A 64-year-o!d man is diagnosed with persistent atrial fibrillation. His past medical history includes hypertension and type 2 diabetes He has no contraindications to any antithrombotic treatments

What antrthromDotlc treatment should be considered first Ime for this patient?

A 66-year-old man presents with a diastolic murmur best heard at the left sternal edge On examination, the apex beat is displaced outwards

Which condition typically presents with these findings?

A 66-year-otd man comes for follow-up He has shortness of breath on exercise, which have increased over the past few months. He became unable to walk more than 200-300 meters on the corridor and cannot climb the stairs easily. He has h>story of hypertension and currently on amlodipine 5 mg OD and indapamide 2.5 mg OD. On examination, he has bilateral basal crackles and mild pitting ankle edema (see lab results).

Blood pressure 188/96 mmHg

Heart rate 79 'min

Test Result Normal Values Hb 133 130-170 ga. (Male)

120-160 gA. (Female)

Sodium 138 134-146 mmol/L

Potassium 4.2 3.5-5.1 mmol/L

Creatinine 133 44-115 pmol/L

Which of the followihg is the most appropriate next therapy?

A 61-year-old woman comes lo the dink: compiainaig of paipllations. She has also noticed some weight loss over the last 2 months. On clinical examination, she has an irregularly irregular pulse and a fine tremor. Her ECG shows atrial fibrillation.

Which of the following is the next most appropriate investigation to do?

A 58-year-oid man comes to the clinic for a follow-up He has been discharged after an acule infenor myocardial infarct ton He is diabetic type 2, on metformin ig BD, aspirin 75 mg atorvastatin 10 mg OD and lisinopril 10 mg OD. Examination revealed bilateral basal crackles on auscultation of the chest

Blood pressure 148/88 mmHg

Hear! rate 76 'min

BMI 24 kg/m2

Which of the following Is the most appropriate medication to add to his regime?

A 72-year-old man presented with an episode of right-sided weakness that lasted 10 minutes and fully resolved and he is clinical stable. He has no other medical illness. On clinical examination, he is in atrial fibrillation.

Blood pressure 110/70 mmHg

Heart rate 95 /min

Temperature 36.6 "C

Which of the following is the most appropriate next step in the management?

A 43-year-old healthy man concernefl about heart disease.

Which of the following is the most important nsk factor of ischemic heart disease?

A 78-year-old woman presents with exertional syncope. On clinical examination・ she has a slow rising carotid pulse and a loud ejection systolic murmur at the upper right sternal edge, radiating to the carotids.

Which of the following is the most likely cause of these findings?

A 55-year-oid man presents with a 3-month history of exertional chest pain. He has previous history of myocardial infarction.

Which of the following is modifiable risk factors in the ireaimeni of ischemic heart disease?

A 78-year-old man diagnosed with heart failure due to left ventncular dysfunction. His currently on aspirin 75 mg OD. simvastatin 40 mg OD and furosemide 40 mg OD. On examination, heart sounds are normal, his chest is clear and there is no peripheral oedema.

Which of the following is the most appropfiate drug therapy to initiate at this stage?

A 68-year-oid man is seen for a foilownip He has longstanding breathlessness and symptoms of cardiac failure. The ECG confirmed a diagnosis of heart failure due to left ventricular dysfundion. His currently on enalopnl 10 mg OD, simvastatin 40 mg OD, furosemide 40 mg OD and omeprazole 20 mg OD. Examination revealed that the chest is clear and heart sounds are normal. There ts no peripheral edema.

Blood pressure 125/83 mmHg

Heart rate 76 /min

Which of the following is the most appropriate next step in the management at this stage?

A 23-year-old man is brought to the hospital after an ep：sode of collapse He states that on a few occasions while playing football he has had some chest pam, breathlessness and felt as he was going to famt. Last night during training, he coUapsed and blacked out fcr a few seconds. Clinical examination revealed a harsh ejection systolic murmur with a palpaUe systolic thrill at the left sternal edge; and a prominent jerky carotid pulse Which of the following is the most likely diagnosis?

A 52-year-oid man develops sudden severe retrosternal chest pain that radiates to his back. Within minutes, he became unconscious He is a heavy smoker and has history of hypertension Blood pressure 85/56 mmHg

Heart rate 92/min

Which of the following is the most likely diagnosis?

A 39-year-old man with asymptomatic hereditary hemochromatosis presentej to the clinic for a

check-up (see laD results).

Test Result Normal Values

Alkaline phosphatase

42 39-117 IU/L

Aianlne aminotransferase 20 5-40 IU/L

Aspanate aminotransferase 22 12-40 IU/L

Ferritin 860 20-300 pg/L (Male)

20-120 pg/L (Female)

Which of the following Is the most appropriate management?

A 29-year-oid man presented with painless jaundice after resolution of uppef respiratory tract viral infection, otherwise he is asymptomatic. Clinical abdominal examination is unremarkable. Peripheral blood smear is normal (see lab results).

Test Result Normal Values

RBC 5.1 4.7-6 1 x 1012/L (Male)

4 2-5 4 x 1012/L (Female)

Hb 133 130-170 gA. (Male)

120-160 gfL (Female)

MCV 88 80-95 fl

Reticulocyte 0.21 0.2-1.2%

Platelets count 220 150-400 x 109/L

WBC 5.2 4.5-10.5 x 109/L

Alkaline phosphatase

41 39-117 IU/L

Alanine aminotransferase 12 5-40 IU/L

Aspartate aminotransferase 20 12-40 IU/L

Indirect bilirubin 18 3.2-12.1 pmol/L

Direct bilirubin 1.51 1.5-6.5 pmol/L

Total bilirubin 19.51 3.5-16.5 pmol/L

HCT 0.44 0.42-0.52 (Male)

0.37-0.48 (Female)

Which of the following is the most likely cause of his jaundice?

A 34-year woman presented with recurrent biliary colic for 5 months. Liver function test is within normal limits. Liver ultrasound shows cholelilhiasis.

Which of the following procedures is the most appropriate?

A 31-year-old woman presented to the Emergency Room with mild acute cholecystitis. She was slartefl on intravenous fluids and empiric antibiotics

Which of the following is the most appropnate next step?

A 34-year-oid man previously healthy brought a laboratory results for hepatits B virus from a

private clinic (see lab results)

Test Result

HBsAg Negative

HBeAg Negative

Anb- HBsAg Positive

Anb-HBc IgG Negative

What is the clinical state the laboratory results indicate?

A 28-year-oid man with 4-months history of non-specific crampy abdominal pain and diarrhea alternate with constipation that is not related to any speafic food. He has no history of food allergy. No histofy of weight toss.

Btood pressure 110/70 mmHg

Heart rate 76 'min

Temperature 36.6 C

BMI 23 kgfm2

Which of the following is the most likely diagnosis?

A 3fl-year-o!d woman presented with a 7-weeks of frequent, loose and bloody bowel movements that associated with campy abdominal and rectal pain. She has family history of crohn's disease Stool analysis is negative (see lab results)

Blood pressure 110/70 mmHg

Heart rate 76 /mln

Temperature 36.6 °C

Test Result Normal Values

RBC 9.2 4.7-6.1 x 1012/L (Male) 4.2-5.4X 1012/L (Female)

Hb111 130-170 g/L (Male) 120-160 g/L (Female)

HCT0.41 0 42-0.52 (Male) 037-0 48 (Female)

 MCH 27 28-33 pg'cell

MCHC 330 320-360 g/L

MCV 77 80-95 fl

Platelets count 220 150-400 x 109/L

C-ieactive peptide 22 <8.2 mg/L

Which of the following is the most appropriate next step in establishing diagnosis?

A 38-year-oid woman with a history of chronic abdominal pain and diarrhea develops tender red nodules on her shins.

The findings are most consistent with which of the following?

A 34-yearoid woman presents with a 4-week history of retrosternal bummg pam. The pain Is often worse following eating. Her past medical history includes depression and she is on escitalopram 10 mg OD. Clinical examination is unremarkable.

Which of the following is the most likely diagnosis?

A 42-year-oid man with no medical problems presents with a 2-day history of profuse bloody diarrhea, severe abdominal cramping and fever. He has recently returned from a week-long trip «o Indonesia. His stool culture is positive for Campytobacter.

Which of the following is the most approptiate treatment?

A 25-year-oid woman presented with episodic abdominal pain and altered bowel habits that have been present intermittently for the past year. The pain is ’’crampy.” and moderate to severe. Defecation brings some relief, but she sometimes must pass several loose, watery stools before the pain resolves. She occasionally notes mucus in her stool and sometimes feels that evacuation is incomplete even though she is unable to pass more stool Her body weight is stable. Abdominal examination are normal.

Which of the following is the most appropriate test to estabhsh diagnosis?

A 21-year-old woman presents with a 3-months history of upper abdominal pain. The discomfort and bloating becomes worse by eating. There is no diarrhea or constipation and her appetite is good. Clinical examinabon of her abdomen is normal. Helicobacter test is negative and other blood tests are all normal.

Which of the following is the most likely diagnosis?

A 40-year-oid woman brought to Emergency Room with severe colicky right upper quadrant pain The pain started after eating fish and chips for lunch. By the time she is seen, an hour later. Ihe pain has settled and she is otherwise asympiomatic Clinical examination is unremarkable

Which of the following Is the most likely cause of her symptoms?

A 24-year-oifl woman is diagnosed with celiac disease

Which of the following foods should she avoid?

A 45-year-old man presents with a sudden onset of unilateral peripheral facial nerve weakness 1 hour ago. He has no medical illness and not on any medication.

Which of the following is most likely to shorten his symptoms?

A 48-year-old woman has a 2-year history of a slowly progressive bilateral tremor. The tremor interferes with her writing and eating. She has recently noted head bobbing and a change in her voice.

Which of the following would be an appropriate first-line medication for her problem?

A 70-year-old man complains of a sudden severe headache while Bending down to pick up his keys this morning He describes it as the worst headache he has ever had; he says it was like

being hit on the back of the neck

Which of the following is the most likely diagnosis?

A 73-year-old diabetic man presents with right-sided weakness. The weakness is equal in the  right face, arm and leg. Sensation, speech and comprehension are intact.

Which of the following arteries is affected?

A 69-year-old man comes to the clinic complaining of inoeasing fatigue and drowsiness and difficulty to arouse. History reveals he was in a vacation 2 weeks ago. Although he admits to taking several falls, he is unaware of any head injury. Neurolog.cal examination showed no lateralizing or focal findings. Head and scalp examinations are negative for focal tenderness and deformity. Plain X-ray of the skull is negative (see lab results).

Test Result Normal Values

RBC 5.1 4.7-6.1 x 1012/L (Male)

4 2-5 4 x 10124. (Female)

Hb 132 130-170 ga. (Male)

120-160 gl. (Female)

HCT 0.40 0.42-0.52 (Male)

037-0 48 (Female)

MCH 30 28-33 pg'cell

MCHC 322 320-360 g/L

MCV 88 80-95 fl

Reticulocyte 0.9 0.2-1.2%

Platelets count 200 150-400 x 109/L

WBC 5.5 4.5-10.5 x 109/L

Neutrophils 50 40-60%

Eosinophils 2 1-4 %

Basophils 0.8 0.5-1 %

Lymphocytes 32 20-40 %

Monocytes 4.1 2-8 %

Calcium 2.3 2.15-2.62 mmoUL

Calcium iomzed 1.2 1.1-1.3 mmoVL

Magnesium 0 8 0.7-1.2 mmol/L

Thyroid-Stimulatmg Hormone 4 4 04-5.0 pU/mL

Thyroxine (T4 free serum) 12 8.5- 15 2 pmol/L

Sodium 136 1 34-146 mmol/L

Potassium 4.2 3.5-5.1 mmol'L

Which of the following Is the most likely diagnosis?

A 72-year-oid woman with Parkinson's disease, complaining of a very annoying tiemor of the  dominant right hand. She is not on any medication She states that her tremor is the only feature that disturbs her functioning

Which of lhe medications would be most likely to improve her tremor?

A 67-year-oid man comes to the clinic complaining that he has a tremor in the right hand. It is best displayed when he reaches for a pen and is manifested easily in the finger-to-nose test.

In which of the following locations is the lesion’

28-year-oid man wlh systemic lupus erythematosus presented to the dinic with a 1-month history of joint pain and morning stiffness. He has no current history of skin rash or other systemic features. His cunent treatment consists of hydroxychtoroquine 400 mg daily. On exam.nation, he has active arthritis at both wrist joints and second proximal interphalengeal joint of both hands (see lab results).

Test Result Normal Values

Hb 125 130-170 ga. (Male)

120-160 gA. (Female)

Platelets count 220 150-400 x 109/L

WBC 5 4 5-10.5 x 109/L

ESR 55 2-10 mnVh (Male)

3-15 mm/h (Female)

Urea 4 5 2.75-7 4 mmol/L

Creabnine 78 44-115 pmol/L

C-reactive peptide 12 <8.2 mg/L

Complement C3 0.9 0.7-1.5 g/L

Complement C4 0.1 0.15-0.45 g/L

Which of the following agents should be added to control the arthritis?

A 30-year-old woman presented to the clinic with 4-month history of multiple joint pain and morning stiffness for 2-hours. On examination, she has active arthritis at multiple small joints of both hands and feet. Hands radiography show erosions at several small joints of both hands (see lab results)

Test Result Normal Values

Hb 110 130-170 ga. (Male)

120-160 gA. (Female)

Platelets count 450 150*400 x 109/L

WBC 10 4.5-10.5 x 109/L

ESR 65 2-10 mm/h (Male)

3-15 mm/h (Female)

Urea 4 2.75-7.4 mmol/L

Creatmine 67 44-115 pmol/L

C-reactive peptide 25 <8.2 mg/L

Rheumatoid factor 450 <58 klU/L

Which of the following is the most appropriate management?

A 75-year-old man presented to the clinic wth a 5-year history of right knee pain that worsens with walking and is relieved with rest. Paracetamol 1 gm 3 times a day resulled m mild improvements. He also has hypertension, diabetes mellitus and chronic kidney diseases. On examination, his right knee is mildly swollen Out not tender or warm wilh significant limitation of his flexion movements. Right knee radiography shows osteophytes and significant joint space narrowing (see lab results).

Test Resull Normal Values

ESR 8 2-10 mm/h (Male)

3-15 mm/h (Female)

Urea 8.5 2.75-7.4 mmol/L

Creafcnine 190 44-115 pmol/L

Which of the following Is the most appropriale treatment?

A 28-year-old woman presented to the clinic with 2-month history of pain and swelling in the hand joints with morning stiffness for 2-hours. She is 3-months postpartum, and taking care of her infant. On examination, she has active arthritis at second and fourth proximal and metacarpophalangeal joints and both wrists (see lab results).

Test Result Normal Values

Hb 120 130-170 g/L (Male)

120-160 gA. (Female)

Platelets count 450 150-400 x 109/L

WBC 6 4.5-10.5 x 109/L

ESR 70 2-10 (Male)

3-15 mm/h (Female)

C-reactive peptide 18 <8.2 mg/L

Which of the following is the most likely diagnosis?

A 35-year-ofd man with rtieumatod arthritis for 6 months on methotrexate 2C mg weekly and ibuprofen daily presented to the clinic with increasing joint pain in both hands and feet associated with morning stiffness for 2-hours. On examination, he shows signs of active arthritis at both wrists. Hand X-rays show erosions at mulbple joints (see lab results). Test Result Normal Values

Hb 120 130-170 gA. (Male)

120-160 g/L (Female)

Platelets count 450 150-400 x 109/L

WBC 8 4.5-10.5 x 109/L

ESR 60 2-10 mnVh (Male)

3-15 mm/h (Female)

C-reactive peptide 1fl <8.2 mg/L

Rheumatoid factor 500 <58 klU/L

Which of the following is the most appropflate additional treatment?

A 65-year-oid-woman presented to the clinic with a 5-day history of pain and swelling in the left knee. Her pain aggravated by walking and relieved by rest No history of small joints involvement or significant morning stiffness.

On examination, left knee is swollen but not warm or erythematous. Left knee X-ray shows osteophytes and joint space narrowing. Joint aspiration reveals 280 leukocytes/mm (see lab results).

Blood pressure 140/80 mmHg

Temperature 36.6 °C

BMI 35 kgfm2

Test Result Normal Values Hb 125 130-170 g/L (Male)

120-160 g/L (Female)

Platelets count 300 150-400 x 109/L

WBC 11.5 4.5-10.5 x 109/L

ESR8 2-10mnVh (Male) 3-15 mm/h (Female)

Which of the following is the most likely arlhribs?

A 55-year-o»d man with rtieumatoid arthritis for 6-years on methotrexate 15 mg weekly and prednisone 5 mg daily presented to the Emergency Department with a 2-day history of left knee pain and swelling. On examination, left knee is swollen, red. warm and tender. Left knee

aspiration revealed high white blood cells 35000 cells'mm and the culture is pending (see lab results).

Blood pressure 105/70 mmHg

Head rate 96 'min

Temperature 39 "C

Oxygen saturation 97 %

Test Result Normal Values Hb 125 130-170 g/L (Male)

120-160 gA. (Female)

Platelets count 450 150-400 x 109/L

WBC 18 4.5-10.5 x 109/L ESR 80 2-10 mmfh (Male)

3-15 mm/h (Female)

C-reactlve peptide 28 <8.2 mg/L

Rheumatoid factor 600 <58 klU/L

Which of the following is the most appropriate immediate management?

A 27-year-oid man with systemic lupus erythematosus (SLE) is seen in the clinic because of worsening fatigue and exertional shortness of breath. He has had no fevers, arthritis, ulcers, rash, chest pain or palpitations. His current treatments are hydroxychloroquine and mycophenolate mofetil. Systemic examination is unremarkable (see lab results). Blood pressure 130/70 mmHg

Respiratory rate 18/min

Temperature 37 3 °C

Test Result Normal Values Hb 78 130-170 gjl (Male)

120-160 gfL (Female) R

eticulocyte 7 0.2-1.2 %

Platelets count 300 150-400 x 109/L

WBC 6 4.5-10.5 x 109/L

Creabnine 85 44-115 pmol/L

Haptoglobm 0.2 0.9-1.4 g/L

Iron 11 11.7-31.8 pmoVL (Male) 9-30.4 pmol/L (Female)

Ferritin 500 20-300 pg/L (Male)

20-120 ng't (Female)

Lactate dehydrogenase 1200 60-160 IU/L

Which of the following anemias is most likely associated with SLE at this stage?

A 32-year-oid woman smoker presented to the clinic w>th 6-months history of polyarthralgia. malar rash and fatigue. Examination revealed active malar rash over her face and lower limb pittmg oedema up to the knees. She has positive antinuclear antibody with high titer (1:1280). She is started on hydroxychloroquine and mycophenolate mofetil (see lab results). Test Result No«mal Values

Hb 110 130.170 g/L (Male)

120-160 g/L (Female)

Platelets count 200 150*400 x 109/L

WBC 3.5 4.5-10.5 x 109/L

ESR 45 2-10 mnVh (Male)

3-15 mnVh (Female)

Urea 5 2.75-7.4 mmol/L

Creatinine 75 44-115 pmol/L

24 hr urine protein 750 0.8-14 mg/dl (Male)

2 5-11 mg^l (Female)

Complement C3 0.4 0 7-1.5 g/L

Complement C4 0 1 015-0.45 g/L

Which of the following non-pharmacological intervention would be most important at this time?

A 40-year-oia man presented to Emergency Department with fever and painful swelling in lhe left knee for 2 days. 2 weeks ago, he had watery, non-bloody diarrhea and abdominal pain for 5- days after eating from a restaurant On physical examination, left knee is warm and lender, with

a moderate effusion. The right wrist is mildly swollen and tender. The left achllles tendon is mildly tender and swollen at its Insertion into the calcaneus. Blood, siool and synovial cultures are negative. However, testing for Clostridium difficile toxin is positive (see lab results). Blood pressure 140/90 mmHg

Heart rate 76 'mln

Temperature 38.5 :C

Test Result Normal Values

ESR 75 2-10 mnVh (Male)

3-15 mm/h (Female)

WBC 18 4.5-10.5 x 109/L

Creabnine 110 44-115 pmol/L

Uric acid 260 200-410 pmol/L (Male) 140-360 pmolA. (Female)

C-reaciive peptide 20 <8.2 mg/L

Rheumatoid factor 35 <58 klU/L

Which of the following is the most likely arihntis?

A 50-year-oid man presented to the clinic with a 15-year history of multiple joints pain with daily significant morning stiffness that lasis for 3 hours. He has been admitted 3 times during the last year to the local hospital for treatment of bacterial pneumonia. Physical examination reveals mulbple rheumatoid nodules and an enlarged spleen. He has active arthritis affeciing multiple metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints symmetrically. Hands x- ray show severe erosive disease of the MCP and PIP joints. Bone marrow aspiration and biopsy reveals an excess of immature forms and maturation arrest with normal differential (see lab

results).

Test Result Normal Values

Hb 90 130-170 gJL (Male)

120-160 g/L (Female)

Platelets count 100 150*400 x 109/L

WBC 2 4.5-10.5 x 109๕

ESR 80 2-10 mnVh (Male)

3-15 mm/h (Female)

Rheumatoid factor 400 <58 klU/L

Which of the following is the most likely diagnosis?

A 30-year-oid woman with systemic lupus erythematosus presented to Emergency Department with seizures and fatigue for 2-days. No history of fever or skin rash. Musculoskeletal and neurologic examinations are normal She has negative septic workup. Bram MRI revealed multiple hyperintense lesions (see lab resulls).

Blood pressure 120/70 mmHg

Temperature 37.2 ”C

Oxygen saturation 95 %

Test Result No»mal Values Hb 110 130-170 ga. (Male)

120-160 g/L (Female)

Platelets count 200 150-400 x 109/L

WBC 6 4.5-10.5 x 109/L

ESR 35 2-10 mnVh (Male)

3-15 mm/h (Female)

APTT 30 30-40 sec

INR 1 0.8-1.2

Lupus anticoagulant negative negative

Urea 6 2.75-7.4 mmolA.

Creatinine 100 44-115 pmol/L

Pressure 300 200-250 mmH20 (Male) 300-400 mmH20 (Female)

Total protein (Women) 0 65 0.15-045 g/L

Anti SS antibodies 35 negative

Complement C3 0.5 0.7-1.5 g/L

Complement C4 0.1 0 15-0.45 g/t

Which of the following is the most appropriate treatment in addition to corticosterods?

A 23-year-old woman with systemic lupus erythematosus (SLE) presented to the dinic with a 3- month history of lower-extremity swelling and shortness of breath. She has not had chest pain, palfxtations, or fevers. On physical examination, she has jugular venous distention and engorgement with inspiration. Heart sounds are distant; a prominent early diastolic sound without gaHops or murmurs is heard. Breath sounds are normal. Abdominal examination reveals shifting dullness. Pitting Merna to the level of the knees is noted (see lab results).

Blood pressure 110/70 mmHg

Heart rate 95 /min

Respiratory rate 25 /min

Temperature 36 6 °C

Oxygen saturation 90 %

Test Result Normal Values Hb 90 130-170 g/L (Male)

120-160 g/L (Female) Platelets count 450 150-400 x 109/L

WBC 3 4.5-10 5 x 109/L Creatinine 150 44-115 jimol/L

Albumin 28 34-56 g/L

Complement C3 0 5 0 7-1.5 g/L Complement C4 01 0 15-0.45 g/L Aspartate aminotransferase 100 12-40IU/L Alanine aminotransferase 94 5-40 IU/L

Which of the following SLE assoaatlon most llkeiy explains the current condition?

A 30-year-o<d man presented to the clinic with left knee pain for one month. 3 months ago, he had an episode of right knee active arthritis that was aspirated and then improved. Synovial fluid aspiration showed leukocyte count 40,000/cu mm, and negative cultures. Clinical examination revealed a swollen and lender left knee only. He has not had rashes or eye symptoms. Knee radiographs are normal (see lab results).

Test Result Noimal Values

Hb 140 130-170 g/L (Male)

120-160 g.^ (Female)

Platelets count 450 150-400 x 109/L

WBC 10 4.5-10.5 x 109/L

ESR 55 2-10 mnVh (Male)

3-15 mm/h (Female)

Urea 4 2.75-7.4 mmol/L

Creatinine 85 44-115 pmol/L

C-reactive peplide 16 <8 2 mg/L

Rheumatoid factor 35 <58 klU/L

Which of the following Is the most appropriate initial treatment?

A 65-year-oid man presented to the clinic wth 3-year history of progressive worsening of bilateral knee pain and stiffness that occurs at resl and at night. He has no history of trauma Paraceiamol and ibuprofen resulted In mild improvements of his joint pain. Upon examination, there is no warmth, erythema or effusion and there is no compromise in joints slabilrty (see lab

results).

Blood pressure 140/90 mmHg

Temperature 36.6 ^DC

Weight 90 kg

Height 160 cm

Test Result No<mal Values Hb 125 130-170 g4. (Male)

120-160 g'L (Female)

Platelets count 300 150-400 x 109/L WBC 9 4.5-10.5 x 109/L ESR 15 2-10 mm/h (Male)

3-15 mm/h (Female)

Blood urea nitrogen 9 2.8 to 8.9 mmol/L Creabnine 115 44-115 pmol/L C-reactive peptide 6 <8.2 mg/L

Which of the following is the most appropriate next investigation?

A 53-year-o«a woman presented to the clinic with polyarthralgia affecting distal and proximal interphalangeal joints bilaterally fo» 3-years. She does not have significant early morning stiffness. Clinical examination revealed no active arthritis (see laD results).

Test Result Ncwmal Values

Hb 140 130-170 g4_ (Male)

120-160 g'L (Female)

Platelets count 200 150*400 x 109/L

WBC 8 4.5-10.5 x 109/L

ESR 12 2-10mm/h (Male)

3-15 mm/h (Female)

Urea 4 2.75-7 4 mmol/L

Creatmine 75 44-115 pmol/L

C-reactive peptide 5 <8.2 mg/L

Which of the following is the best management option at this stage?

A 50-year-old woman presented to the clinic with polyarthralgia affecting distal and proximal interphalangeal joints bilaterally for 3-years. She does not have significant early morning stiffness. Clinical examination revealed no active arthritis but there was non-tender hard nodules over some distal interphalangeal (see lab results)

Test Result Normal Values

Hb 140 130-170 gA. (Male)

120-160 g/L (Female)

Platelets count 190 150-400 x 109/L

WBC 11 4.5-10.5 x 109/L

ESR 15 2-10mrrVh (Male)

3-15 mm/h (Female)

C-reactive peptide 5 <8.2 mg/L

Rheumatoid factor 30 <58 klU/L

Urea 4 2.75-74 mmol/L

Creatinine 75 44-115 pmol/l

Which of the following is the most likely rheumatologicai disease?

A 30-year-o‘d woman with systemic lupus erythematosus is complaining of arthralgia and skin rash for 3 months. Examination revealed active arthritis at two small joints of right hand and

malar rash over her face (see lab results).

Test Result Normal Values

Hb 110 130-170 grt. (Male)

120-160 g/L (Female>

Platelets count 190 150-400 x 109/L

WBC 6 4.5-10.5 x 109/L

ESR 35 2-10 mmfh (Male)

3-15 mm/h (Female)

Urea 5 2.75-7 4 mmolA.

Creatmine 65 44-115 pmol/L

Which of the following advice should be presented to the patient about hydroxychloroquine?

A 38-year-old man presented to the clinic complaining of recurrent painful swelling affecting right knee and left ankle for 6-months despite using non-steroidal anti-inflammatory drugs. His past history revealed urinary tract infection 2-weeks prior to onset of his joint pain. On

examination, he has active arthritis at nght knee and left ankle (see lab results). Test Result Normal Values

Hb 160 130-170 gA. (Male)

120-160 g/L (Female)

Platelets count 450 150-400 x 109/L

WBC 12 4.5-10.5 x 109/L

ESR 65 2-10 mmfh (Male)

3-15 mm/h (Female)

Urea 4 2.75-7 4 mmol/L

Creatinine 100 44-115 pmol/L

C-reactive peptide 20 <8.2 mg/L

Rheumatoid factor 13 <58 klU/L

Color dear clear or light yellow

Protein absent absent

Nitrite absent absent

Leukocytes 2 0-3 per high power field

Which of the following is the most appropriate treatment?

A 50-year-oid man with active rheumatoid arthritis presenied to the clinic complaining of polyarthralg^a and significant early morning stiffness. His current Ireatments are methotrexate, prednisone and hydroxychloroquine

Examination revealed active arthritis at several joints (see lab results).

Test Result Normal Values

Hb 160 130-170 gA_ (Male)

120-160 gTL (Female)

Platelets count 500 150-400 x 109/L

WBC 10 4.5-10.5 x 109/L

ESR80 2-10 mnVh (Male)

3-15 mm/h (Female)

Urea 5 2.75-7.4 mmolA.

Creabnine 75 44-115 pmol/L

C-readive peptide 18 <82 mg/L

Rheumatoid factor 600 <58 klU/L

Aspartate aminotransferase 37 12-40IU/L

Alanine aminotransferase 35 5-40 IU/L

Albumin 50 34-56 g/L

Which of the following is the most appropriate additional treatment option?

A 30-year-oid woman presented to the clinic with poiyarlhralgia. malar rash and mucosal ulcerations for 2-months. Examination revealed active malar rash and arthritis affecting several joints. She has positive anti-nudear antibody with high titer (see lab results).

Test Result Normal Values

Hb 100 130-170 gn. (Male)

120-160 g/L (Female)

Platelets count 90 150-400 x 109/L

WBC 3.5 4.5-10.5 x 109/L

ESR 60 2-10 mnVh (Male)

3-15 mm/h (Female)

Urea 5 2.75-7.4 mmolA.

Creatinine 150 44-115 pmol/L

Protein 1200 0-150 mg?24 hr

Complement C3 0.4 0 7-1.5 g/L

Complement C4 0.1 0 15-0.45 g/L

Which of the following is the best high dose treatment option at this time?

A 30-year-oia v/oman presented to the clinic with polyarthralgia, malar rash and mucosal ulcerations for 2-months. Examination revealed active malar rash and arthritis affecting several  joints. She has positive antwnudear antibody with high titer (see lab results). Test Result Normal Values

Hb 110 130-170 gfl.<Male)

120-160 grt. (Female)

Platelets count 280 150-400 x 109/L WBC 10 4.5-10.5 x 109/L

ESR 65 2-10 mnVh (Male)

3-15 mm/h (Female)

Urea 4 2.75-7.4 mmol/L

Creatinine 60 44-115 pmol/L

Appearance clear clear

Protein absent absent

Leukocytes 2 0-3 per high power field

Erythrocytes 0 0-2 per high power field

Complement C3 0.6 0.7-1.5 g/L

Complement C4 0 13 0 15-0.45 g/L

Alkaline phosphatase 50 39-117 IU/L

Alanine aminotransferase 18 5-40 IU/L

Aspartate aminotransferase 20 12-40 IU/L

Which of the following Is the best treatment option at this time?

A 22-year-oid woman presented to the clinic with 2-months history of polyarihralgia, s๒n rash, mucosal ulcers and fatigue. Her clinical examinations revealed malar rash over her face and active arthntis at several joints (see lab results).

Test Result Normal Values

Hb 100 130*170 gA.<Male)

120-160 g/L (Female)

Platelets count 100 150-400 x 109/L

WBC 3 4.5-10.5 x 109/L

ESR 35 2-10 mmfh (Male)

3-15 mm/h (Female)

Lupus anticoagulant positive negative

Urea 5 2.75-74 mmol/L

Creatinine 78 44-115 pmol/L

C-reactive peptide 5 <8.2 mg/L

Complement C3 0.3 0.7-1.5 g/L

Complement C4 0.13 0.15-0.45 g/L

Which of the following test obtained at this visit is most likely to confirm the diagnosis?

A 24-year-oifl woman is 10-weeks pregnant. She has dysuria and is diagnosed with a urinary tract infection.

Which of the following antiDiotics is contraindicated?

A 58-year-oid man presented with 2-weeks history of tiredness, dyspnea and 5-days history of fever. No previous surgical history. Cardiac exam shows pan systolic murmur at the apex. Hands exam shows splinter hemorrhage on nails.

Temperature 38.5 °C

Which of the following is the most appropriate empirical therapy?

A 62-year-otd man presented with 2-weeks history of tiredness, dyspnea and 5-days history of

fever. No previous surgical history. Cardiac exam shows pan-systolic murmur at the apex. Hands exam shows splinter hemorrhage on nails Temperature 38 8 ^VC

Which of the following is the most likely causative organism?

A 48-year-old diabetic woman presented to Emergency Department will) dysuria (see lab result and report).

Test Result Normal Values

WBC 14 4 5-10.5X 109/L

Creatnine 230 44-115 pmol/L

Urine culture:

> 100,000 cf_E,coli

Which of the following medications is contraindicated?

A 45-year-oia woman presented to Emergency Department with fever, flank sain and dysuna

(see lab result and report).

Test Result Normal Values

WBC 14 4.5-10.5 x 109/L

Urine culture:

> 100,000 ๙๙๗ E.coll

Which of the following is the best empirical treatment option?

A 45-year-old diabetic woman presented to Emergency Department with fever, flank pain and dysuna. She is allergic to penicillin. Examination shows flank tenderness (se? lab result and report).

Temperalure 39 ºC

Test Result Normal Values

WBC 17 4.5-10.5 x 109/L

Urine culture:

> 100.000 cf๙ml E.coli.

Which of the following is absolutely contraindicated?

A 38-year-oid woman, 28-weeks pregnant came for routine follow up. She has no symptoms and her pregnancy is all well. Upon reviewing her labs, a positive urine culture : > 100,000 cfu/mi E.coli was found which was sensitive to ciprofloxacin, nitrofurantoin, trimethoprim/sulfamethoxazole and ceftriaxone

Which of the following is the best treatment oplion?

A 38-year-old woman came for routine follow up 2-months after delivery. She has no symptoms and her baby is well and lactating normally. Upon reviewing her labs, a positive urine culture : >100,000 cfu/mi E coli was noticed which was sensitive to trimethoprim/sulfamelhoxazole. ciprofloxacin, and nitrofurantoin.

Which of the following Is the best treatment option?

A 64-year-oid diabetic woman is receiving hemo-dialysis through a femoral central line. She develops line sepsis. Blood culture grows MRSA (methiollin resistant staphylococcus aureus). She was started on IV vancomycin 1000 mg every 72 hours (to be infused over 20 min). Immediately after starting vancomycin, she started to have flushing, redness and itching over the face, neck and trunk

Which of the following is the most appropriate management approach?

A 27-year-old man recently returned from Umrah. Ptesents to Emergency Department with 1- day history of fever and headache. On examination, positive Kemlg’s sign and petechial rash on extremities and trunk He was isolated and started on antibiotics (see lab results and report)

Temperature 39º C

Test Result Normal Values

proteiMMen) 0.9 0.22-0.33 g/L Glucose 1.2 2.50-3.89 mmol/L

CSF analysis:

WBC differential 87 % neutrophil and 5% lymphocytes.

How many hours after starting antibiotics should isolation be discontinued?

A 24-year-old married woman came to the clinic complaining of yellowish offensive vaginal discharge and itching for 2 weeks duration. She has no other significant medical history. Vaginal swab done which showed motile flagellate organisms on wet film microscopy. Appropriate treatment was initiated.

Which of the following is the best management option for her husband?

A 24-year-old woman came to the clinic complaining of yellowish offensive vaginal discharge and itching for 2 weeks duration. She has no other significant medical history Vaginal swab done which showed motile flagellate organisms on wet film microscopy

Which of the following is the best treatment option?

A 35-year-old man presented with fever, rigors and weight loss for 10 days. He underwent Mitral valve replacement by prosthetic valve a month ago. Echo showed small vegetation.

Blood pressure 90/70 mmHg

Heart rate 100 /min

Temperature 38.7 °C

Which of the following organisms is the most likely to be responsible for his presentation?

A 23-year-oid pregnant woman presented with frequency and dysuria for 5 days (see lab result).

Bfood pressure 110/70 mmHg

Heart rate 76 /min

Temperature 37.6 °C

Test Result Normal Values

Leukocytes 30 0-3 per high power field

Which of the following is the best treatment option?

An 82-year-oid woman admitted to the hospital for meningitis. Her CSF was obtained and Gram starn showed Gram negative cocco-bacilll

Which chemo-prophylaxis should be offered to her contacts?

A 39-year-old man came to the dinic for foilow-up. He is recently diagnosed as pulmonary tuberculosis and was started on rifampicin, Isoniazid, pyrazinamide and ethsmbutol for 4 weeks, Basic lab workup were normal. LFT test was repeated (see lab results). Test Result Normal Values

Direct bilirubin 56 1.5-6.5 pmol/L

Total bilirubin 76 3.5-16.5 pmol/L

Aspartate aminotransferase 465 12-40IU/L

Alanine aminotransferase 620 5-40 IU/L

Alkaline phosphatase 720 39-117 IU/L

Gamma glutamyttransferase 387 6 to 37 IU/L

Which of the following is the most appropriate next step?

A 45-year-oJd man has been diagnosed as a case of pulmonary tuberculosis

Which of lhe following investigations is essential prior Initiation of the therapy?

A 51-year-old woman presented to the hospital with 2-days history of malaise and headache. The headache became more intense and was associated with pain in her neck Her husband reported that she had also fever She was previously v'ell with no significant medical history. On examination, she looked unwell confused, febrile and with positive Kemig's sign. CT scan brain was normal. Lumbar puncture done (see lab results).

Test Result Normal Values

Colour Turbid colourless

Total protein (Women) 0,9 0.15-0.45 g/L

Glucose 1,6 2.50-3.89 mmol/L

Which of the following is the most likely causative organism?

A 35-year-oid man presented to Emergency Room with recurrent attacks of high-grade fever with chills for 1 week He was on a work trip to Sudan 3 weeks ago. Each attack begins with chills for few hours followed by fever up to 40.5 degree, which resolves with profuse sweating The attacks comes every other day. On examination, mild splenomegaly was detected. Blood smear at Emergency Room was negative for parasites.

Blood pressure 110/70 mmHg

Heart rate 120/mln

Temperalure 39 ºC

Which of the following is the most appropriate next step in diagnosis?

A 70-year-oid man admitted with left lower limb swelling and pain diagnosed as DVT where heparin was started. He has a history of diabetes mellitus. hypertension and chronic heart

failure. He is on insulin: furosemide and enalapril (see lab results). Blood pressure 110/70 mmHg

Heart rate 76 /min

Oxygen saturation 94 %

Test Result Normal Values

Sodium 135 134-146 mmol'L

Potassium 6.0 3.5-5.1 mmol/L

Chloride 107 97-108 mmol/L

Urea 7 9 2.75-7 4 mmol/L

Creatmine 120 44-115 pmol/L

APTT 50 30-40 sec

Prothrombin time 14 10-13 sec

Which of the following medications should be discontinued at this stage?

A 70-year-old man presented with progressive dyspnea, palpitation and fatigue for 3 months He is known to have hypertension on captopril. He underwent echo which showed poor left ventricular function so furosemide was added with good control of his symptoms. His vital signs upon the last clinic visit shown below.

Blood pressure 150/90 mmHg

Heart rate 90/mln

Respiratory rate 18/min

Oxygen saturation 95 %

Which of the following medication should be added at this stage?

Asymptomatic healthy 24-year-old woman came for a check-up visit and found to have grade II mid-diastolic murmur over the apex

Which of the following is the best next step in diagnosis?

A 65-year-old man with heart failure requires rate control to treat coexisting atnal fibrillation.

Which of the following is the best treatment option?

A 72-year-o«d man presented with acute sever chest pain with an ECG revealing St segment elevation ll.ll.AVF, leads was treated with thrombolysis but 2 days later acutely unwell with sever dyspnea. On examination, he has loud systolic murmur at the apex, which radiates to the axilla and bilateral crackles at the base of the lungs

Blood pressure 90/60 mmHg

Heart rate 100 /min

Respiratory rate 25 /min

Oxygen saturation 8B %

Which of the following is the most likely diagnosis?

A 28-year-o!d woman who is a known case of mitral stenosis came to the clinic asking about how critical >s her condition Echo was done and mtral valve orifice was recorded

Which of the following mitral valve orifice measurement is cons der critical?

A 38-year-old Indian man presents with progressive dyspnea for 3 months. He has past history of old tuberculosis. He has no other medical problems and not on any medications. His JVP was elevated and rises further on inspiration. Cardiac examination was normal with no murmurs.

Blood pressure 105/60 mmHg

Heart rate 120/min

Oxygen saturabon 93 %

Which of lhe following Is the most likely diagnosis?

A 67-year-oid man known to have hypertension came to Emergency Room with acute onset of pal station. His pulse on the monitor showing pulse rate of 170/min. He have inegular pulse with normal cardiac and chest examinations.

Blood pressure 120/70 mmHg

Respiratory rate 18/min

Oxygen saturation 91 %

Which of the following is the best treatment option?

A 65-year-oid man found lo have an ejection systohc murmur on clinical examination There is no history of chest pam. shortness of breath nor syncope. ECHO confirmed aortic stenosis with good left ventricular systolic function Aortic valve gradient of 40 mmHg.

Blood pressure 100/65 mmHg

Heart rate 67 /min

Which of the following is the most appropriate management option?

A 65-year-old woman came for routine annual check-up found to have with harsh ejection systolic murmur, which propagated to the neck.

Which of the following factors is the most important in deciding the time of the surgery?

A 28-year-old man presents with recent onset of chest pain. The pain is retrosternal, localized, sharp and constant in intensity. He nobced increase in seventy with movement. He started active exerdse program a week prior to the onset of the symptom.

Blood pressure 110/70 mmHg

Heart rate 76 /min

Oxygen saturation 95 %

Which of the following is the most appropriate next step in management?

A 62-year-oJd man presents to Outpatient Clinic with recurrent episodes of sternal chest tightness, which occurs mainly after heavy physical exertion He has no chronic medical problems Clinical examination and baseline ECG were normal.

Which of the following is the most appropriate next step in diagnosis?

A 67-year-old man presents with insomnia, irritabrfity and palpitation for 3 months. He is known to have hypertension, depression and atnal fibrillation. He is on amiodarone, fluoxetine and enaloprii. Clinically, he is unremarkable Blood pressure 130/70 mmHg

Head rate 76 /min

Oxygen saturation 95 %

Which of the following is the most approp<iate next step?

A 54-year-oid man presents with shortness of breath and fever for 1 week. On physical examination, the patient is febrile and dyspneic. His oxygen's saturation is 89% on room air Chest examination shows absent breath sounds and dullness to percussion over right lung field Chest radiography confirms a large right-sided pleural effusion

Which of the following factors indicating the need for therapeutic thoracentesis?

A 54-year-oid man presents with shortness of breath and fever for 1 week. On physical examination, the patient is febrile and dyspneic. His oxygen's saturation is 89% on room air. Chest examination shows absent breath sounds and dullness to percussion over right lung field. Chest radiography confirms a large nght-sided pleural effusion.

Which of the following Is the most useful to establish a diagnosis of exudative pleural effusion?

A 45-year-oid woman is evaluated for a 3-week history of progressive shortness of breath that limit her activities Medical history is significant for asthma and moderate mitral regurgitation Her only medication is an albuterol inhaler as needed. On physical examination, her vital signs are normal. Cardiac examination reveals a grade 3/6 holosystolic murmur radiating to the axilla Lungs are dear to auscultation.

Which of the following is the most appropnate diagnostic test?

A 55-year-oid woman with non-decompensated systolic heart failure and ejection fraction of

25% presents to the dinic for routine follow-up.

Which of the following medications ts the most appropriate management?

A 58-year-old woman was admitted with a diagnosis of acute myocardial infarction received appropriate treatments and now she is ready for discharge. She is so concern about the secondary prevention of infarction.

Which of the following statements is the most appropriate?

A 28-year-oid man Is evaluated In the Emergency Departmeni for severe persistent chest pain for 1-day. The pain is constant but exacerbated when leaning forward and not associated with other symptoms Physical examination is unremarkable apart of a friction rub at lhe left lower sternal border. Electrocardiogram shows diffuse, concave upward ST-segment elevations and PR-segment depression most prominent In leads V1 through V6.

Which of the following is the most appropriate treatment?

A 26’year’Old pregnant woman visits the clinic for regular follow-up. She is asymptomatic. She is in her 30th week of pregnancy. Her physical examinalion reveals a mid-systolic ejection murmur at the right upper sternal border The murmur radiates to carolids No diastolic murmur Is heard.

Which of !he following Is the most likely diagnosis?

A 68-year-old man presented to the Emergency Department with progressive exertional dyspnoea, orthopnea and dry cough for 7 days. His medical history is significant for hypertension. Physical examination reveals raised central venous pressure, fine crackles at lung bases and hepatomegaly. His extremity examinabon reveals bilateral pitting edema. Echocardiogram shows a left ventricular ejection fraction of 60% and normal valves. Chest radiograph shows evidence of pulmonary edema (see lab results).

Blood pressure 160/85 mmHg

Heart rate 86 /min

Respiratory rale 18/min

Test Result Normal Values

Sodium 140 1M-146 mmol/L

Potassium 4 3.5-5.1 mmol/L

Urea 6 2.75-7.4 mmol/L

Creatnlne 88 44-115 pmol/L

Brain natriuretic peptide 900 0-300 ng/L

Which of the following is the most appropriate next step in the management?

A 55-year-old woman presents to the clinic for her regular foflow-up. 6 months ago, she presented to Emergency Department with palpitations and dyspnea and diagnosed to have atrial fibnllation. She is currently asymptomatic with no palpitations. Her medical history is also significant for a transient Ischemic attack and hypertension Her medications are warfarin, metoprolol and candesartan. Her physical examination Is unremarkable Her most recent electrocardiogram shows normal sinus rhythm

Which of the following is the most appropriate management?

A 58-year-o!d woman with hypertension and type 2 diabetes meHitus presents to the clinic for routine follow-up. She has no symptoms. Medicatons are hydrochlorothiazide, losarlan. atorvastatin, and metformin. Cardiac examination shows a grade 2/6 diastolic murmur heard best over the apex. Peripheral pulses are normal. Electrocardiogram shows sinus rhythm with

nonspecific ST changes.

Blood pressure 160/80 mmHg

Heart rate 78 /min

Respiratory rate 18/min

Temperature 36.6 “C

Oxygen saturation 96 %

Which of the following is the most appropriate test to perform next?

A 60-year-old man is evaluated in the clinic for cardiac risk assessment. He is asymptomatic and physically active. He has never smoked. He has no chronic health issues and takes no medications. His physical examinations are normal. Card ovascular risk calculation using the Pooled Cohort Equations predicts a 6.5% risk of a myocardial infarction in the r»ext 10 years that indicate an intermediate risk of myocardial infarction.

Which of the following investigatons should be done next?

A 32-year-old man is evaluated in the clinic because of an abnormal c^iest computerised tomography (CT) scan that revealed a small lung lesion (7 mm) without any other abnormalities He is non-smoker and he is asymptomatic. Physical examination shows no lymphadenopathy

and normal lung examinations (see lab results).

Test Result Normal Values

Hb 140 130-170 ga_ (Male)

120-160 g/L (Female)

Platelets count 300 150-400 x 109/L

WBC 8 4.5-10.5 x 109/L

ESR 11 2-10 mnVh (Male)

3-15 mm/h (Female) Calcium 2.25 2.15-2 62 mmoVL

Which of the following is the most appropriate procedure to cJo next?

A 58-year-old woman with acute onset shortness of breath and pleuritic chest pain She is diagnosed with pulmonary embolism.

Which of lhe following is an indication to do thrombophilia workup?

A 66-year-oid woman with severe COPD is admitted with 4 days of dyspnoea and cough She is alert, in moderate respiratory distress, and has an oxygen saturation of 93% on 3 L/min supplemental oxygen A chest radiography demonstrates no consolidation. She receives intensive bronchodilator therapy and systemic steroids (see lab results)

Test Result Normal Values

ABG PCO2 8.8 4.7-6.0 kPa

pH 7.28 7.36-7.45

ABG PO2 9.9 10.6-14.2 kPa

Which of the following is the best next step in the management?

A 31-year-old woman is evaluated because of daily wheezing and breathlessness that limit her actvities several times a week. Medical history is otherwise unremarkable. She has never smoked. She is diagnosed with moderale persistent asthma

In addition to a short-acting 02-agonlst,

which of the following Is the most appropriate treatment?

A 26-year-oid man presents to lhe clinic with shortness of breath and occasional wheeze that occurs several times per week He develops significant shortness of breath when playing football He notes that it takes several minutes to recover hrs breath wtien this occurs. He also notes coughing during exercise as well He takes no medications On physical examination, vital signs are normal. Mild nasal congestion is noted. His systemic examinations are unremarkable A chest ratJiograph is normal. Spirometry findings are within normal parameters

Which of the following is the most appropriate next step In assessment?

A 28-year-oid woman with bronchial asthma that controlled on budesomde and albuterol inhafers is evaluated in the clinic as she is 6 weeks pregnant. Her symptoms are well controlled on the treatment However, symptoms usually flare in fall and she treats these symptoms with an aOd-on oral leukotriene inhibitor She currently has no asthma symptoms On examination, vital signs are normal. The lungs show good air entry and no wheezes. She is so concern about the safety of medications during pregnancy.

What is lhe best information to be delivered io her with regard to medication safety⁷

A 66-year-oid woman is evaluated for a 6-week history of increasing dyspnea and right-sided pleuritic chest pain with occasional cough. She has lost significant body weight in the last 3 months. She has no other medical problems and takes no medications. Her physical examination reveals dullness to percussion and decreased breath sounds over both lower lung zones. A 4-cm nght breast mass is palpated. Chest radiograph demonstrates Dilateral pleural effusions but no evidence of infiltrate or pulmonary vascular congesbon. Thoracentesis is performed. Pleural fluid Gram stain is negative (see lab results).

Test Result Normal Values

Total Protein 40 10-20 g/L

Fluid ProteirVSerum Protein 0.67 <0 5

Glucose 3 5 >2 2 mmol/L

LDH 350 <200/UL

Total Proteins 60 60-84 g'L

Lactate dehydrogenase 125 60-160 IU/L

Leukocytes 3600 <1000/pL

Which of the following Is the most appropnate statement about the diagnosis?

A 55-year-oid woman with a chronic obstructive pulmonary disease (COPD) on combination of long-actmg p2-agonist and inhaled glucocorticoid and albuterol as needed presents to the clinic with worsening of her symptoms. On physical examination, there is no jugular venous distention Pulmonary examination reveals decreased breath sounds Bilateral lower extremity edema is noted to a level above the ankles. Echocardiogram is normal apart ๙ high mean pulmonary artery pressure, 52 mmHg (see lab results)

Blood pressure 125/75 mmHg

Heart rate 84 /min

Respiratory rate 20 /mm

Temperature 36.6 °C

Oxygen saturation 86 %

BMI 30 kg/m2

Test Result Ncwmal Values

ABG PCO2 7.5 4.7-6.0 kPa

pH 7.6 7.36-7.45

ABG PO2 8.6 10.6-14.2 kPa

Which of the following is the most appropriate treatment at this time?

A 32-year-old man is evaluated for a 10-month history of fatigue and diarrhoea. He has a good appetite but has unintentionally significant weight loss over the past 10 weeks. He has not had blood in the stool, melena. or other obvious source of blood loss. His systemic examinations are unremarkable. Stool is negative for occult blood (see lab results).

Blood pressure 110/70 mmHg

Heart rate 80/min

Respiratory rate 16/min

Temperature 36.6 ºC

BMI 18 kgrm2

Test Result Normal Values

Hb 109 130-170 g/L (Male)

120-160 (Female)

MCH 20 28-33 pg/cell

MCV 70 80-95 fl

Platelets count 455 150-400 x 109'L

WBC8 4 5-10.5X 109/L

Aspartate aminotransferase 30 12-40IU/L

Alanine aminotransferase 26 5-40 IU/L

Albumin 32 34-56 g/L

Total bilirubin 10 3.5-16.5 pmol/L

Which of the following is the best treatment?

A 50-year-oid man presents to the Emergency Department with acute onset of abdominal pain, nausea and vomiting. Atxtominal examination shows tenderness and guarding at the epigastrium. CT scan of the abdomen reveals fluid around the pancreas He was admitted and started on intravenous fluids; analgesics and nasogastric suction (see lab results)

Test Result Normal Values

Hb 120 130-170 g/L (Male)

120-160 g/L (Female)

Platelets count 190 150-400 x 109/L

WBC 18 4.5-10.5 x 109/L

Aspartate aminotransferase 55 12-40IU/L

Alanine aminotransferase 65 5-40 IU/L

Lactate dehydrogenase 6 1.4-3.56 pmol'L

Amylase 850 24-151 IU/L

Lipase 900 0-160 IU/L

Which of the following is the most approp«iate next step in the management?

A 45-year-old man with a diagnosis of gastroesophageal reflux disease who is taking a maximum dose of pantoprazole fo» several weeks presents to the clinic witti heartburn that is minlmalty Improved with treatment The patient verified that he is taking the medication 30 minutes before meals. He takes no other medications. His physical examination is unremarkable. Upper endoscopy findings are normal

Which of the following Is the most appropriate next step In the management?

A 40-year-old man is evaluated in the Emergency Department for several episodes of hematemesis He has no previous similar episodes His history is unremarkable He takes no medications. There is no jaundice or other signs of chronic liver disease Abdominal examination reveals no tenderness, guarding, or rebound (see lab results).

Blood pressure 105/65 mmHg

Heart rate 110/mln

Temperature 36.8 °C

Test Result Normal Values Hb 95 130-170 g/L (Male)

120-160 g/L (Female)

Platelets count 250 150-400 x 109/L

WBC 12 4.5-10.5 x 109/L

Prothrombin time 11 10-13 sec

Alanine aminotransferase 30 5-40 IU/L

Alkaline phosphatase 26 39-117 IU/L

Blood urea nitrogen 14 2.8 to 8.9 mmol/L

Creatinine 88 44-115 Mmol/L

Which of lhe following Is the most likely cause of his gastrointestinal bleeding?

A 35-year-old nurse is seen in the dime after a recent routine screening for viral hepatitis infection. She was found to have positive antibody to hepatitis C virus (HCV). Her medical history is unremarkable; she has not used iliiat drugs or had any history of blood transfusions. She currently feds well and takes no medications. Vital signs and physical examination are normal. Laboratory studies reveal a positive HCV antibody test but HCV RNA testing is negative (see lab results).

Test Result Normal Values

Hb 120 130-170 ga. (Male)

120-160 g/L (Female)

Platelets count 300 150-400 x 109/L

WBC 8 4.5-10.5 x 109/L

Aspartate aminotransferase 26 12-40 IU/L

Alanine aminotransferase 30 5-40 IU/L

Alkaline phosphatase 80 39-117 IU/L

Gamma glutamyl transferase 25 6 to 37 IU/L

Which of the following is the most appropriate action to be done?

A 34-year-old man presents to the clinic with symptoms of gastroesophageal reflux disease that not responding well to esomeprazole 20 mg once a day. Despite mild improvement in his symptoms, he continues to wake up with an acid taste in the middle of the night. He has not had difficulty swallowing. He confirms that he takes the medication properly. Physical examination is unremarkable His laboratory investigation are within normal range.

Which of the following is the most appropriate management for this patient?

A 28-year-oia woman has 2-week history of jaundice and an 11-month history of progressive fatigue and arthralgia. She is not on any regular medication and does not drink alcohol. Her examination reveals hepatosplenomegaly. Viral hepatitis screening tests are negative (see lab results).

Test Result Normal Values

Hb 10 130-170 gA. (Male)

120-160 g/L (Female)

Platelets count 120 150-400 x 109/L

WBC 7 4.5-10.5 x 109/L

Total bilirubin 26 3.5-16.5 pmol/L

Aspartate aminotransferase 920 12-40IU/L

Alanine aminotransferase 890 5-40 IU/L

Alkaline phosphatase 160 39-117 IU/L

Albumin 30 34-56 g/L

Which of the following is the most likely diagnosis?

A 48-year-old woman is seen in the clinic because of recurrent severe nocturnal chest pain for several months that rapidly resolved with sublingual nitrate. She had a normal cardiac catheterization and positive ergonovine echocardiography testing. She does not want lo use mulbple medications and she accept to use only one drug as a long-term maintenance therapy.

Which of the following drugs is the best strategy for long-term management of this patient?

A 38-year-old man wtio is smoker for several years presents to the clinic with progressive shortness of breath. Pulmonary function test (PFT) done which results in the following parameters: forced expiratoy volume (FEVI)rforced vital capacity (FVC) ratio < 0.7 with minimal improvement after bronclxxlilators low diffusing capacity for carbon monoxide (DLCO). Which of the following is the most likely diagnosis?

A 65-year-oid man presents to the Emergency Department with exertional syncope and progressive shortness of breath. Clinical examination reveals fine crackles al both lung bases and mid-systolic murmur at right upper sternal boarder that radiated to carotids. Chest radiography demonstrated clear evidence of pulmonary edema.

Which of the following statements about the assessment and diagnosis is the most accurate?

A 25-year-oid woman non-smoker presents to Emergency Department with sudden onset of severe chest pain and shortness of breath. Her past medical history is significant for caesarean section 4 days ago. Her examinations show a distressed woman with oxygen saturation 92% but otherwise unremarkable. Chest raOiography is unremarkable.

Which of the following is the most appropoate management?

A 25-year-dd man presents to the Emergency Department with progressive shortness of breath, non-productive cough and wheezes for 1 day. On examinations, he has obvious difficulty in breathing and his lungs show with diffuse wheezes but no crackles.

Blood pressure 120/70 mmHg

Heart rate 100 /min

Respiratory rate 28 /min

Temperature 36 6 'C

Oxygen saturation 93 %

Which of the following is the most effective initial treatment at this time?

A patient with a diagnosis of advanced chronic obstructive pulmonary disease (COPD) who is discussing with his doctor the therapeutic benefits of different therapies on his survival rate.

Which of the following therapies is most likely to improve his survival?

A 36-year-oid man presents to Emergency Department with 4-week history of low-grade fever, non-productive cough and shortness of breath On examination, he is febrile with temperature 37.9 °C and his lung examination reveals dullness to percussion with markedly diminished

breath sound over half of the lung field on the right side. A diagnosis of tuberculous pleural effusion is suspected. Chest radiography shows moderate pleural effusion (see lab results).

Test Result Normal Values

Leukocytes 4500 <1000/pL

Total Protein 6 10-20 g/L

Glucose 1.6 >2.2 mmol/L

LDH 650 <200/UL

Which of the following tests is the most sensitive to establish the diagnosis?

A 36-year-oid man presents lo Emergency Department with 5-day history of fever, productive cough and shortness of breath. On examination, he Is febrile with temperature 38.5 °C and his lung examination reveals dullness to percussion with markedly diminished breath sound over half of the lung field on the right side Chest radiography shows right lower and middle lobes consolidation and moderate pleural effusion.

Which of the following is the most appropiiate management?

A 35-year-oi(l-man presented to the Emergency Department with 5-day history of fever, shortness of breath and productive cough. Lung examination reveals dullness to percussion to approximately half of the lung field on the right and his breath sounds are markedly diminished. Chest radiography.

Shows right lower and middle lobes consolidation with moderate pleural effusion.

Which of the following would indicate the need for tube thoracostomy?

A 50-year-old man presents to the dinic with chronic history of productive cough and shortness of breath. A diagnosis of chronic obstructive pulmonary disease (COPD) is suspected. Pulmonary function test is ordered.

Which of the following pulmonary function tests is most likely to represent COPD?

A 55-year-old man with congestive heart failure on multiple treatments came to the clinic for

follow up. The physician discussed with him the importance of compliance and the effect of the  treatments on his life.

Which of the following medications is associated wth reduced mortality rate in congestive heart failure?

A 28-year-oid man presents to the Emergency Department with sudden onset of chest pain that reduced with sitting foiward associated with shortness of breath class II No history of fever. Examinations reveal a normal heart sound with friction rub His cardiac enzymes are within normal range. ECG shows diffuse ST segment elevation.

Blood pressure 130/70 mmHg

Heart rate 90 /min

Respiratory rate 24 /min

Temperature 37.9 ^CC

Oxygen saturation 95 %

What is the most appropriate treatment for this patient?

A 65-year-o(d man presents Io the clinic with progressive exertional shortness of breath that associated with syncope His examinations show a mid-systohc murmur at right upper sternal boarder that radiates to carotids. Chest x-ray shows cardiomegaly. ECG reveals left ventricular hypertrophy.

Which of the following is the most appropriate management?

A 30-year-oid asymptomatic woman presenis to the dinic as pre-employment screening Her examinations are unremarkable. Her laboratory tests revealed, positive HbsAg, anii-HBc (IgG) and antl-HBe but negative anti-HBs and HBeAg

Which of the following statements is the most accurate?

A 55-year-oid man with chronic hepatitis C present to the clinic for regular follow-up. His examination reveals a palpable right upper quadrant mass. CT scan of his abdomen shows a large 6*6 cm mass in the right lobe of the liver. A mass biopsy confirms the diagnosis ๙ hepatocellular carcinoma

What is the most appropriate management steps at this stage?

A 35-year-old woman with rheumatoid arthritis wtio maintained on methotrexate 15 mg weekly. She is currently on remission. 4 months ago. her liver function tests were normal but the most recent liver function tests are shown (see lab results). Test Result Normal Values

Aspartate aminotransferase 300 12-40 IU/L

Alanine aminotransferase 280 5-40 IU/L

Albumin 30 34-56 g/L

What is the most appropriate action to be done for her abnormal liver function tests?

A 30-year-o!d man with 3 years history of intermittent abdominal pain, bloating and diarrhoea is seen in the clinic.

Which of the following complains is highly suggestive ๙ irritable bowel syndrome’

A 30-year-otd woman presents to the Emergency Department with 2-days history of severe abdominal pain that radiated to the back, which is associated with nausea and vomiting. On examination, she has normal vital signs with tender epigastrium t>ut without rebound (see lab results).

Test Result Normal Values

Platelets count 450 150-400 x 109/L

WBC 14 4.5-10.5 x 109/L

Alanine aminotransferase 80 5-40 IU/L

Aspartate aminotransferase 65 12-40 IU/L

Amylase 800 24-151 IU/L

Lipase 750 0-160 IU/L

HCT 49 0.42-0.52 (Male)

037-0.48 (Female)

Which of the following predicJ a poor prognosis for this patient?

A 29-year-o4d man wtio is smoker for 5 years had appendectomy 2 years ago. He came to the dinic to discuss with you his risk to develop Crohn's disease because his brother has Crohn's disease that difficult to be controlled.

Which of the following increase the nsk for the development of Crohn's disease?

A 38-year-oid man presents to the dime complaining of severe epigastric pain that is worse after eating. He describes the pam as burning in nature with mild improvemen! with antacid therapy. Physical examination is unremarkable (see lab results).

Test Result Normal Values

Hb 120 130-170 ga_ (Male)

120-160 gl. (Female)

Platelets count 450 150-400 x 109/L

WBC 10 4.5-10.5 x 109/L

Urea 8.5 2.75-7.4 mmol/L

Creatnine 65 44-115 pmol/L

What is the most appropriate test to establish the diagnosis?

A 29-year-oid man is seen in the pre-employment clinic for routine exam He is asymptomatic Physical examination revealed a systolic murmur that heard at the apex. The murmur is augmented with sustained handgrip and reduced with Valsalva manoeime.

Which of the following is the most likely cause for this murmur?

A 62-year-oid man presents with a 3-month histcxy of epigastric pain after eating and intennlttent heartburn between meals. He has lost weight but does not have any nausea or vomiting. He has not noticed any change in Dowel habit and has not passed any blood or melena stools. He has no past medical history. He quit smoking 2 years ago

What is the most appropriate management strategy?

A 63-year-oid smoker man presents with pain in his left leg, wh.ch is exacerbated by exercise and relieved by rest. Examination revealed weak pulses in the left leg compared to the right. The ankle brachial pressure Index is 0 84

Which of the following is the most likely diagnosis?

A 77-year-dd woman comes to the clinic for a check-up. She has an irreguler pulse when the nurse checked her vitals An ECG has confirmed persistent atrial fibrillation She Is completely asymptomatic. She has a past medical history of migraine and asthma and on salbutamol PRN

for asthma and PRN ibuprofen for her migraines Other clinical examination s normal Blood pressure 138/85 mmHg

Heart rate 88 /min

What antithrombotic treatment should be considered first line in this patient?

A 60-year-old man with chronic history of heart bum for several years, presented with occasional

hematemesis. Upper Gl endoscopy revealed intestinal-type metaplasia at the distal oesophagus.

Which of the following Is the most likely diagnosis?

A 24-year-oid man presented with 2-month of bloody diarrhoea He passes 3-4 loose motions /day associated with blood and mucus He gave history of left lower quadrant pain No fever or weight loss. He underwent sigmoidoscopy, which showed loss of normal vascular pattern with

erosions up to splenic flexure (see lab results)

Test Result Normal Values

4.7-6.1 x 1012/L (Male)

4.2-5.4x1012๕ (Female)

Hb 10.9 130-170 g/L (Male)

120-160 g/L (Female)

Platelets count 488 150-400 x 109/L

WBC 6 4.5-10.5 x 109/L

ESR 32 2-10 mnVh (Male)

3-15 mm/h (Female)

Consistency LIQUID (soft or tight)

Color YELLOW Brown

Mucus and blood *♦ absent

Leukocytes +++ solitary

Which of the following is the best treatment option?

A 16-year-old man presented to the Outpatient Department complaining of diarrhoea for 3 years. He was passing 3-4 large volume stool per day. which was foul smelling and contained undigested food but no blood or mucus. He was also complaining of postprandial bloating and easy fatigability. On examination, he looked pale and has no secondary sexual characteristics

(see lab results)

BMI 14 kg/m2

Test Result Normal Values Hb 10 130-170 g4_ (Male)

120-160 g/L (Female) MCV 70 80-95 fl Platelets count 433 150-400 x 109/L Alanine aminotransferase 90 5-40IU/L Aspartate aminotransferase 60 12-40 IU/L ESR 12 2-10mmfh (Male)

3-15 mm/h (Female)

Which of the following is the most appropriate diagnostic test?

A surgeon was performing a procedure on a patient with chronic hepatitis C infection. He accidentally had a needle slick injury

What is the likelihood of hepatitis C transmission?

A 23-year<ud woman was informed that her husband has chronic hepatitis B infection She was

worried that he had transmitted the virus to her. She is currently asymptomatic apart from fatigue.

What is the first evidence of acute infection in her case?

A 47-year-old alcoholic patient presented with 6-week history of weight loss, fever, and rl hypochondrium pain (see lab result and report).

Test Result Nomal Values

Alpha fetoprotein 120 0-40 ng'mL

Abdominal Ultrasound

Showed ascites and focal liver lesion in a cirrhotic hver

Which of the following is the most likely diagnosis?

A 32-year-old woman 30-week pregnant G1*0»0, presented to the clinic with pruritus and jaundice. There is no lever, abdominal pain, or vomiting. She is not on any medications and no chronic medical illness (see lab results).

Test Result Normal Values

Hb11 130-170 g/L (Male)

120-160 g/L (Female)

Platelets count 160 150-400 x 109/L

WBC 7 4.5-10.5 x 109/L

Alkaline phosphatase 700 39-117IU/L

Alanine aminotransferase 79 5-40 lU'L

Aspartate aminotransferase 100 12-40 IU/L

Which of the following is the most likely diagnosis?

old patient with Chronic hepatitis B , then
discover 70% of the liver was multiple lesions,
next ?

A 34-year-oid pregnant woman, known case of chronic hepatitis B, comes to the clinic for counselling regarding the risk of hepalitis B transmission to her baby (see lab results and report).

Test Result Normal Values

Alkaline phosphatase 198 39-117 IU/L

Alanine aminotransferase 120 5-40 IU/L

Aspartate aminotransferase 67 12-40 IU/L

Hepatitis B viral load

1 million copies/ml

Which one of the following the baby should receive to reduce the vertical transmission risk?

A 69-year-oid man known to have diabetes mellitus, presented to Emergency department with 4-day history of productive cough and tachypnea. On examination, oriented to time place and person. Chest exam revealed right lower lobe crepitation (see lab results and report).

Respiratory rate 23 /min

Temperature 38.5 °C

Test Result Normal Values WBC 12 4.5-10.5 x 109/L

Urea 5 2.75-7 4 mmol/L

Chest X-Ray:

Right lower lobe infiltrate.

Which of the following is the most approp<iate management approach?

A 62-year-oid patient known case of chronic hepatitis C presented with atxlominal pain and swelling Examination showed ascites, abdominal tenderness and peripheral edema Diagnostic ascitic tap done and revealed a neutrophil count of 400/mm (<250 mm)

Blood pressure 110/70 mmHg

Heart rate 90 /min

Temperature 37.6 °C

Which of the following is the appropriate next step in the management?

A 66-year-oid man with hypertension comes to the dinic for a follow-up He is currently taking a combination of losartan and amlodipine, which Is falling to keep his blood pressure within target Examination is unremarkable His blood test and renal function profile were within the normal limits.

What is the most appropriate next step assuming he has no relevant contraindications?

A 59-year-oifl man presents 4 weeks after being discharged from hospital He had been admitted with chesl pain and thrombolysed for a myocardia¹ infarction. 2 days later, he developed martced tongue and facial swelling His vital signs are within the normal limits

Which of the following drugs is most likely to be responsible?

A 77-year-old man with a history of atrial fibrillation is admitted to the hospital following an acute coronary Intervention and treated with a percutaneous coronary intervention His medication on admission were warfarin, paracetamol and allopurinol. Antithromtx>t：c therapy immediately given after his event.

Which of the following regimen should he be prescribed?

A 44-year-oid woman is diagnosed with non-alcoholic steatohepatitis following a liver biopsy.

What is the single most important step can help to prevent the progression of her disease?

A 2S-year-oid woman with imtable bowel syndrome comes to the dlnic complaining that loperamide and antispasmodic medication have not eased her symptoms. She has no new symptoms suggestive of any serious condition.

Which of the following is the most appropnate treatment?

A 36-year-oid man has just completed a 2-week course of HeUcobacter pylori therapy for dyspepsia He has stopped his eradication therapy today and he wants to repeat the test

How soon can the test be re-performed to test for eradication?

A 28-year-old woman who is 38 weeks pregnant presents with dysuria and urinary frequency. A urine dipstick is positive for nitrites and leucocytes.

Which of the following is the most appropriate management?

A 40-year-old woman is noticed to be jaundiced (see lab results).

Test Result

Anti-HBs Negative

Anti-HBc Positive

HBs antigen Positive

IgM anti-HBc Negative

What is the patient’s hepatitis B status?

A 44-year-oid man who was recently diagnosed as chron：c kidney disease stage 4, presented to the dinic to discuss the diet in regard to his condition He has read that potassium rich food should be consumed in moderate amount.

Which of the following foods should he eat in moderation?

A nurse is bitten by a patient who is known to have hepatitis B She has a documented full history of hepatitis B vaccination and was known to be a responder

What is the most appropriate action to reduce lhe chance of contracting hepatitis B?

A 57-year-old man wtio is intolerant of aspirin is started on clopidogrel for the secondary prevention of ischemic heart disease.

Which of the following drugs can make clopidogrel less effective?

A 61-year-dd man with staWe chronic kidney disease stage 3

Which of the following drugs is it safe to prescribe foe this patient?

A 27-year-oid man wtio has a sister with adult polycystic kidney disease came to screen for the disease.

Which of the following is the most appropriate screening test?

A 58-year-old man with chronic obstructive pulmonary disease (COPD) is ready to be discharged home after acute exacerbation of the disease.

Which of the following parameters indicate offering long-term oxygen therapy?

A 28-year-oid woman comes to the clinic for a check-up. She believes that she is allergic to wheat; her symptoms of abdominal bloating and loose stool have improved over the past few months by eating a gluten-free diet

Which of the following is the most appropnate advice to her?

Which of the following extra-intestinal manifestabons of Crohn’s disease activity?

A 22-year-oiO woman develops severe vomiting 4 hours after having lunch at a restaurant

What is the most likely causative organism?

A 61-year-old man with suspected left ventricular heart failure He had B-type natriuretic peplide

(BNP> test, which came back as being slightly elevated

Which of the following factors cause a falsely elevated BNP?

A 29-year-oid man diagnosed with coeliac disease 2 years ago He complains of ongoing diarrhoea, feeling tired and bloating Poor compliance with a gluten-free diet is suspected

Which of the following is the most appropriate method to ascertain this?

A 58-year-old man with chronic kidney disease has been on haemodialysis for chronic kidney disease for the past 8 years.

What is most likely cause of mortality in such case?

A 61-year old man complains of indigestion that has been bothering him for the past 2 months He has never had these symptoms before and he is eating and drinking well. He says he has lost weight over this period. His bowel habits are normal and he does not complain of any abdominal pains. Abdominal examination is normal Blood tests including full blood count, renal function, and liver function as well as C-reactive protein are normal

Which of the following is the best management plan?

A 30-year-oid man comes to the clinic to discuss his recent blooO test results. A few months ago. he had a health visit that showed an abnormality on his liver function tests when the bilirubin level of 41 mol/L (normal 3-20) with the remainder of the liver function profile being within normal limits. He has no significant medical history. On examination, no significant findings. The physician orders second blood test, results show a normal full blood count, renal function and thyroid function The liver function test Is done (see lab results). Tesl Result Normal Values

Alkaline phosphatase 115 39-117IU/L

AJanine aminotransferase 38 5-40 IU/L

Dired bilirubin 7 15-6 5 pmol/L

Total bilirubin 42 3.5-16.5 pmol/L

Which of the following is the most likely diagnosis?

A 22-year-oid woman with cystic fibrosis presents with a 4-month history of weight loss, diarrhoea and atxlominal bloating. She has pale stools There are no specific abnormalities on examination of the abdomen other than she is clubbed with scattered chest crackles

Which of the following is the most likely diagnosis?

A 46-year-oJd man presents with a Kay history of abdominal pain, vomiting and hematemesis History reveals he is a heavy alcohol drinker He has previously Deen admitted with peptic ulceration and is receiving proton pump inhibitor therapy On examination, he has tenderness over the epigastrium.

Blood pressure 110/69 mmHg

Heart rate 112/min

Which of the following is the most likely diagnosis?

A 48-year-oid woman had terminal Ileum resection due to Crohn's disease She presents this time with difficulty in walking. She is anaemic and has lost position sense bilaterally. Which of the following is the most likely diagnosis?

A 43-year-old woman is evaluated during a follow-up visit. She is overweight and has hypertension and type 2 diabetes mellitus. both of which are well controlled. For several years, she has attempted to lose weight through various commercial diets; dietician-monrtored. calofie- restricted diets: and physical activity but her weight has remained stable. Head. neck. lung, and

heart examinations are normal.

Blood pressure 110/70 mmHg

Heart rale 76 /min

Respiratory rate 13/min

Temperature 36.6 “C

BMI 28.5 kg/m2

In addition to continuing catorie restriction and exercise, which of the following is the most appropnate management to help this patient achieve weight loss with tolerable side effect?

A 70-year-oid man was hospitalized 6 days ago for a 4-day history of acute leg ischemia treated with angioplasty and stenting He is now asymptomatic He has a history of stage 3 chronic kidney disease and hypertension that is well-controlled w>th diltiazem and captopril Other medications are aspirin and dopidogrel. On physical examination, lhe patient is afebrile and

normal blood pressure. The remainder of the examination is unremarkable (see lab results).

Test Result Ncwmal Values

Creatinine 140 44-115 pmol/L

Total Cholesterol 5.9 <5.1 mmol/L

LDL (cholesterol) 4.9 <4.0 mmol/L

Which of the following Is the most appropriate therapy for secondary prevention of cardiovascular disease in this patient?

An 18-year-old woman complains of dizziness feeling light-headed frequently with standing up and weight loss around 5 kg over the last 5 months. She has noticed a recent scar on the back of her hand, which has started to turn very dark Blood pressure 90/60 mmHg

Heart rate 99 /min

What is the most appropriate investigation to confirm the diagnosis?

A 40-year-old man diagnosed with pulmonary TB wtio started treatment 3 months ago. presents to the clinic with a week's history of pins and needles in his hands and feet with assoaated numbness. He tells that his symptoms started since he stopped taking the vitamins given to him at the start of his TB treatment.

Which of the following drugs is responsible for lhe symptoms described by the patient?

A 19-year-old man known to have asthma. He has never been admitted to hospital with an asthma exacerbation and experiences symptoms once or twice a week but he is not on any medication. Today he come to discuss the treatment options and he prefer to start medications only if needed during the attacks. His peak expiratory flow reading is currently 85% of the normal predicted value expected for his age and height.

Which of the following is the most appropriate first step in treatment?

A 62-year-old woman is seen in the clinic with a history of wetght loss, loss of appetite and shortness of breath for the last 6 weeks. On examinaiion, trachea is shifted to left side; there is reduced air entry and dullness to percussion on the lower to midzones of the right lung. Blood pressure 110/70 mmHg

Heart rate 102 /min

Respiratory rate 22 /min

Temperature 37 °C

Oxygen saturation 91 %

Which of the following is the most likely diagnosis?

A 59-year-old man comes to the clinic, with a 45 cigarette pack-year history, complaining of breathlessness on exertion and a productive cough of while sputum over the Iasi 6 months. Cardiological investigations are normal (see report).

Spirometry:

Shows an FEV1/FVC of 60% with minimal reversibility after a 2-week tnal of oral steroids.

Which of the following is the most likely diagnosis?

A 30-year-oid woman is admitted with cough, dyspnea, chest pam, SOB, PND and orthopnea 3 days post vaginal delivery. She gave a history of tower limb oedema She has no significant meGical history On examination, she looks in distress with bilateral LL pitting oedema, bilateral basal crackles on lung examinafton. On cardiac examination, apex was displaced down with pan-systolic murmur at the apex radiating to axilla and S3 gallop

Btood pressure 90/70 mmHg

Heart rate 120 /mln

Temperature 37.6 °C

Oxygen saturation 90 %

Which of the following is the most appropriate step in this patient management?

A 30-year-oid woman is admitted with dyspnea, SOB. PND and orthopnea 3 days post vaginal delivery. She gave a history of tower limb oedema She has no significant medical history On examination, she looks in distress with bilateral LL pitting oedema, ^lateral basal crackles on lung examination. On cardiac examinalton, apex was displaced down with pan-systolic murmur

at the apex radiating to axilla and S3 gallop.

Blood pressure 90/60 mmHg

Heart rate 110/min

Temperalure 37.6 °C

Which of the following is the most likely diagnosis?