07-03-2007, 07:50 PM
found that on a link < thanks to the one who posted it originally>
NOT VERY SURE OF ANSWERS
1. One of your bipolar patient who you have been treating with lithium for last 6 years comes to your office for routine check up. she has no symptoms. you run a TSH level and find to be 9. what is the next step?
a. change lithium to carbamazepine
b. decrease lithium dose
c. change lithium to valproic acid
d. continue lithium and monitor patient
*e. continue lithium and add levothyroxine
2. 84 year old man who has history of DM, HTN, was observed by family to have behavioral changes over the past few days. What is the most appropriate initial investigation?
*a. check electrolytes
b. EKG
c. CBC
d. CT of the head
e. MRI
3. 53 y , F, husband died 3 months ago. Tearful and wish to be died with him. Not socially mixed. disturebed. some time feel worthless and saty home most of time. eating is appropriate. came to psyc. Diagnosis?
*a. bereavement
b. acute stress ds
c. depression
d. acute adjustamnet ds
e. PTSD
4. A 29-year-old white female is hospitalized following a right middle cerebral artery stroke confirmed on an MRI scan. Her past medical history is remarkable only for a history of an uncomplicated tonsillectomy during childhood, and a second-trimester miscarriage 3 years ago. The only remarkable finding on physical examination is left hemiplegia.
The initial laboratory workup reveals normal hematocrit and hemoglobin levels, a normal prothrombin time, and a platelet count of 200,000/mm3 (N 140,000-440,000). The active partial thromboplastin time is 95 sec (N 23.6-34.6), and it does not normalize when the patient's serum is mixed with normal plasma. A serum VDRL is positive, and a serum FTA-ABS is nonreactive.
Which one of the following is the most likely diagnosis?
Hemophilia
Neurosyphilis
*Antiphospholipid syndrome
Thrombotic thrombocytopenic purpura
Protein C deficiency
5.A 43-year-old white female presents with a 4-year history of irregular, intermittent vaginal bleeding. She is not taking hormonal therapy. Her past history is negative. Physical examination is normal except for a large, nodular uterus compatible in size with a 16-week pregnancy. Laboratory tests, including hemoglobin and urine hCG levels, are all normal. What is the Diagnosis?
1 polycystic ovarian syndrome
2 carcinoma of the uterine cervix
3 endometrial cancer
*4 uterine leiomyomata
5 ovarian carcinoma
6.Which one of the following is most likely to be a factor in the pathogenesis of gastric ulcer?
1 Excess gastric acid
2 Increased serum gastrin
3 An increased number of parietal cells
*4 Reflux of duodenal contents into the stomach
5 Impaired gastric emptying
While the complete etiology and pathogenesis of gastric ulcer are not known, impairment of the mucosal barrier to the back diffusion of hydrogen ion appears to be involved in the process. The reflux of bile and other duodenal contents into the stomach, which has been found in gastric ulcer patients, is thought to be one mechanism of mucosal barrier disruption. Since most patients with gastric ulcer have normal or low acid production, excessive acid is probably not a factor. Similarly, impaired gastric emptying is not common in such patients, and when it occurs it appears to be a consequence of the condition and not a cause. The number of parietal cells is increased in duodenal ulcer patients but is normal in patients with gastric ulcers. Fasting gastrin levels are variable in the presence of gastric ulcer and appear to correlate inversely with acid secretion. Hypergastrinemia is not a primary factor in gastric ulcer. When it occurs it is a physiologic response to low gastric acidity.
Ref: Schwartz SI (ed): Principles of Surgery, ed 7. McGraw-Hill, 1999, p 1194.
7. A 27-year-old white male has a clinical complex of jaundice and chorea. The diagnosis of Wilson's disease is confirmed by which one of the following?
1 Liver biopsy evidence of chronic active hepatitis
2 History of a manic-depressive psychosis
3 Kayser-Fleischer rings of the cornea
*4 Inability to incorporate a copper isotope into ceruloplasmin
Wilson's disease is an autosomal recessive abnormality in the hepatic excretion of copper, resulting in toxic accumulations of the metal in the liver, brain, and other organs. The manifestations of this disease may include liver disease leading to cirrhosis, neurologic or psychiatric disturbances, and Kayser-Fleischer rings of the cornea. However, none of these conditions is found only with Wilson's disease. Hepatitis B is also associated with chronic active hepatitis. Many psychiatric illnesses, including schizophrenia and other bizarre behavioral disturbances, are indistinguishable from Wilson's disease, but these conditions are not necessarily associated with copper metabolism. Kayser-Fleischer rings may also be associated with certain cataracts. Classically, the diagnosis is made by the demonstration of a serum concentration of ceruloplasmin less than 20 mg/dL and either (1) Kayser-Fleischer rings, or (2) a liver biopsy sample containing greater than 250 micrograms of copper per gram of dry weight. However, the diagnosis can be confirmed by a test of the patient's inability to incorporate radioactive copper into ceruloplasmin.
Ref: Fauci AS , Braunwald E, Isselbacher KJ, et al (eds): Harrison 's Principles of Internal Medicine, ed 14. McGraw-Hill, 1998, pp 2166-2169
8. A 34-year-old white male is brought to the emergency department following an automobile accident in which he was the only occupant of the vehicle. He lost control of the vehicle and hit a utility pole. He was knocked unconscious initially, but he is now awake and combative. You note a strong smell of alcohol. He has a frontal hematoma approximately 3 cm in diameter and an actively bleeding 4-cm laceration of the occiput. He will not permit you to examine him further and he prepares to leave the emergency department.
You should
*1 detain him in the emergency department
2 make him sign out against medical advice
3 tell him that he cannot return if he leaves
4 tell him that if he leaves he can return later
Two of the most important ethical principles are respect for autonomy and beneficence. Respect for autonomy means regarding patients as rightfully self-governing in matters of choice and action. To make an autonomous decision, the patient must be mentally sound, have knowledge and understanding of the facts, and be free of coercion. Beneficence means that physicians are motivated solely by what is good for the patient. There are often ethical conflicts between these two principles. This particular patient is clearly in need of further emergency treatment, but he refuses. He has had a significant head injury, is combative and possibly intoxicated, and therefore cannot be considered mentally sound. The physician should detain him for his own good and provide the appropriate care. Threatening him, having him sign out against medical advice, and encouraging him to return later are not appropriate because his mentation is impaired.
Ref: Goldman L, Bennett JC (eds): Cecil Textbook of Medicine, ed 21. WB Saunders Co, 2000, pp 5-6.
9. A 70-year-old white male is found to have microscopic hematuria on routine urinalysis. The most likely cause is
1 asymptomatic renal stone
*2 benign prostatic hyperplasia
3 bladder cancer
4 coagulopathy
5 urinary tract infection
10. 18 y/o pregnant, first trimester, blood pressure 120/75, has seizures,
which is the diagnosis in this case
a eclampsia
*b.epilepsy
11. A 5 year-old has anemia with Hb 6.2g. You gave iron. After one week treatment follow up, what do you order?
a] hct
b] iron
*c] Reticulocyte count
d] Hb
e] vitamin B12
12. An overweight 60 year old white male comes to your office for an early appointment to know about his cholesterol and heart disease risks. He is a diabetic for the past 25 years, smokes 1 packet per day for the past 20 years, has mild hypertension and is on a betablocker for that. His elder brother died at the age of 52 suddenly. His father had a stroke at the age of 72 and died later.
You send for his fasting lipid profile. You discuss with him the ways how heart disease risk is calculated.When telling him about his coronary artery disease risks,
Which of the following IS NOT A RISK FACTOR for CAD?
a. Hypertension
b. Smoking
c. Brother dying of probable myocardial infarction at 52
*d. Diabetes Mellitus
e.His lipid profile showing a Low HDL level
f. His age
If U have diabetes U are considered just like a person with COronary Heart disease. SO DM does not increase UR risk for coronary heart diseasae BUT IT ITSELF IS CORONARY HEART DISEASE
13. a pregnant pt with preeclampsia. Bp is 160/120. what anti-HTN medication ?
Hydralazine is the DOC for BP control in preeclamptic patients. However, parenteral hydralazine is provided only to pharmacists upon special emergency request. Therefore, the physician must be comfortable using other antihypertensive agents. Labetalol has alpha-adrenergic and beta-adrenergic blocking effects and can be used to provide rapid control of severe hypertension. Other antihypertensive agents have significant adverse effects and should not be used as primary agents. Diazoxide may cause hyperglycemia and inhibit labor, and nitroprusside may cause fetal cyanide toxicity. Diuretics should be avoided because of the relative intravascular volume depletion already present in patients with preeclampsia
14. A 32 weeks pregnant pt with severe cervical dysplasia. Next
1. treatment
2. no treatment
Due pregnancy the immunity os decreased so there may be flare up of cervical dysplasia.
More paps test is done during pregnancy that may be a reason for more diagnosis of cervica dysplasia.
So, HPV should be studied and close observation is required.
Two options
Cryotheraty during pregnancy or after the delivery with good outcome
15. A CO poisoning pt waked up. Vital sign is normal. Q asks of the following, which one is the most important you should keep watching this pt ?
*1.headache
2.weakness
16. Pt presented with unstable angina and after initial mx pt was stabilized.for the next 48hrs he had no angina at rest.EKg was normal.
what is next.
A)Stress test and then catherization
*B)catheterization without a stress test
17. Person with symptoms of Obstructive sleep apnea...what is the first/next step?
a)sleep study
*b)medical workup
c)CPAP treatment
18. what is the prognosis of ADHD
a. most of them become schizophrenic
b. most of them get remission when they grow up
*c. most of them become antisocial(25%)
d. most of them will have depression
19. 50yr old man had polyps now on removal biopy show superficial colon cancer which is not in mucous mem ,,villou adenoma but u knew his dad had colon cancer at age 60 now what
*a.do segmental colectomy
b.do regular follow up
20. Pt. comes wiith SOB, palpitation, EKG shows atrila fib., while starting IV line pt. become unresponsive. Cardiac monitor still shows Atrial fib.
Next to do?
1.start chest compression
*2.synchronous cardioversion
3.asynchronous cardioversion
4.immediate ABG
21. Pt. comes to your clinic, or ER with hx of angina for more than 2 mos.w/c is relieve by rest, next step.
1. admit patient
*2. exercise stress test
3. echo.
4. nuclear study
22. 60 y/o M with recurrent attacks of chest pain for the last 2 mos. and relieve by rest, EKG is N, stress test shows ST depression 3 mm in lead V3-V5 during the 5th minute of Bruce Protocol, HR is 90/min. Next recommendation?
1.Nuclear stress test
*2. Cardiac Cath.
3, Prescribe Niroglycerine
4.Echo.
23. Contraindication of Thronbolytic Tx in MI.
1. less than 12 hrs. post MI
2. ST elevation in 2 consecutive leads
*3. St depression with elevated cardiac enzymes
4. New LBBB
24. Pt. came to ER found to have MI, w/c meds you should discontinue w/c patient is currently taking, BP-140/80, PR- 98.
*1. Ca Ch. blocker
2. B-blocker
3. Nitroglycerine
4. Ace inhibitor
Ca channel blocker. They increase the heart rate, work load on the heart and O2 demand
25. Pt. with CLL on chemoTX via Hickman catheter, complains of fever, chills, on exam, exit site of catheter has erythema and tenderness, you send blood. culture, what is further mgt.?
1. start vanco. and Genta. and remove cath.
2. Remove catheter and culture the tip
*3. start Vanco and genta. but don't remove cath.
4. start Vanco,and genta plus rifampicin
STart Vanco and genta and remove catheter ( and send it for tip culture). This patient is an immunocompromised pt. All patients (also for regular) when U suspect infection, send for culture and start empiric Abx. COrrect them when the sensitivity report comes in accordingly
26. 56 y/o F with fatigue, heavy menstrual bleeding, MCV-70, Hct -30, what's next?
1. Colonoscopy
*2.FOBT
3.Flexsigmoidoscopy
4.Iron supplement
Answer: FOBT. If positive, this means that you have chronic GI bleeding which necesstitates sigmoidoscopy OR colonocopy
27. 10 y/o girl came for regular check up, live in a house built 40 yrs. ago, complains of easy fatigability, on exam, + pallor, next exam to order
1.Pb level
*2.CBC
3. ret. count
4. Iron studies
Answer: CBC. Always start with CBC even if you know that she can have lead poisoning, don't do lead level before CBC!! Start with the general then go to the specific!
28. Child with jaundice and splenomegaly, CBC with periph smear shows spherocytes, Increase MCHC, Dx
*1.hereditary spherocytosis
2,G6PD def.
3. Autoimmune Hemolytic anemia
4. Thallasemia
next Q, what test to order to arrive at a specific DX?
Dx: Spherocytosis and the diagnostic test is osmotic fragility test.
#1 and 3, both has increase MCHC and spherocytes, to diff. do Coomb's test w/c is Neg. in hereditary spherocytosis and Pos.in Autoimmune hem. anemia
29. Pt. with sickle cell anemia comes with SOB, weakness, compared CBC, you noticed decrease of H&H from 10/30 to 5/20, next to order
*1. Direct Coombs test
2, HGB electrophoresis
3. Reticulocyte count
4. Cold agglutinin test
Answer: Coomb test, direct.
# Ret. count, to diff. bet aplastic crisis and hemolytic cisis, (Ret. count is low in aplastic crisis and high in hemolytic crisis).
30. Pt. with hemolytic anemia needed blood transfusion but no match blood available, transufe.
*1.Type O neg. bld.
2. Type AB bld
3. Type O pos. bld.
4. FFP
31. A 68 year old man comes to your offic complaining of a hand tremor. The tremor becomes worse with voluntary movement. he notes that it improves with alcohol consumption. On physical exam, the tremor is coarse in nature. What is the most likely cause of this patient's tremor?
A. Parkinson's disease.
B. Alcoholic neuropathy.
C. Benign familial tremor.
*D. Intention tremor.
E. Huntington's chorea
32. A 20-year-old competitive swimmer is examined because of primary amenorrhea. Her height is 170 cm (67 in.), and she weighs 50 kg (110 lb). Her breasts are well developed. Findings on pelvic examination are normal, and the pubic hair appears to be normal. Cervical mucus is abundant and demonstrates ferning on drying. Urine spot and blood tests for pregnancy are negative. She is given 10 mg of medroxyprogesterone acetate twice a day for 5 days, and 3 days later she experiences menstrual bleeding for the first time. The most likely cause of the amenorrhea is
A. polycystic ovarian disease.
B. 45,X gonadal dysgenesis.
C. chromaphobe adenoma of the pituitary.
*D. functional hypothalamic amenorrhea.
E. prolactinoma of the pituitary.
33. Glucagon is least likely to be used for severe hypoglycemia in
1) Type II DM
*2) Malnourished patient
3) Infant overdose of injected insulin
4) Obese patient > 65yrs
Malnourished patients - have almost NO LIVER GLYCOGEN stores. Glucagon raises the sugar level but inducing an acute glycogeolysis into Glucose through Glucose-6-phosphatase. For that it needs Liver stores
34. 34 yr old man with abdominal pain, n,v,tender abdoman, increase bowel sound , guarding, old scar above umbilicus. x ray show dilated bowel loop,no gas under diaphragm. how to Dx?
*a. ct scan
b. endoscopy
c. colonoscopy
d. barium enema
35* 3 y/o boy diagnosed accidentally a holosystolic harsh murmur best heard at the left sternal border, echo done and Md's Dx was confirmed. According to the mother he's a very active kid and has no physical complaints, now sh'e asking what is best for his son.
*1. refer to cardiothotacic Sx
2. prescribe indomethacin
3. would only refer to SX if pt. become symptomatic
4. observe and repeat Echo. when he's 4 y/o
www.emedicine.com/ped/topic2402.htm
35. Parent of 18 y/o came in for routine PE for their son who is going to participate in baseball team, parents have heard a boy in their sons school died while playing, they ask now every possible test you could do before he would participate in the team.
1. Hx , PE and Echo
2. Hx , PE and EKG
*3. Hx and PE
4. Hx , PE and stress test
36. 28 y/o m HIV + is admitted with severe headache, nausea, vomiting, stiff neck and T 39 C
Which of the following measures is MOST important at this time.
a ceftriaxone
b vancomycin and ceftriaxone
c lumbar puncture
*d amphotericin B and flucytosine
e amphotericine B
37. 45 years old woman with history of DM and mild Hypertension with occational history of seizure for last 6 month came to your office with 6 hours h/o headache right sided partial ptosis, pain in lower half of face and neck rigidity. would be the cause?
a)Trigeminal neuralgia
*b)SAH of Post communicating artery
c)SAH of PICA
d)Brainstem glioma
e)Lacunar stroke
38. A man with 5x5 cm mass in left lobe of thyroid which is found to be papillary carcinoma..The man has develop HOARSENESS. the right lobe of thyroid is irregular on exam.. what is the best treatment
a)radiation
b)partial thyroidectomy plus radiation
c)total thyroidectomy with left neck dissection
*d) total thyroidectomy with removal of enlarged nodes
39. Large Bowel obstruction “ next step in management?
*a. Stat surgery consultation
b. Supportive treatment
c. D/c home and f/u in clinic
40. Pt in ICU setting “ ARDS “ on ventilator. An ABG was given -- FiO2 was 70- asked something like next step in management:
a. Inc fio2
*b. Add peep
c. Dec fio2
41. To confirm the diagnosis of Parkinson™s Disease in a patient presenting with a hx consistent with PD “
*a. CT scan of the head
b. Nothing further
c. LP
42. Pt is a chronic smoker, wants to quit, has tried to quit in the past with patch (?) but didn™t work, really wants to quit now “ next best step is to prescribe?
*a. Bupropion
b. Low dose nicotine patch
c. Do nothing
d. Nicotine gum
43. Pt (HIV -, no other comorbidities) with PPD + (> 15mm), CXR neg “ Txed with INH for 6 months “ F/u?
a. PPD Qyr
b. CXR annually(?)
c. PPD Q5yrs
*d. Tx with INH for another 3months
e. Tx with INH for another 6 mths
44. In a clinic setting, there was TB exposure to all employees : next step?
a. Start tx with all 4 drugs
b. Tx all with INH for 6 months
*c. Do PPD on all those exposed to the active TB person
45. Pt is a nurse with symptoms of hyperthyroidism - Graves Dz vs. Factitious hyperthyroidism distinguished via :
a. TSH
b. FT4 concentration
*c. T3 resin uptake
d. TSI (thyroid peroxidase antibody)
46-1.--Spousal abuse, poor family, having trouble making ends meet, both patient and husband are not educated, patient is not willing to leave husband who uses alcohol frequently and was arrested for DUI. The next step in management in this patient is:
a. Report to Protective agency
b. Remove patient from home and admit
*c. Tell her that you will help in whatever way you can, give her shelter phone number and to go to emergency whenever needed
2--. the second part“ The degree of danger in this situation is correlated with
*a. substance use ( alcohol)
b. arrest for DUI
c. Financial instability of family
d. Poor education level of both parents
47. HIV + man doesn™t want to tell his wife and will not stop relationship with her “ the most appropriate statement to this man is:
a. I really am in a difficult situation here “ can we work together to find the right solution
b. I will inform Public health authorities and they will then inform her
c. The other choices were really inappropriate “ don™t remember what they were
HIV man:
First - talk with him and tell him to tell his wife about the diagnosis
If he does not , in HIV - U HAVE THE RIGHT TO TELL THE PARTNER but it is not mandatory that U must tell the partner.
ref: Kaplan Lectures
48.A 65 year old female who had a stroke a year back and is bed-ridden for almost 15 hours a day due to severe paresis presents to the ER with abdominal distension and pain in the left leg (calf). She could not get up to pick up the phone and 911 was called when the home nurse came to her in the morning. SHe has been having the distension for almost 2-3 weeks but now she finds it intolerable and hurts when she breathes.
PE:
Abd: Ascites +++, Liver enlarged +++, Spleen enlarged ++, no spider angiomata present.
Leg: Left foot has no edema, left leg - calf is extremely tender and DOppler confirms DVT. Right leg has no edema, No vulvar edema
CVS: Right lung bas has minimal rales , no pain, (no chest pain in the HPI), NO JVD, NO neck vein distension
Temp - normal, Pulse - 94, RR - 30
THE CAUSE OF ASCITES IS:
a).Congestive cardiac failure
b).Pulmonary Embolism and Right HF
c).DVT moving into the systemic circulation
*d).Protein C deficiency
e).Atherosclerosis
f).Nephrotic syndrome
g).Cirrhosis secondary to HCV infection
Exclusion:
JVD is not raised - this alone excludes - CCF, Pulmonary embolism causing an acute Right heart failure and all other causes of increased pre load with congestion
There is no lower limb edema and no anasarca. This proves that there is no decreased albumin in the blood.That rules out Nephrotic syndrome. Also in Cirrhosis, the edema is mainly ascites due to portal hyper tension. If Generalized edema develops, it is due to decreased albumin production by the diseased liver. So this also rules out Cirrhosis to some extent. Also in Cirrhosis - liver is not palpable ( liver is palpable only in acute non-fulminant hepatitis. But they do not raise Portal pressure so much to cause dyspnoea)
USMLE gives hints in the questionas here. The guy has DVT ( no hx that the person had a prior episode of DVT or not).
Embolus going into circulation can causae an IVC clot and that causes pedal edema FIRST and later the pressure mounts inn the hepatic veins.
Another condition that can show like this is Acute alcoholic hepatitis - but no alcohol history.
49. A 62-year-old man with metastatic prostate cancer
has a rising PSA level despite treatment with
leuprolide and flutamide. What should be the first
step in managing this asymptomatic man with hormone-
refractory disease?
A) Treat with aminoglutethimide
*B) Discontinue flutamide to attempt to obtain an
antiandrogen withdrawal response
C) Discontinue leuprolide
D) Treat with diethylstilbestrol
E) Perform an orchiectomy
50.A 35-year-old woman with amenorrhea is found to
have an enlarged pituitary gland. Her prolactin
level is 80 ng/L (normal, less than 20 ng/L), and
her thyrotropin level is 100 µU/mL (normal, 0.5 to
4.5 µU/mL). Which of the following is the best
treatment option for this patient?
A) Administration of bromocriptine
*B) Administration of L-thyroxine
C) Irradiation of the pituitary gland
D) Resection of the pituitary gland
E) Use of oral contraceptives
prolactin level above 100 confirms ur diagnosis of proclactiemia.Since here its 80 it might just be due to associated hypothyriodism. Hypothyroidism is confirmed by tsh levels being above 20. so now my answer is give thyroxine
51. A 53 year old woman presents to the emergency room with abdominal pain, nausea, vomiting, hypotensive, tachycardia and disoriented. A FSG check comes back as >500. You quickly get a urine sample and analyze it with a dipstick. It shows the following results:
Specific Gravity=1.005/pH=5.5/1+protein/4+glucose/+ketones/0 RBC,WBC, epithelials cells.
You promptly get IV access and draw the necessary blood studies. Your next step would be to:
a.Give a Normal Saline bolus and run IV fluids wide open
b.Do (1) and give 10 units of regular insulin IV and start an insulin drip at 0.1units/kg/hr
c.Do (1) and give 10 units of NPH and start an insulin drip at 0.1 units/kg/hr
d.Do (1) and start on Diabeta 10 mg
*e.Do (1) await lab results and observe
Diabetic Ketoacidosis
This patient is obviously in D.K.A. as evidenced by high serum glucose, glucosuria and ketonuria. What ones needs to do now is to resusciate the patient with FLUIDS! To reverse the ketone production that is contributing to the acidosis the patient also needs insulin BUT initially this is secondary to fluid resusciation. YOU DO NOT WANT to be giving insulin to any patient without documented electrolytes. With the acidosis and dehydration, patients become potassium depleted. The committment acidosis will contribute to "shifting" potassium out of the cell giving you a falsely elevated potassium. The danger is if a patient is severly potassium depleted in the face of an acidosis, with the fluids correcting the acidosis, the insulin is going to shove more potassium into the cells thus acutely lowering the serum potassium level to potentially dangerous levels. If the potassium gets lower than 2.0-2.5 one is prone to provoking lethal arrhythmias.
References:
DeFronzo RA, Matsuda M, Barrett EJ. Diabetic Ketoacidosis: A combined metabolic-nephrologic approach to therapy. Diabetes Reviews 2(2): 209-238, 1994.
Cefalu W. Diabetic Ketoacidosis. Critical Care Clinics 7(1): 89-108, 1991.
Axelrod L. Diabetic Ketoacidosis. The Endocrinologist, 375-83. Williams and Wilkins, 1992.
52. A 50 year old white man with a history of "mild" heart attacks presents to the emergency department with a 1 hour history of "crushing" chest pain associated with nausea, shortness of breath, diaphoresis and radiation into the left arm and neck. An old EKG from 3 months ago was normal.
As the E.D. physician you would:
a.Give the patient a "white slider" (a mixture of lidocaine & maalox)
b.Give the patient some Valium and tell him that the pain is all in his head
*c.Give the patient an aspirin
d.Give the patient an aspirin, start Heparin and assess for thrombolytic contraindications
e.Give the patient a sublingual nitroglycerin tablet
f.Give the patient a dose of steroids and start on Ibuprofren
53. Ophthalmoscopic examination shows a pale and swollen optic disk of the left eye with scattered flame-shaped hemorrhages in the vicinity of the disk. An afferent pupillary defect is present in the left eye. The most likely cause for these findings is:
*A - Ischemic optic neuritis
B - Talc embolus due to IV heroin abuse
C - Glioma with papilledema
D - Retinal artery occlusion
E - Diabetic neuropathy
Anterior ischemic optic neuropathy involves interruption of the blood flow in the short posterior ciliary arteries that supply the optic disk. This results in a severe loss of vision, altitudinal visual field defects, and a pale, swollen optic disk, with peripapillary hemorrhages.An afferent pupillary defect (APD) occurs when the nerve pathways to the brain fail to properly transmit messages.If an APD is severe (dilation of the affected pupil), it generally indicates optic nerve disease such as ischemic optic neuropathy, optic neuritis, severe glaucoma, central retinal artery or vein occlusion, or in rare cases, a lesion of the optic chiasm or tract due to a pituitary tumor or stroke.
54. A 35 year old woman comes to the ER complaining of palpitations . An EKG shows A FIb. She says that she has NEVER experienced this before and has never been diagnosed like this before. You as the resident examine her -irregularly irregular pulse, a diffuse swelling in her neck. SHe has a pronounced stare as if her eyes are popping out. She also gives history of feeling hot and sweaty and easy arousability. The labs show her TSH level as <0.1 mu/ml (normal: 0.5-5) and free T4 as 6 ng/dl (N = 0.8 to 2). You find her hyperthyroid and remember your endocrine class that U diffuse enlargement with hyperthyroidism can be due to Graves disease and sub acute thyroiditis. As the examination was confusing for you, you call the endocrinologist. The Most likely advice from the endocrinologist will be:
a). Close observation
*b). Start propyl thiouracil
c). 24 hour radioactive iodine uptake scan
d). Start methimazole and also send her for radio iodine ablation now
e). Reassurance only
methimazole for 2-3wks and then ablation. Be careful with the word NOW...you cannot give both metimazole and ablation.
55. A 72 year-old Iranian-born nursing home resident is brought to your clinic because of an abnormal tuberculin test. The patient has Alzheimer's disease, but is physically in good condition. When he was admitted to the nursing home one year ago his tuberculin test was negative at 4 mm. On this year's routine evaluation, his tuberculin test is 13 mm. What is the most likely cause for the positive PPD?
A Active tuberculosis
B Recent infection with Mycobacterium tuberculosis
C Recent infection with nontuberculous mycobacterium
D Inaccurate recording of PPD in the medical record
*E. Recall of waned immunity (booster phenomenon)
This is Booster phenomenon
Booster phenomenon:
Patient had TB while young OR had contact with a open case while young. The system made antibodies in either case. After a period of time, the memory cells wane and the memory of the initial infection is forgotten.
WHen the first PPD is given, the system remembers the initial event in one to two weeks. SO the second PPD comes a positive.
This is differentiated by ( done in many nursing homes and other places where routine PPD testing is done yearly)
DO PPD for the first time
Then do a repeat PPD in 3-4 weeks. If the repeat is POSITIVE then it is Booster. No more PPD is done on this patient after that anytime
ELse just leave it.If pt tests positive next year, here Booster is esxcluded and it is Tuberculous infection
56. A 26 yr old boy failed in kindergarten but did average in college, no hallucinations but flat affect and always worried that he may injure others. Mother got him to doc. happens to be a quiet boy. What is your diagnosis?
Schizophrenia
*depression
passive aggressive personality
antisocial
57. 34 yr old man with abdominal pain, n,v,tender abdoman, increase bowel sound , guarding, old scar above umbilicus. x ray show dilated bowel loop,no gas under diaphragm. how to Dx?
*a. ct scan
b. endoscopy
c. colonoscopy
d. barium enema
58. 32 yrs old woman with breech pregnancy 35 weeks gestation, now she is having contration. mx?
a.c section now
*b.tocolytic
c.observe
d.external podalic version
e.epidural anesthesia
59. Which of the following drugs is the least sedating and anticholinergic, which can be prescribed safely to elderly patients with depression?
a.fluoxetine
b.MAOI
c.Imipramine
*d.Sertraline
e.Trazodone
60. 9 y/o lady had seizure came to ER, neurological deficit present. CT scan of the head showed ring enhancing lesion in brain. What is probable organism?
a. cryptococus
b. grm positve micro coccobacilli
c. strepto cocci
A single ring enhancing lesion - is considered brain abscess Unless Otherwise proved.
Staphylococcus aureus,Streptococci (especially Streptococcus intermedius),Bacteroides and Prevotella species,Enterobacteriaceae,Pseudomonas species
Other anaerobes
61. 8 yr old child with dirty wound after a fight at school “ Parents immigrated from Russia recently and mom doesn™t speak English, sister translates, say that the pt has received one injection since birth “ in this patient, you would give :*a. Td, Tig and hepatitis B vaccineb. Dtap, Hib and MMRc. www.cdc.gov/nip/recs/child-schedule.PDF
62. Ophthalmoscopic examination shows a pale and swollen optic disk of the left eye with scattered flame-shaped hemorrhages in the vicinity of the disk. An afferent pupillary defect is present in the left eye. The most likely cause for these findings is:
*A - Ischemic optic neuritis
B - Talc embolus due to IV heroin abuse
C - Glioma with papilledema
D - Retinal artery occlusion
E - Diabetic neuropathy
ww3.komotv.com/global/story.asp?s=1230651
63. pt was having dvt..on coumadin and heparin suddenly
started to have sob what is next
a)continue him on heparin and coumadin
b)give him tpa
*c)ivc filter
d)embolectomy
64. A 35 year old woman comes to the ER complaining of palpitations . An EKG shows A FIb. She says that she has NEVER experienced this before and has never been diagnosed like this before. You as the resident examine her -irregularly irregularpulse, a diffuse swelling in her neck. SHe has a pronounced stare as if her eyes are popping out. She also gives history of feeling hot and sweaty and easy arousability. The labs show her TSH level as <0.1 mu/ml (normal: 0.5-5) and free T4 as 6 ng/dl (N = 0.8 to 2). You find her hyperthyroid and remember your endocrine class that U diffuse enlargement with hyperthyroidism can be due to Graves disease and sub acute thyroiditis. As the examination was confusing for you, you call the endocrinologist. The Most likely advice from the endocrinologist will be:
a). Close observation
*b). Start propyl thiouracil
c). 24 hour radioactive iodine uptake scan
d). Start methimazole and also send her for radio iodine ablation now
e). Reassurance only
65. One couple adopt 1 yr old baby from overseas( asia). no vaccination report. Baby is doing well & all are happy. after check up HBe Ag +. adopted mom & dad HBs Ag - .
Mx for mom & dad.
a. vaccine
*b. vaccine & Ig
c. Ig
d. Rifampin
e. repeat HB Ag level 6 months later
66. Symptoms of malabsortion plus refractory iron def. anemia and osteomalacia and vesicular pruritic rash over extensor surface of extremity, DX?
*Celiac Sprue
67. 40 y/o M, HepBsAg +, with multisystemic dis. (fever, anorexia, abdominal pain, etc.)comes with foot drop or wrist drop, Dx?
1.Pb poisoning
2. Lyme dis.
*3. Polyarthritis Nodosa
68. Marathon runner, k is high,vital signs and exam is normal, how will you manage?
1) give I/V saline
2) ekg
3) Dialysis
*4) drinking water
NOTES: A prgenant in her 2nd trimester exposed to a child with Varicella one day age. You checked her serum for varicella antibodies titre and it was negative..Give VZV ig (not vaccine) ..It should be given within 96 hours of exposure.
The mother ask you: Does the VZIG protect my fetus againts infection? NO. VZIG is given to prevent MATERNAL NOT CONGENITAL/FETAL infection!. The congenital varicella syndrome results from exposure during the first 16 weeks of pregnancy.
safe:
1-Pneumococcus (polysaccharide)
2-Meningococcus (polysaccharide)
3-Rabies (killed virus)
4-Influenza (inactivated virus)
5-Hepatitis B (purified surface antigen)
6-Hepatitis A
7-Tetanus-Diphtheria (toxoid)
unsafe:
1-Mumps/Measles/Rubellla
2-Yellow fever
3-Varicella
69. jumping sports cause what kind of injuries
?a)stress fx
b) osgoood disease
c)meniscal tear
d)acl tear
e)pcl tear
70. a iv drug abuser is having voluminus diarrhea, whichof the following test u will do
a)check stool for wbc
b)check for ovaparacite
*c)check for acid fast stain
d)check for c dif
Cryptosporidia: No Lukocytes are found in stools and the crypto can be partially acid fast +!!
Microscopic examination of stool specimen for oocysts using modified acid-fast (Kinyoun) stains is the mainstay of diagnosis for most laboratories. This technique stains oocysts pink or red, while fecal debris or yeast assumes the color of blue or green counterstain. Other stains, including monoclonal antibody-based fluorescent stains, also are available.
71. a 14 yr old boy was brought by mom for physical and u notice that there is only one testis, what u will tell mom???
a)its okay to have one testis bcz he can still have kids with one testis
*b)there is inc chance of cancer of testis so we have to do urgent surgery to avoid that
c)since he is not kid any more he wont have any prob
d)heneeds hormones so his testis will come down i think its some where up there..
72. which of the following diease is not reportable
a)enteric fever
b)pertussis
*c)herpz
d)aids
e)tb
73. a kid with blueberry muffin rash and rash behind ear which is maculopapular..what is it??
a)measals
b)toxoplasmosis
c)cong syphilis
*d)rubellla
74. a kid was playing with cat and showed mom a lesion ,he is not having any symptoms..what u will sugggest to mom
*a) just clean with soap and water
b) sinc ehe is not having any s/s no tretament required
c)give ampicillin
d)augumentin
75. a 2 days old child is unable to pass urine what is most
a)vesico ureteral reflex
*b)post urethral valve
c) urinary diverticulum
d) dehydration due to frequent stoool passgae in ist few days..
76. 45 yr old women who went home after gi bleed
a)lmw heparin
b)lovenox
c)venalcaval filter
d)tpa
77. 23 y F, preganant, paternal grand father has heomophila. Has baby XY she ask for chaces of disese in her baby.
a. 25%
b. 50%
*c. nothing
d. 100%
e. 15%
x-linked,
the characteristics are that every affected persons linked to each THROUGH the mother side. In the case, the baby boy's mother is not a carrier. Therefore the boy has nothing to do with the disease
78. A 28-year-old man decides to donate a kidney to his brother, who is in chronic renal failure, after HLA typing suggests that he would be a suitable donor. He is admitted to the hospital, and his right kidney is removed and transplanted into his brother. Which of the following indices would be expected to be decreased in the donor after full recovery from the operation?
Creatinine clearance
*Renal excretion of creatinine
Creatinine production
Daily excretion of sodium
Plasma creatinine concentra
Explanation of Answer:
Because creatinine is freely filtered by the glomerulus, but not secreted or reabsorbed to a significant extent, the renal clearance of creatinine is approximately equal to the glomerular filtration rate (GFR). In fact, creatinine clearance is commonly used to assess renal function in the clinical setting. When a kidney is removed, the total glomerular filtration rate decreases because 50% of the nephrons have been removed, which causes the creatinine clearance to decrease. In turn, the plasma creatinine concentration increases until the rate of creatinine excretion by the kidneys is equal to the rate of creatinine production by the body. Recall that creatinine excretion = GFR x plasma creatinine concentration. Therefore, creatinine excretion is normal when GFR is decreased following removal of a kidney because the plasma concentration of creatinine is elevated.
Creatinine is a waste product of metabolism. Creatinine production is directly related to the muscle mass of an individual, but is independent of renal function.
The daily excretion of sodium is unaffected by the removal of a kidney. The amount of sodium excreted each day by the remaining kidney exactly matches the amount of sodium entering the body in the diet.
79. A 24-year-old AIDS patient develops chronic abdominal pain, low-grade fever, diarrhea, and malabsorption. Oocysts are demonstrated in the stool. Which of the following organisms is most likely to be the cause of the patient™s diarrhea?
Diphyllobothrium latum
Entamoeba histolytica
*Giardia lamblia
Isospora belli
Microsporidia
Explanation of Answer:
All the organisms listed are protozoa. There are two intestinal protozoa specifically associated with AIDS that can cause transient diarrhea in immunocompetent individuals but can cause debilitating, and potentially life-threatening, chronic diarrhea in AIDS patients. These organisms are Isospora belli, treated with trimethoprim-sulfamethoxazole or other folate antagonists) and Cryptosporidium parvum (no treatment currently available).
Diphyllobothrium latum is the fish tapeworm and occasionally causes diarrhea.
Entamoeba histolytica and Giardia lamblia are both causes of diarrhea, but they are not specifically associated with AIDS.
Microsporidia are a protozoan cause of diarrhea but produce spores rather than oocysts
80. 14 yrs old girl never been vaccinated for varicella and she exposed to 5 yrs old her sister with varicella
how would u tx 14 yr one
a.varicella immuno
b.varicella ig g and vaccine
c.var vaccine now
*d.varicella vaccine now and month later
edo nothing.she already exposed
81. A patient with chronic malabsorption presented with absent tendon reflexes, ataxia, loss of pain sensation, ophthalmoplagia, and anemia. He is suffering from which of the following vitamin deficiency?
a) vit. A
*b) vit. B12
c) vit. C
d) vit. D
e) vit. E
FACTS:
1.population most at risk- young pt. then post-menopausal women
2. HIV mother- no to breast feeding
3.HIV pt. become pregnant currently on Tx - advice to continue meds., if not on Tx start Tx in 2nd trimester with triple Tx (azt included)
4.HIV pt, CD4 <200 on bactrim dev. rash - start dapsone or aerosolized pentamidine
5.I.V drug abuser with fever, maculopapular rash, cervical lymphadenopathy, lymphophenia, HIV test(-),heterophil ab (-), -Dx- acute retroviral syndrome
6.Pt. had unprotected sex 2 weeks ago, then came to know the woman was HIV+, pt. wanted to be tested - don't do ELISA, do HIV RNA pcr or p24 antigen
7. Pt CD4-80, do prophy for PCP, MAI and Toxo, using Bactrim, if you use dapsone add Pyrimethamine
8. HIV pt. with thrombocytopenia, best Tx - Antiretroviral Therapy
9.HIV pt with fever, cough, sob, on PE, right lower lobe crepitation, CXR- Right lower lobe infiltrate, CD4-350, Dx - Community Acquired Pneumonia
10.HIV pt. using marijuana with fever, cough, hemoptysis, foud to have necrotizing cavitary pneumonia, Dx- Aspergillosis, to confirm do bronchoscopic biopsy, Tx- amphotericin B, if not improving do Sx excission.
11. HIV pt with PCP on Pentamidine having seizure, first thing to do - Finger stick to r/o hypoglycemia
12. HIv pt with interstitial pneumonia, splenomegaly, palate ulcer from El Salvador, Dx- Histoplasmosis
13. HIv pt. in ICU on TPN via central catheter complains of ocular discomfort w/c lead to visual loss in one eye, Dx - Candida endopthalmitis
14. Pt.admitted for fever, blood cultures growing Candida, Tx with Ampho. B, don't think it is contaminated bac. of chance of having Candida endolpthalmitis.
83. 76yrs old female,menopause 15yrs back.no sex since husband died (15yrs back).very active and not on HRT.she now met a wonderful person,she had sex and there was bleeding after sex. most likely cause
a.caevical ca
*b.atrophic vaginitis
84. The Pap smear result that is potentially the most serious, and requires more aggressive investigation and treatment is
A Normal squamous cells but lack of endocervical cells
B Colonization with Gardnerella vaginalis and Candida
*C Atypical glandular cells of undetermined significance
D Atypical squamous cells of undetermined significance
E Substantial colonization with Trichomonas vaginalis
85. The diagnosis of cervical incompetence has traditionally been made on the basis of an obstetric history consistent with passive and painless midtrimester dilation of the cervix. The presence of uterine contractions, bleeding, ruptured membranes, and intra-amniotic infection do not necessarily exclude the diagnosis of an incompetent cervix, as it is often difficult to ascertain whether these latter complications preceded or followed the dilation. Cervical cerclage is still the best treatment for cervical incompetence. Which of the following is an indication for cerclage
A Cerclage is indicated solely based on risk factors or prior cerclage placed for doubtful indications
*B Clinical evidence of extensive obstetric trauma to cervix
C Chorioamnionitis
D Premature rupture of membranes
E Fetal anomaly incompatible with life
86. You deliver a full term infant after a long second stage of labor. Forceps are used to expedite the delivery because of some concerns over a deteriorating fetal heart tracing. Recurrent late decelerations are present. An easy outlet forceps delivery produces an infant with Apgar scores of 2 at 1 minute, 4 at 5 minutes and 7 at 10 minutes. Which of the following is true?
A A low 1-minute Apgar score correlates with the infant's future outcome
B A low 5-minute Apgar score correlates well with neurologic outcome
C A term infant with a 5-minute Apgar score of less than 4 has a 5% chance of developing cerebral palsy
D One advantage of the Apgar scoring system is that it is independent of the physiologic maturity of the infant
*E Seventy five percent of children with cerebral palsy have normal Apgar scores at birth
87. A 48-year-old woman is undergoing total abdominal hysterectomy for menorrhagia secondary to fibroids. Which of the following accurately describes the structures to be removed in this surgical procedure?
A Ovaries and tubes
B Uterine fundus
C Uterine leiomyomata
*D Uterus (fundus and cervix)
E Uterus, tubes and ovaries
88. which of the following is not a feature of trisomy 21
1. cardiac septal defect
2. mental retardation
3. intestinal atresia
*4. cerebral malformation ( holoprosencephaly
5. hypothyroidism
89. A 3 yr old male presents to ur clinic after being seen 5 days ago in ER for a fever of 40.2 C He apeared well in ER visit with unremarkable UA and CBC. Was given IM cetriaxone. Continued to have spiking fever and has now developed a rash, erythmatous , maculopapular, covering trunk, injected lips and tongue, and adema hands n feet ...the mpst serious complicatoin if left untreated is
1. demyelinating encephlaitis
2. prog joint deformaty
3. renal failure
*4. myocardial dysfunction
5. febrile seizure
ANS: Kawasaki disease
90. 45 y/o M, with recurrent attack of cough with copious,foul smelling sputum and recurrent hemoptysis. On PE shows crackles on both lung bases, CXR shows thickening of bronchial wall and cystic spaces on both lung bases. What is the confirmatory test for DX?
1.xray
*2.CT
3.US
4.Laringoscopy
Chest x-rays can often detect the lung changes caused by bronchiectasis; however, occasionally, results are normal. Computed tomography (CT) is usually the most sensitive test to identify and confirm the diagnosis and to determine the extent and severity of the disease; these are important factors when surgical treatment is being considered.
91.Pt. with hypernatremia and hypotension, what IVF to use?
*1. NSS
2. D5W
3. Free H2O
4. D50W
92. A 21-year-old woman is a restrained passenger in a high-speed motor vehicle collision and presents with neck, abdominal, and back pain, with normal vital signs. She is 32 weeks™ pregnant. Which of the following statements is incorrect?
A. Fetal monitoring is important to detect early fetal distress.
*B. Traumatic placental abruption is almost always associated with vaginal bleeding.
C. Appropriate radiological studies should not be withheld.
D. Ultrasound is not very accurate in detecting placental abruption
Answer: B
In blunt trauma, 50% to 70% of fetal losses result from placental abruption. Fetal mortality in abruption cases is about 50%. Classic clinical findings in placental abruption may include vaginal bleeding, abdominal cramps, uterine tenderness, amniotic fluid leakage, maternal hypovolemia, and fetal distress. However, in some trauma series, up to 60% of placental abruption has no associated vaginal bleeding. Fetal monitoring is a sensitive monitor for fetal distress. Appropriate radiologic studies should never be withheld when necessary to properly care for the mother. Ultrasound is less that 50% accurate in detecting abruption.
*93. A 6-year-old girl ingests an unknown volume of a pesticide called Sevin(®)(a carbamate anticholine-sterase inhibitor) and presents with clinical evidence of toxicity, including pinpoint pupils, vomiting, diarrhea, severe weakness, and heavy oral secretions. Besides prompt intubation and ventilation, appropriate treatment includes which of the following?
A. atropine
B. methylprednisolone
C. pralidoxime
D. epinephrine
Answer: A
Carbamates are reversible acetylcholinesterase inhibitors that lead to hyperstimulation of nicotinic and muscarinic receptors in the autonomic nervous system. The classic presentation includes hypersecretion from all orifices along with diffuse weakness and various central nervous system manifestations. Supportive care, decontamination, and intravenous atropine in high doses are the mainstays of therapy. Pralidoxime is not indicated for carbamate poisoning.
94. Which of the following is appropriate initial antihypertensive therapy for the listed hypertensive emergency in a patient with a blood pressure of 210/116 mm Hg?
A. eclampsia”captopril
B. aortic dissection”nitroprusside
*C. clonidine withdrawal”phentolamine
D. phentolamine cocaine intoxication”propanolol
Answer: C
Eclampsia is a hypertensive emergency in pregnancy with secondary seizures. Traditionally, it has been treated with magnesium sulfate and intravenous hydrala-zine, although labetalol and nicard-ipine are gaining acceptance as appropriate antihypertensive therapy in this setting. Captopril and other angiotensin-converting enzymes are contraindicated in pregnancy because of increased fetal mortality. Antihypertensive therapy for aortic dissection has as a goal not only blood pressure control but also reduction of cardiac contractility to decrease the shear force from the pulse pressure of each contraction. Beta-blocker therapy with propanolol or the shorter-acting, more titratable esmolol is the therapy of choice. Nitroprus-side is inappropriate initial therapy for aortic dissection because it causes reflex increases in heart rate and cardiac contractility. Cocaine intoxication leads to cate-cholamine excess. The resultant severe hypertension will be increased by beta-blocker therapy alone. Propanolol is contraindicat-ed for initial therapy of cocaine-induced hypertension. Clonidine withdrawal is also a state of cate-cholamine excess and is appropriately treated initially by an alpha-blocker such as phentolamine.4,5
95. A depressed 28-year-old woman with AIDS and pulmonary tuberculosis presents with recurrent generalized seizures. She has not stopped seizing despite large doses of lorazepam and fosphenytoin 1 g intravenously. Which of the following should be considered quickly in the patient™s care?
A. thiamine
B. sodium bicarbonate
C. vecuronium with ventilatory support
D. pyridoxine
Answer: D
Pyridoxine (vitamin B6) is the antidote of choice for isoniazid toxicity, a cause of intractable seizures unresponsive to standard therapies. An initial dose of 5 g in adults and 1 g in children is indicated in unknown overdose with intractable seizures.6 Paralysis by neuromuscular blocking agents will hide the motor activity but will not protect from the continuous neuronal hyperstimulation of ongoing seizures, and if used, requires ongoing electroencephalogram monitoring.
96. 45 y/o male with HTN, smoker, DM, and obese, What will help the most to decrease his BP??
A) weight loos
B) stop smoking
C) exercise
D) control DM
ANS: A
97. colonic polyp and screening following resection (one colonic polyp “ which showed ½ adenocarcinoma, the other half is free of cancer “ no family hx) :
a. annual colonoscopy
b. Elective Sigmoid resection
c. Hemicolectomy
ans: b
98. 1-pt presents with dysphagia, drooling, fever, now very lethargic and confused , hx of family going camping and spending lots of time in caves:
Most likely dx:
*a. RABIES
b. Tetanus
c. Pertussis
d. Epiglottitis
99. 2-Most appropriate statement about this patient™s condition at this point is :
a. Very poor prognosis
b. Pt will recover completely with treatment
c. This will worsen in the next 24 hrs then begin improving
ANS: A, A
100. To confirm the diagnosis of Parkinson™s Disease in a patient presenting with a hx consistent with PD “
a. CT scan of the head
b. Nothing further
c. LP
ANS: B
101. Pt is a chronic smoker, wants to quit, has tried to quit in the past with patch (?) but didn™t work, really wants to quit now “ next best step is to prescribe?
*a. Bupropion
b. Low dose nicotine patch
c. Do nothing
d. Nicotine gum
ANS: A
102. A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
a.Increase the warfarin dose to bring the INR into therapeutic range
b.Switch to dicumarol
c.Interrupt the inferior vena cava with a filter
d.Discontinue warfarin and begin heparin at a therapeutic dose
e.Discontinue warfarin and begin thrombolytic therapy
?ANS: D ****
103. A 60 year old male was admitted with chest pain - crushing - that started at around 10.05 PM as soon as he started watching the News. He waited for it to go thinking it as a gas pain but as it did not go off, called ambulance and reached the hospital at 11 PM. Was seen in ER. EKG was taken and showed ST segment depression in V2, V3, V4. He was given Aspirin and started on heparin within the first minute and diagnosis was unstable angina. He is also getting a nitroglycerin drip iv. At 11.20 the cardiologist sees him and he still has pain and sweating, but pain was gone for sometime in between. EKG taken then still shows ST depression in the same leads. No Q wave or ST elevation.
WHat is the next best step?
1. Increase Nitroglycerine
2. Start tPA infusion ASAP
3. Check Troponins
4. Start Plavix
5. Do cardiac catheterization Stat
ANS: 5
104. 25 yrs old woman with history of migraine , take some herbal medicine, what is the name?
a. ginkgo
b. St. john's wort-depression
c. saw palmetto-prostate
*d. feverfew
e. ephedra “ upper BP up FDA took it down
Feverfew
Background: Feverfew is a bushy perennial herb. Parthenolide and glycosides are thought to be its active components.
Medicinal Claims: Feverfew is used to prevent migraine headaches. It may reduce inflammation. Feverfew reduces the clotting tendency of platelets (cell-like particles in the blood that help stop bleeding by forming clots). Evidence from two of three relatively small but well-designed studies supports these effects. Differences in study findings may reflect the different formulations of feverfew used. In studies of people with arthritis, feverfew did not relieve symptoms.
Possible Side Effects: Mouth ulcers and skin inflammation (dermatitis) may occur. Taste may be altered, and heart rate increased. Feverfew may interact with anticoagulants, drugs used to manage migraine headaches, and nonsteroidal anti-inflammatory drugs (NSAIDs). It may reduce the absorption of iron. Feverfew is not recommended for children or for women who are pregnant or breastfeeding.
105. 60 y/o pt. with lymphoma complains of weakness, exertional SOB, easy fatigability, HGb-10, Hct-30, Ret. count -3.5, LDH-400,, + spherocytes, + Coombs test for IgG, most likely DX
1. cold Ab Hemolytic Anemia
2. hereditary sperocytosis
3. autoimmune hemolytic anemia
*4. warm Ab Hemolytic anemia
106. A 5-year-old boy presents with several days of fever to 104°F, along with bilateral conjunctival injection, a strawberry tongue, red and cracked lips, marked cervical adenopathy, as well as erythema and swelling of both hands and feet. Which of the following is accepted therapy for this illness?
A. penicillin
B. prednisone
*C. acetylsalicylic acid
D. azithromycin
Kawasaki syndrome has an abrupt onset, with fever as high as 104°F (40°C) and a rash that spreads over the patient's chest and genital area. The fever is followed by a characteristic peeling of the skin beginning at the fingertips and toenails. In addition to the body rash, the patient's lips become very red, with the tongue developing a "strawberry" appearance. The palms, soles, and mucous membranes that line the eyelids and cover the exposed portion of the eyeball (conjunctivae) become purplish-red and swollen. The lymph nodes in the patient's neck may also become swollen. These symptoms may last from two weeks to three months, with relapses in some patients. The physician will first consider the possible involvement of other diseases that cause fever and skin rashes, including scarlet fever, measles, Rocky Mountain spotted fever, toxoplasmosis (a disease carried by cats), juvenile rheumatoid arthritis, and a blistering and inflammation of the skin caused by reactions to certain medications (Stevens-Johnson syndrome). Kawasaki syndrome is usually treated with a combination of aspirin, to control the patient's fever and skin inflammation, and high doses of intravenous immune globulin to reduce the possibility of coronary artery complications.
107. A 19-year-old man comes to the emergency department because of urethral discharge. Gram stain shows numerous neutrophils, some of which contain gram-negative intracellular diplococci. Ceftriaxone, 250 mg intramuscularly, is administered. Five days later, the patient comes to your office because the discharge has persisted.
Which of the following is the most likely cause of this discharge?
*(A) Chlamydia trachomatis
(B) Ureaplasma urealyticum
© Penicillin-resistant Neisseria gonorrhoeae
(D) Re-infection with Neisseria gonorrhoeae
(E) Urethral stricture
Gram-negative, intracelullar diplococci indicates N.gonorrhoeae.
Tetracycline resistance: 17-23% Penicillin resistance 15-19% Emerging Fluoroquinolone resistance
No resistance to Third Generation Cephalosporins Ceftriaxone (Rocephin)
tratment for NGU clamidia
References MMWR Morb Mortal Wkly Rep (1995) 44:761-5 Fox (1997) J Infect Dis 175: 1396-403
108. Pneumococcal vaccine is indicated for which one of the following?
A. 15-year-old with recurrent sinusitis and URI
b. 8-year-old with recurrent tonslitis
*c. 3-year-old with nephrotic syndrome
d. 6-month-old with sickle-cell disease
e. 3-month-old whose mother has active human immunodeficiency virus (HIV) infection
According to the Immunization Practices Advisory Committee of the Center for Disease Control and Prevention, pneumococcal vaccines should be administered to the following individuals:
--Persons 65 years or older
--Persons aged 2-64 years who have chronic illness that includes chronic cardiovascular disease, chronic pulmonary disease, diabetes mellitus, cirrhosis, alcoholism, or cerebral spinal fluid (CSF) leaks
--Persons aged 2-64 years who have functional or anatomic asplenia, persons who are splenectomized, and particularly those suffering from sickle cell disease
--Persons aged 2-64 years who are living in a particular environment or social setting that may include Alaskan natives, certain American Indian populations, and residents of nursing homes and other long-term care facilities
--Persons who are immunocompromised with illnesses, such as HIV infection, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, organ or bone marrow transplantation, and persons receiving immunosuppressive chemotherapy (including long-term systemic corticosteroids)
--Vaccinate persons without hesitation for whom the vaccination status is unknown
109. A 14 year old boy with acne lesions on face and back on benzoic peroxide and topical tretenoin with only partial response. What will you do next
a. Oral tretenoin
b. Corticosteroids
*c. Oral tetracycline
d. Topical erythromycin
Go from topical to oral and from least harmful to most harmful.
Topical Benzoyl peroxide >> Topical antibiotics >> Topical isotretinoin >> Oral antibiotics >> Oral Isotretinoin.
110. 67 yrs old with lower extermities BP 180/90. upper extremities 150/85 what is Dx?
*a. essential HTN
b. renal artery stenosis
c. pheochromocytoma
d. malignant HTN
e. Stenosis of ascending aorta
It is normal finding to have higher Bp in the lower extremities than the upper ones but I assume that the Q is asking about the most likely cause of the hypertension (whether measured in the upper or lower ex.).
I think essntial htn is the answer
111. A 3-month-old child was exposed to an adult with active pulmonary tuberculosis. What is the recommended approach to this problem?
a. Administer a TST and reevaluate in 3 months.
b. Administer a TST, perform a CXR, and reevaluate in 3 months.
c. Administer a TST, perform a CXR, administer INH, and reevaluate in 3 months.
d. Reevaluate after 3 months.
*e. None of the above.
A child with a positive Mantoux test result but without active disease is a candidate for isoniazid prophylaxis. Active disease is excluded by a normal chest radiograph and a lack of symptoms suggesting TB disease.
Special pediatric cases should be considered candidates for isoniazid prophylaxis even if they lack documentation of a positive Mantoux test:
Newborn prophylaxis: Infants whose mothers have active disease (even if noncontagious) and infants whose mothers have a positive Mantoux test but do not have active disease (preventive therapy can be discontinued after the entire family is demonstrated to have negative tuberculin skin tests)
Children who are both anergic or HIV-positive and from populations where the prevalence of TB infection is higher than 10% (eg, injection drug users, homeless persons, migrant laborers, and individuals from Asia, Africa, or Latin America)
Children who have had close contact within the past 3 months with a person with infectious TB."
www.vnh.org/PreventionPractice/ch09.html
112. A pt on heparin and warfarin develops thrombocytopenia and petechiae, what is next
d/c heparin
d/c warfarin
continue both
*d/c both
MANAGEMENT OF PATIENTS WITH HIT(Heparin induced Thrombhocytopenia)
There are few prospective randomized studies on which to base recommendations regarding the management of HIT. The following guidelines are based on the best available data in January 2002. Patients with HIT are best managed by, or in consultation with, a specialist experienced in managing HIT.
a. All heparin should be discontinued in patients with HIT. This includes unfractionated and low-molecular weight heparins by any route, heparin flushes, and vascular catheters that are heparin-coated.
b. Anticoagulation with an alternative anticoagulant - either danaparoid, lepirudin, or argatroban (listed in historical order of availability) should be given if the original indication for which heparin was initiated still exists (see #6. Anticoagulants for HIT).
c. Patients who have new, progressive or recurrent thrombosis associated with HIT (HIT-associated thrombosis) should be treated with therapeutic-dose anticoagulation with danaparoid, lepirudin, or argatroban. (see #6. Anticoagulants for HIT). Therapy should not be delayed for the results of laboratory testing if the clinical suspicion of HIT is strong.
d. Danaparoid, lepirudin, or argatroban should be strongly considered in patients with HIT even in the absence of thrombosis. Patients with HIT remain at high risk of thrombotic complications for several days or weeks after cessation of heparin.
e. Warfarin should be avoided in acute HIT unless it is used in combination with therapeutic-dose danaparoid, lepirudin, or argatroban. Warfarin has been associated with worsening venous thrombosis, venous limb gangrene, and/or skin necrosis when used alone or in combination with ancrod in acute HIT. However, warfarin is appropriate for longer term anticoagulation in patients with HIT and thrombosis. Warfarin should be delayed until therapeutic anticoagulation with danaparoid, lepirudin or argatroban is achieved, and ideally, until there is substantial resolution of the thrombocytopenia. Warfarin-induced thrombotic complications have been described in patients in whom the alternative anticoagulant was stopped prior to resolution of thrombocytopenia. The optimal duration of anticoagulation in patients with HIT and thrombosis is not known.
113. A healthy 71-year-old man describes visual loss in his right eye. Flashes of lig
NOT VERY SURE OF ANSWERS
1. One of your bipolar patient who you have been treating with lithium for last 6 years comes to your office for routine check up. she has no symptoms. you run a TSH level and find to be 9. what is the next step?
a. change lithium to carbamazepine
b. decrease lithium dose
c. change lithium to valproic acid
d. continue lithium and monitor patient
*e. continue lithium and add levothyroxine
2. 84 year old man who has history of DM, HTN, was observed by family to have behavioral changes over the past few days. What is the most appropriate initial investigation?
*a. check electrolytes
b. EKG
c. CBC
d. CT of the head
e. MRI
3. 53 y , F, husband died 3 months ago. Tearful and wish to be died with him. Not socially mixed. disturebed. some time feel worthless and saty home most of time. eating is appropriate. came to psyc. Diagnosis?
*a. bereavement
b. acute stress ds
c. depression
d. acute adjustamnet ds
e. PTSD
4. A 29-year-old white female is hospitalized following a right middle cerebral artery stroke confirmed on an MRI scan. Her past medical history is remarkable only for a history of an uncomplicated tonsillectomy during childhood, and a second-trimester miscarriage 3 years ago. The only remarkable finding on physical examination is left hemiplegia.
The initial laboratory workup reveals normal hematocrit and hemoglobin levels, a normal prothrombin time, and a platelet count of 200,000/mm3 (N 140,000-440,000). The active partial thromboplastin time is 95 sec (N 23.6-34.6), and it does not normalize when the patient's serum is mixed with normal plasma. A serum VDRL is positive, and a serum FTA-ABS is nonreactive.
Which one of the following is the most likely diagnosis?
Hemophilia
Neurosyphilis
*Antiphospholipid syndrome
Thrombotic thrombocytopenic purpura
Protein C deficiency
5.A 43-year-old white female presents with a 4-year history of irregular, intermittent vaginal bleeding. She is not taking hormonal therapy. Her past history is negative. Physical examination is normal except for a large, nodular uterus compatible in size with a 16-week pregnancy. Laboratory tests, including hemoglobin and urine hCG levels, are all normal. What is the Diagnosis?
1 polycystic ovarian syndrome
2 carcinoma of the uterine cervix
3 endometrial cancer
*4 uterine leiomyomata
5 ovarian carcinoma
6.Which one of the following is most likely to be a factor in the pathogenesis of gastric ulcer?
1 Excess gastric acid
2 Increased serum gastrin
3 An increased number of parietal cells
*4 Reflux of duodenal contents into the stomach
5 Impaired gastric emptying
While the complete etiology and pathogenesis of gastric ulcer are not known, impairment of the mucosal barrier to the back diffusion of hydrogen ion appears to be involved in the process. The reflux of bile and other duodenal contents into the stomach, which has been found in gastric ulcer patients, is thought to be one mechanism of mucosal barrier disruption. Since most patients with gastric ulcer have normal or low acid production, excessive acid is probably not a factor. Similarly, impaired gastric emptying is not common in such patients, and when it occurs it appears to be a consequence of the condition and not a cause. The number of parietal cells is increased in duodenal ulcer patients but is normal in patients with gastric ulcers. Fasting gastrin levels are variable in the presence of gastric ulcer and appear to correlate inversely with acid secretion. Hypergastrinemia is not a primary factor in gastric ulcer. When it occurs it is a physiologic response to low gastric acidity.
Ref: Schwartz SI (ed): Principles of Surgery, ed 7. McGraw-Hill, 1999, p 1194.
7. A 27-year-old white male has a clinical complex of jaundice and chorea. The diagnosis of Wilson's disease is confirmed by which one of the following?
1 Liver biopsy evidence of chronic active hepatitis
2 History of a manic-depressive psychosis
3 Kayser-Fleischer rings of the cornea
*4 Inability to incorporate a copper isotope into ceruloplasmin
Wilson's disease is an autosomal recessive abnormality in the hepatic excretion of copper, resulting in toxic accumulations of the metal in the liver, brain, and other organs. The manifestations of this disease may include liver disease leading to cirrhosis, neurologic or psychiatric disturbances, and Kayser-Fleischer rings of the cornea. However, none of these conditions is found only with Wilson's disease. Hepatitis B is also associated with chronic active hepatitis. Many psychiatric illnesses, including schizophrenia and other bizarre behavioral disturbances, are indistinguishable from Wilson's disease, but these conditions are not necessarily associated with copper metabolism. Kayser-Fleischer rings may also be associated with certain cataracts. Classically, the diagnosis is made by the demonstration of a serum concentration of ceruloplasmin less than 20 mg/dL and either (1) Kayser-Fleischer rings, or (2) a liver biopsy sample containing greater than 250 micrograms of copper per gram of dry weight. However, the diagnosis can be confirmed by a test of the patient's inability to incorporate radioactive copper into ceruloplasmin.
Ref: Fauci AS , Braunwald E, Isselbacher KJ, et al (eds): Harrison 's Principles of Internal Medicine, ed 14. McGraw-Hill, 1998, pp 2166-2169
8. A 34-year-old white male is brought to the emergency department following an automobile accident in which he was the only occupant of the vehicle. He lost control of the vehicle and hit a utility pole. He was knocked unconscious initially, but he is now awake and combative. You note a strong smell of alcohol. He has a frontal hematoma approximately 3 cm in diameter and an actively bleeding 4-cm laceration of the occiput. He will not permit you to examine him further and he prepares to leave the emergency department.
You should
*1 detain him in the emergency department
2 make him sign out against medical advice
3 tell him that he cannot return if he leaves
4 tell him that if he leaves he can return later
Two of the most important ethical principles are respect for autonomy and beneficence. Respect for autonomy means regarding patients as rightfully self-governing in matters of choice and action. To make an autonomous decision, the patient must be mentally sound, have knowledge and understanding of the facts, and be free of coercion. Beneficence means that physicians are motivated solely by what is good for the patient. There are often ethical conflicts between these two principles. This particular patient is clearly in need of further emergency treatment, but he refuses. He has had a significant head injury, is combative and possibly intoxicated, and therefore cannot be considered mentally sound. The physician should detain him for his own good and provide the appropriate care. Threatening him, having him sign out against medical advice, and encouraging him to return later are not appropriate because his mentation is impaired.
Ref: Goldman L, Bennett JC (eds): Cecil Textbook of Medicine, ed 21. WB Saunders Co, 2000, pp 5-6.
9. A 70-year-old white male is found to have microscopic hematuria on routine urinalysis. The most likely cause is
1 asymptomatic renal stone
*2 benign prostatic hyperplasia
3 bladder cancer
4 coagulopathy
5 urinary tract infection
10. 18 y/o pregnant, first trimester, blood pressure 120/75, has seizures,
which is the diagnosis in this case
a eclampsia
*b.epilepsy
11. A 5 year-old has anemia with Hb 6.2g. You gave iron. After one week treatment follow up, what do you order?
a] hct
b] iron
*c] Reticulocyte count
d] Hb
e] vitamin B12
12. An overweight 60 year old white male comes to your office for an early appointment to know about his cholesterol and heart disease risks. He is a diabetic for the past 25 years, smokes 1 packet per day for the past 20 years, has mild hypertension and is on a betablocker for that. His elder brother died at the age of 52 suddenly. His father had a stroke at the age of 72 and died later.
You send for his fasting lipid profile. You discuss with him the ways how heart disease risk is calculated.When telling him about his coronary artery disease risks,
Which of the following IS NOT A RISK FACTOR for CAD?
a. Hypertension
b. Smoking
c. Brother dying of probable myocardial infarction at 52
*d. Diabetes Mellitus
e.His lipid profile showing a Low HDL level
f. His age
If U have diabetes U are considered just like a person with COronary Heart disease. SO DM does not increase UR risk for coronary heart diseasae BUT IT ITSELF IS CORONARY HEART DISEASE
13. a pregnant pt with preeclampsia. Bp is 160/120. what anti-HTN medication ?
Hydralazine is the DOC for BP control in preeclamptic patients. However, parenteral hydralazine is provided only to pharmacists upon special emergency request. Therefore, the physician must be comfortable using other antihypertensive agents. Labetalol has alpha-adrenergic and beta-adrenergic blocking effects and can be used to provide rapid control of severe hypertension. Other antihypertensive agents have significant adverse effects and should not be used as primary agents. Diazoxide may cause hyperglycemia and inhibit labor, and nitroprusside may cause fetal cyanide toxicity. Diuretics should be avoided because of the relative intravascular volume depletion already present in patients with preeclampsia
14. A 32 weeks pregnant pt with severe cervical dysplasia. Next
1. treatment
2. no treatment
Due pregnancy the immunity os decreased so there may be flare up of cervical dysplasia.
More paps test is done during pregnancy that may be a reason for more diagnosis of cervica dysplasia.
So, HPV should be studied and close observation is required.
Two options
Cryotheraty during pregnancy or after the delivery with good outcome
15. A CO poisoning pt waked up. Vital sign is normal. Q asks of the following, which one is the most important you should keep watching this pt ?
*1.headache
2.weakness
16. Pt presented with unstable angina and after initial mx pt was stabilized.for the next 48hrs he had no angina at rest.EKg was normal.
what is next.
A)Stress test and then catherization
*B)catheterization without a stress test
17. Person with symptoms of Obstructive sleep apnea...what is the first/next step?
a)sleep study
*b)medical workup
c)CPAP treatment
18. what is the prognosis of ADHD
a. most of them become schizophrenic
b. most of them get remission when they grow up
*c. most of them become antisocial(25%)
d. most of them will have depression
19. 50yr old man had polyps now on removal biopy show superficial colon cancer which is not in mucous mem ,,villou adenoma but u knew his dad had colon cancer at age 60 now what
*a.do segmental colectomy
b.do regular follow up
20. Pt. comes wiith SOB, palpitation, EKG shows atrila fib., while starting IV line pt. become unresponsive. Cardiac monitor still shows Atrial fib.
Next to do?
1.start chest compression
*2.synchronous cardioversion
3.asynchronous cardioversion
4.immediate ABG
21. Pt. comes to your clinic, or ER with hx of angina for more than 2 mos.w/c is relieve by rest, next step.
1. admit patient
*2. exercise stress test
3. echo.
4. nuclear study
22. 60 y/o M with recurrent attacks of chest pain for the last 2 mos. and relieve by rest, EKG is N, stress test shows ST depression 3 mm in lead V3-V5 during the 5th minute of Bruce Protocol, HR is 90/min. Next recommendation?
1.Nuclear stress test
*2. Cardiac Cath.
3, Prescribe Niroglycerine
4.Echo.
23. Contraindication of Thronbolytic Tx in MI.
1. less than 12 hrs. post MI
2. ST elevation in 2 consecutive leads
*3. St depression with elevated cardiac enzymes
4. New LBBB
24. Pt. came to ER found to have MI, w/c meds you should discontinue w/c patient is currently taking, BP-140/80, PR- 98.
*1. Ca Ch. blocker
2. B-blocker
3. Nitroglycerine
4. Ace inhibitor
Ca channel blocker. They increase the heart rate, work load on the heart and O2 demand
25. Pt. with CLL on chemoTX via Hickman catheter, complains of fever, chills, on exam, exit site of catheter has erythema and tenderness, you send blood. culture, what is further mgt.?
1. start vanco. and Genta. and remove cath.
2. Remove catheter and culture the tip
*3. start Vanco and genta. but don't remove cath.
4. start Vanco,and genta plus rifampicin
STart Vanco and genta and remove catheter ( and send it for tip culture). This patient is an immunocompromised pt. All patients (also for regular) when U suspect infection, send for culture and start empiric Abx. COrrect them when the sensitivity report comes in accordingly
26. 56 y/o F with fatigue, heavy menstrual bleeding, MCV-70, Hct -30, what's next?
1. Colonoscopy
*2.FOBT
3.Flexsigmoidoscopy
4.Iron supplement
Answer: FOBT. If positive, this means that you have chronic GI bleeding which necesstitates sigmoidoscopy OR colonocopy
27. 10 y/o girl came for regular check up, live in a house built 40 yrs. ago, complains of easy fatigability, on exam, + pallor, next exam to order
1.Pb level
*2.CBC
3. ret. count
4. Iron studies
Answer: CBC. Always start with CBC even if you know that she can have lead poisoning, don't do lead level before CBC!! Start with the general then go to the specific!
28. Child with jaundice and splenomegaly, CBC with periph smear shows spherocytes, Increase MCHC, Dx
*1.hereditary spherocytosis
2,G6PD def.
3. Autoimmune Hemolytic anemia
4. Thallasemia
next Q, what test to order to arrive at a specific DX?
Dx: Spherocytosis and the diagnostic test is osmotic fragility test.
#1 and 3, both has increase MCHC and spherocytes, to diff. do Coomb's test w/c is Neg. in hereditary spherocytosis and Pos.in Autoimmune hem. anemia
29. Pt. with sickle cell anemia comes with SOB, weakness, compared CBC, you noticed decrease of H&H from 10/30 to 5/20, next to order
*1. Direct Coombs test
2, HGB electrophoresis
3. Reticulocyte count
4. Cold agglutinin test
Answer: Coomb test, direct.
# Ret. count, to diff. bet aplastic crisis and hemolytic cisis, (Ret. count is low in aplastic crisis and high in hemolytic crisis).
30. Pt. with hemolytic anemia needed blood transfusion but no match blood available, transufe.
*1.Type O neg. bld.
2. Type AB bld
3. Type O pos. bld.
4. FFP
31. A 68 year old man comes to your offic complaining of a hand tremor. The tremor becomes worse with voluntary movement. he notes that it improves with alcohol consumption. On physical exam, the tremor is coarse in nature. What is the most likely cause of this patient's tremor?
A. Parkinson's disease.
B. Alcoholic neuropathy.
C. Benign familial tremor.
*D. Intention tremor.
E. Huntington's chorea
32. A 20-year-old competitive swimmer is examined because of primary amenorrhea. Her height is 170 cm (67 in.), and she weighs 50 kg (110 lb). Her breasts are well developed. Findings on pelvic examination are normal, and the pubic hair appears to be normal. Cervical mucus is abundant and demonstrates ferning on drying. Urine spot and blood tests for pregnancy are negative. She is given 10 mg of medroxyprogesterone acetate twice a day for 5 days, and 3 days later she experiences menstrual bleeding for the first time. The most likely cause of the amenorrhea is
A. polycystic ovarian disease.
B. 45,X gonadal dysgenesis.
C. chromaphobe adenoma of the pituitary.
*D. functional hypothalamic amenorrhea.
E. prolactinoma of the pituitary.
33. Glucagon is least likely to be used for severe hypoglycemia in
1) Type II DM
*2) Malnourished patient
3) Infant overdose of injected insulin
4) Obese patient > 65yrs
Malnourished patients - have almost NO LIVER GLYCOGEN stores. Glucagon raises the sugar level but inducing an acute glycogeolysis into Glucose through Glucose-6-phosphatase. For that it needs Liver stores
34. 34 yr old man with abdominal pain, n,v,tender abdoman, increase bowel sound , guarding, old scar above umbilicus. x ray show dilated bowel loop,no gas under diaphragm. how to Dx?
*a. ct scan
b. endoscopy
c. colonoscopy
d. barium enema
35* 3 y/o boy diagnosed accidentally a holosystolic harsh murmur best heard at the left sternal border, echo done and Md's Dx was confirmed. According to the mother he's a very active kid and has no physical complaints, now sh'e asking what is best for his son.
*1. refer to cardiothotacic Sx
2. prescribe indomethacin
3. would only refer to SX if pt. become symptomatic
4. observe and repeat Echo. when he's 4 y/o
www.emedicine.com/ped/topic2402.htm
35. Parent of 18 y/o came in for routine PE for their son who is going to participate in baseball team, parents have heard a boy in their sons school died while playing, they ask now every possible test you could do before he would participate in the team.
1. Hx , PE and Echo
2. Hx , PE and EKG
*3. Hx and PE
4. Hx , PE and stress test
36. 28 y/o m HIV + is admitted with severe headache, nausea, vomiting, stiff neck and T 39 C
Which of the following measures is MOST important at this time.
a ceftriaxone
b vancomycin and ceftriaxone
c lumbar puncture
*d amphotericin B and flucytosine
e amphotericine B
37. 45 years old woman with history of DM and mild Hypertension with occational history of seizure for last 6 month came to your office with 6 hours h/o headache right sided partial ptosis, pain in lower half of face and neck rigidity. would be the cause?
a)Trigeminal neuralgia
*b)SAH of Post communicating artery
c)SAH of PICA
d)Brainstem glioma
e)Lacunar stroke
38. A man with 5x5 cm mass in left lobe of thyroid which is found to be papillary carcinoma..The man has develop HOARSENESS. the right lobe of thyroid is irregular on exam.. what is the best treatment
a)radiation
b)partial thyroidectomy plus radiation
c)total thyroidectomy with left neck dissection
*d) total thyroidectomy with removal of enlarged nodes
39. Large Bowel obstruction “ next step in management?
*a. Stat surgery consultation
b. Supportive treatment
c. D/c home and f/u in clinic
40. Pt in ICU setting “ ARDS “ on ventilator. An ABG was given -- FiO2 was 70- asked something like next step in management:
a. Inc fio2
*b. Add peep
c. Dec fio2
41. To confirm the diagnosis of Parkinson™s Disease in a patient presenting with a hx consistent with PD “
*a. CT scan of the head
b. Nothing further
c. LP
42. Pt is a chronic smoker, wants to quit, has tried to quit in the past with patch (?) but didn™t work, really wants to quit now “ next best step is to prescribe?
*a. Bupropion
b. Low dose nicotine patch
c. Do nothing
d. Nicotine gum
43. Pt (HIV -, no other comorbidities) with PPD + (> 15mm), CXR neg “ Txed with INH for 6 months “ F/u?
a. PPD Qyr
b. CXR annually(?)
c. PPD Q5yrs
*d. Tx with INH for another 3months
e. Tx with INH for another 6 mths
44. In a clinic setting, there was TB exposure to all employees : next step?
a. Start tx with all 4 drugs
b. Tx all with INH for 6 months
*c. Do PPD on all those exposed to the active TB person
45. Pt is a nurse with symptoms of hyperthyroidism - Graves Dz vs. Factitious hyperthyroidism distinguished via :
a. TSH
b. FT4 concentration
*c. T3 resin uptake
d. TSI (thyroid peroxidase antibody)
46-1.--Spousal abuse, poor family, having trouble making ends meet, both patient and husband are not educated, patient is not willing to leave husband who uses alcohol frequently and was arrested for DUI. The next step in management in this patient is:
a. Report to Protective agency
b. Remove patient from home and admit
*c. Tell her that you will help in whatever way you can, give her shelter phone number and to go to emergency whenever needed
2--. the second part“ The degree of danger in this situation is correlated with
*a. substance use ( alcohol)
b. arrest for DUI
c. Financial instability of family
d. Poor education level of both parents
47. HIV + man doesn™t want to tell his wife and will not stop relationship with her “ the most appropriate statement to this man is:
a. I really am in a difficult situation here “ can we work together to find the right solution
b. I will inform Public health authorities and they will then inform her
c. The other choices were really inappropriate “ don™t remember what they were
HIV man:
First - talk with him and tell him to tell his wife about the diagnosis
If he does not , in HIV - U HAVE THE RIGHT TO TELL THE PARTNER but it is not mandatory that U must tell the partner.
ref: Kaplan Lectures
48.A 65 year old female who had a stroke a year back and is bed-ridden for almost 15 hours a day due to severe paresis presents to the ER with abdominal distension and pain in the left leg (calf). She could not get up to pick up the phone and 911 was called when the home nurse came to her in the morning. SHe has been having the distension for almost 2-3 weeks but now she finds it intolerable and hurts when she breathes.
PE:
Abd: Ascites +++, Liver enlarged +++, Spleen enlarged ++, no spider angiomata present.
Leg: Left foot has no edema, left leg - calf is extremely tender and DOppler confirms DVT. Right leg has no edema, No vulvar edema
CVS: Right lung bas has minimal rales , no pain, (no chest pain in the HPI), NO JVD, NO neck vein distension
Temp - normal, Pulse - 94, RR - 30
THE CAUSE OF ASCITES IS:
a).Congestive cardiac failure
b).Pulmonary Embolism and Right HF
c).DVT moving into the systemic circulation
*d).Protein C deficiency
e).Atherosclerosis
f).Nephrotic syndrome
g).Cirrhosis secondary to HCV infection
Exclusion:
JVD is not raised - this alone excludes - CCF, Pulmonary embolism causing an acute Right heart failure and all other causes of increased pre load with congestion
There is no lower limb edema and no anasarca. This proves that there is no decreased albumin in the blood.That rules out Nephrotic syndrome. Also in Cirrhosis, the edema is mainly ascites due to portal hyper tension. If Generalized edema develops, it is due to decreased albumin production by the diseased liver. So this also rules out Cirrhosis to some extent. Also in Cirrhosis - liver is not palpable ( liver is palpable only in acute non-fulminant hepatitis. But they do not raise Portal pressure so much to cause dyspnoea)
USMLE gives hints in the questionas here. The guy has DVT ( no hx that the person had a prior episode of DVT or not).
Embolus going into circulation can causae an IVC clot and that causes pedal edema FIRST and later the pressure mounts inn the hepatic veins.
Another condition that can show like this is Acute alcoholic hepatitis - but no alcohol history.
49. A 62-year-old man with metastatic prostate cancer
has a rising PSA level despite treatment with
leuprolide and flutamide. What should be the first
step in managing this asymptomatic man with hormone-
refractory disease?
A) Treat with aminoglutethimide
*B) Discontinue flutamide to attempt to obtain an
antiandrogen withdrawal response
C) Discontinue leuprolide
D) Treat with diethylstilbestrol
E) Perform an orchiectomy
50.A 35-year-old woman with amenorrhea is found to
have an enlarged pituitary gland. Her prolactin
level is 80 ng/L (normal, less than 20 ng/L), and
her thyrotropin level is 100 µU/mL (normal, 0.5 to
4.5 µU/mL). Which of the following is the best
treatment option for this patient?
A) Administration of bromocriptine
*B) Administration of L-thyroxine
C) Irradiation of the pituitary gland
D) Resection of the pituitary gland
E) Use of oral contraceptives
prolactin level above 100 confirms ur diagnosis of proclactiemia.Since here its 80 it might just be due to associated hypothyriodism. Hypothyroidism is confirmed by tsh levels being above 20. so now my answer is give thyroxine
51. A 53 year old woman presents to the emergency room with abdominal pain, nausea, vomiting, hypotensive, tachycardia and disoriented. A FSG check comes back as >500. You quickly get a urine sample and analyze it with a dipstick. It shows the following results:
Specific Gravity=1.005/pH=5.5/1+protein/4+glucose/+ketones/0 RBC,WBC, epithelials cells.
You promptly get IV access and draw the necessary blood studies. Your next step would be to:
a.Give a Normal Saline bolus and run IV fluids wide open
b.Do (1) and give 10 units of regular insulin IV and start an insulin drip at 0.1units/kg/hr
c.Do (1) and give 10 units of NPH and start an insulin drip at 0.1 units/kg/hr
d.Do (1) and start on Diabeta 10 mg
*e.Do (1) await lab results and observe
Diabetic Ketoacidosis
This patient is obviously in D.K.A. as evidenced by high serum glucose, glucosuria and ketonuria. What ones needs to do now is to resusciate the patient with FLUIDS! To reverse the ketone production that is contributing to the acidosis the patient also needs insulin BUT initially this is secondary to fluid resusciation. YOU DO NOT WANT to be giving insulin to any patient without documented electrolytes. With the acidosis and dehydration, patients become potassium depleted. The committment acidosis will contribute to "shifting" potassium out of the cell giving you a falsely elevated potassium. The danger is if a patient is severly potassium depleted in the face of an acidosis, with the fluids correcting the acidosis, the insulin is going to shove more potassium into the cells thus acutely lowering the serum potassium level to potentially dangerous levels. If the potassium gets lower than 2.0-2.5 one is prone to provoking lethal arrhythmias.
References:
DeFronzo RA, Matsuda M, Barrett EJ. Diabetic Ketoacidosis: A combined metabolic-nephrologic approach to therapy. Diabetes Reviews 2(2): 209-238, 1994.
Cefalu W. Diabetic Ketoacidosis. Critical Care Clinics 7(1): 89-108, 1991.
Axelrod L. Diabetic Ketoacidosis. The Endocrinologist, 375-83. Williams and Wilkins, 1992.
52. A 50 year old white man with a history of "mild" heart attacks presents to the emergency department with a 1 hour history of "crushing" chest pain associated with nausea, shortness of breath, diaphoresis and radiation into the left arm and neck. An old EKG from 3 months ago was normal.
As the E.D. physician you would:
a.Give the patient a "white slider" (a mixture of lidocaine & maalox)
b.Give the patient some Valium and tell him that the pain is all in his head
*c.Give the patient an aspirin
d.Give the patient an aspirin, start Heparin and assess for thrombolytic contraindications
e.Give the patient a sublingual nitroglycerin tablet
f.Give the patient a dose of steroids and start on Ibuprofren
53. Ophthalmoscopic examination shows a pale and swollen optic disk of the left eye with scattered flame-shaped hemorrhages in the vicinity of the disk. An afferent pupillary defect is present in the left eye. The most likely cause for these findings is:
*A - Ischemic optic neuritis
B - Talc embolus due to IV heroin abuse
C - Glioma with papilledema
D - Retinal artery occlusion
E - Diabetic neuropathy
Anterior ischemic optic neuropathy involves interruption of the blood flow in the short posterior ciliary arteries that supply the optic disk. This results in a severe loss of vision, altitudinal visual field defects, and a pale, swollen optic disk, with peripapillary hemorrhages.An afferent pupillary defect (APD) occurs when the nerve pathways to the brain fail to properly transmit messages.If an APD is severe (dilation of the affected pupil), it generally indicates optic nerve disease such as ischemic optic neuropathy, optic neuritis, severe glaucoma, central retinal artery or vein occlusion, or in rare cases, a lesion of the optic chiasm or tract due to a pituitary tumor or stroke.
54. A 35 year old woman comes to the ER complaining of palpitations . An EKG shows A FIb. She says that she has NEVER experienced this before and has never been diagnosed like this before. You as the resident examine her -irregularly irregular pulse, a diffuse swelling in her neck. SHe has a pronounced stare as if her eyes are popping out. She also gives history of feeling hot and sweaty and easy arousability. The labs show her TSH level as <0.1 mu/ml (normal: 0.5-5) and free T4 as 6 ng/dl (N = 0.8 to 2). You find her hyperthyroid and remember your endocrine class that U diffuse enlargement with hyperthyroidism can be due to Graves disease and sub acute thyroiditis. As the examination was confusing for you, you call the endocrinologist. The Most likely advice from the endocrinologist will be:
a). Close observation
*b). Start propyl thiouracil
c). 24 hour radioactive iodine uptake scan
d). Start methimazole and also send her for radio iodine ablation now
e). Reassurance only
methimazole for 2-3wks and then ablation. Be careful with the word NOW...you cannot give both metimazole and ablation.
55. A 72 year-old Iranian-born nursing home resident is brought to your clinic because of an abnormal tuberculin test. The patient has Alzheimer's disease, but is physically in good condition. When he was admitted to the nursing home one year ago his tuberculin test was negative at 4 mm. On this year's routine evaluation, his tuberculin test is 13 mm. What is the most likely cause for the positive PPD?
A Active tuberculosis
B Recent infection with Mycobacterium tuberculosis
C Recent infection with nontuberculous mycobacterium
D Inaccurate recording of PPD in the medical record
*E. Recall of waned immunity (booster phenomenon)
This is Booster phenomenon
Booster phenomenon:
Patient had TB while young OR had contact with a open case while young. The system made antibodies in either case. After a period of time, the memory cells wane and the memory of the initial infection is forgotten.
WHen the first PPD is given, the system remembers the initial event in one to two weeks. SO the second PPD comes a positive.
This is differentiated by ( done in many nursing homes and other places where routine PPD testing is done yearly)
DO PPD for the first time
Then do a repeat PPD in 3-4 weeks. If the repeat is POSITIVE then it is Booster. No more PPD is done on this patient after that anytime
ELse just leave it.If pt tests positive next year, here Booster is esxcluded and it is Tuberculous infection
56. A 26 yr old boy failed in kindergarten but did average in college, no hallucinations but flat affect and always worried that he may injure others. Mother got him to doc. happens to be a quiet boy. What is your diagnosis?
Schizophrenia
*depression
passive aggressive personality
antisocial
57. 34 yr old man with abdominal pain, n,v,tender abdoman, increase bowel sound , guarding, old scar above umbilicus. x ray show dilated bowel loop,no gas under diaphragm. how to Dx?
*a. ct scan
b. endoscopy
c. colonoscopy
d. barium enema
58. 32 yrs old woman with breech pregnancy 35 weeks gestation, now she is having contration. mx?
a.c section now
*b.tocolytic
c.observe
d.external podalic version
e.epidural anesthesia
59. Which of the following drugs is the least sedating and anticholinergic, which can be prescribed safely to elderly patients with depression?
a.fluoxetine
b.MAOI
c.Imipramine
*d.Sertraline
e.Trazodone
60. 9 y/o lady had seizure came to ER, neurological deficit present. CT scan of the head showed ring enhancing lesion in brain. What is probable organism?
a. cryptococus
b. grm positve micro coccobacilli
c. strepto cocci
A single ring enhancing lesion - is considered brain abscess Unless Otherwise proved.
Staphylococcus aureus,Streptococci (especially Streptococcus intermedius),Bacteroides and Prevotella species,Enterobacteriaceae,Pseudomonas species
Other anaerobes
61. 8 yr old child with dirty wound after a fight at school “ Parents immigrated from Russia recently and mom doesn™t speak English, sister translates, say that the pt has received one injection since birth “ in this patient, you would give :*a. Td, Tig and hepatitis B vaccineb. Dtap, Hib and MMRc. www.cdc.gov/nip/recs/child-schedule.PDF
62. Ophthalmoscopic examination shows a pale and swollen optic disk of the left eye with scattered flame-shaped hemorrhages in the vicinity of the disk. An afferent pupillary defect is present in the left eye. The most likely cause for these findings is:
*A - Ischemic optic neuritis
B - Talc embolus due to IV heroin abuse
C - Glioma with papilledema
D - Retinal artery occlusion
E - Diabetic neuropathy
ww3.komotv.com/global/story.asp?s=1230651
63. pt was having dvt..on coumadin and heparin suddenly
started to have sob what is next
a)continue him on heparin and coumadin
b)give him tpa
*c)ivc filter
d)embolectomy
64. A 35 year old woman comes to the ER complaining of palpitations . An EKG shows A FIb. She says that she has NEVER experienced this before and has never been diagnosed like this before. You as the resident examine her -irregularly irregularpulse, a diffuse swelling in her neck. SHe has a pronounced stare as if her eyes are popping out. She also gives history of feeling hot and sweaty and easy arousability. The labs show her TSH level as <0.1 mu/ml (normal: 0.5-5) and free T4 as 6 ng/dl (N = 0.8 to 2). You find her hyperthyroid and remember your endocrine class that U diffuse enlargement with hyperthyroidism can be due to Graves disease and sub acute thyroiditis. As the examination was confusing for you, you call the endocrinologist. The Most likely advice from the endocrinologist will be:
a). Close observation
*b). Start propyl thiouracil
c). 24 hour radioactive iodine uptake scan
d). Start methimazole and also send her for radio iodine ablation now
e). Reassurance only
65. One couple adopt 1 yr old baby from overseas( asia). no vaccination report. Baby is doing well & all are happy. after check up HBe Ag +. adopted mom & dad HBs Ag - .
Mx for mom & dad.
a. vaccine
*b. vaccine & Ig
c. Ig
d. Rifampin
e. repeat HB Ag level 6 months later
66. Symptoms of malabsortion plus refractory iron def. anemia and osteomalacia and vesicular pruritic rash over extensor surface of extremity, DX?
*Celiac Sprue
67. 40 y/o M, HepBsAg +, with multisystemic dis. (fever, anorexia, abdominal pain, etc.)comes with foot drop or wrist drop, Dx?
1.Pb poisoning
2. Lyme dis.
*3. Polyarthritis Nodosa
68. Marathon runner, k is high,vital signs and exam is normal, how will you manage?
1) give I/V saline
2) ekg
3) Dialysis
*4) drinking water
NOTES: A prgenant in her 2nd trimester exposed to a child with Varicella one day age. You checked her serum for varicella antibodies titre and it was negative..Give VZV ig (not vaccine) ..It should be given within 96 hours of exposure.
The mother ask you: Does the VZIG protect my fetus againts infection? NO. VZIG is given to prevent MATERNAL NOT CONGENITAL/FETAL infection!. The congenital varicella syndrome results from exposure during the first 16 weeks of pregnancy.
safe:
1-Pneumococcus (polysaccharide)
2-Meningococcus (polysaccharide)
3-Rabies (killed virus)
4-Influenza (inactivated virus)
5-Hepatitis B (purified surface antigen)
6-Hepatitis A
7-Tetanus-Diphtheria (toxoid)
unsafe:
1-Mumps/Measles/Rubellla
2-Yellow fever
3-Varicella
69. jumping sports cause what kind of injuries
?a)stress fx
b) osgoood disease
c)meniscal tear
d)acl tear
e)pcl tear
70. a iv drug abuser is having voluminus diarrhea, whichof the following test u will do
a)check stool for wbc
b)check for ovaparacite
*c)check for acid fast stain
d)check for c dif
Cryptosporidia: No Lukocytes are found in stools and the crypto can be partially acid fast +!!
Microscopic examination of stool specimen for oocysts using modified acid-fast (Kinyoun) stains is the mainstay of diagnosis for most laboratories. This technique stains oocysts pink or red, while fecal debris or yeast assumes the color of blue or green counterstain. Other stains, including monoclonal antibody-based fluorescent stains, also are available.
71. a 14 yr old boy was brought by mom for physical and u notice that there is only one testis, what u will tell mom???
a)its okay to have one testis bcz he can still have kids with one testis
*b)there is inc chance of cancer of testis so we have to do urgent surgery to avoid that
c)since he is not kid any more he wont have any prob
d)heneeds hormones so his testis will come down i think its some where up there..
72. which of the following diease is not reportable
a)enteric fever
b)pertussis
*c)herpz
d)aids
e)tb
73. a kid with blueberry muffin rash and rash behind ear which is maculopapular..what is it??
a)measals
b)toxoplasmosis
c)cong syphilis
*d)rubellla
74. a kid was playing with cat and showed mom a lesion ,he is not having any symptoms..what u will sugggest to mom
*a) just clean with soap and water
b) sinc ehe is not having any s/s no tretament required
c)give ampicillin
d)augumentin
75. a 2 days old child is unable to pass urine what is most
a)vesico ureteral reflex
*b)post urethral valve
c) urinary diverticulum
d) dehydration due to frequent stoool passgae in ist few days..
76. 45 yr old women who went home after gi bleed
a)lmw heparin
b)lovenox
c)venalcaval filter
d)tpa
77. 23 y F, preganant, paternal grand father has heomophila. Has baby XY she ask for chaces of disese in her baby.
a. 25%
b. 50%
*c. nothing
d. 100%
e. 15%
x-linked,
the characteristics are that every affected persons linked to each THROUGH the mother side. In the case, the baby boy's mother is not a carrier. Therefore the boy has nothing to do with the disease
78. A 28-year-old man decides to donate a kidney to his brother, who is in chronic renal failure, after HLA typing suggests that he would be a suitable donor. He is admitted to the hospital, and his right kidney is removed and transplanted into his brother. Which of the following indices would be expected to be decreased in the donor after full recovery from the operation?
Creatinine clearance
*Renal excretion of creatinine
Creatinine production
Daily excretion of sodium
Plasma creatinine concentra
Explanation of Answer:
Because creatinine is freely filtered by the glomerulus, but not secreted or reabsorbed to a significant extent, the renal clearance of creatinine is approximately equal to the glomerular filtration rate (GFR). In fact, creatinine clearance is commonly used to assess renal function in the clinical setting. When a kidney is removed, the total glomerular filtration rate decreases because 50% of the nephrons have been removed, which causes the creatinine clearance to decrease. In turn, the plasma creatinine concentration increases until the rate of creatinine excretion by the kidneys is equal to the rate of creatinine production by the body. Recall that creatinine excretion = GFR x plasma creatinine concentration. Therefore, creatinine excretion is normal when GFR is decreased following removal of a kidney because the plasma concentration of creatinine is elevated.
Creatinine is a waste product of metabolism. Creatinine production is directly related to the muscle mass of an individual, but is independent of renal function.
The daily excretion of sodium is unaffected by the removal of a kidney. The amount of sodium excreted each day by the remaining kidney exactly matches the amount of sodium entering the body in the diet.
79. A 24-year-old AIDS patient develops chronic abdominal pain, low-grade fever, diarrhea, and malabsorption. Oocysts are demonstrated in the stool. Which of the following organisms is most likely to be the cause of the patient™s diarrhea?
Diphyllobothrium latum
Entamoeba histolytica
*Giardia lamblia
Isospora belli
Microsporidia
Explanation of Answer:
All the organisms listed are protozoa. There are two intestinal protozoa specifically associated with AIDS that can cause transient diarrhea in immunocompetent individuals but can cause debilitating, and potentially life-threatening, chronic diarrhea in AIDS patients. These organisms are Isospora belli, treated with trimethoprim-sulfamethoxazole or other folate antagonists) and Cryptosporidium parvum (no treatment currently available).
Diphyllobothrium latum is the fish tapeworm and occasionally causes diarrhea.
Entamoeba histolytica and Giardia lamblia are both causes of diarrhea, but they are not specifically associated with AIDS.
Microsporidia are a protozoan cause of diarrhea but produce spores rather than oocysts
80. 14 yrs old girl never been vaccinated for varicella and she exposed to 5 yrs old her sister with varicella
how would u tx 14 yr one
a.varicella immuno
b.varicella ig g and vaccine
c.var vaccine now
*d.varicella vaccine now and month later
edo nothing.she already exposed
81. A patient with chronic malabsorption presented with absent tendon reflexes, ataxia, loss of pain sensation, ophthalmoplagia, and anemia. He is suffering from which of the following vitamin deficiency?
a) vit. A
*b) vit. B12
c) vit. C
d) vit. D
e) vit. E
FACTS:
1.population most at risk- young pt. then post-menopausal women
2. HIV mother- no to breast feeding
3.HIV pt. become pregnant currently on Tx - advice to continue meds., if not on Tx start Tx in 2nd trimester with triple Tx (azt included)
4.HIV pt, CD4 <200 on bactrim dev. rash - start dapsone or aerosolized pentamidine
5.I.V drug abuser with fever, maculopapular rash, cervical lymphadenopathy, lymphophenia, HIV test(-),heterophil ab (-), -Dx- acute retroviral syndrome
6.Pt. had unprotected sex 2 weeks ago, then came to know the woman was HIV+, pt. wanted to be tested - don't do ELISA, do HIV RNA pcr or p24 antigen
7. Pt CD4-80, do prophy for PCP, MAI and Toxo, using Bactrim, if you use dapsone add Pyrimethamine
8. HIV pt. with thrombocytopenia, best Tx - Antiretroviral Therapy
9.HIV pt with fever, cough, sob, on PE, right lower lobe crepitation, CXR- Right lower lobe infiltrate, CD4-350, Dx - Community Acquired Pneumonia
10.HIV pt. using marijuana with fever, cough, hemoptysis, foud to have necrotizing cavitary pneumonia, Dx- Aspergillosis, to confirm do bronchoscopic biopsy, Tx- amphotericin B, if not improving do Sx excission.
11. HIV pt with PCP on Pentamidine having seizure, first thing to do - Finger stick to r/o hypoglycemia
12. HIv pt with interstitial pneumonia, splenomegaly, palate ulcer from El Salvador, Dx- Histoplasmosis
13. HIv pt. in ICU on TPN via central catheter complains of ocular discomfort w/c lead to visual loss in one eye, Dx - Candida endopthalmitis
14. Pt.admitted for fever, blood cultures growing Candida, Tx with Ampho. B, don't think it is contaminated bac. of chance of having Candida endolpthalmitis.
83. 76yrs old female,menopause 15yrs back.no sex since husband died (15yrs back).very active and not on HRT.she now met a wonderful person,she had sex and there was bleeding after sex. most likely cause
a.caevical ca
*b.atrophic vaginitis
84. The Pap smear result that is potentially the most serious, and requires more aggressive investigation and treatment is
A Normal squamous cells but lack of endocervical cells
B Colonization with Gardnerella vaginalis and Candida
*C Atypical glandular cells of undetermined significance
D Atypical squamous cells of undetermined significance
E Substantial colonization with Trichomonas vaginalis
85. The diagnosis of cervical incompetence has traditionally been made on the basis of an obstetric history consistent with passive and painless midtrimester dilation of the cervix. The presence of uterine contractions, bleeding, ruptured membranes, and intra-amniotic infection do not necessarily exclude the diagnosis of an incompetent cervix, as it is often difficult to ascertain whether these latter complications preceded or followed the dilation. Cervical cerclage is still the best treatment for cervical incompetence. Which of the following is an indication for cerclage
A Cerclage is indicated solely based on risk factors or prior cerclage placed for doubtful indications
*B Clinical evidence of extensive obstetric trauma to cervix
C Chorioamnionitis
D Premature rupture of membranes
E Fetal anomaly incompatible with life
86. You deliver a full term infant after a long second stage of labor. Forceps are used to expedite the delivery because of some concerns over a deteriorating fetal heart tracing. Recurrent late decelerations are present. An easy outlet forceps delivery produces an infant with Apgar scores of 2 at 1 minute, 4 at 5 minutes and 7 at 10 minutes. Which of the following is true?
A A low 1-minute Apgar score correlates with the infant's future outcome
B A low 5-minute Apgar score correlates well with neurologic outcome
C A term infant with a 5-minute Apgar score of less than 4 has a 5% chance of developing cerebral palsy
D One advantage of the Apgar scoring system is that it is independent of the physiologic maturity of the infant
*E Seventy five percent of children with cerebral palsy have normal Apgar scores at birth
87. A 48-year-old woman is undergoing total abdominal hysterectomy for menorrhagia secondary to fibroids. Which of the following accurately describes the structures to be removed in this surgical procedure?
A Ovaries and tubes
B Uterine fundus
C Uterine leiomyomata
*D Uterus (fundus and cervix)
E Uterus, tubes and ovaries
88. which of the following is not a feature of trisomy 21
1. cardiac septal defect
2. mental retardation
3. intestinal atresia
*4. cerebral malformation ( holoprosencephaly
5. hypothyroidism
89. A 3 yr old male presents to ur clinic after being seen 5 days ago in ER for a fever of 40.2 C He apeared well in ER visit with unremarkable UA and CBC. Was given IM cetriaxone. Continued to have spiking fever and has now developed a rash, erythmatous , maculopapular, covering trunk, injected lips and tongue, and adema hands n feet ...the mpst serious complicatoin if left untreated is
1. demyelinating encephlaitis
2. prog joint deformaty
3. renal failure
*4. myocardial dysfunction
5. febrile seizure
ANS: Kawasaki disease
90. 45 y/o M, with recurrent attack of cough with copious,foul smelling sputum and recurrent hemoptysis. On PE shows crackles on both lung bases, CXR shows thickening of bronchial wall and cystic spaces on both lung bases. What is the confirmatory test for DX?
1.xray
*2.CT
3.US
4.Laringoscopy
Chest x-rays can often detect the lung changes caused by bronchiectasis; however, occasionally, results are normal. Computed tomography (CT) is usually the most sensitive test to identify and confirm the diagnosis and to determine the extent and severity of the disease; these are important factors when surgical treatment is being considered.
91.Pt. with hypernatremia and hypotension, what IVF to use?
*1. NSS
2. D5W
3. Free H2O
4. D50W
92. A 21-year-old woman is a restrained passenger in a high-speed motor vehicle collision and presents with neck, abdominal, and back pain, with normal vital signs. She is 32 weeks™ pregnant. Which of the following statements is incorrect?
A. Fetal monitoring is important to detect early fetal distress.
*B. Traumatic placental abruption is almost always associated with vaginal bleeding.
C. Appropriate radiological studies should not be withheld.
D. Ultrasound is not very accurate in detecting placental abruption
Answer: B
In blunt trauma, 50% to 70% of fetal losses result from placental abruption. Fetal mortality in abruption cases is about 50%. Classic clinical findings in placental abruption may include vaginal bleeding, abdominal cramps, uterine tenderness, amniotic fluid leakage, maternal hypovolemia, and fetal distress. However, in some trauma series, up to 60% of placental abruption has no associated vaginal bleeding. Fetal monitoring is a sensitive monitor for fetal distress. Appropriate radiologic studies should never be withheld when necessary to properly care for the mother. Ultrasound is less that 50% accurate in detecting abruption.
*93. A 6-year-old girl ingests an unknown volume of a pesticide called Sevin(®)(a carbamate anticholine-sterase inhibitor) and presents with clinical evidence of toxicity, including pinpoint pupils, vomiting, diarrhea, severe weakness, and heavy oral secretions. Besides prompt intubation and ventilation, appropriate treatment includes which of the following?
A. atropine
B. methylprednisolone
C. pralidoxime
D. epinephrine
Answer: A
Carbamates are reversible acetylcholinesterase inhibitors that lead to hyperstimulation of nicotinic and muscarinic receptors in the autonomic nervous system. The classic presentation includes hypersecretion from all orifices along with diffuse weakness and various central nervous system manifestations. Supportive care, decontamination, and intravenous atropine in high doses are the mainstays of therapy. Pralidoxime is not indicated for carbamate poisoning.
94. Which of the following is appropriate initial antihypertensive therapy for the listed hypertensive emergency in a patient with a blood pressure of 210/116 mm Hg?
A. eclampsia”captopril
B. aortic dissection”nitroprusside
*C. clonidine withdrawal”phentolamine
D. phentolamine cocaine intoxication”propanolol
Answer: C
Eclampsia is a hypertensive emergency in pregnancy with secondary seizures. Traditionally, it has been treated with magnesium sulfate and intravenous hydrala-zine, although labetalol and nicard-ipine are gaining acceptance as appropriate antihypertensive therapy in this setting. Captopril and other angiotensin-converting enzymes are contraindicated in pregnancy because of increased fetal mortality. Antihypertensive therapy for aortic dissection has as a goal not only blood pressure control but also reduction of cardiac contractility to decrease the shear force from the pulse pressure of each contraction. Beta-blocker therapy with propanolol or the shorter-acting, more titratable esmolol is the therapy of choice. Nitroprus-side is inappropriate initial therapy for aortic dissection because it causes reflex increases in heart rate and cardiac contractility. Cocaine intoxication leads to cate-cholamine excess. The resultant severe hypertension will be increased by beta-blocker therapy alone. Propanolol is contraindicat-ed for initial therapy of cocaine-induced hypertension. Clonidine withdrawal is also a state of cate-cholamine excess and is appropriately treated initially by an alpha-blocker such as phentolamine.4,5
95. A depressed 28-year-old woman with AIDS and pulmonary tuberculosis presents with recurrent generalized seizures. She has not stopped seizing despite large doses of lorazepam and fosphenytoin 1 g intravenously. Which of the following should be considered quickly in the patient™s care?
A. thiamine
B. sodium bicarbonate
C. vecuronium with ventilatory support
D. pyridoxine
Answer: D
Pyridoxine (vitamin B6) is the antidote of choice for isoniazid toxicity, a cause of intractable seizures unresponsive to standard therapies. An initial dose of 5 g in adults and 1 g in children is indicated in unknown overdose with intractable seizures.6 Paralysis by neuromuscular blocking agents will hide the motor activity but will not protect from the continuous neuronal hyperstimulation of ongoing seizures, and if used, requires ongoing electroencephalogram monitoring.
96. 45 y/o male with HTN, smoker, DM, and obese, What will help the most to decrease his BP??
A) weight loos
B) stop smoking
C) exercise
D) control DM
ANS: A
97. colonic polyp and screening following resection (one colonic polyp “ which showed ½ adenocarcinoma, the other half is free of cancer “ no family hx) :
a. annual colonoscopy
b. Elective Sigmoid resection
c. Hemicolectomy
ans: b
98. 1-pt presents with dysphagia, drooling, fever, now very lethargic and confused , hx of family going camping and spending lots of time in caves:
Most likely dx:
*a. RABIES
b. Tetanus
c. Pertussis
d. Epiglottitis
99. 2-Most appropriate statement about this patient™s condition at this point is :
a. Very poor prognosis
b. Pt will recover completely with treatment
c. This will worsen in the next 24 hrs then begin improving
ANS: A, A
100. To confirm the diagnosis of Parkinson™s Disease in a patient presenting with a hx consistent with PD “
a. CT scan of the head
b. Nothing further
c. LP
ANS: B
101. Pt is a chronic smoker, wants to quit, has tried to quit in the past with patch (?) but didn™t work, really wants to quit now “ next best step is to prescribe?
*a. Bupropion
b. Low dose nicotine patch
c. Do nothing
d. Nicotine gum
ANS: A
102. A 50 year old man presents with a 1-day history of recurrent swelling and pain of the left leg. He was discharged from the hospital 1 week ago after being treated for deep vein thrombophlebitis of the same leg. Since discharge he has been taking warfarin, 2.5 mg daily. His INR is 1.2. A venogram documents recurrent thrombosis extending to the inferior vena cava. Which therapy would you now recommend for this patient?
a.Increase the warfarin dose to bring the INR into therapeutic range
b.Switch to dicumarol
c.Interrupt the inferior vena cava with a filter
d.Discontinue warfarin and begin heparin at a therapeutic dose
e.Discontinue warfarin and begin thrombolytic therapy
?ANS: D ****
103. A 60 year old male was admitted with chest pain - crushing - that started at around 10.05 PM as soon as he started watching the News. He waited for it to go thinking it as a gas pain but as it did not go off, called ambulance and reached the hospital at 11 PM. Was seen in ER. EKG was taken and showed ST segment depression in V2, V3, V4. He was given Aspirin and started on heparin within the first minute and diagnosis was unstable angina. He is also getting a nitroglycerin drip iv. At 11.20 the cardiologist sees him and he still has pain and sweating, but pain was gone for sometime in between. EKG taken then still shows ST depression in the same leads. No Q wave or ST elevation.
WHat is the next best step?
1. Increase Nitroglycerine
2. Start tPA infusion ASAP
3. Check Troponins
4. Start Plavix
5. Do cardiac catheterization Stat
ANS: 5
104. 25 yrs old woman with history of migraine , take some herbal medicine, what is the name?
a. ginkgo
b. St. john's wort-depression
c. saw palmetto-prostate
*d. feverfew
e. ephedra “ upper BP up FDA took it down
Feverfew
Background: Feverfew is a bushy perennial herb. Parthenolide and glycosides are thought to be its active components.
Medicinal Claims: Feverfew is used to prevent migraine headaches. It may reduce inflammation. Feverfew reduces the clotting tendency of platelets (cell-like particles in the blood that help stop bleeding by forming clots). Evidence from two of three relatively small but well-designed studies supports these effects. Differences in study findings may reflect the different formulations of feverfew used. In studies of people with arthritis, feverfew did not relieve symptoms.
Possible Side Effects: Mouth ulcers and skin inflammation (dermatitis) may occur. Taste may be altered, and heart rate increased. Feverfew may interact with anticoagulants, drugs used to manage migraine headaches, and nonsteroidal anti-inflammatory drugs (NSAIDs). It may reduce the absorption of iron. Feverfew is not recommended for children or for women who are pregnant or breastfeeding.
105. 60 y/o pt. with lymphoma complains of weakness, exertional SOB, easy fatigability, HGb-10, Hct-30, Ret. count -3.5, LDH-400,, + spherocytes, + Coombs test for IgG, most likely DX
1. cold Ab Hemolytic Anemia
2. hereditary sperocytosis
3. autoimmune hemolytic anemia
*4. warm Ab Hemolytic anemia
106. A 5-year-old boy presents with several days of fever to 104°F, along with bilateral conjunctival injection, a strawberry tongue, red and cracked lips, marked cervical adenopathy, as well as erythema and swelling of both hands and feet. Which of the following is accepted therapy for this illness?
A. penicillin
B. prednisone
*C. acetylsalicylic acid
D. azithromycin
Kawasaki syndrome has an abrupt onset, with fever as high as 104°F (40°C) and a rash that spreads over the patient's chest and genital area. The fever is followed by a characteristic peeling of the skin beginning at the fingertips and toenails. In addition to the body rash, the patient's lips become very red, with the tongue developing a "strawberry" appearance. The palms, soles, and mucous membranes that line the eyelids and cover the exposed portion of the eyeball (conjunctivae) become purplish-red and swollen. The lymph nodes in the patient's neck may also become swollen. These symptoms may last from two weeks to three months, with relapses in some patients. The physician will first consider the possible involvement of other diseases that cause fever and skin rashes, including scarlet fever, measles, Rocky Mountain spotted fever, toxoplasmosis (a disease carried by cats), juvenile rheumatoid arthritis, and a blistering and inflammation of the skin caused by reactions to certain medications (Stevens-Johnson syndrome). Kawasaki syndrome is usually treated with a combination of aspirin, to control the patient's fever and skin inflammation, and high doses of intravenous immune globulin to reduce the possibility of coronary artery complications.
107. A 19-year-old man comes to the emergency department because of urethral discharge. Gram stain shows numerous neutrophils, some of which contain gram-negative intracellular diplococci. Ceftriaxone, 250 mg intramuscularly, is administered. Five days later, the patient comes to your office because the discharge has persisted.
Which of the following is the most likely cause of this discharge?
*(A) Chlamydia trachomatis
(B) Ureaplasma urealyticum
© Penicillin-resistant Neisseria gonorrhoeae
(D) Re-infection with Neisseria gonorrhoeae
(E) Urethral stricture
Gram-negative, intracelullar diplococci indicates N.gonorrhoeae.
Tetracycline resistance: 17-23% Penicillin resistance 15-19% Emerging Fluoroquinolone resistance
No resistance to Third Generation Cephalosporins Ceftriaxone (Rocephin)
tratment for NGU clamidia
References MMWR Morb Mortal Wkly Rep (1995) 44:761-5 Fox (1997) J Infect Dis 175: 1396-403
108. Pneumococcal vaccine is indicated for which one of the following?
A. 15-year-old with recurrent sinusitis and URI
b. 8-year-old with recurrent tonslitis
*c. 3-year-old with nephrotic syndrome
d. 6-month-old with sickle-cell disease
e. 3-month-old whose mother has active human immunodeficiency virus (HIV) infection
According to the Immunization Practices Advisory Committee of the Center for Disease Control and Prevention, pneumococcal vaccines should be administered to the following individuals:
--Persons 65 years or older
--Persons aged 2-64 years who have chronic illness that includes chronic cardiovascular disease, chronic pulmonary disease, diabetes mellitus, cirrhosis, alcoholism, or cerebral spinal fluid (CSF) leaks
--Persons aged 2-64 years who have functional or anatomic asplenia, persons who are splenectomized, and particularly those suffering from sickle cell disease
--Persons aged 2-64 years who are living in a particular environment or social setting that may include Alaskan natives, certain American Indian populations, and residents of nursing homes and other long-term care facilities
--Persons who are immunocompromised with illnesses, such as HIV infection, leukemia, lymphoma, Hodgkin disease, multiple myeloma, generalized malignancy, chronic renal failure, nephrotic syndrome, organ or bone marrow transplantation, and persons receiving immunosuppressive chemotherapy (including long-term systemic corticosteroids)
--Vaccinate persons without hesitation for whom the vaccination status is unknown
109. A 14 year old boy with acne lesions on face and back on benzoic peroxide and topical tretenoin with only partial response. What will you do next
a. Oral tretenoin
b. Corticosteroids
*c. Oral tetracycline
d. Topical erythromycin
Go from topical to oral and from least harmful to most harmful.
Topical Benzoyl peroxide >> Topical antibiotics >> Topical isotretinoin >> Oral antibiotics >> Oral Isotretinoin.
110. 67 yrs old with lower extermities BP 180/90. upper extremities 150/85 what is Dx?
*a. essential HTN
b. renal artery stenosis
c. pheochromocytoma
d. malignant HTN
e. Stenosis of ascending aorta
It is normal finding to have higher Bp in the lower extremities than the upper ones but I assume that the Q is asking about the most likely cause of the hypertension (whether measured in the upper or lower ex.).
I think essntial htn is the answer
111. A 3-month-old child was exposed to an adult with active pulmonary tuberculosis. What is the recommended approach to this problem?
a. Administer a TST and reevaluate in 3 months.
b. Administer a TST, perform a CXR, and reevaluate in 3 months.
c. Administer a TST, perform a CXR, administer INH, and reevaluate in 3 months.
d. Reevaluate after 3 months.
*e. None of the above.
A child with a positive Mantoux test result but without active disease is a candidate for isoniazid prophylaxis. Active disease is excluded by a normal chest radiograph and a lack of symptoms suggesting TB disease.
Special pediatric cases should be considered candidates for isoniazid prophylaxis even if they lack documentation of a positive Mantoux test:
Newborn prophylaxis: Infants whose mothers have active disease (even if noncontagious) and infants whose mothers have a positive Mantoux test but do not have active disease (preventive therapy can be discontinued after the entire family is demonstrated to have negative tuberculin skin tests)
Children who are both anergic or HIV-positive and from populations where the prevalence of TB infection is higher than 10% (eg, injection drug users, homeless persons, migrant laborers, and individuals from Asia, Africa, or Latin America)
Children who have had close contact within the past 3 months with a person with infectious TB."
www.vnh.org/PreventionPractice/ch09.html
112. A pt on heparin and warfarin develops thrombocytopenia and petechiae, what is next
d/c heparin
d/c warfarin
continue both
*d/c both
MANAGEMENT OF PATIENTS WITH HIT(Heparin induced Thrombhocytopenia)
There are few prospective randomized studies on which to base recommendations regarding the management of HIT. The following guidelines are based on the best available data in January 2002. Patients with HIT are best managed by, or in consultation with, a specialist experienced in managing HIT.
a. All heparin should be discontinued in patients with HIT. This includes unfractionated and low-molecular weight heparins by any route, heparin flushes, and vascular catheters that are heparin-coated.
b. Anticoagulation with an alternative anticoagulant - either danaparoid, lepirudin, or argatroban (listed in historical order of availability) should be given if the original indication for which heparin was initiated still exists (see #6. Anticoagulants for HIT).
c. Patients who have new, progressive or recurrent thrombosis associated with HIT (HIT-associated thrombosis) should be treated with therapeutic-dose anticoagulation with danaparoid, lepirudin, or argatroban. (see #6. Anticoagulants for HIT). Therapy should not be delayed for the results of laboratory testing if the clinical suspicion of HIT is strong.
d. Danaparoid, lepirudin, or argatroban should be strongly considered in patients with HIT even in the absence of thrombosis. Patients with HIT remain at high risk of thrombotic complications for several days or weeks after cessation of heparin.
e. Warfarin should be avoided in acute HIT unless it is used in combination with therapeutic-dose danaparoid, lepirudin, or argatroban. Warfarin has been associated with worsening venous thrombosis, venous limb gangrene, and/or skin necrosis when used alone or in combination with ancrod in acute HIT. However, warfarin is appropriate for longer term anticoagulation in patients with HIT and thrombosis. Warfarin should be delayed until therapeutic anticoagulation with danaparoid, lepirudin or argatroban is achieved, and ideally, until there is substantial resolution of the thrombocytopenia. Warfarin-induced thrombotic complications have been described in patients in whom the alternative anticoagulant was stopped prior to resolution of thrombocytopenia. The optimal duration of anticoagulation in patients with HIT and thrombosis is not known.
113. A healthy 71-year-old man describes visual loss in his right eye. Flashes of lig