Monday, February 5, 2007

Some Recollected Questions:

recalls..hv heard very imp 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 heade. 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

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?
*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
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 optionsCryotheraty 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 ?

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
* segmental colectomy 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

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 rifampicinSTart 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
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
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 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 > 65yrsMalnourished 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 scanb. endoscopyc. colonoscopyd. barium enema35* 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/

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 CWhich 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
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
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 3monthse. 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 wereHIV man:
First - talk with him and tell him to tell his wife about the diagnosisIf 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 edemaCVS: 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 - 30THE CAUSE OF ASCITES IS:a).Congestive cardiac failureb).Pulmonary Embolism and Right HFc).DVT moving into the systemic circulation*d).Protein C deficiencye).Atherosclerosisf).Nephrotic syndromeg).Cirrhosis secondary to HCV infectionExclusion: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 cancerhas a rising PSA level despite treatment withleuprolide and flutamide. What should be the firststep in managing this asymptomatic man with hormone-refractory disease?
A) Treat with aminoglutethimide
*B) Discontinue flutamide to attempt to obtain anantiandrogen withdrawal response
C) Discontinue leuprolide
D) Treat with diethylstilbestrol
E) Perform an orchiectomy

50.A 35-year-old woman with amenorrhea is found tohave an enlarged pituitary gland. Her prolactinlevel is 80 ng/L (normal, less than 20 ng/L), andher thyrotropin level is 100 µU/mL (normal, 0.5 to4.5 µU/mL). Which of the following is the besttreatment 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 contraceptivesprolactin 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

Step 3:

Step 3 is not that easy to pass!! Just dont take it so lightly.