The final written M.B.B.Ch.

EXAMINATION IN MEDICINE
PAPER I 10 9002 9002 01 December ALL QUESTIONS SHOULD BE ANSWERED TIME ALLOWED 2HOURS : 51 . . . . . 1. 2. 3. 4. 5. 6. 7.

1. A 76-year-old woman with long-standing hypertension presented with 2 months history of dysponea on minimal exertion. General examinations revealed a blood pressure of 160/88 mmHg with pulse rate of 96/min. She has an S3 gallop during cardiovascular examination. an echocardiogram shows left ventricular inferior hypokinesia with impaired systolic function. All of the following statements are true regarding patient's case EXCEPT: a. History of paroxysmal nocturnal dysponea is of diagnostic value b. S3 gallop usually associated with increase in left atrial pressures. c. Pulsus alternans is virtually pathognomonic of severe left ventricular failure. d. Exercise testing can be used for risk stratification and determining prognosis e. lifestyle modifications has a little benefit in this patients. 2. A 23 year old female patient brought unconscious to the medical causality. The following arterial blood gas analysis (ABG) is obtained pH 6.96 pO2 106mmHg pCO2 14mmHg Bicarbonate 9mmol/l What is the most accurate description of the metabolic abnormality? a. Respiratory acidosis b. Azotaemia c. Combined respiratory/ metabolic acidosis d. Partially compensated metabolic acidosis e. Compensated metabolic alkalosis 3. A 59 year old patient with known hepatitis related cirrhosis presented with ascites, abdominal tenderness and peripheral oedema. A diagnostic tap revealed a neutrophil count of 400/mm3 (normal <250mm3). All of the following statements are true regarding patient's case EXCEPT: a. spontaneous bacterial peritonitis is the most likely diagnosis b. Pseudomonas aeruginosa is the most likely etiological organism. c. broad-spectrum antibiotic must be initiated as soon as possible d. renal failure is the major cause of death in such a patient e. Repeat ascitic fluid analysis is commonly not recommended to document resolution of the infection. 4. A 25-year-old, with unremarkable medical history, had CBC during routine checkup. Her CBC shows: Hb 10 g/dl; MCV 55 fl; WCC 6 x 109/l; Platelets 190 x 109/l. Haemoglobin electrophoresis is suggested and reported as follows: Hb A 94.5% (Normal > 96%) Hb A2 4.5% (Normal <3.1%) Hb F < 1% (Normal <1%) What is the likely cause of her microcytic anaemia? a. Alpha thalassaemia trait b. Beta thalassaemia trait c. Thalassaemia major d. Lead poisoning e. Sickle cell disease
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5. A 42-year old woman is referred to clinic after a routine health check revealed an ALT of 68 iu/l and the following results: Hepatitis A IgG positive Hepatitis B surface antibody positive Hepatitis C enzyme immunoassay positive. Which test would you request next:a. scan of the liver b. Hepatitis A IgM antibody c. PCR for hepatitis C RNA d. Hepatitis B surface antigen e. Liver biopsy 6. A 30 year old renal transplant recipient has a seven days history of headache as well th as diplopia. Neurological examination revealed mild neck stiffness and left 6 nerve palsy .CT brain without contrast was normal. Lumbar puncture revealed: CSF pressure 220mm of water CSF WBCs 170 (60% polymorph neutrophil, 40% lymphocytes) CSF RBCs 2 RBCs CSF protein 650mg/dl CSF glucose 40mg/dl (concomitant blood sugar=110mg/dl). Which of the following is the most likely diagnosis? a. Mumps meningoencephalitis. b. Listerial meningoencephalitis. c. Pneumococcal meningitis. d. Pseudotumor cerebri . e. HIV meningitis 7. A 43 year old woman presented with history of worsening dysphagia over many years. She initially had dysphagia for solids, followed now by dysphagia to liquids. Recently there had been episodes of ill-defined central chest discomfort and nocturnal cough. All of the following statements are true regarding patient's case EXCEPT: a. Chagas' disease is the most likely diagnosis b. Pulmonary aspiration is common mainly during night c. She is at increasing risk of developing esophageal cancer. d. Plain chest radiograph is of diagnostic value. e. Oesphageal manometry is required for confirming the diagnosis 8. A 25 year old female presented to psychiatric outpatient in a hyper-reactivity state with poor sleep and laughing inappropriately. She was noticed to have flight of ideas, pressure of speech and a clear sense of euphoria. She was not aggressive, able to go to work and productive and creative. All of the following statements are true regarding patient's case EXCEPT: a. Family history will be significant. b. Grandiose delusions are expected. c. Diagnosis of the case is bipolar disorder. d. Antidepressants are the drugs of choice in the management. e. Electrolyte imbalance is a recognized complication.
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9. A 28 year old man presented with acute stiffness and swelling of his knees and ankles, and a painful rash on his legs. The ESR was 86mm in the first hour. Chest x-ray showed bilateral symmetrical hilar lymphadenopathy. All of the following statements are true regarding patient's case EXCEPT: a. History of red eye support the diagnosis b. Restrictive pattern with increases in the diffusing capacity for carbon monoxide in pulmonary function tests is expected. c. Worsening pulmonary symptoms is an indication for use of steroid. d. Serum angiotensin converting enzyme level is frequently elevated in untreated patient. e. Prognosis generally good and associated with spontaneous remission.
10. A 68-year-old man presented to you with sudden onset of severe substernal chest pain that

has persisted for the past 2 hours and radiates to the back. He has no significant past medical history apart from a 20-year history of hypertension. Physical examination shows a diaphoretic, anxious man. His pulse rate is 120/min and regular, respiration rate is 28/min, and blood pressure is 170/90 mm Hg. Systemic examination was unremarkable. Electrocardiography shows sinus tachycardia. A chest radiograph reveals mediastinal widening, mild cardiomegaly, and clear lung fields. Intravenous morphine is prescribed for pain. All of the following statements are true regarding patient's management EXCEPT: a. This patient should be managed at intensive care unit. b. Rapid control of the blood pressure associated with better outcome. c. Transesophageal echocardiography has a high sensitivity and specificity for diagnosis of the patient problem. d. blockers are the treatment of choice for controlling the heart rate and blood pressure. e. Intravenous streptokinase should be started immediately 11. An 18-year-old man is presented with a 4 months history of loose, bloody diarrhea (<than 10 times per day) and cramping abdominal pain. Colonoscopy shows typical changes of ulcerative colitis which confirmed by colonic biopsy. All of the following statements are true regarding patient's case EXCEPT: a. toxic megacolon or sclerosing cholangitis are a recognized complications. b. crypt abscesses in the colonic biopsy are expected. c. topical administration of 5-aminosalicylate enema is the mainstay of therapy. d. Annual Colonoscopy with multiple biopsies should be started. e. Surgical colectomy is indicated in patients who are intractable to medical therapy. 12. A 70-year-old man has a 1-day history of increasing cough, dyspnea, fever, and chills. His has no significant past medical history.On physical examination, he is confused, temperature is 38.7 C, pulse rate is 110/min and regular, respiration rate is 24/min, and blood pressure is 90/60 mm Hg. Examination of the chest discloses diminished breath sounds, bronchial breathing, and crackles, at the left lung base. The leukocyte count is 31,000/L (31 109/L). Blood urea is 60 mg/dL, and serum creatinine is 2.4 mg/dL. A chest radiograph shows a left lower lobe pulmonary infiltrate. All of the following statements are true regarding patient's case EXCEPT: a. Gram negative bacteria are the most likely ethiological agents b. Lobar infiltration on chest xray is most often caused by Streptococcus pneumoniae. c. High urea level assocaited with increase mortality. d. Pulse oximetry provides a simple method to monitor response to oxygen therapy. e. -lactam and macrolides are the imperical antibiotic treatment of choice.
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13. A 40 year old lady presented with 8 weeks history of morning stiffness and swelling of the small joints of the hands. On examination there was a symmetrical swelling and tenderness of all metacarpophalangeal and proximal interphalangeal joints with nodules at the extensor surface of the elbow. All of the following statements are true regarding patient's case EXCEPT: a. A history of dry eyes and dry mouth are suggestive of Felty's syndrome. b. Pleurisy and pleural effusion are known pulmonary manifestations. c. Radiographic features of erosions and peri-articular osteopenia are classical features. d. Low dose methotrexate slows progression of the disease. e. ESR, CRP and Haemoglobin levels are used to monitor the response to treatment. 14. A 65 year old man presents with severe central crushing chest pain. ECG at presentation as shown below. He receives TPA, Heparin and Aspirin. Four hours after initial presentation, he starts feeling dizzy and breathless. His pulse is 40 bpm regular, BP 80/50. Heart sounds are soft and chest clear to auscultation. IV atropine was administered but had no effect. What is the next most important treatment?

a. b. c. d. e.

IV Dopamine. IV Isoprenaline. Insert a permanent pacemaker. Insert a temporary pacemaker. Monitor his progress.

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15. A 32-year-old woman is evaluated for a 5-month history progressive weakness with difficulty in rising from sitting position. Musculoskeletal examination shows proximal muscle weakness in the upper and lower extremities, as well as neck flexor weakness with presence of heliotrope rash, and Gottron's sign. On laboratory studies, complete blood count is normal and ESR is 24 mm/h. Creatinine is normal, and creatine kinase is 3000 U/L. ANA titer is 1:160, and assays for antidouble-stranded DNA, is negative. Urinalysis is normal. Electromyogram reveals spontaneous fibrillations, repetitive discharges, and positive sharp waves. All of the following statements are true regarding patient's case EXCEPT: a. Careful evaluation for an occult malignancy is indicated. b. Interstitial lung disease strongly associated with the presence of antisynthetase antibody. c. Respiratory muscle involvement carry poor prognosis. d. Muscle biopsy is the definitive test to reach the diagnosis. e. Systemic corticosteroids are of little help in treating such patients. 16. A 61-year-old man with a history of ischemic heart disease since 2 years in the form of chronic stable angina; during his follow up visit, you noticed something new in his ECG.

Look at this ECG, what is the abnormality? a. Left bundle branch block. b. Atrial flutter with 3:1 conduction. c. Torsades de pointes ventricular tachycardia. d. Acute inferior wall myocardial infarction. e. Normal ECG.

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17. A 57 year old male, constructor worker presented to the Respiratory OPD complaining of worsening shortness of breath over the last 2 weeks, associated with minimal productive cough, right sided chest pain and generalized fatigability. On examination, trachea was shifted to the left side; chest examination showed reduced chest movement on the right side, with reduced breath sounds on the same side. All of the following statements are true regarding patient's case EXCEPT: a. History of asbestos exposure is significant. b. Tactile vocal fremitus is expected to be decreased. c. Chest CT scan has an important role in detecting the extent of the disease. d. Patient should be started on anti-Tuberculosis therapy immediately. e. Pleurodesis is a mode of treatment in recurrent cases. 18. A 51 year old businessman complains of dyspnoea on exertion. He recently returned from a business trip to the China and India. He has distant heart sounds on auscultation of the chest. A chest radiograph reveals that there is a thin rim of calcification surrounding the cardiac outline. All of the following statements are true regarding patient's case EXCEPT: a. Tuberculosis should be considered as an ethiological factor. b. peripheral edema and ascites are expected finding. c. Presence of pericardial knock is in favour of diagnosis d. ECG finding is diagnostic. e. Surgical treatment is indicated in patients with persistent and prominent symptoms 19. A 20-year-old female complaints of palpitations, breathlessness, unintentional 10 Kg weight loss over the last 6 months, increased perspiration, and heat intolerance. On examination her pulse is 120/minute. Her skin is warm and moist and there is mild tremor in both hands. She has bilateral exopthalmos. Thyroid is nontender, diffusely enlarged. Laboratory results include a serum T4 of 200 nmol/L (NR: - 64-155 nmol/L), and a serum TSH of <0.01 mU/mL(NR:-0.5-5.0 mU/mL). All of the following statements are true regarding patient's case EXCEPT: a. Autoimmune ethiology is the most likely underlying cause b. Wide pulse pressure is expected. c. High output heart failure is well recognized complication d. Radioiodine may be given as primary therapy to this patient e. Digoxin is the drug of first choice if she developed atrial fibrilation. 20. A 50-year-old man with a 15 years history of diabetes on oral hypoglycemic agents is brought to the emergency department because of sudden onset of right-sided weakness. On examination, his blood pressure is 180/100 mm Hg; pulse rate, 80/min regular; he has right hemiparesis. All of the following statements are true regarding patient's case EXCEPT: a. Risk stratification is important part of this patient care. b. Abnormalities of language suggest anterior circulation disease. c. Aspirin should start immediately. d. Urgent lowering of blood pressure to <130/80mmHg is indicated. e. Immediate CT scanning is important to guide the selection of acute interventions to treat such a patient.

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21. A 29-year-old female comes in with generalized fatigability, intermittent eyes drooping and double vision which get worse in the evening. Her exam showed ptosis and mild medial rectus and neck flexor weakness. All of the following statements are true regarding patient's case EXCEPT: a. Her condition is due to presence of IgG acetylcholine receptor antibody b. Tendon reflexes are normal c. Association with other autoimmune diseases is likely d. IV administration of edrophonium will help to confirm the diagnosis e. Thymectomy will have a little effect on her condition 22. A 64-year-old man presented with back pain, fatigue and shortness of breath on exertion. On physical examination, he has pallor but is otherwise normal. He denies blood loss, and his stool is negative for occult blood. He is anemic (hemoglobin 8.4 g/dL) with normochromic, normocytic indices, and his serum creatinine level is 2.9 mg/dL(N=up to 1.3mg/dL). Gamma globulins are elevated. His serum calcium level is 11.8 mg/dL. All of the following statements are true regarding patient's case EXCEPT: a. His condition is due to malignant proliferation of T cells. b. Increase risk of infections is likely due to immune dysfunction. c. His diagnosis is typically confirmed by bone marrow examination. d. High calcium level at presentation caries poor prognosis e. Erythropoietin therapy is not indicated. 23. A 35-year-old woman presents with weakness, generalized swelling in her extremities, and right leg pain. Physical examination reveals a tender, erythematous, and swollen right calf. She also has 2+ pitting edema in all extremities. Blood pressure is 120/70 mm Hg. Venous ultrasound is positive for lower extremity deep vein thrombosis. Laboratory studies reveal: Urea 38 mg/dL(N=10-50); creatinine 1.7 mg/dL (up to 1.3). LFT, PT/PTT are normal. Albumin l.9 g/dL (N=3.74.9), cholesterol 326 mg/dL; triglycerides 425 mg/dL. 24-hour urine shows 6.2 grams of protein. All of the following statements are true regarding patient's case EXCEPT: a. Focal glomerulosclerosis among the most common cause of the idiopathic nephrotic syndrome in adults b. Drug history is important. c. Deep vein thrombosis is a recognized complication. d. Renal biopsy is indicated to determine the cause of proteinuria e. High protein diet is advisable.

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24. A previously well 68 year old man presents with jaundice dark urine and pale stools. Bilirubin 25mg/dL (up to 1.2) AST 30U/L (1-31) Alk. phos. 1210u/L (45-105) Albumin 35g/dL (37-49) GGT 138U/L (4-35) U/S: Normal liver, a collapsed gallbladder with no stones normal cystic duct dilated bile ducts and dilated intra- hepatic ducts. Which of the following is the most likely diagnosis:a. Carcinoma of the head of the pancreas b. Primary biliary cirrhosis c. hydatid disease of liver d. Hepatocellular carcinoma e. Cholelithiasis 25. A 73-year-old previously healthy man brought to the hospital with acute confusion. His temperature is 39.50C blood pressure is 85/60 mmHg, pulse is 140 beats per minute, and respiratory rate is 30 breaths per minute. All of the following statements are true regarding patient's case EXCEPT: a. Nosocomial infections have higher mortality than community-acquired infection. b. Development of multiple organ failure (MOF) carry poor prognosis. c. Broad spectrum antibiotic should be started immediately. d. The Supplemental oxygen should be avoided at the early stage of sepsis. e. Specific investigations will be guided by the careful history and physical examination. 26. A 15 year old female presents following a sore throat with chest pain, fever, and a skin rash. Examination reveals a diastolic murmur. Her ASO titre is elevated. Which of the following is a major criterion for the diagnosis of Rheumatic fever? a. Fever b. Raised ESR c. Polyarthritis d. Migratory erythema e. Prolonged PR interval 27. A 42-year is referred to clinic after a routine health check revealed an ALT of 68 iu/l and the following results: Hepatitis A IgG positive Hepatitis B surface antigen positive Hepatitis C enzyme immunoassay negative. All of the following statements are true regarding patient's case EXCEPT: a. Full recovery occurs in 10-15% of adults following acute HBV infection. b. Simultaneous infections with Hepatitis D virus give rise to severe acute hepatitis. c. Fulminant hepatic failure is an uncommon complication d. Presence of Hepatitis B envelope antigen (HBeAg) in the blood indicate infectivity e. Lamivudine can be used to treat chronic hepatitis B infection by inhibiting viral DNA polymerase.
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28. A 20 year old man complained of a sore throat, fever and general muscle aches and had noticed that his urine had become red 24 hours following the onset of his sore throat- he is unremarkable general and systemic examination. However, blood pressure was 150/85mmHg. Urine dipstick shown (blood++++ and protein++) and his results revealed: Serum Na: 140mmol/L (137-144) Serum urea: 55mg/dL (10-50) Serum Creatinine 1.5mg/dL (up to 1.3) The most likely diagnosis is:a. IgA nephropathy b. Post streptococcal glomerulonephritis c. HIV seroconversion illness d. Wegeners granulomatous e. Infective endocarditis 29. A 25-year-old man presented to dermatology department with widespread red-brown maculopapular scaly asymptomatic rash affecting his trunk, limbs and palms and soles, associated with multiple patches of hair loss scattered all over his scalp. There were multiple pink sessile nodules around the anus extending up to the perineum. 2 months earlier he was treated for a lesion in his penis with topical antibiotic cream that has healed completely. All of the following statements are true regarding patient's case EXCEPT: a. A history of sexual contact is relevant. b. Primary syphilis is the most likely diagnosis. c. VDRL and Rapid plasma Reagen are the specific tests to confirm the diagnosis of syphilis. d. Acyclovir is the treatment of choice. e. The hair loss is irreversible. 30. A 33-year-old woman with an eighteen year history of type I diabetes mellitus presents with proteinuria. She is a smoker of 20 cigarettes daily. Examination reveals a blood pressure of 155/95 mmHg. Investigations reveal: o serum cholesterol 7.6 mmol/L (<5.2) o HbA1c 8.3% (3.8 - 6.4) o 24 hour urinary protein excretion 1. 5 g (< 0. 2) Which intervention is most likely to retard the development of renal failure? a. bendrofluazide b. improve glycaemic control with HbA1c <7% c. lisinopril d. simvastatin e. stop smoking

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31. In the light of the below electrocardiogram, you would expect while examining this patient

a. b. c. d. e.

Opening Snap Pansystolic Murmur as a complication of Acute MI Pericardial rub Cannon waves in the JVP Mid systolic click

31. A 30 year-old Libyan lady was brought to dermatology department because of widespread erosions and easily ruptured painful vesicles and bullae that has been coming and going for the last three years. She denied any lesion free period in spite of regular treatment. All of the following statements are true regarding patient's case EXCEPT: a. Nikolskys sign is expected to be positive. b. Dermatitis herpetiformis is considered as a differential diagnosis. c. Direct and indirect immunoflourescence confirms the diagnosis. d. Prednisolone is the first drug of choice. e. A self limiting condition that will disappear by time. 32. A 40 year old man presents with acute weakness and palpitations. His ECG showed wide complex QRS with tented T wave. Investigations reveal: Sodium 143 mmol/L (137 - 144) Potassium 8.0 mmol/L (3.5-4.9) Urea 80mg/dL (10-50) Creatinine 3.2mg/dL (up to 1.3) Bicarbonate 5 mmol/L (20 - 28) What is the best immediate therapy? a. intravenous calcium gluconate b. intravenous dextrose and insulin c. intravenous sodium bicarbonate d. nebulised salbutamol e. rectal calcium resonium
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33. A 23 year old female is admitted 12 hours after taking an overdose of aspirin. Investigations revealed: Serum sodium 138 mmol/L (137-144), Serum potassium 5.9 mmol/L (3.5-4.9), Serum bicarbonate 14 mmol/L (20-28), Serum urea 85 mg/dL (10-50), Serum creatinine 3.1 mg/dL (up to1.5), Serum salicylate 1120 mg/dL (40-50mg/dL). All of the following statements are true regarding patient's case EXCEPT: a. Tachypenia and bounding pulses are expected during examination. b. Cerebral oedema is a recognized complication. c. Development of a metabolic acidosis is a bad prognostic sign. d. Haemodialysis is the most appropriate treatment of this patient. e. Using of multiple doses of activated charcoal is contraindicated. 34. A 55-year-old plumber presented with a dry nocturnal cough and increasing exertional breathlessness. On examination he had early finger clubbing, cyanosis and bilateral basal crackles. A chest X-ray showed bilateral lower zone shadowing. Investigations revealed: PaO2 (breathing air) 70mmHg FEV1/FVC ratio 85% Which of the following investigations is most likely to establish the diagnosis? a. Echocardiography. b. High resolution CT scan of chest c. Measurement of diffusion capacity d. Serum angiotensin-converting enzyme (ACE) level e. Transbronchial lung biopsy 35. A previously healthy 38-year-old woman presented with 2-week history of fatigue and malaise. Physical examination shows slight scleral icterus and a mildly enlarged spleen. There is no lymphadenopathy. Laboratory studies: Hemoglobin 7.2 g/dL, Reticulocyte count 9.8% A peripheral blood smear shows polychromasia, occasional spherocytes, and a rare nucleated erythrocyte. All of the following statements are true regarding patient's case EXCEPT: a. The anemia most probably is due to haemolysis. b. Presence of spherocyte indicate hereditary base. c. Iron supplementation rarely needed. d. Higher LDH level in the blood is expected. e. Prednisolone is the best initial therapy

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36. A 55-year-old man presents to the Emergency department with mild dyspnoea. He has no significant medical illness apart from a history of rheumatic fever at the age of 15. On examination, his BP is 130/70, oxygen saturation 96% and he is not in heart failure. An ECG is performed. All of the following would aid in slowing the ventricular rate, except?

a. b. c. d. e.

Lignocaine Carotid massage Esmolol Adenosine Diltiazem

37. An 18 years old male patient presented complaining of polydipsia, polyuria, and weight loss 8 Kg over 3 months. On examination pulse 70/ min, B.P 120/80 mmHg, and no pallor, rest of clinical examination was unremarkable, random Blood sugar 220 mg%. All of the following statements are true regarding patient's case EXCEPT: a. History of Celiac disease in the family is of diagnostic value. b. HbA1C is a useful monitoring tool. c. Biguanides should be considered as first line treatment. d. Abdominal pain and vomiting may indicate metabolic acidosis. e. Myopathy is a recognised long term complication.

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38. A 50 year old man with a long history of alcohol abuse is prescribed Phenytoin for epilepsy. Examination was normal except for a liver edge. His full blood count reveals haemoglobin 10.0 g/dL (13-18) MCV 122 fL (80-96) 9 white cell count 2.2 x 10 /L (4-11) platelet count 85 x 10 9/L (150-400) What is the most likely explanation for these results? a. Alcoholic liver disease b. Aplastic anaemia c. Folic acid deficiency d. Hypothyroidism e. Vitamin C deficiency 39. A 64-year-old man with long standing hypertension and diabetes, presented with 20-hour history of right sided weakness. An emergency brain CT scan revealed a large hypodense area in the left fronto-temporo-parietal lobes consisting with an occlusion of the proximal main-stem of the left middle cerebral artery. His ECG done at the A/E department is shown below, What is the rhythm abnormality?

a. b. c. d. e.

Accelerated idioventricular rhythm. Atrial flutter with 4:1 conduction. Atrial fibrillation. Supra-ventricular tachycardia. Pacemaker failure with high junctional rhythm.

40. An 80 year old coal miner who stopped working 16 years previously presents with deteriorating dyspnoea. Investigations show: FEV1 1.4L (predicted 2.5) FVC 2.8L (predicted 3.0) What is the most likely diagnosis? a. Chronic obstructive pulmonary disease b. Cryptogenic fibrosing alveolitis c. Extrinsic allergic alveolitis d. Silicosis e. Simple pneumoconiosis

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41. A 42 year old female presents following an episode of confusion associated with vomiting and abdominal pain. She had a one month history of weight loss and receives thyroxine for hypothyroidism which was diagnosed five years ago. On examination she appeared unwell, with a temperature of 37.5C and her blood pressure was 100/50 mmHg. Investigations revealed: sodium 130 mmol/L (137-144) potassium 4.8 mmol/L (3.5-4.9) urea 56mg/dL (10-50) glucose 40mg/dL (50-75) free T4 9 pmol/L (10-22) TSH 1 mu/L (0.5-5) Which one of the following given intravenously would be the most appropriate initial management? a. iv Cefuroxime b. iv 10% Dextrose infusion c. iv Glucagon d. iv Hydrocortisone e. iv Tri-iodothyronine 42. A 60 year old male presents with bruising and tiredness. Examination reveals 4 finger breadth splenomegaly and his results reveal: Haemoglobin 11 g/dl (11.5-16) White cell count 100x109/l Platelets 900x109/l Blood film reveals a neutrophilia, basophilia, numerous myelocytes and 4% myeloblasts Which of the following is likely to be present in this patient? a. Deletion of chromosome 22 b. Deletion chromosome 13 c. Deletion 11q13 d. Normal chromosomal analysis e. Translocation 9;22 43. A 35 year old man presented with 2 weeks history of weight loss and painful swallowing. General and systemic examinations revealed mouth trush with generlized lymphadenopathy. All of the following statements are true regarding patient's case EXCEPT: a. Sexual contacts is the major mode of HIV transmission. b. Candida oesphagitis is the most likely explanation for painful swallowing. c. ELISA is initial screening test to detect antibodies to HIV-1. d. Cd4 T cells less than 250 is expected finding. e. HAART should not be started unless patient has high HIV viral load.

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44. A 20-year-old woman is brought to the emergency room by her family because they have been unable to get her to eat or drink anything for the past 2 days. The patient, although awake, is completely unresponsive both vocally and nonverbally. She actively resists any attempt to be moved. Her family reports that during the previous 7 months she became increasingly withdrawn, socially isolated, and bizarre; often speaking to people no one else could see. Which of the following is the most likely diagnosis? a. Schizoaffective disorder. b. Delusional disorder. c. Schizophreniform disorder. d. Catatonia. e. PCP intoxication 45. A 62-year-old female presents with confusion associated with a chest infection. She received standard treatment, and four days later she developed green, then bloody diarrhoea. Which of the following organisms is most likely to be responsible for her diarrhoea? a. Campylobacter jejuni b. Clostridium difficile c. Escherichia coli 0157 d. Methicillin-resistant Staphylococcus aureus (MRSA) e. Vancomycin-resistant enterococcus

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