PAPER 1A MEDICAL

1. 48 years old woman with no known medical illness complains of dysuria for 3 days
associated with increased frequency. She has similar symptom twice this year,
treated with antibiotic then resolved. She has no fever, nausea or vomiting. On
examination, blood pressure is 135/85 mmHg, pulse rate is 80 bpm and temperature
is 37℃. Per abdomen is mild tender at suprapubic but no guarding. Urinalysis and
urine culture con rm the diagnosis.

What is the most appropriate prevention advice to the patient?

A. Start prophylactic antibiotics
B. Advice for post coital voiding
C. Suggest cranberry juice
D. Encourage oral uid
E. Topical vaginal estrogen cream

Reference:
https://www.uptodate.com/contents/recurrent-simple-cystitis-in-women

2. 37 years old woman presents with unsteady gait since morning. She had sore throat
and swollen lymph nodes 2 weeks ago. On examination, she has horizontal
nystagmus and dysarthria. Her blood pressure is 125/80 mmHg and pulse rate is
90 bpm. Her motor and sensory examination are normal.

What is the diagnosis?

A. Acute cerebellitis
B. Benign paroxysmal positional vertigo
C. Cerebellar stroke
D. Meniere disease
E. Multiple sclerosis

Reference:
https://www.uptodate.com/contents/overview-of-cerebellar-ataxia-in-adults

3. 31 years old woman complains of lethargy and dark color urine. She had history of
upper respiratory tract infection which had resolved 2 weeks ago. On examination,
she is febrile, pale and jaundice. She has splenomegaly. Her investigation results:

Hemoglobin 7.3
Coomb test Positive

What is the appropriate management?

A. IV cyclophosphamide
B. IV prednisolone
C. Serum haptoglobulin
D. Transfused packed call
E.

Reference:
https://www.uptodate.com/contents/warm-autoimmune-hemolytic-anemia-aiha-in-
adults
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4. 68 years old man presents with memory deterioration and confusion. Family
members say he always talk to himself. There is no signi cant past medical history.
He is a smoker and drinks alcohol on social occasion. His Mini-Mental State
Examination score is 10/30. His blood pressure is 140/85 mmHg and pulse rate is
84 bpm. His pupils react when he looks at near object but not reacting to light.

What is the most appropriate investigation?

A. CT brain
B. Full blood count
C. VDRL test
D. Thyroid function test
E. HIV rapid test

Reference:
https://www.uptodate.com/contents/neurosyphilis

5. 60 years old man presents with generalized muscle pain and cramp for 6 months.
He has no fever or upper respiratory tract infection. He just diagnosed with heart
disease. He was started on aspirin, atorvastatin, perindopril and bisoprolol. On
examination, he is alert and comfortable. His blood pressure is 140/80 mmHg, pulse
rate is 60 bpm and temperature is 37°C. Physical examination is unremarkable. His
investigation result is as below:

Creatine kinase
30 (20-198)

What is the most appropriate management?

A. Change atorvastatin to feno brate
B. Change atorvastatin to rosuvastatin
C. Change atorvastatin to simvastatin
D. Monitor creatine kinase
E. Withhold atorvastatin

Reference:
CPG Management Of Dyslipidaemia (2017)

6. 30 years old man with underlying bronchial asthma currently on MDI Salbutamol and
MDI Budesonide. Regarding his asthma control, he has less than 1 episode of
symptom per week. He also has exercise induced symptoms which require him to
take inhaler every time before jog. His last exacerbation requiring admission almost
3 years ago. On examination, his peak expiratory ow rate is >80% predicted.

What is the most appropriate management?

A. Asthma diary
B. Exercise challenge test
C. IgE allergic test
D. Spirometry
E. Full lung function test

Reference:
Not available
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7. 53 years old man presents with full and intermittent epigastric pain. The pain is
aggravated in the midnight and relieved by taking antacid on as needed basis.
Otherwise, there is no alarm symptom. On examination, his vital signs are stable.
There is mild tenderness at epigastric region and no mass palpable. Urea breath test
is negative.

What is the most appropriate management at this stage?

A. Ultrasound hepatobiliary system
B. Oesophagogastroduodenoscopy
C. Continue antacid
D. H₂ antagonists
E. Proton pump inhibitor

Reference:
https://www.uptodate.com/contents/approach-to-the-adult-with-dyspepsia

8. 63 years old man presents with fever and cough for 5 days. He developed cough
and shortness of breath last night. On examination, he is alert and conscious. His
blood pressure is 110/60 mmHg, pulse rate is 100 bpm, temperature is 37.8°C and
oxygen saturation is 94% under room air. There are reduced air entry with dullness
on percussion over right lower zone of lungs. His investigation results are as below:

Full blood count

White blood cell 3.5
Hemoglobin 16
Hematocrit 55.6
Platelet 100

Renal function test

Sodium 138
Potassium 4.2
Chloride 100
Urea 9.2
Creatinine 190

Chest x-ray Blunted right costophrenic angle

Dengue IgM Pending

What is the most important management?

A. Arterial blood gas
B. Pleural tapping
C. Intravenous bolus graded regime
D. Intravenous normal saline maintenance
E. Supplement oxygen

Reference:
CPG Management Of Dengue Infection In Adults (2015)
9. 54 years old woman complains of bilateral wrists and ngers pain for more than 1
year. The symptom is associated with intermittent fever and early morning sti ness.
On examination, there is tenderness over 2nd, 3rd and 4th distal interphalangeal
joint. Her rheumatoid factor is negative. Her investigation results are as below:

Full blood count

White blood cell 13
Hemoglobin 9.0
Platelet 250

Erythrocyte sedimentation rate 73

What is next step management?

A. Anti-CCP
B. Anti-dsDNA
C. ANA
D. Hand x-ray
E. Complement

Reference:
CPG Management Of Rheumatoid Arthritis (2019)

10. 62 years old man with underlying diabetes mellitus on oral hypoglycemic agent. He
presents with confusion started this morning associated with loss of appetite.
Otherwise, he has no diarrhea or vomiting. On examination, he is drowsy and
dehydrated. His blood pressure is 96/60 mmHg, pulse rate is 108 bpm, temperature
is 38.6°C, respiratory rate is 24 and oxygen saturation is 93%. There is crepitation
and reduced air entry on right lower zone of lung. His investigation results are:

Blood glucose 37.4

Urine ketone 1+

Renal function test

Sodium 160
Potassium 3.9
Urea 21.5
Creatinine 212

Venous blood gas

pH 7.30
HCO3 17

What is the most appropriate management?

A. Actrapid
B. Augmentin
C. Calcium gluconate
D. Normal saline
E. Sodium bicarbonate

Reference:
CPG Management Of Type 2 Diabetes Mellitus (2015)
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11. 20 years old woman is brought to hospital by family members after drinking a bottle
of chemical herbicide. She had an argument with her boyfriend yesterday. On
examination, she is alert and conscious. Her pupils are equal and reactive bilaterally.
Noted multiple ulcers in the oral cavity. Her blood pressure is 120/70 mmHg, pulse
rate is 90 bpm and temperature is 37.6°C. Per abdomen, there is tenderness over all
quadrants. Other systemic examinations are unremarkable.

What is the most appropriate management?

A. Administer atrophine
B. Administer dexamethasone
C. Administer Fuller’s earth
D. Administer N-acetylcysteine
E. Perform gastric lavage

Reference:
https://www.uptodate.com/contents/paraquat-poisoning

12.

13.

14. 55 years old woman with underlying diabetes mellitus on T. Metformin and T.
Gliclazide. She presents with rst episode of syncopal attack preceded by sweating
and nausea. On examination, she is alert but restless. Her blood pressure is
90/60 mmHg, pulse rate is 110 bpm, oxygen saturation is 98% and random blood
sugar is 5.6 mmol/L.

What is the next investigation?

A. CT brain
B. Electrocardiogram
C. Electrolytes
D. Troponin T
E. Full blood count

Reference:
https://www.uptodate.com/contents/syncope-in-adults-clinical-manifestations-and-
initial-diagnostic-evaluation

15. 67 years old woman with known case of chronic obstructive pulmonary disease. She
presents with increase copious amount of sputum for 1 month. On examination, her
vital signs are normal. Her physical examination is unremarkabke.

What is the most appropriate investigation?

A. Bronchoalveolar lavage
B. High-resolution computed tomography
C.
D.
E.

Reference:
Not available
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 16. 66 years old woman presents with constipation for 3 months which improved after
high bre diet. On examination, her body mass index is 29 kg/m2, blood pressure is
130/80 mmHg and pulse rate is 68 bpm. There is no thyroid swelling and re ex is
normal. Her investigation results are as below:

Thyroid stimulating hormone 9.1 (0.4-4.5)

Free thyroxine 15.3 (9.0-24.0)

What is the most appropriate management at this stage?

A. Ultrasound thyroid
B. Start levothyroxine
C. Repeat thyroid function test in 6 weeks
D. Send anti–thyroid peroxidase
E. Send anti-thyroglobulin

Reference:
CPG Management Of Thyroid Disorders (2019)

17. 85 years old man was recently discharged for stroke. He is bedridden and on
nasogastric tube feeding. However, the tube was dislodged 3 weeks ago. He
presents with fever, cough and shortness of breath for 1 day. On examination, he is
alert and conscious. His blood pressure is 140/90 mmHg, pulse rate is 90 bpm and
temperature is 38°C. There is right lower zone crepitations on his lungs. His chest
x-ray shows right lower zone consolidation.

What is the most appropriate parenteral management?

A. Augmentin plus Azithromycin
B. Unasyn
C. Ceftriaxone plus Azithromycin
D. Ceftriaxone plus Metronidazole
E. Cipro oxacin plus Azithromycin

Reference:
National Antimicrobial Guideline (2019)
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 18. 40 years old woman with no known medical illness presents with fever for 3 weeks.
The symptom is associated with nausea, abdominal pain and vomiting. She had
rash at second week of illness (resolved). On examination, she is jaundice. Her blood
pressure is 100/70 mmHg, pulse rate is 60 bpm and temperature is 38°C. There is
dullness over the Traube space and tenderness over epigastric region. Her
investigation result is as below:

Full blood count

White blood cell 10
Hemoglobin 12
Platelet 120

What is the most appropriate investigation?

A. Blood lm for malaria parasite
B. Stool culture and sensitivity
C. Leptospirosis serology
D. Ultrasound hepatobiliary
E. Epstein-Barr virus serology

Reference:
https://www.uptodate.com/contents/epidemiology-microbiology-clinical-
manifestations-and-diagnosis-of-enteric-typhoid-and-paratyphoid-fever

19.

20. 55 years old man with known case of hypertension and chronic kidney disease
comes for follow up. He is currently on T. Perindopril 8 mg OD. He is asymptomatic.
His blood pressure is 138/85 mmHg and pulse rate is 88 bpm. His investigations are
as below:

Renal function test

Urea 11
Creatinine 208
Glomerular ltration rate 31

Urine protein 0.8

What is the next management?

A. Add Amlodipine
B. Add Telmisartan
C. Continue Perindopril
D. Change to Telmisartan
E. Renal replacement therapy

Reference:
CPG Management Of Hypertension (2018)
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21. 70 years old man was diagnosed with Parkinson disease 5 years ago. Currently, he
is on T. Carbidopa-Levodopa. He complains of dizziness since 2 weeks ago. On
examination, his sitting blood pressure is 128/80 mmHg and pulse rate is 78 bpm.

What is next management?

A. Dix Hallpike test
B. Weber and Rinne test
C. Get-up and go test
D. Romberg test
E. Standing BP

Reference:
Consensus Guidelines For The Treatment Of Parkinson's Disease (2012)

22. 45 years old man presents with shortness of breath for 1 month aggravated by lying
down. On examination, his blood pressure is 100/60 mmHg, pulse rate is 120 bpm
and jugular venous pressure is 5 cm. There is crepitations on bilateral lungs and soft
S1 and S2 heart sound.

What is the diagnosis?

A. Dilated cardiomyopathy
B. Congestive cardiac failure
C. Pericarditis
D. Cardiac tamponade
E. Myocardial infarction

Reference:
CPG Management Of Heart Failure (2019)

23. 32 years old woman complains of amenorrhea and lethargy for 2 months. She
previously breastfed her baby then complains milk has dried up. She had history of
postpartum haemorrhage and transfused with 1 pint packed cell. On examination,
her vital signs are normal. No abnormalities noted during per abdomen examination.

What is the diagnostic investigation?

A. Serum FSH/LH
B. MRI pituitary
C. Thyroid function test
D. Ultrasound pelvic
E. Serum prolactin

Reference:
Not available
24. 68 years old man with known case of diabetes mellitus for 10 years. He presents
with fever, intermittent cough and loss of appetite for 3 weeks. On examination, his
vital signs are stable. His random blood sugar is 10 mmol/L and HbA1c is 10%.
There are crepitations at right upper lobe of lungs and his chest x-ray shows
consolidation at right upper zone. Sputum AFB x 3 are negative and sputum C&S
also negative.

What is the best assessment?

A. Bronchoalveolar lavage (BAL)
B. High-resolution computed tomography (HRCT)
C. Nucleic-acid ampli cation test (NAAT)
D. Interferon-gamma (IFN-γ) release assay (IGRA)
E. Mycobacterium tuberculosis culture

Reference:
CPG Management Of Tuberculosis (2012)

25. 65 years old man presents with redness of skin over sacrum prior to discharge from
hospital for stroke. He is bed bound, wearing diapers due to limited mobility and
tolerating semi-solid diet. On examination, he is cachexia. His blood pressure is
120/80 mmHg, pulse rate is 68 bpm and temperature is 37°C. On local examination
over the sacrum, noted skin over sacrum intact with non-blanchable redness.

What is the most appropriate management at this stage?

A. Soft, pressure-reducing mattress
B. Adequate nutrition
C. Frequent repositioning of patient
D. Keep skin dry and clean
E. Physiotherapy for mobility

Reference:
https://www.uptodate.com/contents/clinical-staging-and-management-of-pressure-
induced-skin-and-soft-tissue-injury

26. 40 years old man presents with jaundice for 1 week. It is associated with weakness
and lethargy for 1 month. He has history of severe binging for the past few weeks
and taking 16 units of vodka per week for the past 5 years. On examination, he is
alert but pale and jaundice. His blood pressure is 110/70 mmHg and pulse rate is
92 bpm. He has palmar erythema, mild nger clubbing, spider nevi on the chest area
and hepatomegaly with ascites. Other systemic examination are normal.

What is the most appropriate investigation?

A. Full blood count
B. Coagulation pro le
C. Liver AST/ALT ratio
D. Ultrasound hepatobiliary system
E. Viral hepatitis screening

Reference:
https://www.uptodate.com/contents/alcoholic-hepatitis-clinical-manifestations-and-
diagnosis
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27. 40 years old woman complains of unable to move upper and lower limbs for the
past 12 hours after eating large meal of rice. Previously, she had history of similar
episodes which resolved spontaneously. On examination, she is anxious and has
tremor. Her blood pressure is 140/90 mmHg. Her re ex, tone and sensation are
normal. Her power of upper and lower limb is 4/5.

What is the most likely diagnosis?

A. Gullain-Barre syndrome
B. Myasthenia gravis
C. Multiple sclerosis
D. Thyrotoxic periodic paralysis
E. Transient ischemic stroke

Reference:
https://www.uptodate.com/contents/thyrotoxic-periodic-paralysis

28. 55 years old man came to review his blood investigation after started on
T. Perindopril 2 weeks ago. He is also on T. Amlodipine and T. Atorvastatin.
Currently, he is asymptomatic. His blood pressure is 148/90 mmHg and pulse rate is
80 bpm. Other examination is unremarkable. His blood results are as below:

Baseline Current
Urea 6.0 6.5
Creatinine 110 150
Potassium 3.8 4.0
Sodium 141 140
Chloride 101 103
eGFR 64 45

Urine FEME Normal

What is the most appropriate assessment at this stage?

A. CT scan
B. Renal angiogram
C. Renal biopsy
D. Renal duplex Doppler
E. US kidney, ureter and bladder

Reference:
https://www.uptodate.com/contents/renal-e ects-of-ace-inhibitors-in-hypertension
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 29. 30 years old man presents with progressive limb weakness. It starts with pin needle
sensation over hand and foot. He had history of fever and acute gastroenteritis
1 week ago. On examination, deep tendon re ex is absent and power of limb is 4/5.

What is the most appropriate investigation?

A. Anti-acetylcholine receptor antibody (anti-AChR-Ab)
B. Lumbar puncture
C. Electrolytes
D. Nerve conduction study
E.

Reference:
https://www.uptodate.com/contents/guillain-barre-syndrome-in-adults-clinical-
features-and-diagnosis

30. 20 years old man presents with skin rashes. On examination, there are multiple
hypo-pigmented lesion with raised erythematous border and reduced pain
sensation.

What is the most appropriate management?

A. Oral dapsone and rifampicin
B.
C. Topical clobetasone
D. Topical uconazole
E.

Reference:
https://www.uptodate.com/contents/leprosy-treatment-and-prevention

31.

32. 48 years old farmer presents with productive cough for 3 months associated with
loss of weight 5 kg in 1 month. He smokes 2 packs cigarettes per day for the past
30 years. On examination, his blood pressure is 120/70 mmHg, pulse rate is 90 bpm,
temperature is 36.8 ℃ and oxygen saturation is 97% under room air. His lungs
auscultation ndings are normal. His chest x-ray shows well circumscribed mass at
left perihilar region.

What is the diagnostic investigation?

A. Bronchoscopy
B. CECT thorax
C. PET scan whole body
D. Aspergillus IgE antibody
E. Sputum AFB

Reference:
https://www.uptodate.com/contents/hypersensitivity-pneumonitis-extrinsic-allergic-
alveolitis-clinical-manifestations-and-diagnosis
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33. 35 years old woman presents with increasing facial hair and weight for the past 6
months. She also complains of di culty to stand up from squatting position. She is
previously well and not on any medications. On examination, she is not pale. Her
blood pressure is 150/80 mmHg and pulse rate is 72 bpm. There is striae present
over the abdomen. Other examinations are normal. Her investigation results are as
below:

Fasting blood glucose 7.2

Thyroid function test Normal
Total testosterone 92 (High)
Plasma ACTH 2 (Low)
Urinary free cortisol 958 (High)

What is the most appropriate investigation at this stage?

A. Corticotrophin releasing hormone
B. CT abdomen
C. High dose dexamethasone test
D. MRI brain
E. Serum LH/FSH ratio

Reference:
https://www.uptodate.com/contents/establishing-the-cause-of-cushings-syndrome

34. 25 years old man presents with shortness of breath and giddiness 30 minutes after
taking antibiotic, treated for sore throat. On examination, he is alert and conscious.
His blood pressure is 90/60 mmHg, pulse rate is 100 bpm and oxygen saturation is
94% under room air. There is stridor and generalized rhonchi on the lung
auscultation.

What is the most appropriate management?

A. IM adrenaline
B. IV chlorphenamine
C. IV hydrocortisone
D. Neb salbutamol
E. Oxygen supplement

Reference:
https://www.uptodate.com/contents/anaphylaxis-emergency-treatment
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35. 56 years old man with underlying diabetes mellitus presents with intermittent fever,
lethargy and anorexia for 2 weeks. It is associated with right sided abdominal pain.
He just came back from India 1 month ago. On examination, he is ill looking. His
blood pressure is 110/70 mmHg, pulse rate is 110 bpm and temperature is 41℃.
There is tenderness over right hypochondrium. His liver ultrasound shows multiple
hypo-echoic lesion with irregular border (the largest is 3 cm).

What is the most appropriate diagnostic investigation?

A. Blood culture and sensitivity
B. Cyst aspirate culture and sensitivity
C. Serology for Entamoeba histolytica
D. Stool culture and sensitivity
E. Stool ova and cyst

Reference:
https://www.uptodate.com/contents/pyogenic-liver-abscess

36. 40 years old woman was referred for further investigation of mediastinal
lymphadenopathy. She has history of intermittent fever, prolonged cough and
shortness of breath on exertion for 1 month. It is associated with reduced oral intake
but no loss of weight. On examination, she is alert and pink. Her blood pressure is
124/64 mmHg and pulse rate is 90 bpm. There is nodules tenderness over bilateral
shins. Other examinations are normal. Her investigation results are as below:

Full blood count Normal

Full blood picture Normal
Sputum AFB Normal
Erythrocyte sedimentation rate 120

What is the most appropriate diagnosis?

A. Atypical pneumonia
B. Lung cancer
C. Lymphoma
D. Sarcoidosis
E. Systemic lupus erythematous

Reference:
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-
pulmonary-sarcoidosis
37. 50 years old woman was referred for incidental nding of increase platelet.
Otherwise, she is well and asymptomatic. She is non-smoker and has no past
medical history. On examination, she is not pale or jaundice. Her blood pressure is
130/70 mmHg and pulse rate is 72 bpm. Her spleen is palpable 2 cm below left
costal margin. Other systemic examinations are unremarkable. Her investigation
results are as below:

Full blood count

White blood cell 10.2
Hemoglobin 11
Platelet 800
Mean corpuscular volume 72
Mean corpuscular hemoglobin 25

What is the most important management at this stage?

A. Arrange for bone marrow biopsy
B. Plasmapheresis
C. Peripheral blood lm
D. Start aspirin
E. Start hydroxyurea

Reference:
https://www.uptodate.com/contents/approach-to-the-patient-with-thrombocytosis

38. 52 years old woman with underlying systemic lupus erythematous comes for follow
up. She was started on T. Prednisolone since 5 months ago. She had trivial fall 1
week ago and sustained right Colles fracture. On examination, her blood pressure is
120/70 mmHg, pulse rate is 90 bpm and body mass index is 19.6 kg/m2. There is
right below elbow cast. Her neurological examination is unremarkable.

What is the most appropriate assessment?

A. Bone mineral density
B. Serum calcium
C. Serum parathyroid
D. Serum alkaline phosphatase
E. Skeletal survey

Reference:
https://www.uptodate.com/contents/clinical-features-and-evaluation-of-
glucocorticoid-induced-osteoporosis
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 39. 40 years old female with underlying ileofemoral deep vein thrombosis on T. Warfarin
5 mg OD complains of left leg swelling for 1 month. She has pain especially when
walking long distance and relieve by elevation and rest. On examination, there is left
leg swelling up to knee, no calf tenderness, pulse present and equal bilaterally. Her
latest INR is 2.6.

What is the most important management?

A. Contrast venogram
B. Change warfarin to dabigatran
C. Prescribe compression stocking
D. Angiogram of left lower limb
E. Ankle-brachial pressure index

Reference:
https://www.uptodate.com/contents/post-thrombotic-postphlebitic-syndrome

40. 65 years old man is brought to hospital after has loss of consciousness during
gardening. Prior to that, he denies chest pain, palpitation or profuse sweating. He
has 3 episodes of dizziness on exertion which is relieved with rest. On examination,
his blood pressure is 150/85 mmHg and pulse rate is 75 bpm. There is grade 3
ejection systolic murmur radiated to carotid area. His electrocardiogram shows
normal ndings and echocardiogram shows valvular heart disease.

What is the most appropriate management?

A. Arrange 24 hours Holter monitoring
B. Arrange for cardiac catheterisation
C. Arrange for valve replacement
D. Start ACE inhibitor
E. Start bisoprolol

Reference:
https://www.uptodate.com/contents/indications-for-valve-replacement-in-aortic-
stenosis-in-adults

41.

42. 56 years old farmer with underlying diabetes mellitus presents with multiple abscess
over right shin. On examination, his blood pressure is 150/90 mmHg, pulse rate is 84
bpm and temperature is 38℃. Physical examination is unremarkable.

What is the most appropriate management?

A. Augmention plus Azithromycin
B. Ceftriaxone
C. Ceftazidine
D. Cipro oxacin
E. Cloxacillin

Reference:
National Antimicrobial Guideline (2019), Page 245
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43. 29 years old man presents with fever and cough for 2 days. It is associated with sore
throat and shortness of breath. He works at the poultry farm and recently had many
chicken died for unknown reason. On examination, he is alert and pink. His blood
pressure is 120/70 mmHg, pulse rate is 80 bpm, temperature is 38℃, respiratory
rate is 24 bpm and oxygen saturation is 98%. Physical examination is unremarkable.
His full blood count is normal.

What is the most important management?

A. Notify health district o ce
B. Start Tami u
C. Take nasopharyngeal swab
D. Give empiric antibiotic
E.

Reference:
https://www.uptodate.com/contents/avian-in uenza-a-h7n9-treatment-and-
prevention

44. 39 years old man presents with trismus and irritation. He had motor vehicle accident
and sustained multiple wound 1 week ago but not seek treatment. On examination,
he is irritated. His blood pressure is 130/90 mmHg, pulse rate is 90 bpm,
temperature is 37℃ and oxygen saturation is 97%. Noted also he has drooling of
saliva. Neurological examination is normal.

What is the best management?

A. IV baclofen
B. IV adrenaline
C.
D. Tetanus immunoglobulin
E. Prophylactic intubation

Reference:
https://www.uptodate.com/contents/tetanus

45. 43 years old woman with underlying hypertension and impaired fasting glucose
presents with bilateral knee pain. On examination, her body mass index is 38 kg/m2.
She already tried diet control and exercise but failed.

What is next appropriate management?

A. Bariatric surgery
B. Orlistat
C. Metformin
D. Low calorie diet
E. Phentermine

Reference:
CPG Management Of Obesity (2003), Surgery For Weight Loss, Page 22
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46. 19 years old man presents with unprovoked headache, palpitation and sweating. On
examination, his blood pressure is 170/110 mmHg and pulse rate is 86 bpm. Other
examinations are unremarkable.

What is the most likely diagnosis?

A. Conn’s syndrome
B. Insulinoma
C. Graves' disease
D. Pheochromocytoma
E. Obstructive sleep apnea

Reference:
https://www.uptodate.com/contents/clinical-presentation-and-diagnosis-of-
pheochromocytoma

47. 58 years old man chronic smoker under chest clinic follow up currently on Symbicort
and Tiotropium. He presents with 3 days history of fever, cough and shortness of
breath. On examination, he is alert but lethargic looking. His blood pressure is
130/80 mmHg, pulse rate is 96 bpm and oxygen saturation is 88%. Noted he is
using accessory muscle for breathing. His investigation result is as below:

Arterial blood gas

pH 7.30
PaO2 45
PCO2 55
HCO3 33

What is the most appropriate management?

A. Nasal prong
B. Face mask
C. Venturi mask
D. BiPAP
E. Intubation

Reference:
https://www.uptodate.com/contents/the-evaluation-diagnosis-and-treatment-of-the-
adult-patient-with-acute-hypercapnic-respiratory-failure
 48. 48 years old woman presents with lethargy, intermittent fever and malaise for 2
months. She had history of bariatric surgery 6 years ago for weight management.
On examination, she is alert but pale. Her blood pressure is 132/72 mmHg and pulse
rate is 72 bpm. Noted she has reduced sensation in glove and sock distribution. Her
investigation results are as below:

Full blood count

White blood cell 2.1
Hemoglobin 6.8
Platelet 58
Mean corpuscular hemoglobin 102
Mean corpuscular hemoglobin 30

Random blood sugar 6.2

What is the investigation to aid diagnosis?

A. Thyroid function test
B. Peripheral blood lm
C. Serum ferritin
D. Vitamin B12
E.

Reference:
https://www.uptodate.com/contents/approach-to-the-adult-with-pancytopenia

49. 65 years old woman complains of unsteady gait. She had history of mastectomy for
stage 3 breast cancer. On examination, her vital signs are stable. There is hyper
re exia on her left lower limb.

What is the most appropriate assessment at this stage?

A. MRI brain
B. Mammogram
C. Serum electrolytes
D.
E.

Reference:
https://www.uptodate.com/contents/epidemiology-clinical-manifestations-and-
diagnosis-of-brain-metastases
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50. 68 years old man with underlying end stage renal failure started hemodialysis via
internal jugular catheter presents with fever. On examination his blood pressure is
120/70 mmHg, pulse rate is 80 bpm and temperature is 38℃. There is pansystolic
murmur at mitral area. Blood C&S was taken.

What is the best investigation to con rm the diagnosis?

A. Chest x-ray
B. C-reactive protein
C. Electrocardiogram
D. Echocardiogram
E.

Reference:
https://www.uptodate.com/contents/clinical-manifestations-and-evaluation-of-
adults-with-suspected-left-sided-native-valve-endocarditis
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