1. LIBYAN MEDICAL BOARD FIRST PART REVISION
DR.MAGDI AWAD SASI
2016

4. LIBYAN MEDICAL BOARD
3RD PART
28.3.2016

6. 55yr old female presented with 2month history of Lt. hypochondrial discomfort, early
satiety associated with Wt. loss, night sweat, fever and vomting. no bleeding
tendency. past history remarkable for type 2 DM on OHA .examination: under weight,
pallor, no LN .
Abdomen: spleen hugely enlarged. other system normal. lab data:
WBC =199X10*3/ul PBF= leucocytosis ,basophilia ,immature
RBC =5.5X10*3/ul myeloid precursor (blast 2%)
Hb = 10gm% LDH= 600( high), UA= 10mg
Hct = 33% RFT,LFT normal
MCV=90fl
MCH= 31pg
MCHC= 32gm
PLT=1125x10*3/ul
ESR= 123
The first line of management is:
a. BM aspiration for diagnostic abroval
b. BM for t(8;21)
c. Prognostic approach for Jak-2 mutation by BM aspiration
d. Hydroxyurea ,fluids NS ,allopurinol
e. Search for BCR / ABL

7. Is a reciprocal translocation between the long arms of chromosome 9
and 22.
A large portion of 22q is translocated to 9q ;smaller piece of 9q is
moved to 22q .
The portion of 9q that is traslocated contains abl ,a porto-oncogen
that is the cellular homologue of the ableson murine leukemia
virus.
The abl gene is recived at a specific site on 22q ,the break point
cluster ( bcr ).
The fusion gene bcr—abl produces novel protein that differs from the
normal transcript of abl gene in that it passes tyrosine gene
activity ((characteristic activity for transforming genes)).
At time of diagnosis, Philadelphia chromosome positive clone
dominates.

8. 60yr old male presented with swelling Rt. Side of neck progressive over
3month duration associated with Wt. loss, generalized fatigue, poor
appetite. he noted history recurrent infection during last 3month. past
history remarkable for hypertension on nifidipine. Examination: pallor
,generalized lymphadenopathy ,spleen 3fbcm,liver 2fbcm. lab data :
WBC =90X10*3/ul
Lymphocytes 80% LDH= 678 IU/L( high ),UA= 6mg
Hb = 8gm% RFT, LFT normal .comb’s test –ve
Hct =30%
MCV=90fl
MCH= 33pg
MCHC= 32gm
PLT=234x10*3/ul
ESR= 125 PBF= absolute lymphocytsis ,smear (smudge cell )
The following are poor prognostic factors except:
a. Age > 70year
b. Male sex
c. High LDH
d. CD 38
e. Lymphocyte doubling >2 years

9. Autoimmune warm hemolytic anemia is caused by except:
A. SLE
B. Lymphoma
C. Mycoplasma pneumonia
D. CLL
E. Penicillin

10. 60 year female with CLL presented with fever and confusion . She
started on ceftrixone and vancomycin but 2 days later she is
deteriorating with no improvement.
LP ---2600 WBC ,605 PMN ,gram negative rods
You would recommend:
a. Add ampicillin
b. Add clindamycin
c. Add levofloxacin
d. Change to impenam
e. Ceftriaxone.

11. 1. A 62 year old male with a history of mitral valve prolapse, rhematoid
arhtritis, and colon cancer presents to the emergency room with
increased dyspnea on exertion, lower extremity swelling, and fevers
slowly worsning over the past month.
His temperature is 38.0 C, blood pressure 95/65, heart rate 80, respirations
20, and oxygen saturation 92% on room air. Physical examination
reveals normal breath sounds, a II/VI holosystolic murmur at the apex,
and 1+ bilateral lower extremity pitting edema. Laboratory studies
show a WBC count of 20 thousand and an ESR of 100. Echocardiogram
reveals an 8 mm mobile vegitation on the anterior leaflet of the mitral
valve.
Which of the following is the most likely pathogen?
A) Staphalococcus aureus
B) Pseudomonas auriginosa
C) Candida albicans
D) Streptococcus bovis

12. Answer: D - Streptococcus bovis
This case is a classic presentation of subacute endocarditis. Some pathogens
are more agressive than others and can actually present with septic shock
such as Staph aureus and Pseudomonas auriginosa.
Candidal endocarditis is rare in immunocompetent persons and the vegitations
seen are quite large (usually > 1 cm).
Streptococcus viridins group is the most common cause of endocarditis and
presents in a subacute fashion (similar to Enterococcus endocarditis).
Specifically, Streptococcus bovis (a type of Strep viridins) is strongly
correlated with active colon cancer, thus if blood cultures were indeed
positive for this organism, a colonoscopy should be performed.
Remember that the anterior leaflet of the mitral valve is the most common site
for endocarditis.
The holosystolic murmur at the apex likely represents mitral regurgitation due
to valve destruction by the organism.

13. Empirical therapy
Often antibiotics need to be started before the culture results are available.
Be guided by the clinical setting
Choice of antibioticPresentation
Benzylpenicillin + gentamicinGradual onset (weeks)
Flucloxacillin + gentamicinAcute onset (days) or history of skin
trauma
Vancomycin (or teicoplanin) +
gentamicin + rifampicin
Recent valve prosthesis (possible
meticillin-resistant S. aureus
(MRSA),
diphtheroid, Klebsiella ,
corynebacterium,
or nosocomial staphylococci)
VancomycinIV drug user

14. Treatment includes at least 4-6 weeks of IV antibiotics
which include:
Penicillins or a third generation cephalosporin-----Strep viridins
The combination ampicillin plus gentamicin ------ Enterococcus
Nafcillin or oxacillin for penicillin sensative -------Staph aureus
Vancomycin plus gentamicin for ----methacillin resistant Staph
aureus ((MRSA))

15. 2. 43 year old women had acute onset of shortness of breath
and lightheadness .She had a history of rheumatic fever and
subsequent MVR. On physical examination ,she was
conscious , alert ,pale and tachycardic .HR was 94bpm and
regular with low volume pulse . BP 90/40 mmHg .There were
bilateral rales with raised JVP and gaint a wave . PO2 92%
The urgent intervention to be done:
A. Transthoracic ECHO
B. Blood culture 3 times 6 hours apart and start antibiotics
C. Diuretic therapy with high O2 concentration
D. TEE with urgent cardiothoracic consultation
E. Dopamine pump to be started

18. Class I - There is evidence and/or general agreement that surgery
is indicated in patients with NVE with one of the following:
•Valve stenosis or regurgitation leading to heart failure.
Aortic or mitral regurgitation with hemodynamic evidence of elevated left
ventricular end-diastolic or atrial pressures such as premature closure of the
mitral valve with aortic regurgitation, rapid decelerating mitral regurgitation
signal by continuous wave Doppler (v-wave cutoff sign), or moderate to
severe pulmonary hypertension.
•IE due to fungal or other highly resistant organisms.
Complications such as heart block, annular or aortic abscess, or destructive
penetrating lesions such as fistula from the sinus of Valsalva to the right or
left atrium or right ventricle, mitral leaflet perforation with IE of the aortic
valve, or infection in annulus fibrosis.

20. 3. 38 year female with H/O fever , sever cough ,colored sputum large
in the morning for last 3 days.
chronic morning cough with recurrent chest infection and wheezy
chest for last 20 years after H/O complicated childhood infection
O/E:
Pt sick , dyspnic , use accessory muscles , cyanotic , clubbing ,
BP110/90 ,PR 120/min , TEP 39c
Chest – rhonchi all over , coarse crepts BL basal , RT BB
The ideal antibiotic to be started is:
a. Amoxcillin + Erythromycin
b. Co-amoxiclav + IV clarthromycin
c. Cefuroxime + IV clarthromycin
d. Ceftizidime
e. Ceftrixone

22. Ceftriaxone ---- PCN resistant pneumococci
1. DM
2. Age>65year
3. Immunocompromised
4. Asplenia
5. Renal disease
6. Malignancy
7. Cardiopulmonary disease
8. Alcoholism

23. Ceftizidime :
a. Bronchiectasis
b. Corticosteroids > 10mg /d
c. Malnutrition
d. Hospitilization
e. Broad spectrum antibiotics

25. CAP
TherapyRisk for resistant pneumococci
Macrolide or DoxycyclineAbsent
B lactam + Macrolide OR
Floroquinolone ((not
ciprofloxacine))
Present

26. IN patient
Option 1 ----------------- Fluroquinolone
Optiion 2 -----------------B lactam ((ceftriaxone /cefotaxime )) + macrolide
Older group: Ciprofloxacin, norfloxacin, and ofloxacin
Newer group: Gemifloxacin, levofloxacin, and moxifloxacin

27. ICU
THEARPYCLINICAL SITUATION
B lactam + Azithromycin /FQMost patients
Antipseudomonal B lactam +
FQ
Pseudomonas risk factors
Add Vancomycin or linezolidMRSA
Floroquinolone + AztreonanPCN-- allergic

28. 4. A 50 year old man presents with an acutely swollen
knee and fever. His CRP is 200mg/l. Aspiration yields
2mls of turbid fluid that has negatively birefringent
needle shaped crystals. Renal function shows a
creatinine of 3mg/dl, INR is normal.
What is the best course of action?
A. NSAIDS.
B. Start allopurinol and colchicines.
C. Opiate analgesia.
D. Intra-articular steroid injection.
E. Oral steroids.

29. 5. A 23-year-old male with asthma presented to the emergency department with acute
breathlessness and wheeze following a coryzal illness. He has been treated with high
flow oxygen, regular nebulised bronchodilators and 200 milligrams of intravenous
hydrocortisone.
On examination he was pale, clammy and unable to record a peak flow reading. His pulse
is 140 per min, temperature 37.3°C, and had oxygen saturations of 86% on 15L of
oxygen. Auscultation of his chest reveals poor breath sounds bilaterally with a faint
polyphonic wheeze.
His arterial blood gas on 15L of oxygen reveals:
pH 7.30 (7.36-7.44)
PO2 8.0 kPa (11.3-12.6)
pCO2 7.8 kPa (4.7-6.0)
HCO3 16 mmol/L (20-28)
What is the most appropriate management for this patient?
A. Non-invasive ventilation
B. Intubation and invasive positive pressure ventilation
C. Intravenous magnesium
D. Intravenous aminophylline
E. Intravenous antibiotics

30. Sine respiratory alkalosis is the usual derangement in
asthma ,PaCO2 that is increasing toward normal indicate
impending respiratory failure & the need for frequent
monitoring of ABG.
Metabolic acidosis is another ominous sign of
impending respiratory failure resulting from lactic
acidosis due to fatiguing respiratory muscles.
PEFR <16% ((< 60L/min)) OR FEV1 < 0.6L should be
considered severe asthma.

33. Bronchodilator response ---2 –4 puffs short albuterol
200ml or 12% increase in FEV1 ----asthma , ?? COPD
Bronchodilator challenge reversal to normal spirometry –R/O
COPD
Methacholine FEV1 >20%
C/I CVA ,MI ,HTN ,AAA

35. SEVER
PERSISTENT
MODEARTE
PERSISTENT
MILD
PERSISTENT
INTERMITENT
Throughout the
day
daily>2 days/wk but
notDaily
≤2 days/wkSYMPTOMS
Often 7/wk>1×/wk but not
nightly
3-4×/mo≤2×/moNIGHT TIME
AWAKING
Several times per
day
Daily>2 days/wk but
not daily and not
>1× on any day
≤2 days/wkShort-acting
β2agonist use for
symptom control
(not prevention
of EIB)
Extremely
limited
Some limitationMinor limitationNoneInterference
with normal
activity
FEV1<60%
predicted
FEV1>60% but
<80% predicted
FEV1>80%
predicted
Normal FEV1
between
exacerbations
FEV1>80% predicted
Lung function
FEV1/FVC
reduced >5%
FEV1/FVC
reduced 5%
FEV1/FVC
normal
FEV1/FVC
normal

37. 6. 50 year male C/O chronic cough for years which has got
worse recently . Cough is associated with green color with
occasional phlegm with occasional blood.
No H/O smoking . H/O asthma 20 years not controlled with
maximal treatment .
HRCT –bronchiectatic changes in distal /proximal air ways with
no lobar predilection
What is the most appropriate diagnostic test?
A. bronchoscopy
B. PFT with Methacholine challenge test.
C. Positron-emission tomography.
D. Skin test for Aspergillus fumigates.
E. Sweat chloride test.

38. 7. An 85-year-old man is admitted from home because he has become
increasingly confused and is not coping. He is known to have metastatic
carcinoma of the prostate and takes Zoladex 3 monthly. You note that he
has bruising over the left side of his forehead.
Which of the following investigations will not help you diagnose and
treat his confusion?
A : CT scan of the head
B : Midstream urine sample
C : Calcium
D : Urea and electrolytes
E : Prostatic specific antigen (PSA).

39. 8. A 35-year-old man presents with fatigue and jaundice of 5 days
duration.
Investigations show AST 2300 U/l, ALT 2540 U/l, GGT 650 U/l, total
bilirubin 8.1 mg/dl.
Which of the following is least likely to be performed?
A. Ultrasound examination.
B. Viral serology.
C. Liver auto-antibodies.
D. Liver biopsy.
E. Prothrombin time & INR