Umanand Prasad School of Medicine & Health Sciences

Department of Clinical Sciences

Year 2022
FINAL COURSE EXAMINATION PAPER

INTERNAL MEDICINE (IMED 301)

Important Instructions to Students:

1. Read the questions, instructions carefully and answer the questions.

2. You are allowed an extra 10 minutes reading time (during this time, you are not allowed to
write with pen) and 120 minutes (2 Hours) to complete this paper.
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3. This Final Course Examination Paper is worth 150 marks contributes 40% of the total
course assessments. Students must at least score 40% in this final exam to pass the course.
4. This paper contains 100 multiple choice questions,2 short notes and one long answer. All
questions are compulsory.
5. Write all your answers legibly. The marker has the right to award zero for answers that are not
legible.
6. This is a Open Book Examination. The University views plagiarism, cheating and dishonest
practice as serious offences and if found, offenders are penalized.

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1 Hypokalemia is the condition of low potassium levels in your blood. Hypokalemia ECG
changes are observed by
(a) ST segment elevation
(b) U wave (a position deflection after the T wave)
(c) Tall peaked T waves
(d) Widening of the QRS complex and increased amplitude
2. A normal ECG report must consist of the following information
(a) Rhythm, cardiac axis
(b) Conduction intervals
(c) Description of the ST segments, QRS complexes, T-waves
(d) All of these
3. For the normal heartbeat, depolarization stimulus originates in
(a) His-bundle areas
(b) Epicardium
(c) Sinoatrial (SA)node
(d) Atrioventricular (AV) node

4. The characteristics – slurring of the initial QRS deflection, shortened PR interval, and
prolonged QRS duration are of this condition
(a) Atrial tachycardia
(b) Left bundle branch block
(c) WPW (Wolff-Parkinson-White) syndrome
(d) Myocardial ischemia

5) P wave indicates
(a) Depolarization of right ventricle
(b) Depolarization of left ventricle
(c) Depolarization of both atria
(d) Atria to ventricular conduction time

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6)The drug of choice for Anaerobic bacterial infection is:

a)amoxicillin b)penicillin c)Metronidazole d)cloxacillin

7)The following are causes of Right Heart Failure Except:

a)Emphysema b)Pulmonary Hypertension

c)Right side Pneumothorax d)Chronic Left Heart Failure

8) When a CT scan of the lung is performed for a bronchiectasis, the lung fields show typical circular
lesions. These lesions are known as:

a)Circular lesion b)Silhouette sign

c)Kerley B lines d) Signet ring sign

9)All of these are in the group of Anti Fungal drugs EXCEPT:

a)Ketoconazole b)Amphotericin B c)Griseofulvin d)Esomeprazole

10) Atonic seizures are characterized by

a) prolonged unconsciousness.

b) quick muscular jerky movements.

c) vocalization at the onset of seizure activity.

d) sudden collapse, with the legs unable to support the body

11) The phase of the actual seizure activity is called the

A) aura.

B) prodrome.

C) ictal phase.

D) postictal phase.

12Atonic seizures are characterized by

A) prolonged unconsciousness.

B) quick muscular jerky movements.

C) vocalization at the onset of seizure activity.

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D) sudden collapse, with the legs unable to support the body.

13.Psychogenic pseudoseizures are

A) commonly associated with injuries.

B) often associated with psychologic trauma.

C) characterized by specific CNS abnormalities.

D) very different in appearance to epileptic seizures.

14. All of the following are forms of childhood epilepsy, EXCEPT:

A) Ketogenic

B) Febrile seizures

C) West syndrome

D) Lennox-Gastaut syndrome

15.Ethosuximide is useful for patients with which seizure type?

A) Atonic

B) Absence

C) Tonic-clonic

D) Complex partial

16) Each of the following result in left ventricular hypertrophy except:

A. aortic stenosis B. systemic hypertension

C. coarctation of the aorta D. mitral stenosis

17) Right heart failure causes each of the following except:

A. splenomegaly B. pulmonary edema

C. ankle edema D. distended neck veins

18) Cor pulmonale may be caused by all of the following except:

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A. interstitial fibrosis of the lung B. multiple emboli of the pulmonary vasculature

C. pulmonary emphysema D. aortic valvular disease

19) The unique feature of rheumatic myocarditis is the presence of

A. Aschoff nodules B. group c hemolytic streptococci

C. Foam cells in myocytes D. fibrinoid deposits

20 Acute rheumatic endocarditis follows infections with:

A. alpha-hemolytic streptococci (Streptococcus viridans)

B. Group A beta-hemolytic streptococci

C. coagulase +ve Staphylococcus aureus D. streptococcus pneumoniae

21) The most common valve effected secondary to rheumatic heart disease is :

A. mitral valve B. aortic valve

c. tricuspid valve D. pulmonary valve

22) Each of the following is a major manifestation (Jones criteria) of acute rheumatic fever except:

A. carditis B. erythema marginatum

C. glomerulonephritis D. migratory polyarthritis

E. chorea

23) Which one is bacterial infection in the cardiac lesions?

A. acute rheumatic heart disease B. recurrent rheumatic heart disease

C. both D. neither

24)The most common cause of subacute infective endocarditis is:

A. Candida albicans B. immune reaction to bacterial toxins

C. Staphylococcus aureus D. Streptococcus pneumoniae

E. Streptococcus viridians

25) Syphilitic heart disease most commonly involves:

A. myocardium B. mitral valve

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C. pulmonic valve D. tricuspid valve

E. aortic valve

26) The single most frequent complication of myocardial infarction is:

A. mural thrombosis B. embolism

C. rupture of myocardium D. aneurysm of left ventricle E. arrhythmia

27) Myocardial infarction may result in all of the following except:

A. mural thrombus formation B. congestive failure

C. hemopericardium D. cor pulmonale

28)The most common cause of left heart failure is:

A. emphysema B. pulmonary emboli

C. coronary arteriosclerosis D. hyperthyroidism

29)Complications of chronic rheumatic heart disease include which of the following:

A. constrictive pericarditis B. cardiac tamponade

C. aneurysm of the heart D. mitral stenosis

30) Heart failure is characterized by:

A. renal hypertrophy B. chronic passive congestion of liver and spleen

C. both D. neither

31) 55 year old man presented with severe central chest pain and sweating .ECG shows T-inversion in
lead II ,the Troponin test is negative.Most likely:

a)unstable angina is the diagnosis

2)he should be given streptokinase

c)IV heparin is indicated

d)high chance of developing MI in next few days

32)which one is the most important risk factor for Ischaemic Heart Disease:

a)obesity b)smoking c)high salt intake d)high glucose intake e)hyperlipidaemia

32)Atherosclerotic plaque develops in :

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a)lumen of the vessels b)tunica intima layer c )Tunica media layer d)below the basement membrane

33)Foam cells are one of the important pathological findings in:

a)pericarditis b)development of plaques c)Deep vein thrombosis d)VSD

34) Which of the following blood vessels does not contain valves?

(a) Systemic aorta

(b) Pulmonary aorta

(c) Veins

(d) Arteries

35)Virchows nodes are typically enlarged in cases of:

a)Abdominal malignancies b)lung cancer c)Tuberculosis d)Mumps

36)ABG(arterial blood gas ) are done to find the :

a)PH of blood b)Nitrogen saturation c)blood glucose d)D-dimer

37)Which of the following statement about bronchiectesis is false?

a)Most commonly affects the right lower lobe of the lungs

b)More common in women

c)Age of onset is mostly adulthood

d)Infection in children is a common cause in most developing countries

38)A 55 year old women presents with recurrent cough, blood streaked sputum, shortness of breath,
wheezing and pleuritic chest pain. She has a temperature of 38 degree celcius. On examination you
find clubbing of fingers. She informs you that she has had some weight loss in the past month. Chest
x-ray shows linear lucencies and parallel markings radiating from the hila. The most appropriate
diagnosis is?

a)Pulmonary tuberculosis b)Pneumonia

c)Cylindrical bronchiectesis d)Asthma

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39)A 50 year old male presents with a history of myocardial infarction which he suffered 2 years ago.
He is a chronic smoker. He is now presenting with fatigue, orthopnea and dyspnea on exertion. On
examination you can appreciate an S3 gallop, peripheral cyanosis and clubbing of the fingers. His JVP
is 6 cm above the sternal angle. He also complains of chronic cough and an x-ray shows pulmonary
edema. An ECG shows high voltage QRS complex and sinus tachycardia. This patient is most likely
suffering from?

a)Heart Failure b)Myocardial Infarction

c)Pneumonia d)Arrhythmia

40) The veins from the stomach, intestine, pancreas and spleen drain into

(a) superior portal vein

(b) hepatic portal vein

(c) inferior portal vein

(d) superior dorsal vein

41) Which of the following statements regarding DKA is false?

a. Altered mental status is the most common reason patients with HHS are brought to the hospital

b. In a comatose diabetic patient with an effective serum osmolality

c. Patients with HHS usually have an increased anion gap metabolic acidosis

d. Insulin therapy lowers the K + concentration and may cause severe hypokalemia

42) A 55 year old man presents with syncope, dizziness, shortness of breath, fatigue and a marked
decline in exercise capacity. His ECG shows normal P wave rate, slow ventricular rate and wide QRS
with an idio-ventricular rhythm and a complete dissociation between P waves and QRS complex.
What is the most likely diagnosis?

a)Third degree AV block b)Heart Failure

c)Mobitz type 2 d)Sinus bradycardia

43)A 45 year old male is brought in to the clinic with blurry vision and headache. He is sweating
profusely and is drifting in and out of consciousness. He is a very smoker and consumes alcohol on a
daily basis. His BP is taken by the duty nurse and reported to be 190/115 mmHg. This patient’s BP is
classified as?
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a)High normal b)Hypertension stage 1

c)Hypertension stage 2 d)Severe Hypertension

44) A 70 year old female presents to the Emergency department of Nadi Hospital. She has had
productive cough for 5 days. The sputum is deep yellow in colour. Her temperature on arrival was 39.8
deg Celsius, respiratory rate of 33 breaths per minute, SpO2 of 85%. She is not oriented to time, place
or person. Her blood results show high WBC count and elevated BUN (25 mg/dL). What is the next
most appropriate step in management of this patient?

a)Send home – low risk of dying

b)Consider hospital supervised treatment

c)Admit in hospital and treat as severe pneumonia – high risk of dying

d)Moderate risk so keep under observation for 24 hours and send home

45)Becks triad is seen in cardiac tamponade. What is Becks triad?

a)Jugular venous distention, muffled heart sounds and low blood pressure

b)Carotid distention, prominent S1 and normal blood pressure

c)Jugular venous collapse, prominent S2 and high blood pressure

d) Carotid collapse, prominent S2 and high blood pressure

46)The following liver enzymes are tested to acertain hepatocellular injury?

a)Alkanine phosphatase (ALP)

b)Alanine aminotransferase (ALT) and Aspartate aminotransferase (AST)

c)Conjugated Bilirubin and direct bilirubin

d)Albumin and protein

47)A 45 year old female with a childhood history of rheumatic disease presents to your clinic with
complaints of fatigue. On examination you see that the patient is slightly cyanosed and has clubbing
of fingers. On chest auscultation you hear a soft S1 and a 3rd heart sound at the apex. There is a
pansystolic murmur at the apex that is well appreciated in the left lateral decubitus position. The
murmur radiates to the left axilla and between the scapula at the back. The most likely diagnosis is?

a)Mitral regurgitation b)Mitral stenosis

c)Mitral prolapse d) Aortic regurgitation.

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48)Which of the following is NOT a respiratory causes for clubbing?

a)Lung cancer except SCLC b)COPD

c)Fibrotic lung disease d)Pneumonia

49)Asthma is defined as a chronic obstructive disorder of the airways, in which many cells and cellular
elements play a vital role. It is associated with hyper-responsiveness of airways that leads to recurrent
episodes of wheezing, breathlessness, chest tightness and coughing. On a chest xray plain film which
features are suggestive of asthma?

a)Bronchial thickening, hyperinflation, decrease angle of rib curve and focal atelectesis

b)Focal consolidation, parenchyma thickening, chest widening and cardio-thoracic index increase

c)Patchy opacities, lymph nodes at hilum, prominent vasculature, reduced lung capacity

d)Patchy opacities , peripheral lesions, pleural effusion and deviated trachea

50)ALL of them are true about Torsade de pointes EXCEPT:

a)major side effect of the drug Erythromycin

b)prolong PR interval c)literally means “Twisting of ECG”

d)Prolong QT syndrome

51)Pulsus Paradoxus is:

a)Increase in Diastolic Blood Pressure during expiration more than 5mmHg

b) Increase in Systolic Blood Pressure during inspiration more than 10mmHg

c) Increase in heart rate during expiration

d) Derease in heart rate during Inspiration

52) A restrictive (constrictive) type of cardiomyopathy characteristically occurs in association with:

A. alcoholism

B. amyloidosis

C. asymmetric septal hypertrophy

D. Beriberi (thiamine deficiency

53 ) The first counter – regulatory mechanism to be elicited against hpoglycaemia in normal persons
is:

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a. Epinephrine release

b. Glucagon release

c. Inhibition of insulin release

d. Growth hormone release

e. Cortisol release

54)Atrial fibrillation is :

a)sudden pause in heart beat

b)abnormal rhythm of the heart

c)medical term for heart attack

d)medical term for stroke

55) What is the name of the semi-hard substance composed of cholesterol, fat, calcium, and fibrin
that contributes to atherosclerosis?

a)Collagen b)Plaque

c)Lipoprotein d)Thrombosis

56) The atherosclerosis and arteriosclerosis are classified as disease of

a)arteries b)bones

c)liver d)kidneys

57) When thrombus becomes free-floating and dislodges then the thrombus becomes

a)embolus b)bolus

c)acidosis d)hypnosis

58) The disease in which cholesterol and fatty materials accumulates in the wall of arteries is

a)diabetic syndrome b)tuberculosis

c)arteriosclerosis d)atherosclerosis
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59) A V/Q mismatch induces one very serious condition.

What does the V stand for?

A. Veins B. Ventilation C. Varicose vein D.perfusion

60)What does the Q stand for?

A. Polycystic B. Pressure C.Perfusion D.Volume

61). What does it mean when we say Q?

A. It considers the blood that reaches the alveoli

B. It considers the blood that reaches the heart

C. It considers the blood that can't coagulate

d.it considers the ATMOSPHERIC PRESSURE

62) What does a V/Q mismatch produce?

A. respiratory failure B. respiratory alkalosis

C. Pneumothorax D)respiratory acidosis

63) Normal ventilation/perfusion ratio for the whole lung is

a) 0.4 b) 0.8

c) 1.6 d) 3.2

64) A lung condition that causes mediastinal shift and compression of the functioning lung is called
a)Pneumonia b)pneumothorax c)emphysema d)Bronchial Asthma

65)All of them are risk factors for primary spontaneous pneumothorax EXCEPT

a)Smoking b)Tall thin body in an otherwise healthy person

c)obesity d)Marfan syndrome

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66) All of them are Diseases associated with secondary spontaneous pneumothorax EXCEPT

a)COPD b)Asthma

c)HIV with pneumocystis pneumonia d)Esophageal varices

67) Which of the following is not a predisposing factor for Hypoglycaemia in insulin – treated
patients?

a. Renal failure

b. Older age

c. Hypoglycemia unawareness

d. Alcohol withdrawl

e. Adrenal insufficiency

68) Which of the following statements is false?

a. Hyperosmolar hyperglycemic state (HHS) and diabetic ketoacidosis (DKA) can overlap in some
patients

b. Abdominal pain is a common feature of HHS

c. Severe dehydration is common in HHS

d. Despite total body K + deficit, serum K + is usually normal or elevated at presentation in HHS

69) Which one is correct concerning fluid administration in DKA?

a. It is better to provide more fluids during the initial 12 hours of fluid administration

b. It is better to rehydrate evenly during the subsequent 48 hours of the management of DKA

c. Fluid administration should start simultaneously with insulin administration

d. Fluid administration is the main cause of cerebral edema

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70)Chronic obstructive pulmonary disease, or COPD, includes the diagnosis of which lung diseases?

a)chronic bronchitis b)emphysema c)both d)neither

71)All of them are correct regarding COPD:

a)shortness of breath

b)chronic cough producing phlegm

c)fatigue and exhaustness

d)all of them are correct

72)COPD makes it harder to breathe because:

aThe walls of the airways in the lungs become thick and inflamed

bThe airways are clogged with excess mucus.

c)The lungs lose their elasticity.

d)all of them are correct

73)When the disease reaches an advanced stage, what treatment might be prescribed?

a)Pulmonary rehabilitation b)surgery

c)chemotherapy d)pulmonary rehab and surgery

74)What is the outermost membrane surrounding the brain called?

a)pia mater b)arachnoid mater

c)dura mater d)alma mater

75) What term refers to an inflammation of brain tissues?

a)encephalitis b)meningitis

c)sinusitis d)meningoencephalitis

76) Which of the following is the most common cause of neonatal meningitis?

a)Haemophilus influenzae b)Streptococcus agalactiae

c)Neisseria meningitides d)Streptococcus pneumoniae

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77) Which of these diseases results in meningitis caused by an encapsulated yeast?

a)cryptococcosis b)histoplasmosis

c)candidiasis d)coccidiomycosis

78) How do humans usually contract neurocysticercosis?

a)the bite of an infected arthropod b)exposure to contaminated cat feces

c)swimming in contaminated water d)ingestion of undercooked pork

79) Which one is true concerning potassium in diabetic ketoacidosis?

a. Potassium replacement may not be necessary if its level is normal at initial management of DKA

b. Potassium deficiency may cause tall, peaked symmetrical T waves in the electrocardiogram

c. Potassium replacement is necessary during the whole time period of IV fluid administration

d. Potassium deficiency is the cause of hyponatremia observed at presentation of DKA

80) Choose the correct statement about diabetic ketoacidosis in Type 2 diabetes in children and
adolescents?

a. Type 2 diabetes in childhood and adolescence never presents with diabetic ketoacidosis

b. Diabetic ketoacidosis is rarely the first manifestation of Type 2 diabetes in children and
adolescentsquestions

c. Diabetic ketoacidosis of Type 2 diabetes never necessitates insulin administration

d. Diabetic ketoacidosis is more frequent in Caucasian Type 2 diabetes patients than in Hispanic
populations

81)All of them are true regarding Pneumonia I EXCEPT:

a)is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli

b) Symptoms typically include some combination of productive or dry cough, chest pain, fever,
and difficulty breathing

c)Vaccines to prevent certain types of pneumonia (such as those caused by Streptococcus

pneumoniae bacteria are available

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d) respiratory syncytial virus are the most common cause of community-acquired pneumonia

82) What is the key complication in the first 24 hours of an MI?

a)Fibrinous pericarditis b)coronary artery aneurysm

c)Mitral insufficiency d) Arrhythmia

83) What does the ECG show in prinzmetal angina?

a)ST segment depression b)Absent P waves

c)Prolonged PR interval d)ST segment elevation

84) What is the most frequent etiologic agent of acute infective endocarditis in IV drug abusers?

a)Streptococcus viridans b) staphylococcus epidermidis

c)Streptococcus bovis d)Staphylococcus aureus

85) What type of cardiomyopathy is most commonly associated with the sudden death of young
athletes?

a) Restrictive cardiomyopathy b) Dilated cardiomyopathy

c) Hypertrophic cardiomyopathy

86) What should be the first initial step in the management of diabetic ketoacidosis?

a. To provide fluids intravenously

b. To provide insulin

c. To provide bicarbonate

d. To initiate insulin and fluids simultaneously

87) What is the most commonly involved coronary artery in myocardial infarction (MI)?

a) Right coronary artery (RCA)

b) Left anterior descending artery (LAD)

c) Left circumflex artery (LCA)

d) Posterior descending artery (PDA)

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88) What are the classic signs of a cardiac tamponade?

a) Tachycardia, dyspnoea, fever

b)Hypotension, muffled heart sounds, increased jugular venous distension (JVP)

c) Bradycardia, weakness in arms, diaphoresis

d) Hypertension, palpitations, chest pain

89) What is the most common cause of sudden cardiac death (SCD)?

a) Cocaine abuse b) Mitral valve prolapse

c) Cardiomyopathy d)Ventricular arrhythmia

90) What is the most common cause of mitral stenosis?

a)Rheumatic valvular heart disease b) Congestive heart failure

c) Infective endocarditis d)cardiomyopathy

91) What are the characteristics of stable angina?

a) Chest pain that occurs at rest

b) Bradycardia c) Severe and crushing chest pain (>20 mins)

d) Chest pain that occurs with exertion and/or emotional stress

92) In ECG, What does the P wave represent?

a)Depolarization of the atria

b)Depolarization of the ventricles

c)Represents the repolarization of the ventricles

d)Depolarization of the atria and ventricles

93) Which of the following indicates Ventricular Muscle Depolarization?

a)P wave b)QRS complex

c)T wave d)PR interval

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94) What does the T wave represent in an ECG?

a)Atrial diastole

b)Atrial systole

c)Ventricular diastole

d)Joint diastole

95) A shortened PR interval, slurring (called a delta wave) of the initial QRS deflection, and prolonged
QRS duration are characteristics of

Wolff-Parkinson-White (WPW) syndrome

B. Atrial tachycardia

C. Left bundle branch block

D. Myocardial ischemia

96) The classic ECG changes in Myocardial Infarction (MI) are

a)T-wave inversion

b)ST-segment elevation

c)Development of an abnormal Q wave

d)All of the above

97) In which of these conditions can widened QRS and Tall-tented T waves be observed

a)Hyponatremia

b)Hyperkalemia

c)Hyperglycemia

d)Hyperphosphatemia

98) A particular ECG change observed in Hypokalemia is

a)ST segment elevation

b)U wave, which is a position deflection after the T wave

c)Tall peaked T waves

d)Widening of the QRS complex and increased amplitude

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99) ECG identified by the PR interval tends to become longer with every succeeding ECG complex until
there is a P wave not followed by a QRS is observed in

a)Third-Degree Atrioventricular Block

b)Second-Degree Atrioventricular Block, Type II

c)Second-Degree Atrioventricular Block, Type I

d)First-Degree Atrioventricular Block, Type II

100)Which of the following is strongly associated with QT prolongation?

a)meropenem b)ceftriaxone

c)ciprofloxacin d)azithromycin

SECTION B SHORT NOTES (2 X 15=30 MARKS)

101)Management of Acute attack of Asthma

102)Management of acute attack of seizures

SECTION C LONG ANSWER (20 MARKS)

103: Discuss the etiology, clinical features of management of Diabetic

Ketoacidosis?

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