonia  you should cover for Pseudomonas
42. Which of the following does not cause chronic liver disease 
Hemosiderosis
Cystic fibrosis
43. 60 year old female patient with back pain, on exam she has tenderness,
investigation revealed anemia and hypercalcemia  Multiple myeloma
44.Patient with polyuria and polydipsia, on exam she has painful nodules on
shins, what is the cause of her polyuria 
Hypercalcemia (secondary to sarcoidosis)
45. Patient presented with hypertensive crisis, systolic BP 180. Fundoscopy
revealed narrowing of the arteries. Most appropriate next step 
Treat in the ER with clonidine
Admit to the ward and treat with IV hydralazine
Admit to ICU and treat with nicardipine
46. Which of the following does not provoke encephalopathy  lactulose
47. Poor prognostic factor in paracetamol intoxication 
Prolonged PT
Elevated liver enzymes
Elevated bilirubin
48. One of the following is true as liver injury ensues 
N-acetylcysteine may be harmful
Better prognosis in alcoholics
Better prognosis in elderly
Lactic acidosis
49. Known case of rheumatoid arthritis presented with SOB. Her BP is low, and
you noticed on exam raised JVP, distant heart sounds  cardiac tamponade
50. Case presented with dyspnea, hepatomegaly and raised JVP. On
auscultation there was pericardial knock. His JVP showed prominent x and
y descent on JVP wave  Constrictive pericarditis
51. Case of rheumatoid arthritis with neutropenia and splenomegaly. Most
likely diagnosis is  Felty’s syndrome
52. Young patient, non-smoker, with positive family history for similar disease.
Exam findings or PFT (can’t remember which) are suggestive of COPD.
Most likely diagnosis  α1 anti-trypsin deficiency
53. Which of the following is found in CREST syndrome  anti-centromere Ab
54. 60 year old with proximal muscle weakness, elevated ESR and normal CPK
 Polymyalgia rheumatica
55. Which of the following is not associated with exacerbation of IBD  bowel
motion less than 2 times daily
56. Typical case of SLE (malar rash, symmetric arthritis on exam, and
pancytopenia on labs). Best initial test 
ANA
Anti-ds- DNA
Anti-Smith
57. Hyperthyroid patient on methimazole comes in with a fever  order CBC
(to rule out agranulocytosis as a side effect of his medication)
58. Old patient with recurrent history of passing large amount of urine on some
days, and anuria on others. His BUN/creatinine was > 20 (there were values
for BUN and creatinine), most likely diagnosis  Obstructive uropathy
59. Who of the following should not be treated for asymptomatic bacteriuria 
Elderly
Pregnant
Patient with ureter stone
Immunocompromised
60. Patient with WPW syndrome presented with rapid ventricular rate, best
initial treatment  Procainamide
61. Patient, with free past medical history, presented with periorbital edema
over a period of 6 months, normal serum albumin. On urinalysis, she has 4+
proteinuria 
Membranous glomerulonephritis
Diabetes
62. Case of acromegaly (symptoms and signs were obvious), best initial test 
IGF-1 level
GH level
63. Patient with bilateral lower extremity edema (I think symptoms or signs
suggestive of CHF), on labs you find hyponatremia and hypokalemia 
Diuretic side effect
SIADH
Nephrotic syndrome
64. Patient with toxic multinodular goiter, you would notice on exam 
Lid retraction (upregulation of sympathetic receptors)
Proptosis
Positive thyroid stimulating immunoglobulin
65. Hypothyroid patient on levothyroxine, during pregnancy you would 
Increase the dose (during pregnancy, synthesis of TBG increases, so you
need to increase the dose to fill these proteins with T4)
Decrease the dose
No change
66. Patient who has undergone valve transplantation, presented after 1 month
with a 2 week history of fever, chills. On exam, he has murmur. The most
likely organism to be cultured is 
Staph aureus
Strptococcus viridans
Fungus
67. Patient with a prosthetic valve, he has anemia  hemolytic anemia
68. Patient with a systolic murmur, with radiation to carotids 
Aortic stenosis
Aortic regurgitation
Mitral stenosis
Mitral regurgitation
69. Drop in blood pressure (or weaker pulse, cannot remember which exactly)
during inspiration 
Pulsus paradoxus
Pulsus alternans
70. Which of the following is not a cause of pancreatitis  hypocalcemia
71. Patient with a presentation of Klinefelter syndrome (tall, gynecomastia,
small testes), best diagnostic test 
Chromosome analysis
Serum FSH, LH
Serum testosterone
Some kind of imaging modality
72. Woman in her 30s or 40s, with irregular menses, presented with a 2 year
history of being unable to conceive (PCOS), you would find 
Normal free androgen index
Increased LH to FSH ratio
73. Young female with history of atypical chest pain, on exam she has midsystolic click. Most likely diagnosis  Mitral valve prolapse
74. Patient with a history of congenital heart disease or something like that.
ECG was shown (interpretation: right axis deviation, right ventricular
hypertrophy with a strain). Most like diagnosis 
Pulmonic stenosis
Ebstein anomaly of tricuspid valve
Ventricular septal defect
75. Palestinian female patient with target cells on peripheral smear. Her
hemoglobin A2 is 6%. Most likely diagnosis 
α-thalassemia trait
β-thalassemia trait
76. Patient was treated for pneumonia, developed diarrhea. Best treatment is 
Oral vancomycin
IV vancomycin (ineffective since it does not cross the bowel wall)
77. Patient was treated for an infection with cephalexin and gentamicin. He
developed fever and arthralgia (or rash). On urinalysis, he has 4+
proteinuria. Most likely diagnosis is  Allergic interstitial nephritis
78. Patient was admitted to the hospital post-MI. He has undergone
angiography. His BUN/creatinine ratio was < 15 (there were value for each).
Granular casts on microscopy. Most likely diagnosis 
Acute tubular necrosis
Pre-renal azotemia or decreased perfusion
Post-renal obstruction
79. Patient with acute tubular necrosis (as suggested by his BUN/ creatinine
ratio) 
FeNA would be <1%
FeNa would be 3-5%
FeNa would be >40%
80. Patient presented with RUQ pain and pruritus. Her labs revealed positive
LKM (liver kidney muscle) antibodies. Best treatment 
Prednisone (for autoimmune hepatitis)
Cholestyramine
Ursodeoxycholic acid
81. Patient presented with bilateral joint paint, on exam she has arthritis of
PIPs and MCPs bilaterally. Investigation revealed microcytic anemia. Iron
studies revealed decreased serum iron, increased saturation or decreased
capacity. Best treatment 
Methotrexate (always treat underlying cause in anemia of chronic disease,
erythropoietin can be used in those with renal insufficiency)
Iron
82. Patient presented with ascites. Next step in management 
Treat with salt restriction and spironolactone
Consult surgery
Liver transplantation
83. Patient with uncontrolled diabetes (high readings postprandial) despite
increasing his dose of insulin. He wakes up sometimes in the middle of the
night with some sweating (o kman shi). This could be explained by 
Midnight hypoglycemia with a.m. rebound (Somogyi effect)
Dawn effect
84. Patient presented with cough and hemoptysis. On chest x-ray, you found
bilateral infiltrates in the lower zones. Most likely diagnosis 
Goodpasture syndrome
85. Patient with a history of asthma-like picture, not responding to inhaled
albuterol and steroid. There was a past surgical history for something. Flow
volume loop was shown in the exam (interpretation: box shaped i.e.
flattened during inspiration and expiration). The above finding could be
explained by 
History of tracheal stenosis secondary to prolonged intubation (fixed large
airway obstruction)
Due to her poorly controlled asthma
86. Patient with pneumonia and cavitation on chest x-ray. Most likely organism
to cause this 
Klebsiella (there wasn’t Staph aureus in the answers)
Chlamydia
Mycoplasma
Pneumocystis jeroveci
87. Patient presented to the ER after trauma. He was given blood. 30 minutes
later, he developed fever and started bleeding from sites of cannula. Most
likely cause 
ABO incompatibility
IgA deficiency
Reaction to cytokines
88. 20 year old male patient with a history of back pain and stiffness. On exam,
he has decreased mobility of spine and chest expansion. Treatment for this
condition 
NSAIDs (ankylosing spondylitis)
Prednisone
89. Increased pulmonary artery pressure … ??
90. The best non-invasive test to diagnose H. pylori 
Urea breath test
Serum IgM
Serum IgG
91. Patient with a history of periorbital edema. On urinalysis, there was RBCs
and WBCs. Biopsy revealed IgA deposits. Most likely diagnosis 
IgA nephropathy (:P)
92. Differentiate Mitral stenosis from Austin-Flint murmur 
Presystolic accentuation
Abnormal movement of anterior leaflet of MV
93. Patient with superficial type of bleeding. His PT was normal, but PTT was
prolonged. Most likely diagnosis 
Von Willebrand disease
94. A 37-year-old man with an unremarkable medical history presented to the
emergency department because of abdominal pain. The patient stated that
over the previous month he had experienced gradually worsening
discomfort that he described as being dull and located diffusely throughout
the abdomen. He rated the pain as a 7 on a severity scale of 1 to 10. he also
said that during this same period, he had been having mucus like bowel
movements that had increased in frequency to approximately 10 bowel
movements daily. He denied any sick contacts, recent illness, travel, or
recent antibiotic use. The patient has no known family history of
inflammatory bowel disease. He stated that about 1 month before the onset
of these symptoms, he began training for a marathon, at which time he also
stopped smoking cigarettes. On physical examination, the patient had no
acute distress, but hyperactive bowel sounds and tenderness were noted on
deep palpation. He was found to have a fever of 38°Celsius and heart rate of
100 beats per minute. results of laboratory analysis, including complete
blood cell count, metabolic profile, and lactic acid level, were unremarkable
except for a hemoglobin level of 10.2 g/dl (reference range, 13.5-17.5 g/dl),
and computed tomography (CT) of the abdomen with contrast medium
revealed bowel wall thickening from the hepatic flexure to the rectum.
mesenteric lymphadenopathy was also noted. He was admitted to the
hospital for further evaluation and treatment. Which one of the following
should be the initial step in the management of the abdominal pain and
diarrhea in this patient?
Antidiarrheal agents and pain medication symptomatically
Stool studies, including cultures for clostridium difficile, ova and parasites, and
bacteria
Colonoscopy
Upper endoscopy
Ultrasonography
95. You are on call and have been referred a 40-year-old woman with abdominal
pain and increasing abdominal girth. Her symptoms have been progressing
over several months. There is no history of jaundice. She has a past history of
pulmonary embolism for which she was treated with warfarin five years ago.
On examination, she has mildly jaundiced sclerae. She is alert and
orientated, there is no encephalopathy. Abdominal examination reveals
ascites and hepatosplenomegaly. You arrange an abdominal ultrasound scan
with Dopplers which demonstrates and confirms hepatosplenomegaly and
moderate ascites.
What is the most likely underlying diagnosis?
Budd-Chiari syndrome
Hepatocellular carcinoma (HCC)
Portal vein thrombosis
Primary biliary cirrhosis
Primary sclerosing cholangitis
96. A 42-year-old dentist is reviewed in the medical clinic complaining of
persistent lethargy. Routine bloods show abnormal liver function tests so a
hepatitis screen is sent. The results are shown below: Anti-HAV IgG
negative, HBsAg negative, Anti-HBs positive, Anti-HBc negative, Anti-HCV
positive. What do these results most likely demonstrate?
Hepatitis B infection
Hepatitis C infection
Previous vaccination to hepatitis B and C
Hepatitis C infection with previous hepatitis B vaccination
Hepatitis B and C infection
Best of luck
