INTERNAL MEDICINE – FIRST SEMESTER FINAL

A 30-year-old man presents to his GP with a lesion on his penis, which appeared a week
ago. On further questioning, he reports a change in sexual partner 4 weeks ago. He has
otherwise been well. On examination, there is a painless hard ulcer on the shaft of the
penis. What is the most likely diagnosis?
A. Chancroid
B. Genital herpes
C. Chlamydia
D. Primary syphilis
E. Secondary syphilis

A 34-year-old man presents to his GP with a painless hard penile ulcer. Venereal Disease
Research Laboratory tests and Treponema pallidum haemagglutination assay confirm the
diagnosis of primary syphilis. What is the most appropriate treatment for this patient?
A. Co-amoxiclav
B. Acyclovir
C. Azithromycin
D. Ciprofloxacin
E. Procaine penicillin

A 42-year-old man presents to accident and emergency with a 3-week history of shortness
of breath, dry cough, fevers and malaise. He has presented as his exercise tolerance has
deteriorated. He mentions that he has been HIV positive for ten years. On examination,
there are fine crackles throughout both lung fields. Chest x-ray demonstrates bilateral
perihilar interstitial shadowing. What is the most likely causative organism?
A. Pneumocystis jiroveci
B. Herpes simples virus type 1
C. Herpes simplex virus type 2
D. Streptococcus pneumoniae
E. Mycoplasma pneumoniae

A 42-year-old man presents to accident and emergency with a 3-week history of retrosternal
discomfort after swallowing. He mentions that he has been unable to keep any food down at
all. He has been HIV positive for ten years. He is admitted and endoscopy shows areas of
ulceration throughout the oesophagus. What is the
most likely causative organism?

A. Staphylococcus aureus
B. Crytosporidium parvus
C. Candida albicans
D. Pneumocystis jiroveci
E. Cryptococcus neoformans

A 62 year old man presents to his new primary care physician for a first visit. The patient
has not seen a doctor for more than 10 years.He has mild intermittent bronchial asthma.The
patient is sexually active with a single long term partner. He does not recall receiving any
vaccines since childhood. Which of the following vaccines shouldbe offered ?

a. Pneumococcal,influenza,zoster and tetanus-diptheria-acellular pertussis(Tdap)

b. Pneumococcal,influenza,zoster and tetanus-diptheria (T d)
c. Pneumococcal,influenza,human pailloma virus
d. Pneumococcal,influenza and tetanus-diptheria-acellular pertussis(Tdap)
e. Pneumococcal,influenza and meningococcal

In which of the following patients is it appropriate to administer the vaccination against

herpes zoster?
A. A 35-year-old woman who has never had varicella-zoster infection who is 12 weeks
pregnant with her first child
B. A 54-year-old man who has never had varicella-zoster infection and is otherwise
healthy
C. A 62-year-old man with HIV on antiretroviral therapy with a CD4+ lymphocyte
count of 450/μL
D. A 64-year-old woman with dermatomyositis-associated interstitial lung disease treated
with prednisone 20 mg daily and
azathioprine 150 mg daily
E. A 66-year-old woman who was recently diagnosed with non-Hodgkin lymphoma

A 19-year-old woman comes to your office after being bitten by a bat on the ear while
camping in a primitive shelter. She is unable to produce a vaccination record. On physical
examination, she is afebrile and appears well. There are two small puncture marks on the
pinna of her left ear. What is an appropriate vaccination strategy in this context?
A. Intravenous ribavirin
B. No vaccination
C. Rabies immunoglobulins
D. Rabies inactivated virus vaccine
E. Rabies inactivated virus vaccine plus immunoglobulins
Which of the following statements regarding administration of varicella-zoster vaccine to
patients above the age of 60 is true?

a. It is a killed virus vaccine,so it is safe in immunocompromised patients

b. It is not recommended for patients in this age groups
c. It will decrease the risk of developing postherpetic neuralgia
d. It will not decrease the risk of developing shingles
e. It will not decrease the burden of disease

A 23-year-old previously healthy female letter carrier works in a suburb in which the
presence of rabid foxes and skunks has been documented. She is bitten by a bat, which
then flies away. Initial examination reveals a clean break in the skin in the right upper
forearm. She has no history of receiving treatment for rabies and is unsure about
vaccination against tetanus.The physician should
A. clean the wound with a 20% soap solution
B. clean the wound with a 20% soap solution and administer tetanus toxoid
C. clean the wound with a 20% soap solution, administer tetanus toxoid, and administer
human rabies immune globulin intramuscularly
D. clean the wound with a 20% soap solution, administer tetanus toxoid, administer
human rabies immune globulin IM, and administer human diploid cell vaccine
E. clean the wound with a 20% soap solution and administer human diploid cell vaccine

Feedback: Explanation:The patient in question has been bitten by a member of a species

known to carry rabies in an area in which rabies is endemic. Based on the animal vector
and the facts that the skin was broken and that saliva possibly containing the rabies virus
was present, postexposure rabies prophylaxis should be administered. If an animal involved
in an unprovoked bite can be captured, it should be humanely killed and the head should be
sent immediately to an appropriate laboratory for rabies examination by the technique of
fluorescent antibody staining for viral antigen. If a healthy dog or cat bites a person in an
endemic area, the animal should be captured, confined, and observed for 10 days. If the
animal remains healthy for this period of time, the bite is highly unlikely to have transmitted
rabies. Postexposure prophylactic therapy includes vigorous cleaning of the wound with a
20% soap solution to remove any virus particles that may be present. Tetanus toxoid and
antibiotics should also be administered. Passive immunization with antirabies antiserum in
the form of human rabies immune globulin (rather than the corresponding equine antiserum
because of the risk of serum sickness) is indicated at a dose of 10 units/kg into the wound
and 10 units/kg intramuscularly into the gluteal region. Second, one should actively
immunize with an antirabies vaccine [either human diploid cell vaccine or rabies vaccine
absorbed (RVA)] in five 1-mL doses given intramuscularly, preferably in the deltoid or
anterior lateral thigh area. The five doses are given over a 28-day period. The
administration of either passive or active immunization without the other modality results in
a higher failure rate than does the combination therapy.

A 56 year old man has painful weeping rashes over the upper eyelid and forehead for the
last 2 days along with ipsilateral acute punctate keratopathy. About a year back, he had
chemotherapy for Non-Hodgkin’s lymphoma. There is not other abnormality. WHich of the
following is the most likely diagnosis?
A. Impetigo
B. Systemic Lupus Erythematosus
C. Herpes Zoster
D. pyoderma gangrenosum

A previously healthy 24-year-old woman comes to the physician because of a low-grade

fever and a nonproductive cough for 7 days. She has been able to continue her daily
activities. Her temperature is 37.7°C (99.9°F). A few scattered inspiratory crackles are
heard in the thorax. An x-ray of the chest shows patchy infiltrates in both lungs. Which of the
following is the most appropriate initial pharmacotherapy?
(A) Amoxicillin
(B) Cefaclor
(C) Ciprofloxacin
(D) Erythromycin
(E) Trimethoprim-sulfamethoxazole

A 27-year-old woman comes to the physician for a follow-up examination. She has a 10-
week history of persistent nonproductive cough that is worse at night and a 1-month history
of a hoarse voice. She otherwise feels well. She has not had loss of appetite or change in
exercise tolerance. She has never smoked. Empiric treatment with an oral decongestant
and albuterol inhaler has not improved her symptoms. She has no history of serious illness.
Her temperature is 37°C (98.6°F), pulse is 68/min, respirations are 12/min, and blood
pressure is 110/76 mm Hg. Cardiopulmonary examination and an x-ray of the chest show
no abnormalities. Her FEV1 is normal. Which of the following is the most appropriate next
step in management?
(A) 24-Hour monitoring of esophageal pH
(B) Echocardiography
(C) CT scan of the chest
(D) Inhaled corticosteroid therapy
(E) Nitroglycerin therapy

A 62-year-old man comes to the physician because of a 2-month history of progressive

fatigue and ankle swelling. He had an anterior myocardial infarction 3 years ago and has
had shortness of breath with mild exertion since then. Current medications include labetalol
and daily aspirin. He has smoked one-half pack of cigarettes daily for 30 years. His pulse is
100/min and regular, respirations are 20/min, and blood pressure is 130/75 mm Hg. There
are jugular venous pulsations 5 cm above the sternal angle. Crackles are heard at both lung
bases. Cardiac examination shows an S3 gallop. There is edema from the midtibia to the
ankle bilaterally. Further evaluation of this patient is most likely to show which of the
following findings?

(A) Decreased pulmonary capillary wedge pressure

(B) Impaired contractility of the left ventricle
(C) Prolapse of the mitral valve
(D) Thrombosis of the superior vena cava
(E) Ventricular septal defect

A sexually active 20-year-old woman has had fever, chills, malaise, and pain of the vulva for
2 days. Examination shows a vulvar pustule that has ulcerated and formed multiple satellite
lesions. Nodes are palpated in the inguinal and femoral areas. A smear of fluid from the
lesions establishes the diagnosis. Which of the following is the most likely causal
organism?

A) Chlamydia trachomatis
B) Haemophilus ducreyi
C) Neisseria gonorrhoeae
D) Streptococcus pyogenes (group A)
E) Treponema pallidum

A 52-year-old woman has had dyspnea and hemoptysis for 1 month. She has a history of
rheumatic fever as a child and has had a cardiac murmur since early adulthood. Her
temperature is 36.7°C (98°F), pulse is 130/min and irregularly irregular, respirations are
20/min, and blood pressure is 98/60 mm Hg. Jugular venous pressure is not increased.
Bilateral crackles are heard at the lung bases. There is an opening snap followed by a
lowpitched diastolic murmur at the third left intercostal space. An x-ray of the chest shows
left atrial enlargement, a straight left cardiac border, and pulmonary venous engorgement.
Which of the following is the most likely explanation for these findings?

(A) Aortic valve insufficiency

(B) Aortic valve stenosis
(C) Mitral valve insufficiency
(D) Mitral valve stenosis
(E) Tricuspid valve insufficiency

A 42 year old woman comes to the physician because of a 8 week history of intermittent
nausea and abdominal pain that occurs 20-30 min after eating. The pain extends from the
epigastrium to the right upper quadrant and sometimes to the right scapula, it lasts for 30
min and is not relieved by antacids. The last episode occurred after she ate a hamburger
and french fries. She is currently asymptomatic and has not had vomiting. She is 5ft 5in tall,
and weighs 230lb and has a BMI of 38kg/m2. Exam shows no other abnormalities. Which of
the following is the most appropriate next step in management?
A. Abdominal ultrasonography of the right upper quadrant
B. Upper GIT series with small bowel follow through
C. CT abdomen
D. Endoscopic retrograde cholangiopancreatography
E. Elective cholecystectomy
F. Immediate cholecystectomy

A 52-year-old man comes to the physician with his wife because of a 1-year history of
excessive daytime sleepiness. He does not think the symptoms are problematic, but his wife
is concerned because he sometimes falls asleep on the sofa early in the evening when
guests are present. He also once fell asleep while driving at night and drove off the road,
narrowly avoiding injury. His wife says that he has always snored loudly, and over the past
year, he has had episodes of choking or gasping for breath while sleeping. He is 178 cm (5
ft 10 in) tall and weighs 105 kg (231 lb); BMI is 33 kg/m2 . His pulse is 76/min, respirations
are 14/min, and blood pressure is 150/76 mm Hg. Physical and neurologic examinations
show no other abnormalities. Which of the following is most likely to confirm the diagnosis?

(A) 24-Hour ambulatory ECG monitoring

(B) Multiple sleep latency test
(C) Polysomnography
(D) CT scan of the head
(E) Laryngoscopy

A 47-year-old man is brought to the emergency department 2 hours after the sudden onset
of shortness of breath, severe chest pain, and sweating. He has no history of similar
symptoms. He has hypertension treated with hydrochlorothiazide. He has smoked one pack
of cigarettes daily for 30 years. His pulse is 110/min, respirations are 24/min, and blood
pressure is 110/50 mm Hg. A grade 3/6, diastolic blowing murmur is heard over the left
sternal border and radiates to the right sternal border. Femoral pulses are decreased
bilaterally. An ECG shows left ventricular hypertrophy. Which of the following is the most
likely diagnosis?

(A) Acute myocardial infarction

(B) Aortic dissection
(C) Esophageal rupture
(D) Mitral valve prolapse
(E) Pulmonary embolism

A 22-year-old man is brought to the emergency department 30 minutes after he sustained a

gunshot wound to the abdomen. His pulse is 120/min, respirations are 28/min, and blood
pressure is 70/40 mm Hg. Breath sounds are normal on the right and decreased on the left.
Abdominal examination shows an entrance wound in the left upper quadrant at the
midclavicular line below the left costal margin. There is an exit wound laterally in the left
axillary line at the 4th rib. Intravenous fluid resuscitation is begun. Which of the following is
the most appropriate next step in management?

(A) Upright x-ray of the chest

(B) CT scan of the chest
(C) Intubation and mechanical ventilation
(D) Peritoneal lavage
(E) Left tube thoracostomy

A 22-year-old medical student presents to the GUM clinic with large amounts of yellow-
coloured penile discharge and discomfort on urinating. He has just arrived home from his
summer holiday in Ibiza. What is the most likely diagnosis?
A. Chlamydia
B. Genital herpes
C. Cystitis
D. Gonorrhoea
E. Syphilis
You read a report which was handwritten in a patient’s medical notes who you suspect has
inflammatory bowel disease. The report reads, ‘… there is cobblestoning of the terminal
ileum with the appearance of rose thorn ulcers. These findings are suggestive of Crohn’s
disease’. Select the most likely investigation that this report was derived from:
A. Colonoscopy
B. Sigmoidoscopy
C. Barium follow through
D. Abdominal CT
E. Abdominal ultrasound

A 29-year-old anxious man is diagnosed with mild Crohn’s disease. Due to time constraints,
the patient was asked to come back for a follow-up appointment to discuss Crohn’s disease
in more detail. The patient returns with a list of complications he researched on the internet.
Which of the following are not associated with Crohn’s disease?

A. Cigarette smoking reduces incidence

B. Fistulae formation
C. Abscess formation
D. Non-caseating granuloma formation
E. Associated with transmural inflammation

A 27-year-old investment banker presents to accident and emergency with a 4-day history
of painful rash on his penis and testicles. He also reports feeling generally run down with a
fever and myalgia. He returned from a trip to New York a week ago. On examination, there
is a painful vesicular rash over his penis and testicles. What is the most appropriate
treatment?
A. Oral acyclovir
B. High-dose intravenous acyclovir
C. Oral flucloxacillin
D. Paracetamol
E. Glyceryl trinitrate cream

A 45-year-old man with diabetes, diagnosed with pulmonary TB who started treatment two
months ago, presents to you with a week’s history of pins and needles in his hands and feet
with associated numbness. He tells you that his symptoms started since he stopped taking
the vitamins given to him at the start of his TB treatment. From the list below, which of the
following drugs is responsible for the symptoms described by the patient?
A. Pyrazinamide
B. Rifampicin
C. Ethambutol
D. Isoniazid
E. None of the above

Which of the following is most appropriate test for assessing liver disease in chronic hep-B
a. Liver biopsy
b. USG
c. Ct-scan
d. MRI
What kind of virus is Hepatitis-C is
a. SS-RNA
b. SS-DNA
c. DS-RNA
d. DS-DNA
In addition to total dose of alcohol , which of the following factor is associated with the
development of Alcoholic fibrosis and cirrhosis
a. BMI
b. Male sex
c. Coffee consumption
d. Acetaminophen

Which of the following risk factor for advance fibrosis in non-alcoholic fatty liver
a. Obesity
b. Age
c. Diabetes
d. Hypertension
Which of the following is the most frequent cause of Cirrhosis
a. Wilsons disease
b. Non-alcoholic steatohepatitis
c. Hep-C
d. Autoimmune hepatitis
Portal hypertension in cirrhosis
a. Can be caused by any disease interfering with portal blood flow at any level
within the portal venous system
b. Secondary reduction in portal blood flow attenuates increase in portal hypertension
c. Usually directly evaluated by measuring portal pressure
d. Associated with development pf esophageal varices once threshold value of 20
mmHg is exceeded
Recommendation practice in the management of variceal bleeding includes all of the
following except
a. Patient without varices should be screened endoscopically for appearance of varices
every 2-3 year
b. Acute variceal hemorrhage is best approached by combined use of pharmacologic
agents started from the admission and endoscopic procedure
c. Prophylaxis of infection with broad spectrum antibiotic only given to patients
with history of previous infection
d. Patient surving an episode of variceal bleeding or at the high risk of
bleeding.medocal therapist using beta blockers or nitrated and endoscopic band
ligation or both are recommended for slight treatment

A 56 year old woman comes to chief financial officer of large company and several months
thereafter develops upper abdominal pain that she ascribed to stress.she takes an over
counter antacids which affords temporary relief,but uses no other medication.one night she
awakens with nausea and vomits large volume of coffee ground like material.she becomes
weak and diaphoretic.upon admission she found to have actively bleeding duodenal ulcer.
Which of the following is true ?
a. Most likely etiology is adenocarcinoma of duodenum
b. Etiology of ulcer is different in woman than men
c. Likelyhood she harbors H.pylori >50%
d. Life time residence in USA makes H.pylori unlikely as the etiologic agent
e. Organisms consistent with H.pylori are rarely seen on biopsy of duodenal ulcer

A 36-year-old man presents for a well-patient exam. He gives a history that, over the past
20 years, he has had three episodes of abdominal pain and hematemesis, the most recent
of which occurred several years ago. He was told that an ulcer was seen on a barium upper
GI radiograph. You obtain a serum assay for Helicobacter pylori IgG, which is positive. What
is the most effective regimen to eradicate this organism?
a. Omeprazole 20 mg PO daily for 6 weeks
b. Ranitidine 300 mg PO qhs for 6 weeks
c. Omeprazole 20 mg bid, amoxicillin 1000 mg bid, clarithromycin 500 mg bid for 14
days
d. Pepto-Bismol and metronidazole bid for 7 days

60 year old woman complains of fever& constant left lower quadrant pain for two day
duration.she has not had vomiting&rectal bleeding. She has history of hypertension but
otherwise healthy. Never had similar abdominal pain. No previous surgeries, only regular
medication lisinopril.On examination BP 150/80 mmHg, T-38.9,she has normal bowel
sounds, Left lower quadrant tenderness and rebound. WBC are 28,000 , serum
electrolytes,creatinine& BUN, Liver function tests are normal. What is the next step in
evaluating this patient ??

a. Colonoscopy
b. Barium enema
c. Exploratory laporotomy
d. USG abdomen
e. CT scan of abdomen & Pelvis

A 65 year old woman complains with complex medical history including diabetes,
hypertension,coronary heart disease& gastroesophageal reflux disease.Ongoing use of
alcohol & tobacco, presents with increasing midsternal chest discomfort predominantly
when swallowing solid food, eventually becomes difficult with liquid food. Most likely cause
of patient condition is
a. Cancer
b. Achalasia
c. Esophageal stricture

A 34-year-old male presents with substernal discomfort. The symptoms are worse after
meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid
in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing,
pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the
patient has gained 20 lb in the past 2 years. Your initial approach is
a. A therapeutic trial of ranitidine
b. Exercise test with thallium imaging
c. Esophagogastroduodenoscopy
d. CT scan of the chest

A 74-year-old man presents with the abrupt onset of pain in the left lower abdomen, which
has been progressively worsening over the last 2 days. He states that the pain is
unremitting. He has some diarrhea but no nausea or vomiting. He has no dysuria or
hematuria. His temperature is 102°F. Bowel sounds are decreased. The patient has
involuntary guarding. There is tenderness and rebound tenderness when the left lower
quadrant is palpated. The referred rebound test is positive. A fixed sausage-like mass is
palpable in the area of tenderness. There is no costovertebral angle (CVA) tenderness.
Rectal examination reveals brown stool, which is fecal occult blood test (FOBT) positive.
Bloodwork demonstrates a leukocytosis. Can u explain the clinical findings based on most
likely diagnosis........... ??
a. Colon cancer
 b. Diverticulitis
c. Pancreatitis
d. Pyelonephritis
e. Appendicitis

A 42 year old morbid woman complains of nonproductive cough for 8 months. She becomes
regurgitate after eating and when she does it has sour taste. She has on proton pump
inhibitors for 3 months. Abdominal examination is normal. Rectal examination and FOBT is
negative. Which of the following is next step in the management
a. Barium with esophagography
b. Esophageal manometry
c. Esophageal Ph monitoring
d. Upper endoscopy

A 44 year old male with history of roux en y bypass gastric surgery.one year history
presents with fatigue,parasthecia in feet & hands. Some difficulty in balancing. Which of the
following is most likely reason?
a. Dumping syndrome
b. Malabsorption
c. Bacterial over growth
d. Gastric carcinoma
e. Gastritis

Screening test for COLORECTAL CANCER IS

Answer : FOBT

True regarding Colorectal cancer

a. Colon cancer more common in females than males
b. 5-year survival rate is 80%
c. Colonic tumors are need to be assessed by MRI
d. APC mutations probably more important in rectal tumors than colonic tumors
e. Adoption of total mesorectal excision has reduced local recurrence rate of
rectal cancers to <10%

Which of the following organisms would typically be found in a patient with atypical
community-acquired pneumonia?
A. Staphylococcus aureus
B. Pseudomonas spp.
C. Streptococcus pneumonia
D. Legionella pneumophilia
E. Haemophilus influenza

A 54-year-old woman is seen in clinic with a history of weight loss, loss of appetite and
shortnesss of breath. Her respiratory rate is 19 and oxygen saturations (on room air) range
between 93 and 95 per cent. On examination, there is reduced air entry and dullness to
percussion on the lower to midzones of the right lung. There is also reduced chest
expansion on the right. From the list below, select the most likely diagnosis:

A. Right middle lobe pneumonia

B. Pulmonary embolism
C. Right-sided pleural effusion
D. Right-sided bronchial carcinoma
E. Right lower lobe pneumonia

A 45-year-old woman with unexpected weight loss, loss of appetite and shortness of breath
presents to you in clinic. On examination, there is reduced air entry and dullness to
percussion in the right lung. A pleural tap is performed and the aspirate samples sent for
analysis. You are told that the results reveal a protein content of 30 g/L. From the list
below, select the most likely diagnosis:

A. Bronchogenic carcinoma
B. Congestive cardiac failure
C. Liver cirrhosis
D. Nephrotic syndrome
E. Meig’s syndrome

You are discussing a patient with your registrar who has become acutely short of breath on
the ward. After performing an arterial blood gas, you have high clinical suspicion that the
patient has a pulmonary embolism. Which of the following is the investigation of choice for
detecting pulmonary embolism?
A. Magnetic resonance imaging (MRI) of the chest
B. High-resolution CT chest (HRCT)
C. Chest x-ray
D. Ventilation/perfusion scan (V/Q scan)
E. CT pulmonary angiogram (CT-Pa)
You see a 46-year-old man who has presented to accident and emergency with an acute
onset of shortness of breath. Your registrar has high clinical suspicion that the patient is
suffering from a pulmonary embolism and tells you that the patient’s ECG has changes
pointing to the suspected diagnosis. From the list below, which of the following ECG
changes are classically seen?

A. Inverted T-waves in lead I, tall/tented T-waves in lead III and flattened T-waves in lead III
B. Deep S-wave in lead I, pathological Q-wave in lead III and inverted T-waves in lead
III
C. Flattened T-wave in lead I, inverted T-wave in lead III, and deep S-wave in lead III
D. No changes in lead I, deep S-wave in lead III
E. Deep S-wave in lead I with no changes in lead III

You see a 28-year-old man, with no past medical history, in accident and emergency who
developed an acute onset of pleuritic chest pain and shortness of breath while playing
football. On examination, oxygen saturations are 93 per cent on room air, respiratory rate 20
and temperature is 37.1°C. There is decreased expansion of the chest on the left side,
hyper-resonant to percussion and reduced air entry on the left. The most likely diagnosis is:

A. Left-sided pneumothorax
B. Left-sided pneumonia
C. Left-sided pleural effusion
D. Lung fibrosis
E. Traumatic chest injury

You are asked to request imaging for a patient with a suspected pneumothorax who you
have just examined in accident and emergency. Which of the following would be the most
appropriate first step imaging modality?

A. CT-chest
B. Ultrasound chest
C. Chest x-ray
D. V/Q scan
E. CT-PA

A 68-year-old woman has presented with acute onset shortness of breath 24 hours after a
long haul flight. Her blood results show a raised D-dimer level and the arterial blood gas
shows a PO2 of 8.3 kPa and PCO2 of 5.4 kPa. Your consultant suspects a pulmonary
embolism and the patient needs to be started on treatment while a CT-PA is awaited. From
the list below, please select the most appropriate treatment regime.

A. Commence loading with warfarin and aim for an international normalized ratio (INR)
between 2 and 3
B. Thromboembolic deterrent stockings
C. Aspirin 75 mg daily
D. Prophylactic dose subcutaneous low molecular weight heparin loading with warfarin and
aim for INR between 2 and 3
E. Treatment dose subcutaneous low molecular weight heparin loading with
warfarin and aim for INR between 2 and 3

A 55-year-old man, who has never smoked and with no past medical history, has been
diagnosed with right basal community-acquired pneumonia. There are minimal changes on
his chest x-ray and bloods reveal a neutrophil count of 8.2 and a C-reactive protein (CRP) of
15. He has no drug allergies. Although he has a productive cough of green sputum, his
respiratory rate is 16, oxygen saturations are 97 per cent on room air and his temperature is
37.4°C. You are asked to place him on treatment. Which of the following treatment options
would be appropriate for this patient?

A. Oral amoxicillin
B. Oral erythromycin
C. Intravenous ertapenem
D. Intravenous ertapenem with a macrolide (e.g. clarithromycin)
E. Intravenous tazocin

A 68-year-old woman is admitted to accident and emergency with shortness of breath and
cough. She has been a smoker for 25 years, smoking on average 20 cigarettes a day, and
is a known COPD patient with home oxygen. The observations read a pulse rate of 101,
blood pressure of 100/60, respiratory rate of 20, oxygen saturations of 88 per cent on air
and temperature of 37.2°C. On auscultation you hear bilateral expiratory wheeze. She is
prescribed nebulizers (salbutamol 5 mg ipratropium 500 g) with oxygen and chest x-ray
requested. Intravenous access has been established and bloods sent for analysis. From the
list below, select the most appropriate next step in this patient’s management plan.

A. Arterial blood gas sampling

B. Peak flow assessment
C. Urine dip microscopy and sensitivity
D. Start non-invasive ventilation (e.g. BIPAP)
E. Obtain sputum for microscopy, culture and sensitivity (MC&S)

A 58-year-old man with known COPD, diagnosed eight months ago, attends your clinic with
persistent shortness of breath despite stopping smoking and using his salbutamol inhaler
(given to him at the time of diagnosis), which he finds he is using more frequently. You
assess the patient’s lung function tests that have been recorded just before he saw you in
clinic on this occasion. His FEV1 65 per cent of the predicted value. Oxygen saturations
are 95 per cent on room air, respiratory rate in 18, and his temperature is 37.1°C. From the
list below, select the next most appropriate step in this patient’s management.

A. 40 mg daily oral prednisolone for 5 days

B. Start long-term oxygen therapy
C. Start inhaled corticosteroid therapy
D. Add oral theophylline therapy
E. Add a long-acting 2 agonist inhaler

In an ECG with wide complex tachycardia, which of the following clues most strongly
supports the diagnosis of ventricular tachycardia?
A. Atrial-ventricular dissociation
B. Classic right bundle branch block pattern
C. Irregularly irregular rhythm with changing QRS complexes
D. QRS duration greater than 120 milliseconds
E. Slowing of rate with carotid sinus massage

Which of the following statements is true regarding pulsus paradoxus?

A. It consists of a greater than 15 mmHg increase in systolic arterial pressure with
inspiration.
B. It may be found in patients with severe obstructive lung disease.
C. It is the reversal of a normal phenomenon during inspiration.
D. It results from right ventricular distention during expiration resulting in compression of the
left ventricular volume and subsequent reduction in systolic pulse pressure.
E. All of the above are true.
Which of the following are features of Beck’s triad in cardiac tamponade?
A. Hypotension, electrical alternans, prominent x-descent in neck veins
B. Hypotension, muffled heart sounds, electrical alternans
C. Hypotension, muffled heart sounds, jugular venous distention
D. Kussmaul’s sign, hypotension, muffled heart sounds
E. Muffled heart sounds, hypotension, friction rub

A 48-year-old white man is seen in the clinic for a routine physical examination. He reports
no complaints. Examination shows a blood pressure of 134/82 mmHg with a normal heart
rate. BMI is 31 kg/m2. The remainder of his physical examination is normal. Which of the
following is true regarding lifestyle modification?
A. Brisk walking for as little as 10 minutes, 4 days per week will lower his blood pressure to
within the normal range.
B. Dietary NaCl restriction of less than 6 g per day will reduce his blood pressure.
C. Lifestyle modification will have no effect on his blood pressure.
D. Reduction of alcohol consumption to three or fewer drinks per day will decrease his blood
pressure.
E. Weight loss of approximately 9 kg can be expected to bring his blood pressure to
within the normal limit.

A 46-year-old white female presents to your office with concerns about her diagnosis of
hypertension 1 month previously. She asks you about her likelihood of developing
complications of hypertension, including renal failure and stroke. She denies any past
medical history other than hypertension and has no symptoms that suggest secondary
causes. She currently is taking hydrochlorothiazide 25 mg/d. She smokes half a pack of
cigarettes daily and drinks alcohol no more than once per week. Her family history is
significant for hypertension in both parents. Her mother died of a cerebrovascular accident.
Her father is alive but has coronary artery disease and is on hemodialysis. Her blood
pressure is 138/90 mmHg. Body mass index is 23. She has no retinal exudates or other
signs of hypertensive retinopathy. Her point of maximal cardiac impulse is not displaced but
is sustained. Her rate and rhythm are regular and without gallops. She has good peripheral
pulses. An electrocardiogram reveals an axis of –30 degrees with borderline voltage criteria
for left ventricular hypertrophy. Creatinine is 1.0 mg/dL. Which of the following items in her
history and physical examination is a risk factor for a poor prognosis in a patient with
hypertension?
A. Family history of renal failure and cerebrovascular disease
B. Persistent elevation in blood pressure after the initiation of therapy
C. Ongoing tobacco use
D. Ongoing use of alcohol
E. Presence of left ventricular hypertrophy on ECG

37-year-old woman with no significant past medical history except for a childhood murmur is
evaluated for severe pain of sudden onset in her right lower extremity. Examination is
notable for a young, uncomfortable woman with normal vital signs except for a heart rate of
110 beats/ min. Right leg has pallor distal to the right knee and is cold to the touch, and the
dorsalis pedis pulse is absent. Which of the following studies is likely to diagnose the
underlying reason for the patient’s presentation?
A. Angiography of right lower extremity
B. Blood cultures
C. Echocardiogram with bubble study
D. Serum c-ANCA
E. Venous ultrasound of right upper extremity

A 68-year-old man with a history of coronary artery disease is seen in his primary care clinic
for complaint of cough with sputum production. His care provider is concerned about
pneumonia, so a chest radiograph is ordered. On the chest radiograph, the aorta appears
tortuous with a widened mediastinum. A contrast-enhanced CT of the chest confirms the
presence of a descending thoracic aortic aneurysm measuring 4 cm with no evidence of
dissection. What is the most appropriate management of this patient?
A. Consult interventional radiology for placement of an endovascular stent.
B. Consult thoracic surgery for repair.
C. No further evaluation is needed.
D. Perform yearly contrast-enhanced chest CT and refer for surgical repair when the
aneurysm size is greater than 4.5 cm.
E. Treat with beta blockers, perform yearly contrast-enhanced chest CT, and refer for
surgical repair if the aneurysm grows more than 1 cm/year.

A 71 year old man complains of occasional low back pain. his BP is 150/80 mmHg,pulse 80
beats/min. cardiac examination reveals S4 gallop.abdominal examination reveals pulsatile
mass approximately 5 cm in diameterand palpable in epigastric area. Peripheral pulses are
normal. Which of the following is the appropriate test to evaluate the problem
ANSWER: Abdominal ultrasound
35 year old woman presents with sharp central chest pain that actively exacerbates each
time she moves breathing in or lies flat. Pain tends to stay in center but occasionally moves
towards neck& shoulder. Pain relieved by sitting forward. The patient doesnot drink
alcohol,No smoke,not diabetic.Pericardial rub is on auscultation. Most appropriate
diagnostic evaluation is

a. Echocardiogram
b. Calcium score
c. Chest x ray
d. ECG
e. Serum amylase

Your clinic patient has been diagnosed with pulmonary tuberculosis (TB) following a three-
month history of haemoptysis and fever. The patient is due to start on treatment and you are
asked by your registrar which of the following regimes is the most suitable. The patient has
no known drug allergies and, in addition, liver function tests and urea and electrolytes
results are all within normal ranges. From the list below, which of the following answers is
the most appropriate and recommended treatment regimen for this patient?

A. Three months of isoniazid, rifampicin, ethambutol and pyrazinamide, followed by three

months of isoniazid and rifamipicin
B. Four months of isoniazid and rifampicin, followed by two months of isoniazid, rifampicin,
ethambutol and pyrazinamide
C. Six months of isoniazid, rifampicin, ethambutol and pyrazinamide
D. Six months of isoniazid and rifampicin
E. Two months of isoniazid, rifampicin, ethambutol and pyrazinamide, followed by
four months of isoniazid and rifampicin

A 65-year-old man presents with central crushing chest pain for the first time. He is
transferred immediately to the closest cardiac unit to undergo a primary percutaneous
coronary intervention. There is thrombosis of the left circumflex artery only. Angioplasty is
carried out and a drug-eluding stent is inserted. What are the most likely changes to have
occurred on ECG during admission?

A. ST depression in leads V1–4

B. ST elevation in leads V1–6
C. ST depression in leads II, III and AVF
D. ST elevation in leads V5–6
E. ST elevation in leads II, III and AVF
A 78-year-old woman is admitted with heart failure. The underlying cause is determined to
be aortic stenosis. Which sign is most likely to be present?

A. Pleural effusion on chest x-ray

B. Raised jugular venous pressure (JVP)
C. Bilateral pedal oedema
D. Bibasal crepitations
E. Atrial fibrillation

A patient is admitted with pneumonia. A murmur is heard on examination. What finding

points to mitral regurgitation?

A. Murmur louder on inspiration

B. Murmur louder with patient in left lateral position
C. Murmur louder over the right 2nd intercostal space midclavicular line
D. Corrigan’s sign
E. Narrow pulse pressure

A 55-year-old man has just arrived in accident and emergency complaining of 20 minutes of
central crushing chest pain. Which feature is most indicative of myocardial infarction at this
moment in time?

A. Inverted T waves
B. ST depression
C. ST elevation
D. Q waves
E. Raised troponin

A 66-year-old woman presents to accident and emergency with a 2-day history of shortness
of breath. The patient notes becoming progressively short of breath as well as a sharp pain
in the right side of the chest which is most painful when taking a deep breath. The patient
also complains of mild pain in the right leg, though there is nothing significant on full
cardiovascular and respiratory examination. Heart rate is 96 and respiratory rate is 12. The
patient denies any weight loss or long haul flights but mentions undergoing a nasal
polypectomy 3 weeks ago. The most likely diagnosis is:

A. Muscular strain
B. Heart failure
C. Pneumothorax
D. Angina
E. Pulmonary embolism

While on call you are called by a nurse to a patient on the ward complaining of light
headedness and palpitations. When you arrive the patient is not conscious but has a patent
airway and is breathing with oxygen saturation at 97 per cent. You try to palpate a pulse but
are unable to find the radial or carotid. The registrar arrives and after hearing your report of
the patient decides to shock the patient who recovers. What is the patient most likely to
have been suffering?

A. Torsades de Pointes
B. Ventricular fibrillation
C. Sustained ventricular tachycardia
D. Non-sustained ventricular tachycardia
E. Normal heart ventricular tachycardia

A 78-year-old woman is admitted to your ward following a 3-day history of shortness of

breath and a productive cough of white frothy sputum. On auscultation of the lungs, you
hear bilateral basal coarse inspiratory crackles. You suspect that the patient is in congestive
cardiac failure. You request a chest x-ray. Which of the following signs is not typically seen
on chest x-ray in patients with congestive cardiac failure?

A. Lower lobe diversion

B. Cardiomegaly
C. Pleural effusions
D. Alveolar oedema
E. Kerley B lines

A 56-year-old man presents to your clinic with symptoms of exertional chest tightness which
is relieved by rest. You request an ECG which reveals that the patient has first degree heart
block. Which of the following ECG abnormalities is typically seen in first degree heart block?

A. PR interval 120 ms
B. PR interval 300 ms
C. PR interval 200 ms
D. PR interval 200 ms
E. PR interval 120 ms

A 48-year-old woman has been diagnosed with essential hypertension and was
commenced on treatment three months ago. She presents to you with a dry cough which
has not been getting better despite taking cough linctus and antibiotics. You assess the
patient’s medication history. Which of the following antihypertensive
medications is responsible for the patient’s symptoms?

A. Amlodipine
B. Lisinopril
C. Bendroflumethiazide
D. Frusemide
E. Atenolol

A 21-year-old man is on his way home from a party when he experiences the sudden onset
of rapid palpitations. He feels uncomfortable but not short of breath and has no chest pain.
He goes to the nearest accident and emergency department, where he is found to have a
supraventricular tachycardia (SVT) at a rate of 170/minute. Carotid sinus massage
produced transient reversion to sinus rhythm, after which the tachycardia resumed. What
would be the next step in your management?

A. Repeat carotid sinus massage

B. IV verapamil
C. IV propranolol
D. IV adenosine
E. Synchronized DC cardioversion

A 44-year-old woman presents with episodes of headaches, associated with anxiety,

sweating and a slow pulse rate. At the time of her initial consultation, her blood pressure
was 150/95 mmHg seated, but 24 hour ambulatory monitoring shows a peak of 215/130
mmHg, associated with the symptoms described above. Which of the following would be
your initial diagnostic procedure?

A. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis

B. Measurement of random plasma catecholamines
C. Measurement of urinary metanephrines over several 24 hour periods
D. Glucose tolerance test
E. Pharmacological provocation using clonidine

X ray showing BOOT shape HEART

a. Pulsu paradoxus
b. Basilar rales
c. ST gallop
 d. Epigastric tenderness
e. Strong apical beat

You are seeing for first time 45 year old female patient of your partner . review of patient
records show that her systemic BP is >140 at both of her last clinic appointment. Her
medical record is significant for only diabetes mellitus. Her BP is160/90. What is the next
best step in her management of hypertension ??

a. Ask patinet to keep rhythm records with BP and bring with her on return appointment
b. Advise healthy sodium diet , refer to nutritionist
c. Prescribe ACE inhibitors + healthy diet
d. Prescribe dihydropyridine Calcium channel blockers + healthy diet
e. Arrange echocardiogram

68 year old man complaints of pain in his calves while walking. He notes bilateral foot pain
which awakens him at night . His BP is 117/68 mmHg . Physical examination denotes
diminished bilateral lower extremities. ABI measures 0.6 .Patient current medication
includes aspirin,hydrochlorothiazide. Which of the following best initial management?

a. smoking cessation therapy

b. smoking cessation therapy + gradual exercise
c. smoking cessation therapy + scheduled arteriography
d. smoking cessation therapy + warfarin + calcium channel blocker
e. smoking cessation therapy + consultation with vascular surgeon

51 year old man involve in motor cycle accident. He was not wearing seat belt. On arrival at
E.R patient complains of tight chest pain,shortness of breath. His BP 120/80 but decreased
to 90/50 at the end of inspiration. He has JVD with distal heart sounds. Lung examination
reveals normallung sounds bilaterally. What is the most likely diagnosis ?

a. Aortic dissection
b. Cardiac tamponade
c. Pneumothorax
d. CHF
e. Dilated cardiomyopathy

Which of the following is considered as differential diagnosis of unstable angina

 a. Aortic dissection
b. Pericarditis
c. Pneumothorax
d. Pulmonary embolism
e. All of the above

A 78 year old man with diabetes & hypertension presents to your office with progressing
dyspnea, lower extremity swelling. In addition to ordering an echocardiogram for
assessment of LV systolic function. What is the most appropriate test to assess diastolic
function ??

a. Cardiac MRI
b. Echocardiogram Doppler imaging technique
c. Eho straight imaging technique
d. Left heart catheterization
e. BNP

Most common cause of infective endocarditis in IV drug users is ???

a. Streptococcus
b. Staphylococcus aureus
c. Enterococcus
d. Viridans

A 22-year-old man is brought to the emergency department 30 minutes after he sustained a

gunshot wound to the abdomen. His pulse is 120/min, and blood pressure is 70/40 mm Hg.
Breath sounds are normal on the right and decreased on the left. Abdominal examination
shows an entrance wound in the left upper quadrant at the midclavicular line below the left
costal margin. There is an exit wound laterally in the left axillary line at the 4th rib.
Intravenous fluid resuscitation is begun. Which of the following is the most appropriate next
step in management?

A. upright xray of chest

B. CT scan of chest
C. intubation and mechanical ventilation
D. peritoneal lavage
E. left tube thoracostomy
A previously healthy 17-year-old girl comes to the physician because of a 2-month history of
exercise-induced cough and nasal congestion. She plays field hockey and has noticed she
coughs when running up and down the field. The cough is nonproductive and resolves with
rest. She has not had chest pain or palpitations. She takes no medications and does not
smoke. Her sister has asthma. The patient appears well. Her pulse is 68/min, respirations
are 16/min, and blood pressure is 100/75 mm Hg. Pulse oximetry on room air shows an
oxygen saturation of 99%. Cardiopulmonary examination shows no abnormalities. An x-ray
of the chest shows no abnormalities. Spirometry shows an FEV1:FVC ratio of 90% and an
FEV1 of 90% of predicted. Which of the following is the most likely diagnosis?

a. Asthma
b. Chronic bronchitis
c. GERD

An obese 33-year-old woman has had four 12-hour episodes of severe, sharp,vpenetrating
pain in the right upper quadrant of the abdomen associated with vomiting but no fever. She
has no diarrhea, dysuria, or jaundice and is asymptomatic between episodes. There is slight
tenderness to deep palpation in the right upper quadrant. Which of the following is the most
appropriate next step in diagnosis?

A) Supine and erect x-ray films of the abdomen

B) Upper gastrointestinal series
C) Ultrasonography of the upper abdomen
D) CT scan of the abdomen
E) HIDA scan of the biliary tract

A 19-year-old college student comes to the physician because of vaginal irritation and pain
with urination for 5 days. Two weeks ago, she had streptococcal pharyngitis treated with
amoxicillin. She has been sexually active with two partners over the past year; she uses
condoms for contraception. Her last menstrual period was 1 week ago. Her temperature is
37.2°C (99°F), and blood pressure is 90/60 mm Hg. Pelvic examination shows erythema of
the vulva and vagina and a thick white vaginal discharge. The pH of the discharge is 4.
Which of the following is the most likely cause of these findings?

A. Bacterial vaginosis
B. Candidiasis
C. Chlamydia trachomatis infection
D. Escherichia coli infection
E. Neisseria gonorrhoeae infection

Answer: B. Recent antibiotic use is a risk factor for developing candida vaginitis. This
patient also has the classic white vaginal discharge. The pH is also < 4.5, which is
consistent with Candida.

A previously healthy 27 yr old man comes to the physician 4 wks after after noticing 3
nontender lesions on his penis. He says they have not changed in size. He has multiple
male and female partners and uses condoms inconsistently. He takes no medications. He
drinks 2-5 beers on social occasions. He occasionally marijuana. His temp is 98.4. There is
no lymphadenopathy. Exam shows 3 sessile, flesh colored lesions on the shaft of penis that
are 10mm in diameter. On application of dilute solution of acetic acid, the lesions turn white.
The remainder of the exam shows no abnormalities. Which of the following is the most
appropriate next step in diagnosis?
A. Topical ganciclovir
B. Oral acyclovir
C. Oral doxycycline
D. IM penicillin
E. Cryotherapy

An 18-year-old man is brought to the emergency department 10 minutes after he sustained

a stab wound to his chest. On arrival, he is unresponsive to painful stimuli. His pulse is
130/min, respirations are 8/min and shallow, and palpable systolic blood pressure is 60 mm
Hg. He is intubated and mechanically ventilated, and infusion of 0.9% saline is begun. After
5 minutes, his pulse is 130/min, and blood pressure is 70/40 mm Hg. Examination shows a
2-cm wound at the left sixth intercostal space at the midclavicular line. There is jugular
venous distention. Breath sounds are normal. The trachea is at the midline. Heart sounds
are not audible. Which of the following is the next appropriate step ??

a. Pericardiocentesis
b. Ct scan
c. MRI

A 77-year-old woman is brought to the emergency department after collapsing at home. Six
hours ago, she had the sudden onset of massive bright red rectal bleeding. On arrival, her
blood pressure is 90/60 mm Hg, and pulse is 120/min. Abdominal examination shows no
abnormalities. Insertion of a nasogastric tube yields clear aspirate. Her hematocrit is 28%.
Which of the following is the most likely diagnosis?

A ) Colon cancer
B ) Diverticulosis
C ) Duodenal ulcer
D ) Hemorrhoids
E ) Inflammatory bowel disease

A 55-year-old man has had crushing substernal chest pain on exertion over the past 6
weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin as needed and
one aspirin daily. He has smoked two packs of cigarettes daily for 30 years. Examination
shows normal heart sounds and no carotid or femoral bruits. Treatment with a β-adrenergic
blocking agent is most likely to improve his symptoms due to which of the following
mechanisms?

A) Decreasing diastolic relaxation

B) Decreasing myocardial contractility
C) Dilating the coronary arteries
D) Peripheral vasodilation
E) Preventing fibrin and platelet plugs

During a routine examination, a 32-year-old man has a blood pressure of 120/80 mm Hg.
He is concerned because his father, grandfather, and two uncles have hypertension. He
works as a systems programmer for
a large computer company and frequently has to meet tight deadlines. He has smoked one
pack of cigarettes daily for 10 years. He is 4.5 kg (10 lb) overweight and drinks three cups of
coffee daily. Which of the following measures is most likely to reduce this patient's risk for
hypertension over the next 5 years?

A) Increase intake of dietary fiber

B) Restrict caffeine
C) Stress management
D) Weight loss
A 27 year old man has fever,macular rash and lymphadenopathy. He had unprotected sex
with a male partner 2 weeks before the onset of these symptoms and has just learned that
the partner is infected with HIV.the patients rapid HIV test is negative. What is the best test
to evaluate this patient for HIV infection ?
a. HIV enzyme-linked immunoabsorbent assay(ELISA)
b. PCR for HIV RNA
c. Western blot testing
d. Glycoprotein 120 using ELISA
e. PCR FOR HIV DNA

an ill looking 58 year old man with a 20 year history of diabetes mellitus presents with
severe pain and swelling of his right arm that started 2 days ago after some minor trauma.
He has a temperature of 103.6 F . examination of the arm reveals a 133 cm area of dark red
epidermal induration.large bullae filled with purple fluid are seen in the center of the wound.
Some parts of the wound are friable and appear black in color. Crepitus is felt with palpation
of the arm. Laboratory data reveals a leukocytosis and an elevated serum creatinine
phosphokinase. Which o fthe following is the most likely diagnosis ?
a. Erysipelas
b. Folliculitis
c. Celluitis
d. Necrotizing Fasciitis
e. Fourniers gangrene

You see a 40-year-old woman who was diagnosed with Crohn’s disease ten years ago. Due
to a severe attack of Crohn’s which failed to respond to medical therapy, she had a small
bowel resection. Your registrar tells you that she is at risk of developing vitamin B12
deficiency as a result of her surgery. Which part of the small bowel is responsible for the
absorption of vitamin B12?

A. Jejunum
B. Proximal ileum
C. Duodenum
D. Terminal ileum
E. None of the above
a 33 year old woman in her second trimester of her first pregnancy comes to see you in
october. she has no prior medical history and no complaints except for rhinitis. so far no one
around her has been sick,but she wants to be protected during the upcoming flu season.
her vital signs and the remainder of her physical examination are normal for her stage of
pregnancy, other than mildly erythematous nasal mucosa and clear drainage. What is the
most appropriate recommendation regarding protection against the flu for this patient ??
a. She should receive the influenza intramuscular vaccination at this time
b. She should receive the influenza vaccine intranasal mist at this time
c. She should not receive flu vaccination until her rhinitis has resolved
d. She should not receive flu vaccination because she is pregnant

A 40-year-old woman cut her finger while cooking in her kitchen. Two days later she
became rapidly ill with fever and shaking chills. Her hand became painful and mildly
erythematous. Later that evening her condition deteriorated as the erythema progressed
and the hand became a dusky red. Bullae and decreased sensation to touch developed
over the involved hand. What is the most important next step in the management of this
patient?

a. Surgical consultation and exploration of the wound

b. Treatment with clindamycin for mixed aerobic-anaerobic infection
c. Treatment with penicillin for clostridial infection
d. Vancomycin to cover community-acquired methicillin-resistant Staphylococcus
e. Evaluation for acute osteomyelitis

A 19-year-old man has a history of athlete’s foot but is otherwise healthy when he develops
sudden onset of fever and pain in the right foot and leg. On physical examination, the foot
and leg are fiery red with a well-defined indurated margin that appears to be rapidly
advancing. There is tender inguinal lymphadenopathy. Which organismis the most likely
cause of this infection?

a. Staphylococcus epidermidis
b. Tinea pedis
c. Streptococcus pyogenes
d. Mixed anaerobic infection
e. α-Hemolytic streptococci
A college wrestler develops cellulitis after abrading his skin during a match. He is afebrile
and appears well, but the lateral aspect of his arm is red and swollen with a draining
pustule. Gram stain of the pus shows gram-positive cocci in clusters. Which of the following
statements is correct?

a. The patient will require hospital admission and treatment with vancomycin.
b. The organismwill almost always be sensitive to oxacillin.
c. The organismis likely to be sensitive to trimethoprim-sulfamethoxazole.
d. Community-acquired methicillin-resistant staphylococci have the same sensitivity pattern
as hospital- acquired methicillin-resistant staphylococci.
e. The infection is likely caused by streptococci.

Which of the following people should receive pneumococcal vaccine ???

a. People with chronic respiratory disease
b. Householdcontact of case of pneumococcal meningitis
c. People who have cerebrospinal leaks
d. Any one has developed invasive pneumococcal disease has not been vaccinated in
past