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SEPTEMBER 2, 2011

DEPARTMENT 0F INTERNAL MEDICINE SCHOOL OF MEDICINE ADDIS ABABA UNIVERSITY YEAR III EXAM Time allowed: 2 .00 Hr. Instruction 1. Write your name and ID 2. Choose the best single answer and write on separate answer sheet

1. A 28 year old lady presented with recurrent heart burn, belching, morning dry cough and throat irritation. Physical exam is unremarkable. Which of these is most likely? a. PUD b. GERD c. Bronchitis d. Pancreatitis 2. Which is true statement regarding H. pylori infection a. It causes gastritis b. It is a carcinogen c. It is a motile bacteria d. All 3. Which of the following is the commonest cause of hepatitis in Ethiopia a. HBV b. HCV c. Alcohol d. Toxin 4. A 35 year old hotel worker presented with dizziness and tarry stool of three days. Which of the following will be most appropriate for the patient? a. Colonoscopy b. Esophagogastroduodenoscopy c. Stool occult blood test d. Barium meal study 5. True statement regarding patients with chronic hepatitis? a. Majority are asymptomatic b. Symptoms are specific c. Arthralgia and skin rashes are not features d. Symptoms last longer than three months 6. The following are poor prognostic factors of viral hepatitis except. a. High viremia b. Alcoholism c. Extreme ages d. Non-obese 7. The following are stigmata of CLD except. a. Testicularatrophy b. Dupytrens contracture c. Palmar erythema d. Parotid atrophy

8. Cirrhosis can result in the following except. a. Hypoalbuminemia b. HCC c. Varices d. Hyperglycemia 9. A 20 year old student presented with watery diarrhea and cachexia of 10 months. All of these are possible DDX except: a. Malabsorption b. Chronic pancreatitis c. Enteropathy d. Cholangitis 10. Which of these indicate acute abdomen? a. Severe abdominal pain with guarding. b. Silent abdomen c. Intractable vomiting d. Tenesmus 11. The following symptoms indicate IBS except: a. Abdominal pain worsens with defecations. b. Abdominal symptoms better during night. C. Weight loss is not a common feature. d. Abdominal symptoms are recurrent for long duration. 12. A 24 year old driver presented with recurrent painless hematochezia. Which of the following is likely? a. Esophageal Varices b. Hemorrhoid c. Colon ca d. Duodenal ulcer 13. A 30 year old primigramida presented with post prandial vomiting, heartburn, nausea andperiumblical cramp of one month duration. Which of these is likely Dx? a. PUD b. NUD c. Cholecystitis d. All 14. Important cause (S) of FUO a. Intra-abdominal abscesses b. Tuberculosis c. Infective endocarditis d. All of the above

15. Sever inflammatory response syndrome (SIRS) may be due to a. Infectious b. Trauma c. Burns d. All of the above 16. N. Meningitis is a. The most common cause of bacterial meningitis in all age groups b. The leading cause of bacterial meningitis among children and young adults c. The only form of bacterial meningitis that cannot cause epidemic meningitis, but Endemic d. Gram positive diplococci, often intracellular 17. In distinguishing group A streptococcal pharyngitis from viral causes a. Exudates are never seen with viral causes. b. Cough is associated with viral pharyngitis. c. Diarrhea is associated with GAS pharyngitis. d. Presence of cervical lymphadenopathy is not suggestive of GAS pharyngitis 18. Common causes of acute bronchitis are a. Upper respiratory tract viruses b. Mycoplasm pneumonia, chlamydophila pneumonia c. Streptococcal pneumonia, Hoemophilus influenza and Moraxella catrrhalis d. a and b 19. Initial diagnosis of pneumonia is made by a. Good patient history b. Meticulous physical examination c. Chest radiography d. All of the above 20. Frequent causes of spontaneous bacterial peritonitis are a. E.coli followed by S.aureus b. E.coli followed by klebsiella pneumonia and S. pneumonia c. Anaerobes and microorohilic organisms d. band C 21. Parasite (S) contributing to the pathogenesis of appendicitis a. Enterobiusvermicularis b. Ascariasislumbricoides c. Strongloidesstercoralis d. All of the above

22. One of the following is not a component of minor criteria for infective endocarditis a. Predisposing heart condition or intravenous drugs use b. Splenomegaly c. Mycotic aneurysm d. Positive rheumatoid factor 23. The most common etiology of septic arthritis in adults is a. Salmonella b. Streptococcus c. S. aureus d. N. gonorrhoeae 24. One of the following genital lesions is not associated with pain a. Chancroid b. Herpes simplex lesion c. Syphilitic lesion d. a and C 25. Which of the following is not in WHO stage 4? a. Kaposi`s sarcoma b. CMV retinitis c. HIV-encephalopathy d. Body weight loss of >10% 26. Which of the following is true when there is HIV-TB co infection? a. Pulmonary tuberculosis in AIDS patients is associated with lower bacillary burden than in HIV negative patients b. Smear for AFB has better yield than AFB culture c. Positive AFB smear is 100% specific for M. tuberculosis d. Cavitory lesions are common in advanced HIV disease 27.Which one of the following does not cause pre-renal azotemia? a. b. c. d. NSAIDS (Non-steroidal ) anti-inflammatory drugs Amino glycosides ACEI (Angiotensin -converting enzyme inhibitors) Nephrotic syndrome

28. A clinical parameter very useful to differentiate pre-renal azotemia from acute tubular necrosis? a. b. c. d. The absence of hematuria The absence of significant protenuria Prompt recovery with volume replacement Prompt recovery with diuretics

29. Which one of the followings is not a complication of Acute kidney injury (AKI)? a. b. c. d. Infection Metabolic acidosis Hypokalemia Hyponatremia

30. Among the following causes of glomerular disease which one is more likely to present with the acute nephritic syndrome? a. b. c. d. FSGS (Focal segmental glomerulosclerosis) MN (Membranous nephropathy) Small vessel vasculitis Diabetic nephropathy

31. Which one of the following statements is not true about glomerular diseases? a. Segmental glomerular pathology indicates part of an individual glomerulus is affected b. Nephritic and Nephrotic syndromes are not mutually exclusive c. Hyperlipidemia and lipiduria coexist in the Nephrotic syndrome d. HIV associated nephropathy usually causes membranous type of glomerular pathology 32. Which one of the following is not a complication of the Nephrotic syndrome? a. b. c. d. Deep vein thrombosis Acute Kidney injury Clinical hypothyroidism Anemia

33. True statement about urinary tract infection (UTI) a. b. c. d. Pyuria is very specific for UTI The presence of high grade fever and vomiting indicates cystitis A positive nitrite on urine deep stick could suggest the possibility of UTI Pyelonephritis in a patient with bladder outlet obstruction secondary to BPH is not necessarily complicated UTI

34. Which one of the following manifestations of chronic kidney disease (CKD) is also a risk factor for CKD progression? a. b. c. d. Hyperkalemia Recurrent Hypoglycemia Hyponatremia Proteinuria

35. Which statement is true about CKD? a. b. c. d. Estimated GFR of 40 ml/min is stage two CKD Cardiovascular disease is the leading cause of death in CKD Anemia of CKD is typically hypochromic microcytic The bleeding diathesis of CKD is caused by thrombocytopenia

36. Which of the following clinical scenarios would result in Normal anion gap metabolic acidosis? a. b. c. d. Prolonged septic shock Severe diabetic ketoacidosis Voluminous chronic diarrhea End stage renal disease

37. Which one of the following statements is correct about Hyponatremia? a. Hyponatremia indicates low ECF volume b. Clinical symptoms of Hyponatremia depend mainly on rapidity of onset. c. SIADH(Syndrome of inappropriate ADH Secretion) is a prototype example of hypovolemic Hyponatremia d. Arrhythmias are the most serious complications of Hyponatremia 38. A thirty year old male patient presented with two days history of high grade fever, chills, vomiting and right side flank pain. He had similar illness few months back that improved with antibiotic treatment.Which one of the following decisions is correct about this patient? a. Repeat urine microscopy is sufficient for the workup of the patient b. As there is history of improvement with antibiotics, starting antibiotics without further laboratory tests is the best decision for the patient. c. Urine culture and sensitivity is not necessary, if urine microscopy shows WBC casts. d. Urine culture and Ultrasound of the kidneys / the urinary tract are necessary investigations.

39. Which of one of the followings is not a cause of Hypokalemia? a. b. c. d. Watery diarrhea Loop diuretics Prolonged convulsive Status Epilepticus Cushings syndrome

40.In autoimmune hemolytic anemia a. The RBCs are microcytic and hypochromic. b. Combs test (Direct Antibody Test) is usually negative. c. Corticosteroids are the main stay of treatment. d. Serum haptoglobin is increased. 41.Which of the following statements about immune thrombocytopenia (ITP) is true? a. Platelet transfusion is absolutely contraindicated as it leads to further Sensitization of the platelets with more destruction. b. The adult-type (chronic ITP) is usually self-limited condition. c. Splenectomy is indicated only for patients with splenomegaly. d. Bone marrow study usually shows normal or increased megakaryocytic Population without any abnormality in the other marrow elements. 42. Which of the following conditions is associated with isolated elevation of aPTT( partial thromboplastin time) a. Hemophilia B ( Factor IX deficiency). b. Warfarin treatment c. Disseminated Intravascular Coagulation(DIC). d. Coagulation abnormality in chronic liver disease. 43. Massive splenomegaly is a spleen which is palpable more than 8cm below left costal margin. Which one of the following hematological malignancies has this feature as a clinical manifestation? a. Hodgkin's lymphoma b. Multiple Myeloma c. Idiopathic Myelofibrosis d. Acute Lymphoblastic Leukemia 44. A 60year old man presents with 2months' history of bone pain associated with features Of severe anemia. He is found to hypertension and marked pallor. Otherwise the rest of Physical examination is unremarkable. His skeletal x-ray shows multiple lytic lesions as well as fracture of 2 of the lower thoracic spines. All of the following investigations are vital in the diagnosis and prognosis of this patient except:-

a. Bone marrow aspiration b. CT scan of the chest and abdomen c. Serum calcium level d. Serum beta-2 microglobulin 45. All of the following conditions cause macrocytosis except a. Chronic liver disease b. Pernicious Anemia c. Treatment with Zidovudine( AZT) d. Anemia of chronic illness. 46. Which of the following statements about is incorrect regarding Acute Lymphoblastic Leukemia in adults? a. B-cell phenotype is more common that T-cell variant b. A proportion of patients present with pancytopenia c. Philadelphia chromosome is considered favorable cytogenetic finding. d. Maintenance treatment regimes are continued for 2years. 47. Which one of the following hematological malignancies is exclusively of T-cell origin a. Hairy cell leukemia b. Multiple Myeloma c. Chronic Lymphocytic Leukemia d. Mycosis Fungiodes 48. Polycythemia Vera is one of the classical Myeloproliferative Diseases. All of the following statements about Polycythemia Vera is true except:a. It is caused by conditions which lead to prolonged hypoxic states like chronic lungand cardiac problems. b. The disease has significant chance of progression into Acute Leukemia c. Males are affected more than females d. Thrombotic events at unusual sites are part of the clinical manifestation 49. Which of the following statements is regarding Acute Myelogenous Leukemia is False:a. AML is known to occur years following treatment with alkylating agents for other malignancies. b. Some AML subtypes present with tissue infiltrations as gingival hypertrophy, soft tissuechloromas and bone involvements even. c. AML tends to affect younger age groups. d. In AML organomegaly is usually absent 50. In Hemophilia A a. All the daughters of the affect father are unaffected but obligate carriers. b. Initial presentation is mucocutaneous bleeding c. Prothrombin Time (PT) is prolonged d. Family history is negative in about 1/3 of the cases.

51. Which of the following conditions is least likely to predispose to the development of Venous Thromboembolism? a. Use of over the counter multivitamin supplements b. Use of oral contraceptive pills c. HIV infection d. Cigarette smoking 52. One of the following is true about acute coronary syndrome a. The spectrum does not include unstable angina b. ECG change is the most important criterion in the diagnosis of acute MI c. NSTEMI includes patients with acute chest pain who are troponin positive d. The diagnosis of unstable angina is limited to those with pain at rest 53. One of the following is not a feature of typical angina a. b. c. d. Retrosternal in location Trigger][ed by exertion Relieved by nitrates Sharp pain

54. All of the following are established risk factors of atherosclerosis except a. b. c. d. Diabetes mellitus Black race Hypertension High LDL-Cholesterol

55. Which of the following is an earliest valvular lesion in a case of acute rheumatic fever? a. b. c. d. Mitral stenosis Mitral regurgitation Aortic stenosis Aortic regurgitation

56. Which of the following clinical findings is consistent with severe mitral stenosis? a. Loud S1 b. Presence of S3 c. Prolonged diastolic murmur d. Prolonged systolic murmur
57. Which of the following is important in minute to minute control of blood pressure? a. Intravascualr volume b. Autonomic nervous system

c. Renin-angiotensin-aldosterone system d. Vascular stiffness

58. Which of the following is not cause of secondary hypertension a. b. c. d. Renovascular disorder Acromegaly Excess salt intake None

59. A BP of 170/130 with retinal haemorrhages suggest: a. b. c. d. Malignant Hypertension Hypertensive urgency Renovascular hypertension Grade 2 Hypertension

60.Which one of the following does not represent the neurohormonal response during heart failure a. b. c. d. Increased sympathetic nervous system activity Heightened RAAS (Rennin AngiotensineAldestrone) systems activity Decreased Atrial Natriuretic Peptide (ANP) level Increased Arginine Vasopressin (AVP) activity

61. Among the following choices which one is least specific for the diagnosis of HF a. b. c. d. PND S3 gallop Orthopnea Dyspnea

62. A 57-years-old male merchant from Addis presents with dyspnea at rest and lower extremity edema of 02 months duration.On examination he had jugular venous distention, an audible S4, and the apical impulse was not displaced. His CXR showed normal cardiac silhoutte and echocardiography revealed a thickened left ventricle with ejection fraction of 65%.Chose the correct answer a. b. c. d. He does not fulfill Framinghams criteria for heart failure He has NYHA functional class III heart failure He has stage B heart failure He has a diastolic heart failure

63. One of the following correct WHO definition of cardiomyopathy a. Restrictive cardiomyopathy is defined by decrease end diastolic volume ,increase filling pressure and unchanged systolic function b. Dilated cardiomyopathy is defined by decrease end diastolic volume, end systolic volume and ejection fraction c. Hypertrophic cardiomyopathy is defined by asymmetric left ventricular hypertrophy and autosomal dominant inheritance d. Dilated cardiomyopathy is defined by increase end diastolic volume, end systolic volume and ejection fraction 64. Which of the following has worst prognosis? a. Hypertensive cardiomyopathy b. Ischemic cardiomyopathy c. Postpartum cardiomyopathy d. Valvular cardiomyopathy 65. Which of the following is not cause of restrictive cardiomyopathy? a.Amyloidosis b. Sarcoidosis c. Loefflers syndrome d. Hemochromatosis 66. Risk factor for micro-colonization of air way which predispose for Pneumonia include all of the following except. a. Presence of co-morbidity b. Use of antibiotics c. Seizure d. None 67.Which one of the following statement is false about community acquired pneumonia a. Chlamydia infection causes stasis of cilia. b. Shunting is the main cause of hypoxia. c. Etiologic diagnosis is not possible in most of the cases. d. Hospital mortality is about 20%. 68. One of the following is not a component of severity sign (CURB-65) of pneumonia a. b. c. d. Convulsion Respiratory rate greater than 30/min Age > 65 years BUN > 20 mg/dl.

69.Regarding lung abscess all are true Except. a. b. c. d. Commonly caused by combination of aerobic and anaerobic bacteria. HIV infection predispose to this disease. CXR shows air fluid level. Clubbing of finger nail is not a feature.

70. One of the following is not risk factor for TB transmission. a. Exposure to infectious patient b. Duration of exposure c. Level of function of cell mediated immunity d. Smear positivity of cases 71. Which one of the following statement is true about primary TB? a. Usually involve middle or lower zone b. Most of them progress and develop a disease c. Seen in non-HIV adult patients d. PPD test is negative. 72. Regarding Bronchial asthma, one of the following statements is false. a. It is reversible air way disease b. Usually started during adult hood c. Despite treatment prognosis is poor as compared to COPD. d. It is poorly environmental. 73. The nature of peripheral Neuropathy in AIDS patients is a. Sensorimotor neuropathy b. Acute inflammatory demyelinating neuropathy c. Mononeuropathy multiplex d. All of the above 74 The most common cause intracranial mass lesion in HIV/AIDS patients is a. Syphilitic guma b. Cryptococcoma c. Toxoplamosis d. Lymphoma 75.The commonest cause of myelopathy associated with HIV diseases is e. f. g. h. Tuberculoma Vacuolar CMV Herpes Zoster

76 The sensitivities of CSF tuberculosis test a. AFB smear= 10 to 30% b. CSF culture for mycobacterium tuberculosis= 45 to 70% c. RCR for mycobacterium tuberculosis= 70 to 75% d. All are correct 77 The non-tuberculosis commonest cause of chronic meningitis in AIDS patient is a. Syphilitic b. Cryptococcus meningitis c. Viral meningitis d. Amoebic meningitis 78 Which of the following is true about epilepsy? a. Normal electroencephalogram rules out epilepsy b. Generalized seizure is more common than partial seizure c. Neuroimaging studies are more important in generalized than focal seizure d. Absence seizure usually begins in childhood 79 Which of the following is false? a. The prevalence of epilepsy is more common in developing than developed countries b. Epilepsy occurs more commonly in females than males c. Most complex partial seizures raise from the temporal lobe d. In absence seizure the individual is unaware of having had the seizure 80. Which of the following is true? a. Following a second seizure the risk of having further seizure is 10% b. Most patients with atypical absence seizure are mentally retarded c.In severe head injury anticonvulsant prophylaxis decreases the risk of late posttraumatic seizure. d.Most women with epilepsy show worsening of seizure during pregnancy 81.Which of the following is not true about spinal epidural abscess? a.The most common mode of spread is direct extension of infection from adjacent sites than hematogenous spread b.Diseases resulting in impairment of the immune status can predispose to spinal epidural abscess c.The absence of fever doesnt rule out the its possibility d.Blood cultures can be positive in one fourth of patients

82. Which of the following is not present in diseases of the spinal cord? a.Incontinence b.Increases deep tendon reflexes c.Sensory level d.Down going plantar response 83. Which of the following is absent in anterior spinal artery syndrome? a.Sensory level to pain b.Weakness of the extremities c. Incontinence d. Loss of position and vibration sence 84.The most common cause of intracerebralhaemorrhage is a. Diabetes mellitus b. Use of warfarin and aspirin c. Hypertension d. None of the above 85.One of the following is not the effect of cigarette smoking. a. Interstial lung disease b. Lung Ca c. COPD d. None 86.Regarding lung ca one of the following is true. a. All histologic of lung cancer are due to smoking. b.Squamous cell Ca usually present as peripherally located mass. c.Adenocarcinoma is commonest histologic type. d.Women have high relative risk to develop lung ca as compared to male. 87. Which one of the following statement is true regarding TB-HIV co-infection? a. Sensitivity of diagnostic tool for TB decreases. b.TB decreases viral load c. Mortality is similar with non-HIV if treated properly d. All are true. 88.One of the following statements is false about PCP. a. Caused by fungus called Pneumocystis carini b.More severe in non-HIV than in HIV patients c. LDH is usually elevated and has also prognostic value. d. Common OI in HIV patient.

89. Which of the following is not helpful to diagnosis pre-diabetes? a. HbA1 C b. Fasting Blood sugar level c. Random blood sugar level d. Oral glucose tolerance test 90. In the immediate management of moderate DKA all of the following measures should be instituted except. a. Insulin b. IV fluids c. Bicarbonate d. Potassium 91. A 40 year old has goiter for 10 year & is being evaluated for palpitation. Which of the following findings would suggest hyperthyroidism due to toxic nodular goiter? a. High TSH & High T3& T4 b. Low TSH & High T3& T4 c. High TSH & Low T3& T4 d. Low TSH & Low T3& T4 92.Which one of the following hormone is produced by the adrenal medulla? a. Cortisol b.Aldostrone c. Epinephrin d. Androgen 93. Which one of the following is the least cause of Cushing`s Syndrom? a. BronchogenicCa b.Adrenal adenoma c. Pitutary ACTH producing micro/macroadenoma d.Adrenal carcinoma 94.Identify the wrong statement about pheochromocytoma a.Pheochromocytomes are steroid producing tumors b. Prevalence is about 2-8/1 million person per year. c. Mean age at diagnosis is about 40 d. May be associated with MEN 2,neurofibromatosis 95. Which one of the following is more confirmatory test to diagnose prolactinoma? a. CT/MRI scan b. Serum prolactin >100microgram/L C. Serum ADH level >300 microgram/L d. Insulin induced hypoglycemia

96. Which of the following is not the commonest of Hyperthyroidism? a. Grave`s disease b. Toxic multinodular goiter c. Gestational thyrotoxicosis d. Toxic adenoma 97. A man is diagnosed to have new onset diabetes & he has the following values FBS= 350 mg/dl, HbA1C 12%. What is the best initial drug treatment? a. Metformin b. Glibenclamide c. Pioglitazone d. Insulin 98. All of the following infection are causes for hypopiturarism except a. Syphilis b. Tuberculosis c. Malaria d. Cysticercosis 99.A 65 years old female from Gojampresent with history of profound weakness, weight gain, forgetfulness and constipation of 2 years duration. What is the most likely diagnosis? a. Metabolic syndrome b.Cushing`s syndrome c.Primary hypothyroidism d. Depression 100. All of the following are correct regarding Rhumatoid arthritis except a. Involvement of distal interphalangeal joint b. Symmetrical involvement c. Morning stiffness d. Involvement of wrist joint