EXAMINATION No:__________________

UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH, COMMUNITY DEVELOPMENT,
GENDER ELDERLY AND CHILDREN
THE MEDICAL COUNCIL OF TANGANYIKA

PRE-INTERNSHIP EXAMINATION FOR DOCTOR OF MEDICINE DEGREE

DATE: OCTOBER 13, 2021 TIME: 9:00 – 12:00 Hours

CODE; 2021MD008
INSTRUCTIONS
1. This examination consists of 53 printed pages with 150 multiple choice
questions
2. Answer all questions
3. Use the answer sheets provided to shade the most correct answer in the
corresponding letters
4. Use a pencil or black ink pen
5. Cellular phones, calculators and other unauthorized materials are not
allowed in the examination room
6. Write your MCT examination number in each page of your both question
and answer sheets

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 EXAMINATION No:__________________

1. Mr. Massawe is a 38-year-old man with alcoholic liver disease presented to the
District hospital with haemetemesis and he had mild epigastric pain. On
examination, he had spider naevi over his chest wall and was clinically jaundiced.
There was no hepatomegaly and no ascites on examination. His heart rate was
110 bpm, blood pressure 90/50 mmHg, respiratory rate 20bpm and oxygen
saturation 96% on room air. Investigations: Hb 11 g/dL, WBC 10.5 × 10 9/L, Plts 35
× 109/L, INR 1.4, APTT 44s and Fibrinogen 1.9 g/L. What is the most appropriate
way to manage his coagulopathy?
A. Cryoprecipitate
B. Fresh frozen plasma
C. Platelet transfusion
D. Prothrombin complex concentrate
E. Vitamin K

2. A 65-year-old male presents to the neurology outpatient department with a history

of recurrent bouts of unsteadiness and vomiting over the last 10 years, with partial
resolution. He has also had episodes of visual problems, which he describes as
the sudden loss of vision in the right eye, with an almost complete recovery of
vision over the course of the next few weeks. He has a history of type 2 diabetes
and is hypertensive and is generally non-compliant with his treatment. He is also
a smoker with a 50-pack years history. His medication includes glimepiride 2mg
daily and metformin 500mg TDS. He also takes telmisartan 40mg daily. On
examination, he has nystagmus in the right eye with the fast component towards
the right. His gait is ataxic and he has evidence of spasticity in both lower limbs
with exaggerated reflexes and bilateral ankle clonus. Fundoscopic examination
revealed a pale optic disc. MRI brain shows diffuse lesions in multiple sites. The
report queried demyelinating plaques vs multiple infarcts. Which of the following
would be the most appropriate next investigation?

A. MRI spinal cord

B. CSF examination for oligoclonal bands
C. MR angiography of the verterbrobasilar system
D. Titres of anti-Hu antibodies
E. Visual evoked potentials

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 EXAMINATION No:__________________

3. You are called by a nurse to review a patient in the stroke ward. He is a 75years
old who suffered from a right sided intracerebral hemorrhage the previous day.
The nursing staff were concerned due to a decreased conscious level. On
examination you note a right sided dilated pupil and a left sided hemiparesis. His
Glasgow coma score is 13 (M5, V4, E4). What is the most likely diagnosis?

A. Tonsillar herniation
B. Transtentorial herniation
C. Subfalcine herniation
D. Central herniation
E. Uncal herniation

4. Mr. Mkali, a 47-year-old man is referred from ED with increasing shortness of

breath. He is a known HIV patient managed by the local general practitioner. He
is not on any antiretroviral treatment. He presents with a two-week history of
worsening shortness of breath and he is now breathless on minimal exercise. He
has a non-productive cough and has felt lethargic for the last week. On
examination he is afebrile, his blood pressure is 120/89 mmHg and he is slightly
tachycardic at 110bpm. His respiratory rate is 18bpm at rest with saturations of 98
percent in room air. When he mobilizes to the toilet, he becomes very tachypnoeic
and his saturations drop to 90%. His blood tests are as follows: Hb 11.0 g/dl,
Platelets 201 x 109/l, WBC 9.6 x 109/l, Neutrophils 4.5 x 109/l, Na+ 138 mmol/l, K+
4.1 mmol/l, Urea 7.8 mmol/l, Creatinine 20 µmol/l, CRP 70 mg/l, Bilirubin 5 µmol/l,
ALP 89 u/l, ALT 43 u/l, Albumin 34 g/l. An ABG is done which shows pH 7.35, pO2
7.7, pCO2 4.6, HCO3- 21, Lactate 2.2. His chest x-ray shows fine bilateral reticular
nodular shadowing. What is the most appropriate treatment to start in this patient?
A. Tazocin
B. Co-trimoxazole
C. Aciclovir
D. Co-trimoxazole and corticosteroids
E. Highly active anti-retroviral treatment

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 EXAMINATION No:__________________

5. A 64-year-old woman is evaluated in the emergency department 4 hours after the

abrupt onset of sharp, tearing chest and back pain. Medical history is significant
for hyperlipidemia. Her only medication is atorvastatin. On physical examination,
temperature is 36.8 °C, blood pressure is 173/99 mmHg and pulse rate is
90beats/min. Blood pressure measurements in both arms are equal. The
remainder of the physical examination is unremarkable. CT angiography shows a
descending thoracic aortic aneurysm with a maximal diameter of 6.8 cm and aortic
dissection originating just distal to the left subclavian artery and extending to just
below the diaphragm; there is no involvement of the renal arteries. Which of the
following is the most appropriate initial management?

A. Immediate endovascular stenting

B. Immediate open surgical repair
C. Medical therapy
D. Repeat CT angiography in 12 hours
E. Perform CBG

6. Juma is 23years old from Kigoma,he presents with the acute onset of fever, skin
lesions on his extremities that are papular and erythematous with a hemorrhagic
and necrotic center, joint pain and an acute tenosynovitis of the dorsum of his left
foot. He has no past medical history and takes no medications. He does not smoke,
drink alcohol or use illicit drugs. On physical examination, the patient has a
temperature of 39.1°C. Passive flexion and extension of the left great toe causes
severe pain over the dorsum of the midfoot and ankle. Which of the following is the
most likely diagnosis?

A. De Quervain tenosynovitis
B. Reiter syndrome
C. Acute gouty attack
D. Disseminated gonococcal infection
E. Still disease

7. Your aunt is 34 years old, she was recently told by another physician that her blood
test was positive for Helicobacter pylori. She completed a course of medication but
is concerned about this finding. This patient is at risk for which of the following?

A. Squamous cell carcinoma of the esophagus

B. Adenocarcinoma of the esophagus
C. Non-Hodgkin lymphoma of the small intestine
D. Gastroesophageal reflux disease
E. Mucosa-associated tissue lymphomas (MALT)

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 EXAMINATION No:__________________

8. A 47years old nurse presents to your office complaining of a poorly healing ulcer
of her left second digit. The ulcer started a week ago and is painless. The patient
has tried using over the counter antibacterial and hydrocortisone creams without
improvement. She denies trauma to the hand. The patient has a temperature of
38.4°C and left-sided epitrochlear and axillary adenopathy. She has a 4cm ulcer
on the dorsal side of the left second digit covered by a black eschar and
surrounded by an extensive amount of non-pitting edema. Which of the following
is the most likely diagnosis?

A. Smallpox infection
B. Cutaneous anthrax
C. Cat-scratch disease
D. Leprosy infection
E. Brown recluse spider bite

9. Ms. Jane is a 67years old woman, presents to your clinic with complaints of painful
hips and shoulders as well as headache. She relates that the muscle pain is felt
on both arms and hips. She feels that her shoulders are stiff and the hips cannot
move when she wakes up. It almost takes 40 minutes of painful physical activity
for the stiffness to relent. Her appetite is decreased and she has lost 5 kg. “To
make me even more miserable, the terrible headaches has just been started”, she
mentions. The headache is felt on the right side and is throbbing with no response
to analgesics. On physical examination, she is noted to have painful restricted
movements of shoulder and hip joints bilaterally. Her right temple is tender to
touch. She is not febrile and the rest of the exam is inconclusive. Which one of the
following would be the most appropriate next step in management?

A. Check serum creatine kinase (CK) level.

B. Check rheumatoid factor.
C. Check ESR.
D. Perform a muscle biopsy.
E. Star the patient on prednisolone.

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 EXAMINATION No:__________________

10. A 43years old gentleman who is admitted and found to have a STEMI has chest
pain on the ward. He is currently recovering from his percutaneous coronary
intervention the day before and has felt well until now. The pain is over the left side
of the chest and severe if he breathes. He has no cough or fevers and his
observations are within normal limits. On examination, he has normal heart sounds
and a clear chest. He is mildly tender over the chest wall. His femoral puncture
sites are clean with no haematoma. He is in sinus rhythm on the cardiac monitor
and has soft non-oedematous calves. No JVP is seen. Lab results shows; Na+ 156
mmol/l, K+ 3.4 mmol/l, Urea 5.6 mmol/l, Creatinine 78 µmol/l, CRP 45 mg/l, Hb
13.4 g/dl, Platelets 398 x 109/l, WBC 13.0 x 109/l. ECG shows a sinus rhythm, T
wave inversion in V1-V3, PR 180bpm and flat in most leads. The chest x-ray has
clear lung fields, heart is at the upper limit of normal for size. What is the likely
diagnosis?
A. Hospital acquired pneumonia
B. Pericarditis
C. Pulmonary embolism
D. Coronary artery dissection
E. Pleurisy

11. Mr. Kanani a 73-year-old gentleman presents to you with progressive shortness of
breath. He can now walk 10 yards before stopping to catch his breath and he is
unable to lie flat. He sleeps upright in his armchair and has stopped sleeping in his
bed over the last three months. He has known hypertension and has had two
previous myocardial infarctions. On examination, his apex beat is displaced to the
7th intercostal space in the left mid-axillary line and there are crepitations in the
two lung bases. His JVP is raised at 5cm and there is bilateral leg edema.
Laboratory investigations; Troponin <20 ng/ml, B-natriuretic peptide 14,000 ng/L
(normal range 0-200), Chest X-ray cardiomegaly and increased alveolar
shadowing in the perihilar areas ECG QRS 110ms, large volume complexes in
chest leads. Which intervention is proven to reduce mortality in this case?

A. Cardiac Resynchronisation Therapy (CRT)

B. Digoxin
C. Furosemide
D. Ramipril
E. Coronary artery bypass graft

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 EXAMINATION No:__________________

12. You are an intern doctor at regional hospital and you review a 67years old man
who has type 2 diabetes. His glycaemic control is reasonable with metformin
therapy; the latest HbA1c is 54 mmol/mol (7.1%). A few weeks ago he was noted
to have a clinic blood pressure reading of 152/90 mmHg. A 24 hour blood pressure
monitor was requested. The report shows his average blood pressure was 142/88
mmHg. What is the most appropriate course of action?

A. Do nothing for now, monitor his blood pressure regularly

B. Start an ACE inhibitor
C. Start a calcium channel blocker
D. Repeat the 24 hour blood pressure monitor in 4-8 weeks’ time
E. Request an ultrasound of his kidneys

13. A 56-year-old male patient with no history of ischaemic heart disease had a non-
ST elevation myocardial infarction 20 days ago and was started on aspirin,
atorvastatin, bisoprolol and enalapril as an inpatient. He has been discharged to
your care in the cardiology outpatients department. He presents for review 1 month
later saying he remains breathless on minimal exertion (walking 50 metres) with
no chest pains. There is no evidence of pulmonary oedema on examination. A
recent echocardiogram shows a left ventricular ejection fraction of 40%. His beta
natriuretic peptide level is 436 pg/mL (normal <100 pg/mL). What would be most
appropriate to add to his oral therapy?
A. Furosemide
B. Spironolactone
C. Hydralazine and isosorbide dinitrate
D. Irbesartan
E. Ivabradine

14. A 38years old man presents to your gastroenterology clinic. He is a businessman,

working for an iron and steel trading company and makes regular trips to Morocco
to visit mining executives. He has been newly diagnosed with HIV and he is not on
any medication. For the previous four months, he has been troubled by diarrhoea,
up to 8 motions a day, with abdominal bloating and cramping. There is no blood
visible in the stool. He has previously been treated for tuberculosis as a child. A
stool sample is sent to the lab, and Modified Ziehl-Neelson stain reveals multiple
red staining round objects measuring 5 microns in diameter. What will be the most
appropriate treatment?
A. Anti-retroviral therapy
B. Co-trimoxazole
C. Rifampicin, isoniazid, ethambutol, pyrazinamide
D. Metronidazole
E. Ciprofloxacin

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 EXAMINATION No:__________________

15. A 23-year-old intravenous drug user presents to you with bilateral groin abscesses.
After drainage of the abscesses, he is started on intravenous flucloxacillin and
gentamicin. Twelve hours later he complained of diplopia which deteriorated, and
also developed dysphagia and muscle weakness and needed ventilatory support.
His past medical history is significant of myasthenia gravis. What is the diagnosis?

A. Aminoglycoside-induced neuromuscular blockade

B. Guillain-Barre syndrome
C. Metastatic brain abscess
D. Tetanus
E. Wound botulism

16. Mr. Mkude is a 65 years old man, referred to your Respiratory clinic by his General
Practitioner. The patient gives a three month history of a productive cough and
steady weight loss of 10 kg. His sputum had initially been yellow, but over the past
week he has noticed streaks of blood. He also complains of sweats at night and
sometimes has had to change his bedclothes. He has a longstanding history of
bronchial asthma that has required admission to hospital on several occasions. On
two occasions, he has been admitted in respiratory distress and has required
intubation and ventilation. His current therapy includes salbutamol and
beclomethasone inhalers and prednisolone 5mg once daily which he has taken for
several years. He also has a home nebulizer which he uses as required. His chest
x-ray in clinic shows right apical consolidation. The last chest radiograph, taken six
months previously on admission to hospital, had been normal. A sputum sample
proves to be positive for acid alcohol fast bacilli. A presumptive diagnosis of
pulmonary tuberculosis is made and he is started on anti-tuberculous therapy. Five
days later, he presents to Casualty with breathlessness and wheeze. On
examination he is afebrile. Widespread expiratory wheezes are heard throughout
his chest. His Peak Expiratory Flow Rate (PEFR) is measured at 110 L/min. His
chest x-ray does not show any significant change from the last film taken in Chest
Clinic. Which of the following options would be the most appropriate step in his
management?
A. Continue anti-tuberculous therapy and steroids at current dose
B. Continue anti-tuberculous therapy and reduce steroid dose
C. Continue anti-tuberculous therapy and increase steroid dose
D. Stop anti-tuberculous therapy and continue steroids at current dose
E. Stop anti-tuberculous therapy and steroids and start broad-spectrum
antibiotics

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 EXAMINATION No:__________________

17. A 35-year-old woman presents at the OPD complaining of chronic crampy

abdominal pain and intermittent constipation and diarrhea, but no weight loss or
gastrointestinal bleeding. Her abdominal pain is usually relieved with defection.
Colonoscopy and upper endoscopy with biopsies are normal, and stool cultures
are negative. Which of the following is the most likely diagnosis?
A. Infectious colitis
B. Irritable bowel syndrome
C. Crohn’s disease
D. Ulcerative colitis
E. Typhoid

18. A 60 years old man was diagnosed last year with adenocarcinoma of the lung, and
a 4cm mass lesion was treated with a right lower lobectomy. He now has an
abdominal CT scan that reveals scattered hepatic mass lesions and hilar
lymphadenopathy. For several weeks, he has had increasing malaise. A urinalysis
reveals marked proteinuria, and a 24 hour urine protein collection is 2.7 g/24hr.
His serum urea is 30 mmol/L (2.5-7.5) with creatinine of 450 μmol/L (60-110). A
renal biopsy is performed, and there is focal deposition of IgG and C3 with a
granular pattern. He is most likely to have which of the following conditions?

A. Goodpasture’s syndrome
B. Membranous glomerulonephritis
C. Minimal change glomerulonephritis
D. Nodular glomerulosclerosis
E. Rapidly progressive glomerulonephritis

19. You have been called to attend a 25years lady with known systemic lupus
erythematosus presenting with the nephrotic syndrome. You perform a renal
biopsy and this confirms diffuse proliferative glomeronephritis (WHO Class IV).
Which of the following treatment regimens would you advise?
A. Azathioprine alone
B. Prednisolone alone
C. Azathioprine and prednisolone
D. Prednisolone and intravenous cyclophosphamide
E. Prednisolone and methotrexate

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 EXAMINATION No:__________________

20. A 48years old man is referred to your clinic by his primary care provider after recent
laboratory studies showed glomerular filtration rate, calculated using the MDRD
Study equation of 55 mL/min/1.73 m2. Medical history includes diagnosis of type 2
diabetes mellitus 10 years ago and diagnosis of hypertension five years ago.
Current medications include carvedilol 12.5mg twice daily, lisinopril 20mg daily,
and glipizide 5mg daily. Recent laboratory studies of serum show hemoglobin A1c
of 8.0% and potassium level of 4.5 mEq/L. BMI is 24.2 kg/m 2. Pulse rate is 64bpm
and blood pressure is 124/64 mmHg. Physical examination shows no
abnormalities. To prevent further decrease in this patient's glomerular filtration
rate, which of the following changes to his drug regimen is most appropriate?
A. Increase the dosage of carvedilol to 25 mg twice daily
B. Increase the dosage of glipizide to 10 mg twice daily
C. Increase the dosage of lisinopril to 40 mg daily
D. Replace glipizide with metformin 500 mg twice daily
E. Replace lisinopril with losartan 50 mg daily

21. Ms. Grace is a 65year old woman with stage 4 chronic kidney disease secondary
to hypertension comes to OPD because she has had dysuria and increased urinary
frequency during the past two days. She has not had fever or hematuria.
Temperature is 37.3°C, PR is 90bpm and BP is 142/85 mmHg. On physical
examination, no flank tenderness is noted. Urinalysis shows cloudy urine that is
positive for leukocyte esterase, nitrites and protein. Results of urine culture are
pending. Which of the following medications is the most appropriate therapy for
this patient's condition?
A. Intramuscular administration of ceftriaxone
B. Intravenous administration of gentamicin
C. Intravenous administration of vancomycin
D. Oral administration of ciprofloxacin
E. Oral administration of nitrofurantoin

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 EXAMINATION No:__________________

22. You are called by a nurse to review a 66years old man presenting with increasing
lethargy and confusion. Past medical history includes depression, Barrett's
oesophagus, and benign prostatic hyperplasia. Current medications are sertraline
100mg, lansoprazole 30mg BD, and tamsulosin 400mg. Blood tests are as follows:
Hb 10.4 g/dl, Na+ 118 mmol/l, Platelets 168 x 109/l, K+ 4.1 mmol/l, WBC 8.7 x
109/l, Urea 7.9mmol/l, Neuts 2.5 x 109/l Creatinine 173 µmol/l, Lymphs 3.0 x 10 9/l,
Eosin 0.6 x 109/l, Corrected calcium 3.01mmol/l and Total protein 95g/l Albumin
30g/l. Urinary sodium 7mmol/l, Urinary osmolality 100mOsm/kg and Plasma
osmolality of 280mOsm/kg. What is the most likely cause of this patient's
hyponatraemia?

A. Syndrome of inappropriate ADH secretion due to underlying

malignancy
B. Multiple myeloma
C. Psychogenic polydipsia
D. Adrenal insufficiency
E. Drug-induced syndrome of inappropriate ADH secretion

23. A 39 years old female presents to you in the ward after admission with end-stage
renal failure secondary to IgA nephropathy. She was discharged 3 days earlier
following an admission due to collapse in the context of hyperkalaemia (Potassium
7.8 mmol/l). She has been transferred to the medical assessment unit having
developed rigors on dialysis earlier today. Bloods taken at the end of dialysis
reveal: White cell count 15.2 x 109/l, Sodium 134 mmol/l, Potassium 2.1 mmol/l,
Urea 10.6 mmol/l, Creatinine 400 µmol/l and C-reactive protein 119 mg/dL. What
is the immediate priority in her management?
A. Replace potassium (K+)
B. Replace magnesium (Mg2+)
C. Intravenous antibiotics
D. Intravenous calcium gluconate
E. Insulin/dextrose infusion

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 EXAMINATION No:__________________

24. Mr. Marunde is a 72years old man, he is brought to you from a nursing home. He
is normally bedbound and suffers from diabetes, peripheral vascular disease and
ischemic heart disease. He has become increasingly drowsy over the past two
days. He has not been on travel though has been ill with a cough the previous days
and complained of a runny nose. He responds to voice but is difficult to rouse.
There is no neck stiffness and the tone is normal in all 4 limbs. Power is difficult to
assess but there appears to be no focal weakness. He has responsive pupils and
no ophthalmoplegia. He has a systolic murmur heard and his chest has
crepitations in the left base. His observations show heart rate 96bpmn, blood
pressure 110/65 mmHg, temperature 38.4ºC, saturations 96% in air and
respiratory rate 14bpm. During examination, he develops a brief seizure lasting 30
seconds which settles without any interventions. Labs show; Na+ 139 mmol/l, K+
5.3 mmol/l, Urea 8.9 mmol/l, Creatinine 120 µmol/l, CRP 90 mg/l, Hb 13.4 g/dl,
Platelets 398 x 109/l and WBC 13.2 x 109/l. Chest x-ray raised left hemidiaphragm
seen in previous scans, CT head no acute infarction or haemorrhage seen. Which
management option should be prioritized as the most urgent?
A. Lumbar puncture
B. Acyclovir
C. Dexamethasone
D. Amoxicillin + clarithromycin
E. Paracetamol

25. Mr. Hamis is a middle-aged man, presents to the emergency department while you
are on call with mild epigastric pain and a single episode of coffee-ground vomit.
He had no past medical history and was not on any medication. On examination
his heart rate was 70 beats per minute and regular. His blood pressure was 132/80
mmHg, respiratory rate 12bpm and oxygen saturation 99% on air. Physical
examination was normal. Investigations were as follows: haemoglobin 14. 5 g/dL,
platelet count 120 × 109/L. What further information is required to calculate his
Blatchford score?
A. Age
B. Creatinine
C. Platelets
D. Prothrombin time
E. Urea

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 EXAMINATION No:__________________

26. You are the first on call today and you are called by the nurse to review a 75years
old woman who presents to casuality with two episodes of coffee-ground vomiting
and epigastric pain. She had a past medical history of ischemic heart disease and
had previously had two myocardial infarctions. She had symptomatic angina about
once a month. She was taking regular aspirin 75mg, ramipril 5mg, bisoprolol 5mg,
simvastatin 40mg and nicorandil 20mg bd. On examination she had mild epigastric
tenderness on palpation. Her heart rate was 68 beats per minute, blood pressure
120/82 mmHg, respiratory rate 20bpm, and oxygen saturation 96% on air. Upper
gastrointestinal endoscopy was performed, which showed a duodenal ulcer.
Haemostasis was achieved at endoscopy. She was started on a proton pump
inhibitor. What is the best management of her anti-platelet therapy?
A. Continue aspirin
B. Discontinue aspirin
C. Discontinue aspirin for one week then restart
D. Discontinue aspirin until repeat endoscopy in six weeks
E. Switch to clopidogrel

27. A 28years old woman has noticed a change in her appearance; most notably her
clothes do not fit her properly and are especially tight around the waist. Her face
appears flushed and more rounded than usual, despite exercising regularly and
eating healthily her weight has steadily increased over the last 3 weeks. On visiting
your clinic, you notice her blood pressure has increased since her last visit and
she has bruises on her arm. She is especially worried about a brain tumor. The
most appropriate investigation would be;

A. Low-dose dexamethasone test

B. High-dose dexamethasone test
C. Urinary catecholamines
D. Computed tomography (CT) scan
E. Urinary free cortisol measurement

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 EXAMINATION No:__________________

28. A 34years old patient presents to you at the endocrinology clinic. He has had
difficulties with erections and sexual desire, as well as low energy. He was referred
by the GP after a morning serum testosterone was low. His problems started six
months ago, following increasing symptoms of acid reflux. He also has DM-1. His
current medications include Levemir, Novorapid, omeprazole and
metoclopramide. Capillary monitoring of sugar levels has been within normal
range, but prolactin has found to be elevated. What is the most appropriate action?

A. Start testosterone replacement

B. Stop metoclopramide
C. Prescribe testosterone replacement
D. MRI of pituitary
E. Stop omeprazole

29. A 23-year-old woman presents to your clinic complaining of months of weight gain,
fatigue, amenorrhea, and worsening acne. She cannot precisely identify when her
symptoms began, but she reports that without a change in her diet she has noted
a 12.3-kg weight gain over the past 6 months. She has been amenorrheic for
several months. On examination she is noted to have truncal obesity with bilateral
purplish striae across both flanks. Cushing’s syndrome is suspected. Which of the
following tests should be used to make the diagnosis?
A. 24-hour urine free cortisol
B. Basal adrenocorticotropic hormone (ACTH)
C. Corticotropin-releasing hormone (CRH) level at 8 a.m.
D. Inferior petrosal venous sampling
E. Overnight 1-mg dexamethasone suppression test

30. A 63years old woman walks into your consultation room with a 5year history of
psoriasis involving her elbows that has been controlled with topical glucocorticoids
and a vitamin D analogue. However, in the past 9–12 months she has developed
worsening and new lesions involving her knees, gluteal regions, and scalp. She is
increasingly uncomfortable and has noted swelling of her digits with pain and
stiffness. She is up to date on all cancer screening and has no sign of systemic
infection. Her physical examination is only notable for the psoriatic plaques that
are red and scaling, and swollen, tender DIPs on both hands. All of the following
therapies are indicated for worsening widespread systemic psoriatic disease
EXCEPT:
A. Alefacept
B. Cyclosporine
C. Infliximab
D. Methotrexate
E. Prednisone

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 EXAMINATION No:__________________

31. A 33years old woman, who is otherwise well, presents to the emergency
department with symptoms of recurrent episodes of hemoptysis. She has no fever,
weight loss, cough, or sputum production. She is not experiencing any dyspnea or
chest discomfort and is not taking any medications. She works in an office setting,
reports no travel history, and her family history is negative for lung disorders or
bleeding diathesis. Her vital signs, oxygen saturation, and physical examination
are entirely normal. The CXR, biochemistry, CBC, and coagulation profile are also
normal. Which of the following is the most appropriate initial diagnostic test?

A. Echocardiogram
B. gallium scan
C. CT scan of chest
D. bronchoscopy
E. pulmonary function tests

32. Ms. Ashura, a 55years old woman with a past medical history of hypertension
presents to the emergency department because her tongue and lips feel swollen.
During the history, she tells you she recently started a new blood pressure
medication. Her only other medication is a baby aspirin. Her vitals at triage are BP
130/70 mmHg, HR 85 beats/minute, RR 16 breaths/minute, temperature 36.7°C,
and oxygen saturation 99% on room air. On physical examination, you detect mild
lip and tongue swelling. Over the next hour, you notice that not only are her tongue
and lips getting more swollen, but that her face is also starting to swell. Which is
the most likely causative agent?
A. Metoprolol
B. Furosemide
C. Aspirin
D. Lisinopril
E. Diltiazem

33. Makala who is a 41years old restrained driver has been involved in a high-speed
motor vehicle collision is brought to the emergency department. The patient is
breathing without difficulty and has bilateral and equal breath sounds. He has
strong peripheral pulses. His HR is 121 beats/minute. His Glasgow Coma Scale
(GCS) is 14. The secondary survey reveals bruising of the chest wall. You are
concerned about a possible cardiac injury. Which area of the heart is most
commonly involved in cardiac contusion?

A. Right atrium
B. Right ventricle
C. Left atrium
D. Left ventricle
E. Septum

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 EXAMINATION No:__________________

34. A 20years old boy arrives at the casuality with multiple stab wounds to his chest.
His BP is 85/50 mmHg and HR is 123 beats/minute. Two large bore intravenous
lines are established and IV fluids are running wide open. On examination, the
patient is mumbling incomprehensibly, has good air entry on lung examination and
has jugular venous distension. As you are listening to his heart, the nurse calls out
that the patient has lost his pulse and that she cannot get a BP reading. Which of
the following is the most appropriate next step in management?
A. Atropine IV push
B. Epinephrine IV push
C. Placement of bilateral chest tubes
D. Emergency thoracotomy
E. Perform pericardiocentesis

35. A 19years old bodaboda is brought into resuscitation room by his father after a
head on cycling accident. The patient was not wearing a helmet. Upon
presentation, his BP is 125/75 mmHg, HR is 105 beats/minute, RR is 19
breaths/minute, and oxygen saturation is 100 percent on 10L of oxygen via face
mask. His eyes are closed but he opens them to verbal command. He also moves
his arms and legs on command. When you ask him questions, he is disoriented
but able to converse. What is the patient’s GCS score?
A. 11
B. 12
C. 13
D. 14
E. 15

36. You are on duty in the emergency department when you are notified that an
explosion and mass causality event has occurred. The first patient, an
approximately 30years old man, arrives poorly responsive and confused. He is
sweating profusely and vomiting, with an episode of diarrhea. Vital signs include a
blood pressure of 170/90 mm Hg, respiratory rate of 22 breaths/minute, heart rate
of 55 beats/minute, temperature 37.0°C, and pulse oximetry 93% on room air. He
requires frequent suctioning of his airway. His pupils are pinpoint and he has
prominent rales on lung exam. After you clear and control the patient’s airway,
what is the most appropriate initial pharmacologic therapy?

A. Atropine
B. Flumazenil
C. Methylene blue
D. Naloxone
E. Sodium bicarbonate

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 EXAMINATION No:__________________

37. Ms. Maria, a 60years old woman with a history of diabetes is brought to the
emergency department by Samaritans who state that the patient was found on a
bus in a lethargic and diaphoretic condition. Her point of care glucose level at the
EMD was 1.9 mmol/L. at EMD, you quickly administered dextrose through an IV
line. The patient became alert and responsive, stating that she just took her normal
medication. Her blood sugar went up to 6.1mmol/L and she remained this way
throughout the time at EMD. However, in the ward after being admitted you notice
that the patient is again diaphoretic and is mumbling her speech. Her glucose level
is now 2.6 mmol/L. You administer dextrose and she improves. Which of the
following diabetes medications commonly causes hypoglycemia for which the
patient is likely to require hospital admission?

A. Regular insulin
B. Metformin
C. Glyburide
D. Sitagliptin
E. Acarbose

38. You receive a 34years old man with a history of severe asthma at the emergency
department with sudden onset difficulty in breathing. Vital signs include RR 36
breaths/minute, temperature 37°C and oxygen saturation of 85 percent on room
air. Despite aggressive treatment, he requires emergency endotracheal intubation.
He is given etomidate and succinylcholine for rapid sequence induction. Shortly
after intubation, he develops muscle rigidity and a temperature of 40.0°C. Which
of the following is the most appropriate next step in treatment?
A. Administer bromocriptine
B. Administer dantrolene
C. Administer IV antibiotics and order a chest X-ray
D. Administer IV fluids
E. Administer physostigmine

39. A 7years old girl with known sickle cell disease and a previous history of
admissions for acute painful crises presents to you with a 1day history of fever and
cough. She is tachypnoic on presentation with a temperature of 38.8°C.
Auscultation of the chest reveals rales on the right. A chest radiograph confirms
the diagnosis of pneumonia. After initial treatment with antibiotics and IV fluids,
patients with this condition are most at risk of developing which complication?
A. Acute chest syndrome
B. Sepsis
C. Empyema
D. Stroke
E. Congestive heart failure

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 EXAMINATION No:__________________

40. A 9years old boy with a known history of sickle cell anemia is brought to the
emergency department after sudden onset of left sided hemiplegia. The mother
states that her son had rhinorrhea and nasal congestion for the past 2 days, but
has otherwise been in a good state of health. What is the best diagnostic modality
to evaluate for possible cerebrovascular accident?
A. Cerebral angiography
B. LP
C. Magnetic resonance imaging and angiogram (MRI/MRA) of the
head and neck
D. Non-contrast computerized tomography (CT) scan of the head
E. Positron emission tomography (PET) scan

41. You receive a 74years old woman with a history of diabetes brought to the
emergency department with altered mental status. Her home health aide states
that the patient ran out of her medications 4 days ago. Her BP is 130/85 mm Hg,
HR is 110 beats/minute, RR is 18 breaths/minute, and temperature is 37.6°C. On
examination, she cannot follow commands but responds to stimuli. Laboratory
results reveal white blood cell count of 14,000/L, hematocrit 49%, platelets 325/L,
sodium 128 mEq/L, potassium 3.0 mEq/L, chloride 95 mEq/L, bicarbonate 22
mEq/L, blood urea nitrogen 40 mg/dL, creatinine 1.8 mg/dL, and glucose 55.6
mmol/L. Urinalysis shows 3+ glucose, 1+ protein, and no blood or ketones. After
addressing the ABCs, which of the following is the most appropriate next step in
management?
A. Administer a 2 to 3 L bolus of NS, followed by IV insulin
B. Administer a 2 to 3 L bolus of NS, followed by IV insulin and IV
phenytoin
C. Administer 10 units of IV insulin, followed by 2 L of NS
D. Order a computed tomographic (CT) scan of the brain
E. Arrange for emergent hemodialysis

42. A 30 years old woman is brought to the emergency department by her neighbors
after swallowing 34 tablets of paracetamol. On arrival; HR is 120bpm, BP
110/80mmHg and RR 20bpm. The most important initial management step is?
A. administration of activated charcoal
B. administration of N Acetyl cysteine
C. transfer to the liver transplant unit
D. referral to psychiatry for review
E. Checking for paracetamol level

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 EXAMINATION No:__________________

43. You are on the day team call at emergency department and a 23 years old lady
presents with history of lower abdominal pain, abnormal vaginal discharge,
dyspareunia, fever nausea and vomiting for 5days. The most likely diagnosis is?
A. Acute appendicitis
B. Ruptured ovarian cyst
C. Ovarian torsion
D. Pelvic inflammatory disease
E. Acute pyelonephritis

44. A 20years old man presents to the emergency department after being stung by a
bee. His skin is red and covered with welts. He has obvious swelling of his lips and
tongue, but no wheezes. After treatment with appropriate medications, he
complains of throat swelling and his voice is hoarse. He has stridorous inspirations
but a normal respiratory rate and oxygen saturation. What is the most appropriate
management of this patient airway?
A. Continued observation as long as oxygen saturation remains normal
B. Call anesthesia and prepare for RSI.
C. Begin high-dose nebulized albuterol and continue to observe.
D. Prepare for cricothyroidotomy.
E. Sedation

45. Your brother is 48years of age, he comes at the emergency department presenting
with chest pain. In the initial evaluation of this patient, which of the following is the
most important diagnostic test?
A. Chest x-ray
B. ECG
C. Serum cardiac markers
D. Computed tomography
E. Cholesterol levels

46. A 17years old adolescent boy who is a type I diabetic is brought in by his parents
with concern about diabetic ketoacidosis. He has had several prior episodes of
DKA. Which of the following is diagnostic of DKA?
A. Polyuria, polydipsia, fatigue
B. Hypotension, dehydration, fruity breath odor
C. Hyperglycemia, ketosis, metabolic acidosis
D. Serum blood sugar of 600 mg/dL in the face of high concentrations
of insulin
E. Elevated HCO3 and elevated glucose

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 EXAMINATION No:__________________

47. You are attending a 32yearsmold woman at ED who is noted to have persistent
hypotension from suspected toxic shock syndrome despite 6 L of normal saline
given intravenously. Which of the following is the best next step?
A. Use colloid (albumin) for the next bolus.
B. Initiate norepinephrine infusion.
C. Administer corticosteroid therapy.
D. Transfuse with fresh-frozen plasma.
E. Activated protein C.

48. A 20years old man involved in a motor vehicle accident is brought into the
resuscitation room having lost much blood at the accident scene. His initial blood
pressure is 80/40 mmHg and heart rate 130 beats per minute. He is given 3 L of
normal saline intravenously and is still hypotensive. Which of these statements
most accurately describes the pathophysiology of his condition?
A. Insufficient cardiac preload
B. Insufficient myocardial contractility
C. Excessive systemic vascular resistance
D. Excessive IL-6 and leukotrienes
E. Volume overload

49. A 73years old man had a cardiac arrest while being attended at ED. The rhythm
was pulseless electrical activity. Cardiopulmonary resuscitation was started at a
rate of 30 chest compressions to 2 ventilations. What is the correct rate of chest
compressions?
A. 80–100 per minute
B. 90–110 per minute
C. 100–120 per minute
D. 110–130 per minute
E. 120–140 per minute

50. A 35years old woman presents to the ED complaining of feeling lightheadedness.

She noticed some vaginal bleeding earlier in the day. Her blood pressure is 85/53
mm Hg, heart rate is 130 beats per minute and respiratory rate is 18 breaths per
minute. Which of the following is the most appropriate next step in management?
A. Obtain a urine pregnancy test.
B. Obtain a serum quantitative beta human chorionic gonadotropin (β-hCG).
C. Obtain immediate IV access and begin fluid resuscitation.
D. Obtain stat OB/GYN consult.
E. trans-vaginal ultrasound

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 EXAMINATION No:__________________

51. A 76years old woman was admitted to the ward with a one-week history of
diarrhoea. She was opening her bowels four times per day. She had recently
started a new medication. On examination, her temperature was 36.4°C, pulse
was 74 beats per minute, and blood pressure was 134/78 mmHg. She had a
resting tremor in the right upper limb. Her abdomen was soft, with mild generalized
tenderness. Which of the following drugs is most likely to have caused her
diarrhoea?
A. Bisoprolol
B. Co-careldopa
C. Omeprazole
D. Paracetamol
E. Simvastatin

52. A patient at 17 weeks gestation is diagnosed as having an intrauterine fetal

demise. She returns to your office 5 weeks later and has not had a miscarriage,
although she has had some occasional spotting. This patient is at increased risk
for which of the following?
A. Septic abortion
B. Recurrent abortion
C. Consumptive coagulopathy with hypofibrinogenemia
D. Future infertility
E. Ectopic pregnancies

53. You are an intern on call in gynecological ward and you attend a 26years old
married woman whose LMP was 2 ½ months ago developed bleeding, uterine
cramps, and passed some tissue per vagina. Two hours later she began to bleed
heavily. What is the most likely diagnosis is?
A. Twin pregnancy
B. Threatened abortion
C. Inevitable abortion
D. Premature labor
E. Incomplete abortion

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 EXAMINATION No:__________________

54. A 17years old G1P0 woman presents to labor and delivery complaining of
contractions at 38 weeks’ gestation. Her BP at the beginning of pregnancy was
90/60 mm Hg. She has gained 21kg throughout pregnancy (4.5kg in the past 4
weeks). Her BP on presentation was 145/80 mm Hg. A urine dip stick is +1 protein.
On examination, her cervix is 3 cm dilated, 90% effaced, 1 station. What is the next
step in her management?
A. MgSO4
B. Betamethasone
C. Send laboratory tests
D. Artificial rupture of the membranes
E. Send home until in active labor

55. Mwanahawa is 26years old woman, G1P0 presents for a prenatal visit at 34 weeks
GA. She complains of some mild nausea and vomiting over the past 3 days. She
has no headache and no visual changes. Her BP is 142/83 mmHg. On
examination, she has +1 lower extremity pitting edema, and +3 reflexes bilaterally
with four beats of clonus. A urinalysis dip has +1 protein. The laboratory test results
come back with elevated LFTs, low platelets, a normal hematocrit, and an elevated
LDH. What is her diagnosis?
A. Preeclampsia
B. Eclampsia
C. Chronic hypertension
D. HELLP syndrome
E. Gestational Hypertension

56. A 25 year old patient at 32 weeks of amenorrhea was brought to maternity ward.
These are the clinical findings on the physical examination. Pale, dehydrated, PR:
120bpm; BP 90/60 mmHg; delay in the capillary refilling time; bleeding by mouth.
Abdominal exam: Fundal height 36 cm, tenderness, and hard uterus, no Fetal
heart heard. Vaginally: scanty blood coming through the canal, reddish area
around the external cervical Os was noticed. Which among the following is the
most likely diagnosis?
A. Placental abruption.
B. Placenta praevia type IV.
C. Cervical carcinoma.
D. Severe placental abruption with IUFD and CID.
E. Vasa praevia with IUFD.

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 EXAMINATION No:__________________

57. A 28years old G2P1L1 woman who is 18 weeks pregnant presents to the ED with
increasing left lower extremity swelling, redness, and pain. She first noticed these
symptoms 2 days ago and has tried elevation and warm compresses, which have
not helped. She has no personal or family history of blood clots. She is otherwise
healthy, and her only medication is a prenatal vitamin. In the ED, her vital signs
are normal. Physical examination is significant for left lower extremity edema, calf
tenderness, and erythema. You suspect that she has a lower extremity DVT, and
you plan to start her on anticoagulation therapy Which of the following is the most
important test to confirm your diagnosis?
A. Venography
B. D-dimer
C. Left lower extremity venous Doppler ultrasound
D. MRI of the left lower extremity
E. No further testing is indicated

58. A 28years old G2P1 woman, presents to the emergency department with
abdominal pain since the past day. She reports a 1week history of nausea with
occasional vomiting. She has noticed some breast tenderness as well. She denies
dysuria, vaginal bleeding, or any bowel symptoms. She reports that her last period
was 4 weeks ago, but was lighter than normal. She has been using condoms for
contraception. On arrival, her vital signs include a temperature of 37°C, BP of
117/68 mmHg, pulse rate of 78 beats per minute, and respiratory rate of 16 breaths
per minute. Cardiovascular and respiratory examinations are normal. She notes
some suprapubic abdominal discomfort with palpation, but she does not have
rebound tenderness or guarding. A speculum examination reveals a closed cervix
without bleeding. A pelvic examination is mildly uncomfortable and reveals a
normally sized, anteverted uterus, and palpably normal adnexa. A urine pregnancy
test is positive. What is the test you should order first?
A. Type and cross
B. CBC
C. Quantitative level of β-hCG
D. Pelvic ultrasound
E. Urine gonorrhea and chlamydia testing

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 EXAMINATION No:__________________

59. A 31years old G1P0 woman at 39 weeks and 4 days presents to labor and delivery
unit, with regular contractions occurring every 3 to 5 minutes. Her contractions last
30 to 90 seconds. She is not sure if she has been leaking any fluid from her vagina.
You take her history and conduct a physical examination. Rupture of membrane
would be supported by which of the following?
A. Nitrazine paper remaining orange when exposed to fluid in the vagina
B. A negative fern test
C. An ultrasound with a normal AFI
D. A negative tampon test
E. Speculum examination with evidence of pooling in the vagina

60. A 33years old woman at 37 weeks gestation confirmed by early sonogram

presents with moderate to severe vaginal bleeding, and is note by sonogram to
have placenta Previa, which of the following is the best management for her?
A. Induction of labor
B. Give tocolytic drugs
C. Caesarean section
D. Expectant management
E. Artificial rupture of the membrane

61. A 19years old woman comes to the emergency room and reports that she fainted
at work earlier in the day. She has mild vaginal bleeding. Her abdomen is diffusely
tender and distended. In addition, she complains of shoulder and abdominal pain.
Her temperature is 36.5°C, pulse rate is 120bpm and blood pressure is 96/50
mmHg. To confirm the diagnosis suggested by the available clinical data, the best
diagnostic procedure is?
A. Pregnancy test
B. Posterior colpotomy
C. Dilation and curettage
D. Culdocentesis
E. Laparoscopy

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 EXAMINATION No:__________________

62. A 24 years old woman (gravida 2, para 0, abortus 1) is seen in the emergency
department because of vaginal bleeding and abdominal cramps. Her LMP was 10
weeks ago. History is unrevealing except for an induced abortion 2 years ago
without complications. She presently denies instrumentation for abortion. Physical
examination reveals a BP of 110/70 mmHg, pulse 120bpm, and temperature
38.3°C. The abdomen is tender with slight rebound in the lower quadrants. The
pelvic examination reveals blood in the vault and a foul-smelling discharge from
the cervix, which is dilated to 2 cm. The uterus is 8 to 10weeks size and tender,
and no adnexal masses are palpated. What is the most likely diagnosis?
A. choriocarcinoma
B. hydatidiform mole
C. pelvic inflammatory disease (PID)
D. septic abortion
E. twisted ovarian cyst

63. A 35years old woman had a spontaneous vaginal delivery 10 days ago. She
delivered a healthy baby girl and is currently breastfeeding. There were no
complications throughout labour and the midwife has documented that the
placenta appears complete. She now presents with irregular dark red vaginal
bleeding over the past 2 days. Her blood pressure is 130/75 mmHg, pulse rate is
85 beats/minute and respiratory rate is 18 breaths/minute. She has a temperature
of 37.4 °C. What is the next most appropriate action?
A. Crossmatch 2 units of packed red cells
B. Cervical smear
C. Pelvic ultrasound
D. High vaginal swab
E. Reassure, no action required

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 EXAMINATION No:__________________

64. A 35years old G2P1L1 woman at 40 weeks 6 days presents to labor and delivery
triage with a 5hour history of painful contractions. Monitoring reveals contractions
every 3 minutes and cervical examination on arrival is 3 cm dilated, 50% effaced,
and 22 station. Her pregnancy has been complicated by gestational diabetes and
20kg weight gain in pregnancy (BMI 24). In her first pregnancy, she presented at
2 cm dilation and 90% effacement. Her labor progressed slowly with dilation of 1
cm every 3 hours until labor arrested at 7 cm. A healthy baby girl weighing 4,200g
was delivered by cesarean section after arrest at 7 cm for 4 hours. Today your
patient requests a trial of labor after cesarean section. You recheck her cervix 2
hours later and find that it is 4 cm dilated, 90% effaced, and 21 station. The
estimated fetal weight by Leopold’s is 4000g. A recent ultrasound preformed at 38
weeks estimated the fetal weight at 3,900g. You admit the patient to labor and
delivery for expectant management. Which of the following factors was least likely
to result in her prior failure to progress?
A. Obstetric conjugate diameter of the pelvis greater than 11.5 cm
B. Inadequate strength of uterine contractions
C. Fetal size or position
D. Maternal pelvis shape
E. Fetal lie

65. Ms. Maria is 33years old G8P5L6 woman with fundal height of 39 cm presents for
initial prenatal visit in your clinic. She is currently an inmate at a local jail. She is
imprisoned on charges of marijuana possession. She has had no prenatal care.
She is unsure of her last period but reports that she started feeling the baby move
approximately 5 months ago. She denies vaginal bleeding, leaking fluid, or
contractions during the pregnancy. She reports using marijuana nearly daily
throughout the pregnancy. She has not been taking any medications in pregnancy
and has had no other exposures. The father of the baby is not involved. She does
not have custody of her other children and has an open DHS case. She hopes to
regain custody and is interested in drug rehabilitation. Ultrasound performed in
your clinic shows gestational age to be approximately 40 weeks 3 days. What is
the most common cause of a diagnosis of post-term pregnancy?
A. Inaccurate dating
B. Fetal anomaly
C. Delayed presentation to prenatal care
D. Advanced maternal age
E. Multi-parity

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 EXAMINATION No:__________________

66. A 33 year old woman presents to you with a positive pregnancy test and concerns
about this pregnancy. She has had 3 early miscarriages in the past with no live
births. Based on her last menstrual period, she is now 6 weeks gestation. She was
investigated for antiphospholid syndrome in the past and her lupus anticoagulant
antibodies were found to be positive. Her BMI is 22 kg/m2 and she is a non-
smoker. What is the most appropriate management?
A. Cervical cerclage
B. Bed rest until delivery
C. Prophylactic vaginal progesterone
D. Low molecular weight heparin and aspirin
E. Reassure, no change of management

67. You comfirm an intrauterine pregnancy of approximately 10 weeks gestation in a

30-year-old gravida 5, para 4 woman with an IUD in place. The patient expresses
a strong desire for the pregnancy to be continued. On examination, the string of
the IUD is noted to be protruding from the cervical os. The most appropriate course
of action is?
A. Leave the IUD in place without any other treatment
B. Leave the IUD in place and continue prophylactic antibiotics
throughout pregnancy
C. Remove the IUD immediately
D. Terminate the pregnancy because of the high risk of infection
E. Perform a laparoscopy to rule out a heterotopic ectopic pregnancy

68. A 38 year old woman is seen in your clinic for the evaluation of a swelling in her
right vulva. She has also noted pain in this area when walking and during coitus.
On examination a mildly tender fluctuant mass was noticed just outside the
introitus in the right vulva. What the most likely diagnosis?
A. Bartholin's abscess.
B. Lymphogranuloma venerum.
C. Chancroid.
D. Vulva carcinoma.
E. Herpes infection.

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 EXAMINATION No:__________________

69. On bimanual examination, you palpated bilateral adnexal masses from the
abdomen examination of Mwanahamisi. A vaginal US was done for her and it
showed bilateral tubo-ovarian abscesses. What is the most appropriate next step
in her management?
A. Admit the patient for emergency laparoscopic drainage of the
abscess.
B. Admit the patient and give her IV antibiotic.
C. Treat with multiple oral antibiotics as an outpatient.
D. Call interventional radiotherapy to perform "CT guided Percutaneous
aspiration".
E. Admit the patient for exploratory laparotomy, TAH and BSO

70. A 32 year old woman with Polycystic ovarian syndrome has infertility of 1 year’s
duration. Her menses occur at irregular intervals, and basal body temperature is
monophasic. An endometrial biopsy shows endometrial hyperplasia with mild
atypia. The most appropriate therapy is?
A. Danazol
B. Megrostol acetate
C. Oral contraceptive
D. Clomiphene citrate
E. Human Gonadotropins

71. A 42years old lady overweight and smoker attends your clinic and complains of
heavy periods. An ultrasound scan reveals a normal uterus. She would like a long
term treatment with minimal side effects that would offer treatment for the
menorrhagia and provide contraception although she is still unsure if she would
like children in the future. What is the most appropriate management?
A. Combined oral contraceptive pills
B. Endometrial ablation
C. Levonorgestrel intra-uterine system
D. Progestogen implant
E. Copper intrauterine contraceptive device

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 EXAMINATION No:__________________

72. Your next patient is a 65-year-old G2P2 new patient who has been referred from
her primary care provider for recurrent yeast vaginitis. Review of her outside
medical records reveals five episodes of vulvar pruritus that were treated with oral
and vaginal antifungal pruritus has been persistent for more than a year. She was
married for 35 years but is now widowed and has not been sexually active in 3
years. You examine her and find a thin white atrophic epithelium and a contracted,
small introitus. There is loss of the normal architecture of the labia minora. An area
of hypopigmentation surrounds the labia and the anus in a figure-of-eight pattern.
Wet prep shows a pH of 5.5, rare pseudohyphae, no lactobacilli, no WBC or RBC,
and rare clue cells. What would you do next?
A. Collect fungal cultures
B. Screen for gonorrhea and chlamydia
C. Prescribe a longer course of oral fluconazole (Diflucan)
D. Check a fasting glucose level
E. Perform a vulvar biopsy

73. A couple presents to your clinic because they have been trying to conceive for 18
months. During the interview you learn that the man has fathered a child in a
previous relationship and is in good health. The woman is 28 and reports that she
has had painful menses for the past 5 or 6 years. After completing your history,
you explain to your patient that you need to perform an examination before making
any recommendations. You explain that women with endometriosis often have a
normal examination but that there are certain findings that are associated with
endometriosis. During your examination, which of the findings listed below would
NOT increase your suspicion that she has endometriosis?
A. A fixed deviated uterus
B. Uterosacral nodularity on rectovaginal examination
C. Tender adnexa
D. An enlarged irregular uterus
E. A fixed adnexal mass

74. Ms. Anna is a 29years old G2P1 woman of 22 weeks’ pregnant who reports of
pelvic bulge and bothersome pressure. Physical examination reveals cervical
prolapse, approaching the opening of the vaginal introitus. She is worried that the
prolapse will worsen as the pregnancy progresses. What can you offer this patient
for her symptomatic prolapse?
A. Pessary trial
B. Reassessment after delivery but nothing during the pregnancy
C. Cerclage
D. Hysteropexy
E. Uterosacral ligament fixation

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 EXAMINATION No:__________________

75. You are called to review a 72years old woman complains of vaginal bleeding. On
evaluation, a 2cm vaginal lesion is found in the upper third of the anterior vagina.
On bimanual and rectovaginal examination, the mass extends to the lateral pelvic
wall. On biopsy, vaginal carcinoma is confirmed. What stage cancer does this
patient most likely have?
A. 0
B. I
C. II
D. III
E. IV

76. A 48-year-woman who had two normal pregnancies 13 and 15 years ago presents
with the complaint of amenorrhea for 7 months visits your clinic and She expresses
the desire to become pregnant again. After exclusion of pregnancy, which of the
following tests is next indicated in the evaluation of this patient's amenorrhea?
A. Hysterosalpingogram.
B. Endometrial biopsy.
C. Thyroid function test.
D. Testosterone and DHAS levels.
E. LH and FSH levels.

77. A 34 year old lady comes to you for removal of an intrauterine device. On speculum
examination, the cervix is visualised but the intrauterine device thread is not seen.
Her last menstrual period is 2 weeks ago and she has been having regular sexual
intercourses with her partner. She has a negative pregnancy test. What is the
appropriate action?
A. Transabdominal ultrasound
B. Transvaginal ultrasound
C. Abdominal X-ray
D. Combined oral contraceptive pill
E. Repeat speculum examination under general anaesthesia

78. Ms. RN is receiving external beam radiation for treatment of metastatic endometrial
cancer. The treatment field includes the entire pelvis. Which of the following tissues
within this radiation field is the most radiosensitive?
A. Vagina
B. Ovary
C. Rectovaginal septum
D. Bladder
E. Rectum

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 EXAMINATION No:__________________

79. A 19years old woman comes to your office with a compliant of never having had
menses. Physical examination shows that she is 1.37 m tall and weighs 42 kg. She
lacks breast and pubic hair development. There is webbing of her neck and cubitus
valgus. Which of the following is likely to be true?
A. Testicular feminization.
B. Klinefelter syndrome.
C. Turner's syndrome.
D. Congenital adrenal hyperplasia.
E. Normal but delayed development.

80. A 49 years old woman comes at the OPD complaining that several years it feels
as though "her organ are progressively falling out her vagina" along with this, she
complains of losing urine with straining, occasional urgency, and sometimes a
feeling of incomplete emptying of her bladder with voiding. On further examination
you will find :
A. Rectocele
B. Cystocele
C. Enterocele
D. Complete uterine prolapse
E. UTI

81. A 31-year-old obese woman presents to your office for an infertility consultation.
She and her husband have been attempting pregnancy for the preceding 18
months. She states that her menses are irregular, occurring every 25 to 47 days,
and sometimes she skips menses altogether. They are sometimes heavy, other
times light with just brown spotting. She notes that her menses have always been
this way, ever since menarche at age 12. She denies any history of sexually
transmitted infections and her husband has proven paternity with a previous wife.
She notes that she has never been pregnant. On further questioning, she admits
to plucking and shaving excessive hair from her chin, around her navel, and on her
lateral thigh. She also admits to bothersome acne and extreme difficulty with
weight loss. Physical examination reveals obesity with BMI 31, normal breast
development, and presence of excessive hair as described by the patient. Pelvic
examination reveals normal external genitalia and unremarkable bimanual
examination. What additional information do you need to make your diagnosis?
A. Day 3 serum FSH and estradiol
B. Pelvic ultrasound
C. Serum testosterone, DHEA-S, and prolactin
D. None of the above
E. All of the above

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 EXAMINATION No:__________________

82. On a routine-screening CBC, a 1year old child is noted to have a microcytic

anemia. A follow up hemoglobin electrophoresis demonstrates an increased
concentration of hemoglobin A2. The most appropriate next step in the
management of this child’s condition is which of the following?
A. Initiate oral iron therapy.
B. Provide family counseling alone.
C. Begin oral, daily folate, and penicillin therapy.
D. Arrange for a bone marrow aspiration.
E. Initiate therapy with dimercaptosuccinic acid (Succimer).

83. A father brings his 3years old daughter to the emergency department after noting
her to be pale and tired and with a subjective fever for several days. Her past
history is significant for an upper respiratory infection 4 weeks prior, but she had
been otherwise healthy. The father denies emesis or diarrhea, but does report his
daughter has had leg pain over the previous week, waking her from sleep. He also
reports that she has been bleeding from her gums after brushing her teeth.
Examination reveals a listless pale child. She has diffuse lymphadenopathy with
splenomegaly but no hepatomegaly. She has a few petechiae scattered across
her face and abdomen and is mildly tender over her shins, but does not have
associated erythema or joint swelling. A CBC reveals a leukocyte count of 8,000/μL
with a hemoglobin of 4 g/dL and a platelet count of 7,000/μL. The automated
differential reports an elevated number of atypical lymphocytes. Which of the
following diagnostic studies is the most appropriate next step in the management
of this child?
A. Epstein-Barr virus titers
B. Serum haptoglobin
C. Antiplatelet antibody assay
D. Reticulocyte count
E. Bone marrow biopsy

84. A 10years old boy is admitted to Temeke hospital because of bleeding. Pertinent
laboratory findings include a platelet count of 50,000/μL, prothrombin time of 15
seconds (control 11.5 seconds), activated partial thromboplastin time of 51
seconds (control 36 seconds), thrombin time of 13.7 seconds (control 10.5
seconds), and factor VIII level of 14% (normal 38%-178%). Which of the following
is the most likely cause of his bleeding?
A. Immune thrombocytopenic purpura (ITP)
B. Vitamin K deficiency
C. Disseminated intravascular coagulation (DIC)
D. Hemophilia A
E. Hemophilia B

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85. A 35 week preterm female is 4 hours old. She was born by emergency LSCS due
to breech position after preterm labour. Her mother received 1.2g IV benzyl
penicillin 3hours before delivery. APGARs were 91 and 95 respectively and birth
weight was 2600g. She has now had 4 episodes of apnea >20 seconds, with her
HR dropping to <80 beats per minute and her SPO2 to <70%. She requires firm
stimulation to resolve these episodes and between episodes her SPO2 goes up to
96% on room air. Her examination is normal. Which one is the MOST appropriate
next step in the management of her apnea?
A. Administer IV caffeine
B. Place her on 100% oxygen
C. Intubate and ventilate the baby
D. Perform a septic work-up and start IV antibiotics
E. Start continuous positive airway pressure (CPAP) ventilation

86. A 13months old female baby presents to the emergency department with difficulty
in breathing. On examination, she has intercostal recessions and a bilateral
widespread wheeze. Her temperature is 37.9 C and respiratory rate is 35
breaths/minute. What is the SINGLE most likely diagnosis?
A. Bacterial upper respiratory tract infection
B. Pneumonia
C. Bronchiolitis
D. Respiratory distress syndrome
E. Alpha 1 antitrypsin deficiency

87. You are on call on postnatal ward and the mother calls with concerns of her
newborn. Her baby was born at term by an uncomplicated vaginal delivery in the
birthing Centre yesterday evening. The baby is feeding well and not irritable. This
is parents’ first child and the parents are especially concerned as the baby has a
yellowish color to his skin and eyes. What is the SINGLE most appropriate
management?
A. Reassure
B. Reassure and advise to seek medical opinion if jaundice continues
beyond 2 weeks’ time
C. Make an outpatient appointment for the newborn at the paediatric
jaundice clinic
D. Inform the community midwife
E. Advise to return to the hospital and to be seen within the next 2 hours

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 EXAMINATION No:__________________

88. A 16years old boy is referred to your practice for leg claudication. Blood pressure
in his right arm is 150/110 mmHg, while blood pressure in his left leg is 80/60
mmHg. On auscultation, a systolic murmur best heard over the middle of the upper
back is detected. You also find that the patient’s femoral pulses are diminished
when compared to his brachial pulses. Which of the following is the most likely
diagnosis?
A. Patent ductus arteriosus
B. Ventricular septal defect
C. Coarctation of the aorta
D. Atrial septal defect
E. Tetralogy of Fallot

89. Madenge who is 7years old boy is brought to your office at Lugalo hospital by her
mother because of a rash that appeared 3 days ago. Her temperature is 37.2°C
and her face has an intense rash with a “slapped-cheek” appearance. The most
likely etiologic agent is?
A. Adenovirus
B. Rotavirus
C. Parvovirus
D. Coxsackievirus
E. Echovirus

90. Previously healthy 5days old male who was born at home develops bruising and
melena. The pregnancy, delivery, and postnatal course were unremarkable. The
infant is breastfeeding vigorously every 2 hours. Findings on physical examination
are unremarkable except for several large bruises. Laboratory testing reveals:
haemoglobin of 81 g/L (8.1 g/dL); white blood cell count, 9.4 x 10 9/L (9,400/mm3);
prothrombin time of 37 seconds; partial thromboplastin time of 39 seconds; platelet
count of 242 x 109/L (242,000/mm3); and fibrinogen, 2.34 g/L (234 mg/dL). Of the
following, the MOST likely cause of the bleeding is?
A. Liver disease
B. Vitamin K deficiency
C. Von Willebrand’s disease
D. Factor VIII deficiency haemophilia
E. Disseminated intravascular coagulation

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 EXAMINATION No:__________________

91. For the past year, a 12years old boy has had recurrent episodes of swelling of his
hands and feet, which has been getting worse recently. These episodes occur
following exercise and emotional stress, last for 2 to 3 days, and resolve
spontaneously. The last episode was accompanied by abdominal pain, vomiting,
and diarrhea. The results of routine laboratory workup are normal. An older sister
and a maternal uncle have had similar episodes, but they were not given a
diagnosis. He presents today with another episode. Which of the following is the
most likely diagnosis?
A. Systemic lupus erythematosus
B. Heart failure
C. Congenital nephrotic syndrome
D. Angioedema
E. Henoch-Schönlein purpura

92. A term large for gestational age newborn infant was born 50 hours ago by cesarean
section to a 26-year-old primigravida mother with insulin-dependent gestational
diabetes. The infant’s initial glucose was 1.4mmol/L, but after feeding subsequent
glucoses have all been above 3.3mmol/L. The infant is now diaphoretic and
irritable, and seems to have some twitching and tremors of the extremities. The
most likely cause of this infant’s problems is which of the following?
A. Hypernatremia
B. Hypocalcemia
C. Hypoglycemia
D. Hyperphosphatemia
E. Hypokalemia

93. Halima is a 19years old primiparous woman, develops toxemia in her last trimester
of pregnancy and during the course of her labor is treated with magnesium sulfate.
At 38 weeks’ gestation, she delivers a 2100g infant with Apgar scores of 1 at 1
minute and 5 at 5 minutes. Laboratory studies at 18 hours of age reveal a
hematocrit of 79%, platelet count of 100,000/μL, glucose 41 mg/dL, magnesium
2.5 mEq/L, and calcium 8.7 mg/dL. Soon after, the infant has a generalized
seizure. Which of the following is the most likely cause of the infant’s seizure?
A. Polycythemia
B. Hypoglycemia
C. Hypocalcemia
D. Hypermagnesemia
E. Thrombocytopenia

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 EXAMINATION No:__________________

94. A 5 weeks old male infant presents to clinic with jaundice during routine check-up.
His mother reports a normal vaginal delivery at term with a birth weight of 3.5 kg.
On examination, the baby is irritable, below average centiles for weight, and the
liver is enlarged. Pale stools and dark urine on diaper were observed. The mother
is currently not breastfeeding and had picked him on formula. What is the SINGLE
most likely diagnosis?
A. Galactosemia
B. Glucose-6-phosphate dehydrogenase (G6PD) deficiency
C. Rh incompatibility
D. Congenital viral infection
E. Biliary atresia

95. Oral medications are often used as an early treatment for generalized spasticity.
Which of the following works at the level of skeletal muscle to block calcium release
from the sarcoplasmic reticulum?
A. dantrolene sodium
B. clonidine
C. tizanidine
D. baclofen
E. diazepam

96. You are following a 6years old boy for iron deficiency anemia. Two months after
initiation of therapy (6 mg/kg/day of elemental iron), there has been minimal
improvement in the hemoglobin and ferritin levels despite adequate adherence.
Findings on history and physical examination are normal. What is the MOST
appropriate investigation to perform NEXT?
A. serology for anti-tissue transglutaminase levels
B. upper gastrointestinal (GI) series with small bowel follow-through
C. upper endoscopy
D. bone marrow aspirate
E. Full Blood Count

97. You are caring for a 14years old adolescent boy with trisomy 21. Which of the
following tests is MOST appropriate to order on an annual basis, as part of the
regular health supervision for this adolescent?
A. ECG
B. thyroid function
C. sleep oximetry
D. x-rays of the cervical spine
E. None of the above

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 EXAMINATION No:__________________

98. A 37weeks gestation boy is born after an uncomplicated pregnancy to a 33years

old mother. At birth, he was lethargic and had an HR of 40bpm. Oxygen was
administered via bag and mask, and he was intubated; his HR remained at 40
beats/min. Which of the following is the most appropriate next step?
A. Administer IV bicarbonate.
B. Administer IV atropine.
C. Administer IV epinephrine.
D. Administer IV calcium chloride.
E. Begin chest compressions

99. You are on call at the postnatal ward at Kunenge hospital and a 8days old infant
continues to have jaundice which was first noted on the second day of life; his
latest total and direct bilirubin levels are 12.5 and 0.9 mg/dL, respectively. The
baby and the mother have type O positive blood, the direct and indirect Coombs
tests are negative, the infant’s reticulocyte count is 15%, and a smear of his blood
reveals no abnormally shaped cells. He is bottle feeding well, produces normal
stools and urine, and has gained weight well. Which of the following remains in the
differential diagnosis?
A. Gilbert syndrome
B. Disseminated intravascular coagulation
C. Spherocytosis
D. Polycythemia
E. An undiagnosed blood group isoimmunization

100. Which of the following is a potentially distinguishing feature of osteogenesis

imperfecta versus rickets?
A. Poor muscle tone
B. Easily fractured long bones
C. Increased susceptibility to respiratory infections
D. Small stature
E. Blue sclera

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 EXAMINATION No:__________________

101. A 14years old boy with known SCD is been admitted for vasoocclusive
crisis. He has been receiving IV fluids and IV narcotics for the last 2 days. He
seemed to be getting better, but the nurse has just called you and stated his
temperature is now 38°C. On examination, you find his respiratory rate to be 32
breaths/min, and his oxygen saturation is 90%. What is the next step in
management?
A. Order spiral CT.
B. Initiate antibiotics and provide supplemental oxygen via nasal
cannula.
C. Obtain STAT hemoglobin level.
D. Initiate incentive spirometry.
E. Administer another dose of narcotics.

102. A 2-year-old girl has increased work of breathing. Her father notes she has
had cough and subjective fever over the past 3 days. She has been complaining
that her “belly hurts” and has experienced one episode of posttussive emesis, but
no diarrhea. Her immunizations are current, and she is otherwise healthy. Her
temperature is 38.9°C. She is somnolent but easily aroused. Respirations are 28
breaths/min, and her examination is remarkable for decreased breath sounds at
the left base posteriorly with prominent crackles. Which of the following acute
interventions is the next best step in your evaluation?
A. Blood culture
B. Chest radiography
C. Pulse oximetry
D. Sputum culture
E. Viral nasal swab

103. At a routine healthy clinic visit of a 3years old child, you detect a systolic
murmur that has never heard before. In addition, the cardiac examination
demonstrates a right ventricular impulse in the precordium and a widely split
second heart sound. An electrocardiogram demonstrates right ventricular
hypertrophy. What is the most likely heart lesion in this child?
A. Atrial septal defect
B. Coarctation of Aorta
C. Mitral valve prolapse
D. Patent ductus arteriosus
E. Isolated tricuspid regurgitation

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 EXAMINATION No:__________________

104. A female is born via spontaneous vaginal delivery at 28 weeks of gestation

because of preterm labor. Which of the following would be a risk factor for CP?
A. Hypoglycemia
B. Apnea of prematurity
C. Intraventricular hemorrhage
D. Blood transfusion
E. Mechanical ventilation

105. A 9years old boy is brought to the hospital by his parents with severe
shortness of breath. He has a history of asthma and has become unwell over the
past few days with a productive cough. His symptoms are worsening and he feels
the salbutamol inhalers are no longer effective in helping breathe. On examination,
he has a widespread wheeze on auscultation. There are intercostal recessions and
use of accessory muscles. His oxygen saturations were 88% at room air and
respiratory rate was 45 breaths/minute. Oxygen was immediately commenced. He
was given back to back nebulizers with salbutamol and ipratroprium bromide.
Intravenous hydrocortisone was administered. Due to poor response, he was given
intravenous salbutamol and intravenous aminophylline. His symptoms continue to
deteriorate with signs of exhaustions and poor respiratory effort. What is the next
most appropriate medications to be considered?
A. Nebulised corticosteroids
B. Intravenous magnesium sulphate
C. Oral monteleukast
D. Intramuscular adrenale
E. Nebulized adrenaline

106. You receive a 5years old boy at OPD for several days of swelling. His
mother first noted some upper respiratory symptoms including rhinorrhea and non-
productive cough about 2 weeks ago with no fevers. He initially seemed to get
better, but swelling of his eyelids started 2days ago, prompting her to give him
antihistamine the past two evenings. The swelling has persisted and spread to his
face, abdomen and hands. The child has also decreased appetite and fatigue.
Primarily, he complains of some abdominal discomfort with no vomiting or
diarrhea. His weight is 20.2kg, HR of 122bpm and blood pressure of 85/52 mmHg.
He has notable swelling of his face, eyelids and distal extremities, his lungs are
clear, the abdomen is fairly distended. The reminder of his examination is normal.
Urinalysis reveals trace blood with 4+ and Ph 5 other findings are normal. Which
of the following laboratory results would be most unexpected?
A. Serum sodium of 129 mEq/L
B. Serum bicarbonate of 12 mEq/L
C. Serum albumin of 1.8 g/dL
D. Serum calcium of 7.0 mg/dL
E. Serum creatinine of 0.6 mg/Dl

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 EXAMINATION No:__________________

107. A mother brings her 3years old son with Down syndrome to your clinic
because his gums have been bleeding for 1 week. She reports that he has been
less energetic than usual. Examination reveals that the child has an oral
temperature of 37.8°C, pallor, splenomegaly, gingival bleeding, and bruises on the
lower extremities. Which of the following is most likely?
A. Aplastic anemia
B. Idiopathic thrombocytopenic purpura
C. Leukemia
D. Leukemoid reaction
E. Megaloblastic anemia

108. A previously healthy 18months child has been in a separate room from his
family. The family notices the sudden onset of coughing, which resolves over a
few minutes. Subsequently, the patient appears to be normal except for
increased amounts of drooling and refusal to take foods orally. The most likely
explanation for this toddler’s condition is;
A. Severe gastroesophageal reflux
B. Foreign body in the airway
C. Croup
D. Epiglottitis
E. Foreign body in the esophagus

109. A 5 weeks neonate born to a HIV positive mother was brought to the health
facility for vaccination today. Her mother was started on a combination of
Effervirenz/Tenofovir/Lamivudine during pregnancy and has opted for
breastfeeding. In addition to the vaccination, In Tanzania guidelines what is the
recommended blood sample to be taken from this child today?
A. CD4 testing
B. Viral load test
C. Dry blood spot
D. Rapid test for HIV
E. HIV resistance test

110. A 16 years old girl, newly diagnosed with HIV today, has CD4 count
980cells/mm3. She has been apparently well until when she went for medical
checkup as a requirement for her medical examination report attached to her new
school joining instruction. According to the Tanzania national guideline which of
the following statement is correct;
A. She should start Nevirapine prophylaxis
B. She should start Antiretroviral treatment
C. She should start Cotrimoxazole prophylaxis
D. She should start ARV when CD4 drops below 350 cells/mm3
E. She should start ARV when CD4 drops below 500 cells/mm3

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 EXAMINATION No:__________________

111. A 10years old boy was healthy until about 10 days ago when he developed
7 days of fever, chills, severe muscle pain, pharyngitis, headache, sclerai injection,
photophobia, and cervical adenopathy. After 7days of symptoms, he seemed to
get better, but yesterday he developed fever, nausea, emesis, headache, and mild
nuchal rigidity. Cerebrospinal fluid (CSF) shows; 200 WBC/ µL (all monocytes) and
an elevated protein. Correct statement about this infection include which of the
following?
A. The condition is obtained from arthropod vectors.
B. Central nervous system involvement is uncommon.
C. Most cases are mild or subclinical.
D. Appropriate treatment includes intravenous (IV) immune globulin
(IVIG) and aspirin.
E. Hepatic and renal involvement occurs in the majority of cases.

112. Juma is a 3years old boy and is brought to OPD by his grandmother with
failure to thrive for 5 months. Her body weight is 8kg and her height is 100cm.
Weight for Height is between -2SD and -3SD. The management of this child
includes;
A. High protein diet
B. RUTF 2 Sachets a day
C. F75 110mls/kg for 24hours
D. F100 110mls/kg for 24hours
E. Ceftriaxone 100mg/kg od for 5 days

113. Which of the following is considered appropriate treatment option for a

53years old woman who develops two liver metastases two years following left
modified radical mastectomy, chest wall radiation, systemic chemotherapy (A+C),
and tamoxifen therapy for her T2N2, estrogen receptor positive, and HER2/neu
negative invasive ductal carcinoma?
A. Aromatase inhibitor
B. Trastuzumab
C. Radiation therapy to the liver
D. Liver resection
E. Increase tamoxifen dose

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 EXAMINATION No:__________________

114. A 35year old woman presents to your clinic with the complaint of a lump in
her left breast. She first noticed the mass two weeks ago in the shower and the
patient says that she has not noticed whether the mass appears and disappears
with the occurrence of her menses. The patient’s past medical history was
insignificant and she claims that she is on no long term medication. Further
questioning reveals that the patient has no further complaints of night sweats,
weight loss or a fever and this is the first breast mass that she has noticed. She
has no family history of breast cancer. On physical examination, it was revealed
that a 2.5 cm by 1.5 cm mass is present in the left lower quadrant of her left breast.
The mass was regular and firm in consistency and was non-tender and mobile.
The skin over her left nipple appeared to be normal and no discharge from her left
nipple could be appreciated. The rest of the breast examination was unremarkable
with no enlarged lymph nodes palpated in her neck or axillary region. Examination
of her right breast was unremarkable. Fine needle aspiration was subsequently
done. The results show duct-like epithelium surrounded by fibrous bridging. What
is the most likely diagnosis?
A. Fibroadenoma
B. Firboadenosis
C. Breast cancer
D. Fat necrosis
E. Sclerosing adenosis

115. A 41-year-old man complains of regurgitation of saliva and of undigested

food. An esophagram reveals a dilated esophagus and a bird’s-beak deformity.
Manometry shows a hypertensive lower esophageal sphincter with failure to relax
with deglutition. Which of the following is the safest and most effective treatment
of this condition?
A. Medical treatment with sublingual nitroglycerin, nitrates, or calcium-
channel blockers
B. Repeated bougie dilations
C. Injections of botulinum toxin directly into the lower esophageal
sphincter
D. Dilation with a Gruntzig-type balloon
E. Surgical esophagomyotomy

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 EXAMINATION No:__________________

116. A 60-year-old previously healthy businessman notices that his eyesare

yellow and he has been losing weight. On physical examination the patient has
jaundice and scleral icterus with a palpable mass in the right upper quadrant.
Abdominal ultrasound demonstrates biliary ductal dilation without gallstones.
Which of the following is the most appropriate next step in the workup of this
patient?
A. Esophagogastroduodenoscopy (EGD)
B. Endoscopic retrograde cholangiopancreatography (ERCP)
C. Acute abdominal series
D. Computed tomography (CT) scan
E. Positron emission tomography (PET) scan

117. A 43-year-old man presents to the emergency department with severe

abdominal pain and substernal chest pain. The patient’s symptoms began
approximately 12 hours earlier after he returned from a party where he consumed
a large amount of alcohol that made him ill. Subsequently, he vomited several
times and then went to sleep. A short time thereafter, he was awakened with
severe pain in the upper abdomen and substernal area. His past medical history
is unremarkable, and he is currently taking no medications. The patient appears
uncomfortable and anxious. His temperature is 38.8°C, pulse rate 120 beats/min,
blood pressure 126/80 mmHg and respiratory rate 32 breaths/min. The findings
from an examination of his head and neck are unremarkable. The lungs are clear
bilaterally with decreased breath sounds on the left side. The cardiac examination
reveals tachycardia and no murmurs, rubs, or gallops. The abdomen is tender to
palpation in the epigastric region, with involuntary guarding. The results of a rectal
examination are normal. Laboratory studies reveal that his white blood count is
26,000/mm3 and that his hemoglobin, hematocrit, and electrolyte levels are
normal. The serum amylase, bilirubin, aspartate transaminase (AST), alanine
transaminase (ALT), and alkaline phosphatase values are within normal limits. A
12-lead electrocardiogram shows sinus tachycardia. His chest radiograph reveals
moderate left pleural effusion, a left pneumothorax, and pneumomediastinum.
What is the most likely diagnosis?

A. Diaphragmatic perforation
B. Mallory weis syndrome
C. Esophageal perforation
D. Aortic dissection
E. Hemopneumothorax

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 EXAMINATION No:__________________

118. You are registrar at Dodoma general hospital, you attend a 45years old man
diagnosed with an exophytic adenocarcinoma of the distal esophagus that
penetrates to but does not penetrate through the muscularis propria. A CT scan of
the chest does not demonstrate evidence of distant metastases. Which of the
following is the most appropriate treatment?
A. Placement of endoscopic stent to relieve obstruction and initiate
chemotherapy
B. Initiation of chemotherapy followed by endoscopic resection of the
tumor, if tumor shrinkage is achieved
C. Initiation of chemotherapy followed by esophagectomy and
additional postoperative chemotherapy
D. Nutritional therapy followed by esophagectomy
E. Combined chemoradiation

119. Assuming you are the attending medical doctor and 60years old man comes
to you with 10years history of achalasia. His dysphagia has been worsening, and
he underwent an esophageal dilation; shortly after this procedure, he develops
acute chest pain, tachycardia, and fever 6 hours after esophageal dilatation for
achalasia. Which of the following diagnostic procedures is most appropriate for this
patient?
A. A barium esophagogram
B. A Gastrografin esophagogram
C. Esophagoscopy
D. Chest x-ray
E. Upright abdominal x-ray

120. A 42years old man has bouts of intermittent crampy abdominal pain and
rectal bleeding. Colonoscopy is performed and demonstrates multiple
hamartomatous polyps. The patient is successfully treated by removing as many
polyps as possible with the aid of intraoperative endoscopy and polypectomy.
Which of the following is the most likely diagnosis?
A. Ulcerative colitis
B. Villous adenomas
C. Familial polyposis
D. Peutz-Jeghers syndrome
E. Crohn colitis

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 EXAMINATION No:__________________

121. While doing you internship at Kigoma regional hospital, a 17years old high
school student presents to you with a painful fluctuant mass in the midline between
the gluteal folds. Rectal exam is unremarkable with no masses, fluctuance, or
tenderness. Which of the following is the most likely diagnosis?
A. Pilonidal abscess
B. Perianal abscess
C. Perirectal abscess
D. Fistula-in-ano
E. Anal fissure

122. A 57years old asymptomatic man comes to you on his regular medical
checkup. You note him to have a prostate that is normal in shape and size on rectal
examination. His PSA level is 38 ng/mL (normal; 2.5 ng/mL). Which of the following
is the best next step for this patient?
A. Observation
B. Transrectal ultrasound examination with a prostate biopsy
C. Repeated PSA testing in 6 months
D. CT scan of the abdomen and pelvis
E. Initiation of finasteride therapy

123. While at Mbeya zonal hospital, a 40 years old female underwent a

laparotomy one week ago. On day 6 post-operatively, you are asked to review her
by the nurse in charge. The patient complains that she has not been able to open
her bowels since the operation and that she has vomited twice since yesterday.
Her past medical history includes hypertension, diagnosed two years ago, for
which she takes Lisinopril. She has a twenty pack year smoking history. She does
not drink alcohol at all. On examination, the patient appears to be anxious and
uncomfortable. She is also noted to be overweight. She has a distended abdomen
and no bowel sounds can be auscultated. There is no tenderness on palpation,
apart from some mild discomfort around the laparotomy site. A plain X-ray of her
abdomen revealed gas distributed throughout the small and large gut. Minor fluid
levels were seen on an erect abdominal X-Ray. Her vitals are as follows: BP
130/82 mmHg and HR 90 bpm. What is the next best step to manage this patient?
A. Immediate laparotomy
B. Nasogastric tube insertion and intravenous fluids
C. Observe for 48 hours
D. Administer laxatives
E. Conservative management with anti-muscarinic agents

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 EXAMINATION No:__________________

124. A 33years woman from Tabora is attended at a regional hospital with a

history of three previous C-sections. She presents to the hospital with her third
bout of small bowel obstruction over the past 2 years. She has been managed with
nonoperative treatment consisting of NG suction, NPO, and IV fluid for the past 4
days. With her course of management, the patient has had a decrease in
abdominal distension, but her NG tube output has diminished but continues to be
bilious and voluminous (currently 600 mL/24 h). Which of the following is the most
appropriate management option?
A. Place a central venous catheter for total parenteral nutrition (TPN)
administration and continue her nonoperative treatment for an
additional 2 weeks.
B. Obtain a CT scan.
C. Perform a laparotomy.
D. Remove her NG tube and initiate PO feedings.
E. Prescribe an enema to stimulate bowel activity.

125. An elderly woman presents to the emergency department with postprandial

RUQ pain, nausea, and emesis over the last 12 hours. The pain is persistent and
radiates to her back. She is afebrile, and her abdomen is tender to palpation in the
RUQ. Sonography demonstrates cholelithiasis, gallbladder wall thickening, and a
dilated CBD measuring 12mm. Laboratory studies reveal the following values:
WBC count 13,000/mm3, AST 220 U/L, ALT 240 U/L, alkaline phosphatase 385
U/L and direct bilirubin 4.0 mg/dL. Which of the following is the most appropriate
treatment at this time?
A. Admit the patient to the hospital, provide intravenous hydration, and
check hepatitis serology values.
B. Admit the patient to the hospital and perform a laparoscopic
cholecystectomy.
C. Admit the patient to the hospital, provide intravenous hydration, begin
antibiotic therapy, and recommend ERCP.
D. Provide pain medication in the emergency department and ask the
patient to follow up in the clinic.
E. Schedule the patient for laparotomy with cholecystectomy and liver
biopsy.

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 EXAMINATION No:__________________

126. A 45years old man presents to you with right upper quadrant abdominal
pain. Vital signs show a temperature of 38°C heart rate 100 beats/minute, blood
pressure 135/90 mmHg. CT scan shows a large, calcified cystic mass in the right
lobe of the liver. He denies any recent travel. Echinococcus is suggested by the
CT findings. Which of the following is the most appropriate management of
echinococcal liver cysts?
A. Percutaneous catheter drainage
B. Medical treatment with albendazole
C. Medical treatment with steroids
D. Medical treatment with metronidazole
E. Surgical resection of the cysts

127. An elderly obese man of approximately above 50years of age has become
irritable, his face has changed to a round configuration, he has developed purplish
lines on his flanks, and he is hypertensive. A 24 hour urine collection demonstrates
elevated cortisol levels. This is confirmed with bedtime cortisol measurements of
700 ng/ mL. Which of the following findings is most consistent with the diagnosis
of Cushing disease?
A. Decreased ACTH levels
B. Glucocorticoid use for the treatment of inflammatory disorders
C. A 3-cm adrenal mass on computed tomography (CT) scan
D. Suppression with high-dose dexamethasone suppression testing
E. A 1-cm bronchogenic mass on magnetic resonance imaging (MRI)

128. You attend a 66years old woman at ED with a history of having passage of
several maroon colored stools earlier in the day. She complains of feeling light-
headed following these episodes. The patient has a history of hypertension and
osteoarthritis. She takes metoprolol and NSAIDs daily. Her initial blood pressure
is 100/85 mmHg, and heart rate is 90 beats/min. Her initial hematocrit is 34%. The
patient’s blood pressure improves with initial IV fluid resuscitation. An NG tube was
placed and gastric lavage reveals only bilious fluid. During a 4hour period of
observation in the resuscitation room the patient remains stable without further
passage of bloody stools. Which of the following is the most appropriate next step?
A. OGD
B. Mesenteric angiography
C. Abdominal CT scan
D. Colonoscopy
E. Pelvic X-ray

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 EXAMINATION No:__________________

129. A 46years old intoxicated man was driving down the highway in the wrong
direction when his vehicle struck a pickup truck head on. He presents with pulse
rate of 130 beats/min, blood pressure of 90/62 mmHg and respiratory rate of 30
breaths/min. His pupils are 5 mm and are equally round and reactive bilaterally, he
does not open his eyes to painful stimulus, he moans with painful stimulus, and he
withdraws from painful stimulus. His oxygen saturation with oxygen by face mask
is 86%. In addition to the possibility of closed head injury, what other factor most
likely is a contributing factor for his low GCS?
A. Hypoxia
B. Polysubstance abuse
C. History of seizure disorder
D. Alcohol intoxication
E. Chronic syphilis infection

130. An adult man sustains a stab wound to the abdomen 8cm superior to the
umbilicus. His skin is cool and he is diaphoretic. His blood pressure is 74/40 mm
Hg, and his pulse is 130 beats/min. His abdomen is distended and diffusely tender.
Which of the following management possibilities is most appropriate?
A. Abdominal CT scan
B. Diagnostic peritoneal lavage
C. Laparoscopy
D. Celiotomy
E. Local wound exploration

131. A 16years old adolescent boy is brought to the intensive care unit after
multiple blunt trauma approximately 12 hours previously. His injuries included a
femur fracture. He is noted to have a PO2 of 60 mmHg, despite the use of 100%
oxygen by rebreather mask and has become confused. The chest radiograph
reveals clear lung fields and a normal cardiac size. Which of the following is the
most likely diagnosis?
A. Pulmonary contusion
B. Fat embolism
C. Atelectasis
D. ICU psychosis
E. Occult pneumothorax

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 EXAMINATION No:__________________

132. You among one the doctors in a call team, a 24years old man comes to you
with complains of colicky intermittent umbilical and right lower quadrant abdominal
pain of 24 hours’ duration. He complains of anorexia and nausea. His temperature
is 36.7°C. Which of the following is the most likely diagnosis?
A. Acute appendicitis
B. Chronic appendicitis
C. Gastroenteritis
D. Acute pancreatitis
E. Intussusception

133. Which of these is the most appropriate DVT prophylactic measure for a
36years old man who just underwent an exploratory laparotomy, distal
pancreatectomy, splenectomy and gastric repair for a gunshot wound to the
abdomen? The patient had approximately 3000 mL of blood loss prior to surgical
control of his bleeding and repairs of his injuries. Following his operation, he has
been stable in the ICU with a hematocrit of 28% and international normalized ratio
(INR) of 1.7.
A. LMW heparin.
B. 5000 U of fractionated heparin TID.
C. 5000 U of fractionated heparin BID.
D. Pneumatic compression devices.
E. Withhold DVT prophylaxis until the INR returns to normal.

134. Which of the following patients has the highest risk of developing colorectal
cancer?
A. A 45years old man whose younger brother has a history of colon
cancer
B. A 30years old woman with a BRCA1 mutation
C. A 55years old man with a 15-year history of ulcerative colitis
D. A 50years old man with a history of resected adenomatous colonic
polyps
E. A 44years old man with FAP syndrome (polyposis coli)

135. A 45years old woman attended at a tertiary hospital and is diagnosed with
pancreatic cancer. The histology appears to be adenocarcinoma. Which of the
following is most accurate regarding this type of malignancy?

A. Most of these cancers are located in the head of the pancreas.

B. Right upper quadrant pain, fever, and jaundice are commonly seen.
C. Most of these cancers are located in the tail of the pancreas.
D. Curative surgery is typically obtained when the malignancy is located in
body of the pancreas.
E. This tumor is highly chemosensitive.

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 EXAMINATION No:__________________

136. You have received a 44years old man for being evaluated for possible anal
fissure. Which of the following findings suggest the diagnosis of an anal fissure?
A. Fever, a fluctuant mass, obesity, and diarrhea
B. Painless rectal bleeding, a purple anal mass, and an ulcer
C. Presence of a purulent sinus, erythema, and a fluctuant mass
D. A history of nighttime incontinence of gas and stool
E. Severe anal pain, a tear in the posterior anoderm, bleeding, and
increased sphincter tone

137. A previously healthy 9months old boy is brought to the emergency

department with severe, intermittent abdominal pain. During the attacks, which are
episodic and occur every 10 to 15 minutes, the child draws his legs up to his
abdomen. The child is vomiting and has haem positive stools. On physical
examination, a tender, mobile, sausage shaped mass is found in the mid abdomen.
Which of the following is the most likely diagnosis?
A. Intussusception
B. Jejunal atresia
C. Neuroblastoma
D. Intestinal duplication cyst
E. Perforated appendicitis

138. You are attending 54years old man with lower back pain of 3 weeks’
duration that has not diminished with rest. He is diagnosed with a “herniated disk.”
Which of the following describes the most common location of herniated disks in
the lumbar spine region?
A. L1-2
B. L2-3
C. L3-4
D. L4-5
E. L5-S1

139. Ms. Nyaru is a 47years old woman complaining of lower back pain with
radiation to the right leg, and she is treated with ibuprofen and bed rest. Over the
next 3 weeks, the patient’s pain worsens, and she complains of difficulty with
voiding and bowel movements. Which of the following is the most likely diagnosis?
A. Spinal stenosis
B. Lumbar neoplasm
C. Cauda equina syndrome
D. Tuberculosis of the spine (Pott disease)
E. Compression fracture

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 EXAMINATION No:__________________

140. You are working as a doctor in the surgical department. A 65years old man
is in the ward following resection of an adenocarcinoma in his descending colon.
During the operation, the surgeon also opted to do a left hemicolectomy. On the
tenth postoperative day, he suddenly developed left abdominal pain. By the time
he had alerted the nurse to his pain, three hours had already lapsed. The pain is
severe and dull in nature and worsens when he moves or turns to his sides. There
is no associated nausea or vomiting. His past medical history is significant for a
back ground of chronic obstructive disease of which part of his medications include
oral steroids. He also has a thirty pack-year smoking history. Upon physical
examination, the patient appears to be anxious and lethargic. Abdominal
examination reveals an area of tenderness at his left lower quadrant but no rigidity
or guarding is present. Bowel sounds are sluggish. His vitals are as follows:
Temperature 37.8 C, BP 130/82 mmHg and HR 100 bpm. What is the most likely
cause of his pain?
A. Paralytic ileus
B. Anastomotic leak
C. Pelvic haematoma
D. Metastatic spread
E. Intestinal obstruction

141. Mr. Kalunguyeye is a 60years old man who comes to you seeking medical
attention because of recurrent urinary tract infections. The patient also reports a
history of increasing difficulty in urination (decreased flow, straining, and hesitancy)
over the last several months. A PSA level is mildly elevated and a prostate biopsy
proves benign. Which of the following is the most appropriate initial management
of this patient with benign prostatic hyperplasia?
A. α-Adrenergic blocker
B. 5-Alpha reductase inhibitor
C. α-Adrenergic blocker and 5-alpha reductase inhibitor
D. Transurethral resection of the prostate
E. Open prostatectomy

142. A 35years old man involved in a motor vehicle crash is found to have
multiple cerebral contusions within the left frontal lobe. His GCS is 6 and
neurosurgery places an intracranial pressure monitor. His intracranial pressure is
found to be 27 mmHg. Which of the following strategies should be attempted next
to control his ICP?
A. Administration of hypertonic saline
B. Administration of norepinephrine
C. Hyperventilation to obtain a Pco2 of 20
D. Placement of the patient in Trendelenburg position
E. Avoidance of all sedating drugs

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 EXAMINATION No:__________________

143. A 18years old football player from Namungo football club is seen in the
emergency department with severe knee pain incurred after being hit by a tackler
while running. Which of the following findings on physical examination is most
sensitive for an anterior cruciate ligament injury?
A. Positive anterior drawer test
B. Excessive varus laxity of the knee
C. Locked knee
D. Positive Lachman test
E. Positive posterior drawer test

144. A 54years old man with a history of seizure disorder has shoulder pain and
deformity following a grand mal seizure. On examination his right arm is found to
be adducted and internally rotated. Which of the following directions is his humeral
head likely to dislocate following seizure activity?
A. Anteriorly
B. Superiorly
C. Posteriorly
D. Laterally
E. Medially

145. A 65years old man from Njombe presents to you with acute onset of pain,
swelling, and erythema of the left knee. He denies previous episodes or trauma to
the knee. The differential diagnosis includes septic arthritis and gout. Which of the
following is the best study to differentiate between gout and septic arthritis?
A. White blood cell count
B. X-ray of the knee
C. Magnetic resonance imaging (MRI) of the knee
D. Bone scan
E. Evaluation of synovial fluid aspirate

146. A 34years old bodaboda driver is extricated from an automobile after a

motor vehicle collision. The patient has an obvious deformity of his right thigh
consistent with a femur fracture. Upon closer examination of the right thigh, there
is bone visible through an open wound. He has palpable pulses and an ankle
brachial index (ABI) = 1. In addition to IV antibiotics, which of the following is the
most appropriate management of his open femur fracture?
A. Observation
B. Splint placement
C. External fixation
D. Early irrigation and debridement
E. Four-compartment calf fasciotomies

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 EXAMINATION No:__________________

147. Following an acute spinal cord injury, a patient presents with systemic
hypotension and relative bradycardia. His bulbocavernosus reflex is present. This
is characteristic of what type of response in acute spinal cord injuries;
A. Spinal shock
B. Cardiac shock
C. Neurogenic shock
D. Septic shock
E. Hypovolemic shock

148. A 36years old male sustains an open segmental tibia fracture after a motor
traffic crash associated with an overlying 8 cm soft tissue avulsion that requires
skin grafting for soft tissue coverage. No vascular injury is identified. What is the
most appropriate Gustilo Anderson classification of this injury?
A. Type I
B. Type II
C. Type IIIA
D. Type IIIB
E. Type IIIC

149. A 3years old boy from Bukoba presents to you at OPD with irritability, fever,
and a warm, swollen leg. Imaging shows an area concerning for osteomyelitis and
trans cortical biopsy reveals multiple Salmonella species. This child most likely
also has which of the following conditions?
A. Osteogenesis imperfect
B. Child abuse
C. Thalassemia
D. Sickle cell anemia
E. Renal failure

150. You examine a 2months old boy because he has been straining while
passing stool and has a distended abdomen. He is very low on the growth chart
for age. A contrast enema is ordered by the primary care physician which shows
a contracted segment of colon with dilated proximal colon. Which of the following
is the best test for definitive diagnosis?
A. Colonoscopy
B. Defecography
C. Endoanal ultrasound
D. Anorectal manometry
E. Suction rectal biopsy

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