Question 33

65 year old african american patient is brought to the ER with fever and shortness of breath for last 2 days. He is a chronic smoker for last 25 years and has been occassionally consuming alcohol. He gives history of heroin abuse. On chest auscultation he has diffuse rhonchis and decreased breath sounds at the right base. His BP is 88/30 mm Hg, P 120/min, Oxygen saturation of 86 %, and has a Temperature of 102.5 F. Chest X Ray is suggestive of bilateral lower lobe patches. His saturation continues to drop in the ER. He is appropriately managed with IV antibiotics and mechanical ventilation. On third day of hospitalization in the ICU, he appears to be confused. His ABG is given as PaO2 = 92, PCO2 = 50, HCO3 = 12, and SaO2 94 %. His other investigations are as follows:
Hb 13.8, Hct = 45, TLC 14500, Neutophils 70, Lymphocytes 26, Bands 2, Eosinophils 1, Basophils 1, Glucose = 240 mg%, Na = 121, K = 3.9, Cl = 100, Ca = 9.0, Mg = 2.1. What is the most likely cause of his confusion?

a) Diabetes Mellitus

b) Diabetes Insipidus

c) SIADH

d) Alcohol withdrawal

e) Ventilator associated pneumonia

f) Drug abuse

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Question 32

54 year male patient comes to the ER with pain in abdomen. The pain is present since a week, but it is become so severe now that he had to rush to the ER. He also gives history of having pain in his calves for the last week. On examination, he has a palpable liver and spleen. There is shifting dullness present. He also gives history of severe itching after taking showers, and had been on allopurinol for Gout since a few months. His Liver enzymes are raised and PT is 24 with an INR of 2.0, Hb is 17 gm%, and Hct is 60. He has a remote history of alcohol dependence, and smokes 2 - 3 cigerettes per day for last 10 years. He lives with his only sexual partner for the last 30 years and occassionally uses condoms. He has never been treated with any STDs. What is pathological cause of his condition at present?

a) Peliosis hepatis

b) Myeloproliferative diseases

c) Alcoholism

d) CBD obstruction

e) Hematobilia

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Question 32

What is the definitive treatment for this patient discussed under question 31?

a) Methylene Blue

b) Vitamin C

c) 100 % Oxygen

d) Blood Transfusion

e) Bronchodilators

f) Surgery

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Question 31

37 year old white male is brought to the ER with acute onset breathlessness. He is a known case of HIV on Triple therapy. Last month his CD4 count was 180 when he visited his physician. He appears to be thin and weak. His BP is 90/40 mm Hg, pulse is 92/min, and he has no fever. He lives with his same sex partner for last 3 years. The partner is also HIV positive and on treatment. He is a chronic smoker and occasionally consumes alcohol and marijuana. No other significant history is obtained. On chest auscultation, there are few scattered rhonchi and rest of the examination is unremarkable. He appears to be cyanotic and the arterial blood gas shows decreased Saturation with a normal PaO2. What is the most likely cause of his decreased saturation?

a) Drug induced

b) Tuberculosis

c) Pneumocystic Carini

d) CO Poisoning

e) Anemia

f) Smoking induced

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Question 30

45 year Caucasian male is brought to the ER with acute onset breathlessness. He gives history of having burning micturation and fever since 7 days. He was seen by the community clinic and was prescribed Antibiotics and Tylenol a week ago for his symptoms. But his symptoms did not subside and fever persisted. Since yesterday he was having heavy breathing and he was brought to the hospital today due to severe breathlessness and high grade fever. On examination, he is febrile, T = 102 F, BP is 90/30 mm Hg, P = 122/min. The O2 Sat is 85%, He was given nasal oxygen and rapid IV infusion in the ER. the portable CXR suggests ground glass appearance, and his chest shows diffuse rhonchi. He has a past history of smoking 2-3 cigarettes per day for last 15 years, and occasionally consumes beer on weekends. His father and mother are healthy. He works as a manager in textile industry. After initial resuscitation, his BP was found to be 100/40 mm Hg, but his O2 saturation is just 87%. The ABG was taken and results are awaited. CBC shows Hb 14.2, and TLC of 18600. This is an example of:

a) Diffusion defect

b) Ventilation defect

c) Perfusion defect

d) Restrictive Lung disease

e) Obstructive Lung Disease

f) Occupational Hazard

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Question 29

The mother of the boy (mentioned under question 28) inquires about the child's prognosis. She is worried if he can grow up and have children. What is the physicians response to the mother's concerns.

A) Patients with this disease are fertile and can reproduce

B) Patients with this disease are infertile

C) Patients with this disease has huge testes and spermatogenesis would be abnormal

D) Patients with this disease have problems with gender identity

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Question 28

A 5 year old boy is brought to the office for evaluation. He is joyful in the office, but the mother gives history that his social, speech and motor development is inappropriate. In fact, he lost his speech at the age of 2 years. He has constant dribbling and often remains constipated. The mother says he had feeding problems during infancy and used to cry like meowing. He has strabismus and epicanthic folds. On auscultation, he has a pansystolic murmur. His IQ was tested and was found to be around 55. What is the most likely chromosomal alteration in this patient.

A) Nondisjunction

B) Mosaicism

C) Translocation

D) Deletion

Answer posted under comments for question 29.

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Question 27

14 year old boy is brought to the Office with swelling of the right knee. The joint is extremely tender, and the boy walks with a limp. He has no fever or any history of trauma to the knee. Both his parents are healthy and fine. He gives history of his paternal uncle who had some eye surgery in childhood, but he passed away in his adolescent years. The X ray of the right knee shows spiculated pattern and bone lifting periosteum. Which of the following regulatory gene is responsible for the boy's knee lesion?

A) BRCA 1

B) MYC

C) RB

D) TP 53

E) RAS

Answer will be posted in the comments section.

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Question 26

62 year old Caucasian alcoholic male is brought to the ER in a semi-concious state. He remains drowsy and is unable to answer to questions. On examination, he is drowsy, responds to shaking, and then goes back to drowsiness. His Serum ketone levels are high, and his blood sugar level on glucometer shows 36 mg%. He has swelling on his great toes bilaterally. Serum AST is greater than ALT. Serum Bilirubin is 9.2 mg%. What is the biochemical cause of his swelling of toes?

A) Lactic Acid & Beta Hydroxy butyric Acid

B) Raised GGT

C) Hypertriglyceridemia

D) Mitochondrial Toxins

E) Increased NAD

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Question 23

What is the Causative Organism in the vignette discussed in question 22?

a) Salmonella typhi Muriam

b) Staphylococcus aureus

c) Streptococcus pyogenes

d) Streptococcus viridans

e) Staphylococcus epidermidis

f) Streptococcus Bovis

g) Mycobacterium TB

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Question 22

24 year old man comes to the emergency room with history of fever, malaise, and shortness of breath. He has been having fever for last 7 days for which he tried over the counter acetaminophen for symptomatic relief. He appears in moderate distress. He is disheveled, and has smell of alcohol on his clothes. There are some scars on his both forearms. He confesses to be an alcoholic and drug abuser. He has a past history of pulmonary TB treated at the community center about 3 years ago. He has no past histroy of any neurological or psychiatric illnesses. He usually does not visit a doctor, and does not remember about his vaccination status. The veins on his right forearm are thick and cord like but are non tender. He has history of sulfa and penicillin allergy. On examination his Temp is 101.2 degrees, BP is 98/46 mm Hg, and Pulse is 112/min. His chest examination reveals few rhonchis. On cardiac examination the physician hears an abnormal sound in his left lower border of sternum (see media). He does not remember of any childhood cardiac illness. He has no neck stiffness. What is the most likely diagnosis?

a) Rheumatic Heart Disease

b) Ventricular Septal Defect

c) Tuberculous pericarditis

d) Cardiac Tamponade

e) Infective Endocarditis

This vignetter applies to Question 22 to 24

Answers will be posted under comments section soon.

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Question 21

25 year old nurse complaints of dizziness and sweating in the ER. A few days ago she had similar complaints and was adviced to go home from work after stabilizing. She joined work yesterday after leave. This is her third episode of similar complaints. She usually have such complaints whenever she is stressed due to patient overload, and feels better with rest and some juice. Today, her BP is 124/88 mm Hg, pulse is 102/min. She is sweating profusely. The doctor requests for blood chemistry, glucose level, and C- peptide level. The electrolytes levels are as follows, Na 134, K 3.4, Cl 98, Ca 9.2, Mg 2.4, BUN 20, Creat 0.9. Her Glucose level is 54 mg %, and C peptide levels are high. The doctor orders her 5 % Dextrose 100 cc, and she is stabilized subsequently. What is the most likely diagnosis?

A) Factitious disorder
B) Insulinoma
C) Glucagonoma
D) Manchausen Syndrome
E) Hypochondriasis

Answer will be posted soon under comments section.

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Question 20

22 year old male comes to the clinic with complaints of swelling on his back. He says the swelling is cosmetically ugly. It is non tender and has not changed since few years. He also complains of some swelling on his scalp. Occasionally, he has pain in his abdomen, and passes black stools often. Rectal examination is non contributory. Stool shows altered blood. The physician schedules him for a colonoscopy. He is an adopted child of his parents, and does not know anything about his biological parents. On colonoscopy, the physician notes several polyp. What is the most likely diagnosis.

A) Gardener's Syndrome
B) Turcot's Syndrome
C) Diverticulosis
D) HNPCC
E) Colon Ca
F) Angiodysplasia

Answer will be posted in the comments section soon.

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Question 18

The patient in question 17 is stabilized. What cardiac finding is most likely to be present in this patient?

A) Mitral regurgitation
B) Tricuspid regurgitation
C) Aortic Regurgitation
D) Mitral Stenosis
E) Tricuspid Stenosis
F) Aortic Stenosis


Answer will be posted under comments section soon.

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Question 17

A 45 year old Caucasian male is brought to the ER with complaints of breathlessness since few hours. He gives complaints of flushing and dermatitis since few days. Lately, he noticed he gets flushing and increase in number of bowel movements daily which are watery in consistency. He is not able to recall the exact time since the symptoms began. He has a rash around his collar. He vitals are stable except he is breathing heavily. On respiratory examination, he has wheezing all over. He complains of pain in upper abdomen. What is the most likely diagnosis?

A) Vitamin deficiency
B) Food Poisoning
C) Asthmatic attack
D) Serotonin tumor
E) Inflammatory bowel disease.

Answer will be posted under comments section soon.

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Question 15

What organism is most commonly associated with the diagnosis mentioned in Question 14?

A) Coxsackie Virus
B) Human T Cell Virus
C) Cytomegalovirus
D) Ebstein Baar
E) H. Pylori
F) S. Hematobium
G) C. Sinesis
H) Human immunodeficiency Virus
I) Hantavirus
J) Picorna Virus

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Question 14

22 year old Hispanic male was brought to the ER with breathlessness and swelling in the neck. On history he says he has these symptoms for some time now. He does not have any history of fever, weight loss, night sweats or hemoptysis. He has never been in contact with anyone suffering from TB and he says he is an electrician by profession. His mother was diagnosed with TB long ago for which she took Anti-TB medicines for an year. His father is a smoker and has DM. He stays along with his girlfriend since last six years, and his parents stay by themselves. He studies part time, and has a healthy baby from his present girlfriend. He has never been ill, and was completely immunized as a child. he does not smokes and drinks beer on weekends. On examination his vitals and systemic examination is unremarkable, except his non tender lymph node swelling in the supraclavicular area. The physician orders him a Complete blood count and X ray Chest. On chest X ray he is found to have hilar swellings. Lymph node biopsy suggest cells having CD15 and CD30. What is the most likely diagnosis?

A) Squamous Cell Ca of Lymph node
B) Squmaous Cell Ca of lung with mets
C) Small Cell Ca of lung with mets
D) Large Cell Ca of lung with mets
E) Nodular Sclerosing B cell malignancy
F) Nodular Sclerosing T Cell malignancy
G) Lymphocyte depleted B Cell malignancy
H) Lymphocyte depleted T Cell malignancy
I) Non hodgkins lymphoma
J) Non smokers lung Ca
K) Hairy Cell Leukemia

Please solve questions 15 & 16 alonwith before reading the answer in the comment section.

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Question 12

(Source: Professor Yasser Metwally, 2008)

83 year old woman is brought to the clinic with abnormal movements of hand. She complains that she has difficulty in walking and doing things for some months. She denies any history of fever or neck stiffness. She has a past history of DM, HTN, Rheumatoid arthritis for several years. She is taking metformin, thiazide, aspirin and multivitamin daily. She lives with her son and daughter in law since her husband passed away 7 years ago and says that her kids are "very caring" and nice to her. During the interview, the physician notes that she shows no affect while talking, and her hands are constantly shaking. Her memory appears to be intact. When asked to walk she walks with a typical gait as shown above in the media. An appropriate diagnosis is made and treatment is begun. What is the pathophysiology of the disease under consideration?

A) Trinucleotide repeat
B) Degeneration of Substantia Nigra
C) Decreased Dopamine and increased Acetylcholine
D) Copper deposition
E) Iron deposition
F) Drug induced
G) Old age changes

For Answer click comments :)

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Question 11

Source: Professor Yasser Metwally, 2008)

An 85 year old male patient is brought to the clinic from the nursing home with symptoms of abnormal movement. He has recently completed a course for Tubeculous meningits for 9 months. He has no neck stiffness or fever. The neurological examination shown above in the media suggests a lesion in the brain which may be due to previous TB infection. Most likely, where should be the lesion located?

A) Occipital Lobe
B) Wernickes area
C) Brocas area
D) Subthalamic nuclei
E) Cerebeller tonsils
F) Cardiac vegetations
G) Trinucleotide repeat disorder in caudate

For Answer click comments

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Question 10

(Source: Professor Yasser Metwally, 2008)

51 year old woman is brought by neighbors with symptoms of abnormal movements since several days now. The woman stays alone and there are distant relatives who come to visit often. The woman's past medical file on record do not say about anything significant but there is a history about her father having some movement disorder at the age of 55 and that he died of aspiration pneumonia. The examination findings are given above in the video. The doctor suspects some neurological inherited disorder. Where is the neurological defect located in this patient?

A) Globus Pallidus, due to GAA repeat on short arm of chromosome 9
B) Caudate nucleus, due to GAA repeat on short arm of chromosome 9
C) Caudate nucleus, due to CAG repeat on short arm of chromosome 4
D) Caudate nucleus, due to CAG repeat on long arm of chromosome 4
D) Substantia nigral pathway
E) Mitral Valve vegetations
F) Caudate nucleus, due to CTG repeat on long arm of chromosome 19

For Answer click comments.

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