اسئلة الباطنية العامة 12/2013
Medicine 12 2013
1) A 30 year old woman is noted to have blood pressures in the 160/100 mmHg range . She also has increased obesity , especially around her abdomen , with striae . She has been bruising very easily and has hirsutism . Which of the following is the most likely diagnosis ?
A . Hyperthyroidism
B . Hyperparathyroidism
C . Coarctation of aorta
D . Cushing syndrome
E . Pheochromocytoma
2) A 45 year old man with type two diabetes is noted to have blood pressures of 145/90 and 150/96 mmHg on two separate occasions . Which of the following is the best initial therapy for this patient ?
A . Hydrochlorothiazide .
B . ACE_i .
C . B blockers .
D . CCB .
E . B blockers and Hydrochlorothiazide .
3) A 62 year old diabetic man underwent an abdominal aortic aneurysm repair 2 days ago . He is being treated with Gentamycin for a UTI . His urine output has fallen to 300 ml over 24 hours , and his serum creatinine has risen from 1.1 mg/dl on admission to 1.9 mg/dl . Which of the following laboratory values would be most consistent with a prerenal etiology of his renal insufficiency ?
A . FEna of 3% .
B . Urinary sodium level of 10 mEq/L .
C .CVP reading of 10 mmHg .
D . Gentamycin trough level of 4uq/ml .
4) A 22 year old woman presents with fatigue, arthralgias , and a nagging dry cough for the past 6 weeks , but no shortness of breath . On physical examination, her lungs are clear to auscultation , and she has bilateral pretibial tender Erythematous raised nodules . Which of the following is your best next step ?
A . Chest radiograph .
B . CT chest .
C . Empiric treatment for Postnasal drip .
D . Antinuclear antibody .
E . Initiation of antituberculosis therapy .
5) An obese 50 year old man with a history of asthma returns with complaints of occasional dyspepsia and nocturnal cough . He wakes up in the morning with a sour taste in his mouth . His current medications include inhaled corticosteroids and a short acting B2 agonist . Which of the following should be your next step ?
A . 24 hour esophageal PH monitoring .
B . Chest radiograph .
C . Initiation of omeprazole .
D . Short course of oral corticosteroids .
E . Initiation of allergy desensitization
6) A patient with known asthma undergoing therapy with inhaled corticosteroids and intermittent short acting B2 agonist presents with complaints of nocturnal awakening secondary to cough and occasional wheezing . This episode occurs three to four times per week . Pulmonary function tests in the past have shown mild obstructive lung disease . Which of the following is the best next step ?
Oral steroids
Leukotriene inhibitors
Long acting B2 agonist
Theophylline
Antireflux therapy
7) Which of the following is most accurate ?
Cough caused by Captopril may resolve with switching to enalapril .
Initial treatment of a chronic cough should include codeine or a similar opiate derivative to suppress the cough .
Cough caused by reflux can be effectively ruled out by a negative history of heartburn or dyspepsia .
More than one condition often is responsible for causing a chronic cough in a given patient .
8) A 55 year old man is noted to have moderately severe congestive heart failure with impaired systolic function . Which of the following drugs would most likely lower his risk of mortality ?
ACE_i
Loop diuretics
Digoxin
Aspirin
9) A 35 year old woman is noted to have chest pain with exertion , and has been passing out recently . On examination she is noted to have a harsh systolic murmur . Which of the following is the best therapy for her condition ?
Coronary artery bypass
Angioplasty
Valve replacement
Carotid endarterectomy
10) A 55 year old man is noted to have congestive heart failure and states that he is comfortable at rest but becomes dyspneic even with walking to bathroom . On echocardiography , he is noted to have an ejection fraction of 47% . Which of the following is the more accurate description of this patients condition ?
Diastolic dysfunction
Systolic dysfunction
Dilated cardiomyopathy
Pericardial disease
11) A 24 year old man develops seizures following an emergent splenectomy after a car accident . His serum sodium level is initially 116 mEq / L and is corrected to 120 mEq/L over the next 3 hours with hypertonic saline . Which of the following factors most likely led to his Hyponatremia ?
Elevation of serum vasopressin
Administration of hypertonic solutions
Volume depletion
Seizures induced Hyponatremia
12) A 56 year old man complaining of fatigue and weight loss . He has never had any health problems , but he has smoked a pack of cigarettes per day for about a 35 years . His physical examination is notable for a low to normal blood pressure , skin hyperpigmentation , and digital clubbing . He appears euvolemic . The sodium level is 126 mEq/L , potassium level is 6.7 mEq/L , creatinine level is normal, and bicarbonate and chloride levels are low . Which of the following is the likely cause of his Hyponatremia given his presentation ?
SIADH
Hypothyroidism
Gastrointestinal losses
Adrenal insufficiency
Renal insufficiency
13) An 83 year old woman comes to your office complaining of a headache and mild confusion . Her medical history is remarkable only for HTN , which is well controlled by Hydrochlorothiazide . Her examination and laboratory tests show no signs of infection , but her serum sodium level is 119 mEq/L , and plasma osmolarity is 245 mOsm/kg . She appears to be clinically Hypovolemic . Which of the following is the best initial therapy ?
Fluid restriction
Infusion of 0.9%saline
Infusion of 3% saline
Infusion of 3% saline with Furosemide
14) A 58 year old man has undergone a lengthy colon cancer surgery . On the first postoperative day , he is noted to have significant Hyponatremia with a sodium level of 128 mEq /L . You suspect that the Hyponatremia is due to the intravenous infusion of hypotonic solution . Which of the following laboratory findings supports your diagnosis ?
Urine sodium > mmol/L
Urine osmolality > 200 mOsm /L
Serum osmolarity < 280 mOsm /kg
Serum potassium > 5 mEq/L
15) Which of the following patients is most likely to be a candidate for bone mineral density screening ?
A 65 year old, thin , white woman who smokes and is 15 years postmenopausal .
A 40 year old white woman who exercises daily and still menstruates .
A healthy 75 year old white man who is sedentary .
A 60 year old overweight black woman .
A 35 year old asthmatic woman who took prednisone 40 mg/d for a 2 week course 1 week ago
16) During which of the following periods in a woman's life is the most bone mass accumulated ?
Ages 15 to 25
Ages 25 to 35
Ages 35 to 45
Ages 45 to 55
17) A 60 year old woman presents with the results of her DEXA scan . She has a T score of _1.5 at the hip and _2.5 at the spine . Which of the following is the most accurate interpretation of these results ?
She has osteoporosis at the spine and osteopenia at the hip .
She has osteoporosis in both area's .
This is a normal examination .
She has osteoporosis of the hip and osteopenia at the spine .
You need to know the Z score .
18) You see a 70 year old woman in your office for a routine checkup , and you order a DEXA scan for bone mineral density screening . The T score returns as 2.5 standard deviations SD in the spine and _2.6 in the hip . Which of the following statements is most accurate ?
This patient has osteopenia .
Estrogen replacement therapy should be started with an anticipated rebuilding of bone mass to near normal within 1 year .
Swimming will help build bone mass .
Bisphosphonates would reduce the risk of hip fracture by 50%
19) A 35 year old woman complains of calf tenderness and acute dyspnea . The arterial blood gas reveals PO2 ( Partial pressure of oxygen ) of 76 mmHg . Which of the following is the most common physical examination finding of pulmonary embolism ?
Wheezing .
Increased pulmonary component of the second heart sound .
Tachypnoea .
Calf swelling .
Pulmonary rales .
20) A 39 year old man is noted to have a DVT without any known risk factors . He notes that his brother also developed a pulmonary embolism at age 45 years , and his mother developed a clot in the leg when she was in her thirties . Which of the following is the most likely inherited disorder in this patient ?
Protein S deficiency
Antithrombin 3 deficiency
Factor 5 Leiden mutation
Antiphospholipid antibody syndrome
Familial malignancy syndrome
21) A 54 year old woman is noted to have cervical cancer and presents with significant vaginal bleeding with a hemoglobin level of 7 g/dL . Her left leg is swollen , which on Doppler investigation reveals a DVT . Which of the following is the best treatment for the thrombus ?
Intravenous unfractionated heparin .
Fractionated subcutaneous heparin .
Subcutaneous unfractionated heparin.
Oral warfarin ( Coumadin ) .
Vena cava filter .
22) A 72 year old man develops severe pain and swelling in both knees , shortly after undergoing an abdominal hernia repair surgery . Physical examination shows warmth and swelling of both knees with large effusions . Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefringent crystals in the synovial fluid . Gram stain is negative . Which of the following is the most likely diagnosis ?
Gout
Septic arthritis
Calcium oxalate deposition disease
Reactive arthritis
Pseudogout
23) A 65 year old man with a history of chronic HTN , DM , and degenerative joint disease presents with acute onest of severe pain of the metatarsophalangeal joint and swelling of the left first toe . Physical examination shows exquisite tenderness of the joint , with swelling , warmth , and Erythema . The patient has no history of trauma or other significant medical problems . Synovial fluid analysis and aspiration is most likely to show which of the following ?
Hemorrhagic fluid .
Needle_ shaped , negatively birefringent crystals .
Gram negative organisms .
Noninflammatory fluid .
Rhomboidal , positively birefringent crystals
24) A 17 year old sexually active adolescent male presents with a 5 day history of fever , chills , and persistent left ankle pain and swelling . On physical examination , maculopapular and pustular skin lesions are noted on the trunk and extremities . He denies any symptoms of genitourinary tract infection . Synovial fluid analysis is most likely to show which of the following ?
WBCs 75.000/mm3 with 95% polymorphonuclear leukocytes .
RBCs 100.000/mm3 , WBCs 1000/mm3 .
WBCs 48.000/mm3 with 80% lymphocytes .
WBCs 500/mm3 with 25% polymorphonuclear leukocytes .
25) A 22 year old man presents with complaints of low back pain for 3 to 4 months and stiffness of the lumbar area , which worsen with inactivity . He reports difficulty in getting out of bed in the morning and may have to roll out sideways , trying not to flex or rotate the spine to minimize pain . A Lumbosacral spine X_Ray film would most likely show which of the following ?
Degenerative joint disease with spur information .
Sacroiliitis with increased sclerosis around the sacroiliac joints .
Vertebral body destruction with wedge fractures .
Osteoporosis with compression fractures of L3_L5 .
Diffuse osteonecrosis of the LS spine .
26) A 36 year old woman was seen by her physician due to pain in her hands, wrists , and knees . She is diagnosed with rheumatoid arthritis . Which of the following treatments will reduce joint inflammation and slow progression of the disease ?
NSAIDs
Joint aspiration
Methotrexate
Systemic corticosteroids
27) An 18 year old adolescent female is brought to the emergency room because she fainted at a rock concert . She apparently recovered spontaneously , did not exhibit any seizure activity , and has no medical history . Her heart rate is 90 bpm and blood pressure 110/70 mmHg . Neurologic examination is normal . The pregnancy test is negative . Which of the following is the most appropriate management ?
Admit to hospital for cardiac evaluation .
Outpatient echocardiogram .
Twenty four hour Holter monitor .
Reassurance and discharge home .
28) A 67 year old woman has diabetes and mild HTN . She is noted to have some diabetic retinopathy , and she states that she cannot feel her legs . She has recurrent episodes of lightheadedness when she gets up in the morning .She comes in now because she had fainted this morning . Which of the following is the most likely cause of her syncope ?
Carotid sinus Hypersinsivety
PE
Autonomic neuropathy
Critical aortic stenosis
29) A 74 year old man with no prior medical problems faints while shaving . He has a quick recovery and has no neurologic deficits . His blood sugar level is normal , and ECG shows a normal sinus rhythm . Which of the following is the most useful diagnostic test of his probable condition ?
Carotid massage
Echocardiogram
CT scan of head
Serial cardiac enzymes
30) A 49 year old man is admitted to the intensive care unit with a diagnosis of an inferior MI . His heart rate is 35 bpm and blood pressure 90/50 mmHg . His ECG shows a mobitz type 1 heart block . Which of the following is the best next step ?
Atropine
Transvenous pacer
Lidocaine
Observation
31) A 42 year old woman is being treated with infliximab for rheumatoid arthritis . After 6 months of therapy , she develops persistent fever , weight loss , and night sweats , and tuberculosis is suspected . Which of the following is most likely location of the tuberculosis ?
Middle and lower lung zones .
Pleural space .
Apical segment of the upper lung lobes .
Cervical or supraclavicular lymph nodes .
32) A 24 year old man has been treated with INH , Rifampicine ,and pyrazinamide for active pulmonary tuberculosis . After 3 months , he states that he is having numbness and tingling of both feet but no Back pain . He denies taking other medications . Which of the following is the most appropriate next step ?
CT scan of the lumbar spine .
Initiate pyridoxine .
Continue the tuberculosis agents and monitor for further neurological problems .
Initiate a workup for tuberculosis Adenopathy compression on the femoral nerve.
33) A 25 year old woman is seen in the clinic because her father was diagnosed with and has been treated for tuberculosis . She denies a cough and her chest radiograph is normal . A PPD test shows 10 mm of induration . Her only medication is an OCP . Which of the following is the best next step ?
Oral INH and barrier contraception .
Combination therapy including INH, Rifampicine and pyrazinamide .
Observation .
Induce three sputum samples .
34) Which of the following tests is the most appropriate to follow for a patient receiving isoniazed and rifampin for tuberculosis treatment ?
Renal function tests
Liver function tests
Slit_lamp examinations
Amylase and lipase tests
35) Which of the following is not a dermatologic manifestation of Dermatomyositis ?
Calcinosis cutis
Malar rash
Gottron papules
Heliotrope rash
36) A 19 year old man develops diarrhea ,and 2 weeks later experiences gait difficulties and foot tingling , which of the following problems associated with his condition ?
Acute inflammatory demyelinating polyneuropathy .
Acute stroke .
Myasthenia gravis .
Inflammatory Myopathy .
Transverse cord myelitis .
37) A 34 year old woman presents with fatigable muscle weakness with climbing stairs or blow drying her hair . This is associated with some shortness of breath , which improves with test . Which of the following condition associated with her symptoms ?
Acute inflammatory demyelinating polyneuropathy .
Acute stroke .
Myasthenia gravis .
Inflammatory Myopathy .
Transverse cord myelitis .
38) Multiple sclerosis is characterized by which of the following diagnostic findings ?
Oligoclonal bands in cerebrospinal fluid .
Increased N_acetyl aspartate with MR spectroscopy .
Abnormal peripheral nerve conduction by electromyograph ( EMG) / nerve conduction velocity ( NCV) studies .
Meningeal enhancement on contrast MRI of brain .
39) A 33 year old man is noted to have exacerbations of weakness . He is diagnosed with MS . Which of the following findings is consistent with the diagnosis ?
The diagnosis of MS is based on clinical lesions separated by time and space .
Oligo bands in the CSF are specific for multiple sclerosis .
Steroids are effective in improving the course of disease .
This is a genetic disorder well characterized on chromosome 11
40) A 33 year old man is noted to have exacerbations of weakness . He is diagnosed with MS . He is noted to have significantly progressive disease . Which of the following is likely to be helpful for his symptoms of weakness ?
Mitoxantrone
Corticosteroids therapy
Plasmapheresis
Immunoglobulin therapy
41) Which of the following signs is most suggestive of Parkinson disease rather than the other neurodegenerative diseases ?
Unilateral resting tremor .
Supranuclear downed gaze palsy .
Orthostatic hypotension early in the course the disease .
Early falls .
Abnormal cerebral MRI .
42) Which of the following medications is most likely to be able to help both relieve cardinal features of Parkinson disease as well as reduce drug induced dyskinesias ?
Levodopa
Dopamine agonists
Amantadine
Anticholinergics
Haloperidol
43) Which of the following medications would be most likely to cause drug induced Parkinsonism ?
Trihexyphenidyl
Metoclopramide
Diazepam
Carbidopa
Levodopa
44) Which of the following tests is used to diagnose benign Paroxysmal positional vertigo ?
Weber test
Rinne test
Dix_Hallpike maneuver
Brandt Daroff maneuver
Epley maneuver
45) A 40 year old woman has recurring episodes of disabling vertigo , lasting 30 minutes , and accompanied by roaring tinnitus , aural pressure and low frequency hearing loss . Her physical examination is normal . What is the most likely diagnosis ?
Benign Paroxysmal positional vertigo .
Acute suppurative labyrinthitis .
Acute serous labyrinthitis .
Meniere disease .
Vertebrobasilar insufficiency .
46) A 45 year old woman complains of recurring episodes of vertigo that began after she bumped her head rather forcefully 2 week ago . Her spells last 10 to 15 seconds and occur whenever she goes to bed or wakes up . She denies any hearing loss or tinnitus . Her physical examination is normal except for a latent , rotatory nystagmus when she is lying with the right ear down . What is the most likely diagnosis ?
A . Acute serous labyrinthitis .
B . Benign Paroxysmal positional vertigo .
C . Vestibular migraine .
D . Meniere disease .
E . Viral vestibular neuronitis .
47) A 66 year old woman is noted to have asymptomatic atrial fibrillation. Which of the following is most common complication of her atrial fibrillation ?
A . sudden death .
B . stroke .
C . shock .
D . dyspnea .
E . myocardial infarction
48) A 65 year old woman is presents to the ED with a dyspnea , fatigue , and palpitations . Her blood pressure is 85/50 mmHg and her heart rate is 140 bpm . Which of the following is the best treatment for this patient ?
A . Diltiazem
B . Metoprolol
C . Coumadin
D . Cardioversion
E . Aspirin
49) A 62 year old man is seen in the ED for lower abdominal pain which has since resolved , however , his heart rate was 80 bpm and palpated irregularly . On ECG , he is diagnosed with atrial fibrillation with a ventricular response of 114 bpm . He does not recall being told about this condition . Which of the following is the best initial treatment for this patient ?
A . Diltiazem
B . Cardioversion
C . Synthroid
D . Ibutilide
E . Aspirin
50) Approximately what percentage of patients with bacterial meningitis present with the classic triad of fever , neck stiffness and altered mental status ?
< 25 %
< 50 %
> 75 %
> 99 %
51) A 58 year old man presents to his physician's office complaining of 2 hours of substernal chest pain and dyspnea . Which of the following is the most important next step in management ?
A . Administration of Propranolol .
B . Aspirin to chew .
C . Sublingual nitroglycerin .
D . Administration of a diuretic agent .
E . Chest radiograph .
52) A 45 year old man is seen in ED 3 hours of substernal chest pain radiating to his left arm . The ECG shows only nonspecific changes . Hearing that the ECG is normal , he requests to go home . Which of the following statements is most accurate ?
A . The patient may be safely discharged home .
B . If a repeat ECG in 30 minutes is normal , MI is essentially ruled out and the patient may be safely discharged .
C . The patient should be advised that half of heart attack patients have a nondiagnostic ECG and serial cardiac biomarkers levels should be assessed .
D . The patient should undergo an immediate thallium stress test to further assesses for coronary artery disease to help clarify the management .
53) Which of the following tumor markers is appropriately matched with the cell type cancer and can be followed during treatment as an adjunct to assess disease burden ?
CA_125 _ Colon cancer .
Calcitonin _ Follicular carcinoma of the thyroid .
CD30 _ Hairy cell leukemia .
HCG _ GTD .
Neuron specific enolase _ Non small cell carcinoma of the lung
54) A 66 year old woman has CLL with a stable white blood cell count of between 60.000 and 70.000 /uL . She is currently hospitalized with pneumococcal pneumonia . This is the patients third episode of pneumonia within the past 12 months . What finding on laboratory testing would be most likely in this patient ?
Granulocytopenia .
Hypogammaglobulinemia .
Impaired T cell function with normal T lymphocyte count .
Low CD4 count .
No specific abnormality is expected .
55) A 55 year old man is found to have a serum calcium of 13 mg/dl after coming to clinic complaining of fatigue and thirst for the past month . A chest radiograph demonstrates a 4 cm mass in the right lower lobe . Which of the following serum tests is most likely to reveal the cause of his hypercalcemia ?
A . ACTH .
B . ADH .
C . Insulin like growth factor .
D . PTH .
E . PTH related protein .
56) All of the following conditions may be associated with a thymoma except ?
A . Erythrocytosis .
B .Hypogammaglobulinemia .
C . Myasthenia gravis .
D . Polymyositis .
E . Pure red blood cell aplasia .
57) All of the following statements regarding the anemia of chronic kidney disease are true except ?
A . The degree of anemia correlates with the stage of chronic kidney disease .
B . Erythropoietin levels are reduced .
C . Ferritin is reduced .
D . It is typically Normocytic and normochromic .
E . Reticulocytes are decreased .
58) A 24 year old man with a history of poorly treated chronic ulcerative colitis is found to have anemia with a hemoglobin of 9 g/dl and a reduced mean corpuscular volume . His Ferritin is 250 . Which of the following is the most likely cause of his anemia ?
Folate deficiency
Hemoglobinopathy
Inflammation
Iron deficiency
Sideroblastic anemia
59) All of the following statements are true regarding the criteria to diagnose hypereosinophilic syndrome except ?
A . Increased bone marrow Eosinophils must be demonstrated .
B. It is not necessary to have increased circulating Eosinophils .
C . Primary myeloid leukemia must be excluded .
D . Reactive Eosinophilia must be excluded .
E . There must be less than 20% myeloblasts in blood or bone marrow .
60) Which of the following Hemolytic anemias can be classified as extracorpuscular ?
Elliptocytosis
PNH
Pyruvate kinase deficiency
SCA
TTP
61) Which of the following statements regarding Polycythemia rubra vera is correct ?
A . And elevated plasma Erythropoietin level excludes the diagnosis .
B. Transformation to acute leukemia is common .
C . Thrombocytosis correlates strongly with thrombotic risk .
D . Aspirin should be prescribed to all of these patients to reduce thrombotic risk .
E . Phlebotomy is used only after hydroxyurea and interferon have been tried .
62) All of the following are vitamin K dependent coagulation factors except ?
Factor 10
Factor 7
Protein C
Protein S
Factor 8
63) All of the following laboratory values are consistent with an intravascular Hemolytic anemia except ?
Increased haptoglobin
Increased LDH
Increased Reticulocyte count
Increased unconjugated bilirubin
Increased urine hemosiderin
64) All of the following are consistent with nonproliferative diabetic retinopathy except ?
Blot hemorrhages
Cotton wool spots
Neovascularization
Occurs in first or second decade of DM
Retinal vascular microaneurysms
65) All of the following are potential causes of elevated LDL except ?
Anorexia nervosa
Cirrhosis
Cholestasis
Nephrotic syndrome
Thiazide diuretics
66) Which of the following is the most common cause of Cushing syndrome ?
ACTH producing pituitary adenoma .
Adrenocortical adenoma .
Adrenocortical carcinoma .
Ectopic ACTH secretion .
McCune Albright syndrome .
67) A 27 year old woman with mild obesity is seen in her primary care office for increased thirst and Polyuria . DM is suspected , and a random plasma glucose of 211 mg/d confirms this diagnosis . Which of the following tests will strongly indicate that she has type one DM ?
A .Anti GAD 65 antibody .
B .Peroxisome proliferator activated receptor _ 2 polymorphism testing .
C . Plasma insulin level .
D . Testing for HLA_DR3 .
E . There is no laboratory test indicating type one DM .
1) A 30 year old woman is noted to have blood pressures in the 160/100 mmHg range . She also has increased obesity , especially around her abdomen , with striae . She has been bruising very easily and has hirsutism . Which of the following is the most likely diagnosis ?
A . Hyperthyroidism
B . Hyperparathyroidism
C . Coarctation of aorta
D . Cushing syndrome
E . Pheochromocytoma
2) A 45 year old man with type two diabetes is noted to have blood pressures of 145/90 and 150/96 mmHg on two separate occasions . Which of the following is the best initial therapy for this patient ?
A . Hydrochlorothiazide .
B . ACE_i .
C . B blockers .
D . CCB .
E . B blockers and Hydrochlorothiazide .
3) A 62 year old diabetic man underwent an abdominal aortic aneurysm repair 2 days ago . He is being treated with Gentamycin for a UTI . His urine output has fallen to 300 ml over 24 hours , and his serum creatinine has risen from 1.1 mg/dl on admission to 1.9 mg/dl . Which of the following laboratory values would be most consistent with a prerenal etiology of his renal insufficiency ?
A . FEna of 3% .
B . Urinary sodium level of 10 mEq/L .
C .CVP reading of 10 mmHg .
D . Gentamycin trough level of 4uq/ml .
4) A 22 year old woman presents with fatigue, arthralgias , and a nagging dry cough for the past 6 weeks , but no shortness of breath . On physical examination, her lungs are clear to auscultation , and she has bilateral pretibial tender Erythematous raised nodules . Which of the following is your best next step ?
A . Chest radiograph .
B . CT chest .
C . Empiric treatment for Postnasal drip .
D . Antinuclear antibody .
E . Initiation of antituberculosis therapy .
5) An obese 50 year old man with a history of asthma returns with complaints of occasional dyspepsia and nocturnal cough . He wakes up in the morning with a sour taste in his mouth . His current medications include inhaled corticosteroids and a short acting B2 agonist . Which of the following should be your next step ?
A . 24 hour esophageal PH monitoring .
B . Chest radiograph .
C . Initiation of omeprazole .
D . Short course of oral corticosteroids .
E . Initiation of allergy desensitization
6) A patient with known asthma undergoing therapy with inhaled corticosteroids and intermittent short acting B2 agonist presents with complaints of nocturnal awakening secondary to cough and occasional wheezing . This episode occurs three to four times per week . Pulmonary function tests in the past have shown mild obstructive lung disease . Which of the following is the best next step ?
Oral steroids
Leukotriene inhibitors
Long acting B2 agonist
Theophylline
Antireflux therapy
7) Which of the following is most accurate ?
Cough caused by Captopril may resolve with switching to enalapril .
Initial treatment of a chronic cough should include codeine or a similar opiate derivative to suppress the cough .
Cough caused by reflux can be effectively ruled out by a negative history of heartburn or dyspepsia .
More than one condition often is responsible for causing a chronic cough in a given patient .
8) A 55 year old man is noted to have moderately severe congestive heart failure with impaired systolic function . Which of the following drugs would most likely lower his risk of mortality ?
ACE_i
Loop diuretics
Digoxin
Aspirin
9) A 35 year old woman is noted to have chest pain with exertion , and has been passing out recently . On examination she is noted to have a harsh systolic murmur . Which of the following is the best therapy for her condition ?
Coronary artery bypass
Angioplasty
Valve replacement
Carotid endarterectomy
10) A 55 year old man is noted to have congestive heart failure and states that he is comfortable at rest but becomes dyspneic even with walking to bathroom . On echocardiography , he is noted to have an ejection fraction of 47% . Which of the following is the more accurate description of this patients condition ?
Diastolic dysfunction
Systolic dysfunction
Dilated cardiomyopathy
Pericardial disease
11) A 24 year old man develops seizures following an emergent splenectomy after a car accident . His serum sodium level is initially 116 mEq / L and is corrected to 120 mEq/L over the next 3 hours with hypertonic saline . Which of the following factors most likely led to his Hyponatremia ?
Elevation of serum vasopressin
Administration of hypertonic solutions
Volume depletion
Seizures induced Hyponatremia
12) A 56 year old man complaining of fatigue and weight loss . He has never had any health problems , but he has smoked a pack of cigarettes per day for about a 35 years . His physical examination is notable for a low to normal blood pressure , skin hyperpigmentation , and digital clubbing . He appears euvolemic . The sodium level is 126 mEq/L , potassium level is 6.7 mEq/L , creatinine level is normal, and bicarbonate and chloride levels are low . Which of the following is the likely cause of his Hyponatremia given his presentation ?
SIADH
Hypothyroidism
Gastrointestinal losses
Adrenal insufficiency
Renal insufficiency
13) An 83 year old woman comes to your office complaining of a headache and mild confusion . Her medical history is remarkable only for HTN , which is well controlled by Hydrochlorothiazide . Her examination and laboratory tests show no signs of infection , but her serum sodium level is 119 mEq/L , and plasma osmolarity is 245 mOsm/kg . She appears to be clinically Hypovolemic . Which of the following is the best initial therapy ?
Fluid restriction
Infusion of 0.9%saline
Infusion of 3% saline
Infusion of 3% saline with Furosemide
14) A 58 year old man has undergone a lengthy colon cancer surgery . On the first postoperative day , he is noted to have significant Hyponatremia with a sodium level of 128 mEq /L . You suspect that the Hyponatremia is due to the intravenous infusion of hypotonic solution . Which of the following laboratory findings supports your diagnosis ?
Urine sodium > mmol/L
Urine osmolality > 200 mOsm /L
Serum osmolarity < 280 mOsm /kg
Serum potassium > 5 mEq/L
15) Which of the following patients is most likely to be a candidate for bone mineral density screening ?
A 65 year old, thin , white woman who smokes and is 15 years postmenopausal .
A 40 year old white woman who exercises daily and still menstruates .
A healthy 75 year old white man who is sedentary .
A 60 year old overweight black woman .
A 35 year old asthmatic woman who took prednisone 40 mg/d for a 2 week course 1 week ago
16) During which of the following periods in a woman's life is the most bone mass accumulated ?
Ages 15 to 25
Ages 25 to 35
Ages 35 to 45
Ages 45 to 55
17) A 60 year old woman presents with the results of her DEXA scan . She has a T score of _1.5 at the hip and _2.5 at the spine . Which of the following is the most accurate interpretation of these results ?
She has osteoporosis at the spine and osteopenia at the hip .
She has osteoporosis in both area's .
This is a normal examination .
She has osteoporosis of the hip and osteopenia at the spine .
You need to know the Z score .
18) You see a 70 year old woman in your office for a routine checkup , and you order a DEXA scan for bone mineral density screening . The T score returns as 2.5 standard deviations SD in the spine and _2.6 in the hip . Which of the following statements is most accurate ?
This patient has osteopenia .
Estrogen replacement therapy should be started with an anticipated rebuilding of bone mass to near normal within 1 year .
Swimming will help build bone mass .
Bisphosphonates would reduce the risk of hip fracture by 50%
19) A 35 year old woman complains of calf tenderness and acute dyspnea . The arterial blood gas reveals PO2 ( Partial pressure of oxygen ) of 76 mmHg . Which of the following is the most common physical examination finding of pulmonary embolism ?
Wheezing .
Increased pulmonary component of the second heart sound .
Tachypnoea .
Calf swelling .
Pulmonary rales .
20) A 39 year old man is noted to have a DVT without any known risk factors . He notes that his brother also developed a pulmonary embolism at age 45 years , and his mother developed a clot in the leg when she was in her thirties . Which of the following is the most likely inherited disorder in this patient ?
Protein S deficiency
Antithrombin 3 deficiency
Factor 5 Leiden mutation
Antiphospholipid antibody syndrome
Familial malignancy syndrome
21) A 54 year old woman is noted to have cervical cancer and presents with significant vaginal bleeding with a hemoglobin level of 7 g/dL . Her left leg is swollen , which on Doppler investigation reveals a DVT . Which of the following is the best treatment for the thrombus ?
Intravenous unfractionated heparin .
Fractionated subcutaneous heparin .
Subcutaneous unfractionated heparin.
Oral warfarin ( Coumadin ) .
Vena cava filter .
22) A 72 year old man develops severe pain and swelling in both knees , shortly after undergoing an abdominal hernia repair surgery . Physical examination shows warmth and swelling of both knees with large effusions . Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly positive birefringent crystals in the synovial fluid . Gram stain is negative . Which of the following is the most likely diagnosis ?
Gout
Septic arthritis
Calcium oxalate deposition disease
Reactive arthritis
Pseudogout
23) A 65 year old man with a history of chronic HTN , DM , and degenerative joint disease presents with acute onest of severe pain of the metatarsophalangeal joint and swelling of the left first toe . Physical examination shows exquisite tenderness of the joint , with swelling , warmth , and Erythema . The patient has no history of trauma or other significant medical problems . Synovial fluid analysis and aspiration is most likely to show which of the following ?
Hemorrhagic fluid .
Needle_ shaped , negatively birefringent crystals .
Gram negative organisms .
Noninflammatory fluid .
Rhomboidal , positively birefringent crystals
24) A 17 year old sexually active adolescent male presents with a 5 day history of fever , chills , and persistent left ankle pain and swelling . On physical examination , maculopapular and pustular skin lesions are noted on the trunk and extremities . He denies any symptoms of genitourinary tract infection . Synovial fluid analysis is most likely to show which of the following ?
WBCs 75.000/mm3 with 95% polymorphonuclear leukocytes .
RBCs 100.000/mm3 , WBCs 1000/mm3 .
WBCs 48.000/mm3 with 80% lymphocytes .
WBCs 500/mm3 with 25% polymorphonuclear leukocytes .
25) A 22 year old man presents with complaints of low back pain for 3 to 4 months and stiffness of the lumbar area , which worsen with inactivity . He reports difficulty in getting out of bed in the morning and may have to roll out sideways , trying not to flex or rotate the spine to minimize pain . A Lumbosacral spine X_Ray film would most likely show which of the following ?
Degenerative joint disease with spur information .
Sacroiliitis with increased sclerosis around the sacroiliac joints .
Vertebral body destruction with wedge fractures .
Osteoporosis with compression fractures of L3_L5 .
Diffuse osteonecrosis of the LS spine .
26) A 36 year old woman was seen by her physician due to pain in her hands, wrists , and knees . She is diagnosed with rheumatoid arthritis . Which of the following treatments will reduce joint inflammation and slow progression of the disease ?
NSAIDs
Joint aspiration
Methotrexate
Systemic corticosteroids
27) An 18 year old adolescent female is brought to the emergency room because she fainted at a rock concert . She apparently recovered spontaneously , did not exhibit any seizure activity , and has no medical history . Her heart rate is 90 bpm and blood pressure 110/70 mmHg . Neurologic examination is normal . The pregnancy test is negative . Which of the following is the most appropriate management ?
Admit to hospital for cardiac evaluation .
Outpatient echocardiogram .
Twenty four hour Holter monitor .
Reassurance and discharge home .
28) A 67 year old woman has diabetes and mild HTN . She is noted to have some diabetic retinopathy , and she states that she cannot feel her legs . She has recurrent episodes of lightheadedness when she gets up in the morning .She comes in now because she had fainted this morning . Which of the following is the most likely cause of her syncope ?
Carotid sinus Hypersinsivety
PE
Autonomic neuropathy
Critical aortic stenosis
29) A 74 year old man with no prior medical problems faints while shaving . He has a quick recovery and has no neurologic deficits . His blood sugar level is normal , and ECG shows a normal sinus rhythm . Which of the following is the most useful diagnostic test of his probable condition ?
Carotid massage
Echocardiogram
CT scan of head
Serial cardiac enzymes
30) A 49 year old man is admitted to the intensive care unit with a diagnosis of an inferior MI . His heart rate is 35 bpm and blood pressure 90/50 mmHg . His ECG shows a mobitz type 1 heart block . Which of the following is the best next step ?
Atropine
Transvenous pacer
Lidocaine
Observation
31) A 42 year old woman is being treated with infliximab for rheumatoid arthritis . After 6 months of therapy , she develops persistent fever , weight loss , and night sweats , and tuberculosis is suspected . Which of the following is most likely location of the tuberculosis ?
Middle and lower lung zones .
Pleural space .
Apical segment of the upper lung lobes .
Cervical or supraclavicular lymph nodes .
32) A 24 year old man has been treated with INH , Rifampicine ,and pyrazinamide for active pulmonary tuberculosis . After 3 months , he states that he is having numbness and tingling of both feet but no Back pain . He denies taking other medications . Which of the following is the most appropriate next step ?
CT scan of the lumbar spine .
Initiate pyridoxine .
Continue the tuberculosis agents and monitor for further neurological problems .
Initiate a workup for tuberculosis Adenopathy compression on the femoral nerve.
33) A 25 year old woman is seen in the clinic because her father was diagnosed with and has been treated for tuberculosis . She denies a cough and her chest radiograph is normal . A PPD test shows 10 mm of induration . Her only medication is an OCP . Which of the following is the best next step ?
Oral INH and barrier contraception .
Combination therapy including INH, Rifampicine and pyrazinamide .
Observation .
Induce three sputum samples .
34) Which of the following tests is the most appropriate to follow for a patient receiving isoniazed and rifampin for tuberculosis treatment ?
Renal function tests
Liver function tests
Slit_lamp examinations
Amylase and lipase tests
35) Which of the following is not a dermatologic manifestation of Dermatomyositis ?
Calcinosis cutis
Malar rash
Gottron papules
Heliotrope rash
36) A 19 year old man develops diarrhea ,and 2 weeks later experiences gait difficulties and foot tingling , which of the following problems associated with his condition ?
Acute inflammatory demyelinating polyneuropathy .
Acute stroke .
Myasthenia gravis .
Inflammatory Myopathy .
Transverse cord myelitis .
37) A 34 year old woman presents with fatigable muscle weakness with climbing stairs or blow drying her hair . This is associated with some shortness of breath , which improves with test . Which of the following condition associated with her symptoms ?
Acute inflammatory demyelinating polyneuropathy .
Acute stroke .
Myasthenia gravis .
Inflammatory Myopathy .
Transverse cord myelitis .
38) Multiple sclerosis is characterized by which of the following diagnostic findings ?
Oligoclonal bands in cerebrospinal fluid .
Increased N_acetyl aspartate with MR spectroscopy .
Abnormal peripheral nerve conduction by electromyograph ( EMG) / nerve conduction velocity ( NCV) studies .
Meningeal enhancement on contrast MRI of brain .
39) A 33 year old man is noted to have exacerbations of weakness . He is diagnosed with MS . Which of the following findings is consistent with the diagnosis ?
The diagnosis of MS is based on clinical lesions separated by time and space .
Oligo bands in the CSF are specific for multiple sclerosis .
Steroids are effective in improving the course of disease .
This is a genetic disorder well characterized on chromosome 11
40) A 33 year old man is noted to have exacerbations of weakness . He is diagnosed with MS . He is noted to have significantly progressive disease . Which of the following is likely to be helpful for his symptoms of weakness ?
Mitoxantrone
Corticosteroids therapy
Plasmapheresis
Immunoglobulin therapy
41) Which of the following signs is most suggestive of Parkinson disease rather than the other neurodegenerative diseases ?
Unilateral resting tremor .
Supranuclear downed gaze palsy .
Orthostatic hypotension early in the course the disease .
Early falls .
Abnormal cerebral MRI .
42) Which of the following medications is most likely to be able to help both relieve cardinal features of Parkinson disease as well as reduce drug induced dyskinesias ?
Levodopa
Dopamine agonists
Amantadine
Anticholinergics
Haloperidol
43) Which of the following medications would be most likely to cause drug induced Parkinsonism ?
Trihexyphenidyl
Metoclopramide
Diazepam
Carbidopa
Levodopa
44) Which of the following tests is used to diagnose benign Paroxysmal positional vertigo ?
Weber test
Rinne test
Dix_Hallpike maneuver
Brandt Daroff maneuver
Epley maneuver
45) A 40 year old woman has recurring episodes of disabling vertigo , lasting 30 minutes , and accompanied by roaring tinnitus , aural pressure and low frequency hearing loss . Her physical examination is normal . What is the most likely diagnosis ?
Benign Paroxysmal positional vertigo .
Acute suppurative labyrinthitis .
Acute serous labyrinthitis .
Meniere disease .
Vertebrobasilar insufficiency .
46) A 45 year old woman complains of recurring episodes of vertigo that began after she bumped her head rather forcefully 2 week ago . Her spells last 10 to 15 seconds and occur whenever she goes to bed or wakes up . She denies any hearing loss or tinnitus . Her physical examination is normal except for a latent , rotatory nystagmus when she is lying with the right ear down . What is the most likely diagnosis ?
A . Acute serous labyrinthitis .
B . Benign Paroxysmal positional vertigo .
C . Vestibular migraine .
D . Meniere disease .
E . Viral vestibular neuronitis .
47) A 66 year old woman is noted to have asymptomatic atrial fibrillation. Which of the following is most common complication of her atrial fibrillation ?
A . sudden death .
B . stroke .
C . shock .
D . dyspnea .
E . myocardial infarction
48) A 65 year old woman is presents to the ED with a dyspnea , fatigue , and palpitations . Her blood pressure is 85/50 mmHg and her heart rate is 140 bpm . Which of the following is the best treatment for this patient ?
A . Diltiazem
B . Metoprolol
C . Coumadin
D . Cardioversion
E . Aspirin
49) A 62 year old man is seen in the ED for lower abdominal pain which has since resolved , however , his heart rate was 80 bpm and palpated irregularly . On ECG , he is diagnosed with atrial fibrillation with a ventricular response of 114 bpm . He does not recall being told about this condition . Which of the following is the best initial treatment for this patient ?
A . Diltiazem
B . Cardioversion
C . Synthroid
D . Ibutilide
E . Aspirin
50) Approximately what percentage of patients with bacterial meningitis present with the classic triad of fever , neck stiffness and altered mental status ?
< 25 %
< 50 %
> 75 %
> 99 %
51) A 58 year old man presents to his physician's office complaining of 2 hours of substernal chest pain and dyspnea . Which of the following is the most important next step in management ?
A . Administration of Propranolol .
B . Aspirin to chew .
C . Sublingual nitroglycerin .
D . Administration of a diuretic agent .
E . Chest radiograph .
52) A 45 year old man is seen in ED 3 hours of substernal chest pain radiating to his left arm . The ECG shows only nonspecific changes . Hearing that the ECG is normal , he requests to go home . Which of the following statements is most accurate ?
A . The patient may be safely discharged home .
B . If a repeat ECG in 30 minutes is normal , MI is essentially ruled out and the patient may be safely discharged .
C . The patient should be advised that half of heart attack patients have a nondiagnostic ECG and serial cardiac biomarkers levels should be assessed .
D . The patient should undergo an immediate thallium stress test to further assesses for coronary artery disease to help clarify the management .
53) Which of the following tumor markers is appropriately matched with the cell type cancer and can be followed during treatment as an adjunct to assess disease burden ?
CA_125 _ Colon cancer .
Calcitonin _ Follicular carcinoma of the thyroid .
CD30 _ Hairy cell leukemia .
HCG _ GTD .
Neuron specific enolase _ Non small cell carcinoma of the lung
54) A 66 year old woman has CLL with a stable white blood cell count of between 60.000 and 70.000 /uL . She is currently hospitalized with pneumococcal pneumonia . This is the patients third episode of pneumonia within the past 12 months . What finding on laboratory testing would be most likely in this patient ?
Granulocytopenia .
Hypogammaglobulinemia .
Impaired T cell function with normal T lymphocyte count .
Low CD4 count .
No specific abnormality is expected .
55) A 55 year old man is found to have a serum calcium of 13 mg/dl after coming to clinic complaining of fatigue and thirst for the past month . A chest radiograph demonstrates a 4 cm mass in the right lower lobe . Which of the following serum tests is most likely to reveal the cause of his hypercalcemia ?
A . ACTH .
B . ADH .
C . Insulin like growth factor .
D . PTH .
E . PTH related protein .
56) All of the following conditions may be associated with a thymoma except ?
A . Erythrocytosis .
B .Hypogammaglobulinemia .
C . Myasthenia gravis .
D . Polymyositis .
E . Pure red blood cell aplasia .
57) All of the following statements regarding the anemia of chronic kidney disease are true except ?
A . The degree of anemia correlates with the stage of chronic kidney disease .
B . Erythropoietin levels are reduced .
C . Ferritin is reduced .
D . It is typically Normocytic and normochromic .
E . Reticulocytes are decreased .
58) A 24 year old man with a history of poorly treated chronic ulcerative colitis is found to have anemia with a hemoglobin of 9 g/dl and a reduced mean corpuscular volume . His Ferritin is 250 . Which of the following is the most likely cause of his anemia ?
Folate deficiency
Hemoglobinopathy
Inflammation
Iron deficiency
Sideroblastic anemia
59) All of the following statements are true regarding the criteria to diagnose hypereosinophilic syndrome except ?
A . Increased bone marrow Eosinophils must be demonstrated .
B. It is not necessary to have increased circulating Eosinophils .
C . Primary myeloid leukemia must be excluded .
D . Reactive Eosinophilia must be excluded .
E . There must be less than 20% myeloblasts in blood or bone marrow .
60) Which of the following Hemolytic anemias can be classified as extracorpuscular ?
Elliptocytosis
PNH
Pyruvate kinase deficiency
SCA
TTP
61) Which of the following statements regarding Polycythemia rubra vera is correct ?
A . And elevated plasma Erythropoietin level excludes the diagnosis .
B. Transformation to acute leukemia is common .
C . Thrombocytosis correlates strongly with thrombotic risk .
D . Aspirin should be prescribed to all of these patients to reduce thrombotic risk .
E . Phlebotomy is used only after hydroxyurea and interferon have been tried .
62) All of the following are vitamin K dependent coagulation factors except ?
Factor 10
Factor 7
Protein C
Protein S
Factor 8
63) All of the following laboratory values are consistent with an intravascular Hemolytic anemia except ?
Increased haptoglobin
Increased LDH
Increased Reticulocyte count
Increased unconjugated bilirubin
Increased urine hemosiderin
64) All of the following are consistent with nonproliferative diabetic retinopathy except ?
Blot hemorrhages
Cotton wool spots
Neovascularization
Occurs in first or second decade of DM
Retinal vascular microaneurysms
65) All of the following are potential causes of elevated LDL except ?
Anorexia nervosa
Cirrhosis
Cholestasis
Nephrotic syndrome
Thiazide diuretics
66) Which of the following is the most common cause of Cushing syndrome ?
ACTH producing pituitary adenoma .
Adrenocortical adenoma .
Adrenocortical carcinoma .
Ectopic ACTH secretion .
McCune Albright syndrome .
67) A 27 year old woman with mild obesity is seen in her primary care office for increased thirst and Polyuria . DM is suspected , and a random plasma glucose of 211 mg/d confirms this diagnosis . Which of the following tests will strongly indicate that she has type one DM ?
A .Anti GAD 65 antibody .
B .Peroxisome proliferator activated receptor _ 2 polymorphism testing .
C . Plasma insulin level .
D . Testing for HLA_DR3 .
E . There is no laboratory test indicating type one DM .
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