1.

The most essential and urgent strategy for treating suffocation caused by massive hemoptysis is
A. Artificial respiration
B. Oxygen therapy with mask
C. Assurance of an adequate airway patency
D. Respiratory stimulant
E. Fluid supplement or blood transfusion

2. Which of the following can be found in ventricular fibrillation?

A. Palpitation with arthralgia
B. Palpitation with syncope
C. Palpitation with anemia
D. Palpitation with edema
E. Palpitation with weight loss

3. Which of the following statement is correct about the clinical explanation of tendon reflexes and pathological
reflexes?
A. Diminished tendon reflexes refer to upper motor neuron lesion.
B. Exaggerated tendon reflexes are usually caused by lower motor lesion.
C. Exaggerated tendon reflexes are caused by deep sensory dysfunction.
D. Exaggerated tendon reflexes are usually caused by upper motor lesion.
E. Pathological reflexes are only found in pathological state.

4. What is the best screening test for early diabetic nephropathy?

A. Urine microalbuminuria
B. Dipstick urinalysis
C. Renal biopsy
D. Fasting blood glucose
E. 24-Hour urine collection for creatinine clearance

5. The coagulation test(s) in diagnosis of DIC include(s)

A. PT, APTT, and TT: very prolonged
B. Platelet count: low with a clear downward trend
C. Fibrinogen level: markedly reduced
D. High level of FDP and D-dimer
E. All of the above

6. Which of the following is the most valuable for diagnosing ulcerative colitis
A. Clinical manifestations
B. Stool test
C. X- ray barium meal
D. Fibrocolonoscopy
E. Serum immune globulin test

7. Systolic click and late systolic blowing murmur at the apex in CHD patient is caused by
A. Ventricular aneurysm
B. Heart failure
C. Relative mitral insufficiency
D. Mitral prolapse caused by dysfunction or rupture of papillary muscle
E. Rupture of interventricular septum

8. Which of the following in NOT secondary hypertension?

A. Renal artery stenosis
B. Pheochromocytoma
C. Primary aldosteronism
D. Cushing’s syndrome
E. Accelerated hypertension
9. Which of the following type of leukemia is the most likely to have bleeding tendency?
A. ALL
B. M1
C. M3
D. M5
E. M6

10. Which of the following is highly associated with the activity of systemic lupus erythematosus (SLE)?
A. Anti-Ro (SS-A)
B. Anti-single-stranded DNA antibodies
C. Anti-U1-RNP antibodies
D. Antinuclear antibodies
E. Anti-double-stranded DNA antibodies

11. Which of the following drugs should be used with highly caution in chronic pulmonary heart disease?
A. Sedatives
B. Bronchodilator
C. Antibiotics
D. Expectorant
E. Respiration stimulant

12. The following items are the common complications caused by nephrotic Syndrome, EXCEPT
A. Infection
B. Impaired glucose tolerance
C. Thrombosis and emboli
D. Acute renal failure
E. Abnormalities in protein and lipid metabolism

13. A 35-year-old patient on treatment for thyrotoxicosis is on propylthiouracil (PTU). She complains of cough and
upper respiratory tract infection. Which one of the following is most likely?
A. Neutrophil leucocytosis
B. Neutropenia
C. Eosinophilia
D. Monocytosis
E. Lymphocytosis

14. A 76-year-old man suffered from chest pain for 3 hours, come to the emergency and is diagnosed as acute
anterior myocardial infarction. Which of the following is not a clear contraindication to the use of thrombolytic
agents?
A. Left carotid artery occlusion with hemiparesis 2 weeks ago.
B. Transurethral resection of prostate 1 week ago.
C. Diastolic blood pressure of 110 mmHg during chest pain
D. The age
E. Epigastric pain and melena 1 week ago treated with PPI

15. A patient presents with a tender, swollen leg after a 6-hour car ride, during which he did not stop. Deep
venous thrombosis is suspected. The most appropriate diagnostic study for this patient is
A. Venous Doppler ultrasonography
B. Venography
C. Magnetic resonance imaging
D. Impedance plethysmography
E. Fibrinogen uptake test

16. The most common and dangerous electrolyte disturbance in obliguric stage of acute renal failure is
A. Hyponatremia
B. Hypernatremia
C. Hyperkalaemia
D. Hypokalaemia
E. Hypochloremia

17. Hoarseness caused by left upper pulmonary carcinoma due to compression of

A. Vagal nerve
B. Hypoglossal nerve
C. Accessory nerve
D. Glossopharyngeal nerve
E. Left recurrent laryngeal nerve

18. Which of the following is the most significant in the diagnosis of respiratory failure?
A. Cyanosis
B. Hypotension and tachycardia
C. PaO2 < 60mmHg
D. Small pupils
E. Restlessness

19. Which of the following description is the most suitable about the clinical manifestation of asthma?
A. Local inspiratory wheezes
B. Prolonged expiration and diffuse expiratory wheezes at both lungs
C. Recurrent inspiratory wheezes
D. Diffuse inspiratory wheezes
E. Recurrent and local expiratory wheezes

20. The most dangerous and common complication in the patient with massive hemoptysis is
A. Severe anemia
B. Shock
C. Suffocation
D. Secondary infection
E. Atelectasis

21. A girl, 20 years old, felt bursting pain in right chest suddenly while lifting a heavy box. Which of the diseases
could be suspected firstly?
A. Myocardial infarction
B. Pulmonary infarction
C. Pneumonia
D. Acute pancreatitis
E. Right pneumothorax

22. A male, 45years old, a two-weeks history of chest discomfort, dry cough accompanied by dyspnea. PE: In right
lower part of the lung, tactile fremitus decreased, dullness to percussion and decreased breath sound found. The
most likely diagnosis is
A. Myocardial infarction
B. Right pulmonary embolism
C. Pneumonia
D. Diffuse interstitial fibrosis
E. Right pleural effusion

23. Which statement belongs to angiotensin-converting enzyme inhibitors?

A. Work by inhibiting the conversion of angiotensin I to angiotensin II
B. Relieve symptoms and prolong life in heart failure
C. Not safe in pregnancy
D. May cause hyperkalaemia
E. All of the above is right
24. The most important mechanism of hyperresponsiveness in asthma is
A. Decreased β-receptor activities
B. Increased vagal cholinergic tone
C. Genetic factor
D. Inflammation of the airways
E. Spasm of airway smooth muscle

25. Which one of the followings can indicate the renal failure?
A. Increase of GFR and BUN
B. Increase of Ccr and Scr
C. Increase of Scr and BUN
D. Increase of GFR and Scr
E. Increase of Ccr and BUN

26. Which one of the following is WRONG about the pathogenesis of ascites formation in liver cirrhosis?
A. High portal vein pressure
B. Primary aldosteronism
C. Hypoalbuminemia
D. Over-secretion of antidiuretic hormone
E. None of the above

27. Which one of the following is right about the acute pancreatitis?
A. Serum amylase reached the peak value in 8 hours
B. A sustained increase in urinary amylase for 2-4 weeks
C. Amylase does not necessarily reflect the level of severity
D. The level of serum amylase more than 2 times of normal can be diagnosed with acute pancreatitis
E. None of the above

28. Of these five tests, which is useful to confirm the diagnosis of autoimmune hemolysis?
A. Coombs test
B. Uric acid level in plasma
C. Serum ferritin
D. Erythrocyte sedimentation rate
E. None of the above

29. In which of the following disorders is the APTT (activated partial thromboplastin time) prolonged?
A. Factor V deficiency
B. Idiopathic thrombocytopenic purpura
C. Factor VIII deficiency
D. Factor VII deficiency
E. None of the above

30. Which of the following findings indicates the diagnosis of β-Thalassemia?

A. Basophilic stippling
B. Target red cells
C. Heinz bodies
D. Howell-Jolly bodies
E. None of the above

31. Studies suggest that the good prognosis is seen in patients with acute myeloid leukemia with which
chromosomal abnormality?
A. 11q deletion
B. Trisomy 12
C. t (15;17)
D. 17p deletion
E. None of the above
32. During chronic myeloid leukemia, which of the following symptoms is suggestive of an acute blastic
transformation?
A. Headache
B. Bone pain
C. Diarrhea
D. Cough
E. None of the above

33. Which of the following disorders has been proven to be of B cell origin?
A. Chronic lymphocyte leukemia
B. Hodgkin’s lymphoma
C. Chronic myeloid leukemia
D. Large granular lymphocyte leukemia
E. None of the above

34. Which one of the followings can indicate the renal failure?
A. Increase of GFR and BUN
B. Increase of Ccr and Scr
C. Increase of Scr and BUN
D. Increase of GFR and Scr
E. Increase of Ccr and BUN

35. Which is the most common complication of Crohn’s Disease?

A. Toxic shock
B. Hemorrhage of colon
C. Intestinal obstruction
D. Carcinogenesis
E. None of the above

36. The following are symptoms and signs of right heart failure. EXCEPT

A. Abdominal distention, nausea and vomiting

B. Exertional dyspnea
C. Edema
D. Positive hepto-jugular reflux and hepatomegaly
E. Bilateral basal crepitations

37. Which of the following peptic ulcer need eradication of Helicobacter pylori if the ulcer is detected Hp infection
positive?
A. Active ulcer
B. Healing ulcer
C. Scaring ulcer
D. Ulcer accompanied by complications
E. All peptic ulcer

38. A 50-year-old male, presented with sudden cerebral accident one week before and vomiting about 500 ml
blood three days prior to admission, accompanied by melena. He had no gastric disorders or hepatitis in the past.
The most likely diagnosis is
A. Chronic gastritis
B. Gastric carcinoma
C. Acute erosive and hemorrhagic gastritis
D. Bleeding of bile ducts
E. Prolapse of gastric mucosa
39. A 30-year-old male, presented with severe epigastric pain recently and had syncope suddenly in this morning.
He also had 8-year- history of duodenal ulcer in the past. The most likely cause of syncope is
A. Cerebral infarction
B. Perforation of the ulcer
C. Bleeding of the ulcer
D. Malignancy of the ulcer
E. Cerebral hemorrhage

40. Which of the following serum measurement is the most valuable for estimating the liver function if hepatic
cirrhosis?
A. Alanine transaminase (ALT)
B. Aspartate transaminase (AST)
C. Coagulation function
D. A/G ratio
E. Bilirubin

41. A 44-year-old male, presented with abdominal distension and fatigue for 3 years. PE: enlargement of spleen
palpated 2.5cm below the costal margin. Mild tender gynecomastia found, but no mass. The most likely disorder
leading to gynecomastia is
A. Chronic mastadenitis
B. Breast carcinoma
C. Hyperthyroidism
D. Liver cirrhosis
E. Galactocele

42. The most valuable evidence for diagnosing latent hepatocirrhosis is

A. Portal hypertension
B. Hard liver
C. A/G ratio decreased
D. Hepatic face, spider angioma and liver palm
E. Liver biopsy

43. Which of the following pathological change belongs to precancerous lesion in chronic gastritis?
A. Incomplete metaplasia of small intestine
B. Incomplete metaplasia of large intestine
C. Dysplasia of gastric mucosa
D. Atrophy of proper gastric glands
E. Complete metaplasia of large intestine

44. A 35-year-old female, presented with upper abdominal pain accompanied by nausea and vomiting for 3 hours
after taking meat pie and stewed egg. Abdominal pain was continuous and lancinating. Lab findings showed blood
WBC 14×109/L, N 0.82, Serum amylase 200u (Somogyi). Acute pancreatitis was suspected. Which of the following
is the most helpful to the diagnosis?
A. Urgent endoscopy
B. Ultrasonography of biliary apparatus
C. Abdominal roentgenoscopy
D. Recheck serum amylase at once
E. Recheck serum amylase 5 hours later

45. A 65-year-old male, was found death in the next morning after the dinner at night. PE: a small amount of
coffee grounds observed in his bed and Grey-Turner sign found at the patient’s left flank. The most possible cause
of death is?
A. Acute myocardial infarction
B. Severe acute pancreatitis
C. Hypertension associated with cerebral hemorrhage
D. Bleeding gastric ulcer
E. Hypertension associated with cerebral infarction
46. A 35-year-old female, presented with fever accompanied by mucocutaneous hemorrhage for one week. PE:
sternal tenderness found. Lab: Hb: 70g/L, WBC: 14×109/L, Plt: 12×109/L. Which of the following method should be
requested most?
A. Bone marrow puncture
B. Bleeding and clotting tests
C. Urine and stool routine examinations
D. Serum iron and ferritin measurement
E. Antibodies to platelets measurement

47. The most valuable evidence for differentiating aplastic anemia from acute leukemia is
A. Severity of anemia
B. Severity of infection
C. Location of bleeding
D. Manifestations caused by infiltration of leukemic cells
E. White blood cell count

48. A 57-year-old male, had painless and progressive enlargement of bilateral cervical lymph nodes accompanied
by irregular fever with temperature higher than 38℃. PE: One 3cm ×2 cm enlarged cervical lymph node palpated
at each side respectively. One 2cm × 1cm enlarged lymph node palpated at right axillary and inguinal area
respectively. These enlarged lymph nodes are mobile and non-tender. Which of the following was the best
method for diagnosing Hodgkin’s disease?
A. Bone marrow puncture
B. Bone marrow biopsy
C. Biopsy of lymph node
D. Chest CT
E. Abdominal CT

49. A 30-year-old male, who had a 10-year-history of DM with insulin therapy, but no blood glucose monitoring
performed, presented with edema of eyelids and lower extremities for 3 months. Lab investigations showed:
urine glucose (+++), urine protein (+++), WBC 0-3 /HP, a few granular castes found. The diagnosis should be
considered first.
A. Chronic nephritis
B. Sclerosis of renal artery
C. Pyelonephritis
D. Acute nephritis
E. Diabetic nephropathy

50. The patient with thyrotoxicosis couldn’t move his lower limbs suddenly and in physical examination knee
reflex decreased, but no muscular atrophy found. The most possible diagnosis is
A. Associated with myasthenia gravis
B. Associated with acute myopathy
C. Associated with chronic myopathy
D. Associated with peripheral neuritis
E. Associated with periodic paralysis

51. A 40-year-old alcoholic male is being treated for tuberculosis, but he has not been compliant with his
medications. He complains of increasing weakness and fatigue. He appears to have lost weight, and his blood
pressure is 80/50 mmHg. There is increased pigmentation over the elbows. Cardiac exam is normal. The next step
in evaluation should be the most valuable.
A. CBC with iron and iron-binding capacity
B. Erythrocyte sedimentation rate
C. Early-morning serum cortisol and cosynotropin stimulation
D. Blood cultures
E. Serum biochemistry panel
52. A 44-year-old woman is noted to be nervous and has heat intolerance. Her thyroid gland is diffusely enlarged,
non-tender, with an audible bruit. Her TSH is very low. Which of the following is the most likely etiology?
A. Lymphocytic thyroiditis
B. Hashimoto thyroiditis
C. Graves’ disease
D. Multinodular toxic goiter
E. Plummer disease

53. You confirm acromegaly in a 58-year-old woman, and a MRI of the pituitary shows a microadenoma. The best
choice for treatment is
A. Transsphenoidal surgery
B. Medical therapy with somatostatin agonist
C. Irradiation
D. Medical therapy with bromocriptine
E. Trans-frontal surgery

54. A 40-year-old male was treated with clindamycin and gentamicin for acute diverticulitis. He has developed
oliguria and an increasing serum creatinine over the past several days. On physical exam he is alert and oriented.
There is no evidence for congestive heart failure. A three-component coarse heart sound is heard through systole
and diastole. On the fifth hospital day, the BUN is 70 mg/dL, creatinine is 7 mg/dL, and serum K+ is 6.0 eq/dL. An
ECG shows acute ST-segment elevation in most leads. The next step in management would be
A. Acute hemodialysis
B. Pericardiocentesis
C. Thrombolytic therapy
D. Calcium gluconate
E. Aspirin 325mg

55. The patient with COPD presented with sudden left upper chest pain this morning. The chest pain was stabbing
and progressive accompanied with dyspnea and he could not lie flat. PE showed left breath sounds diminished
significantly. HR 120 bpm, slightly arrhythmia. Which of the following is the most likely diagnosis?
A. Angina
B. Pulmonary embolism
C. Pleuritis
D. Spontaneous pneumothorax
E. Acute left heart failure

56. Which of the following is or are the alarming symptom(s) for those who are older than age 45 or for patients of
any age suggestive of gastric malignancy
A. Unexplained weight loss
B. Repeated vomiting
C. Dysphagia
D. Anemia and/or bleeding from the stomach
E. All the above

57. A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several
months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the
metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no
alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?
A. The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor should be obtained.
B. The prodrome of lethargy suggests chronic fatigue syndrome.
C. Lack of systemic symptoms suggests osteoarthritis
D. X-rays of the hand are likely to show joint space narrowing and erosion.
E. An aggressive search for occult malignancy is indicated.
58. A 70-year-old patient with chronic obstructive lung disease requires 2L/min of nasal O2 to treat his hypoxia,
which is sometimes associated with angina. The patient develops pleuritic chest pain, fever, and purulent sputum.
While using his oxygen at an increased flow of 5L/min he becomes stuporous and develops a respiratory acidosis
with CO2 retention and worsening hypoxia. What would be the most appropriate next step in the management of
this patient?
A. Stop oxygen
B. Begin medroxyprogesterone
C. Intubate and begin mechanical ventilation
D. Observe patient 24 hours before changing therapy
E. Begin sodium bicarbonate

59. A 30-year-old athlete presents to your office complaining of intermittent wheezing. This wheezing begins
shortly after running. The patient admits to smoking 1-2 packs of cigarettes per day for 5 years. What finding
would be consistent with asthma?
A. Hyperinflation present on chest x-ray
B. Improvement in FEV1 after bronchodilator
C. Low oxygen saturation on finger oximetry
D. Decreased FVC on PFT testing
E. Dyspnea on assuming a supine position

60. A 60-year-old male has had a chronic cough with clear sputum production for over 5 years. He has smoked one
pack of cigarettes per day for 20 years and continues to do so. X-ray of the chest shows hyperinflation without
infiltrates. Arterial blood gases show a pH: 7.38, PCO2: 40 mmHg, and PO2: 65 mmHg. Spirometry shows an
FEV1/FVC of 45 % without bronchodilator response. Which of the following is the most important treatment
modality for this patient?
A. Oral corticosteroids
B. Home oxygen
C. Broad-spectrum antibiotics
D. Smoking cessation program
E. Oral theophylline

61. An anxious young woman who is taking birth control pills presents to the emergency room with shortness of
breath. Which of the following physical findings would make the diagnosis of pulmonary embolus unlikely?
A. Wheezing
B. Pleuritic chest pain
C. Right-sided S3 heart sound
D. Hemoptysis
E. Bilateral rales

62. A 50-year-old male with emphysema develops the sudden onset of shortness of breath and left-sided pleuritic
chest pain. Pneumothorax is suspected. Which of the following physical examination findings would be consistent
with the diagnosis?
A. Localized wheezes at the left base
B. Hyper-resonance, decreased breath sounds in the left chest with trachea deviation the right
C. Increased tactile fremitus on the left side
D. Decreased breath sounds on the left side with deviation of the trachea to the left
E. Rales at the left base.

63. A 55-year-old patient presents to you after a 3-day hospital stay for gradually increasing shortness of breath
and leg swelling while away on a business trip. He was he had congestive heart failure, but is asymptomatic now,
with normal vital signs and physical examination. An echocardiogram shows an estimated ejection fraction of
38%. The patient likes to keep medications to a minimum. He is currently on aspirin and simvastatin. Which would
be the most appropriate additional treatment?
A. Begin an ACEI inhibitor and then add a beta-blocker on a scheduled basis
B. Begin digoxin plus furosemide on a scheduled basis
C. Begin spironolactone on a scheduled basis
D. Begin furosemide plus nitroglycerin
64. You are helping with school sports physicals and see a 16-year-old boy who has had trouble keeping up with
his peers. Which of the following auscultatory findings suggests a previously undiagnosed ventricular septal
defect?
A. A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with radiation to the
carotids; the murmur is augmented with exercise.
B. A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border.
C. A holosystolic murmur at the mid-left sternal border
D. A diastolic decrescendo murmur at the mid-left sternal border
E. A continuous murmur through systole and diastole at the upper left sternal border.

65. A 75-year-old patient presents to the ER after a syncopal episode. He is again alert and in retrospect describes
occasional substernal chest pain pressure and shortness of breath on exertion. His blood pressure is 110/80 and
lungs have a few bibasilar rales. Which auscultatory finding would best explain his findings?
A. A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border
B. A diastolic decrescendo murmur heard at the mid-left sternal border
C. A holosystolic murmur heard best at the apex
D. A mid-systolic click
E. A pericardial rub

66. A 30-year-old female presents with a chief complaint of palpitations. A 24-hour Holter monitor shows
occasional unifocal premature ventricular contractions and premature atrial contractions. Which of the following
is the best management for this patient?
A. Anxiolytic therapy
B. Beta-blocker therapy
C. Digoxin
D. Quinidine
E. Reassurance, no medication

67. In the ICU, a patient suddenly becomes pulseless and unresponsive, with cardiac monitor indicating ventricular
tachycardia. The crash cart is immediately available. What is the best first therapy?
A. Amiodarone 150mg IV push
B. Lidocaine 1.5 mg/kg IV push
C. Epinephrine 1 mg IV push
D. Defibrillation at 200J
E. Defibrillation at 360J

68. A 70-year-old female has been healthy except for hypertension treated with a thiazide diuretic. She presents
with sudden onset of a severe, tearing chest pain, which radiates to the back and is associated with dyspnea and
diaphoresis. Blood pressure is 210/94 mmHg. Lung auscultation reveals bilateral basilar rales. A faint murmur of
aortic insufficiency is heard. The BNP level is elevated at 550pg/ml (normal <100). ECG shows nonspecific ST-T
changes. Chest x-ray suggests a widened mediastinum. Which of the following is the most likely diagnosis?
A. Infective endocarditis
B. Myocardial ischemia
C. Aortic dissection
D. Pulmonary embolism
E. Pneumothorax

69. A 55-year-old female presents to the ER with lethargy and blood pressure of 250/150 mmHg. Her family
member indicate that she was complaining of severe headache and visual disturbance earlier in the day. They
report a history of asthma but no known kidney disease. On physical examination, retinal hemorrhage is present.
Which of the following is the best approach?
A. Intravenous labetalol therapy
B. Continuous-infusion nitroprusside
C. Clonidine by mouth to lower blood pressure
D. Nifedipine sublingually to lower blood pressure
E. Intravenous loop diuretic
70. A 55-year-old obese woman develops pressure-like substernal chest pain lasting 1 hour. She works as a
housekeeper, lifting and exertion have precipitated similar pain in the recent past. There is a positive family
history of gallstones (mother and sister). Her ECG shows that ST segment in Lead II, III, aVF 0.3-0.4mv elevated,
while no pathological Q wave found. Which of the following is the most likely diagnosis?
A. Costochondritis
B. Acute anterior myocardial infarction
C. Acute inferior myocardial infarction
D. Pericarditis
E. Gastroesophageal reflux

71. A 35-year-old male complains of substernal chest pain aggravated by inspiration and relieved by sitting up.
Lung fields are clear to auscultation, and heart sounds are somewhat distant. Chest x-ray shows an enlarged
cardiac silhouette. Which of the following is the best next step in evaluation?
A. Right lateral decubitus chest X-ray
B. Cardiac catheterization
C. Echocardiogram
D. Serial ECGs
E. Thallium stress test

72. You are seeing a 45-year-old female patient of your partner for the first time in your clinic. A quick review of
the patient’s medical record shows that her systolic blood pressure was greater than 140mmHg at both of her last
clinic appointments. Her medical history is otherwise significant only for diabetes mellitus. Her blood pressure
today is 164/92mmHg. What is the best next step in her blood pressure management?
A. Ask the patient to keep a written record of her blood pressure and bring with her to a return appointment
B. Advise the patient to begin a heart healthy, low sodium diet and refer to a nutritionist.
C. Prescribe an ACE inhibitor in addition to heart healthy diet
D. Prescribe a dihydropyridine calcium-channel blocker in addition to a heart healthy diet
E. Arrange for echocardiogram to assess for end-organ damage

73. A 50-year-old obese female is taking oral hypoglycemic agents. While being treated for an upper respiratory
infection, she develops lethargy and is brought to the emergency room. Neurological examination is non-focal;
she does not have neck rigidity. Laboratory results are as follows: Na: 134mmol/L, K: 4.0 mmol/L, HCO3: 25
mmol/L, Glucose: 50 mmol/L, BUN: 30 mmol/L, Creatinine: 3.0mg/dl, HbA1c: 6.8%, BP: 120/80mmHg lying down,
105/65mmHg sitting. Which of the following is the most likely cause of this patient’s coma?
A. Diabetic ketoacidosis
B. Hyperosmolar coma
C. Inappropriate ADH
D. Noncompliance with medication
E. Bacterial meningitis

74. A 50-year-old female is 5 ft 7 in tall and weighs 185 Ib. There is a family history of diabetes mellitus. Fasting
blood glucose (FBG) is 8.89 mmol/L and 8.61 mmol/L on two occasions. HbA1c is 7.8%. You educate the patient on
medical nutrition therapy. She returns for re-evaluation in 8 weeks. She states she has followed diet and exercise
recommendations but her FBG remains between 7.2 mmol/Land 7.78 mmol/L and HbA1c is 7.3%. She is
asymptomatic and physical examination shows no abnormalities. Which of the following is the treatment of
choice?
A. Thiazolidinediones
B. Encourage compliance with medical nutrition therapy
C. Insulin
D. Metformin
E. Observation with repeat HbA1c

75. You recently evaluated a 28-year-old woman who presented with complaints of shakiness and heat
intolerance. The patient plans to have children and is currently using no contraception. On examination you noted
tachycardia with an HR of 102, a fine tremor, a diffuse goitor, and proptosis. You now have the laboratory results
and note a TSH <0.001, elevated total T4 of 17.8, and increased T3 uptake. Radionuclide uptake by the thyroid
gland is elevated. You tell her that she has Graves’ disease. What is the best treatment plan for this patient?
A. Propylthiouracil
B. Radioactive iodine
C. Propranolol
D. Thyroid surgery
E. Oral corticosteroids

76. A 36-year-old female complains of inability to lose weight despite low-calorie diet and daily exercise. She has
also noticed that she is cold intolerant. She is wearing a jacket even though it is summer. She also reports
constipation and hair loss. These symptoms have been worsening over the past 2 to 3 months. An elevated TSH
and low total and free T4 confirm your suspicion of hypothyroidism. You suspect the etiology of this patient’s
hypothyroidism to be autoimmune thyroiditis. What is the best test to confirm the diagnosis of autoimmune
thyroiditis?
A. Thyroid peroxidase antibody (TPOAb)
B. Antinuclear antibody
C. 24-hour radioactive iodine uptake
D. Thyroid ultrasound
E. Thyroid aspiration

77. A 58-year-old male is referred to your office after evaluation in the emergency room for abdominal pain. The
patient was diagnosed with gastritis but a CT scan with contrast performed during the workup of his pain revealed
a 2-cm adrenal mass. The patient has no history of malignancy and denies erectile dysfunction. Physical
examination reveals a BP of 122/78mmHg with no gynecomastia or evidence of Cushing syndrome. His serum
potassium is normal. What is the next step in determining whether this patient’s adrenal mass should be
resected?
A. Plasma aldosterone / renin ratio
B. Estradiol level
C. Plasma metanephrines and dexamethasone-suppressed cortisol level
D. Testosterone level
E. Repeat CT scan in 6 months

78. On routine physical examination, a 28-year-old woman is found to have a thyroid nodule. She denies pain,
hoarseness, hemoptysis, or local symptoms. Serum TSH is normal. Which of the following is the best next step in
evaluation?
A. Thyroid ultrasonography
B. Thyroid scan
C. Surgical resection
D. Fine needle aspiration of thyroid
E. No further evaluation

79. A 55-year-old type-2 diabetic patient has lost weight and has had good control of his blood glucose on oral
metformin, with HbA1c of 6.4 %. He has a history of mild hypertension and hyperlipidema. According to the
guidelines for ongoing medical care in diabetic patients, which of the following statements is correct regarding
routine testing for diabetic patients
A. HbA1c testing should be performed 2 to 4 times a year depending on patient’s diabetes control (if patient HbA1c
at goal, twice yearly is adequate)
B. Lipid profile detected annually
C. Home glucose measurements are usually performed once daily in well-controlled type 2 diabetes
D. Urine microalbumin annually
E. All of the above

80. A 19-year-old man with T1DM with insulin therapy is taking 30 units of NPH insulin each morning and 15 units
at night. Because of persistent morning glycosuria with some ketonuria, the evening dose is increased to 20 units.
This worsens the morning glycosuria, and now moderate ketones are noted in urine. The patient complains of
sweats and headaches at night. Which of the following is the most appropriate next step in management?
A. Measure blood glucose levels at bedtime.
B. Increase the evening dose of NPH insulin further
C. Add regular insulin to NPH at a ratio of 2/3 NPH to 1/3 regular
D. Obtain blood sugar levels between 2:00 to 5:00AM
E. Add lispro via a calculated scale to each meal; continue NPH

81. A 25-year-old woman is admitted for hypertensive crisis. The patient’s urine drug screen is negative. In the
hospital, blood pressure is labile and responds poorly to antihypertensive therapy. The patient complains of
palpitations and apprehension. Her past medical history shows that she developed hypertension during an
operation for appendicitis at age 23. Lab tests shows Hct: 49% (37-48), WBC: 11 × 109 (4.3-10.8), Plasma glucose:
8.89 mmol/L (4.17-6.39), Plasma calcium: 11mg/dl (9-10.5). Which of the following is the most likely diagnosis?
A. Anxiety attack
B. Renal artery stenosis
C. Essential hypertension
D. Type 1 diabetes mellitus
E. Pheochromocytoma

82. A 30-year-old woman has prominent cervical and dorsal fat pads, purple abdominal striae, unexplained
hypokalaemia, and diabetes mellitus. Which of the following is the most likely diagnosis?
A. Acromegaly
B. Essential hypertension
C. Empty Sella syndrome
D. Cushing syndrome
E. TSH-secreting adenoma

83. A 20-year-old female presents after recent upper respiratory infection. She complains of neck pain and heat
intolerance. The thyroid is tender. Erythrocyte sedimentation rate is elevated; free thyroxine value is modestly
elevated. Which of the following is the most likely diagnosis?
A. Subacute thyroiditis
B. Graves’ disease
C. Factitious hyperthyroidism
D. Struma ovarii
E. Multinodular goiter

84. A 40-year-old man with long-standing alcohol abuse complains of abdominal swelling, which has been
progressive over several months. He has a history of gastrointestinal bleeding. On physical examination, there are
spider angioma and palmar erythema. Abdominal collateral vessels are seen around the umbilicus. There is
shifting dullness, and bulging flanks are noted. Which of the following is the most important first step in the
patient’s evaluation?
A. Diagnostic paracentesis
B. Upper GI series
C. Ethanol level
D. CT scan of the abdomen
E. Examination of peripheral blood smear

85. A 70-year-old man presents with a complaint of fatigue. There is no history of alcohol abuse or liver disease;
the patient is taking no medications. Scleral icterus is noted on physical examination; the liver and spleen are
nonpalpable. The patient has a normocytic, normochromic anemia. Urinalysis shows bilirubinuria with absent
urine urobilinogen. Serum bilirubin is 12 mg/dl. AST and ALT are normal, and alkaline phosphatase is 300U/L
(three times normal). Which of the following is the best next step in evaluation?
A. Ultrasound or CT scan of the abdomen
B. Viral hepatitis profile
C. Reticulocyte count
D. Serum ferritin
E. Antimitochondrial antibodies
86. A 63-year-old woman with cirrhosis caused by chronic hepatitis C is hospitalized because of confusion. She has
guaiac- positive stools and a low-grade fever. She has received lorazepam for sleep disturbance. On physical
examination, the patient is confused. She has no meningeal signs and no focal neurologic findings. There is
hyperreflexia and a nonrhythmic flapping tremor of the wrists. Which of the following is the most likely
explanation for this patients mental status change?
A. Tuberculous meningitis
B. Subdural hematoma
C. Alcohol with drawal seizure
D. Hepatic encephalopathy
E. Central nervous system vasculitis from cryoglobulinemia

87. A 45-year-old diabetic woman presents with two days of severe upper abdominal pain that radiates into the
back and has been associated with nausea and vomiting. She takes insulin but has been non-compliant for several
weeks. She denies alcohol consumption. Her serum is lipemic. Which of the following is the most likely diagnosis?
A. Acute diverticulitis
B. Acute pancreatitis
C. Acute cholecystitis
D. Intestinal obstruction
E. Irritable bowel syndrome

88. A 58-year-old male with long-standing cirrhosis resulting from hepatitis C develops vague right upper quadrant
pain and weight loss. A right quadrant mass is palpable. Serum alkaline phosphatase is elevated. Which of the
following is the most likely disease process?
A. Primary biliary cirrhosis
B. Sclerosing cholangitis
C. Anaerobic liver abscess
D. Hepatocellular carcinosis
E. Hemochromatosis

89. A young woman complains of one week of fatigue., change in skin color, and dark brown urine. She has right
upper quadrant tenderness and ALT of 1035 U/L (normal <40). Which of the following is the most likely diagnosis?
A. Hemolysis secondary to G6PD deficiency
B. Pancreatic carcinoma
C. Acute viral hepatitis
D. Gilbert syndrome
E. Cirrhosis of liver

90. An 88-year-old white woman with osteoarthritis has noticed mild epigastric discomfort for several weeks.
Naproxen has helped her joint symptoms. She suddenly develops hematemesis and hypotension. Which of the
following is the most likely disease process?
A. Gastric ulcer
B. Aortoenteric fistula
C. Mallory-Weiss tear
D. Hereditary hemorrhagic telangiectasia (HHT)
E. Adenocarcinoma of the colon

91. A 39-year-old alcoholic presents with massive hematemesis and hypotension. Examination reveals
hemorrhoids and ascites. Which of the following is the most likely diagnosis?
A. Colon polyp
B. Esophageal varices
C. Adenocarcinoma of the colon
D. Acute erosive gastritis
E. Peptic ulcer
92. A 75-year-old woman, previously health., presents with low-grade fever, diarrhea, and rectal bleeding.
Colonoscopy shows continuous erythema from rectum to mid-transverse colon. The cecum is normal. Which of
the following is the most likely diagnosis?
A. Ulcerative colitis
B. Crohn disease
C. Ischemic colitis
D. Diverticulitis
E. Tuberculoma of the colon

93. An 83-year-old woman presents for follow-up of hypertension, type 2 diabetes mellitus, and depression. She
complains of fatigue and mild edema. Her medications include hydrochlorothiazide 25mg/d, atenolol 50mg/d,
glyburide 5mg bid, and paroxetine 20mg/d. Physical examination shows BP 152/88mHg, weight 42kg, clear lung
fields, normal liver and spleen, and peripheral edema. She appears mildly pale. CBC shows Hb 96 g/L with an MCV
of 87 and normal WBC and platelets. Chem profile shows Na 136mmol/L, K 4.9 mmol/L, Cl 108 mmol/L, creatinine
1.5 mg/dL, and glucose 9.89 mmol/L. Liver enzymes are normal. What is the most likely cause of her anemia?
A. Anemia of chronic kidney disease (CKD)
B. Anemia of chronic disease caused by diabetes
C. Depression with nutritional folate deficiency
D. Occult colon cancer
E. Medication-induced bone marrow suppression

94. A 53-year-old male with septic shock develops acute renal failure with a serum creatinine of 6.4 mg/dL. Which
of the following is a specific indication to initiate dialysis?
A. BUN rises to 75mg/dL
B. Urine output fails to <10ml/h
C. Pericardial friction rub develops
D. Hematocrit falls to <30%
E. Continued hypotension

95. A 73-year-old female with arthritis presents with confusion. Neurologic examination is nonfocal, and CT of the
head is normal. Laboratory data include: Na+: 140mmol/L, K+: 3.0 mmol/L, Cl-: 107 mmol/L, HCO3: 12 mmol/L;
Arterial blood gases: PO2: 62, PCO2: 24, pH: 7.40. What is the acid-base disturbance?
A. Respiratory alkalosis with appropriate metabolic compensation
B. High anion-gap metabolic acidosis with appropriate respiratory compensation
C. Combined metabolic acidosis and respiratory alkalosis
D. No acid-base disorder
E. Hyperchloremic (normal anion gap) metabolic acidosis with appropriate respiratory compensation

96. A 76-year-old man is admitted with pneumonia. He has a history of diabetes mellitus. Admission creatinine is
1.2mg/dl. He responds to ceftriaxone and azithromycin. He develops occasional urinary incontinence treated with
anticholinergics, but his overall status improves and he is ready for discharge by the fifth hospital day. On that
morning, however, he develops urinary hesitancy and slight suprapubic tenderness. The creatinine is found to be
3.0 mg/dL; UA is clear with no RBCs, WBCs, or protein. What is the most likely cause of the patient’s renal failure?
A. Prerenal azotemia because of intravascular volume depletion
B. Ischemia-induced acute tubular necrosis
C. Nephrotoxin-induced acute tubular necrosis
D. Acute interstitial nephritis
E. Postrenal azotemia because of obstructive uropathy
97. A 55-year-old male is being evaluated for constipation. There is no history of prior gastrectomy or of upper GI
symptoms. Hemoglobin is 100gL, mean corpuscular volume (MCV) is 72fL (normal 86-98), serum iron is 4 ug/dl
(normal is 50-150), iron-binding capacity is 450ug/dl (normal 250-370), saturation is 1% (normal 20%-45%), and
ferritin is 10ug/L (normal 15-400). Which of the following is the best next step in the evaluation of this patient’s
anemia?
A. Red blood cell folate
B. Serum lead level
C. Colonoscopy
D. Bone marrow examination
E. Hemoglobin electrophoresis with A2 and F levels

98. A 68-year-old man was treated with intravenous antibiotics for 5 days because of a left lower lobe pneumonia.
On review in the outpatient department 8 weeks later, he has improved but still has a troublesome cough with
some flecks of blood in the sputum. On examination, there is dullness to percussion at the left base, with some
bronchial breathing and coarse crackles. Vocal resonance is increased. What is the most likely diagnosis?
A. Parapneumonic effusion
B. Pulmonary infarction
C. Empyema
D. Carcinoma of the bronchus
E. Recurrent chest infection

99. A 40-year-old male presents to the office with history of palpitations that last for a few seconds and occur two
or three times a week. There are no other symptoms. ECG shows a rare single unifocal premature ventricular
contraction (PVC). The most likely cause of this finding is
A. Underlying coronary artery disease
B. Valvular heart disease
C. Hypertension
D. Apathetic hyperthyroidism
E. Idiopathic or unknown

100. A 50-year-old obese female is taking oral hypoglycemic agents. While being treated for an upper respiratory
infection, she develops lethargy and is brought to the emergency room. On physical exam, there is no focal
neurologic finding or neck rigidity. Laboratory results are as follows: Na+: 134meq/L, K+: 4.0meq/L, HCO3: 25
meq/L, glucose: 50 meq/L, BUN: 84 mg/dL, creatine 3.0mg/dL, BP: 120/80 mmHg sitting, BP 105/65mmHg lying.
The most important treatment in this patient is
A. Large volumes of fluid, insulin; seek concurrent illnesses
B. Bicarbonate infusion 100 meq/L
C. Rapid glucose lowering with intravenous insulin
D. 30meq/hr of KCL
E. Broad-spectrum antibiotics