IM Boards Refresher

Board
Refresher:
Internal Medicine
Jaime Alfonso M. Aherrera, MD DPCP
Jose Eduardo DL. Duya, BSPH, MD, DPCP
1. You’ve been seeing Mrs. Reyes, 42/F at the
OPD for chronic heart failure and she has been
minimally symptomaLc on a beta-‐blocker. She
comes back to you with acute decompensated
heart failure. Which of the following might have
triggered her decompensaLon?
A. Alcohol abuse

B. Smoking
C. Pregnancy
D. Fluid restricLon
1. You’ve been seeing Mrs. Reyes, 42/F at the
OPD for chronic heart failure and she has been
minimally symptomaLc on a beta-‐blocker. She
comes back to you with acute decompensated
heart failure. Which of the following might have
triggered her decompensaLon?
A. Alcohol abuse

B. Smoking
C. Pregnancy
D. Fluid restricLon
found to be helpful, particularly in patients with advanced disease.
Table 234-4 Factors That May Precipitate Acute Decompensation in

Patients with Chronic Heart Failure
Dietary indiscretion
Myocardial ischemia/infarction
Arrhythmias (tachycardia or bradycardia)

Discontinuation of HF therapy
Infection
Anemia
Initiation of medications that worsen HF
Calcium antagonists (verapamil, diltiazem)

Beta blockers
Nonsteroidal anti-inflammatory drugs

Antiarrhythmic agents [all class I agents, sotalol (class III)]
Anti-TNF antibodies
Alcohol consumption
Pregnancy
Worsening hypertension
Acute valvular insufficiency
2. You remember that Mrs Reyes has had
rheumaLcheart disease since she was 25 years old.
On examinaLon, she has an accentuated S1, a
diastolic rumble over the apex and a wide, notched
P wave on 12L ECG. Which valvular lesion does she
most probably have?
A.  Mitral stenosis
B.  Mitral regurgitaLon
C.  AorLc stenosis
D.  AorLc regurgitaLon
2. You remember that Mrs Reyes has rheumaLc
heart disease since she was 25 years old. On
examinaLon, she has an accentuated S1, a diastolic
rumble over the apex and a wide, notched P wave
on 12L ECG. Which valvular lesion does she most
probably have?
A.  Mitral stenosis

B.  Mitral regurgitaLon
C.  AorLc stenosis
D.  AorLc regurgitaLon
Mitral Stenosis (MS)
•  Most common valvular lesion in RHD
•  RheumaLc heart disease is the leading cause
of MS (others congenital, SLE, RA)
•  LeW atrial myxoma mimics symptoms
•  Accentuated S1, diastolic rumble, opening
snap
LA enlargement on CXR and ECG (wide, notched P wave)

•  Left Atrial Enlargement

–  PA view:
•  Double density
•  Enlargement of LA
appendage
•  Upliftment of left mainstem
bronchus
•  Widening of carinal angle
3. Which ECG finding disLnguishes
acute MI from pericardiLs?
A. ST elevaLons are concave

B. Development of Q waves
C. Tall P waves
D. T wave inversions usually seen within days
before ST segments become isoelectric
3. Which ECG finding disLnguishes acute
MI from pericardiLs?
A. ST elevaLons are concave
B. Development of Q waves
C. Tall P waves
D. T wave inversions usually seen within days
before ST segments become isoelectric
Electocardiographic Changes in
ACUTE PERICARDITIS
(4 Stages)

Stage 1 Widespread elevaLon of the ST segments,
oWen with upward concavity, reciprocal
depressions only in aVR and/or V , as well
1
as PR depression.

Stage 2 ST segment return to normal
Stage 3 T wave inversion
Stage 4 Normal

In contrast, in AMI:
•  ST ElevaLons are convex
•  Reciprocal depression more prominent
•  Development of Q waves
•  Notching and loss or R-‐wave amplitude
•  T-‐wave inversions are usually seen within
hours before the ST segments have
become isoelectric
4. DiagnosLc feature of cardiac
tamponade
A.  Pericardial knock
B.  Pulsus paradoxus
C.  Thickened and calcified pericardium
D.  Increased myocardial thickness
4. DiagnosLc feature of cardiac
tamponade
A.  Pericardial knock
B.  Pulsus paradoxus
C.  Thickened and calcified pericardium
D.  Increased myocardial thickness
Cardiac Tamponade
•  Beck’s triad (hypotension, soW/muffled heart
sounds, distended neck veins)
•  Pulsus paradoxus: greater than normal (10
mmHg) inspiratory decline in systolic arterial
pressure
•  Prominent x descent
•  Electrical alternans
•  Pericardial effusion
•  EqualizaLon of diastolic pressures
Table 239-‐2 Features That DisNnguish Cardiac Tamponade from ConstricNve PericardiNs
and Similar Clinical Disorders
CharacterisLc Tamponade ConstricNve RestricNve RVMI
PericardiNs Cardiomyopathy
Clinical
Pulsus paradoxus Common Usually absent Rare Rare
Jugular veins
Prominent y descent Absent Usually present Rare Rare
Prominent x descent Present Usually present Present Rare
Kussmaul's sign Absent Present Present Present
Third heart sound Absent Absent Rare May be present
Pericardial knock Absent OWen present Absent Absent
Electrocardiogram
Low ECG voltage May be present May be present May be present Absent
Electrical alternans May be present Absent Absent Absent
Echocardiography
Thickened pericardium Absent Present Absent Absent
Pericardial effusion Present Absent Absent Absent
RV size Usually small Usually normal Usually normal Enlarged
Myocardial thickness Normal Normal Usually increased Normal
Right atrial collapse and Present Absent Absent Absent
RVDC
Increased early filling, ↑ Absent Present Present May be present
mitral flow velocity
Exaggerated respiratory Present Present Absent Absent
variaLon in flow velocity
5. IniLal anL-‐hypertensive therapy
with thiazide diureLc should be given
to which paLent?
A.  48/M CHF FuncLonal Class III, BP 160/90
B.  50/M BP 140/90 with gouty arthriLs
C.  23/F with CKD stage 5 from chronic
glomerulonephriLs BP 150/90
D.  55/F with dyslipidemia & bronchial asthma,
BP 150/90
5. IniLal anL-‐hypertensive therapy
with thiazide diureLc should be given
to which paLent:
A.  48/M CHF FuncLonal Class III, BP 160/90
B.  50/M BP 140/90 with gouty arthriLs
C.  23/F with CKD stage 5 from chronic
glomerulonephriLs, BP 150/90
D.  55/F with dyslipidemia & bronchial asthma,
BP 150/90
Drugs for Hypertension
Drug Class Examples IndicaNons ContraindicaNons
Thiazides Hydrochlorothiazide IniLal therapy Diabetes, Gout,
Chlorthalidone Hyperuricemia,
Hypokalemia
Loop diureNcs Furosemide CHF, renal failure Diabetes
Ethacrynic acid Hypokalemia
Aldosterone Spironolactone CHF, primary Renal failure
antagonists Eplerenone aldosteronism Hyperkalemia
Beta blockers
Cardioselec-ve Metoprolol Angina Asthma
Atenolol CHF (systolic) COPD
Nonselec-ve Propranolol Post-‐MI 2nd or 3rd degree
Sinus tachycardia AV block
Combined Carvedilol Ventricular Sick sinus
alpha/beta Labetalol tachyarrhythmia syndrome
antagonist

ACE inhibitors Captopril Post-‐MI/CHD Acute renal failure,
Enalapril CHF with low EF bilateral renal artery
Lisinopril Nephropathy stenosis,
hyperkalemia,
Pregnancy
Angiotensin Losartan CHF with low EF Same as ACEI
receptor Valsartan Nephropathy
blockers Olmesartan ACE-‐induced cough
Calcium
antagonists
Dihydropyridine Nifedipine
Felodipiine

Non-‐ Verapamil Post-‐MI, angina, 2nd or 3rd degree AV
dihydropyridine DilLazem Supraventricular block
tachycardias
/ CauNon
Alpha
antagonists
Selec-ve Prazosin, Terazosin ProstaLsm

Nonselec-ve Phenoxybenzamine Pheochromocytoma
SympatholyNcs Clonidine
Methyldopa
Reserpine
Direct Hydralazine Severe Coronary
vasodilators Minoxidil Artery Disease
Renin inhibitors Aliskiren DiabeLc Pregnancy
nephropathy
HPIM 18th ed

tiate pharmacologic treatment to lower BP at SBP !140 mm Hg or DBP !90
mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert
2014 Guideline for Management of High Blood Pressure Opinion – Grade E) Special Communication Clinical Review & Education
Recommendation 5
Box. Recommendations for Management of Hypertension

JNC VIII In the population aged !18 years with diabetes, initiate pharmacologic treat-
ment to lower BP
to increase. atof
In 2 SBPthe trialsmm
!140 Hgprovide
that or DBP !90 mm Hg
evidence and treat toan
supporting
SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E)
goal lower than 150 mm Hg, the average treated SBP was 143 to 144
a goal
SBP
Recommendation 1
mm Hg.2,3 Many6participants in those studies achieved an SBP lower
Recommendation
Inthan
the general
140 mm nonblack
Hg withpopulation,
treatmentincluding
that wasthose with diabetes,
generally initial
well tolerated.
In the general population aged !60 years, initiate pharmacologic treat-
antihypertensive
Two other trials treatment
9,10 should include a thiazide-type diuretic,
suggest there was no benefit for an SBP goal lower cal-
ment to lower blood pressure (BP) at systolic blood pressure (SBP) !150
cium channel blocker (CCB), angiotensin-converting enzyme inhibitor
mm Hg or diastolic blood pressure (DBP) !90 mm Hg and treat to a goal than 140 mm Hg, but the confidence intervals around the effect sizes
(ACEI), or angiotensin receptor blocker (ARB). (Moderate Recommenda-
SBP <150 mm Hg and goal DBP <90 mm Hg. (Strong Recommendation –
were
tion wideB)and did not exclude the possibility of a clinically impor-
– Grade
Grade A)
tant benefit. Therefore, the panel included a corollary recommen-
Recommendation 7
Corollary Recommendation dation based on expert opinion that treatment for hypertension does
In the general black population, including those with diabetes, initial anti-
In the general population aged !60 years, if pharmacologic treatment for not need totreatment
be adjusted if treatment results in SBP lower
hypertensive should include a thiazide-type diuretic or than 140
CCB. (For
high BP results in lower achieved SBP (eg, <140 mm Hg) and treatment is
mm Hg
general andpopulation:
black is not associated
Moderate with adverse effects–on
Recommendation health
Grade or black
B; for qual-
well tolerated and without adverse effects on health or quality of life, treat-
patients with
ity of life. diabetes: Weak Recommendation – Grade C)
ment does not need to be adjusted. (Expert Opinion – Grade E)
While all panel
Recommendation 8 members agreed that the evidence supporting
Recommendation 2
Inrecommendation
the population aged 1 is!18
veryyears
strong,
withthe panel
CKD, was(or
initial unable
add-on)to reach una-
antihyper-
In the general population <60 years, initiate pharmacologic treatment to
tensive
nimity on the recommendation of a goal SBP of lower than 150out-
treatment should include an ACEI or ARB to improve kidney mm
lower BP at DBP !90 mm Hg and treat to a goal DBP <90 mm Hg. (For ages
comes. This applies to all CKD patients with hypertension regardless of race
30-59 years, Strong Recommendation – Grade A; For ages 18-29 years, Hg. Some members recommended continuing the JNC 7 SBP goal
or diabetes status. (Moderate Recommendation – Grade B)
Expert Opinion – Grade E) of lower than 140 mm Hg for individuals older than 60 years based
Recommendation
on expert opinion. 9 12 These members concluded that the evidence
Recommendation 3
The main objective of hypertension treatment is to attain and maintain goal
In the general population <60 years, initiate pharmacologic treatment to was insufficient to raise the SBP target from lower than 140 to lower
BP. If goal BP is not reached within a month of treatment, increase the dose
lower BP at SBP !140 mm Hg and treat to a goal SBP <140 mm Hg. (Expert ofthan 150 mm
the initial drugHg in high-risk
or add a secondgroups,
drug fromsuchoneas ofblack persons,
the classes those
in recom-
Opinion – Grade E) with CVD6including
mendation stroke,
(thiazide-type and those
diuretic, withormultiple
CCB, ACEI, ARB). The risk factors.
clinician The
should
Recommendation 4 continue to assess BP and adjust the treatment regimen
panel agreed that more research is needed to identify optimal goals until goal BP is
reached. If goal BP cannot be reached with 2 drugs, add and titrate a third
In the population aged !18 years with chronic kidney disease (CKD), ini- of SBP for patients with high BP.
drug from the list provided. Do not use an ACEI and an ARB together in the
tiate pharmacologic treatment to lower BP at SBP !140 mm Hg or DBP !90
same patient. If goal BP cannot be reached using only the drugs in recom-
mm Hg and treat to goal SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert
Opinion – Grade E) Recommendation
mendation 6 because of2a contraindication or the need to use more than 3
drugs to reach
In the generalgoal BP, antihypertensive
population younger thandrugs
60from other
years, classes
initiate can be
pharma-
Recommendation 5 used. Referral to a hypertension specialist may be indicated for patients in
cologic treatment to lower BP at DBP of 90 mm Hg or higher and
In the population aged !18 years with diabetes, initiate pharmacologic treat- whom goal BP cannot be attained using the above strategy or for the man-
ment to lower BP at SBP !140 mm Hg or DBP !90 mm Hg and treat to a goal
treat toof
agement a goal DBP of lower
complicated than
patients for 90 mmadditional
whom Hg. clinical consulta-
SBP <140 mm Hg and goal DBP <90 mm Hg. (Expert Opinion – Grade E) Forisages
tion 30 through
needed. 59 years,
(Expert Opinion Strong
– Grade E)Recommendation – Grade A
For ages 18 through 29 years, Expert Opinion – Grade E
Recommendation 6
Mechanism of Action
Despite these and other differences, the various beta blockers now
BETA BLOCKERS
available are approximately as effective as antihypertensive agents. A
Beta-adrenoceptor blocking drugs
Non-selective Selective With alpha-

blocking
activity
– + – +
ISA ISA ISA ISA
Nadolol Pindolol Atenolol Acebutolol Labetalol

Propranolol Carteolol Esmolol (Practolol) Bucindolol
Timolol Penbutolol Metoprolol Celiprolol Carvedilol
Sotalol Alprenolol Bisoprolol
Tertalolol Oxprenolol Betaxolol
Bevantolol
6. Treatment of choice for acute
pericardiLs occuring post-‐STEMI
A.  Ibuprofen 200mg 3 Lmes daily

B.  Aspirin 650mg 4 Lmes daily
C.  Prednisone 1mg/kg daily
D.  Warfarin 2.5 to 5mg daily
pericardiLs occuring post-‐STEMI
A.  Ibuprofen 200mg 3 Lmes daily

B.  Aspirin 650mg 4 Nmes daily
C.  Prednisone 1mg/kg daily
D.  Warfarin 2.5 to 5mg daily
7. A 64/M came to the ER for chest heaviness starLng
3 hours prior, unrelieved by nitrates given to him at
the previous hospital. On PE, BP 80/50 HR 64 RR 20
neck veins were flat, breath sounds clear while heart
sounds were disLnct. On 12L ECG, ST elevaLon was
seen in leads II, III and AVF. What is the next step in
stabilizing this paLent?
A.  Give morphine

B.  Give intravenous fluids
C.  Start dopamine drip
D.  Start dobutamine drip
7. A 64/M came to the ER for chest heaviness starLng
3 hours prior, unrelieved by nitrates given to him at
the previous hospital. On PE, BP 80/50 HR 64 RR 20
neck veins were flat, breath sounds clear while heart
sounds were disLnct. On 12L ECG, ST elevaLon was
seen in leads II, III and AVF. What is the next step in
stabilizing this paLent?
A.  Give morphine
B.  Give intravenous fluids
C.  Start dopamine drip
D.  Start dobutamine drip
8. FibrinolyLc therapy can be given to
which of the following paLents as
treatment for STEMI:
A.  64/M presenLng with severe, tearing chest
pain
B.  49/M diabeLc with BP 190/110
C.  45/F with lupus nephriLs and acLve menses
D.  40/M who had ischemic stroke 6 months ago
8. FibrinolyLc therapy can be given to
which of the following paLents as
treatment for STEMI:
A.  64/M presenLng with severe, tearing chest
pain
B.  49/M diabeLc with BP 190/110
C.  45/F with lupus nephriNs and acNve menses
D.  40/M who had ischemic stroke 6 months ago
Absolute ContraindicaNons to
Fibrinolysis
•  History of cerebrovascular hemorrhage at any
Lme
•  Nonhemorrhagic stroke or other
cerebrovascular event within the past year
•  Marked hypertension (SBP>180 mmHg and/or
a DBP>110 mmHg) at any Lme during the
acute presentaLon
•  Suspicion of aorLc dissecLon
•  AcLve internal bleeding (excluding menses).
RelaNve ContraindicaNons to
Fibrinolysis
•  Current use of anLcoagulants (internaLonal
normalized raLo 2)
•  Recent (<2 weeks) invasive or surgical procedure or
prolonged (>10 min)
•  Cardiopulmonary resuscitaLon
•  Known bleeding diathesis
•  Pregnancy,
•  Hemorrhagic ophthalmic condiLon (e.g., hemorrhagic
diabeLc reLnopathy)
•  AcLve pepLc ulcer disease
•  History of severe hypertension that is currently
adequately controlled
9. In assessment of blood pressure,
using an inappropriately small BP cuff
will result in:

A.  OveresLmaLon of the true blood pressure
B.  UnderesLmaLon of the true blood
pressure
C.  No change in the true blood pressure
D.  OveresLmaLon only of the systolic blood
pressure
9. In assessment of blood pressure,
using an inappropriately small BP cuff
will result in:

A.  OveresNmaNon of the true blood pressure
B.  UnderesLmaLon of the true blood
pressure
C.  No change in the true blood pressure
D.  OveresLmaLon only of the systolic blood
pressure
10. A 59 year old male presents with chest
pain. On auscultaLon, you were able to
appreciate a midsystolic murmur radiaLng
to the caroLds. You also noted a weak and
delayed pulse. Your likely diagnosis is:

A. AorLc stenosis
B. AorLc regurgitaLon
C. Acute myocardial infarcLon
D. Pulmonary embolism

10. A 59 year old male presents with chest
pain. On auscultaLon, you were able to
appreciate a midsystolic murmur radiaLng
to the caroLds. You also noted a weak and
delayed pulse. Your likely diagnosis is:

A. AorNc stenosis
B. AorLc regurgitaLon
C. Acute myocardial infarcLon
D. Pulmonary embolism

11. A 75 year old male comes in for angina. He
is a heavy smoker and alcoholic beverage
drinker. He was also said to have a “fasy liver”
by ultrasound. On further history, he admits to
have been taking “the blue pill” (sildenafil) for
erecLle dysfuncLon (last intake was the day
prior). Which anL-‐anginal drug is absolutely
contraindicated for this paLent:

A. Metoprolol
B. DilLazem
C. Nitroglycerin
D. Aspirin
11. A 75 year old male comes in for angina. He
is a heavy smoker and alcoholic beverage
drinker. He was also said to have a “fasy liver”
by ultrasound. On further history, he admits to
have been taking “the blue pill” (sildenafil) for
erecLle dysfuncLon (last intake was the day
prior). Which anL-‐anginal drug is absolutely
contraindicated for this paLent:

A. Metoprolol
B. DilLazem
C. Nitroglycerin
D. Aspirin
12. A 35 year old male with a heavy
smoking history develops claudicaLon on
the right foot with gangrene on the Lps of
the toes. Popliteal pulses on both
extremiLes are normal. Your likely
diagnosis is:

A. Atheroembolism
B. Deep venous thrombosis
C. Fibromuscular dysplasia
D. ThromboangiiLs obliterans

12. A 35 year old male with a heavy
smoking history develops claudicaLon on
the right foot with gangrene on the Lps of
the toes. Popliteal pulses on both
extremiLes are normal. Your likely
diagnosis is:

A. Atheroembolism
B. Deep venous thrombosis
C. Fibromuscular dysplasia
D. ThromboangiiNs obliterans

Buerger’s Disease
QUESTION 13
A 65 year old male was hospitalized for stroke 8
months prior and was subsequently bedridden
aWer. He was rushed to the emergency room
for sudden onset difficulty of breathing.

Upon arrival at the emergency room, there was
note of blood-‐Lnged sputum, with the
following vital signs BP: 110/70 HR: 72 regular,
RR: 34 and there was clear breath sounds.
Emergency 2D echo showed McConnell’s sign.
13. What is the most common
cause of death for paLents with
this condiLon?
A. Pump failure from myocardial ischemia

B. Progressive right heart failure
C. Respiratory failure from hypoxemia
D. Sudden cardiac death from cardiac
dysrhythmia
cause of death for paLents with
this condiLon?
A. Pump failure from myocardial ischemia
B. Progressive right heart failure
C. Respiratory failure from hypoxemia
D. Sudden cardiac death from cardiac
dysrhythmia
Pulmonary embolism (PE)
•  Dyspnea is the most common symptom
•  Tachypnea is the most common sign
•  Risk factors: Bedridden > 3 days
AcLve Cancer
Major surgery < 12 wks
•  Progressive right heart failure is the usual
cause of death from PE
SIGNS
•  McConnell’s Sign: hypokinesis of the RV Free
Wall with NORMAL moLon of the RV Apex
•  Homan’s sign: posterior calf pain on acLve
dorsiflexion of the foot against resistance (for
DVT)
•  Hamman’s sign: crunching / clicking noise
synchronous with the heartbeat & best heard
in the leW lateral decubitus posiLon
QUESTION 14
A 54 year old diabeLc male, with a 60 pack
year smoking history sought consult at the
OPD 1 week ago for exerLonal dyspnea and
cough with whiLsh sputum which started 8
months ago. He was rushed to the emergency
room for a 3 day history of worsening
difficulty of breathing, cough and decreased
sensorium. Upon arrival, he was seen drowsy
with absent breath sounds and bipedal
edema.
14. Which of the following should be
the next step in managing this
paLent?
A.  Intubate the paLent
B.  Nebulize with Salbutamol
C.  Start theophylline drip
D.  Give Furosemide IV boluses
14. Which of the following should be
the next step in managing this
paLent?
A.  Intubate the paNent
B.  Nebulize with Salbutamol
C.  Start theophylline drip
D.  Give Furosemide IV boluses
15. A diagnosLc thoracentesis is
warranted for which of the following
situaLons?
A. Pleural effusions are equally present on
both lung fields.
B. PaLent is febrile
C. Free fluid separates the lung from the
chest wall by >10 mm
D. Sputum AFB is posiLve
15. A diagnosLc thoracentesis is
warranted for which of the following
situaLons?
A. Pleural effusions are equally present on
both lung fields.
B. PaLent is febrile
C. Free fluid separates the lung from the
chest wall by >10 mm
D. Sputum AFB is posiLve
TransudaLve vs ExudaLve?
Light’s Criteria
•  Pleural fluid protein/serum protein >0.5
•  Pleural fluid LDH/serum LDH >0.6
•  Pleural fluid LDH more than two-‐thirds normal
upper limit for serum
Factors indicaNng the likely need for a
procedure more invasive than a
thoracentesis (increasing order of
importance)
•  Loculated pleural fluid
•  Pleural fluid pH <7.20
•  Pleural fluid glucose <3.3 mmol/L (<60 mg/dL)
•  PosiLve Gram stain or culture of the pleural
fluid
•  Presence of gross pus in the pleural space
QUESTION 16
A 50 year old female, on chronic dialysis, was
transferred from a nursing home for
decreased in sensorium. On history, there was
a 1 week history of cough with yellowish
sputum, associated with high grade fever and
progressive difficulty of breathing.
On examinaLon, she was drowsy, with coarse
crackles on the right lower lung field. Vital
signs were BP: 70/50 HR 118 and RR 27 and
febrile at 39.2°C.
16. Which of the following would put
her at risk of Pseudomonas aeruginosa
infecLon?
A. Chronic dialysis
B. Family member with a Pseudomonas infecLon
C. Hypotension despite fluid resuscitaLon
D. Living in a nursing home
16. Which of the following would put
her at risk of Pseudomonas aeruginosa
infecLon?
A. Chronic dialysis
B. Family member with a Pseudomonas infecLon
C. Hypotension despite fluid resuscitaLon
D. Living in a nursing home
Clinical CondiLons Associated with and
Likely Pathogens in Health Care–
Associated Pneumonia
CondiNon MRSA Pseudomonas Acinetobacter MDR Enterobac-‐
teriaciae
HospitalizaLon for 48 h X X X X
HospitalizaLon for 2 X X X X
days in prior 3 months
Nursing home or X X X X
extended-‐care-‐facility
residence
AnLbioLc therapy in X X
preceding 3 months
Chronic dialysis X
Home infusion therapy X
Home wound care X
Family member with X X
MDR infecLon
QUESTION 17
A 30 year old paLent sought consult for
chronic cough for 3 months. She was
previously diagnosed with pulmonary
tuberculosis but only completed treatment for
3 months. Laboratory test showed posiLve
sputum TB culture and chest x-‐ray revealed
cavitary TB.
17. Which of the following makes
this paLent most likely to transmit
PTB?
A. Age of the paLent
B. PosiLve sputum TB culture
C. Presence of cavitary TB on chest x-‐ray
D. Previous TB treatment
17. Which of the following makes
this paLent most likely to transmit
PTB?
A. Age of the paLent
B. PosiLve sputum TB culture
C. Presence of cavitary TB on chest x-‐ray
D. Previous TB treatment
18. When should treatment failure
in pulmonary tuberculosis be
suspected?
A. Chest x-‐ray remained unchanged aWer 6
weeks
B. Sputum AFB smears remain posiLve
aWer 5 months
C. Sputum cultures remain posiLve aWer 2
months
d. If paLent stops medicaLons for 1 week
18. When should treatment failure in
pulmonary tuberculosis be
suspected?
A. Chest x-‐ray remained unchanged aWer 6
weeks
B. Sputum AFB smears remain posiNve
aber 5 months
C. Sputum cultures remain posiLve aWer 2
months
D. If paLent stops medicaLons for 1 week
TB Treatment Failure/Resistance
•  If sputum AFB is posiLve at 3 months and
paLent is adherent
•  If sputum cultures remain posiLve at 3
months
•  In some like extensive cavitary disease and
large numbers of organisms, AFB smear
conversion may lag behind culture conversion
19. What is the mechanism of
acLon of Rifampicin ?

A. Inhibits fasy acid synthase and mycolic acid
synthesis
B. Inhibits arabinosyltransferases involved in
cell wall synthesis
C. Inhibits mycobacterial DNA-‐dependent RNA
polymerase, blocking RNA synthesis
D. Mechanism is unclear
19. What is the mechanism of
acLon of Rifampicin ?

A. Inhibits fasy acid synthase and mycolic acid
synthesis (INH)
B. Inhibits arabinosyltransferases involved in
cell wall synthesis (EMB)
C. Inhibits mycobacterial DNA-‐dependent
RNA polymerase, blocking RNA synthesis
D. Mechanism is unclear
20. Which of the following laboratory/
imaging finding suggests the presence
of chronic hypoxemia in COPD?
A. Compensatory increase of bicarbonate

in arterial blood gas
B. FEV1/FVC < 0.7 on spirometry
C. Low hematocrit
D. Right ventricular hypertrophy
20. Which of the following laboratory/
imaging finding suggests the presence
of chronic hypoxemia in COPD?
A. Compensatory increase of bicarbonate

in arterial blood gas
B. FEV1/FVC < 0.7 on spirometry
C. Low hematocrit
D. Right ventricular hypertrophy
21. A 30 year old female came in for severe
abdominal pain radiaLng to the back. Amylase and
lipase were significantly elevated. On the 3rd
postoperaLve day, she had sudden worsening of
dyspnea with a respiratory rate of 34. Arterial blood
gas showed a PO2 of 40 with an FiO2 of 40%.
Best management for this paLent will be:
A. Give stat dose of Furosemide IV bolus with BP

precauLons
B. Start IV broad-‐spectrum anLbioLcs immediately
C. Increase FiO2 to 60%
D. InsLtute venLlatory support with a low Ldal volume
21. A 30 year old female came in for severe
abdominal pain radiaLng to the back. Amylase and
lipase were significantly elevated. On the 3rd
postoperaLve day, she had sudden worsening of
dyspnea with a respiratory rate of 34. Arterial blood
gas showed a PO2 of 40 with an FiO2 of 40%.
Best management for this paLent will be:
A. Give stat dose of Furosemide IV bolus with BP

precauLons
B. Start IV broad-‐spectrum anLbioLcs immediately
C. Increase FiO2 to 60%
D. InsNtute venNlatory support with a low Ndal volume
22. How is Paragonimus westermani
(Lung Fluke) transmised?
A. Respiratory droplets
B. IngesLon of crayfish
C. Transfer from infected blood and body
fluids
D. InhalaLon of infecLous larva
22. How is Paragonimus westermani
(Lung Fluke) transmised?
A. Respiratory droplets
B. IngesNon of crayfish
C. Transfer from infected blood and body
fluids
D. InhalaLon of infecLous larva
23. A 22 year old college student sought consult
for a 7 day history of high grade fever. He also
complained of headache, body malaise, and
abdominal pain. On physical examinaLon, vital
signs were as follows: BP 110/60 HR 70 RR 18
Temp 39.4°C, the liver was enlarged, there was
splenomegaly, and blanching, maculopapular
rash over the anterior chest.
What is the primary consideraLon?
A. Dengue hemorrhagic fever
B. Leptospirosis
C. Malaria
D. Typhoid fever
23. A 22 year old college student sought consult
for a 7 day history of high grade fever. He also
complained of headache, body malaise, and
abdominal pain. On physical examinaLon, vital
signs were as follows: BP 110/60 HR 70 RR 18
Temp 39.4°C, the liver was enlarged, there was
splenomegaly, and blanching, maculopapular
rash over the anterior chest.
What is the primary consideraLon?
A. Dengue hemorrhagic fever
B. Leptospirosis
C. Malaria
D. Typhoid fever
24. Aling Dahlia is a 55 year old diabeLc paLent
you haven't seen in years. She comes back to
you with burning pain when she urinates and
vulvar itching. On closer inspecLon, you note
clumped white vaginal discharge on a
background of erythematous vaginal epithelium.
What is your treatment of choice?
A. Metronidazole 2g orally single dose

B. Metronidazole 500mg BID for 7 days
C. Fluconazole 150mg orally single dose
D. Azithromycin 2g orally single dose
24. Aling Dahlia is a 55 year old diabeLc paLent
you haven't seen in years. She comes back to
you with burning pain when she urinates and
vulvar itching. On closer inspecLon, you note
clumped white vaginal discharge on a
background of erythematous vaginal epithelium.
What is your treatment of choice?
A. Metronidazole 2g orally single dose

B. Metronidazole 500mg BID for 7 days
C. Fluconazole 150mg orally single dose
D. Azithromycin 2g orally single dose
25. Your cousin complains to you that she has
been having repeated episodes of vomiLng and
watery diarrhea for the past 3 hours. She denies
any fever, abdominal cramps and did not noLce
blood in her vomitus or stools. She tells you that
she has just come from a friend's wedding 4
hours ago where she ate fried rice, potato salad,
roast beef and prawns.

Which of the following organisms most probably
caused her complaints in addiLon to oral
rehydraLon?
25. Which of the following is a
reasonable treatment regimen for
your cousin ?
A. Bismuth or Loperamide
B. Bismuth plus Clindamycin
C. Ciprofloxacin plus Metronidazole
D. Ciprofloxacin alone
25. Which of the following is a
reasonable treatment regimen for
your cousin ?
A. Bismuth or Loperamide
B. Bismuth plus Clindamycin
C. Ciprofloxacin plus Metronidazole
D. Ciprofloxacin alone
26. Most common clinical findings in
the acute clinical syndrome of HIV
A. Mucocutaneous ulceraLon, Kaposi’s

sarcoma
B. Diarrhea, myalgia, urethral discharge
C. PharyngiLs, lymphadenopathy, fever
D. Weight loss, night sweats, prostraLon
26. Most common clinical findings in
the acute clinical syndrome of HIV
A. Mucocutaneous ulceraLon, Kaposi’s

sarcoma
B. Diarrhea, myalgia, urethral discharge
C. PharyngiNs, lymphadenopathy, fever
D. Weight loss, night sweats, prostraLon
27. True regarding treatment of
schistosomiasis
A. Drug of choice is praziquantel in 2 to 3 doses
given in 4 weeks.
B. Early hepatomegaly and bladder lesions do
not resolve with chemotherapy.
C. Treatment of severe acute schistosomiasis or
Katayama fever involves parasite eliminaLon
and supporLve treatment such as
glucocorLcoids.
D. Treatment of schistosmiasis in a paLent with
co-‐infecLon with HIV will reduce HIV viral
load and increase CD4 counts.
27. True regarding treatment of
schistosomiasis
A. Drug of choice is praziquantel in 2 to 3 doses
given in 4 weeks.
B. Early hepatomegaly and bladder lesions do
not resolve with chemotherapy.
C. Treatment of severe acute schistosomiasis or
Katayama fever involves parasite eliminaLon
and supporLve treatment such as
glucocorLcoids.
D. Treatment of schistosmiasis in a paNent with
co-‐infecNon with HIV will reduce HIV viral
load and increase CD4 counts.
28. Which of the following vaccines
can be given safely to pregnant
women?

A.  Measles, mumps, rubella (MMR)
B.  Varicella
C.  Tetanus toxoid
D.  Herpes zoster
28. Which of the following vaccines
can be given safely to pregnant
women?

A.  Measles, mumps, rubella (MMR)
B.  Varicella
C.  Tetanus toxoid
D.  Herpes zoster
29. Capt. Reyes is a naval officer who is
now going to be assigned to Papua New
Guinea. He consults you since he is
concerned about malaria in the area and
intends to bring his pregnant wife and 12
y/o son with him.

Which of the following should be your
advice to them?

A. It is very important to apply anL-‐mosquito
repellants especially in mid-‐aWernoon when the
anopheline mosquitoes most oWen feed
B. Travellers should take their chemoprophylaxis 12-‐24
hours prior to departure and conLnue unLl 1 week
aWer departure
C. Pregnant women can be given mefloquine as
chemoprophylaxis
D.  Chemoprophylaxis for malaria when given
appropriately assures protecLon for travellers and
diagnosis other than malaria should be sought when
they present with fever.
A. It is very important to apply anL-‐mosquito
repellants especially in mid-‐aWernoon when the
anopheline mosquitoes most oWen feed
B. Travellers should take their chemoprophylaxis 12-‐24
hours prior to departure and conLnue unLl 1 week
aWer departure
C. Pregnant women can be given mefloquine as
chemoprophylaxis
D.  Chemoprophylaxis for malaria when given
appropriately assures protecLon for travellers and
diagnosis other than malaria should be sought when
they present with fever.
30. Which of the following is true
regarding serologic tests for syphilis?
A. RPR remains the standard in examining
cerebrospinal fluid (CSF)
B. VDRL is the test of choice for rapid serologic
diagnosis in a clinical sezng
C. RPR Lters correlate with VDRL Lters during
treatment and may be used interchangeably
D. A non-‐reacLve FTA-‐ABS test on CSF rules out
asymptomaLc neurosyphilis.
30. Which of the following is true
regarding serologic tests for syphilis?
A. RPR remains the standard in examining
cerebrospinal fluid (CSF)
B. VDRL is the test of choice for rapid serologic
diagnosis in a clinical sezng
C. RPR Lters correlate with VDRL Lters during
treatment and may be used interchangeably
D. A non-‐reacNve FTA-‐ABS test on CSF rules out
asymptomaNc neurosyphilis.
Syphilis DiagnosNcs: Nontreponemal
•  RPR test is easier to perform and uses unheated
serum; test of choice for rapid serologic diagnosis
in a clinical sezng and can be automated.
•  VDRL test remains the standard for examining
CSF.
•  RPR and VDRL tests are recommended for
screening or for quanLtaLon of serum anLbody
•  VDRL Lters do not correspond directly to RPR
Lters
Syphilis DiagnosNcs: Treponemal
•  Treponemal anLbody–absorbed (FTA-‐ABS)
test and the T. pallidum parLcle aggluLnaLon
(TPPA) test
•  Confirmatory test for syphilis
•  Has high false negaLve rate
•  Cannot disLnguish between current and
treated syphilis
31. Mucocutaneous lesions, generalized non-‐
tender lymphadenopathy, skin erupLons that
involves palms and soles and rarely, lues
maligna or severe necroLc lesions, occur in
which stage of syphilis infecLon?

A. Primary syphilis
B. Secondary syphilis
C. Latent syphilis
D. Late syphilis

31. Mucocutaneous lesions, generalized non-‐
tender lymphadenopathy, skin erupLons that
involves palms and soles and rarely, lues
maligna or severe necroLc lesions, occur in
which stage of syphilis infecLon?

A. Primary syphilis
B. Secondary syphilis
C. Latent syphilis
D. Late syphilis

Syphilis
•  Primary Lesion
–  Appears at the site of inoculaNon, usually persists for 4–6 weeks, and
then heals spontaneously.
•  Secondary Syphilis
–  Generalized parenchymal, consLtuLonal, & mucocutaneous
manifestaLons of Secondary syphilis usually appear 6–8 weeks aber
the chancre heals.
•  Latent Phase
–  Secondary lesions subside within 2–6 weeks, and infecLon enters the
latent stage (detectable ONLY by serologic tesNng)
•  TerLary Disease
–  MOST common types :
•  Gumma (a usually benign granulomatous lesion)
•  Cardiovascular syphilis (usually involving the vasa vasorum of the ascending aorta
and resulLng in aneurysm)
•  Late symptomaNc neurosyphilis (tabes dorsalis and paresis)
32. This blood fluke is now
classified as a human carcinogen
A. Schistosoma japonicum
B. Schistosoma hematobium
C. Schistosoma mekongi
D. Schistosoma intercalatum
32. This blood fluke is now
classified as a human carcinogen
A. Schistosoma japonicum
B. Schistosoma hematobium
C. Schistosoma mekongi
D. Schistosoma intercalatum
33. Most common clinical
manifestaLon of Neisseria
meningi-des in humans:
A. AsymptomaLc colonizaLon of the

nasopharynx
B. Bacterial meningiLs
C. Meningococcal sepLcemia
D. Occult bacteremia
manifestaLon of Neisseria
meningi-des in humans:
A. AsymptomaNc colonizaNon of the

nasopharynx
B. Bacterial meningiLs
C. Meningococcal sepLcemia
D. Occult bacteremia
34. A 30 year old female wondered why despite
her appeLte she seemed to be wasLng away. She
has been having vague abdominal pain and watery
diarrhea for a month now, despite treatment with
Ciprofloxacin. She consults you regarding this,
wondering if it has anything to do with her love for
raw fish. Upon doing a basery of tests, you note an
albumin level of 12 (normal value: 40). Fecalysis
results showed peanut-‐shaped eggs. What is your
diagnosis?
A. TRICHINELLA
B. CAPILLARIASIS
C. ENTEROBIASIS
D. ASCARIASIS
34. A 30 year old female wondered why despite
her appeLte she seemed to be wasLng away. She
has been having vague abdominal pain and watery
diarrhea for a month now, despite treatment with
Ciprofloxacin. She consults you regarding this,
wondering if it has anything to do with her love for
raw fish. Upon doing a basery of tests, you note an
albumin level of 12 (normal value: 40). Fecalysis
results showed peanut-‐shaped eggs. What is your
diagnosis?
A. TRICHINELLA
B. CAPILLARIASIS
C. ENTEROBIASIS
D. ASCARIASIS
35. A 53 year old male came in at the OPD for
jaundice. On history he was a heavy chronic
alcoholic beverage drinker and has a strong family
history for hepatocellular cancer. On physical
examinaLon, he has gynecomasLa and a few
spider angiomata.

HepaLLs profile: HBsAg, anL-‐HCV: Non-‐reacLve
AST was twice elevated as the ALT, low albumin,
prolonged PT
CBC: HGB 92 HCT 0.23 MCV 102 MCH 35 Platelet
166

35. Which would be the most likely
cause of this paLent’s chronic liver
disease?

A. Alcoholic liver disease
B. Chronic hepaLLs B infecLon
C. Hepatocellular carcinoma
D. Fasy liver
35. Which would be the most likely
cause of this paLent’s chronic liver
disease?

A. Alcoholic liver disease
B. Chronic hepaLLs B infecLon
C. Hepatocellular carcinoma
D. Fasy liver
36. What is your interpretaLon of the
following hepaLLs profile?
HbS (-‐) AnL-‐HBs (+) AnL-‐HBc IgG (+)
HBeAg (-‐) AnL-‐HBe (+/-‐)

A. Chronic hepaLLs B, high infecLvity
B. Late acute or chronic hepaLLs B, low
infecLvity
C. Recovery from hepaLLs B
D. VaccinaLon against HBV
36. What is your interpretaLon of the
following hepaLLs profile?
HbS (-‐) AnL-‐HBs (+) AnL-‐HBc IgG (+)
HBeAg (-‐) AnL-‐HBe (+/-‐)

A. Chronic hepaLLs B, high infecLvity
B. Late acute or chronic hepaLLs B, low
infecLvity
C. Recovery from hepaNNs B
D. VaccinaLon against HBV
37. A 30 year old female sought consult for
melena. She is complaining of 1 year history of
recurrent burning epigastric pain, someLmes
awakening the paLent in the middle of the
night and was relieved by intake of antacids or
food. On physical examinaLon, she has
epigastric tenderness, orthostaLc hypotension,
melena on DRE.

What is the procedure of choice to confirm the
cause of melena?

37. What is the procedure of choice
to confirm the cause of melena?
A. Barium swallow
B. Abdominal CT scan
C. Upper GI endoscopy
D. Lower GI endoscopy

37. What is the procedure of choice
to confirm the cause of melena?
A. Barium swallow
B. Abdominal CT scan
C. Upper GI endoscopy
D. Lower GI endoscopy

38. Mr Tan is a 58 year old male company
execuLve who came in for a prevenLve check-‐up.
History and physical examinaLon are unremarkable
but you noted microcyLc, hypochromic anemia in
his CBC. Urinalysis, blood chemistry and chest x-‐
rays are normal. What is your next step?

A. Reassure him that the anemia might be from
stress
B. Order for abdominal CT scan
C. Order PSA, CEA, AFP and LDH
D. Refer to GI for flexible sigmoidoscopy
38. Mr Tan is a 58 year old male company
execuLve who came in for a prevenLve check-‐up.
History and physical examinaLon are unremarkable
but you noted microcyLc, hypochromic anemia in
his CBC. Urinalysis, blood chemistry and chest x-‐
rays are normal. What is your next step?

A. Reassure him that the anemia might be from
stress
B. Order for abdominal CT scan
C. Order PSA, CEA, AFP and LDH
D. Refer to GI for flexible sigmoidoscopy
39. A 30 year old male presents with
dysphagia to solid and liquids. A barium
swallow x-‐ray done showed tapering of the
esophagus with a beak-‐like appearance.
DiagnosLc criteria by esophageal manometry
would show:

A.  Over-‐acLvity of peristalsis
B.  Impaired LES relaxaLon
C.  Air fluid level
D.  Dilated esophagus
39. A 30 year old male presents with
dysphagia to solid and liquids. A barium
swallow x-‐ray done showed tapering of the
esophagus with a beak-‐like appearance.
DiagnosLc criteria by esophageal manometry
would show:

A.  Over-‐acLvity of peristalsis
B.  Impaired LES relaxaNon
C.  Air fluid level
D.  Dilated esophagus
Esophageal disorders
Achalasia Barium swallow: Esophageal dilataLon,
tapering at the gastroesophageal juncLon
and an air-‐fluid level within the esophagus
Manometry: Impaired LES relaxaLon and
absent peristalsis
Diffuse “Corkscrew” esophagus on barium swallow
esophageal Manometry: simultaneous contracLons,
spasm uncoordinated ("spasLc") acLvity
Candida CharacterisLc white plaques with friability
esophagiLs
40. A 50 year old male, smoker, alcoholic drinker
comes in for sudden severe nonremizng abdominal
pain. Heart rate was noted to be irregularly
irregular. There was only very minimal tenderness,
out of proporLon to the symptoms. The gold
standard of diagnosis is:

A. Radiograph showing bowel-‐wall edema
(“thumbprinLng”)
B. DemonstraLon of pneumatosis intesLnalis
C. Oral and IV dynamic CT scan
D. Lapatoromy
40. A 50 year old male, smoker, alcoholic drinker
comes in for sudden severe nonremizng abdominal
pain. Heart rate was noted to be irregularly
irregular. There was only very minimal tenderness,
out of proporLon to the symptoms. The gold
standard of diagnosis is:

A. Radiograph showing bowel-‐wall edema
B. DemonstraLon of pneumatosis intesLnalis
C. Oral and IV dynamic CT scan
D. Lapatoromy
41. Which among these diseases
will have a serum-‐ascites albumin
gradient of >1.1 g/dL?

A. Cirrhosis
B. Peritoneal carcinomatosis
C. Tuberculous peritoniLs
D. NephroLc syndrome

41. Which among these diseases
will have a serum-‐ascites albumin
gradient of >1.1 g/dL?

A. Cirrhosis
B. Peritoneal carcinomatosis
C. Tuberculous peritoniLs
D. NephroLc syndrome

SAAG
– Serum to Ascites Albumin
Gradient (SAAG):
• >1.1g/dL = cause is MOST likely due
to PORTAL HYPERTENSION (usually
in sezng of cirrhosis)
• < 1.1g/dL = infecLon or malignancy
42. A 20 year old female comes in for
abdominal pain occurring 3 days per
month in the last three months.
Associated symptoms include
improvement of pain with defecaLon and
soW frequent stools. She most likely has:
A. Irritable bowel syndrome

B. Inflammatory bowel disease
C. GastrointesLnal tuberculosis
D. IntesLnal parasiLsm
A. Irritable bowel syndrome

B. Inflammatory bowel disease
C. GastrointesLnal tuberculosis
D. IntesLnal parasiLsm
43. What is the role of lactulose in
paLents with hepaLc encephalopathy?
A. Evacuate blood from the

gastrointesLnal tract
B. InacLvate colonic bacteria
C. Induce diarrhea
D. Promote colonic alkalinizaLon
43. What is the role of lactulose in
paLents with hepaLc encephalopathy?

B. InacNvate colonic bacteria
C. Induce diarrhea
44. Which of the following should you
consider accurate in the management of
gallstones and its complicaLons?

A. You can employ Ursodeoxycholic acid (UDCA) in
the treatment of pigment stones less than 5mm
B. ProphylacLc cholecystectomy may be
considered for those young paLents with low
surgical risk
C. Morphine should be employed in the
management of severe pain in acute cholecysLLs
D. Cholecystectomy is advised in all paLents with
porcelain gallbladder
44. Which of the following should you
consider accurate in the management of
gallstones and its complicaLons?

A. You can employ Ursodeoxycholic acid (UDCA) in
the treatment of pigment stones less than 5mm
B. ProphylacLc cholecystectomy may be
considered for those young paLents with low
surgical risk
C. Morphine should be employed in the
management of severe pain in acute cholecysLLs
D. Cholecystectomy is advised in all paNents with
porcelain gallbladder
45. Which of the following is NOT a
criteria in the Child-‐Pugh ClassificaLon
for staging of cirrhosis?
A. Bilirubin
B. ParLal thromboplasLn Lme
C. Serum albumin
D. Ascites

45. Which of the following is NOT a
criteria in the Child-‐Pugh ClassificaLon
for staging of cirrhosis?
A. Bilirubin
B. ParNal thromboplasNn Nme
C. Serum albumin
D. Ascites

Child-‐Pugh ClassificaNon
•  Serum albumin
•  Serum bilirubin
•  Prothrombin Lme
•  Ascites
•  HepaLc encephalopathy
•  MELD classificaNon: InternaLonal normalized

raLo (INR), serum bilirubin, and serum creaLnine
46. A 75 year old male with hypertension and
dyslipidemia presents with hematochezia of
about ¼ cup. Which of the following will you
consider first as it is the most common cause
of hematochezia among the elderly?

A. Bleeding hemorrhoids
B. Colon carcinoma
C. PepLc ulcer disease
D. DiverLcular bleeding
46. A 75 year old male with hypertension and
dyslipidemia presents with hematochezia of
about ¼ cup. Which of the following will you
consider first as it is the most common cause
of hematochezia among the elderly?

A. Bleeding hemorrhoids
B. Colon carcinoma
C. PepLc ulcer disease
D. DiverNcular bleeding
47. What is the standard radiologic
procedure for diagnosis of
nephrolithiasis?

A. Abdominal CT scan with IV contrast
B. KUB-‐IVP
C. Plain helical CT scan of the abdomen
D. Ultrasound of the abdomen

47. What is the standard radiologic
procedure for diagnosis of
nephrolithiasis?

A. Abdominal CT scan with IV contrast
B. KUB-‐IVP
C. Plain helical CT scan of the abdomen
D. Ultrasound of the abdomen

48. R.F. is a 65 year old male recently admised
for his first cycle of chemotherapy for acute
leukemia. Two days aWer his iniLal chemo
dose, you note that his urine output has been
going down.
Physical examinaLon revealed undistended
bladder and posiLve Chvostek's sign, rest is
unremarkable.
Stat blood chemistry revealed normal creaLne
kinase, hypocalcemia, hyperphosphatemia,
hyperuricemia and mild hyperkalemia.
Urinalysis unremarkable except for uric acid
crystals
48. What is your treatment of choice?
A. GlucocorLcoids
B. Intravenous crystalloids with
allopurinol
C. Intravenous crystalloids only
D. Intravenous furosemide
48. What is your treatment of choice?
A. GlucocorLcoids
B. Intravenous crystalloids with
allopurinol
C. Intravenous crystalloids only
D. Intravenous furosemide
49. In which of the following individuals
would you recommend kidney biopsy?
A.  64/M with diabetes and hypertension for 15
years, poor compliance to meds, complains to
you of pruritus and insomnia, serum creaLnine
350 mmol/L
B. 21/F complaining of headache and hypogastric

pain. BP 170/100 HR 90, urinalysis reveals
protein 1+, RBC 3+, WBC 1+ , RBC casts 1+

C. 23/M complaining of edema. He claims to be
healthy except for a bout of sore throat 2 weeks
ago. BP 160/90, HR 88, urinalysis reveals protein
trace, RBC 2+, WBC 1+.

D. 25/M came to the ER for no urine output. You
note stable vital signs and unremarkable physical
exam except for mulLple bruises on his thighs
and legs. Serum BUN 14.0 mmol/L, creaLnine
380 mmol/L, foley catheter has minimal tea-‐
colored urine
49. In which of the following individuals
would you recommend kidney biopsy?
A.  64/M with diabetes and hypertension for 15

years, poor compliance to meds, complains to
you of pruritus and insomnia, serum creaLnine
350 mmol/L
B. 21/F complaining of headache and hypogastric

pain. BP 170/100 HR 90, urinalysis reveals
protein 1+, RBC 3+, WBC 1+ , RBC casts 1+

C. 23/M complaining of edema. He claims to be
healthy except for a bout of sore throat 2 weeks
ago. BP 160/90, HR 88, urinalysis reveals protein
trace, RBC 2+, WBC 1+.

D. 25/M came to the ER for no urine output. You
note stable vital signs and unremarkable physical
exam except for mulLple bruises on his thighs
and legs. Serum BUN 14.0 mmol/L, creaLnine
380 mmol/L, foley catheter has minimal tea-‐
colored urine
50. Which of the following suggest
a chronic eLology for the kidney
disease?
A. Bilateral size of kidney on ultrasound 10 cm

B. ElevaLon of serum creaLnine >6 weeks
C. OsteiLs fibrosa cysLca
D. Presence of oliguria

50. Which of the following suggest
a chronic eLology for the kidney
disease?
A. Bilateral size of kidney on ultrasound 10 cm

C. OsteiNs fibrosa cysNca

51. A 45 year old female has been
complaining of dysuria and urinary
frequency which started 1 week prior to
admission. She now presented to the
emergency room because of fever, chills,
nausea and persistent vomiLng and CVA
tenderness on the right.

51. When should you contemplate on
further imaging studies or urologic
consult for this paLent?

A. If we find WBC casts on urinalysis
B. When fever persists aWer therapy
C. When urine culture does not reveal any
organism
D. Imaging studies and urologic consult are
always needed to establish diagnosis in this
case
51. When should you contemplate on
further imaging studies or urologic
consult for this paLent?

A. If we find WBC casts on urinalysis
B. When fever persists aber therapy
C. When urine culture does not reveal any
organism
D. Imaging studies and urologic consult are
always needed to establish diagnosis in this
case
kidney injury from scleroderma or
"scleroderma renal crisis"
A. GlucocorLcoids
B. ACE inhibitors
C. Sildenafil
D. Hemodialysis
kidney injury from scleroderma or
"scleroderma renal crisis"
A. GlucocorLcoids
B. ACE inhibitors
C. Sildenafil
D. Hemodialysis
53. A 57 year old diabeLc, weighing 60kg, came to
the emergency room for difficulty of breathing.
Blood chemistry results (in mmol/L):

BUN 15.56 CreaLnine 266 Na 140
K 4.9 Ca 1.45 Alb 1 4
Which of the following would you expect to see in
this paLent’s ECG?

A. Peaked T waves
B. Prominent U waves
C. Prolonged QT interval
D. Shortened QT interval
53. A 57 year old diabeLc, weighing 60kg, came to
the emergency room for difficulty of breathing.
Blood chemistry results (in mmol/L):

BUN 15.56 CreaLnine 266 Na 140
K 4.9 Ca 1.45 Alb 1 4
Which of the following would you expect to see in
this paLent’s ECG?

A. Peaked T waves
B. Prominent U waves
C. Prolonged QT interval
D. Shortened QT interval
•  Prolonged QT: Hypocalcemia
•  Short QT: Hypercalcemia
54. 40/M diagnosed with lung cancer
underwent Chest CT with IV contrast.
Baseline creaLnine prior to introducLon of IV
contrast was 100 mmol/L. Repeat serum
creaLnine determinaLon was 215 mmol/
LaWer 24 hours. What was the best
intervenLon that could have prevented this
from occurring?
A. HydraLon with saline soluLon
B. N-‐acetylcysteine
C. IV Sodium Bicarbonate
D. Use of iodinated contrast material
54. 40/M diagnosed with lung cancer
underwent Chest CT with IV contrast.
Baseline creaLnine prior to introducLon of IV
contrast was 100 mmol/L. Repeat serum
creaLnine determinaLon was 215 mmol/
LaWer 24 hours. What was the best
intervenLon that could have prevented this
from occurring?
A. HydraNon with saline soluNon
B. N-‐acetylcysteine
C. IV Sodium Bicarbonate
D. Use of iodinated contrast material
55. CondiLon characterized by
hematuria, thinning and splizng of the
GBMs, mild proteinuria, chronic
glomerulosclerosis leading to renal
failure and sensorineural deafness
A. AnL-‐GBM disease
B. Alport’s Syndrome
C. Thin Basement Membrane disease
D. Nail-‐Patella Syndrome

55. CondiLon characterized by
hematuria, thinning and splizng of the
GBMs, mild proteinuria, chronic
glomerulosclerosis leading to renal
failure and sensorineural deafness
A. AnL-‐GBM disease
B. Alport’s Syndrome
C. Thin Basement Membrane disease
D. Nail-‐Patella Syndrome

56. Most common acute complicaLon
of hemodialysis parLcularly among
diabeLc paLents
A.  InfecLon
B.  Muscle cramps
C.  Bleeding
D.  Hypotension
56. Most common acute complicaLon
of hemodialysis parLcularly among
diabeLc paLents
A.  InfecLon
B.  Muscle cramps
C.  Bleeding
D.  Hypotension
57. Most common type of renal
stones
A.  Calcium stones
B.  Uric acid stones
C.  CysLne stones
D.  Struvite stones

57. Most common type of renal
stones
A.  Calcium stones
B.  Uric acid stones
C.  CysLne stones
D.  Struvite stones

58. A 22 year old female sought consult at the
out-‐paLent department for an enlarging anterior
neck masses noted 3 years ago. This was
accompanied by heat intolerance, palpitaLon,
tremors.

On physical examinaLon, there was (+)
exophthalmos , periorbital edema, hyperreflexia,
enlarged anterior neck mass that moves with
degluLLon, (-‐) cervical lymphadenopathy and
tachycardic with an irregularly irregular rhythm.
58. What is the expected finding for
this paLent on nuclear imaging?
A. Focal areas of increased uptake
B.  Homogenous gland with decreased
uptake
C. Increased tracer uptake distributed
homogenously
D. Focal areas of decreased uptake

58. What is the expected finding for
this paLent on nuclear imaging?
A. Focal areas of increased uptake

B.  Homogenous gland with decreased
uptake
C. Increased tracer uptake distributed
homogenously
D. Focal areas of decreased uptake

59. Which of the following is correct
regarding radioacLve iodine (RAI)
therapy?
A. Propylthiouracil should be stopped 2 days
before RAI treatment
B. LactaLng women may receive RAI
treatment with cauLon
C. RAI may be given to selected paLents with
thyroid storm
D. AnLthyroid drugs should be given to
elderly and those with cardiac diseases before
RAI treatment
59. Which of the following is correct
regarding radioacLve iodine (RAI)
therapy?
A. Propylthiouracil should be stopped 2 days
B. LactaLng women may receive RAI
treatment with cauLon
C. RAI may be given to selected paLents with
thyroid storm
D. AnNthyroid drugs should be given to
elderly and those with cardiac diseases
60. Which of the following clinical
features seen in Cushing’s syndrome
are considered more specific and more
useful in its diagnosis?

A. Facial plethora
B. Thin, silvery striae
C. Distal myopathy
D. Easy bruisability
60. Which of the following clinical
features seen in Cushing’s syndrome
are considered more specific and more
useful in its diagnosis?

A. Facial plethora
B. Thin, silvery striae
C. Distal myopathy
D. Easy bruisability
Clinical Features More Specific to
Cushing’s Syndrome
•  Fragility of the skin, with easy bruising and broad
(>1 cm)
•  Purplish striae
•  Proximal myopathy
•  If ectopic ACTH produc-on, hyperpigmentaLon

of the knuckles, scars, or skin areas exposed to
increased fricLon is seen
61. Which of the following is
appropriate precauLon regarding
exercise in paLents with Type 1
diabetes?
A. Perform formal exercise tesLng in paLents
with autonomic neuropathy
B. Cancel the acLvity if blood glucose is less
than 100 mg/dl prior to exercise
C. Avoid vigorous exercise if there is untreated
nonproliferaLve DM reLnopathy
D. Inject insulin into exercising muscle if blood
glucose is more than 300 mg/dl
61. Which of the following is
appropriate precauLon regarding
exercise in paLents with Type 1
diabetes?
A. Perform formal exercise tesNng in paNents
with autonomic neuropathy
B. Cancel the acLvity if blood glucose is less
than 100 mg/dl prior to exercise
C. Avoid vigorous exercise if there is untreated
nonproliferaLve DM reLnopathy
D. Inject insulin into exercising muscle if blood
glucose is more than 300 mg/dl
62. Which of the following is appropriate
in the comprehensive management and
follow-‐up of a paLent with diabetes?
A. Screening for diabeLc nephropathy for

Type 1 diabetes at the Lme of diagnosis
B. Annual monitoring of blood pressure
C. Lipid profile and creaLnine quarterly
D. Eye and foot examinaLon by doctors
annually

62. Which of the following is appropriate
in the comprehensive management and
follow-‐up of a paLent with diabetes?
A. Screening for diabeLc nephropathy for

Type 1 diabetes at the Lme of diagnosis
B. Annual monitoring of blood pressure
C. Lipid profile and creaLnine quarterly
D. Eye and foot examinaNon by doctors
annually

63. What is the earliest symptom of
pituitary failure (trophic hormone
failure) among adults?
A.  Hypogonadism
B.  Growth retardaLon
C.  HyperprolacLnemia
D.  Headache

63. What is the earliest symptom of
pituitary failure (trophic hormone
failure) among adults?
A.  Hypogonadism
B.  Growth retardaLon
C.  HyperprolacLnemia
D.  Headache

•  Trophic hormone failure associated with
pituitary compression or destrucNon usually
occurs SEQUENTIALLY:
–  GH > FSH > LH > TSH > ACTH
–  During childhood: growth retardaLon is oWen the
presenNng feature
–  In adults: HYPOGONADISM is the earliest
symptom
64. Most sensiLve hormonal test for
phaeochromocytoma and paragangliomas,
that is also considered to be less
suscepLble to false-‐posiLve elevaLons
from stress
A.  Plasma metanephrine
B.  Urine vanillylmandelic acid
C.  Urine catecholamines
D.  Plasma catecholamines

64. Most sensiLve hormonal test for
phaeochromocytoma and paragangliomas,
that is also considered to be less
suscepLble to false-‐posiLve elevaLons
from stress
A.  Plasma metanephrine
B.  Urine vanillylmandelic acid
C.  Urine catecholamines
D.  Plasma catecholamines

65. This agent for dyslipidemia may
increase insulin resistance and worsen
glycemic control at high doses
A.  SimvastaLn
B.  NicoLnic acid
C.  Gemfibrozil
D.  Fenofibrate

65. This agent for dyslipidemia may
increase insulin resistance and worsen
glycemic control at high doses
A.  SimvastaLn
B.  NicoNnic acid
C.  Gemfibrozil
D.  Fenofibrate

66. Which of the following represents
definite risk from hormone
replacement therapy for menopause?
A. Colorectal cancer
B. Coronary heart disease
C. Endometrial cancer
D. Ovarian cancer
66. Which of the following represents
definite risk from hormone
replacement therapy for menopause?
A. Colorectal cancer
B. Coronary heart disease
C. Endometrial cancer
D. Ovarian cancer
Hormone replacement therapy
Definite Risks Endometrial cancer
Venous thromboembolism
Gallbladder disease
Breast cancer
Definite Benefits Symptoms of menopause
Osteoporosis
Uncertain Risks and Coronary heart disease
Benefits Stroke
Ovarian cancer
Colorectal cancer
Diabetes mellitus
CogniLve funcLon
Women’s Health IniLaLve, 2001
QUESTION 67

A 50 year old paLent came for consult
for progressive generalized body
weakness. Laboratory examinaLon
revealed anemia and hypercalcemia
and the presence of a pulmonary mass
on chest x-‐ray.
67. Which of the following will be
appropriate differenLals for the case?
A. Squamous cell Lung cancer

B. Small cell Lung cancer
C. Pulmonary tuberculosis
D. All of the above

67. Which of the following will be
appropriate differenLals for the case?
A. Squamous cell Lung cancer

B. Small cell Lung cancer
C. Pulmonary tuberculosis
D. All of the above

Malignancy-‐Related Hypercalcemia

Solid tumor with metastases
•  Breast

Solid tumor with humoral mediaLon of hyperCa2+
•  Lung
•  Kidney

Hematologic malignancy
•  MulLple myeloma
•  Lymphoma, Leukemia
68. AWer one week, paLent complained of
dyspnea. facial swelling, hoarseness, difficulty of
breathing. On physical examinaLon, there was
dilated neck vein, increased collateral veins over
the anterior chest and edema of the face and
arms. What is the treatment of choice for his
condiLon?
A. Intravenous diureLcs
B. Intravenous glucocorLcoids
C. Emergent radiotherapy
D. Emergent surgery and decompression
68. AWer one week, paLent complained of
dyspnea. facial swelling, hoarseness, difficulty of
breathing. On physical examinaLon, there was
dilated neck vein, increased collateral veins over
the anterior chest and edema of the face and
arms. What is the treatment of choice for his
condiLon?
A. Intravenous diureLcs
B. Intravenous glucocorLcoids
C. Emergent radiotherapy
D. Emergent surgery and decompression
SVC Syndrome
69. Which of the following
suggests a beser prognosis for
paLents with breast cancer?
A. Estrogen/progesterone receptor posiLvity
B. High proporLon of cells in S-‐phase
C. Overexpression of HER2-‐neu gene
D. Presence of microvessels

suggests a beser prognosis for
paLents with breast cancer?
A. Estrogen/progesterone receptor
posiNvity
B. High proporLon of cells in S-‐phase
C. Overexpression of HER2-‐neu gene
D. Presence of microvessels
70. Which drug is a monoclonal
anLbody against Her2/neu and is
being used in the treatment of breast
and gastric carcinoma?
A. Cyclophosphamide
B. Trastuzumab
C. Rituximab
D. ImaLnib mesylate

70. Which drug is a monoclonal
anLbody against Her2/neu and is
being used in the treatment of breast
and gastric carcinoma?
A. Cyclophosphamide
B. Trastuzumab
C. Rituximab
D. ImaLnib mesylate

71. A 45 year old female was brought to the
emergency room because of dizziness. On
further inquiry, there was note of menorrhagia
for the past 4 months. On complete blood
count, hemoglobin was 70 g/L, hematocrit was
0.25; the MCV and MCH were low, rest of CBC
were normal. What is the most appropriate
form of treatment to correct her anemia?
A. Blood transfusion
B. Folic acid tablets
C. Intravenous iron
D. Intravenous Vitamin B12
71. A 45 year old female was brought to the
emergency room because of dizziness. On
further inquiry, there was note of menorrhagia
for the past 4 months. On complete blood
count, hemoglobin was 70 g/L, hematocrit was
0.25; the MCV and MCH were low, rest of CBC
were normal. What is the most appropriate
form of treatment to correct her anemia?
A. Blood transfusion
B. Folic acid tablets
C. Intravenous iron
D. Intravenous Vitamin B12
72. Hans is a 29 year old who came to the
clinic because he passed out blood instead
of urine. On further invesLgaLon, you
note anemia both on physical examinaLon
and complete blood count, increased
reLculocyte count and LDH levels,
hemoglobinuria on urinalysis and normal
KUB ultrasound. Bone marrow aspirate
microscopy reveals erythroid hyperplasia.
72. Which of the following lab results
will confirm the diagnosis in this case?
A. Decreased bone marrow iron stain

B. Undetectable haptoglobulin
C. CD 55-‐ and CD 59-‐ cells
D. Fetal hemoglobin pasern
72. Which of the following lab results
will confirm the diagnosis in this case?
A. Decreased bone marrow iron stain

B. Undetectable haptoglobulin
C. CD 55-‐ and CD 59-‐ cells
D. Fetal hemoglobin pasern
Paroxysmal Nocturnal Hemoglobinuria

•  Triad:
–  Hemolysis
–  Pancytopenia
–  Venous Thrombosis
•  Deficiency with CD59 and CD55.
•  Associated with mutaLons in PIG-‐A gene
73. A 20 year old female presents with pallor,
jaundice, and icteric sclerae.
Hemoglobin 55 g/L, hematocrit 17%, RBC 2.5
x 1012, reLculocytes increased, indirect
hyperbilirubinemia, posiLve direct Coomb’s
test. Peripheral smear shows many
spherocytes, polychromatophilic macrocytes
and nucleated red cells.

What is your diagnosis?
73. What is your diagnosis?
A. Iron deficiency anemia
B. AplasLc anemia
C. MegaloblasLc anemia
D. Autoimmune hemolyLc anemia

A. Iron deficiency anemia
B. AplasLc anemia
C. MegaloblasLc anemia
D. Autoimmune hemolyNc anemia

74. During your duty in the ER, a paLent was
referred to you for dyspnea. She is a 40-‐year
old female who was diagnosed with mitral
stenosis previously stable on low dose
Digoxin. She has a history of fever, malaise
and more frequent bowel movement in the
past 2 days.
On PE, she was agitated, BP 70/40 HR 110 RR
24 Temp 39; mucosa was dry, neck veins
were flat however breath sounds were clear,
heart sounds were disLnct but irregularly
irregular, abdomen was soW.
74. What is your next step?
A. Hydrate the paLent with lactated
Ringer’s.
B. Start low dose dopamine drip.
C. Start dobutamine drip.
D. Do immediate DC cardioversion at 200J.

74. What is your next step?
A. Hydrate the paNent with lactated
Ringer’s.
B. Start low dose dopamine drip.
C. Start dobutamine drip.
D. Do immediate DC cardioversion at 200J.
75. You are making rounds with your
OB consultant. In front of you is a
35week AOG pregnant paLent that
has been having elevated blood
pressure since 2 days ago. Right in
front of you, the paLent had a seizure.
Blood pressure was taken and BP =
200/110mmHg.
75. What do you do?
A. Give Captopril 25mg tab sublingual stat
every 15 minutes
B. Give magnesium sulfate intramuscularly
C. Hook the paLent to Nicardipine drip
D. Load with Phenytoin IV
75. What do you do?
A. Give Captopril 25mg tab sublingual stat
every 15 minutes
B. Give magnesium sulfate intramuscularly
C. Hook the paLent to Nicardipine drip
D. Load with Phenytoin IV
76. 60 year old male suddenly had
dizziness and diaphoresis. BP is
60/40mmHg with cold clammy extremiLes.
ECG shows the following. What do you do?

76. What do you do?
A. Give IV Streptokinase

B. Give Verapamil 5mg IV STAT
C. Provide synchronized electrical
cardioversion
D. Start CPR

76. What do you do?
A. Give IV Streptokinase

B. Give Verapamil 5mg IV STAT
C. Provide synchronized electrical
cardioversion
D. Start CPR

77. A 59 year old male was brought in for
drowsiness. Serum calcium was significantly
elevated. A malignancy is suspected as an
eLology for the hypercalcemia. Which of the
following will not be useful to decrease his
calcium levels immediately?
A. Intravenous furosemide
B. Intravenous saline
C. Pamidronate
D. Calcitonin
77. A 59 year old male was brought in for
drowsiness. Serum calcium was significantly
elevated. A malignancy is suspected as an
eLology for the hypercalcemia. Which of the
following will not be useful to decrease his
calcium levels immediately?

A. Intravenous furosemide
B. Intravenous saline
C. Pamidronate
D. Calcitonin
Treatment of HyperCa
78. A 65 year old paLent, known hypertensive
but poorly compliant to medicaLons, came in
for altered mental status and severe headache.
Blood pressure taken on admission was
260/100mmHg. Management would include:
A. Give captopril 25mg sublingually for three
doses. If there is poor response, start
nicardipine drip
B. Start nicardipine drip immediately
C. Give captopril 25mg every 8 hours per orem
D. Observe for 1 hour. If symptoms resolve,
discharge on short acLng anL-‐hypertensives
78. A 65 year old paLent, known hypertensive
but poorly compliant to medicaLons, came in
for altered mental status and severe headache.
Blood pressure taken on admission was
260/100mmHg. Management would include:
A. Give captopril 25mg sublingually for three
doses. If there is poor response, start
nicardipine drip
B. Start nicardipine drip immediately
C. Give captopril 25mg every 8 hours per orem
D. Observe for 1 hour. If symptoms resolve,
discharge on short acLng anL-‐hypertensives
79. A 60 year old male sought consult for
right knee joint pain which started 1 year
ago. Now he presents with right knee
tenderness and effusion since 4 days ago
and he also complains of fever 38.0oC.

You decided to perform arthrocentesis.
Synovial fluid analysis shows 30,000 cells/
uL with 70% neutrophils. PosiLve for rod
shaped strongly negaLve birefringent
crystals.
A. CPPD disease
B. Gouty arthriLs
C. OsteoarthriLs
D. SepLc arthriLs
A. CPPD disease
B. Gouty arthriNs
C. OsteoarthriLs
D. SepLc arthriLs
Crystals
•  Gout: strongly negaLve birefringent needle-‐
shaped or rod-‐shaped
•  CPPD DeposiLon Disease: weakly posiLve
birefringent Rhomboid, Rectangular or Rod-‐like
•  Calcium ApaLte DeposiLon Disease: shiny intra or
extracellular non-‐birefringent globules or
aggregates that stain purplish with Wright’s stain
and bright red with Alzarin Red.
•  Calcium Oxalate DeposiLon Disease: strongly
birefringent bipyramidal
characterisLc symptom will favor the
diagnosis of rheumatoid arthriLs?
A. Migratory polyarthriLs
B. Morning sLffness of 10 minutes
C. Symmetric involvement
D. Subacute monoarLcular arthriLs
characterisLc symptom will favor the
diagnosis of rheumatoid arthriLs?
A. Migratory polyarthriLs
B. Morning sLffness of 10 minutes
C. Symmetric involvement
D. Subacute monoarLcular arthriLs
81. DiagnosLc test specific for
rheumatoid arthriLs and useful in
predicLng its prognosis
A. Rheumatoid Factor
B. ESR
C. AnL-‐CCP anLbodies
D. CRP

81. DiagnosLc test specific for
rheumatoid arthriLs and useful in
predicLng its prognosis
A. Rheumatoid Factor
B. ESR
C. AnN-‐CCP anNbodies
D. CRP

82. Which of the following is an
inhibitor of inosine monophosphate
and purine synthesis used in the
treatment of SLE?
A. Cyclophosphamide
B. Methotrexate
C. Mycophenolate mofeLl
D. Allopurinol

82. Which of the following is an
inhibitor of inosine monophosphate
and purine synthesis used in the
treatment of SLE?
A. Cyclophosphamide
B. Methotrexate
C. Mycophenolate mofeNl
D. Allopurinol

83. AutoanLbody seen more
frequently in drug-‐induced lupus
than in SLE
A. AnLphospholipid
B. AnL-‐RNP
C. AnL-‐histone
D. AnL-‐Sm

83. AutoanLbody seen more
frequently in drug-‐induced lupus
than in SLE
A. AnLphospholipid
B. AnL-‐RNP
C. AnN-‐histone
D. AnL-‐Sm

84. Two weeks aWer starLng allopurinol in
your paLent with gout, the paLent noted
development of blisters over 8% of the body
with note of oral ulcers and associated
diarrhea. What is your impression?
A. Toxic Epidermal Necrolysis

B. Stevens Johnson Syndrome
C. Staphylococcal Scalded Skin Syndrome
D. Bullous Pemphigoid
84. Two weeks aWer starLng allopurinol in
your paLent with gout, the paLent noted
development of blisters over 8% of the body
with note of oral ulcers and associated
diarrhea. What is your impression?
A. Toxic Epidermal Necrolysis

B. Stevens Johnson Syndrome
C. Staphylococcal Scalded Skin Syndrome
D. Bullous Pemphigoid
Spectrum
•  Stevens-‐Johnson syndrome: <10% detached
•  SJS / TEN Overlap: 10–30% detached
•  Toxic epidermal necrolysis overlap: >30%
detached
85. Nina came to your clinic due to a possible
celluliLs. She menLoned that she
experienced wheals, chest pain and difficulty
of breathing shortly aWer taking Amoxicillin.
Which of the following anLbioLcs may sLll be
given safely?
A. Piperacillin-‐tazobactam
B. Cefuroxime
C. Clindamycin
D. Co-‐amoxyclav
85. Nina came to your clinic due to a possible
celluliLs. She menLoned that she
experienced wheals, chest pain and difficulty
of breathing shortly aWer taking Amoxicillin.
Which of the following anLbioLcs may sLll be
given safely?
A. Piperacillin-‐tazobactam
B. Cefuroxime
C. Clindamycin
D. Co-‐amoxyclav
86. Most frequently associated
with the transfusion of cellular
blood components
A. Febrile nonhemolyLc transfusion
reacLon
B. GraW versus host disease
C. Transfusion – related acute lung injury
D. HepaLLs C infecLon
86. Most frequently associated
with the transfusion of cellular
blood components
A. Febrile nonhemolyNc transfusion
reacNon
B. GraW versus host disease
C. Transfusion – related acute lung injury
D. HepaLLs C infecLon
87. Who of the following paLents
will you diagnose with Anaphylaxis?
A. 45/F with maculopapular rashes 3 weeks
aWer starLng Allopurinol
B. 50/M feels light-‐headed with rashes aWer
taking Co-‐amoxiclav. BP is 60/40
C. 18/M with hives within minutes aWer eaLng
crabs
D. 28/F OR nurse with rashes on her hands
usually noted aWer her duty
87. Who of the following paLents
will you diagnose with Anaphylaxis?
A. 45/F with maculopapular rashes 3 weeks
aWer starLng Allopurinol
B. 50/M feels light-‐headed with rashes aber
taking Co-‐amoxiclav. BP is 60/40
C. 18/M with hives within minutes aWer eaLng
crabs
D. 28/F OR nurse with rashes on her hands
usually noted aWer her duty
Anaphylaxis
•  Hallmark of AnaphylacLc ReacLon: Onset of
manifestaNons within seconds to minutes
aber introducNon of anNgen.
•  Treatment: 0.3-‐0.5 ml of Epinephrine 1:1000
IM or SC; 2.5 ml of Epinephrine 1:10,000 IV
88. Which of the following diseases is the most
likely diagnosis for these spinal tap findings?
High leukocyte count (up to 1000/L), with a
predominance of lymphocytes a protein content
of 1–8 g/L (100–800 mg/dL) and a low glucose
concentraLon
A. Herpes simplex encephaliLs
B. Tuberculous meningiLs
C. Streptococcal meningiLs
D. Gonococcal meningiLs
88. Which of the following diseases is the most
likely diagnosis for these spinal tap findings:
high leukocyte count (up to 1000/L), with a
predominance of lymphocytes a protein content
of 1–8 g/L (100–800 mg/dL); and a low glucose
concentraLon
A. Herpes simplex encephaliLs

B. Tuberculous meningiNs
C. Streptococcal meningiLs
D. Gonococcal meningiLs
cause of subarachnoid hemorrhage
A. Bleeding from an AV malformaLon
B. Rupture of a saccular aneurysm
C. Head trauma
D. Coagulopathy

cause of subarachnoid hemorrhage
A. Bleeding from an AV malformaLon
B. Rupture of a saccular aneurysm
C. Head trauma
D. Coagulopathy

90. In a rabies endemic area like the
Philippines, the diagnosis of Rabies must
be considered even without
symptoms of hydrophobia and
aerophobia with:
A. AsepLc meningiLs
B. “Dumb paralysis” with fever
C. Increased intracranial pressure
D. Hemiplegia

90. In a rabies endemic area like the
Philippines, the diagnosis of Rabies must
be considered even without
symptoms of hydrophobia and
aerophobia with:
A. AsepLc meningiLs
B. “Dumb paralysis” with fever
C. Increased intracranial pressure
D. Hemiplegia

91. Kernig sign is performed and
elicited by:
A. PaLent in supine posiLon, thigh flexed, knee
flexed. Pain during passive extension of the knee
B. PaLent in supine posiLon, thigh flexed, knee
extended. Pain during passive flexion of the knee
C. PaLent in supine posiLon. Passive flexion of the
neck results in spontaneous flexion of the hips
and knees
D. PaLent in supine posiLon. Passive extension of
the neck results in spontaneous extension of the
hips and knees
91. Kernig sign is performed and
elicited by:
A. PaNent in supine posiNon, thigh flexed, knee
flexed. Pain during passive extension of the knee
B. PaLent in supine posiLon, thigh flexed, knee
extended. Pain during passive flexion of the knee
C. PaLent in supine posiLon. Passive flexion of the
neck results in spontaneous flexion of the hips
and knees
D. PaLent in supine posiLon. Passive extension of
the neck results in spontaneous extension of the
hips and knees
92. A 55 year old male, previously
diagnosed with a glioblastoma mulLforme
came in for decreased sensorium. Imaging
revealed perilesional edema. What is the
appropriate treatment?
A. Furosemide
B. Hypertonic saline
C. HydrocorLsone
D. Dexamethasone

92. A 55 year old male, previously
diagnosed with a glioblastoma mulLforme
came in for decreased sensorium. Imaging
revealed perilesional edema. What is the
appropriate treatment?
A. Furosemide
B. Hypertonic saline
C. HydrocorLsone
D. Dexamethasone

93. What feature would favor
seizures over syncope?
A. No precipitaLng factor
B. DuraLon of unconsciousness: seconds
C. Less than 15 seconds duraLon of tonic
movements
D. DuraLon of disorientaLon aWer the
event: less than 5 minutes

93. What feature would favor
seizures over syncope?
A. No precipitaNng factor
B. DuraLon of unconsciousness: seconds
C. Less than 15 seconds duraLon of tonic
movements
D. DuraLon of disorientaLon aWer the
event: less than 5 minutes

Syncope versus Seizure
SYNCOPE SEIZURE
•  Less common myoclonus •  Typically with myoclonic
•  Shorter loss of jerks
consciousness •  Loss of consciousness more
than 5 minutes
•  Less muscle aches post-‐
•  Post-‐ictal confusion
asack
•  Rarely preceded by emoLon
•  Can have urinary or pain
inconLnence •  Urinary and fecal
•  Autonomic manifestaLons inconLnence
•  Autonomic manifestaLons
94. A 45 year old male sought consult at OPD
because of mulLple sharply demarcated,
erythematous plaques with scaling located
predominantly in the elbows and knees as
well as occasional shoulder and knee pains.
A. Lichen planus
B. Pityriasis rosea
C. Psoriasis
D. Tinea versicolor
94. A 45 year old male sought consult at OPD
because of mulLple sharply demarcated,
erythematous plaques with scaling located
predominantly in the elbows and knees as
well as occasional shoulder and knee pains.
A. Lichen planus
B. Pityriasis rosea
C. Psoriasis
D. Tinea versicolor
95. Which primary skin lesions is
correctly paired with its descripLon?
A. Macule: Flat, colored lesion, <2cm in
diameter, raised above the surface of the
surrounding skin
B. Tumor: >5 cm firm lesion raised above the
surface of the surrounding skin
C. Plaque: >1cm, flat-‐topped, raised lesion with
edges that are always disLnctly demarcated
D. Vesicle: Small, fluid-‐filled lesion, >0.5cm in
diameter, raised above the plane of
surrounding skin
95. Which primary skin lesions is
correctly paired with its descripLon?
A. Macule: Flat, colored lesion, <2cm in
diameter, raised above the surface of the
surrounding skin
B. Tumor: >5 cm firm lesion raised above the
surface of the surrounding skin
C. Plaque: >1cm, flat-‐topped, raised lesion with
edges that are always disLnctly demarcated
D. Vesicle: Small, fluid-‐filled lesion, >0.5cm in
diameter, raised above the plane of
surrounding skin
Primary Skin Lesions
96. True regarding Type 2 Lepra
reacLon (erythema nodosum
leprosum or ENL)
A. The most dramaLc manifestaLon is
footdrop
B. Edema is the most characterisLc
microscopic feature
C. Fever is not common
D. Other symptoms include neuriLs,
lymphadeniLs, uveiLs, orchiLs, and
glomerulonephriLs
96. True regarding Type 2 Lepra
reacLon (erythema nodosum
leprosum or ENL)
A. The most dramaLc manifestaLon is
footdrop
B. Edema is the most characterisLc
microscopic feature
C. Fever is not common
D. Other symptoms include neuriNs,
lymphadeniNs, uveiNs, orchiNs, and
glomerulonephriNs
Lepra reacLons
Type 1 Type 2 or ENL
•  Occurs in borderline forms of •  Lepromatous end of the
leprosy leprosy spectrum
•  Classic signs of inflammaLon •  Crops of painful erythematous
within previously involved papules that resolve
macules, papules, and plaques spontaneously in a few days
•  Most dramaLc manifestaLon •  Profound fever, neuriLs,
is footdrop lymphadeniLs, uveiLs, orchiLs,
•  Edema is the most and glomerulonephriLs
characterisLc microscopic •  Skin biopsy of ENL papules
feature reveals vasculiLs or
panniculiLs
•  Anemia, leukocytosis, and
abnormal liver funcLon tests
97. This test is performed on
scaling skin lesions when a fungal
infecLon is suspected
A. Tzanck Smear
B. Diascopy
C. KOH preparaLon
D. Patch tesLng

97. This test is performed on
scaling skin lesions when a fungal
infecLon is suspected
A. Tzanck Smear
B. Diascopy
C. KOH preparaNon
D. Patch tesLng

98. An example of a category A
bioterrorist agent
A. E. coli 0157:H7

B. Extremely-‐drug resistant (XDR) M.
tuberculosis
C. SARS Coronavirus
D. Variola major

98. An example of a category A
bioterrorist agent
A. E. coli 0157:H7

B. Extremely-‐drug resistant (XDR) M.
tuberculosis
C. SARS Coronavirus
D. Variola major

Microbial Bioterrorism
A Anthrax Botulism Plague Smallpox Tularemia
Arenaviruses: Lassa, New World (Machupo, Junin, Guanarito,
and Sabia)
Bunyaviridae: Crimean-‐Congo, RiW Valley
Filoviridae: Ebola, Marburg
B Brucellosis
Epsilon toxin of Clostridium perfringens Glanders Melioidosis
Psisacosis Q fever
Ricin toxin from Ricinus communis Typhus fever
Staphylococcal enterotoxin B Viral encephaliLs
Water safety threats (e.g., Vibrio cholerae, Cryptosporidium
parvum)
Food safety threats (e.g., Salmonella spp., Escherichia coli
0157:H7, Shigella)
C Emerging infecLous diseases threats such as Nipah, hantavirus,
SARS coronavirus, and pandemic influenza
99. Best prevenLve measure
for high alLtude pulmonary
edema
A. Acetazolamide
B. Nifedipine
C LimitaLon of fluid intake prior to
ascent
D. Gradual ascent
99. Best prevenLve measure
for high alLtude pulmonary
edema
A. Acetazolamide
B. Nifedipine
C LimitaLon of fluid intake prior to
ascent
D. Gradual ascent
100. Mrs C is a 48 y/o female who consulted
you a few years back for dyspepsia. She
comes to your clinic now with easy
faLgability, weakness, incoordinaLon and
memory disturbances. She claims she cannot
tolerate eaLng without taking antacids.
Physical and neurologic exams are
unremarkable. Among the labs you ordered,
only her CBC is abnormal showing red blood
cells with high MCV and high MCH.
nutrients is she most likely
deficient with?
A. Iron
B. Folate
C. Cyanocobalamin
D. Vitamin D

nutrients is she most likely
deficient with?
A. Iron
B. Folate
C. Cyanocobalamin
D. Vitamin D

101. Cause of normal anion gap
metabolic acidosis:
A. Diarrhea
B. Alcoholic ketoacidosis
C. Uremia
D. Salicylate ingesLon
101. Cause of normal anion gap
metabolic acidosis:
A. Diarrhea
B. Alcoholic ketoacidosis
C. Uremia
D. Salicylate ingesLon
102. Which of the following is a risk
factor for stroke in a paLent with atrial
fibrillaLon?
A. Age more than 65 years old

B. Mitral regurgitaLon
C. Diabetes mellitus
D. Marked right atrial enlargement

102. Which of the following is a risk
factor for stroke in a paLent with atrial
fibrillaLon?
A. Age more than 65 years old

B. Mitral regurgitaLon
C. Diabetes mellitus
D. Marked right atrial enlargement

Risk Factors for Stroke in
Atrial FibrillaNon
•  History of stroke or transient ischemic asack
•  Mitral stenosis
•  Hypertension
•  Diabetes mellitus
•  Age >75 years
•  CongesLve heart failure
•  LeW ventricular dysfuncLon
•  Marked leW atrial enlargement (>5.0 cm)
•  Spontaneous echo contrast
103. True of manifestaLons of
myxomas
A. Most appear singly
B. Most are pedunculated on a
fibrovascular stalk
C. Most are located in the leW atrium
D. They have a characterisLc “tumor plop”
appreciated during diastole
103. True of manifestaLons of
myxomas
A. Most appear singly
B. Most are pedunculated on a
fibrovascular stalk
C. Most are located in the leW atrium
D. They have a characterisLc “tumor plop”
appreciated during diastole
medicaLons should be not be started
in paLents with hyperkalemia?
A. Carvedilol
B. Dobutamine
C. Captopril
D. Furosemide

medicaLons should be not be started
in paLents with hyperkalemia?
A. Carvedilol
B. Dobutamine
C. Captopril
D. Furosemide

105. For angina, nitrates may be
administered. Nitroglycerin is most
commonly administered sublingually
in what dose
A.  5 mg
B.  10 mg
C.  0.4 mg
D.  4 mg
105. For angina, nitrates may be
administered. Nitroglycerin is most
commonly administered sublingually
in what dose
A.  5 mg
B.  10 mg
C.  0.4 mg
D.  4 mg
dyspnea. As a child, she had cyanosis,
selecLvely involving the toes only (but
not the fingers). She was said to have a
“defect in her heart”, but was lost to
follow up. On auscultaLon, you should
expect:
A.  A fixed splizng of S2
B.  A holosystolic murmur
C.  A conLnuous machinery murmur
D.  Early systolic murmur
dyspnea. As a child, she had cyanosis,
selecLvely involving the toes only (but
not the fingers). She was said to have a
“defect in her heart”, but was lost to
follow up. On auscultaLon, you should
expect:
A.  A fixed splizng of S2
B.  A holosystolic murmur
C.  A conNnuous machinery murmur
D.  Early systolic murmur
107. The most common congenital
heart valve defect is:
A.  Pulmonic stenosis

B.  Mitral stenosis
C.  Bicuspid aorLc valve
D.  Mitral regurgitaLon
107. The most common congenital
heart valve defect is:
A.  Pulmonic stenosis

B.  Mitral stenosis
C.  Bicuspid aorNc valve
D.  Mitral regurgitaLon
108. A 40 year old female came in for dyspnea.
Blood pressure on admission was 120 /20
mmHg. AuscultaLon revealed a high-‐pitched,
blowing, decrescendo diastolic murmur at the
right sternal border. You also noted capillary
pulsaLons (alternate flushing and paling of the
skin) at the root of the nail while pressure is
applied to the Lp of the nail. This is called:

A.  Corrigan’s pulse
B.  Quincke’s pulse
C.  Traube’s sign
D.  Duroziez’s sign
108. A 40 year old female came in for dyspnea.
Blood pressure on admission was 120 /20
mmHg. AuscultaLon revealed a high-‐pitched,
blowing, decrescendo diastolic murmur at the
right sternal border. You also noted capillary
pulsaLons (alternate flushing and paling of the
skin) at the root of the nail while pressure is
applied to the Lp of the nail. This is called:

A.  Corrigan’s pulse
B.  Quincke’s pulse
C.  Traube’s sign
D.  Duroziez’s sign
AorLc RegurgitaLon
•  De Musset sign: head may bob with each heartbeat
•  Corrigan pulse: water hammer pulses with abrupt
distenLon and quick collapse
•  Traube sign: pistol shot sounds – booming systolic and
diastolic sounds heard over femoral artery
•  Muller sign: systolic pulsaLon of uvula
•  Duroziez sign: systolic murmur heard over femoral
artery when compressed proximally and a diastolic
murmur when compressed distally
•  Hill sign: exaggerated difference in SBP between upper
and lower extremiLes
109. A 35 year old male comes in for dyspnea
and orthopnea. On examinaLon, she had a
heart rate of 110 with an irregularly irregular
rhythm. An opening snap, followed by a
diastolic rumble was audible on auscultaLon.
You requested a chest x-‐ray and expect to find
A.  Widening of the carinal angle
B.  LeW ventricular enlargement
C.  Tubular heart with a widened
mediasLnum
D.  Paucity of pulmonary vasculature
109. A 35 year old male comes in for dyspnea
and orthopnea. On examinaLon, she had a
heart rate of 110 with an irregularly irregular
rhythm. An opening snap, followed by a
diastolic rumble was audible on auscultaLon.
You requested a chest x-‐ray and expect to find
A.  Widening of the carinal angle
B.  LeW ventricular enlargement
C.  Tubular heart with a widened
mediasLnum
D.  Paucity of pulmonary vasculature
110. Most common parasiLc cause of
cardiomyopathy is Chagas’ disease.
What is the eLology?

A.  Trypanasoma cruzi transmised by the
reduviid bug
B.  Trypanosoma brucei transmised by the
Tsetse fly
C.  Toxoplasmosis transmised by cysts
D.  Trichinella spiralis caused by ingesLon of
larva of undercooked meat
110. Most common parasiLc cause of
cardiomyopathy is Chagas’ disease.
What is the eLology?

A.  Trypanasoma cruzi transmired by the
reduviid bug
B.  Trypanosoma brucei transmised by the
Tsetse fly
C.  Toxoplasmosis transmised by cysts
D.  Trichinella spiralis caused by ingesLon of
larva of undercooked meat
111. A 35 year old male came in for
dyspnea. He had a blood pressure of
60/40mmHg with muffled heart
sounds and distended neck veins.
Your acute management is:

A.  Immediately start inotropic support
B.  Place in Trendelenberg posiLon and
observe
C.  Give furosemide 40mg IV stat bolus
D.  Do 2D echo-‐guided pericardiocentesis
111. A 35 year old male came in for
dyspnea. He had a blood pressure of
60/40mmHg with muffled heart
sounds and distended neck veins.
Your acute management is:

A.  Immediately start inotropic support
B.  Place in Trendelenberg posiLon and
observe
C.  Give furosemide 40mg IV stat bolus
D.  Do 2D echo-‐guided pericardiocentesis
112. Most out-‐of hospital deaths
from STEMI is due to

A.  Heart failure
B.  Ventricular fibrillaLon
C.  Premature ventricular contracLons
D.  Pulmonary edema
112. Most out-‐of hospital deaths
from STEMI is due to

A.  Heart failure
B.  Ventricular fibrillaNon
C.  Premature ventricular contracLons
D.  Pulmonary edema
113. A 22 year old male will be working abroad as
a construcLon worker in Dubai. This paLent came
in to your clinic for clearance. He is asymptomaLc.
On PE, you noted grade II/VI midsystolic murmur at
the apex. Chest x-‐ray and ECG were normal. What
would be your next step?
A.  Reassure and clear him for work, no further tests
B.  Delay giving of clearance and schedule for 2D
echocardiography
C.  Refer to cardiologist for clearance
D.  Admit for further work-‐up: Holter monitoring,
cardiac enzymes and possible coronary
angiography
113. A 22 year old male will be working abroad as
a construcLon worker in Dubai. This paLent came
in to your clinic for clearance. He is asymptomaLc.
On PE, you noted grade II/VI midsystolic murmur at
the apex. Chest x-‐ray and ECG were normal. What
would be your next step?
A.  Reassure and clear him for work, no further
tests
B.  Delay giving of clearance and schedule for 2D
echocardiography
C.  Refer to cardiologist for clearance
D.  Admit for further work-‐up: Holter monitoring,
cardiac enzymes and possible coronary
angiography
114. What is a relaLve contraindicaLon
of thrombolysis in ST-‐ segment elevaLon
myocardial infarcLon?

A.  History of cerebrovascular
hemorrhage
B.  Suspicion of aorLc dissecLon
C.  AcLve internal bleeding
D.  Pregnancy
114. What is a relaLve contraindicaLon
of thrombolysis in ST-‐ segment elevaLon
myocardial infarcLon?

A.  History of cerebrovascular
hemorrhage
B.  Suspicion of aorLc dissecLon
C.  AcLve internal bleeding
D.  Pregnancy
115. Presents as refractory
hypertension, mostly asymptomaLc
but infrequently may have
paresthesias, polyuria, or muscle
weakness secondary to hypokalemic
alkalosis
A.  Cushing’s syndrome
B.  Pheochromocytoma
C.  Primary aldosteronism
D.  AorLc coarctaLon
115. Presents as refractory
hypertension, mostly asymptomaLc
but infrequently may have
paresthesias, polyuria, or muscle
weakness secondary to hypokalemic
alkalosis
A.  Cushing’s syndrome
B.  Pheochromocytoma
C.  Primary aldosteronism
D.  AorLc coarctaLon
116. Abdominal aorLc aneurysm
repair is indicated for asymptomaLc
paLents if the diameter is:
A. > 4.5cm
B. > 5.5 cm
C. > 6.0 cm
D. > 7.0 cm
116. Abdominal aorLc aneurysm
repair is indicated for asymptomaLc
paLents if the diameter is:
A. > 4.5cm
B.  > 5.5 cm
C. > 6.0 cm
D. > 7.0 cm
117. Which of the following physical
examinaLon findings, if present in
COPD suggest advanced disease?
A. Barrel chest
B. Temporal wasLng
C. Clubbing of the digits
D. Cyanosis
117. Which of the following physical
examinaLon findings, if present in
COPD suggest advanced disease?
A. Barrel chest
B. Temporal wasNng
C. Clubbing of the digits
D. Cyanosis
118. The standard monotherapy
for lung abscess
A. CeWriaxone
B. Metronidazole
C. Clindamycin
D. Ampicillin-‐Sulbactam
118. The standard monotherapy
for lung abscess
A. CeWriaxone
B. Metronidazole
C. Clindamycin
D. Ampicillin-‐Sulbactam
119. Which of the following points to
an exacerbaLon in a paLent with
established COPD
A. ExerLonal dyspnea
B. Increased dyspnea
C. Presence of airflow obstrucLon
D. ResLng hypoxemia

119. Which of the following points to
an exacerbaLon in a paLent with
established COPD
A. ExerLonal dyspnea
B. Increased dyspnea
C. Presence of airflow obstrucLon
D. ResLng hypoxemia

120. The following are true regarding
non-‐imaging tests in diagnosing
pulmonary embolism EXCEPT:
A. The D-‐dimer is a useful "rule in" test

B. The D-‐dimer has a limited role in hospitalized
paLents
C. Arterial blood gas lacks diagnosLc uLlity for
pulmonary embolism
D. Elevated cardiac biomarkers predict an
increased mortality from pulmonary embolism
120. The following are true regarding
non-‐imaging tests in diagnosing
pulmonary embolism EXCEPT:
A. The D-‐dimer is a useful "rule in" test

B. The D-‐dimer has a limited role in hospitalized
paLents
C. Arterial blood gas lacks diagnosLc uLlity for
pulmonary embolism
D. Elevated cardiac biomarkers predict an
increased mortality from pulmonary embolism
121. When aWer iniLaLon of adequate
therapy in pneumonia do you expect
fever to resolve?
A. 24 hours
B. 36 hours
C. 48 hours
D. 72 hours

121. When aWer iniLaLon of adequate
therapy in pneumonia do you expect
fever to resolve?
A. 24 hours
B. 36 hours
C. 48 hours
D. 72 hours

122. Among COPD paLents,
supplemental oxygen should be
provided to maintain arterial oxygen
saturaLon at what level?
A. 80%
B. 85%
C. 90%
D. 95%

122. Among COPD paLents,
supplemental oxygen should be
provided to maintain arterial oxygen
saturaLon at what level?
A. 80%
B. 85%
C. 90%
D. 95%

IndicaNons for Supplemental O2 in
COPD
•  ResLng O2 sat < 88%

•  ResLng O2 sat < 90% in those with
pulmonary hypertension and right heart
failure
123. OccupaLonal lung disease
characterized by the characterisLc
HRCT pasern known as “crazy paving”
A.  Chronic beryllium disease

B.  Coal worker’s pneumoconiosis
C.  Asbestosis
D.  Silicosis
123. OccupaLonal lung disease
characterized by the characterisLc
HRCT pasern known as “crazy paving”
A.  Chronic beryllium disease

B.  Coal worker’s pneumoconiosis
C.  Asbestosis
D.  Silicosis
124. What is the most common cause
of respiratory hypoxia, which is usually
correctable by inspiring 100% oxygen?
A.  HypovenLlaLon
B.  Intrapulmonary right to leW shunLng
C.  Pulmonary atelectasis
D.  VenLlaLon perfusion mismatch
124. What is the most common cause
of respiratory hypoxia, which is usually
correctable by inspiring 100% oxygen?
A.  HypovenLlaLon
B.  Intrapulmonary right to leW shunLng
C.  Pulmonary atelectasis
D.  VenNlaNon perfusion mismatch
125. Which among the following is
an example of obstrucLve lung
disease?
A.  Bronchiectasis
B.  Asbestosis
C.  Pulmonary fibrosis
D.  Guillain-‐Barre syndrome
125. Which among the following is
an example of obstrucLve lung
disease?
A.  Bronchiectasis
B.  Asbestosis
C.  Pulmonary fibrosis
D.  Guillain-‐Barre syndrome
126. An asthmaLc paLent was given
ipratropium bromide for rescue
medicaLon. What is its most common
side effect?
A.  Tachycardia or palpitaLons

B.  Tremors
C.  Dry mouth
D.  Urinary retenLon
126. An asthmaLc paLent was given
ipratropium bromide for rescue
medicaLon. What is its most common
side effect?
A.  Tachycardia or palpitaLons

B.  Tremors
C.  Dry mouth
D.  Urinary retenLon
cancer associated with asbestos
exposure?
A.  Lung cancer

B.  Mesothelioma
C.  Tumors of the pericardium
D.  Laryngeal carcinoma
cancer associated with asbestos
exposure?
A.  Lung cancer

B.  Mesothelioma
C.  Tumors of the pericardium
D.  Laryngeal carcinoma
128. A 60 year old male presented
with cough and dyspnea of three days
duraLon. You requested for a sputum
gram stain and culture. An adequate
sputum sample has:
A.  Presence of organisms

B.  Presence of > 25 neutrophils
C.  Presence of > 25 squamous cells
D.  Presence of > 25 white blood cells
128. A 60 year old male presented
with cough and dyspnea of three days
duraLon. You requested for a sputum
gram stain and culture. An adequate
sputum sample has:
A.  Presence of organisms

B.  Presence of > 25 neutrophils
C.  Presence of > 25 squamous cells
D.  Presence of > 25 white blood cells
129. Type of emphysema usually
observed in paLents with alpha-‐1-‐
anLtrypsin deficiency, which has a
predilecLon for the lower lobes:
A.  Centriacinar emphysema
B.  Peripheral emphysema
C.  Lobar emphysema
D.  Panacinar emphysema
129. Type of emphysema usually
observed in paLents with alpha-‐1-‐
anLtrypsin deficiency, which has a
predilecLon for the lower lobes:
A.  Centriacinar emphysema
B.  Peripheral emphysema
C.  Lobar emphysema
D.  Panacinar emphysema
130. During the natural course of
ARDS, which phase do we expect
clinical recovery wherein paLents are
usually liberated from mechanical
venLlaLon?
A.  ProliferaLve phase

B.  FibroLc phase
C.  Recovery phase
D.  ExudaLve phase
130. During the natural course of
ARDS, which phase do we expect
clinical recovery wherein paLents are
usually liberated from mechanical
venLlaLon?
A.  ProliferaNve phase

B.  FibroLc phase
C.  Recovery phase
D.  ExudaLve phase
131. Chest radiograph finding
specifically indicaLng past exposure to
asbestos and not pulmonary
impairment:
A.  Pleural plaque

B.  Pleural effusion
C.  Pleural fibrosis
D.  Pleural mesothelioma
131. Chest radiograph finding
specifically indicaLng past exposure to
asbestos and not pulmonary
impairment:
A.  Pleural plaque

B.  Pleural effusion
C.  Pleural fibrosis
D.  Pleural mesothelioma
132. A 30 year old male comes in for
dyspnea. ExaminaLon on the right
basal lung field revealed: dullness on
percussion, increased fremitus, and
crackles. Your diagnosis is probably:
A.  Asthma
B.  Pneumothorax
C.  Pleural effusion
D.  ConsolidaLon / pneumonia
dyspnea. ExaminaLon on the right
basal lung field revealed: dullness on
percussion, increased fremitus, and
crackles. Your diagnosis is probably:
A.  Asthma
B.  Pneumothorax
C.  Pleural effusion
D.  ConsolidaNon / pneumonia
133. The following cause of ARDS is
due to a direct lung injury:
A.  Sepsis
B.  Chest trauma
C.  Near drowning
D.  MulLple blood transfusions
133. The following cause of ARDS is
due to a direct lung injury:
A.  Sepsis
B.  Chest trauma
C.  Near drowning
D.  MulLple blood transfusions
ARDS
134. What is the prevailing
mechanism for the development of
emphysema?
A.  Dutch hypothesis

B.  BriLsh hypothesis
C.  Hygiene hypothesis
D.  Elastase: AnL-‐elastase hypothesis
134. What is the prevailing
mechanism for the development of
emphysema?
A.  Dutch hypothesis

B.  BriLsh hypothesis
C.  Hygiene hypothesis
D.  Elastase: AnN-‐elastase hypothesis
135. The CURB-‐65 criteria is used in
pneumonia as a severity of illness
score. Which is INCORRECTLY paired?
A. C: CreaLnine > 250

B. U: Urea > 7 mmol/L
C. R: Respiratory rate > 30/min
D. B: Blood pressure < 90/60
135. The CURB-‐65 criteria is used in
pneumonia as a severity of illness
score. Which is INCORRECTLY paired?
A. C: CreaNnine > 250

B. U: Urea > 7 mmol/L
C. R: Respiratory rate > 30/min
D. B: Blood pressure < 90/60
CURB
–  The CURB-‐65 criteria include five variables:
•  (C) Confusion
•  (U) Urea >7 mmol/L
•  (R) Respiratory rate 30/min
•  (B) BP, systolic 90 mmHg or diastolic 60 mmHg
•  (65)
Age 65 years
cause of hemoptysis worldwide?
A.  Pneumonia
B.  Tuberculosis
C.  Bronchogenic carcinoma
D.  Upper respiratory tract infecLon
cause of hemoptysis worldwide?
A.  Pneumonia
B.  Tuberculosis
C.  Bronchogenic carcinoma
D.  Upper respiratory tract infecLon
137. A 60 year old male was previously
diagnosed with tuberculosis but was never
compliant to medicaLons. He presented
with a three month history of producLve
cough and dyspnea. Chest x-‐ray revealed
presence of tram tracks. What is your
diagnosis?
A.  Asbestosis
B.  Emphysema
C.  Bronchiectasis
D.  Lung abscess
137. A 60 year old male was previously
diagnosed with tuberculosis but was never
compliant to medicaLons. He presented
with a three month history of producLve
cough and dyspnea. Chest x-‐ray revealed
presence of tram tracks. What is your
diagnosis?
A.  Asbestosis
B.  Emphysema
C.  Bronchiectasis
D.  Lung abscess
138. A 45 year old female with an ovarian
malignancy comes in for dyspnea and hemoptysis.
On examinaLon, she was tachycardic and
tachypneic, but with stable blood pressure. Her
enLre leW lower extremity is swollen and tender
with erythema. To confirm your diagnosis you
would request for:

A.  D-‐dimer
B.  Pelvic CT scan
C.  Chest CT scan
D.  Venous duplex scan, lower extremity
138. A 45 year old female with an ovarian
malignancy comes in for dyspnea and hemoptysis.
On examinaLon, she was tachycardic and
tachypneic, but with stable blood pressure. Her
enLre leW lower extremity is swollen and tender
with erythema. To confirm your diagnosis you
would request for:

A.  D-‐dimer
B.  Pelvic CT scan
C.  Chest CT scan
D.  Venous duplex scan, lower extremity
139. Most common mode of
transmission of HIV in developing
countries such as the Philippines
A. Perinatal transfer
B. Homosexual transmission
C. Heterosexual transmission
D. Contaminated IV drug paraphernalia

139. Most common mode of
transmission of HIV in developing
countries such as the Philippines
A. Perinatal transfer
B. Homosexual transmission
C. Heterosexual transmission
D. Contaminated IV drug paraphernalia

140. The heart valve most
commonly affected with infecLve
endocardiLs among IV drug users
A. Mitral valve
B. Tricuspid valve
C. Pulmonic valve
D. AorLc valve

140. The heart valve most
commonly affected with infecLve
endocardiLs among IV drug users
A. Mitral valve
B. Tricuspid valve
C. Pulmonic valve
D. AorLc valve

manifestaLon of InfecLve
EndocardiLs:
A. Fever
B. Chills
C. Heart murmur
D. Janeway lesions

manifestaLon of InfecLve
EndocardiLs:
A. Fever
B. Chills
C. Heart murmur
D. Janeway lesions

142. True about the diagnosis of
InfecLve EndocardiLs (IE):
A. Diagnosis is based on the Jones Criteria
B. Organisms can oWen be cultured from blood
despite prior anLbioLc therapy
C. Diagnosis of IE is rejected if fever and
symptoms resolve in less than 4 days of
therapy
D. Typical organisms recovered in blood culture
are E.coli and S.viridans

142. True about the diagnosis of
InfecLve EndocardiLs (IE):
A. Diagnosis is based on the Jones Criteria
B. Organisms can oWen be cultured from blood
despite prior anLbioLc therapy
C. Diagnosis of IE is rejected if fever and
symptoms resolve in less than 4 days of
therapy
D. Typical organisms recovered in blood culture
are E.coli and S.viridans

143. Which sexually transmised
disease is associated with
gummas?

A. Syphilis
B. Human papilloma virus
C. HIV
D. Donovanosis

143. Which sexually transmised
disease is associated with
gummas?

A. Syphilis
B. Human papilloma virus
C. HIV
D. Donovanosis

144. Pasteurella multocida is known to
commonly infect dog and cat bites.
What is the anLbioLc of choice for this
organism?
A. Cloxacillin
B. Penicillin G
C. Co-‐amoxyclav
D. Clindamycin

144. Pasteurella multocida is known to
commonly infect dog and cat bites.
What is the anLbioLc of choice for this
organism?
A. Cloxacillin
B. Penicillin G
C. Co-‐amoxyclav
D. Clindamycin

145. Remains the standard and
recommended duraLon of IV
anLobioLc therapy for osteomyeliLs
A. 2-‐4 weeks

B. 4-‐6 weeks
C. 8-‐12 weeks
D. 3-‐6 months

145. Remains the standard and
recommended duraLon of IV
anLobioLc therapy for osteomyeliLs
A. 2-‐4 weeks

B. 4-‐6 weeks
C. 8-‐12 weeks
D. 3-‐6 months

146. AnLbioLc/s that may be used
for only 3 days in acute
uncomplicated cysLLs in women
A. TMP-‐SMX
B. Nitrofurantoin
C. Quinolones
D. All of the above

146. AnLbioLc/s that may be used
for only 3 days in acute
uncomplicated cysLLs in women
A. TMP-‐SMX
B. Nitrofurantoin
C. Quinolones
D. All of the above

147. DramaLc but mild reacLon
consisLng of fever, chills, myalgias,
tachycardia with mild hypotension noted
aWer iniLaLon of anLbioLc therapy for
leptospirosis
A.  Lucio reacLon

B.  Weil’s Syndrome
C.  Nicoladoni Branham Sign
D.  Jarisch-‐Herxheimer ReacLon
147. DramaLc but mild reacLon
consisLng of fever, chills, myalgias,
tachycardia with mild hypotension noted
aWer iniLaLon of anLbioLc therapy for
leptospirosis
A.  Lucio reacLon

B.  Weil’s Syndrome
C.  Nicoladoni Branham Sign
D.  Jarisch-‐Herxheimer ReacNon
148. Most important risk factor
associated with the development
of perinephric abscesses
A.  Diabetes mellitus
B.  Prior urologic surgery
C.  Chronic kidney disease
D.  Nephrolithiasis with obstrucLon
148. Most important risk factor
associated with the development
of perinephric abscesses
A.  Diabetes mellitus
B.  Prior urologic surgery
C.  Chronic kidney disease
D.  Nephrolithiasis with obstrucNon
149. Most commonly implicated
organism/s in Primary Bacterial
PeritoniLs:
A. Escherichia coli
B. Pseudomonas aeruginosa
C. Anaerobic bacteria
D. Mixed infecLon

149. Most commonly implicated
organism/s in Primary Bacterial
PeritoniLs:
A. Escherichia coli
B. Pseudomonas aeruginosa
C. Anaerobic bacteria
D. Mixed infecLon

150. Single most reliable laboratory
parameter in liver abscess
A. Increased AST and ALT

B. Increased alkaline phosphatase
C. NormocyLc, normochromic anemia
D. Increased direct bilibubin

150. Single most reliable laboratory
parameter in liver abscess
A. Increased AST and ALT

B. Increased alkaline phosphatase
C. NormocyLc, normochromic anemia
D. Increased direct bilibubin

151. Most common
extrapulmonary manifestaLon of
tuberculosis
A. TB meningiLs

B. TB adeniLs
C. Pos's disease
D. Genitourinary TB

151. Most common
extrapulmonary manifestaLon of
tuberculosis
A. TB meningiLs

B. TB adeniNs
C. Pos's disease
D. Genitourinary TB

152. In which tuberculous infecLon
are systemic steroids like
dexamethasone proven to posiLvely
influence outcomes?
A. TB meningiLs
B. Pos's disease
C. Tuberculous pericardial effusion
D. Miliary TB

152. In which tuberculous infecLon
are systemic steroids like
dexamethasone proven to posiLvely
influence outcomes?
A. TB meningiNs
B. Pos's disease
C. Tuberculous pericardial effusion
D. Miliary TB

153. The single most important
agent of Traveler's diarrhea
A. Enterotoxigenic E. coli

B. Salmonella typhi
C. Campylobacter jejuni
D. Rotavirus

153. The single most important
agent of Traveler's diarrhea
A. Enterotoxigenic E. coli

B. Salmonella typhi
C. Campylobacter jejuni
D. Rotavirus

154. Least common but the most
severe of the pneumonic
complicaLons of influenza
A.  Secondary bacterial pneumonia
B.  Primary influenza viral pneumonia
C.  Mixed viral and bacterial pneumonia
D.  Chronic bronchiLs with aspiraLon
pneumonia
154. Least common but the most
severe of the pneumonic
complicaLons of influenza
A.  Secondary bacterial pneumonia
B.  Primary influenza viral pneumonia
C.  Mixed viral and bacterial pneumonia
D.  Chronic bronchiLs with aspiraLon
pneumonia
Influenza-‐related Pneumonia
TYPE CLINICAL SIGNS/SYMPTOMS REMARKS
Primary influenza Acute influenza that does not At risk: MS, pregnancy,
pneumonia resolve but instead progresses elderly, COPD
relentlessly, with persistent
fever, dyspnea, and eventual CXR: IntersLLal infiltrates
cyanosis ARDS-‐like features
Secondary Improvement of the paLent's At risk: COPD, elderly
bacterial condiLon over 2–3 days is
pneumonia followed by a reappearance of Agents: Streptococcus
fever along with clinical signs pneumoniae,
and symptoms of bacterial Staphylococcus aureus,
pneumonia Haemophilus influenzae
Mixed Viral and Mixed features of viral and At risk: COPD, cardiac
Bacterial bacterial pneumonia diseases
Pneumonia
CXR: Patchy infiltrates or
areas of consolidaLon
155. Which Plasmodium species has
72-‐hour duraLon of erythrocyLc stage,
15-‐day duraLon of intrahepaLc phase
and preference for older red cells
A.  P. vivax
B.  P. ovale
C.  P. malariae
D.  P. falciparum
155. Which Plasmodium species has
72-‐hour duraLon of erythrocyLc stage,
15-‐day duraLon of intrahepaLc phase
and preference for older red cells
A.  P. vivax
B.  P. ovale
C.  P. malariae
D.  P. falciparum
Malaria
agitaLon and hydrophobia. On further
probing, his relaLves recall a history of
dog bite 2 weeks prior. The most
characterisLc pathologic finding in this
disease is:
A.  Negri body
B.  Amyloid body
C.  Babes nodules
D.  Filamentous virion
agitaLon and hydrophobia. On further
probing, his relaLves recall a history of
dog bite 2 weeks prior. The most
characterisLc pathologic finding in this
disease is:
A.  Negri body
B.  Amyloid body
C.  Babes nodules
D.  Filamentous virion
157. Largest intesLnal nematode
parasite of humans, reaching up to
40cms in length
A. Trichuris trichiura
B. Ascaris lumbricoides
C. Stongyloides stercoralis
D. Enterobius vermicularis
157. Largest intesLnal nematode
parasite of humans, reaching up to
40cms in length
A. Trichuris trichiura
B. Ascaris lumbricoides
C. Stongyloides stercoralis
D. Enterobius vermicularis
158. A 30 year old commercial sex worker
comes in for recurrent whiLsh material on
her tongue. She has had weight loss, daily
febrile episodes, and generalized
lymphadenopathies. To confirm your
diagnosis, you will request for:
A.  ELISA
B.  RNA PCR
C.  Western blot
D.  p24 anLgen capture
158. A 30 year old commercial sex worker
comes in for recurrent whiLsh material on
her tongue. She has had weight loss, daily
febrile episodes, and generalized
lymphadenopathies. To confirm your
diagnosis, you will request for:
A.  ELISA
B.  RNA PCR
C.  Western blot
D.  p24 anLgen capture
159. Mainstay preferred
diagnosLc test for Leptospirosis
A.  Culture assays

B.  Serologic tests
C.  PCR idenLficaLon
D.  Dark-‐field microscopy
159. Mainstay preferred
diagnosLc test for Leptospirosis
A.  Culture assays

B.  Serologic tests
C.  PCR idenLficaLon
D.  Dark-‐field microscopy
160. CondiLon with increased
suscepLbility to Salmonella
infecLons
A. Alcoholism
B Antacid ingesLon
C. Age less than 5 years
D. Maternal colonizaLon

160. CondiLon with increased
suscepLbility to Salmonella
infecLons
A. Alcoholism
B Antacid ingesNon
C. Age less than 5 years
D. Maternal colonizaLon

Increased Risk for Salmonella:
•  Decreased gastric acidity
–  Antacids
–  Achlorhydria

•  GI mucosal alteraLon
–  Prior surgery
–  Inflammatory bowel disease
161. Best diagnosLc test for
localized and generalized
tetanus infecLon

A. Wound culture
B. Tetanus toxin PCR
C. Clostridium IgM
D. None needed

161. Best diagnosLc test for
localized and generalized
tetanus infecLon

A. Wound culture
B. Tetanus toxin PCR
C. Clostridium IgM
D. None needed

162. Preferred anLbioLc for
tetanus infecLon
A. CeWriaxone
B. Penicillin G
C. Clindamycin
D. Metronidazole

162. Preferred anLbioLc for
tetanus infecLon
A. CeWriaxone
B. Penicillin G
C. Clindamycin
D. Metronidazole

163. InfecLon predominantly
transmised by sexual
intercourse
A.  HepaLLs C virus
B. Sarcoptes scabiae
C. Chlamydia trachoma-s
D. Gardnerella vaginalis
163. InfecLon predominantly
transmised by sexual
intercourse
A.  HepaLLs C virus
B. Sarcoptes scabiae
C. Chlamydia trachoma8s
D. Gardnerella vaginalis
164. Most common cause of acute
epididymiLs in sexually acLve men
less than 35 years old

A.  Chlamydia trachomaLs
B.  Neisseria gonorrhoea
C.  Enterobacteriaceae
D.  Herpes simplex virus type 2
164. Most common cause of acute
epididymiLs in sexually acLve men
less than 35 years old

A.  Chlamydia trachomaNs
B.  Neisseria gonorrhoea
C.  Enterobacteriaceae
D.  Herpes simplex virus type 2
165. Most common manifestaLon of
infecLon with Clostridium difficile
A. Fever
B. Diarrhea
C. Abdominal pain
D. Leucocytosis
165. Most common manifestaLon of
infecLon with Clostridium difficile
A. Fever
B.  Diarrhea
C. Abdominal pain
D. Leucocytosis
166. What is the normal mean annual
decline in glomerular filtraLon rate
with age in ml/min/body surface area?
A. 0.5
B. 1.0
C. 1.5
D. 2.0

166. What is the normal mean annual
decline in glomerular filtraLon rate
with age in ml/min/body surface area?
A. 0.5
B. 1.0
C. 1.5
D. 2.0

suggest a chronic eLology for the
kidney disease?
A. Bilateral kidney size on ultrasound 10 cm

C. OsteiLs fibrosa cysLca

suggest a chronic eLology for the
kidney disease?
A. Bilateral kidney size on ultrasound 10 cm

C. OsteiNs fibrosa cysNca

168. This diureLc reversible inhibit
the resorpLon of Na-‐K-‐Cl in the
thick ascending limb of Henle’s
loop
A. Bumetanide
B. Thiazide
C. Metolazone
D. Spironolactone
168. This diureLc reversible inhibit
the resorpLon of Na-‐K-‐Cl in the
thick ascending limb of Henle’s
loop
A. Bumetanide
B. Thiazide
C. Metolazone
D. Spironolactone
diureLcs can retain potassium?
A.  Furosemide
B.  Chlorthalidone
C.  Triamterene
D.  Ethacrynic acid
diureLcs can retain potassium?
A.  Furosemide
B.  Chlorthalidone
C.  Triamterene
D.  Ethacrynic acid
170. The pentad of thromboLc
thrombocytopenic purpura
includes the following, EXCEPT
A.  HemolyLc anemia

B.  Thrombocytopenia
C.  Neurologic symptoms
D.  HepaLc failure

170. The pentad of thromboLc
thrombocytopenic purpura
includes the following, EXCEPT
A.  HemolyLc anemia

B.  Thrombocytopenia
C.  Neurologic symptoms
D.  HepaNc failure

TTP
•  PENTAD of findings:
–  Microangiopathic hemolyLc anemia
–  Thrombocytopenia
–  Renal failure
–  Neurologic findings
–  Fever
171. Primary renal pathophysiologic
lesion in acute leptospirosis is injury
in the _______________

A.  Glomerulus
B.  Ascending loop of henle
C.  Descending loop of henle
D.  Proximal convoluted tubule
171. Primary renal pathophysiologic
lesion in acute leptospirosis is injury
in the _______________

A.  Glomerulus
B.  Ascending loop of henle
C.  Descending loop of henle
D.  Proximal convoluted tubule
172. Most common cause of
nephroLc syndrome in the elderly
A.  Minimal change disease

B.  Membranous glomerulonephriLs
C.  Focal segmental glomerulosclerosis
D.  MembranoproliferaLve
glomerulonephriLs
nephroLc syndrome in the elderly
A.  Minimal change disease

B.  Membranous glomerulonephriNs
C.  Focal segmental glomerulosclerosis
D.  MembranoproliferaLve
glomerulonephriLs
173. KimmelsLel-‐Wilson
nodules are seen in:
A.  Fabry’s disease
B.  Urate nephropathy
C.  DiabeLc Nephropathy
D.  Analgesic nephropathy
173. KimmelsLel-‐Wilson
nodules are seen in:
A.  Fabry’s disease
B.  Urate nephropathy
C.  DiabeNc Nephropathy
D.  Analgesic nephropathy
174. First line of therapy for the
management of hypertension in
CKD
A. Salt restricLon
B. ACE inhibitors
C. Loop diureLcs
D. Calcium channel blockers
174. First line of therapy for the
management of hypertension in
CKD
A. Salt restricNon
B. ACE inhibitors
C. Loop diureLcs
D. Calcium channel blockers
175. Diagnosis for thyroid biopsy
revealing psammoma bodies with
Orphan Annie appearance
A. AnaplasLc thyroid cancer

B. Follicular thyroid cancer
C. Papillary thyroid cancer
D. Thyroid lymphoma

175. Diagnosis for thyroid biopsy
revealing psammoma bodies with
Orphan Annie appearance
A. AnaplasLc thyroid cancer

B. Follicular thyroid cancer
C. Papillary thyroid cancer
D. Thyroid lymphoma

176.  A 55 year old diabeLc female came in for
decrease in sensorium.
CBG showed 780mg/dL
ABG pH of 7.32 HCO3 20 pO2 92 pCO2 30
On further inquiring, she was poorly
compliant to her medicaLons and was
complaining of cough with yellowish sputum
for 3 days, vomiLng abdominal pain for 1
day. There was glucosuria and +1 ketonuria
on urinalysis.
What is the most likely
diagnosis?
A. DiabeLc ketoacidosis
B. Hyperglycemic hyperosmolar state
C. Cerebral infarct
D. Sepsis syndrome

What is the most likely
diagnosis?
A. DiabeLc ketoacidosis
B. Hyperglycemic hyperosmolar state
C. Cerebral infarct
D. Sepsis syndrome

DKA VS HHS
177. What is an appropriate
iniLal resuscitaLon step?
A. Give insulin IV bolus with potassium
B. Hydrate with plain NSS
C. Order for STAT plain cranial CT
D. Start broad-‐spectrum IV anLbioLcs

177. What is an appropriate
iniLal resuscitaLon step?
A. Give insulin IV bolus with potassium
B. Hydrate with plain NSS
C. Order for STAT plain cranial CT
D. Start broad-‐spectrum IV anLbioLcs

178. What BP level is
considered hypertension in
diabeLc paLents?
A. > 120/80
B. > 125/75
C. > 130/80
D. > 140/90

178. What BP level is
considered hypertension in
diabeLc paLents?
A. > 120/80
B. > 125/75
C. > 130/80
D. > 140/90

insulin preparaLon provide
basal insulin?
A. NPH insulin
B. Insulin aspart
C. Regular insulin
D. Insulin glargine

insulin preparaLon provide
basal insulin?
A. NPH insulin
B. Insulin aspart
C. Regular insulin
D. Insulin glargine

180. Diabetes medicaLons that
can cause hypoglycemia even if
used alone
A. Me•ormin
B. Alpha-‐glucosidase inhibitors
C. Thiazolidinediones
D. Sulfonylureas

180. Diabetes medicaLons that
can cause hypoglycemia even if
used alone
A. Me•ormin
B. Alpha-‐glucosidase inhibitors
C. Thiazolidinediones
D. Sulfonylureas

181. Microadenomas differ
from macroadenomas in size.
What is the cut off?
A. 5 mm
B. 10 mm
C. 15 mm
D. 20mm
181. Microadenomas differ
from macroadenomas in size.
What is the cut off?
A. 5 mm
B.  10 mm
C. 15 mm
D. 20mm
182. A 35 year old female presents with
amenorrhea, inferLlity, and galactorrhea.
ProlacLn level was significantly elevated at
> 200 g/L. An MRI revealed findings
suggesLve of microadenoma. The
mainstay of therapy is:
A.  Dopamine agonist

B.  Surgical debulking
C.  Transphenoid resecLon
D.  Radiotherapy
182. A 35 year old female presents with
amenorrhea, inferLlity, and galactorrhea.
ProlacLn level was significantly elevated at
> 200 g/L. An MRI revealed findings
suggesLve of microadenoma. The
mainstay of therapy is:
A.  Dopamine agonist

B.  Surgical debulking
C.  Transphenoid resecLon
D.  Radiotherapy
183. A 20 year old male was found to
have a parathyroid adenoma, pituitary
adenoma, and pancreaLc tumor. This
familial pituitary syndrome is called:
A.  MEN-‐1
B.  MEN-‐2A
C.  MEN-‐2B
D.  MEN-‐3
183. A 20 year old male was found to
have a parathyroid adenoma, pituitary
adenoma, and pancreaLc tumor. This
familial pituitary syndrome is called:
A.  MEN-‐1
B.  MEN-‐2A
C.  MEN-‐2B
D.  MEN-‐3
Disease AssociaLons in the MulLple Endocrine
Neoplasia (MEN) Syndromes

MEN 1 MEN 2A MEN 2B
Parathyroid hyperplasia or Medullary Thyroid Medullary Thyroid
adenoma Carcinoma Carcinoma

Islet cell hyperplasia, Pheochromocytoma Pheochromocytoma
adenoma, or carcinoma
Parathyroid hyperplasia Mucosal and
Pituitary hyperplasia or or adenoma gastrointesLnal
adenoma neuromas

Other, less common Marfanoid features
manifestaLons: foregut
carcinoid,
pheochromocytoma,
subcutaneous or visceral
lipomas

184. A 46 year old female has a 3cm
thyroid nodule at the isthmus. Which
feature is a risk factor for thyroid
carcinoma for this paLent?
A. Age
B. Sex
C. Nodule size
D. Nodule locaLon
184. A 46 year old female has a 3cm
thyroid nodule at the isthmus. Which
feature is a risk factor for thyroid
carcinoma for this paLent?
A. Age
B. Sex
C. Nodule size
D. Nodule locaLon
Risk Factors for Thyroid Carcinoma in
PaLents with Thyroid Nodule
•  History of head and neck irradiaLon
•  Age <20 or >45 years
•  Bilateral disease
•  Increased nodule size (>4 cm)
•  New or enlarging neck mass
•  Male gender
•  Family history of thyroid cancer or MEN 2
•  Vocal cord paralysis, hoarse voice
•  Nodule fixed to adjacent structures
•  Extrathyroidal extension
•  Suspected lymph node involvement
•  Iodine deficiency (follicular cancer)
185. A 35 year old female with
palpitaLons has a low TSH and a
normal FT4. Your next approach to
management:
A.  Treat as Graves’ disease with methimazole
B.  Get an MRI to rule out a TSH secreLng
pituitary adenoma
C.  Treat as subclinical hyperthyroidism and
observe
D.  Measure FT3 to rule out T3 toxicosis
185. A 35 year old female with
palpitaLons has a low TSH and a
normal FT4. Your next approach to
management:
A.  Treat as Graves’ disease with methimazole
B.  Get an MRI to rule out a TSH secreLng
pituitary adenoma
C.  Treat as subclinical hyperthyroidism and
observe
D.  Measure FT3 to rule out T3 toxicosis
186. A 28 year old pregnant female
was diagnosed with Graves’ disease.
You prefer propylthiouracil for this
paLent because:
A.  Has beser bioavailability during pregnancy

B.  It has low transplacental transfer
C.  It is more effecLve than methimazole in
pregnant paLents
D.  Methimazole does not cross the placenta
during pregnancy
186. A 28 year old pregnant female
was diagnosed with Graves disease.
You prefer propylthiouracil for this
paLent because:
A.  Has beser bioavailability during pregnancy

B.  It has low transplacental transfer
C.  It is more effecLve than methimazole in
pregnant paLents
D.  Methimazole does not cross the placenta
during pregnancy
187. Screening for diabetes
mellitus is recommended for all
individuals who are more than:
A. 25 years old
B. 35 years old
C. 45 years old
D. 55 years old
187. Screening for diabetes
mellitus is recommended for all
individuals who are more than:
A. 25 years old
B. 35 years old
C.  45 years old
D. 55 years old
finding is consistent with portal
hypertension?
A. Hypoalbuminemia
B. Obliterated Traube’s space
C. Spider angioma
D. AST: ALT raLo more than 2

finding is consistent with portal
hypertension?
A. Hypoalbuminemia
B. Obliterated Traube’s space
C. Spider angioma
D. AST: ALT raLo more than 2

189. What is the role of lactulose
in paLents with hepaLc
encephalopathy?
B. InacLvate colonic bacteria
C. Induce diarrhea

189. What is the role of lactulose
in paLents with hepaLc
encephalopathy?
B. InacNvate colonic bacteria
C. Induce diarrhea

190. Associated with increased
risk of pepLc ulcer disease:
A. Atopic diseases
B. Nephrolithiases
C. Blood group A
D. Acute renal failure

190. Associated with increased
risk of pepLc ulcer disease:
A. Atopic diseases
B. Nephrolithiases
C. Blood group A
D. Acute renal failure

Increased Risk for PUD
•  Strong associaLon •  Possible associaLon
–  Systemic mastocytosis –  Hyperparathyroidism,
–  Chronic pulmonary coronary artery disease,
disease polycythemia vera,
–  Chronic renal failure chronic pancreaLLs
–  Cirrhosis •  Blood type O
–  Nephrolithiasis •  NSAIDs
–  Alpha 1-‐anLtrypsin
deficiency
191. Least common
complicaLon of pepLc ulcer
A. Gastric outlet obstrucLon

B. PerforaLon
C. Bleeding
D. GastriLs
191. Least common
complicaLon of pepLc ulcer
A. Gastric outlet obstrucNon

B. PerforaLon
C. Bleeding
D. GastriLs
A.  Irritable bowel syndrome

B.  Inflammatory bowel disease
C.  GastrointesLnal tuberculosis
D.  IntesLnal parasiLsm
A.  Irritable bowel syndrome

B.  Inflammatory bowel disease
C.  GastrointesLnal tuberculosis
D.  IntesLnal parasiLsm
193. A 50 year old male, smoker, alcoholic
drinker comes in for sudden severe
nonremizng abdominal pain. Heart rate was
noted to be irregularly irregular. There was only
very minimal tenderness, out of proporLon to
the symptoms. The gold standard of diagnosis
is:
A.  Radiograph showing bowel-‐wall edema

B.  DemonstraLon of pneumatosis intesLnalis
C.  Oral and IV dynamic CT scan
D.  Lapatoromy
193. A 50 year old male, smoker, alcoholic
drinker comes in for sudden severe
nonremizng abdominal pain. Heart rate was
noted to be irregularly irregular. There was only
very minimal tenderness, out of proporLon to
the symptoms. The gold standard of diagnosis
is:
A.  Radiograph showing bowel-‐wall edema

B.  DemonstraLon of pneumatosis intesLnalis
C.  Oral and IV dynamic CT scan
D.  Lapatoromy
194. Single most common risk
factor for hepaLLs C
A. HIV
B. Blood transfusion
C. InjecLon drug use
D. Risky sexual behavior
194. Single most common risk
factor for hepaLLs C
A. HIV
B. Blood transfusion
C.  InjecNon drug use
D. Risky sexual behavior
195. Best therapy for
hepatorenal syndrome
A. Dialysis
B. OctreoLde
C. Midodrine
D. Liver transplant
195. Best therapy for
hepatorenal syndrome
A. Dialysis
B. OctreoLde
C. Midodrine
D. Liver transplant
rectal bleeding in infancy
A. Trauma
B. Anal fissure
C. Hemorrhoids
D. Imperforate anus

rectal bleeding in infancy
A. Trauma
B. Anal fissure
C. Hemorrhoids
D. Imperforate anus

197. Best imaging study for iniLal
evaluaLon of a suspected pancreaLc
disorder and for the complicaLons of
acute and chronic pancreaLLs
A. CT
B. MRI
C. ERCP
D. Ultrasound

197. Best imaging study for iniLal
evaluaLon of a suspected pancreaLc
disorder and for the complicaLons of
acute and chronic pancreaLLs
A. CT
B. MRI
C. ERCP
D. Ultrasound

198. Leading cause of acute
pancreaLLs
A. Idiopathic
B. Alcoholism
C. Cholelithiases
D. Hypertriglyceridemia

198. Leading cause of acute
pancreaLLs
A. Idiopathic
B. Alcoholism
C. Cholelithiases
D. Hypertriglyceridemia

199. Which of the following lab tests
used in the diagnosis of acute
pancreaLLs remain elevated for 7 to
14 days aWer the iniLal bout?
A. Lipase
B. Calcium
C. Amylase
D. Hematocrit

199. Which of the following lab tests
used in the diagnosis of acute
pancreaLLs remain elevated for 7 to
14 days aWer the iniLal bout?
A. Lipase
B. Calcium
C. Amylase
D. Hematocrit

200. Hallmark of anaphylaxis
A.  Vascular collapse leading to
hypotension
B.  UrLcarial erupLons which are intensely
pruriLc
C.  Respiratory distress from laryngeal
edema
D.  Rapid onset aWer introducLon of
anLgen
200. Hallmark of anaphylaxis
A.  Vascular collapse leading to
hypotension
B.  UrLcarial erupLons which are intensely
pruriLc
C.  Respiratory distress from laryngeal
edema
D.  Rapid onset aber introducNon of
anNgen
201. Chronic UrLcaria is defined
as asacks lasLng more than
A. 2 weeks
B. 4 weeks
C. 6 weeks
D. 8 weeks
201. Chronic UrLcaria is defined
as asacks lasLng more than
A. 2 weeks
B. 4 weeks
C.  6 weeks
D. 8 weeks
202. Key effector cell of the
biologic response in allergic
rhiniLs, urLcaria, anaphylaxis and
systemic mastocytosis
A. Mast cell
B. Basophil
C. Eosinophil
D. DendriLc cell
202. Key effector cell of the
biologic response in allergic
rhiniLs, urLcaria, anaphylaxis and
systemic mastocytosis
A. Mast cell
B. Basophil
C. Eosinophil
D. DendriLc cell
203. A 20 year old paLent develops
severe maculopapular rashes all over
aWer a bee sLng. Associated signs and
symptoms include dyspnea, wheezing,
vomiLng, an dizziness. Drug of choice is:
A.  Diphenhydramine
B.  HydrocorLsone
C.  Norepinephrine
D.  Epinephrine
203. A 20 year old paLent develops
severe maculopapular rashes all over
aWer a bee sLng. Associated signs and
symptoms include dyspnea, wheezing,
vomiLng, an dizziness. Drug of choice is:
A.  Diphenhydramine
B.  HydrocorLsone
C.  Norepinephrine
D.  Epinephrine
204. Most common pulmonary
manifestaLon of SLE
A. PleuriLs
B. Pneumonia
C. Pleural effusion
D. Pulmonary fibrosis
204. Most common pulmonary
manifestaLon of SLE
A. PleuriNs
B. Pneumonia
C. Pleural effusion
D. Pulmonary fibrosis
205. “Salt and pepper”
appearance of the skin is seen in:
A.  Systemic Lupus Erythematosus

B.  Systemic Sclerosis
C.  Ankylosing SpondyliLs
D.  Behcet’s Syndrome
205. “Salt and pepper”
appearance of the skin is seen in:
A.  Systemic Lupus Erythematosus

B.  Systemic Sclerosis
C.  Ankylosing SpondyliLs
D.  Behcet’s Syndrome
206. The pathergy test is used in
the diagnosis of:
A.  Henoch Schonlein Purpura
B.  Takayasu ArteriLs
C.  Behcet’s Syndrome
D.  Ankylosing SpondyliLs
206. The pathergy test is used in
the diagnosis of:
A.  Henoch Schonlein Purpura
B.  Takayasu ArteriLs
C.  Behcet’s Syndrome
D.  Ankylosing SpondyliLs
DiagnosLc Criteria for Behcet’s
–  Recurrent Oral UlceraNon plus TWO of the
following:
•  Recurrent Genital UlceraLon
•  Eye lesions
•  Skin lesions
•  Pathergy Test (Nonspecific skin inflammatory reacLvity to any scratches or
intradermal saline injecLon)
207. Accounts for most non-‐
gonococcal isolates in infecLous
arthriLs in adults of all ages
A.  Staphylococcus aureus

B.  Gram negaLve bacilli
C.  Β-‐hemolyLc streptococci
D.  Mycobacterium tuberculosis
207. Accounts for most non-‐
gonococcal isolates in infecLous
arthriLs in adults of all ages
A.  Staphylococcus aureus

B.  Gram negaLve bacilli
C.  Β-‐hemolyLc streptococci
D.  Mycobacterium tuberculosis
208. Most common variety of
psoriasis
A. Gusate
B. Pustular
C. Plaque-‐type
D. Inverse
208. Most common variety of
psoriasis
A. Gusate
B. Pustular
C.  Plaque-‐type
D. Inverse
209. Most common
dermatophyte infecLon
A.  Tinea corporis
B.  Tinea cruris
C.  Tinea capiLs
D.  Tinea pedis
209. Most common
dermatophyte infecLon
A.  Tinea corporis
B.  Tinea cruris
C.  Tinea capiLs
D.  Tinea pedis
210. This differenLates primary
from secondary causes of
polycythemia
A. RBC mass
B. EPO levels
C. Arterial O2 saturaLon
D. Carboxyhemoglobin levels
210. This differenLates primary
from secondary causes of
polycythemia
A. RBC mass
B.  EPO levels
C. Arterial O2 saturaLon
D. Carboxyhemoglobin levels
•  Low EPO à Polycythemia Vera
•  High EPO à Secondary Causes
211. Most convenient
laboratory test to diagnose iron
deficiency anemia
A. TIBC
B. Serum iron
C. Serum ferriLn
D. Serum transferrin
211. Most convenient
laboratory test to diagnose iron
deficiency anemia
A. TIBC
B. Serum iron
C.  Serum ferriNn
D. Serum transferrin
212. Thalassemia might favor a
natural protecLon against which
infecLon?
A.  Malaria
B.  Dengue Fever
C.  Typhoid Fever
D.  HIV
212. Thalassemia might favor a
natural protecLon against which
infecLon?
A.  Malaria
B.  Dengue Fever
C.  Typhoid Fever
D.  HIV
213. Mainstay of treatment for
sickle cell anemia
A.  HydraLon
B.  Hydroxyurea
C.  Red Cell Transfusion
D.  Bone marrow transplant
213. Mainstay of treatment for
sickle cell anemia
A.  HydraLon
B.  Hydroxyurea
C.  Red Cell Transfusion
D.  Bone marrow transplant
214. OsmoLc Fragility Test
is used to diagnose:
A. G6PD deficiency
B. Sickle cell anemia
C. Hereditary spherocytosis
D. Paroxysmal nocturnal
hemoglobinuria
214. OsmoLc Fragility Test
is used to diagnose:
A. G6PD deficiency
B. Sickle cell anemia
C.  Hereditary spherocytosis
D. Paroxysmal nocturnal
hemoglobinuria
215. Most common physical
finding in Chronic Myelogenous
Leukemia

A. Pallor
B. Petechiae
C. Lymphadenopathy
D. Splenomegaly
215. Most common physical
finding in Chronic Myelogenous
Leukemia

A. Pallor
B. Petechiae
C. Lymphadenopathy
D. Splenomegaly
216. A 50 year old female diagnosed
with leukemia showed “smudge” or
basket cells on peripheral blood
smear. Your diagnosis is:
A.  Acute promyelocyLc leukemia

B.  Chronic lymphocyLc leukemia
C.  Acute lymphoblasLc leukemia
D.  Mantle cell lymphoma
216. A 50 year old female diagnosed
with leukemia showed “smudge” or
basket cells on peripheral blood
smear. Your diagnosis is:
A.  Acute promyelocyLc leukemia

B.  Chronic lymphocyNc leukemia
C.  Acute lymphoblasLc leukemia
D.  Mantle cell lymphoma
217. Most rapidly progressive
lymphoma
A.  Diffuse large B-‐cell lymphoma
B.  Burkis’s lymphoma
C.  Mantle cell lymphoma
D.  Follicular lymphoma
217. Most rapidly progressive
lymphoma
A.  Diffuse large B-‐cell lymphoma
B.  Burkir’s lymphoma
C.  Mantle cell lymphoma
D.  Follicular lymphoma
218. Given with Cyclophosphamide
chemotherapy to reduce the risk of
bladder damage
A. N-‐acetylcysteine
B. Mesna
C. Acrolein
D. Leucovorin
218. Given with Cyclophosphamide
chemotherapy to reduce the risk of
bladder damage
A. N-‐acetylcysteine
B.  Mesna
C. Acrolein
D. Leucovorin
219. Co-‐administered with 5-‐
fluorouracil to enhance
cytotoxicity in the treatment of GI
cancers
A.  N-‐acetylcysteine

B.  Mesna

C.  Acrolein
D. Leucovorin
219. Co-‐administered with 5-‐
fluorouracil to enhance
cytotoxicity in the treatment of GI
cancers
A.  N-‐acetylcysteine

B.  Mesna

C.  Acrolein
D.  Leucovorin
220. Hematologic malignancy
associated with an increased risk
for disseminated intravascular
coagulaLon
A. Chronic Myeloid Leukemia

B. Acute PromyelocyLc Leukemia
C. Non-‐Hodgkin’s Lymphoma
D. MulLple myeloma
220. Hematologic malignancy
associated with an increased risk
for disseminated intravascular
coagulaLon
A. Chronic Myeloid Leukemia

B.  Acute PromyelocyNc Leukemia
C. Non-‐Hodgkin’s Lymphoma
D. MulLple myeloma

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A. Alcohol abuse

A. Alcohol abuse

Table 234-4 Factors That May Precipitate Acute Decompensation in

Arrhythmias (tachycardia or bradycardia)

Initiation of medications that worsen HF

Calcium antagonists (verapamil, diltiazem)

Nonsteroidal anti-inflammatory drugs

A. Mitral stenosis

LA enlargement on CXR and ECG (wide, notched P wave)

• Left Atrial Enlargement

A. ST elevaLons are concave

as PR depression.

HPIM 18th ed

Box. Recommendations for Management of Hypertension

Beta-adrenoceptor blocking drugs

Non-selective Selective With alpha-

Nadolol Pindolol Atenolol Acebutolol Labetalol

A. Ibuprofen 200mg 3 Lmes daily

A. Ibuprofen 200mg 3 Lmes daily

A. Give morphine

A. Pump failure from myocardial ischemia

A. Compensatory increase of bicarbonate

A. Compensatory increase of bicarbonate

A. Give stat dose of Furosemide IV bolus with BP

A. Give stat dose of Furosemide IV bolus with BP

A. Metronidazole 2g orally single dose

A. Metronidazole 2g orally single dose

A. Mucocutaneous ulceraLon, Kaposi’s

A. Mucocutaneous ulceraLon, Kaposi’s

A. AsymptomaLc colonizaLon of the

A. AsymptomaNc colonizaNon of the

A. Irritable bowel syndrome

A. Irritable bowel syndrome

A. Evacuate blood from the

A. Evacuate blood from the

• MELD classiﬁcaNon: InternaLonal normalized

B. 21/F complaining of headache and hypogastric

A. 64/M with diabetes and hypertension for 15

B. 21/F complaining of headache and hypogastric

A. Bilateral size of kidney on ultrasound 10 cm

A. Bilateral size of kidney on ultrasound 10 cm

A. Focal areas of increased uptake

• If ectopic ACTH produc-on, hyperpigmentaLon

A. Screening for diabeLc nephropathy for

A. Screening for diabeLc nephropathy for

A. Squamous cell Lung cancer

A. Squamous cell Lung cancer

A. Decreased bone marrow iron stain

A. Decreased bone marrow iron stain

A. Give IV Streptokinase

A. Give IV Streptokinase

A. Toxic Epidermal Necrolysis

A. Toxic Epidermal Necrolysis

A. Herpes simplex encephaliLs

A. E. coli 0157:H7

A. E. coli 0157:H7

A. Age more than 65 years old

A. Age more than 65 years old

A. Pulmonic stenosis

A. Pulmonic stenosis

A. The D-­‐dimer is a useful "rule in" test

A. The D-­‐dimer is a useful "rule in" test

A.  Mitral stenosis

•  Left Atrial Enlargement

A.  Ibuprofen 200mg 3 Lmes daily

A.  Ibuprofen 200mg 3 Lmes daily

A.  Give morphine

A. Give stat dose of Furosemide IV bolus with BP

A. Give stat dose of Furosemide IV bolus with BP

A. Mucocutaneous ulceraLon, Kaposi’s

A. Mucocutaneous ulceraLon, Kaposi’s

A. AsymptomaLc colonizaLon of the

A. AsymptomaNc colonizaNon of the

A. Irritable bowel syndrome

A. Irritable bowel syndrome

•  MELD classiﬁcaNon: InternaLonal normalized

A.  64/M with diabetes and hypertension for 15

•  If ectopic ACTH produc-on, hyperpigmentaLon

A. Give IV Streptokinase

A. Give IV Streptokinase

A.  Pulmonic stenosis

A.  Pulmonic stenosis

A. The D-‐dimer is a useful "rule in" test

A. The D-‐dimer is a useful "rule in" test

•  ResLng O2 sat < 88%

A.  Chronic beryllium disease

A.  Chronic beryllium disease

A.  Tachycardia or palpitaLons

A.  Tachycardia or palpitaLons

A.  Lung cancer

A.  Lung cancer

A.  Presence of organisms

A.  Presence of organisms

A.  ProliferaLve phase

A.  ProliferaNve phase

A.  Pleural plaque

A.  Pleural plaque

A.  Dutch hypothesis

A.  Dutch hypothesis

A. C: CreaLnine > 250

A. C: CreaNnine > 250

A. 2-‐4 weeks

A. 2-‐4 weeks

A.  Lucio reacLon

A.  Lucio reacLon

A.  Culture assays

A.  Culture assays

A.  HemolyLc anemia

A.  HemolyLc anemia

A.  Minimal change disease

A.  Minimal change disease

A.  Dopamine agonist

A.  Dopamine agonist

A.  Has beser bioavailability during pregnancy

A.  Has beser bioavailability during pregnancy

A. Gastric outlet obstrucLon

A. Gastric outlet obstrucNon

A.  Irritable bowel syndrome

A.  Irritable bowel syndrome

A.  Radiograph showing bowel-‐wall edema

A.  Radiograph showing bowel-‐wall edema

A.  Systemic Lupus Erythematosus

A.  Systemic Lupus Erythematosus

A.  Staphylococcus aureus

A.  Staphylococcus aureus

A.  Acute promyelocyLc leukemia

A.  Acute promyelocyLc leukemia

A. Chronic Myeloid Leukemia

A. Chronic Myeloid Leukemia