MEDICINE P3
1. A 58-year old woman who is 12 months post chemotherapy for breast cancer
comes to the clinic with shortness of breath. Her BP is 135/82 mmHg and her
pulse is 92 beats/min and regular. Her JVP is raised, apex beat is palpable and
displaced laterally and she has bi-basal crackles. What is the most likely
diagnosis?
A. Carcinomatous pericardial effusion
B. Chemotherapy related cardiac failure
C. Lymphangitis carcinomatosa
D. Malignant pleural effusion
E. Radiation related pulmonary fibrosis
2. A 55-year old man presents with chest pain. His ECG shows acute changes in
leads II, III, and aVF. His troponin-T is abnormally high 8 hours after the onset of
chest pain. Which coronary artery is most likely involved?
A. Left anterior descending artery
B. Left circumflex artery
C. Left main stem artery
D. Right coronary artery
E. Diagonal artery
3. A 56-year old man presents with progressive abdominal and ankle swelling,
fatigue and dyspnoea. Pulse is 100 beats/min and irregular in rhythm. The JVP is
elevated and rises further with inspiration. Apex beat is impalpable and heart
sounds are barely audible. What is the most likely cause of his symptoms?
A. Ischaemic heart disease
B. Dilated cardiomyopathy
C. Constrictive pericarditis
D. Rheumatic heart disease
E. Chronic kidney disease
4. A 60-year old man with chronic congestive cardiac failure is seen in the Cardiac
Clinic. He is concerned that his breasts have enlarged. Which one of the
following medicines is the most likely cause?
A. Captopril
B. Carvedilol
C. Furosemide
D. Spironolactone
1
E. Warfarin
5. You review a 22-year old woman with rheumatic heart disease in the cardiac
clinic. Which one of the following signs would suggest mitral stenosis?
A. An undisplaced apex beat
B. An early diastolic murmur
C. An apical systolic thrill
D. A large volume pulse
E. Clubbing of the fingers
6. A 15-year old boy presents to the medical outpatients department for the first
time. He was being followed by the paediatricians for Tetralogy of Fallot. Which
of the following features is most likely to be present?
A. Pulmonary plethora on the chest x-ray
B. Rib notching and cardiomegaly on CXR
C. Pulmonary ejection systolic murmur
D. Wide fixed splitting of the second heart sound
E. Left ventricular hypertrophy
7. A 62-year old man is on treatment for hypertension. He comes to the clinic
complaining of swollen gums. Which one of the following medications is the
most likely cause?
A. Atenolol
B. Doxazosin
C. Nifedipine
D. Enalapril
E. Methyldopa
8. A 70-year old man is admitted with an INR of 5. He is on warfarin for atrial
fibrillation and recently took Chinese herbal medication. How should you
manage his anticoagulation?
A. Continue warfarin at lower dose
B. Temporarily stop warfarin
C. Give fresh frozen plasma
D. Give tranexamic acid
E. Stop warfarin and give vitamin K
2
9. A 64-year old man is taking multiple medications. He attends his general
practitioner with sudden onset of pain and inflammation affecting the first
metatarsophalangeal joint of his right foot. The GP suspects acute gout. Which
one of the following is most likely to precipitate acute gout?
A. Atenolol
B. Prednisolone
C. Lisinopril
D. Low dose aspirin
E. Spironolactone
10. A 47-year old patient presents to the Emergency Department with a suspected
drug overdose. She has a reduced conscious level, gross ataxia and there is
extensive bruising of her limbs. There is a coarse nystagmus on left and right
lateral gaze. Which one of the following medicines could she have taken?
A. Atenolol
B. Carbamazepine
C. Diazepam
D. Amitriptyline
E. Paracetamol
11. A 58-year old patient with long standing diabetes mellitus comes to the clinic
with a swollen, deformed right ankle. He has diabetic peripheral neuropathy. His
ESR is 8 mm/h. What is the most likely diagnosis?
A. Charcot’s arthropathy
B. Gouty arthritis
C. Infective arthritis
D. Osteoarthritis
E. Reactive arthritis
12. A 45-year old woman presents with ankle swelling and facial puffiness. A
urinalysis shows 3+ proteinuria and serum albumin is 10gm/dL. Which of the
following findings would be consistent with the diagnosis?
A. High serum calcium
B. Increased serum cholesterol
C. Prolonged prothrombin time
D. Hypernatremia
E. Elevated bilirubin
3
13. A 36-year old man presents with an episode of haematemesis. An endoscopy
shows extensive peptic ulceration. He has a history of recurrent abdominal pain
for which he obtains relief from ranitidine. Which hormone should be measured?
A. Cholecystokinin
B. Gastrin
C. Glucagon like peptide 1 (GLP-1)
D. Secretin
E. Somatostatin
14. A 32-year old woman presents with symptoms of anaemia and paraesthesiae.
Ankle jerks are absent. What would you expect to find on peripheral smear?
A. Schistoocytes
B. Target cells
C. Howell Jolly bodies
D. Hypersegmented neutrophils
E. Smear cells
15. A 32-year old man is referred to the clinic by his GP, who suspects irritable bowel
syndrome. He has intermittent bouts of diarrhoea, problems with bloating, and
flatulence. He has been feeling increasingly tired over the past few months. He is
pale and has a BMI of 18Kg/m2. Blood tests reveal mild anaemia and small bowel
biopsy shows partial villus atrophy and increased lymphocytes. What is the most
appropriate treatment?
A. Antiretroviral therapy
B. Gluten free diet
C. Lactose free diet
D. Metronidazole
E. Prednisolone
16. A 60-year old man presents with an 18-month history of dysphagia for both
solids and liquids. Occasionally he regurgitates undigested food and there is no
weight loss. Which investigation is most likely to confirm the diagnosis?
A. Barium swallow
B. CT scan chest
C. Upper GI endoscopy
D. Oesophageal manometry
E. Video fluoroscopy
17. A 48-year old farm labourer presents unconscious 2 weeks after a fight at a
beerhall. You suspect an epidural or subdural haematoma. The friend who
4
brought him refuses to sign for consent for craniotomy. What is the best option
for the attending doctor?
A. Proceed with craniotomy and get consent when patient recovers
B. If one pupil is dilated, wait for the other to dilate, then proceed with
craniotomy
C. There is no need for consent as this is a lifesaving procedure
D. If no other relative can be found, apply for consent at the nearest
magistrate’s court
E. Obtain consent from the District Hospital Superintendent
18. A 75-year old man presents with severe backache, bone pain and constipation.
Which of the following metabolic disturbances is most likely to explain the
constipation?
A. Hypercalcaemia
B. Hyperglycaemia
C. Hyperkalaemia
D. Hyperuricaemia
E. Hypothyroidism
19. A 49-year old man has regularly been taking over the counter stimulant laxative
preparations for constipation. Which of the following is the most commonly
recognised adverse effect of treatment?
A. Hypocalcaemia
B. Gastroparesis
C. Hypokalaemia
D. Hyponatraemia
E. Toxic megacolon
20. A 36-year old man is admitted via the Emergency Department with short history
of abdominal pain and vomiting. Which of the following would most strongly
suggest a diagnosis of acute pancreatitis?
A. Hypoglycaemia
B. Haemoglobin of 9.6g/dL
C. Serum amylase 192 IU/L (NR60-80/L)
D. Serum calcium 1.94mmol/L (NR 2.22-2.60)
E. Serum triglycerides 1.7mmol/L (NR 0-1.7)
21. A 56-year old woman with oesophageal varices is admitted to the High
Dependence Unit following a bout of haematemesis. She is now stable after
5
resuscitation. Which one of the following interventions could reduce the risk of
re-bleeding?
A. Oral propranolol
B. IV somatostatin
C. IV terlipressin
D. IV omeprazole
E. Upper GI endoscopy
22. A 45-year-old woman presents to the clinic with chronic myeloid leukemia
(CML). You decide that she is a suitable candidate for imatinib therapy. Which
one of the following correctly describes the mode of action of imatinib?
A. Inhibitor of epidermal-derived growth factor
B. Inhibitor of MAP kinase
C. Inhibitor of serine kinase
D. Inhibitor of tyrosine kinase
E. Vascular endothelial growth factor inhibitor
23. You requested a peripheral blood film on one of your patients with unexplained
anaemia. Which of the following features would most strongly suggest
underlying iron deficiency?
A. Elliptocytes
B. Howell jolly bodies
C. Red cell inclusion bodies
D. Target cells
E. Tear-drop cells
24. A 40-year old woman is referred for assessment of anaemia associated with mild
jaundice.Which of the following features most strongly suggests haemolysis as
the underlying cause?
A. High conjugated serum bilirubin
B. Positive urine bilirubin test
C. Raised serum haptoglobin level
D. Macrocytosis
E. Reticulocytosis
25. A 20-year old lady has just delivered a stillborn baby. She is said not to have bled
post-delivery. The creatinine is 1000μmol/L. Her haemoglobin is 8g/dL, platelets
6
80x109/L and MCV 100fL. Her AST is 300IU/L (NR 10-40 IU/L). What is the most
likely cause of the acute kidney injury?
A. HELLP syndrome
B. Haemolytic uraemic syndrome
C. Bilateral cortical necrosis
D. Pre-renal failure
E. Acute tubular necrosis
26. A third-year medical student develops fever and headache 2 weeks after
returning from Easter holidays in Honde Valley. He drank fresh cow’s milk during
the visit. Which test would you consider to be most urgent?
A. Stool culture
B. Brucella test
C. Lumbar puncture
D. HIV test
E. Malaria parasites
27. A 72-year old man who was treated for TB 8 years ago comes to the hospital
complaining of haemoptysis. He has had night sweats over the past few months
and a chronic cough. He smokes 10 cigarettes per day and has signs of right
upper lobe consolidation on examination. His WCC is elevated at 11.5 x 109/L
and Aspergillus precipitins are positive. The chest x-ray reveals a right upper lobe
cavitating lesion. Which of the following is the most likely diagnosis?
A. Allergic bronchopulmonary aspergillosis
B. Aspergilloma
C. Bronchial carcinoma
D. Invasive aspergillosis
E. Reactivated tuberculosis
28. A 40-year old man attends the Emergency Department with his girlfriend. He has
been unwell for the past few days with a severe headache and right arm
weakness. He has had a headache on and off for a month. He is also becoming
increasingly confused. He has a mild pyrexia of 37.6°C and the right arm is weak
with power of 4/5. His blood pressure is 150/90. CSF protein is elevated and
there is a mononuclear leucocytosis. What is the most likely diagnosis?
A. Cerebral infarct
B. CMV encephalitis
C. Cryptococcal meningitis
D. Herpes encephalitis
7
E. Toxoplasmosis
29. A 13-year old female presents unwell with fever and joint pains for 3 weeks. On
examination, she has a continuous murmur at the second left intercostal space.
Which of the following clinical findings would make you suspect bacterial
endocarditis?
A. Collapsing pulse
B. Erythema marginatum
C. Microscopic haematuria
D. Generalised lymphadenopathy
E. Leukonychia
30. A 16-year old girl has been working with animals at a local farm. She comes to
the Emergency department with a headache, fever and non-bloody diarrhoea.
Her BP 159/89mmHg, and she is pyrexial at 37.8°C. She has a purpuric rash and
widespread petechial haemorrhages. Her results show haemoglobin of 9.2g/dl,
WCC 11.5 x 109 /L, platelets 51x109/L, sodium 139mmol/L, potassium
6.1mmol/L, creatinine 209 μmol/L. Urinalysis shows: Blood ++, protein ++, only
50ml was passed. Which of the following is the most likely causative organism?
A. Campylobacter jejuni
B. Escherichia coli
C. Listeria monocytogenes
D. Salmonella typhi
E. Shigella dysenteriae
31. A 36-year old man presents with a 4 week history of diarrhoea, originally thought
to be due to Salmonella infection from a roast chicken, but unresponsive to
ciprofloxacin. He passes watery loose stools up to 10 times per day. His WCC is
10.5 x 109/L and creatinine of 190μmol/L. Acid fast staining of the stool reveals
red oocysts against a blue-green background. What is the most likely organism?
A. Cryptosporidium parvum
B. Giardia lamblia
C. Isospora belli
D. Mycobacterium avium-intracellulare
E. Shigella shiga
32. You are asked to counsel a 27-year old woman who has had HIV infection for 4
years. She is expecting her first child and is 8 months pregnant. What is the most
appropriate advice you can give her?
8
A. Antiretroviral treatment should be withheld in the peri-partum period
B. Breastfeeding does not increase transmission risk.
C. Delivery by caesarean section reduces transmission risk
D. Maternal viral titres do not influence transmission likelihood
E. Vaginal delivery has transmission rate of 80-90%
33. You are five months into your medicine rotation. A colleague who has just joined
the team asks you for advice following a needlestick injury while drawing blood
from an HIV positive patient. Which of the following is correct regarding
potential transmission of HIV infection:
A. Antiretrovirals should be taken within 1 to 2 hours.
B. Start on tenofovir, lamivudine and nevirapine
C. Overall transmission risk is around 10%
D. Negative HIV antibody serology at 1 month is reassuring
E. Stage of HIV infection of the patient is irrelevant
34. A 26-year old man presents with a 4 week history of night sweats, fever and
malaise. There is generalized lymphadenopathy. Full blood count shows WCC 1.2
x 109/L, Hb 8.2 g/dL and platelets 56x109/L. A plain chest x-ray shows extensive
bilateral nodular infiltration. Which investigation is most likely to be diagnostic?
A. Sputum microscopy
B. Peripheral film
C. Liver biopsy
D. Pleural biopsy
E. Blood cultures
35. The following are correctly paired
A. Prazosin: productive cough
B. Enalapril: ankle oedema
C. Thiazides: hypoglycaemia
D. Beta-blockers: wheezing
E. Codeine: iron deficiency anaemia
For the following questions 36-40 choose the most appropriate diagnosis from one of
the following answers. Each option can be used once, more than once, or not at all.
The patients all presented with troublesome pruritus and evidence of scratch marks.
A. Candidiasis
B. Polycythaemia vera
C. Hypothyroidism
9
D. Uraemia
E. Iron deficiency
F. Obstructive jaundice
G. Non Hodgkin lymphoma
H. Psoriasis
I. Impetiginised scabies
36. A 55-year old man presents in casualty after a blackout, he also complains of
dizziness and a headache. He has scratch marks on the skin and there is
splenomegaly. There is no lymphadenopathy.
37. A 30-year old woman presents with tiredness, loss of weight, pruritus and night
sweats. There is generalized lymphadenopathy and hepatosplenomegaly. She is
apyrexial.
38. A 26-year old woman has a dry pruritic scaling rash on the extensor surfaces of
her elbows and knees as well as on her scalp. Her nails are heavily pitted and
some are ridged.
39. An 81-year old barman has a history of abdominal pain associated with weight
loss, occasional dysphagia and vomiting. Examination reveals scratch marks,
Virchow’s node and there is a palpable epigastric mass. He is a bit pale but not
jaundiced.
40. A 62-year old man with type 2 diabetes mellitus and hypertension is started on
an ACE inhibitor by his GP. Six weeks later he presents with breathlessness,
nausea and pruritus. He is pale with a puffy face and he is a bit confused.
41. A 40 year old woman presents with a right sided pleural effusion and ascites.
Abdominal ultrasound scan reveals a left ovarian mass. What is the most likely
diagnosis?
A. Pseudomyxoma peritonei
B. Meig’s syndrome
C. Budd-Chiari syndrome
D. Nephrotic syndrome
E. Tuberculosis
For each of the following scenarios where poisoning is suspected, question 42-44
choose the single most likely cause from the list below. Each option can be used once,
more than once, or not at all.
A. Lead
B. Paracetamol
10
C. Arsenic
D. Organophosphates
E. Paraquat
F. Salicylates
G. Ethanol
42. A 50-year old farmer presents with nausea, vomiting, hypersalivation and
bronchospasm.
43. A 16-year old girl presents with weakness, excessive salivation, abdominal pain,
vomiting and diarrhoea. There is ‘raindrop’ pigmentation of the skin and her
nails are not normal.
44. A 4-year old boy presents with anorexia and vomiting. Examination shows pallor,
a blue line on the gums and he has foot drop. FBC confirms anaemia.
45. A 40-year old is seen in casualty complaining of chest pain and shortness of
breath. She is apyrexial and her chest examination is normal. Her right calf is
swollen and tender. Which of the following ECG findings is most likely to be
present?
A. Frequent ventricular ectopics
B. Prominent P wave in lead II
C. Prolonged QT interval
D. Right bundle branch block
E. Sinus tachycardia
46. A 48-year old man with advance HIV infection presents with a 4-month history of
poor vision, intermittent fever and weight loss. There is hepatosplenomegaly.
What is the most likely diagnosis?
A. B-cell lymphoma
B. Systematic cytomegalovirus infection
C. Disseminated tuberculosis
D. Systemic candidiasis
E. Bacillary angiomatosis
47. Which of the following is a typical feature of molluscum contagiosum infection?
A. It is a zoonosis
B. Impaired immunity is characteristic
C. Does not resolve spontaneously
D. Should be excised to prevent malignant transformation
E. Heals with scarring
11
48. A 25 year-old man with a history of recent HIV diagnosis presents to the casualty
after a first episode generalized tonic-clonic convulsion. He seemed tired in the
morning but still managed to go off to work. While at work he collapsed and had
a self-limiting seizure (5 minutes duration).He was afebrile and had GCS 13 (E3
V4 M6) (fluctuating) for about 4 hours without improvement. Pupils were equal
and reactive and he had no focal neurological deficits. He vomited 5 times during
this time but was clinically euvolemic. His CT head was normal. After returning
from the scan he had another self-limiting seizure that lasted 2 minutes.
He had the following laboratory test results (between seizures):
What initial management would you give this patient after seeing his laboratory results?
A. Diazepam 10mg IV PRN
B. 3% Normal Saline infusion
C. 0.9% Normal Saline infusion
D. Phenytoin IV bolus dose
E. Intravenous glucose
49. A 26-year-old male presents with nausea, vomiting and confusion. The following
blood gas is obtained on admission.
12
What acid/base abnormality is evident from these results ?
A. Metabolic alkalosis
B. Metabolic acidosis
C. Respiratory alkalosis
D. Respiratory acidosis
E. None
50. The above patient’s biochemistry reveals the following:
Bilirubin 63 (4-22)
ALP 184 (36-100)
ALT 5003 (12-48)
Protein 47 (66-83)
Albumin 27 (38-48)
What is the likely diagnosis?
A. Acute pancreatitis
B. Acute cholecystitis
C. Fulminant liver failure
D. Acute renal failure
13
E. Acute glibenclamide overdose
51. 76 year old male living alone. Found obtunded at home by neighbors. Breathing
rapidly and muttering incoherently. No other history available.
Admission arterial blood gas shown (note that despite the labeling this specimen is
arterial):
What is the likeliest diagnosis given these lab findings:
A. Ethanol overdose
B. Acute renal failure
C. Salicylate toxicity
D. Diabetic ketoacidosis
E. Heart failure
52. A 45 year old woman with metastatic ovarian cancer is admitted for VATS
pleurodesis (video-assisted thoracoscopic surgery) and drainage of bilateral
pleural effusions.
Her admission chest X-ray is shown below:
14
During her operation, 2L of fluid is drained from the left chest. Shortly thereafter, pink
frothy sputum starts coming out of the ET tube and the patient markedly desaturates.
The patient is transferred to the intensive care unit. The following chest x-ray is
obtained:
15
What is the likely diagnosis?
A. Acute tension Pneumothorax
B. Re-expansion pulmonary edema
C. Re-accumulation of pleural fluid
D. Acute decompensated heart failure
E. Adult respiratory distress syndrome
16
