C.N.

S
1- 25-year-old student presented to your office complaining of sudden
and severe headache for 4 hours. History revealed mild headache
attacks during the last few days. On examination: agitated and
restless. What Dx must be considered this case?
A. Severe migraine attack
B. Cluster headache
C. Subarachnoid hemorrhage
D. Hypertensive encephalopathy
E. encephalitis
2- Greatest risk for stroke:
a- DM.
b- family history of stroke.
c- high blood pressure.
d- hyperlipidemia.
e- cigarette smoking.
-the most important factor predisposing to stroke is:
a)DM
b) HTN
C) Hyperlipidemia
d) Cholesterol
-one of the following is the single most important cause of stroke:
a-D.M.
b-HTN
c-family history
d- hyperlipidemia
e-hypercholesteremia
3- Pt come within 3 hrs C/O Lt side weakness, examination revealed
Lt side hemiparesis, pulse 120/min irregular with diastolic murmur at
mitral area. 1st step of management:
a) heparin
b) digoxin
e) EEG
d) carotid angiography
e) echo
4- Patient suspected of having brain abscess, the most important q. in the history is:
• frontal sinusitis. • ear discharge.
• head injury. • bronchioctasis.
• Hx. of vomiting.
-which of following mostly occur in a patient with intracranial abscess
a)cough b)vomiting
c)ear discharge d)frontal sinusitis
 Cardiology
1-Pt had arthritis in two large joint & pansystolic murmur ( carditis ) ,Hx of URTI the most
important next step:
a- ESR
b- ASO titre
c- Blood culture

2-The following are features of rheumatic fever, except:

a)restless, involuntary abnormal movements.
b)subcutaneous nodules.
c)rashes over trunk and extremities.
d)short PR interval on ECG.
e)migratory arthritis

- The following are features of rheumatic heart disease except:

1) Restless involuntary abnormal movement
2) Rashes over trunk and extremities
3) Short P-R interval on ECG
4) Migratory arthritis

2- years old lady on …….., feels dizzy on standing, resolves after 10-15 minutes on sitting,
decrease on standing, most likely she is having :
a- orthostatic hypotension

3- what is the most appropriate treatment for the above patient :

a- antiemetic
b- antihistamine
c- change the antidepressant to SSRI
d- thiazide diuretics
e- audiometry
4- High output HF causes includes all except:
• anemia.
• Mitral Regurgitation (MR)
• AV fistula.
• paget’s disease.

12- Premature ventricular contraction (PVC),all are true except:

a) If anti-arrhythmic given after MI for protection of PVC --> decrease chance of sudden death.
b) Use of anti-arrhythmic type I increase mortality.
c) PVC in normal population doesn’t increase risk of sudden death.

- Premature ventricular contracture (PVC), all are true except:-

- Use antiarrhythmic post MI improve prognosis
- Use of antiarrythmic type 1 increase mortality
Antiarrhythmic drugs should be avoided in pts with asymptomatic ventricular arrhythmias after MI, since mortality risk increases.

5- MI with premature ventricular contractions, the best Tx:

• digoxin.
• lidocaine.
• quinidine.
- A patients ECG showed anterior wall Ml with PVCs he’s on digoxin, warfarrin , lasix what
treatment would you like to add:

- patient had anterior wall MI and will he was transferred to ICU the nurse notice that he has
PVC .... 20 per minute. He is on digoxin, diuretic. What do you want to add?
a- propanolol.
b- amiodarone.
c- moxillin.
d- nothing.

-A 60 year old male presented with Hx of 2hrs chest pain ECG showed ST elevation on V1-V4
with multiple PVC & ventricular tachycardia. The management is:
a. Digoxin
b. Lidocane
c. Plavix & morphine
d. Amidarone

6- A 48 years old female with long standing infection present with bradycardia, your
management will be:
a. IV. fluid
b. Atropine.
c. Dopamine

7- Indication for valve replacement in infective endocarditis include all except:

a. Viral endocarditis.
b. Resistant bacterial endocarditis.
c. Fungal endocarditis.
d. Aortic valve regurgitation.

8- A 61-year-old man with known ischemic heart disease and peripheral vascular disease is
started on an ACE inhibitor by his GP for hypertension. Three weeks later he is admitted
with increasing confusion and vomiting. Investigations reveal: CBC Hb 14.9 g/dI, MCV 88 fI,
WBC 13.6 x 109/L; U & Es: Na+ 131 mmol/L, K+ 7.3 moI/L, urea 37.8 mmol/L, Cr 858
umol/L. The patient is suffering from:
A. Diabetic nephropathy.
B. Phaeochromocytoma.
C. Polycystic kidney disease.
D. Raised intracranial pressure.
E. Renal artery stenosis.
9- Which of the following is the least likely to cause infective endocarditis:
a. ASD
b. VSD
C. Tetrology of Fallot
d. PDA

10-Which of the following is believed to reduce mortality in CHF?

a. Digitalis
b. Furosamide
C. Enalopril
d. Procainamide
e. Asprin
11-All may cause increased BP except:
a. Obesity
b. High alcohol intake
c. Smoking
d. Gout
e. NSAID use

13-All can cause secondary hyperlipidemia except:

a. Hypothyroidism
b. Alcoholism
c. Nephrotic syndrome
d. Estrogen therapy
e. Hypertension

- Causes of Secondary hyperlipidemia are all except:

a. HTN
b. Nephritic syndrome
c. Hypothyroidism
d. Obesity

14-Coarctation of the aorta in commonly associated with which of the following syndromes?
a)down b)turner
c)patau d)edward
e)holtorain

Coarctation of the aorta is the most common cardiac defect associated with Turner syndrome.

15-a patient came to you & you found his BP to be 160/100,he isn’t on any medication yet.
Lab investigations showed: Creatinine (normal) ,Na 145 (135-145) ,K 3.2(3.5-5.1) ,HCO3
30(22-30) What is the diagnosis?
a)essential hypertension
b)pheochromocytoma
c)addisons disease
d)primary hyperaldosteronism

16- 35-year-old woman presented with exertional dyspnea. Precordial examination revealed
loud S1 and rumbling mid diastolic murmer at apex. Possible complications of this condition
can be all the following except:
A. Atrial fibrillation
B. Systemic embolization
C. Left ventricular failure
D. Pulmonary edema
E. Pulmonary hypertension

17- A 70-year-old male was brought to the emergency with sudden onset of pain in his left
lower limb. The pain was severe with numbness. He had an acute myocardial infarction 2
weeks previously and was discharged 24 hours prior to his presentation. The left leg was cold
and pale, right leg was normal. The most likely diagnosis is:
A. Acute arterial thrombosis.
B. Acute arterial embolus.
C. Deep vein thrombosis.
D. Ruptured disc at L4-5 with radiating pain
E. Dissecting thoraco-abdominal aneurysm.
18- 70-year-old woman has had Ml. 2 days after admission she developed abdominal pain and
diarrhea with passage of blood. Abdomen x-ray showed distended intestine with no fluid level.
Serum amylase level slightly elevated with mild fever. The diagnosis is:
A. Ulcerative colitis
B. Acute pancereatitis
C. lschemic colitis
D. Diverticulitis
E. Phenindione-induced colitis (*phenindione is an anticoagulant)
phenindione [an anticoagulant chemically related to anisindione that is no longer available]

19- Blood pressure, all of the following are true except:

a) if 2/3 of cuff -* false high BP
b) internal cuff must cover 80% of arm
c) follow circadian vary 4 late night high BP
d) high BP—* 3 standard deviation away from normal
e) you have to have more than one reading to Dx high BP

21- All of the following causes secondary HTN, except:

a) Pheochrmocytoma.
b) Addison’s disease.
c) Hyperaldosteronism (conn’s disease)
d) Renal disease.
e) Pregnancy.
f) Primary hypothyroidism.

22- Most important complication of systemic hypertension:

• Pontine infarction
• Renal artery stenosis
• Subdural hemorrhage
• Intracerebral hemorrhage

-complications of systemic hypertension are all except:

a) Intracerebellar haemorrhaqe
b)Renal artery stenosis.(this causes HTN)

23- S3 can be auscultated in all, except:

• Mitral stenosis
• Mitral regurgitation
• Lt sided heart failure
• Thyrotoxicosis

-S3 occur in all of the following except:

a) Tricuspid regurgitations.
b) young athelete.
c) LV failure.
d) mitral stenosis.

24- Pt with chronic atrial fibrillation more than 6 months, all can be given except:
• Cardioversion
• Heparin
• Digoxin
-Treatment of chronic atrial fibrillation all, except:
a) cardioversion
b) digoxin
c ) warfarin

26-Treatment of unstable angina include all except:

a) heparin
b) nitroglycerin
c) β-blocker
d) aspirin
e)……..

27-The first symptom of left heart failure is:

a) orthopnea
b) edema
c) dyspnea on exertion

- The first symptom in pt with Lt heart failure:

a) orthopnea.
b)PND.
c) Pedal edema.
d) Exertional dyspnea. ??

- The first symptoms of LHF is

1) Orthopnea
2) Dyspnea on exertion
3) Oedema

29- pt with low grade fever and arthalgia for 5 days, presented with pansystolic murmer at
the apex.H/O difficulty in swallowing with fever 3 wks back. Most likely diagnosis:
a) bacterial endocarditis
b) viral myocarditis
c) acute rheumatic fever
d) pericarditis

31- In atrial fibrillation and stroke, all are true , except:

a) Aspirin can be given in AF for prevention of stroke.
b) Warfarin can be given in AF for prevention of stroke.
c) Non valvular AF can cause stroke.

- One of the following is not useful in patient with atrial fibrillation “AF” and Stroke:
a- Aspirin and AF
b- Warfarin and AF
c- Valvular heart disease can lead to CVA in young patient
d- AF in elderly is predisposing factor

- regarding atrial fibrillation “AF”, all of the following are true except:
a) Non valvular AF will lead to stroke.

-Regarding atrial fibrillation...:

A- Non valvular atrial fibrillation will lead to stroke.
33-the following murmer can be accentuated by postioning of the patient:
a-aortic regurgitation by sitting
b- venous hum by lying down
c-pericardial rub by sitting
d-outflow innocent murmer by sitting

34- ECG stress test is indicated in the following except:

-routine (yearly) test in asymptomatic patients
- in high risk jobs
- 40 year old patient before starting exercise program

35- Pulmonary stenosis:

a. Commonest lesion in turner’s syndrome.
b. P2 is loud indicates severe stenosis.
c. Ejection click means it is valvar.
d. All of the above.
 D.M.
1-a patient ( known case of DM ) presented to u with diabetic foot ( infection) the antibiotic
Antibiotics
Appropriate monotherapy for cellulitis includes cefazolin or clindamycin. Although gram-negative
organisms are the unusual causes of cellulitis, even in diabetes, if they are suspected, a
fluoroquinolone (eg, levofloxacin) may be used in conjunction with clindamycin.

2- In DKA, all the following are true except:

a. Increase of corticosteroid, glucagon and GH.
b. Body water deficit is 4 to 6 L

3- A 14 years old boy with type 1 D.M. presented in coma. His blood glucose level is 33
mmol/l. Na is 142 mmol/l, K is 5.5 mmol/l, bicarb is 10 mmol/l. the following are true except:
a. The initial Rx. Should be l.V. normal saline 3 L/hour for 1-2 hours
b. IV. insulin loading dose 1 u/kg is necessary. (0.1 U/kg/h is the true)
c. IV. Na bicarbonate could be given if pH is 7 or less.
d. Hyprephosphatemia can occur during treament.
e. Hyperchloremia can occur during treatment

Hyperosmolar Coma: Treatment & Medication

All patients with HNS require hospitalization, and most should be admitted directly to the intensive
care unit (ICU). When available, an endocrinologist should direct the care of these patients. The
main goals of treatment are to
(1) vigorously rehydrate the patient while maintaining electrolyte homeostasis;
(2) correct hyperglycemia;
(3) treat underlying diseases; and
(4) monitor and assist cardiovascular, pulmonary, renal, and CNS function.
1. Intravenous fluid hydration and electrolyte homeostasis
o Phosphate, magnesium, and calcium are not replaced routinely, but a patient symptomatic with
tetany requires replacement therapy.
 Correction of hyperglycemia
o All patients with HNS require treatment with intravenous insulin; however, immediate treatment
with insulin is contraindicated in the initial management of patients with HNS. The osmotic
pressure that glucose exerts within the vascular space contributes to the maintenance of
circulating volume in these severely dehydrated patients. Institution of insulin therapy drives
glucose, potassium, and water into cells. This results in circulatory collapse if fluid has not been
replaced first.
 Begin a continuous insulin infusion of 0.1 U/kg/h.

For blood glucose concentrations of less than 250 mg/dL, decrease the insulin infusion rate by 0.5
U/h.

4-A 45 year old presented with polyurea, urine analysis showed glucosurea & -ve ketone FBS
l4mmoI. What is the best management of this patient?
a. Intermediate IM insulin till stable
b. NPH or Lent insulin 30mg then diet
C. Sulphonylurea
d. Diabetic diet only
e. Metformin

-A 36 years old female with FBS = 14 mmol & glucosuria, without ketones in urine, the
treatment is:
a) Intermittent I.M. insulin NPH. b) Salphonylurea + diabetic diet.
c) Diabetic diet only. d) Metformin.

- A 36 years old man, obese. Recently, developed polyuria, polydepsia and weight loss. Urine
analysis showed glucosuria and –ve ketone. FBS is 280 mg/dl. The best initial therapy is:
a. Intermitted l.M. insulin iniection till stabe.
b. NPH or Lenti insulin 30 units daily + diabetic diet.
c. Sulphonylurea + D.D.
d. Metformin

- A 30 y male came to ER with polyuria but -ve keton. Random blood sugar 280 mg/dl.
management:
• Nothing done only observe
• Insulin 30 U NPH+ diet control
• Diet and exercise
• Oral hypoglycemic

5- A 30 years old teacher complaining of excessive water drinking and frequency of urination,
0/B Normal. You suspect DM and request FBS = 6.8 .the Dx is:
a. DM
b. DI
c. Impaired fasting glucose
d. NLbloodsugar
e. Impaired glucose tolerance
Glucose tolerance is classified into three categories based on the FPG :
(1) FPG ≤ 5.5 mmol/L (100 mg/dL) is considered normal;
(2) FPG = 5.6–6.9 mmol/L (100–125 mg/dL) is defined as IFG; and
(3) FPG ≥ 7.0 mmol/L (126 mg/dL) warrants the diagnosis of DM.

Based on the oral glucose tolerance test (OGTT),

Impaired glucose tolerance (IGT) is defined as plasma glucose levels between 7.8 and 11.1
mmol/L (140 and 199 mg/dL) and
[

diabetes is defined as a glucose > 11.1 mmol/L (200 mg/dL) 2 h after a 75-g oral glucose load.
Some individuals have both IFG and IGT. Individuals with IFG and/or IGT, recently designated
pre-diabetes by the American Diabetes Association (ADA), are at substantial risk for developing
type 2 DM (25–40% risk over the next 5 years) and have an increased risk of cardiovascular
disease.
The current criteria for the diagnosis of DM emphasize that
1) the FPG is the most reliable and convenient test for identifying DM in asymptomatic
individuals.
2) A random plasma glucose concentration ≥ 11.1 mmol/L (200 mg/dL) accompanied by classic
symptoms of DM (polyuria, polydipsia, weight loss) is sufficient for the diagnosis of DM.
Oral glucose tolerance testing, although still a valid means for diagnosing DM, is not recommended
as part of routine care.

6- 60 years old male complaining of decreased lipido , decreased ejaculation, FBS = 6.5 mmol,
increased prolactin, Normal FSH and LH, your opinion is
a. Measure Testosterone level
b. He has DM
c. Do CT of head
d. He has Normal Fasting Blood sugar

7- A 46-year-old man, a known case of diabetes for the last 5 months. He is maintained on
Metformin 850 mg Po TID, diet control and used to walk daily for 30 minutes. On
examination : unremarkable. Some investigations show the following: FBS 7.4 mmol/L ,2 hr
PP 8.6 mmol/L ,HbA1c 6.6% ,Total Cholesterol 5.98 mmol/L ,HDLC 0.92 mmol/L ,LDLC
3.88 mmolIL , Triglycerides 2.84 mmolIL (0.34-2.27) ,Based on evidence, the following
concerning his management is true:
1. The goal of management is to lower the triglycerides first.
2. The goal of management is to reduce the HbA1c.
3. The drug of choice to reach the goal is Fibrates.
4. The goal of management is LDLC ≤ 2.6 mmol/L.
5. The goal of management is total cholesterol ≤ 5.2 mmol/L.

According to guidelines of the ADA and the American Heart Association, the target lipid values in
diabetic individuals (age >40 years) without cardiovascular disease should be:
1) LDL < 2.6 mmol/L (100 mg/dL);
2) HDL > 1.1 mmol/L (40 mg/dL) in men and >1.38 mmol/L (50 mg/dL) in women; and
3) triglycerides < 1.7 mmol/L (150 mg/dL).

Fibrates have some efficacy and should be considered when the HDL is low in the setting of a mild
elevation of the LDL.
8- Regarding the criteria of the diagnosis of diabetes mellitus, the following are true except:
1. Symptomatic patient plus casual plasma glucose ≥7.6 mmol/L is diagnostic of diabetes mellitus.
2. FPG ≥ 7.0 mmol/L plus 2 h-post 75 gm glucose ≥ 11.1 mmol/L is diagnostic of diabetes
mellitus.
3. FPG ≤ 5.5 mmol/L = normal fasting glucose.
4. FPG ≥ 7.0 mmol/L = provisional diagnosis of diabetes mellitus and must be confirmed in
another setting in asymptomatic patient.
5. 2-h post 75 gm glucose ≥ 7.6 mmol/L and < 11.1 mmol/L = impaired glucose tolerance.
Impaired glucose tolerance (IGT) is defined as plasma glucose levels between 7.8 and 11.1
mmol/L (140 and 199 mg/dL)

9- In DKA, use: both wrong

a) Short and intermediate acting insulin.
b) Long acting insulin.

12- a 70 yr old male, suddenly felt down & he is diabetic, it could be:
a) May be the ptnn is hypertensive and he developed sudden rising BP
b) He might forgot his oral hypoglycemic agent dose
c) Sudden ICH which rise his ICP
-A 70 year Saudi diabetic male suddenly fell down, this could be:
A-Maybe the patient is hypertensive and he developed a sudden rise in BP.
B-He might had forgot his oral hypoglycemic drug.
C-Sudden ICH which raise his ICP.
Autonomic Neuropathy
 Drugs
1- The mechanism of action of ASA:
• inhibition of the platlet cyclo-oxygenase.
• decrease the lipids.

2- Anticoagulant effect of heparin based on:

A. Alteration of thrombin levels
B. Potentiation of antithrombin III
C. Activation of plasmin into plasminogen
D. Inactivation of ionized calcium
E. Reduction of available factor VII

- Heparin anticoagulant action depend on:

a) potentiation of antithrombin three .
b) change plasmin to plasminogen .
c) affect prothrombin .
d) affect ionized Ca++ .
- The mechanism of action of heparin:
• activation of antithrombin III.

3- Heparinization includes all except:

-increase PT
-increase PTT
-Anti inflammatory.
- open potential collateral vessels

4- Which drug can be givin to G6PD patient?

a- ASA
b- Sulphonamide.
c- Nitrofurantoin.
d- Chloroquine.

- All of the following drugs contraindicated in G6PD deficiency, except: -

- Aspirin
- Nitrofurantoin
- Chlorquine
- Sulphonamide
- Gentamycin

5- One of the following combination of drugs should be avoided:

a) cephaloridine and paracetamol
b) penicillin and probenecid
c) digoxin and levodopa
d) sulphamethoxazole and trimethoprim
e) tetracycline and aluminium hydroxide

6- All of the following drugs advised to be given to elderly pt, except:

a) cimitidine
b) thyroxin
c) digoxin
d) chloropropamide
7- Furosemide increase excretion of:
a) Na+
b) K+
c) phosph.
d) non of the above

8-All of the following are side effects of furasomide except:

a. Hyperkalemia
b. Hypoglycemia
C. Bronchospasm
d. Haemolytic anemia
e. Pre-renal azotemia

9- Digoxin toxicity:
a) tinnitus
b) pleural effusion
c) nausea
d) all of the above
e) none of the above

10- Which of the following is not associated with phenytoin toxicity?

- hirsutism
- osteomalacia
- ataxia
- osteoprosis

11- Complications of long term phenytoin therapy include the following except:
A. Hisutism.
B. Osteoporosis.
C. Osteomalacia.
D. Macrocytosis.
E. Ataxia.

-Which of the following side effect is not associated with phenytoin:

a) Hirsutism
b) Macrocytic anemia
c) Osteomalacia.
d) Ataxia
e) Osteoporosis

12-All of them are renal complications of NSAIDs except:

a. Acute renal failure
b. Tubular acidosis
C. Interstitial nephritis
d. Upper GI bleeding

- NSAIDs cause all except:

a. Acute Renal failure
b. Tubular necrosis
c. Hypokalemia
d. Interstitial nephritis
-all the following regarding NSAID are true except:
A-acute renal failure
b-acute tubular necrosis
c-interstisial nephritis
d- hypokalemia

13- Which one of these drugs is administered orally:

a) Amikacin.
b) Neomycin.
c) Gentamycin.
d) Streptomycin.
e) Tobramycin.

14- Chronic use of steroids will give:

a) Osteomalacia.
b) Myopathies of pelvic girdle.
c) Increased risk of breast Ca.
d) Hypoglycemia.

15- All of the following cause gastric irritation, except:

a) Erythromycin.
b) NSAIDS.
c) Sucralfate. Antiulcer agent; gastric mucosa protectant.
d) Diclofenac.
e) Penicillins.

16- All of the following are anti-arrhythmic drugs, except:

a) Xylocaine.
b) Digoxin.
c) Quinidine.
d) Amiodarone.
e) Procainamide.

Group IA : Quinidine sulfate PO ,Quinidine gluconate PO ,Procainamide IV PO , Disopyramide PO

Group IB : Lidocaine IV , Mexiletine PO
Group IC : Flecainide PO , Propafenone PO
Group II : Metroprolol IV , Esmolol IV
Group III : Amiodarone PO IV , Ibutilide IV , Dofetilide PO , Sotalol PO
Group IV : Verapamil IV PO , Diltiazem IV
Other : Digoxin IV, PO , Adenosine IV

17- All can be used for the treatment of acute gout except:
a) Allopurinol.
b) Penicillamine.
c) Gold salt. In severe inflammation
d) Paracetamol.
e) Indomethacin.

18- pt on chemotherapy presented with fever, all should be done, except:

a) blood culture
b) urine culture
c) aspirin is effective
d) broad spectrum antibiotics
19- Nitroglycerine cause all of the following, except:
a) increase coronary blood flow.
b) Methemoglobinemia.
c) Venous pooling of blood.
d) Efficient for 5 mm if taken sublingual.
e) Lowers arterial blood pressure
- Nitroglycerine cause all the following except:
a- Lowers arterial blood pressure
b- Increase coronary blood flow
c- Effect for 5 min if taken sublingually
d- Causes venous pooling of blood
e- Can produce methemoglobinemia
20- Allopurinol, one is true:
b) Effective in acute attack of gout.
c) decreases the chance of uric acid stone formation in kidneys
d) Salicylates antagonize its action.
- Regarding Allopurinol:
- is a uricouric agent
- decrease the development of uric acid stones
- useful in acute attack of gout
21- Oral anticoagulants:
a) can be given to pregnants during 1st trimester
b) can be reversed within 6 hours
c) are enhanced by barbiturates
d) can not cross blood brain barrier
e) none of the above
22- which drug does not cross the placenta:
a) Heparin
b) Aspirin
c) Warfarin
d) Tetracycline
e) Diazepam
23- all the following are side effect of thiazide diuretics except:
a-has diabetogenic effect
b-cause hypocalcemia
c-cause hypomagnesimia
d-flat curve response
e-cause hypokalemia
24 - regarding β2 blocker all are true except:
a-morning dose effective more than evening dose.
b-long term maintance therapy should be avoided
25- All true about cephalosporin use, except:
- The most common side-effect is allergy
- There is a skin test for cephalosporin sensitivity
Attempts to develop a skin test for allergy to cephalosporins have been unsuccessful
26-which of the following combination is safe:
a-alcohol and metronidazole
b-digoxin and amiodarone
c-warafrin and propanolol
d-furosemide and gentamycin
 Endocrinology
1- 42 y/o female presented with 5 months Hx of N, V & malaise. Na is low, Cr is high, Glucose
is 2.7 mmol/L & HCo3 is 10.
a- hypothyroidism.
b- Addison’s disease.
c- hypervolemia because of the vomiting.
d- pheochromocytoma.
e- SIADH.

-43 yo female presented wIt 6 mnth history of malaise , N,V. Lab results: Na = 127, K 4.9,
urea 15, Ceriatinine = 135, HCO3 = 13 ,glucose 2.7. Most likely Dx is:
a. Hypothyroidism
b. Pheochromocytoma
c. Hypovolemia due to vomiting
d. SIADH
e. Addison’s disease
Creatinine S Female 44–80 µmol/L (0.5–0.9 ng/mL) Male 53–106 µmol/L (0.6–1.2 ng/mL)
Potassium S 3.5–5.0 mmol/L (3.5–5.0 meq/L)
Sodium S 136–146 mmol/L (136–146 meq/L)
[HCO3–] 22–30 mmol/L (22–30 meq/L)

2- In a patient with elevated serum level of calcium without hypocalciuria, which of the
following tests is almost always diagnostic of primary hyperparathyroidism:
a. Elevated serum level of ionized calcium.
b. Elevated serum level of chloride and decreased serum phosphorus.
c. Elevated serum level of intact parathyroid hormone (PTH).
d. Elevated 24-hour urine calcium clearance.
e. Elevated urinary level of cyclic AMP.
Primary hyperparathyroidism is confirmed by demonstration of an inappropriately high
PTH level for the degree of hypercalcemia.

3- Some patients develop hypoparathyroidism after thyroid or parathyroid operations. What

is the treatment for hypoparathyroidism:
a. Oral 1,25-vitamin D and calcium.
b. Transplantation of fetal parathyroid tissue.
c. Intramuscular PTH injection.
d. Reoperation to remove the thymus.
e. Oral phosphate binders.
 G.I.T
1-a 28 year old lady presented with history of increased bowel motion in the last 8
months.About 3-4 motions/day .Examination was normal.Stool analysis showed: Cyst,yeast:
nil ,Mucus –ve Culture:no growth, Whats the most likely diagnosis?
a)inflammatory bowel disease
b)irritable bowel disease
c)diverticulitis
2- Fecal leukocytes come with all except:
a) Shigellosis.
b) Clindamycin induced colitis.
c) Idiopathic ulcerative colitis.
3- Which of the following is the most potent known stimulator of gastric acid secretion:
a. Pepsinogen.
b. Gastrin.
c. Acetylcholine B.
d. Enterogastrone.
e. Cholecystokinin
4-In acute pancreatitis the chief adverse factor is:
a. Hypercalcaemia (> 12 mg/dl).
b. Age above 40 years.
c. Hypoxia.
d. Hyperamylasemia (> 600 units).
e. Gallstones.

5- Complications following pancreatitis may include all of the following except:

a. Pulmonary atelectasis.
b. Altered mental status.
c. Shock.
d. Afferent loop syndrome.
e. Sepsis.
6- All are true in black hairy tongue, except:
a) Hydrocortisone can be used.
b) Advice pt not brush his tongue.
- All true about black hairy tongue, except:-
- Advice patient not to brush his tongue
- It is caused by bacterial over growth
- Bad oral hygiene is a potential cause
- Antibiotics may be prescribed if refractory
7-regarding aphthous ulceration in the mouth all are true except:
a-there is no treatment for acute ulcer
b-tetracycline suspension helps in healing
c-there is immunological role in its development
d-mostly idiopathic in origin
8- Diarrhea can occur in all the following, except:
- Hypothyroidism
- Hyperthyroidism
 Hematology
1-60 year old male was refer to you after stabilization investigation show Hgb 18,5 g/dl , hect.
64% , RBC 7.8 , WBC 15.3 & Plt. 570 Diagnosis :
a- iron def. Anemia
b- Hgb pathy
c- CLL
d- 2ry polycythemia
e- Polycythemia rubra Vera

Hematocrit males 0.388 – 0.464 38.8 – 46.4

females 0.354 – 0.444 35.4 – 44.4
Hemoglobin males 133–162 g/L 13.3–16.2 g/dL
females 120–158 g/L 12.0–15.8 g/dL
Mean corpuscular hemoglobin (MCH) 26.7–31.9 pg/cell 26.7–31.9 pg/cell
Mean corpuscular hemoglobin concentration(MCHC) 323–359 g/L 32.3–35.9 g/dL
Mean corpuscular volume (MCV) 79–93.3 fL 79–93.3µm3
Platelet count 165–415 .109/L 165–415103/mm3
Erythrocyte count males 4.30–5.601012/L 4.30–5.60106/mm3
Females 4.00–5.201012/L 4.00–5.20106/mm3
Leukocytes Count 3.54–9.06109/L 3.54–9.06103/mm3

Polycythemia vera is a blood disorder in which the bone marrow makes too many red blood cells.
Polycythemia vera may also result in the overproduction of white blood cells and platelets. Most of
the health concerns associated with polycythemia vera are caused by a blood-thickening effect that
results from an overproduction of red blood cells.

2- 55 y/o female presented to ER because her family noticed skin discoloration. Has Hx of 5
kg loss over 3 weeks. Her medical Hx is -ve apart from vitiligo. Her examination is within
normal except for scleral icterus & skin jaundice. Her lx : WBC 2500 ,Plt 70000 (165–415 x
1000/mm3) , MCV 106, Hct 17, Retics count 15, T.bil 3, which of the following test will be
more associated with the syndrome she has:
a- Chromosomal kariotype of bone marrow.
b- Antiparietal cells antibodies.
c- Extrahepatic biliarv obstruction
d- Decrease gastric fluid

3- 32-year-old Saudi man from Eastern province came to you for routine pre-employment
physical exam. He has always been healthy and his examination is normal. Lab: HCT 35%
(38.8–46.4) , MCV: 63fL (79–93.3 fL) , WBC: 6800/ml ,retics: 4000/ml (0.7%) (0.8–2.3% red
cells) Platelet: 27000/u1 his stool: -ve for occult blood The most direct way to confirm
suspected diagnosis:
A. Peripheral smear
B. Measure Hb A2 level
C. G6PD screening
D. Measure iron, TIBC and ferritin level
E. Bone marrow stain for iron

4- 26-year-old man presented with headache and fatigue. Investigations revealed: Hb 8 g/dI ,
MCV 85 fL retics 10% ,All the following investigations are useful except :
A. Coomb’s test
B. Sickling test
C. Serum bilirubin
D. Serum iron as it is normocytic anemia with reticulocytosis (hemolysis or hemorrhage)
E. Hb electrophoresis

5- Increased bleeding time is seen in all of the following except:

a) Hemophilia.
b) Scurvy.
c) VwD (Von-Willebrand disease).

Prothrombin Partial thromboplastin Bleeding

Condition
time time time
Vitamin K deficiency prolonged prolonged unaffected
Disseminated intravascular
prolonged prolonged prolonged
coagulation
Haemophilia unaffected prolonged unaffected

6- critical count of platelets which lead to spontaneous bleeding is:

a) 1000
b) 50.000
c) 75.000
d) 100.000
e) 20.000

7- Serum ferritin reflects:

a) Total iron stores.
b) Serum iron.
c) Bone marrow iron.
d) None of the above.

8-In a patient with Hb = 8, MCV = 82, retic = 10%, all is needed except:
a) Hb electrophoresis.
b) Coombs test.
c) Serum iron level.
d) Serum bilirubin level

9- pt with fever, pallor petechei, echemosis, CBC as WBC 2,800 Imm3 ,Hb 6 & plt 2900. next
step of investigation:
a)bone marrow aspiration

10- A 23 year old white female is diagnosed as having chronic ITP . Which of the following
will best predict a favorable remission after splenectomy:
a. Presence of antiplatelet antibodies.
b. Increased bone marrow megakaryocytes.
c. Absence of splenomegaly.
d. Platelet count of 170000/mm3 on corticosteroids.
e. Complement on platelet surfaces.

11- Which of the following would most likely indicate a hemolytic transfusion reaction in an
anesthetized patent?
a) shaking chills and muscle spasm
b) fever and oliguria
c) heperpyrexia and hypotention
d) tachycardia and cynosis
e) bleeding and hypotention

12- Which of the following organs is likely to receive a proportionately greater increase in
blood flow?
a) kidneys
b) liver
c) heart
d) skin
e) none of the above
 Infectious Diseases
1- a 24 yrs old pt. came for check up after a promiscuous relation 1 month ago .. he was
clinically unremarkable, VDRL : 1/128 … he was allergic 2 penicillin other line of
management is :

2- a 25 yrs old Saudi man presented with Hx of mild icterus , otherwise ok .. hepatitis screen :
HBsAg +ve , HBeAg +ve , anti-HBcAg +ve , the diagnosis :
a- acute hepatitis B
b- convalescent stage of hep. B
c- recovery with seroconversion Hep . B
d- Hep B carrier
e- chronic active Hep. B
3-What is the least effective AB of the following to staph. aureus:
• clindamycin.
• erythromycin.
• amoxicillin.
• Vancomycin.
Fewer than 5% of staph. aureus isolates are sensitive to penicillin.
- Which of the following antibiotics has the least activity against S. aureus?
a. Erythromycin.
b. Clindamycin.
c. Vancomycin.
d. Dicloxicillin.
e. First generation cephalosporins.

4- regarding protective measures of malaria, all true except:

- infestation occur more in day than night :
- using insect repellant is useful
5- Regarding typhoid fever, all are true except:
• fever and red spots appear on the same time.
• can be completely eradicated even in the presence of gall stones.
• transmitted by food, milk and water.
• can be treated by quinolones.
6- Within 6 hours after attending a dinner party, 10 participants developed sever N/V,
abdominal cramp and diarrhea. Most of them resolved spontaneously. Few were admitted for
correction of dehydration. The most probable cause is:
a. Salmonella food poisoning.
b. Botulism.
c. Staphylococcal food poisoning.
d. Giardiasis.
e. Clostridium perfringes food poisoning.
-A family went to a dinner party after 6 hours they all had symptoms of abdominal
pain,nausea, vomiting and dehydration. Some of them recovered while others needed
hospitilzation. What’s the most likely organism?
a) giardia
b) staph aurens
c) salmonella
d) c . perfiringis
e) c.boyulism

Bacterial Food Poisoning

Incubation Period, Organism Symptoms Common Food Sources

1–6 H

Ham, poultry, potato or egg salad,

Staphylococcus aureus Nausea, vomiting, diarrhea
mayonnaise, cream pastries

Bacillus cereus Nausea, vomiting, diarrhea Fried rice

8–16 H

Abdominal cramps, diarrhea (vomiting

Clostridium perfringens Beef, poultry, legumes, gravies
rare)
Abdominal cramps, diarrhea (vomiting
B. cereus Meats, vegetables, dried beans, cereals
rare)
 >16 H

Vibrio cholerae Watery diarrhea Shellfish

Enterotoxigenic Escherichia coli Watery diarrhea Salads, cheese, meats, water

Ground beef, roast beef, salami, raw

Enterohemorrhagic E. coli Bloody diarrhea
milk, raw vegetables, apple juice

Salmonella spp. Inflammatory diarrhea Beef, poultry, eggs, dairy products

Campylobacter jejuni Inflammatory diarrhea Poultry, raw milk

Potato or egg salad, lettuce, raw

Shigella spp. Dysentery
vegetables

Vibrio parahaemolyticus Dysentery Mollusks, crustaceans

7- The following are characteristics features of brucellosis except:

a. Lymphadenopathy
b. Hepatomegly.
c. Splenomegaly.
d. Diarrhea.
e. Backache.

- All symptoms and signs of brucellosis, except:

• Back pain. • Lymphadenopathy
• Splenomegaly • Hepatomegaly
• Gastroenteritis

8- in brucellosis, all of the following are true except:

a) brucella abortus cause more severe form than B. melitansis in children .
b) human to human is rarely documented .
c) human can be infected through inhalation .
d) brucella species are small, non motile gram -ve coccobacilli .
e) pt with high titer can show false -ve .

9- 82 y/o female presented to ER in confusion with hypotension. BP was 70/20, P=l6O/min,

rectal T= 37.7°C. The most likely of the following would suggest sepsis as a cause of
hypotension is:
a- Low systemic vascular resistance & high cardiac output.
b- High systemic vascular resistance & low cardiac output.
c- Pulmonary capillary wedge pressure less than 26.
d-PH is less than 7.2.
e- Serum lactate dehydrogenase more than 22.
10-A 55 years old male with COPD , complaining of 1 wk fever and productive cough on CXR
showed Left upper pneumonia, sputum culture +ve for H.inf, most drug effective is
a. Pencillin
b. Doxycycline
c. Cefuroxime
d. Gentamycin
e. Carbinacillin
- A 55 years old man known case of COPD. Now complaining of 1 week fever, productive
cough. CXR showed left upper lobe pneumonia. Sputum culture positive H.influenza. what
are you going to give him?
a- penicillin.
b- doxycyclin.
c- cefuroxirne.
d- gentamycin.
e- carbincillin

11-Which one of the following diseases is not transmitted by mosquitoes?

a)rift valley fever
b)yellow fever
c)relapsing fever
d)filariasis
e)dengue fever

12- Pt presents with fever swelling is felt,Ant.lymph node swelling warm, tender & fluctuant
Dx:
a) viral infection .
b) bacterial lymphadenitis .
c) Hodgkin L.
d) ALL .
13- Patient with H/O fever, peripheral blood film +ve for malaria:
a) Banana shaped erythrocyte is seen in P. vivax
b) Mostly due to P. falciparium
c) Treated immediately by primaquin 10mg for 3 days
d) Response to Rx will take 72 hr to appear

14-The following drugs can be used in prophylaxis of malaria in chlorquine-resistant area,

except:
a) Mefloquin .
b) Doxycycline .
c) Proguanil .
d) Chlorquine + dapsone + pyrimethamine .
- the following can be used in prophylaxis in malaria in chlorquine resistant area except:
a-mefloquine
b-doxycycline
c-chlorquine with proguanil
e-dapsone

15- Hepatitis most commonly transferred by blood is:

a) HBV.
b) HAV.
c) HCV (previously known as non a non b).
d) None of the above.
16- The greatest risk of developing chronic hepatitis and cirrhosis occurs after:
a. Hepatitis A infection.
b. Hepatitis B infection.
c. Hepatitis C infection.
d. Hepatitis D infection.
e. Hepatitis E infection.
17- In a gram-negative bacterial septicemia:
a) pseudomonas is the most common organism involved.
b) Many of the advese changes can be accounted for by endotoxin.
c) The cardiac index is low
d) Central venous pressure is high.
e) Endotoxin is mainly a long-chain peptide.

18- In septic shock:

a) The mortality rate is 10 to 20%.
b) Gram-negative organisms are involved exclusively
c) The majority of patients are elderly
d) The most common source of infection is alimentary tract.
e) Two or more organisms are responsible in the majority of cases.
21- HSV type 1 infection of the oral cavity, all true except:
a- Is the commonest viral infection in the oral cavity
b- Can give gingivostomatitis
c- In primary infection, there is systemic involvement
d- May present with tonsillitis without oral lesion

32- A 40 year old white male is transferred to your institution in septic shock less than 24
hours after onset of symptoms of a non-specific illness. He underwent a splenectomy for
trauma 5 years ago. Antibiotic coverage must be directed against:
a. Streptococcus, group A.
b. Klebsiella pneumoniae.
c. Staphylococcus aureus.
d. Escherichia coli.
e. Streptococcus pneumoniae.
 Metabolic & Acid-Base Balance
1- When lactic acid accumulates, body will respond by:
a) Decrease production of bicarbonate
b) Excrete C02 from the lungs
c) Excrete Chloride from the kidneys
d) Metabolize lactic acid in the liver
2- What is the initial management of acute hypercalcemia?
a) Correction of exter-cellular fluid (by adequate rehydration)
- The first step in the management of acute hypercalcemia should be:
A. Correction of deficit of Extra Cellular Fluid volume.
B. Hemodialysis.
C. Administration of furosemide.
D. Administration of mithramycin.
E. Parathyroidectomy.
3- All of the following signs or symptoms are characteristics of an extracellular fluid volume
deficit except: means dehydration
A. Dry, sticky oral mucous membranes.
B. Decreased body temperature.
C. Decreased skin turgor.
D. Apathy.
E. Tachycardia.
4- Blood pH
a) high after diarrhea
b) low after vomiting
c) more in Rt atrium than Lt atrium
d) lower in Rt atrium than Lt ventricle
e) lower in renal vein than renal artery
6- All cause recent loss of weight, except:
• AIDS
• Cancer
• Nephritic syndrome
• Kwashiorkor
5 -In a patient with weight loss, all can be a cause except:
a) Thyrotoxicosis.
b) Nephrotic syndrome.
c) TB.
d) AS.
6- The most common cause of hypercalcaemia in a hospitalized patient is:
a. Dietary, such as milk-alkali syndrome.
b. Drug related, such as the use of thiazide diuretics.
c. Granulomatous disease.
d. Cancer.
e. Dehydration
7- Hyperkalemia is characterized by all of the following except:
a) nausea and vomiting.
b) Peaked T-waves.
c) Widened QRS complex.
d) Positive Chvostek sign.
e) Cardiac arrest in diastole.

8- Normal daily caloric intake is:

a) 0.3 kcal/kg
b) 1.3kcal/kg
c) 2.Okcal/kg
d) 3.Skcal/kg
e) 35kcallkg
9-Hypokalemia occurs with all except:
a) Metabolic alkalosis.
b) Acute tubular acidosis.
c) Chronic diarrhea.
d) Hyperaldosteronism.
e) Furosemide.
 Renal Diseases
1- Pre-Renal Failure:
a. Casts
b. Urine Osm <400
C. Urine Na <20 mmol/L
d. Decreased water excretion
2-Polycystic renal disease is:
a. AD
b. AS
C. Sex-linked dominant
d. Sex-linked recessive
e. Autosomal dominant combined with...
3-Patient with Hx of severe hypertension, normal creatinine, 4g protein 24 hrs. right kidney
16cm & left kidney 7cm with... suggesting of left renal artery stenosis. Next investigation:
a. Bilateral ... renal angiography
b. Right percutanious biopsy
C. Left precutanious biopsy
d. Right open surgical biopsy
e. Bilateral renal vein determination
4 -Urine analysis will show all except:
a) Handling phosphate.
b) Specific gravity.
c) Concentrating capacity.
d) Protein in urine.
5- In acute renal failure, all is true except:
a) Phosphatemia.
b) Uremia.
c) Acid phosphate increases.
d) K+ increases.
 Respiratory System
1- a 58 yrs. old male pt. came with HX of fever, cough with purulent foul smelling sputum and
CXR showed : fluid filled cavity … the most likely diagnosis is :
a- abscess
b- TB
c- bronchieactesis
2- One of the major factors causing physiological hypoxemia is:
• ventilation-perfusion mismatch.
• decreased diffusional capacity of the alveolar membrane.
• increase in the level of 2,3 DPG.

3- 55 years old male patient presented with cough for 10 years which did not bother him
much, it is productive of mucoid and purulent sputum alternatively, Hx of excessive smoking
for 23 years. He is obese 123 kg. He was wheezing during talking with you. On examination
you find rhonchi allover his chest, the most probable diagnosis is:
a. Chronic bronchitis.
b. Emphysema.
c. Pneumothorax.
d. Cystic fibrosis.
e. Bronchiactasis.
- 55-year-old male presented to your office for assessment of chronic cough. He stated that he
has been coughing for the last 10 years but the cough is becoming more bothersome lately.
Cough productive of mucoid sputum, occasionally becomes purulent. Past history: 35 years
history smoking 2 packs per day. On examination: 124 kg, wheezes while talking.
Auscultation: wheezes allover the lungs. The most likely diagnosis is:
A. Smoker’s cough
B. Bronchiectasis
C. Emphysema
D. Chronic bronchitis
E. Fibrosing alveolitis
4- Forced vital capacity:
a. Volume of gas that can be expelled after inspiration in one minute.
b. Volume of gas that can be expelled in the 1st second.
c. Volume of gas that can be expelled after maximal inspiration.
d. Maximal air flow rate in FVC.
e. Maximal air flow in 1 second.
5- Asthma after 40 years old. What is true?:
a. Could be psychological.
b. Eosinophiles are increased significantly.
c. Peak expiratory value change from night to day.
d. Oral steroid change the peak expiratory value significantly.
6- Air Bronchogram is characteristic feature of:
-Pulmonary edema.
-HMD= Hyaline membrane disease.
-Lobar Pneumonia.
-Lung Granuloma.
7-ln moderate to severe asthmatic patient you find all except:
a. Decrease Po2 <60
b. PCO2 >60
c. HCO3 decreased
d. IV hydrocortisone relief after few hours
e. Dehydration
- In moderate to sever asthmatic patient, you will find all the following except:
a- P02 < 60
b-PCO2>60
c- low HCO3
d- IV hydrocortisone will relieve the symptoms after few hours.
e- dehydration.
- Regarding moderately severe asthma, all true except:
- PO2<6OmmHg
- PCO2 > 60 mm Hg ,early in the attack
- Pulsus Paradoixcus
- I.V cortisone help in few hours
8- The most specific investigation for pulmonary embolism is:
a. Perfusion scan
b. X-ray chest
C. Ventilation scan
d. Pulmonary angiography
9-A 30 year old male presented with Hx of left sided chest pain & shortness of breath BP
80/50. On examination left sided chest hyper-resonanse. The most likely diagnosis is:
a- pneumonia with pleural effusion.
b- MI.
C. Spontaneous pneumothorax
10-history of recurrent pneumonia, foul smelling sputum with blood, clubbing:
a. Bronchiactasis
11-Patient in ER: dyspnea, Rt sided chest pain , engourged neck viens and weak heart sounds
, absent air entry over Rt lung Plan of Treatment for this patient:
a) IVF, Pain killer, 02
b) Aspiration of Pericardium
c) Respiratory Stimulus
d) Intubation
e) Immediate needle aspiration chest tub
12-Which of the following radiological features is a characteristic of miliary tuberculosis:
A) Sparing of the lung apices
B) Pleural effusion
C) Septal lines
D) Absence of glandular enlargement
E) Presence of a small cavity
-Radiological features of Miliary TB?
a- Sparing lung apices.
b --------------------------
c- Septal line.
d- No glandular enlargement
e- Small cavity.

13- Which one of the following regimens is the recommended initial treatment for most adults
with active tuberculosis?
1. A two-drug regimen consisting of isoniazid (INH) and rifampin (R ifad in).
2. A three-drug regimen consisting of isoniazid, rifampin, and ethumbutol MyambutoI).
3. A four-drug regimen consisting of isoniazid, refimpin, pyarazinamide and ethumbutol.
4. No treatment for most patients until infection is confirmed by culture.
5. A five-drug regimen consisting of Isoniazid, rifampin, pyrazinamide, ethu mbutol and
ciprofloxacin
Table 158-2 Recommended Dosagea for Initial Treatment of Tuberculosis in Adultsb
Dosage

Drug Daily Dose Thrice-Weekly Dose c

Isoniazid 5 mg/kg, max 300 mg 15 mg/kg, max 900 mg

Rifampin 10 mg/kg, max 600 mg 10 mg/kg, max 600 mg

Pyrazinamide 20–25 mg/kg, max 2 g 30–40 mg/kg, max 3 g

Ethambutol d 15–20 mg/kg 25–30 mg/kg

14- A 24-year-old woman develops wheezing and shortness of breath when she is exposed to
cold air or when she is exercising. These symptoms are becoming worse.Which of the
following is the prophylactic agent of choice for the treatment of asthma in these
circumstances?
A. Inhaled β2 agonists.
B. Oral aminophylline.
C. Inhaled anticholinergics.
D. Oral antihistamines.
E. Oral corlicosteroids.
15- 25-year-old man had fixation of fractured right femur. two days later he became dyspnic,
chest pain and hemoptysis. ABG: pH 7.5 po2: 65 pCo2: 25 initial treatment is:
A. Furosemide
B. Hydrocortisone
C. Bronchoscopy
D. Heparin
E. Warfarin
16- Which one shifts oxyheamoglobin dissociation curve to the left :
a) Hypoxia.
b) Acidosis.
c) High altitude.
d) None of the above.

several factors indicate how the curve is affected:

 Variation of the hydrogen ion concentration. This changes the blood's pH. A decrease in pH shifts the
standard curve to the right, while an increase shifts it to the left. This is known as the Bohr effect.
 Effects of carbon dioxide. Carbon dioxide affects the curve in two ways: first, it influences intracellular pH
(the Bohr effect), and second, CO2 accumulation causes carbamino compounds to be generated through
chemical interactions. Low levels of carbamino compounds have the effect of shifting the curve to the right,
while higher levels cause a leftward shift.
 Effects of 2,3-DPG. 2,3-diphosphoglycerate, or 2,3-DPG, is an organophosphate, which are created in
erythrocytes during glycolysis. The production of 2,3-DPG is likely an important adaptive mechanism,
because the production increases for several conditions in the presence of diminished peripheral tissue O 2
availability, such as hypoxemia, chronic lung disease, anemia, and congestive heart failure, among others.
High levels of 2,3-DPG shift the curve to the right, while low levels of 2,3-DPG cause a leftward shift, seen in
states such as septic shock and hypophosphatemia.
  Temperature. Temperature does not have so dramatic effect as the previous factors, but hyperthermia causes
a rightward shift, while hypothermia causes a leftward shift.
 Carbon Monoxide.Hemoglobin binds with carbon monoxide 240 times more readily than with oxygen,and
therefore the presence of carbon monoxide can interfere with the hemoglobin's acquisition of oxygen. In
addition to lowering the potential forhemoglobin to bind to oxygen, carbon monoxide also has the effect of
shifting the curve to the left. With an increased level of carbon monoxide, a person can suffer from severe
hypoxemia while maintaining a normal PO2.
 Effects of Methemoglobinemia (a form of abnormal hemoglobin). Methemoglobinemia causes a leftward
shift in the curve.
 Fetal Hemoglobin. Fetal hemoglobin (HbF) is structurally different from normal hemoglobin (Hb). The fetal
dissociation curve is shifted to the left relative to the curve for the normal adult. Typically, fetal arterial oxygen
pressures are low, and hence the leftward shift enhances the placental uptake of oxygen.

Some Clinical Uses of the Dissociation = Curve

The oxyhemoglobin dissociation curve, and the role of hemoglobin, are important clinically in understanding the
relationship of arterial, oxygen saturation to the partial pressure of oxygen in arterial blood, particularly as it relates to
disease. For example, it is useful to observe in healthy patients that the slope of the curve increases significantly from
the mid-sixties (PaO2) downward, which indicates to the health professional that decreases in PaO2 in this region will
have dramatic effects on arterial oxygen saturation.

17- All of the following are true about pulmonary embolism, except:
a) Normal ABG.
b) Sinus tachycardia is the most common ECG finding.
c) Low plasma D-dimer is highly predictive for excluding PE.
d) Spiral CT is the investigation of choice for diagnosis.
e) Heparin should be given to all pts with high clinical suspicion of PE.
18- In mycoplasma pneumonia, there will be:
a) A (+ve) cold agglutinin titer.
b) Lobar consolidation.
19- The treatment of community acquired pneumonia is:
a) First generation cephalosporin.
b) Penicillin G + second generation cephalosporin.
c) Erythromycin.
d) Erythromycin + Gentamycin.

Only occasionally do all the pieces of the diagnostic puzzle fit together easily to yield an etiology of
community acquired pneumonia CAP; hence, therapy is empiric most of the time. For empiric
outpatient therapy, a macrolide alone is appropriate.

20- All indicate severity of bronchial asthma , except:

a) Intercostal and supraclavicular retraction
b) Exhaustion
c) PO2 <6OmmHg
d) P02< 60 mmHg +PCO2> 45 mmHg
e) Pulsus paradoxis > 2OmmHg
21- a 25 year old pregnant presented with fever and sore throat (in flue season) then she
developed non productive cough and dyspnea, she was extremely hypoxic, the most likely Dx:
a) Staph. Pneumonia
b) Strep. Pharyngitis
c) Pneumococcal pneumonia
d) Viral pneumonia
22-interstitial lung disease all of the following are true except:
a) Insidious onset exertional dyspnea
b) Bibasilar inspiratory crepitation in physical examination
c) Haemoptysis is an early symptom
d) Total lung capacity volume is reduced
- Interstitial lung disease All true except:
A-Insidious onset exertional dyspnea.
B-Bibasilar inspiratory crepitations in physical examination.
C-Haemoptysis is an early sign.
D-Total lung volume is reduced.
22- Primary TB:
a) Usually involves upper lobe of lung.
b) Normal X-ray.
c) +ve PPD test.
d) None of the above.
e) All of the above.