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MCC Practice Examination

INSTRUCTIONS 1. For multiple-choice items which have only one correct or best answer the options

have been lettered A, B, C, etc. 2. For multiple-choice items which have one or more correct answers the options

have been lettered a, b, c, etc. 3. For multiple choice/single response type questions, mark your choice(s) on the

optical score sheet provided. Use the pencil provided and erase any errors thoroughly.

4. If you have any comments or criticisms about an item or the overall examination,

please make them on the blank sheet at the end of this booklet.

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EXAMINATION QUESTIONS Please answer questions 1-3 based on information from the following vignette. Mr. John Wong, a 34-year-old restaurant owner, visits his family physician’s office for a routine check-up. On repeated testing his blood pressure is elevated at 180/105 mmHg. He admits to stress at work and states that his father was diagnosed as hypertensive at the age of 60 but, thus far, has not required treatment. He has no symptoms with the exception of mild constipation for which he takes bran supplements. He is on no prescribed medication although he does admit to occasionally taking Chinese herbal remedies. He denies taking any other medications. He smokes 25 cigarettes per day but takes no alcohol. On physical examination he is not obese, has no signs of cardiovascular disease, and no hypertensive retinopathy. The results of investigations are given below: Urine analysis negative Na 146 mmol/L K 2.8 mmol/L Cl 102 mmol/L HCO3 33 mmol/L Urea 4.2 mmol/L Creatinine 92 mmol/L Glucose 6.2 mmol/L 1. What is the most likely explanation for hypokalemia A. increased urinary losses of potassium B. reduced dietary intake C. surreptitious laxative abuse D. metabolic alkalosis E. chinese herb nephropathy 2.Which of the following investigations is/are indicated? a. dietary intake assessment b. captopril renal isotope scan c. urine metanephrines d. plasma Renin Activity e. 24 hour urine collection for aldosterone estimation

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3. Which of the following is/are appropriate step(s) in management? a) Arrange for the patient to go to the nearest ER b) 5 mmol of Potassium Chloride intravenously c) Refer the patient for further investigation d) Oral Potassium supplements e) Thiazide diuretic for treatment of hypertension

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Please answer questions 4 – 6 based on information from the following vignette. Primary hypertension is almost always the most likely diagnosis for patients with hypertension. For each patient in questions 1-3 select the SECONDARY CAUSE of hypertension worthy of investigation from choices A-N. If No secondary cause is worthy of investigation, SELECT CHOICE “O”. Choices A-O may be used once, more than once or not at all. A. Acute renal failure B. Birth control pills C. Chronic renal failure D. Coarctation of the aorta E. Licorice ingestion F. Pheochromocytoma G. Polycythemia H. Primary hyperaldosterone (mineralocorticoid excess) I. Renal artery stenosis, bilateral J. Renal artery stenosis, unilateral K. Renal parenchymal disease L. Sympathomimetics (e.g. ephedrine for nasal congestion) M. Transplant donor N. White coat hypertension O. None of the above 4. Mr. Harry Conroy, a 52-year-old newspaper assistant editor, is seen in the office of his family physician complaining of blood in the urine over the past four days. He states that he has had this on two previous occasions, both in relation to an upper respiratory tract infection. On both previous occasions the urine cleared spontaneously over a period of five to seven days. At the time of the present visit he states that he has been feeling lethargic with a sore throat for the past five days. He is a vegetarian and smokes a pack of cigarettes each day. Blood pressure is 170/95 mmHg in both arms, sitting and supine, on repeat testing. Urine analysis shows specific gravity 1020, nitrites negative, +++ blood and +++ protein. Urine microscopy reveals oxalate crystals, dysmorphic red blood cells and red cell casts.

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5. Mr. James McKeen, a 49-year-old tax assesor, visits his family physician’s office for his monthly blood pressure check. He has been hypertensive for the past four years and his blood pressure control has been erratic during this time. His only other medical problem is gout, which he experiences on average once every eighteen months. He continues to smoke two packages of cigarettes per day. He has a maternal family history of hypertension and cerebrovascular disease and a paternal family history of lung carcinoma. His present antihypertensive medications are hydrochlorothiazide and adalat XL. On physical examination he is obese with blood pressure is 174/96 mmHg. Urine analysis at his last three visits has shown a trace of protein. Urine microscopy is unremarkable. A 24 hour urine collection shows a normal creatinine clearance with excretion of 340mg of albumin during this time period. Serum liver enzymes are normal. 6. Ms. Jane Wallace, a 29-year-old interior decorator, visits his family physician’s office for a routine check-up. On repeated testing her blood pressure is elevated at 180/105 mmHg. She admits to stress at work and states that her father was diagnosed as hypertensive at the age of 60 but, thus far, has not required treatment. She has no symptoms with the exception of mild constipation for which she takes bran supplements. She is on no prescribed medication although she does admit to occasionally taking Vitamins C and E. She denies taking any other medications. She does not smoke but takes alcohol socially. On physical examination she is not obese, has no signs of cardiovascular disease, and no hypertensive retinopathy. The results of investigations are given below: Urine analysis negative Na 146 mmol/L K 2.8 mmol/L Cl 102 mmol/L HCO3 33 mmol/L Urea 4.2 mmol/L Creatinine 92 mmol/L Glucose 6.2 mmol/L

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Please answer questions 7 – 9 using information from the following vignette. Mrs. Hogan brings her daughter Natascha to the emergency room. Natascha is a previously well, one-year-old girl who developed a fever two days ago. Her temperature, measured orally by her mother, was 39.8o C. For the past two days Natascha has been listless and has eaten very little other than juice and milk. She has had neither diarrhea nor vomiting. Her mother thinks she may have had a bit of a runny nose earlier in the week. Her mother has been treating her with Tylenol, and although Natascha appears flushed and ill when the fever is high, she is her usual self when the fever is down. Her mother is concerned because Natascha has had a fever once before and it was an ear infection that required antibiotics. Her mother is wondering if she needs some today. Natascha has otherwise been a healthy child and has received all her immunizations including MMR vaccine one week ago. On examination, she is sleeping in her mother’s arms during the interview. She cries during the entire exam, but is comforted after by her mother and stops crying. Her temperature is 40 degrees Celsius rectally. Her tympanic membranes are normal. Her throat is mildly erythematous, with no exudate. Her lungs are clear, respiratory rate is 30/min, and there are no extra heart sounds. Abdomen is soft. She has a diaper rash. 7. What causes of fever must you consider in this case?

a. viral infection b. vaccine reaction c. meningitis d. occult bacteremia e. urinary tract infection

8. What investigations would you undertake in this case?

a. lumbar puncture b. urinalysis & urine culture c. CBC and differential d. chest X ray e. blood cultures

9. A CBC is drawn and her WBC is 20 x 109/L, with a high neutrophil count. All other investigations are normal. How would you manage this case?

a. administer aspirin q4h b. administer ibuprofen q6h c. administer acetaminophen q4h d. admit to hospital, refer to a pediatrician e. administer Ceftriaxone im

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Please answer questions 10 - 13 using information from the following vignette.

Ms Angela Keating, a 38-year-old woman originally from Australia, presents with a 3-month history of fatigue and diarrhea. Over the last 4 months she has been having between 3 to 5 soft bowel movements per day. She denies constipation, blood in her stool or liquid stool. Her normal bowel routine that dates back to childhood is 1 to 3 bowel movements per day and she remembers the occasional episode of liquid stool and rarely hard, painful to pass bowel movements. She is normally very active, but recently she has had to take leave of absence from her job as a waitress at a hotel in the mountains. She states she has lost about 5 kg in the last 6 months. Her past medical history is negative except for two therapeutic abortions. About two weeks ago she finished a course of antibiotics prescribed for a Chlamydia infection. Her medications include acetaminophen 500 mg po tid prn for joint pains, the birth control pill, a multivitamin, and a topical hydrocortisone cream she uses for a an itchy skin rash that she has had for several years on her back and buttocks. Her family history is negative except that her mother has osteoporosis (age 63) and her father has panic attacks. Her physical examination revealed a thin, pale, tired looking female appearing younger than her stated age. Vital signs revealed a BP of 110/70 mmHg, HR 90/min, temperature 36.5 C. Pale conjunctiva, no oral lesions or lymphadenopathy. Her chest and cardiovascular exam was normal except for a 2/6 systolic ejection murmur at the LSB. MSK and CNS exam were normal except for leukonychia, a vesicular rash and excoriations on her buttocks. Mild hepatomegally was noted by percussion and palpation but no masses, tenderness or splenomegally were noted. Rectal exam was normal. CBC: Hgb 82 g/l, microcytic red cells and Howell Jolly bodies were noted on the peripheral smear. Her electrolytes and glucose were normal. 10. In assessing the cause of her diarrhea which of the following is/are correct; a. If diarrhea continues with fasting it is more likely to be an osmotic diarrhea. b. Smaller volumes of diarrhea and tenesmus are more commonly associated with small

bowel diarrhea. c. Chronic diarrhea is defined as any diarrheal episode lasting longer than 10 days. d. Irritable bowel syndrome can be associated with the passage mucus per rectum. e. Antibiotic associated colitis can cause chronic diarrhea. 11. Which of the following is/are consistent with the diagnosis of irritable bowel syndrome; a. chronic alternating constipation and diarrhea b. pain relieved by having a bowel movement c. pain or diarrhea waking the patient from sleep d. onset before the age of 45 years e. a feeling of incomplete evacuation following a bowel movement.

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12. Which of the following is/are a likely causes of Ms AK’s problems; A. Ulcerative colitis B. Antibiotic associated colitis C. Celiac disease D. Cystic fibrosis E. Hemochromatosis 13. In regards to investigating the cause of Ms A.K.’s problems which of the following are true. a. There is a reproducible and accurate blood test for the diagnosis of Crohn’s disease. b. There is a reproducible and accurate blood test for the diagnosis of Celiac disease. c. An upper endoscopy may aid in the diagnosis of both Celiac disease and Giardia.(0.5) d. HIV serology should be ordered e. A macrocytic anemia favors the diagnosis of ulcerative colitis over Crohn’s disease.

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Please answer questions 14 – 15 based on information from the following vignette. Cody, a six-year-old boy presently undergoing treatment for Wilm's tumor, visits the oncology clinic regarding a sudden loss of vision in his right eye of one day's duration. He has completed his treatment protocol six months ago and has been stable until this new symptom developed. His general physical examination shows no obvious problems. His vision in the right eye is restricted to light perception only. His vision in the left eye is 20/20. Pupils are 4 mm in size each eye, pupillary reactions are sluggish right eye, but brisk with a normal consensual reaction when the light is shown to the left eye. Swinging the flashlight from left to right eye, the right pupil dilates. Swinging the flashlight from right to left eye, the left pupil constricts. Fundal examination shows a normal optic nerve, peripheral retina, within normal vessel pattern. 14. The pupillary reactions demonstrated represent: A Horner’s Syndrome (impaired pupil dilatation) B. Adie’s pupil (pathological pupil reaction) C. afferent pupillary defect (Marcus-Gunn pupil) D. normal pupillary reactions E. anisocoria (inequality of pupils in diameter)

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15. The most likely diagnosis is: A metastasis to the right optic nerve B. Orbital tumor C. hemorrhage within the right optic nerve sheath D. retinal detachment E. Increased Intracranial Pressure

***** 16. A 64-year-old man is brought to see you by his wife because of increasing memory problems and confusion over three months. He has become gradually more listless and apathetic, with a significant change in personality. She has noted that he has had increasing difficulty with recalling recent events. One week ago, while he was driving home with her from visiting a friend, he became lost and was unable to find his way home. The patient does not complain of memory problems, but has complained of bilateral headache over the past two months, for which he has been taking acetaminophen, 1mg daily. Review of systems shows that he smokes one pack per day, and has drunk four bottles of beer every day for twenty years, although his drinking has decreased over the last two months. On examination, the patient is disoriented for time, does not recall the name of the current Prime Minister, and has difficulty subtracting 7 from 100. He shows hyperactive reflexes in his legs, and plantar responses are upgoing bilaterally. His gait is slightly unsteady and wide-based. What is the most likely diagnosis? A. Chronic bilateral subdural hematoma. B. Glioma involvingboth frontal lobes. C. Azheimer’s disease. D. Hypothyroidism. E. Lewey-body dementia.

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Please answer questions 17 – 18 based on information from the following vignette. A fourteen-year-old boy attends his family physician’s office for examination of his eyes. His mother believes something is wrong with them because he is constantly blinking. The boy is otherwise well. He was suspected to have Attention Deficit / Hyperactivity Disorder (AD/HD) in elementary school, but was never placed on stimulant medication. He currently takes no medications. He was adopted at birth, thus his family history is not known. During conversation with the boy, you note that he frequently clears his throat, yet he denies sore throat or other upper respiratory tract symptoms. He blinks frequently, yet is able to hold his eyes open during examination with an ophthalmoscope. His fundi, visual acuity, extraocular movements, visual fields, eyelids and eyelashes are normal. He also exhibits intermittent facial grimacing without apparent pain. The remainder of his examination is normal. 17. This boy’s eye movements are most consistent with which of the following? A. Fidgeting B. Motor tics C. Simple partial seizures D. Blepharospasm E. Blepharitis 18. Which of the following conditions are frequently associated with this boy’s diagnosis? a. Oppositional Defiant Disorder (ODD) b. Attention Deficit / Hyperactivity Disorder (AD/HD) c. Conduct Disorder (CD) d. Obsessive Compulsive Disorder (OCD) f. Developmental Coordination Disorder (DCD)

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Please answer questions 19 – 20 based on information from the following vignette. A 14-year-old male presents to your office complaining of recent growth of his breasts. He has a history of cardiac disease and is currently taking digoxin and hydrochlorothiazide. On examination your patient is slim, his blood pressure is 160/96 mmHg, and he has bilateral non-tender gynecomastia. The remainder of his physical examination is within age normal limits. 19. The patient asks you why his breasts are growing and you site which of the following reasons as a possible cause? A. His slender body habitus B. Digitalis C. His elevated blood pressure D. Hydrochlorothiazide E. His underlying cardiac disease 20. Your patient desires more information about breast enlargement in males. Which of the following information should be given?

a. Gynecomastia is very uncommon and he needs to have his breast tissue biopsied as soon as possible to exclude breast carcinoma.

b. Asymptomatic palpable breast tissue can be seen in normal males, particularly in neonates, at puberty and with increasing age above 45 years.

c. Avoid heavy alcohol abuse since it may be lead to gynecomastia d. Gynecomastia will almost never spontaneously regress leading to the single

therapeutic option of surgical removal of the breast tissue. e. Gynecomastia results from an increased estrogen to testosterone ratio.

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Please answer questions 21 – 23 based on information from the following vignette. Mr. William Connell, a 41-year-old freelance photographer, is seen in the office of his family physician complaining of red discolouration of his urine over the past four days. He states that he has had this on two previous occasions, both in relation to an upper respiratory tract infection. On both previous occasions the urine cleared spontaneously over a period of five to seven days. At the time of the present visit he states that he has been feeling lethargic with a sore throat for the past five days. He is a vegetarian and smokes a pack of cigarettes each day. Blood pressure is 170/95 mmHg in both arms, sitting and supine, on repeat testing. Urine analysis shows specific gravity 1020, nitrites negative, +++ blood and +++ protein. Urine microscopy reveals oxalate crystals, dysmorphic red blood cells and red cell casts.

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21.Which ONE of the following is the most likely diagnosis? A. IgA nephropathy B. Ingestion of beets C. Renal calculi D. Bladder carcinoma E. Post-streptococcal glomerulonephritis 22. Which of the following investigations does this patient require? a. Cystoscopy b. Urine culture c. Serum creatinine d. Plain X-ray of the kidney, ureter and bladder e. 24 hour urine collection for creatinine clearance and protein excretion 23. The presence of dysmorphic red blood cells is indicative of: A. Urine infection B. Delay in analysis of the urine sample C. Glomerular bleeding D. Urothelial malignancy E. Urinary tract calculus

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Please answer questions 24 – 25 based on the following vignette.

Miss Tracy Patterson, a 17-year-old university student, visits her family physician’s office complaining of fatigue and “strong smelling” urine. Her only past medical problem is infectious mononucleosis two years previously form which she made a complete but protracted recovery. Her only medication is the birth control pill. She is a member of the university basketball team and has noted a dip in her performance since the onset of these symptoms. She denies any other symptoms. There are no abnormal findings on examination. Blood pressure is 110/68 mmHg. Urine analysis shows specific gravity 1030, nitrites negative, + protein. Urine microscopy reveals a few vaginal epithelial cells/hpf, 0-1 wbc’s/hpf, and 0-1 hyaline casts/hpf. A 24 hour urine collection shows a normal creatinine clearance with 0.41g of protein for this time period.

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24. Which ONE of the following is the most likely diagnosis? A. IgA nephropathy B. Membranous glomerulonephritis C. Exercise-induced proteinuria D. Urinary tract infection E. Reflux nephropathy 25. Which of the following investigation(s) does this patient require? a. Cystoscopy b. Split urine collections (0800 – 2000, and 2000 – 0800) c. Repeat 24 hour collection after avoiding exercise d. Renal biopsy e. Serum and urine electrophoresis

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Please answer questions 26 – 27 based on information from the following vignette. Theresa Gallagher, arrives at her family physician’s office complaining of easy bruising over the past month. She is not as concerned about her “rash-like” skin bruising as she is about her gums bleeding with brushing her teeth over the past three days. Theresa is 25 years old and otherwise healthy. She is not taking any medications, and drinks only socially. She has never been hospitalized except for the birth of her daughter three years ago after an uneventful pregnancy. Family history is completely negative. She denies any large bruises, denies deep muscle or joint pain, and has not noticed any blood in her urine.

26. What investigations would you order?

a. CBC and differential b. Serum electrolytes & creatinine c. fibrin split products d. PT & PTT (includes INR) e. AST, ALT, alkaline phosphatase

27. The only abnormality detected is a platelet count of 70,000/mm3. What is/are the possible cause(s)?

a. Renal failure b. Folate/B12 deficiency c. Lymphoma/leukemia d. Factor VIII deficiency e. SLE

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28. A concerned father calls your office because his three-week-old son Damien has a fever of 39.5 degrees Celsius measured axially. He was born at term and had no complications after a spontaneous vaginal delivery. He was breast-feeding well until yesterday. Since then he has been sleeping more. He has a two-year-old brother who has a cold. What is the best advice to give the parents? A. Treat the fever with Tylenol, bring the baby to the office if fever lasts over 48 hours B. Bring baby to the office for further evaluation sometime later today. C. Take baby to the emergency room for hospital admission D. Make a house call E. Make appointment for the baby with a pediatrician Please answer questions 29 – 31 based on information from the following vignette. Mr. David Wallace is a 57 year old male that presents with a longstanding history of heartburn and reflux of acid-like material in to his mouth. He usually treats himself with oral antacids but lately they have not been as effective. Yesterday he had some pain and a sticking sensation after swallowing a piece of bread. He has noticed this on at least on 3 separate occasions before, these episodes having occurred over the last 2 months or so. When asked to point to where he feels the food is sticking he points to he points to an area just below his thyroid gland. Each time he could not swallow, he was able to down the food with water and did not need to seek medical attention. He has not had trouble swallowing hot or cold liquids. His past medical history is significant for polio as a child and feels he has some arm and leg weakness due to that. He has a 50-pack year smoking history. His family history is negative except he has one sister that died of breast cancer. His physical exam is completely normal. 29. In assessing Mr. Wallace which of the following is/are correct; a. Since he points to an area near his thyroid he probably has oropharyngeal dysphagia

secondary to post polio syndrome. b. Assess for signs of stroke or post-polio syndrome since his dysphagia is likely due to

a neuromuscular disease. c. He likely has uncomplicated reflux esophagitis and should be managed with a proton

pump inhibitor and requires no further investigation. d. Esophageal carcinoma usually presents with both liquid and solid dysphagia e. Since coughing, choking, and aspiration are absent, difficulty in initiating swallowing

(in contrast to difficulty swallowing) may be safely excluded

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30. Which of the following management/investigation strategies is/are most appropriate for Mr. Wallace? a. Start him on H2 antagonist (ranitidine) and arrange for him to have an upper

endoscopy. b. If a barium swallow is normal and his symptoms progress start him on a proton pump

inhibitor and advice him that since the barium swallow is normal no further investigation are required.

c. Since an upper endoscopy is not available in your community you order a chest xray

and a barium swallow. d. His barium swallow is normal but the dysphagia persists, order a CT scan of his head

to rule out a neurological cause of his dysphagia. e. Since dysphagia can occur in uncomplicated reflux esophagitis you reassure the

patient that he has uncomplicated gastroesophageal reflux and counsel him on conservative management of reflux disease suggest he eat small meals, quits smoking and limits his caffeine consumption.

31. The most likely diagnosis for Mr. D. W. is: A. Lower esophageal ring B. Peptic stricture C. Esophageal carcinoma D. Esophageal spasm E. Achalasia

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32. The emergency room nurse pages you to come examine a two-year old girl who is the daughter of one of your patients. Upon arriving in the emergency room, you see an obtunded girl with no known prior medical problems. Her father states that his daughter fell down the stairs earlier in the evening, but he does not think that she hit her head during the fall. Physical examination shows no visible signs of external injury. After a brief but complete physical examination, the only abnormality detected was on examination of her eyes. Although examination of her anterior chambers is normal, posteriorly in each eye there are large, dome-shaped hemorrhages in the macula. In addition, there are multiple scattered retinal hemorrhages visible in the retinal periphery of each eye.

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The most likely diagnosis in this case is: A. acute myelogenous leukemia B. diabetic retinopathy C. childhood hypertensive retinopathy D. child abuse (shaken baby s yndrome) E. retinal edema 33. A 63-year-old man experienced a ten-minute attack of right-sided weakness with associated difficulty speaking one week ago. Carotid ultrasound testing showed bilateral carotid atheroma, with a 20% carotid stenosis on the left, and an 80% carotid stenosis on the right. Past illnesses include mild hypertension under treatment. Review of systems reveals no symptoms suggestive of coronary artery disease. His neurological examination is normal. Appropriate management of this patient would be:

A. Left carotid endarterectomy. B. Right carotid endarterectomy. C. Coumadin anti-coagulation. D. Enteric coated aspirin. E. Hydergine (ergoloid mesylates).

34. Sara has terminal bone cancer unresponsive to chemotherapy. She is 7 years old and has been in hospital for palliative care for just over 3 weeks. Today she is feeling tired, she is repeatedly complaining of pain in her leg, and wants to be held in her mother’s arms. She refuses to eat because according to her there is no point in eating if she will die anyway. Which of the following procedures is/are appropriate for Sara (choose all correct ones):

a. force feed b. provide adequate analgesia c. initiate parental nutrition d. prescribe antidepressants e. provide emotional support

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Please answer questions 35 – 36 based on information from the following vignette. A full term infant with a birth weight of 3.5 kg, length of 50 cm and head circumference of 35 cm (all at 50th percentile) comes for an office appointment at 2 weeks of age. The mothers states that the infant was discharged home at 24 hours of age and has done well since. The infant is being fed Carnation milk diluted to 25%. The child’s sleep pattern is characterised by 1.5 hours of sleep after each feed. His weight today is identical to birth. On exam the infant appears to be well hydrated, the mucosa colour is normal and in no distress. The exam is unremarkable except for irritability. 35. Why has the infant failed to gain weight?

A. This infant was small for gestational age at birth B. This infant is microcephalic C. The nutritional support provided to this child is adequate for a newborn D. Encourage breast feeding or change milk to an appropriate infant formula E. Recommend that the dilution of the milk be changed to 50%

36. Considering the appropriate nutritional management of infants, select the appropriate

advice to be given to new mothers:

A. Avoid feeding newborn infants in the first 12 hours of life in order to prevent aspiration

B. Breast milk is deficient in iron and iron supplementation is recommended for breast fed infants

C. Breast milk does not contain enough vitamin D and vitamin D supplementation is recommended for exclusively breast fed infants

D. Institute solid food at three months of age E. Breast milk may causes diarrhea if used exclusively, so formula should be added

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Please answer questions 37 – 39 based on information from the following vignette. Mr. Lyle Murrin, a 75-year-old retired train engineer, saw his family physician on March 18, 2000 complaining of breathlessness. He had signs of cardiac failure with atrial fibrillation. Serum creatinine at that time was 145 µmol/L, similar to the value from eight months ago. Because he was in moderate distress, he was admitted to hospital. No invasive procedures were considered necessary. His diagnosis of congestive heart failure led to treatment with enalapril, furosemide, and digoxin. He was discharged from hospital on March 28, 2000. Today, April 3rd, 2000 he returns to the office of his family physician complaining of increasing nausea, vomiting, decreasing amounts of urine, pain in his right great toe and difficulty sleeping. He has a history of hypertension and ischemic heart disease. On physical examination he appears unwell with a heart rate of 46 bpm (irregularly irregular). Sitting BP is 190/88 mmHg. JVP is 5cm above the sternal angle. He has an apical pan-systolic murmur, a right carotid and bilateral femoral artery bruits, bilateral basal inspiratory crackles and a red tender swollen right first metatarsal phalangeal joint. The results of his initial investigations are given below: Na 139 mmol/L Hb 114g/L K 5.8 mmol/L WBC 14.3 x109/L HCO3 22 mmol/L Plat 274 x109/L Cl 101 Urea 13.5mmol/L Creatinine 325µmol/L 37. What is the most likely explanation for the rise in serum creatinine? A. Hypertensive nephrosclerosis B. Bilateral renal artery stenosis C. Dehydration secondary to diuretics D. Urate-containing renal calculi E. Chronic glomerulonephritis 38. Which of the following investigations is/are indicated? a. Antineutrophil cytoplasmic antibody titre b. Abdominal ultrasound with duplex Doppler c. ASO titre d. Urine analysis and microscopy e. Cystoscopy

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39. Which of the following treatments is/are indicated? a. Fluid challenge of 500mls normal saline b. Stop enalapril c. Stop digoxin d. Allopurinol e. Stop diuretics

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Please answer questions 40 – 41 based on information from the following vignette. Mr. Tom McDonald, a 51-year-old accountant, visits his family physician’s office for his three monthly blood pressure check. He has been hypertensive for the past five years and his blood pressure control has been erratic during this time. His only other medical problem is gout, which he experiences on average once every eighteen months. He continues to smoke a pack of cigarettes per day. He has a paternal family history of hypertension and cerebrovascular disease and a maternal family history of colonic carcinoma. His present antihypertensive medications are hydrochlorothiazide and nifedipine XL. On physical examination he is obese with a BMI of 32. Blood pressure is 170/94 mmHg. Urine analysis at his last three visits has shown a trace of protein. Urine microscopy is unremarkable. A 24 hour urine collection shows a normal creatinine clearance with excretion of 270mg of albumin during this time period. Stool occult blood test is negative on three occasions. 40. Which of the following investigations does this patient require? a. Cystoscopy b. Split urine collections (0800 – 2000, and 2000 – 0800) c. Fasting blood glucose d. Renal biopsy e. Fasting lipids 41. The most likely cause of albuminuria in this patient is: A. membranous glomerulonephritis B. orthostatic albuminuria C. diabetic nephropathy D. glomerular hypertension E. tubulo-interstitial nephritis

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42. The laboratory calls a physician’s office to report an INR of 10 on Mr. Becker. Upon review of the office chart, it is noted that the patient is a 68-year-old man on Coumadin 5-mg daily for atrial fibrillation. He also has osteoarthritis of the knee and chronic obstructive pulmonary disease. Other medications being taken include Ventolin, Atrovent, Becloforte, and Indocid. When Mr. Becker is reached at home by telephone, he is feeling well and has not noticed any bleeding.

Your initial steps should include:

a. admit to hospital b. decrease the dose of Coumadin to 3 mg per day and recheck the INR in 3 days c. hold the Coumadin and recheck INR daily for the next three days d. discontinue the Indocid e. administer vitamin K 10 mg sc/po daily for 3 days.

Please answer questions 43 – 45 based on information from the following vignette. Fernando Fournasier is a new patient who recently moved into town and has arranged to have a routine physical exam for life insurance. He is a healthy 60-year-old restaurant owner. His only medical problem has been hypertension that was diagnosed 6 years ago and has been well controlled on Enalapril, 10 mg daily. He has no complaints. He doesn’t smoke and attempts to eat a low fat diet. On physical exam, you note that his blood pressure is 140/88, and his heart rate 80. JVP is 2 cm above the sternal angle. Upon listening to his chest, you hear a systolic murmur at the left sternal border that is as loud as his heart sounds. He has no extra sounds. He has no heaves or thrills. He states he has never been told he had a murmur. The rest of his exam is normal. 43. Possible etiologies of this murmur are:

a. Aortic/pulmonary regurgitation b. Aortic/pulmonary stenosis c. Mitral/tricuspid regurgitation d. Mitral/tricuspid stenosis e. innocent flow murmur

44. Signs and symptoms that indicate the need for further investigation are:

a. Dyspnea b. petechia c. fatigue d. syncope e. the presence of a thrill

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45. If a pathologic murmur is likely, initial investigation(s) would include: a. BP 24-hr monitor b. ECG c. Holter monitor d. Echocardiogram e. thallium scan

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Please answer questions 46 – 48 based on information from the following vignette. Ms Webb, a 19-year-old female presents to her family physician’s office with a 3-day history of vomiting (7 to 10 times per day) and retching. Yesterday, for the first time, she noticed some streaks of blood in her greenish vomit on one occasion. She has not had a bowel movement in two days and denies diarrhea, blood in her stool, early satiety, pain associated with eating, or weight loss. She admits to feeling cold, weak and light headed for 3 days. Over the last several years she occasionally brings up sour tasting liquid into her mouth and often this is associated with epigastric pain and burning in her chest. Her past medical history and family medical history is negative. She is has been taking Tylenol (acetaminophen) for back pain the last few days. Her physical exam reveals; BP 90/70, HR 110, temperature 38.4C. Head and neck, chest and cardiovascular exams are normal except for a 2/6 systolic murmur and some tenderness to percussion over her left lower lung field posteriorly. Her abdominal exam was normal. 46. In assessing Ms Webb which of the following is/are correct? a. Her symptoms likely represent an exacerbation of her reflux esophagitis. b. An ultrasound of the pancreas, liver and biliary track should be ordered immediately

to rule out gallstones or pancreatitis. c. Blood cultures would be unlikely to be helpful since her temperature is less that 38.5. d. Due to the blood in the vomit, this is classic for peptic ulcer disease. e. It is likely that her weakness and light-headedness is due gastrointestinal losses

causing contraction of EABV

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47. For Ms Webb’s vomiting, select the most useful initial investigation / treatment A. Upper endoscopy, lipase and amylase B. Send a stool sample for cultures and sensitivity and ova and parasites to rule out food poisoning C. A full neurological exam followed by a CT scan of the head if abnormalities are noted D. Routine lab work including a CBC, electrolytes and send urine for routine and microscopic exam. E. Give her a pink lady (liquid antacid mixed with viscous xylocaine) and see if that improves her symptoms. 48. Select the most likely diagnosis A. Gastroenteritis B. Acid Peptic disease C. Obstruction of bowel D. CNS infection E. Systemic infection

*****

Please answer questions 49 – 51 based on information from the following vignette. James Smith, a nine-year-old boy, is sent to the emergency room for further evaluation. He has had three days of treatment with intravenous cefuroxime and cloxacillin with no improvement in his left eye signs and symptoms. He has had a three-week history of purulent rhinorrhea, a temperature of 37.2 C, and a white count of 10. 5 x 109. The referral notes indicates that a recent X-ray showed evidence of pansinusitis. On examination, his vision was 20/20 in each eye, the eyelids of the left eye were swollen shut. There was marked conjunctival induration, chemosis, proptosis, and limited elevation of the left eye. Pupillary reactions were sluggish in the left eye. Fundal examination was normal in both eyes, without evidence of papilledema or optic atrophy. 49. Which of the following statements is a feature of a dangerous red eye: A. improvement after three days of pharmacologic treatment B. pupil unreactive to direct light C. full extraocular movements D. the absence of proptosis and severe ocular pain E. bilateral red eyes

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50. The most likely diagnosis in this case is: A. Acute angle closure glaucoma B. Acute orbital cellulitis/abscess C. Dacryocystitis D. Endophthalmitis E. Blepharitis 51. Which of the following is indicated in this case: A. CT scan/ MRI scan B. Fluorescein angiography C. Referral to an ophthalmologist immediately D. Dilation of the eye with indirect ophthalmoscopy E. Slit Lamp examination

*****

52. Mr. R.M. is 76 years of age. He has a past history of age-related macular degeneration, hypertension, prior alcohol abuse, osteoarthritis of his right hip, and manic-depressive disorder. Current medications are - lithium carbonate 300 mg. t.i.d, hydrochlorothiazide 25 mg. daily, and indomethacin 25 mg. tid. Over the last year he has complained of mild word finding problems with delayed retrieval ("its at the tip of my tongue") and mild problems with recall. With cueing he can usually recall the item. About two weeks ago he was started on indomethacin for worsening hip pain. A week ago he was seen by his ophthalmologist and told he should give up driving because of his deteriorating vision. You were called by his wife to see him at home because of the development of confusion over the last 2-3 days. According to the wife the confusion varies over the course of the day. On examination he is intermittently agitated and has trouble focusing his attention. He is disoriented to time and his short-term memory is impaired. The most likely diagnosis is: A. Acute Mania. B. Delirium. C. Dementia. D. Grief Reaction. E. Major Depression.

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Please answer questions 53 – 54 based on information from the following vignette. A 32 weeks gestation infant is born with a birth weight of 1000 grams (< 3rd percentile). At birth the infant required no resuscitation but has quickly developed tachypnea and cyanosis on room air. The physical examination is remarkable for respiratory distress with bilateral rales on lung auscultation. The vital signs at 1 hour age revealed a heart rate of 150 beats per minute, respiratory rate of 80 / min, temperature of 35.7 o C and heel stick glucose check of < 2 mmol/L. 53. How would you classify this infant according to gestational age and measurement

parameters? A. Adequate for Gestational Age B. Small for Gestational Age C. Large for Gestational Age D. Dysmature E. Full term

54. Immediate management of this infant should include:

a. observe the infant undressed in an open, unheated bassinet b. obtain sample of blood gases and pH c. slowly warm the infant to 36.8 o C d. give a bolus of D10W, 10 ml/kg e. give a bolus of D10W, 2 ml/kg

*****

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Please answer questions 55 – 56 based on information from the following vignette. Miss Patricia Thomson, a 36-year-old schoolteacher, attended the office of her family physician one week ago complaining of dysuria. Urine culture had grown E coli for which trimethoprim and pyridium (bladder analgesic) were started. She has chronic renal insufficiency due to reflux nephropathy with a baseline serum creatinine of about 150µmol/L. Her only regular medication is the birth control pill. Today she complains of nausea and vomiting since starting trimethoprim along with a bad taste in her mouth. On physical examination, she appears well with a heart rate of 84 bpm and sitting BP of 110/68 mmHg. She has no renal angle tenderness. The results of her investigations are given below: Date: One week Today Repeat today ago Na (mmol/L) 139 140 139 K (mmol/L) 5.5 6.8 6.6 HCO3 (mmol/L) 20 21 20 Cl (mmol/L) 108 108 109 Urea (mmol/L) 9.8 10.3 10.1 Creatinine (µmol/L) 155 186 183 Glucose (mmol/L) 4.3 EKG Sinus rhythm with peaked T waves 55. What is the most likely explanation for the rise in potassium? A. Birth control pills B. Increased dietary intake C. Trimethoprim D. Metabolic acidosis E. Pyridium 56. Which of the following are appropriate steps in management? a. Arrange for the patient to go to the nearest ER by ambulance b. Stop trimethoprim and repeat potassium c. Arrange for an urgent out-patient nephrology consultation d. Start Sodium Bicarbonate and repeat potassium e. Intravenous calcium gluconate, insulin and glucose

*****

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Please answer questions 57 – 58 based on information from the following vignette. Mr. Balwindar Singh, a 54 year old accountant, who is seen in the office of a walk-in clinic complaining of increasing breathlessness on exertion. He has been an IDDM for 12 years, hypertensive for seven years and had a myocardial infarction complicated by “mild” cardiac failure one year ago. He also complains of thirst, polyuria and daytime somnolence. He smokes half a pack of cigarettes per day and takes four units of alcohol per day. On examination his pulse is regular at 92 beats per minute and blood pressure is 174/96 mmHg with no postural change. Jugular venous pulse is 5cm above sternal angle. Prescribed medications are lisinopril 5mg, hydrochlorothiazide 25mg, atorvastatin 10mg, ASA 325mg, and insulin. The results of investigations are given below: Urine analysis negative Urine electolytes Na 125 mmol/L Na 105 mmol/L K 4.8 mmol/L K 54 mmol/L Cl 92 mmol/L Cl 101 mmol/L HCO3 22 mmol/L Serum osmolarity 273 mmol/L Urea 4.1 mmol/L Urine osmolarity 586 mmol/L Creat 86 mmol/L Glucose 8.2 mmol/L Cholesterol 4.2 mmol/L Triglycerides 1.4 mmol/L 57. What is the most likely explanation for hyponatremia A. Mineralocorticoid deficiency B. Thiazide diuretics C. Inappropriate ADH secretion D. Hyperglycemia E. Psychogenic polydipsia 58. Which of the following is the most appropriate management of hyponatremia in this case? A. Oral demeclocycline B. Water restriction C. Stop lisinopril D. Oral Sodium Chloride supplements E. Add a loop diuretic

*****

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59. Mrs. Danbury, a 60-year-old woman attends her family physician’s office to discuss some chest discomfort that she has had recently. She has difficulty describing her discomfort. It is not really pain, but there is definite discomfort in the area of her breastbone. She has had the ‘discomfort’ on waking up in the morning, and it has recurred for four or five times over the past month. She is not very active, but she has noticed a “twinge” in her chest when she was walking with her dog yesterday. She has also noticed the same chest discomfort after dinner the past two nights. The discomfort usually lasts a few minutes. The main reason for her visit today is because last night the pain lasted for half an hour. Associated symptoms include shortness of breath while walking upstairs over the past two weeks. She denies any chest discomfort at the present moment. She does not smoke. Her father died of a stroke and had also had a heart attack at 53 years of age; her mother died of stomach cancer when the patient was 8 years old. Physical examination is normal and the BP is 150/95 mmHg, similar to her reading the previous year.

What is the most likely diagnosis? A. Pulmonary embolus B. Peptic ulcer disease C. myocardial infarction D. stable angina E. unstable angina F. pericarditis G. aortic dissection Please answer questions 60 – 61 based on information from the following vignette. A 69-year-old man comes into your office for a complete physical. He has had hypertension for 20 years well controlled with a beta blocker. He also has high cholesterol for which he has had prescribed Pravachol for the past 13 years. He does not smoke. He has no complaints. On physical examination his blood pressure is 146/87 mmHg and no other abnormalities are discovered. Routine blood work reveals: Na 142 mmol/L, K 4.5 mmol/L, Chloride 109 mmol/L, bicarbonate 21 mmol/L, creatinine 212 :mol/L. 60. What further questions would you ask this patient, given the lab results?

a. Any change in vision b. Any change in pattern of voiding c. Any NSAID use d. Any headaches e. Any bone pain

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61. Additional investigations should include:

a. intravenous pyelogram b. microscopic urinalysis c. 24-hr urine for protein and creatinine clearance d. 24-hr urine for protein electrophoresis e. renal ultrasound

*****

Please answer questions 62 – 65 based on information from the following vignette. A 37 year female presents to your office complaining of a 7 day history of diarrhea, bloating and abdominal pain. She has 4 to 6 watery bowel movements per day but denies blood in her stool. The pain and diarrhea occasionally wakes her from sleep and she has lost 3 kg in the last 14 days. She describes the diarrhea as large volume and has noted a decrease in her urine output. She denies tenesmus. She has not been traveling recently, other than a short hiking trip in the mountains 10 days ago. She does not take any medications and has no known allergies. She denies previous gastrointestinal problems, but she does get some diarrhea and cramping when she is under stress at work and when she is menstruating. She has one sister that has Crohn’s disease. Her vital signs are normal, and her physical exam is normal except that she is obese and she has mild periumbilical tenderness. Rectum is empty. A walk-in clinic she attended 3 days ago obtained stool cultures. These were negative she was told she has irritable bowel syndrome. The patient desires a second opinion. 62. Which of the following is/are correct; a. She does not meet the criteria for the diagnosis for diarrhea since some days she is

only having 4 bowel movements per day. b. Her symptoms are consistent with a flare of her irritable bowel syndrome and since

stool cultures were negative no further investigations are required. Advise increasing the fiber in her diet to 12-20 g per day and to avoid stress.

c. She is unlikely to be Giardia since the stool culture was negative and she has not seen blood in her stool.

d. Bloody diarrhea is more common in ulcerative colitis than Crohn’s disease. e. The diagnosis of Giardia often requires multiple stool collections.

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63. Which of the following statements is/are true? a. Large volume diarrhea is more commonly associated with a small bowel pathogen

than a large bowel pathogen. b. Sigmoidoscopy is the only way to confirm the diagnosis of Giardia c. Stool culture and sensitivity is the diagnostic test of choice in assessing a patient you

suspect may have antibiotic induced colitis. d. Bacterial pathogens generally cause a shorter duration of illness than parasitic and

protozoan infections. e. Of viral pathogens, cytomegalovirus (CMV) is the most likely cause of her

symptoms. 64. In the management of acute diarrhea which of the following is/are correct? a. Most patients with stool cultures positive for Salmonella require treatment. b. First line therapy for Giardia is metronidazole c. First line therapy for Salmonella is metronidazole d. First line therapy for Clostridium difficile is metronidazole e. In treatment of traveler’s diarrhea antibiotics are not of proven value. 65. The most likely diagnosis is: A. Rotavirus B. E.Coli, enterotoxigenic C. Protozoa D. Inflammatory bowel disease E. Irritable bowel

*****

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Please answer questions 66 – 67 based on information from the following vignette. A 6-hour-old infant is admitted to the special care nursery for hypotonia. She was delivered following an uncomplicated term pregnancy by spontaneous vaginal delivery. Her mother is a 40 year old gravid 3, para 3 healthy woman and her father is 38 years old and healthy. There is no family history of pregnancy loss, neonatal problems or congenital abnormalities. The infant’s birth weight was 3.66 kg. On examination, her heart rate is 130 beats/min, respiratory rate is 30 breaths/min, and temperature is 37.1oC. She has a round face, upslanting palpebral fissures, small ears and excess nuchal skin. She has bilateral single palmar creases. The infant is hypotonic. There is no respiratory distress but a II/VI cardiac murmur is audible. Abdominal examination reveals no masses and there is a 2-vessel umbilical cord. She has normal female genitalia and stable hips. 66. Which of the following laboratory result would confirm your diagnosis of this infant? A. Elevated phenylalanine on neonatal screen B. Elevated TSH on neonatal screen C. Karyotype result of 45, XO D. Karyotype result of 47, +21 E. Dilated ventricles on cranial ultrasound 67. Based upon this child’s most likely diagnosis, what are important investigations to complete in the neonatal period? (Choose all that apply.)

a. Cranial ultrasound b. Cardiac echocardiogram c. Hip X-ray d. TSH and free T4 e. Chromosome analysis

*****

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Please answer questions 68 – 69 based on information from the following vignette. For each elderly patient with dizziness, select the most likely diagnosis (A-J). Diagnosis: A. Benign Paroxysmal Positional Vertigo. B. Parkinson's Disease. C. Postural Hypotension. D. Multi-sensory deficits. E. Central Vascular Disease. F. Peripheral polyneuropathy G. Anxiety. H. Poor vision. I. Cervical Spondylosis. J. Drug Toxicity. 68. A 65 year old female with complaints of dizziness. She has a history of hypertension

and mild high frequency hearing loss. On examination her blood pressure is 163/87 lying and 156/81 standing. Visual acuity is 6/9 in both eyes. Vigorous head or neck movements worsen her complaints of dizziness. She has a restricted range of neck motion. Touch and vibration sense is normal. You cannot elicit her ankle jerks. She had a negative response to the Dix-Hallpike test.

69. A 72 year-old male with complaints of transient spinning dizziness when he turns

over in bed at night. He suffers from degenerative arthritis of his weight-bearing joints and takes 282's (ASA 375 mg.-cafeine citrate 30 mg.-codeine phosphate 15 mg.) every four hours as needed (he takes 4-6 tablets per day) for this. On examination his blood pressure is 134/82 lying and 139/80 standing. Visual acuity was 6/6 (with his glasses on). He had a positive response to the Dix-Hallpike test.

*****

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Please answer questions 70 – 71 based on information from the following vignette. A 18 year old female presents to you with unwanted hair growth on her chest, abdomen and face. This is of recent (2-3 years) onset and she is shaving these areas daily. Upon further questioning you also elicit a 5-6 year history of oligomenorrhea (previously her menses occurred every month since menarche at age 13 years), increasing weight, decrease in strength and easy bruising. 70. Which of the following would you be specifically looking for on physical examination? A. Acne B. Peripheral neuropathy C. Purple striae D. Hepatomegaly E. Decreased axillary and pubic hair growth 71. Which of the following investigations should now be undertaken? A. Serum cortisol B. Serum estradiol C. Serum LH/FSH ratio D. ACTH stimulation test of the adrenals E. 24 hour urinary free cortisol

*****

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Please answer questions 72 – 75 based on information from the following vignette. Mrs. Agnes Carlin, a 50-year-old homemaker, visits the office of her family physician complaining of increasing breathlessness, anorexia, weight loss and fatigue. She has been a NIDDM for 11 years and has developed complications of proliferative retinopathy, ischemic heart disease and peripheral vascular disease. She was diagnosed to be hypertensive eight years previously and was first noted to have microalbuminuria at that same time. Past history revealed that about 18 months previously she had noted a lump in her right breast, but mammography was normal. At that same visit routine laboratory investigation was normal except for mild elevation of her serum creatinine which was 152µmol/L. Six months ago she developed ankle swelling, and at which time her serum creatinine was 204 µmol/L. Her medication at present includes ASA 325mg daily, furosemide 120mg daily, hormone replacement therapy , metformin 500mg twice daily, and nifedipine XL 90 mg daily. On physical examination she has diffuse nodularity in both breasts, pulse is regular at 78 bpm, sitting BP is 184/92 mmHg in her right arm sitting, and JVP is 6cm above sternal angle. She has a left femoral bruit, bilateral basal inspiratory crackles, bilateral leg edema and absent pedal pulses on the left. The results of the initial investigations are: Urine analysis: large glucose and protein. Na 138 mmol/L Hb 98g/L K 5.2 mmol/L WBC 11.2 x109/L HCO3 22 mmol/L Plat 356 x109/L Cl 102 Urea 17.8mmol/L Creatinine 348µmol/L Glucose 17.8mmol/L 72. What is the most likely explanation for the elevated serum creatinine? A. Chronic glomerulonephritis B. Dehydration secondary to diuretics C. Reflux nephropathy D. Bilateral renal artery stenosis E. Diabetic nephropathy 73. Which of the following investigations is/are indicated? a. Antineutrophil cytoplasmic antibody titre b. Renal biopsy c. Cbc d. Abdominal ultrasound e. Calcium, Phosphate, and albumin

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74. Which of the following treatments is/are indicated? a. Beta-blocker b. Increase dose of metformin c. Fluid challenge of 500mls normal saline d. ACE inhibitor e. Increased dose of diuretics 75. Which of the following is/are contraindicated in this patient? a. Transplantation b. ACEI c. Erythropoietin d. Metformin e. High salt intake

***** Please answer questions 76 – 77 based on information from the following vignette. Mrs. Margaret Devlin is an 84-year-old nursing home resident whom you have been called to see. She has become increasingly confused over the past ten days and has not had a bowel movement during this time. She does not give a coherent history and there are no other complaints reported by her son or the staff at the nursing home. She has been at the nursing home for ten months and suffers from multi-infarct dementia. She is a diet-controlled diabetic. Her regular medications are thyroxine 0.1 mg, daily ASA 325 mg daily, and lorazepam 1mg at night. She has not been taking her medication for the past week. On examination she has reduced skin turgor and dry mucous membranes. Pulse is regular at 98 beats per minute and blood pressure is 104/66 mmHg supine. Jugular venous pulse is not visible. The results of investigations are given below: Urine analysis negative Urine electolytes Na 158 mmol/L Na 23 mmol/L K 4.8 mmol/L K 54 mmol/L Cl 109 mmol/L Cl <10 mmol/L HCO3 34 mmol/L Serum osmolarity 353 mmol/L Urea 19.1 mmol/L Urine osmolarity 879 mmol/L Creat 156 :mol/L Glucose 4.2 mmol/L 76. What is the most likely explanation for hypernatremia A. Cranial diabetes insipidus B. Untreated hypothyroidism C. Nephrogenic diabetes insipidus D. Hyperglycemia-induced osmotic diuresis E. Impaired thirst

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77. Which of the following is the most appropriate management of hypernatremia in this case? A. Intravenous 0.9% saline B. Intranasal DDAVP C. Intravenous D5W solution D. Salt-restricted diet E. Intravenous tri-iodothyroxine (T3)

***** Please answer questions 78 – 79 based on information from the following vignette. An 80-year-old man arrives in the Emergency room complaining of shortness of breath and cough. He first noticed problems about a month ago when he found himself short of breath while carrying in the groceries. Since then, he has become progressively worse, so that now he is short of breath when going for his daily walk. Last night, he also woke up short of breath. He has also noticed a non-productive cough. He denies fever or chest pain. He is a non-smoker and drinks whiskey occasionally. He has been treated for hypertension for 20 years with hydrochlorthiazide 25 mg daily. He is on no other medications, except for Tylenol for some joint pain. On examination, he is in mild distress. His heart rate is 100 per minute, BP is 150/85 mmHg, respiratory rate is 30 per minute and he is afebrile. He has diffuse inspiratory crackles at both lung bases, and expiratory wheezes. He has no murmurs and it is difficult to hear his heart sounds because of his somewhat labored breathing. His JVP is 6 cm above the sternal angle. The results of the initial investigations are: Hgb 140 g/L, WBC 5.8 x 109/L, platelets 200 x 109/L, Na 130 mmol/L, Potassium 4 mmol/L, Creatinine 135 :mol/L. A chest x-ray reveals a diffuse interstitial infiltrate in both lung fields, with vascular redistribution. Oxygen saturation monitor reads 84%. 78. The most likely diagnosis is: a. exacerbation of chronic obstructive pulmonary disease b. congestive heart failure c. bacterial pneumonia d. pneumoconiosis e. atypical pneumonia 79. Initial management steps would include:

a. admit to hospital b. Erythromycin and cefuroxime IV c. intravenous steroids d. furosemide IV e. ACE inhibitor

*****

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80. Ms Johnson, a 47-year-old female, presents with a 2-month history of epigastric pain following meals. She denies vomiting, weight loss, gastrointestinal blood loss, dysphagia, early satiety or pain that wakes her form sleep. Her past medical his is significant for being sexually abused as a child by her step father, and panic attacks about which she states that she has an appointment to see a psychiatrist. Occasionally, she notes a burning sensation in her chest which concerns her since her brother had a heart attack at the age of 54. She has a longstanding history of alternating constipation and diarrhea and diffuse abdominal pain but assures you that this pain is different. Which of the following is/are appropriate in this case? a. Ms Johnson most likely has irritable bowel syndrome and no further investigations

are required b. Heartburn and dyspepsia occur in up to 20 to 40% of the adult population, but the

possibility of cardiac ischemia should be investigated c. In the setting of uncomplicated reflux, conservative management (eating smaller

meals, quitting smoking, losing weight, limiting caffeine consumption, and elevating the head of bed) can be as effective as therapy with an H2 antagonist.

d. Request that you see her again in 3 months, but warn her that she may develop pain

with swallowing and possibly a sticking sensation. Should this occur, she will be started on a course of omeprazole.

e. Panic attacks, non-cardiac chest pain, non-ulcer dyspepsia, and a history of sexual

abuse are all more common in patients with irritable bowel syndrome. Please answer questions 81 – 82 based on information from the following vignette. Mrs. Smith brings her six-year-old son James to your office for evaluation. She has identified James as having a cross left eye that was first noticed six months ago. Her concern increased when James started to complain of frontal headaches when reading. Occasionally, his mother noticed that James was less attentive to books, and less interested in coloring and drawing. There is no family history of strabismus. James has a large angle left Esotropia, fixing only with his right eye. Structurally, his eye examination is normal. His pupillary reactions are normal and he has full movement of both eyes with no nystagmus. On comparing red reflexes with your ophthalmoscope from right to left eye, the left reflex appears less distinct than the right.

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81. The most likely diagnosis is: A. Convergence insufficiency B. Congenital Esotropia C. Acquired Exotropia D. Sixth cranial nerve palsy E. Thyroid ophthalmopathy 82. The patient most likely has what type of refractive error: A. Myopia (nearsighted) B. Hyperopia (farsighted) C. Astigmatism D. Emmetropia (no refractive error) E. Myopia and astigmatism combined

***** 83. A 70-year-old retired farmer complains of difficulty walking because of poor balance for three months. His symptoms have become gradually worse, so that he now uses a cane, and no longer leaves the house after dark. Review of systems is negative except for some fatigue, a chronic cough, and some numbness in his feet. He has a 40 pack-year smoking history. His neurologic examination shows normal optic fundi, normal strength in all limbs, and downgoing plantar responses. His gait is wide-based. He is able to stand with his feet together and his eyes open, but begins to fall almost immediately when he closes his eyes. Which of the following tests is most likely to give the correct diagnosis: A. Chest x-ray. B. MRI scan of the spinal cord. C. Contrast enhanced brain CT scan. D. Serum Vitamin B12 level. E. Blood glucose level.

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84. Mr. N.C. is 77 years old. You have seen him on five separate occasions over the last six months. His blood pressures were 172/85, 168/80, 164/77, 165/83 and 171/83 respectively. He has no symptom signs of ischemic heart disease, cerebrovascular disease, peripheral vascular disease, or renal insufficiency. Urinalysis, Complete Blood Count, Potassium, Sodium, Fasting Glucose, Fasting Lipids, and Standard ECG are all normal. He is a non-smoker and drinks one to two beers per week. His height is 176 cm. and he weighs 68 kg. Serum urate is 512 :mol/L (normal range 210-490 :mol/L). There is no history of gout. He has been restricting his dietary sodium intake to 110-130 mmol/day for the last six months. He habitually walks briskly three to four times a week for sixty minutes. At this point you should recommend – a. Non-pharmacological treatment solely. b. A low-dose thiazide diuretic. c. A long-acting dihydropyridine calcium channel blocker. d. An ACE inhibitor. e. A beta-adrenergic anatgonist. Please answer questions 85 – 86 based on information from the following vignette. A 15-year old boy man with a 2-year history of type 1 diabetes mellitus presents to your office for the first time. He is currently injecting both R (regular) and N (intermediate) insulin before breakfast and before supper. In the past week his Hemoglobin A1c was 0.068 (N: 0.043-0.061), but his home glucose monitoring profile shows fasting blood glucose levels ranging from 2.5 to 18.8 mmol/L. He generally feels unwell, has poor concentrating ability, sleeps poorly and frequently has nightmares. 85. Which of the following would now be the most appropriate plan of action? A. Instruct the patient that his overall glycemic control is within the optimal target range and hence no changes are required in his glycemic control. B. Send the patient to the diabetes dietician for instructions in how to treat his morning blood sugars by altering his breakfast. C. Send him to the sleep apnea clinic for evaluation of his sleep disturbance. D. Decrease his R and N insulin before breakfast E. Check for nighttime hypoglycemia by home blood glucose monitoring at 3 am. 86. Which of the following investigations should be undertaken at this time? A. Serum amylase B. Hemoglobin A1c

C. Meter check (random laboratory serum glucose to correlate with meter glucose reading)

D. Sleep study E. ACTH stimulation test for adrenal insufficiency

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54. a b c d e

55. A B C D E

56. a b c d e

44

57. A B C D E

58. A B C D E

59. A B C D E F G

60. a b c d e

61. a b c d e

62. a b c d e

63. a b c d e

64. a b c d e

65. A B C D E

66. A B C D E

67. a b c d e

68. A B C D E F G H I J

69. A B C D E F G H I J

70. A B C D E

71. A B C D E

72. A B C D E

73. a b c d e

74. a b c d e

75. a b c d e

76. A B C D E

77. A B C D E

78. a b c d e

79. a b c d e

80. a b c d e

81. A B C D E

82. A B C D E

83. A B C D E

84. a b c d e

85. A B C D E

86. A B C D E

45

Diagnostic Laboratory Investigations

Electrolytes: Hematology: [Na+] – serum 135-145 mmol/L Hemoglobin & 120-160g/L urine 40 – 220 mmol/d (diet dependent) % 140–180 g/L [K+] – serum 3.5-5 mmol/L WBC 4.0 – 10.0x109/L urine 25 – 125 mmol/d (diet dependent) Differential [C1-] – serum 95 – 105 mmol/L Segs 35-70 urine 110-225 mmol/d (diet dependent) Lymph 20-50 [HCO3

-]/[CO2] Eos 0-6 - serum 24-30 mmol/L Platelets 140-440x109/L Other Serum Tests Albumin 30-55 g/L Calcium 2.12-2.54 mmol/L Cholesterol <5.2 mmol/L desirable; . 6.2 mmol/L increased risk of CHD CK (Creatine kinase) 0-225 U/L Creatinine 60-124 µmol/L Glucose 3.6-6.1 mmol/L Osmolality 280-300 mmol/Kg Protein, total 60-85 g/L Urea 1.7 – 8.3 mmol/L Urate M: 230-535 µmol/L; F: 130-460 µmol/L Other urine tests: Creatinine 8.8-17.7 mmol/d Creatinine Clearance 1.6 – 2.3 ml/sec (96-138 ml/min) Osmolality during maximum concentration – 655-1395 mmol/Kg During maximum dilution - ,100 mmol/Kg Protein 0.15 g/d Specific gravity 1.001 – 1.035 Urea 333-583 mmol/d Urinalysis pH 5.0-8.0 (routine & micro) Dipstix – negative WBC 0-5/HPF RBC 0-2/HPF CASTS 0-2/LPF Arterial blood normal values [H+] 40±2 nmol/L pH 7.4±0.02 [HCO3

-] 25±2 mmol/L Paco2 40±2 mm Hg Anion gap in plasma: 12±2 mmol/L (excluding potassium)