1 .You’ve been seeing Mrs. Reyes, 42/F at theOPD for chronic heart failure and she has been minimally symptomatic on a beta blocker. She comes back to you with acute decompensated heart failure. Which of the following might have triggered her decompensation?
A. Alcohol abuse B. Smoking C. Pregnancy D. Fluid restriction
Alcohol and Smoking – acute renal failure
Pregnancy – fetus added to blood volume which causes decompensatory heart failure
Fluid restriction is a treatment.
2. You remember that Mrs. Reyes has rheumatic heart disease since she was 25 years old. On examination, she has an accentuated S1, a diastolic rumble over the apex and a wide notched P wave on 12L ECG. Which valvular lesion does she most probably have?
A. Mitral stenosis B. Mitral regurgitation C. Aortic stenosis D. Aortic regurgitation .
Accentuated S1 – mitral valve Mitral Stenosis
Most common in RHD
Others congenital dse, SLE and RA Left atrial myxoma mimics symptoms
Accentuated S1, Diastolic rumble and opening snap
3. Which ECG findin distinguishes acute MI from pericarditis?
E. ST elevations are concave F. Development of Q Waves G. Tall P waves
H. T wave inversiotns usually seen within days before ST segments become isoelectric
ECG on Myocardial Ischemia:
Aggravated by effort or activity
The diagnosis of acute myocardial infarction is not only based on the ECG. A myocardial infarction is defined as: Elevated blood levels of cardiac enzymes (CKMB
or Troponin T) AND
One of the following criteria are met: o The patient has typical complaints, o The ECG shows ST elevation or
depression.
o Pathological Q waves develop on the ECG.
o A coronary intervention had been performed (such as stent placement) ECG on Pericarditis:
Aggravatesd by lying on supine
In pericarditis four stages can be distinguished on the ECG:
stage I: ST elevation in all leads. PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)
stage II: pseudonormalisation (transition) stage III: inverted T-waves
stage IV: normalization
Keep into account that in stage I pericarditis, ST-elevation is present in all leads except in aVR, V1 and III.
**Dressler’s Syndrome – Pericarditis after MI triad of features:
o fever,
o pleuritic pain and o pericardial effusion
4. Diagnostic feature of cardiac tamponade I. Kussmaul’s sign
J. Pulsus Paradoxus
K. Thickened/calcified pericardium L. Incresed myocardial thick ness ** Kussmaul's sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration. Usually present in: Constrictive pericarditis and restrictive cardiomyopathy **Cardiac Tamponade
Too much fluid in the Pericardial sac Beck’s Triad
o Hypotension
o Soft/muffled heart sound o Distended neck veins
Pulsus Paradoxus (HALLMARK): greater than normal (10mmHg) inspiratory decline in systolic arterial pressure
Prominent x descent Electrical alternans Pericardial effusion
Equalization of diastolic pressures ** See also figure 1
5.Initial anti-hypertensive therapy with Thiazide diuretic should be given to which patient:
A. 48/MCHF Functional Class III, BP 160/90
B. 50/M BP 140/90 with gouty arthritis C. 23/F with CKD stage 5 from chronic
glomerilonephtitis BP 150/90
D. 55/F with dyslipidemia and bronchial asthma, BP 150/90
** (seefigure 2)
6.Treatment of choice for acute pericarditis occurring post-STEMI
A. Ibuprofen 20mg 3 times daily B. Aspirin 650mg 4 times daily C. Prednisone 1mg/kg daily D. Warfarin 2.5 to 5mg daily ___________ Syndrome
Initial dose for MI: Aspirin 80 mg tab
2nd choice: Ibuprofen (studies show it increases 2nd
chances of MI again.)
Prednisone is contra-indicated due to this thinning effect on the pericardial sac
Warfarin is also CI due to its effect on the sac to bleed. 7.A 64/M came to the ER for chest heaviness starting 3 hours prior, unrelieved by nitrates given to him at the previous hospital On PE, BP 80/50 HR 64 RR20 neck veins were flat, breath sounds clear while heart sounds were distinct. On 12L ECG, ST elevation was seen in leads II, III and AVF. What is the next step in stabilizing this patient?
A. Give morphine
B. Give intravenous fluid C. Start dopamine drip D. Start dobutamine drip
The patient has Inferior wall MI so the preload is not enough going to the heart which causes the hypotension. Dobutamine and Morphine nitrate – not given due to its vasodilation effects which can even worsen the low BP status
Dopamine – not given due to the ST elevations on ECG finding which could worsen due to effects of increase cardiac activity.
8.Fibrinolytic therapy can be given to which of the following patients as treatment for STEMI
A. 64/M presenting with severe, tearing chest pain.
B. 49/M diabetic with BP 190/110 C. 45/F with lupus nephtritis and active
menses.
D. 40/M who had ischemic stroke months ago.
Absolute Contraindications to Fibrinolysis:
History of Cerebrovascular hemorrhage at any time
Non-hemorrhagic stroke or other
Cerebrovascular event within the past year Marked hypertension (SBP>180 mmHg and/or a
DBP>110mmHg) at any time during the acute presentation
Suspicion of aortic dissection (tearing chest pain) Active internal bleeding (excluding menses) 9. In assessment of blood pressure, using an inappropriately small BP cuff will result in:
A. Overestimation of the true blood Pressure
B. Underestimation of the true blood Pressure
C. No change in the true blood pressure D. Overestimation only of the systolic blood
pressure.
10. A 59 year old male presents with chest pain. On auscultation, you were able to appreciate a midsystolic murmur radiating to the carotids. You also noted a weak and delayed pulse.
Your likely diagnosis is:
A. Aortic stenosis B. Aortic regurgitation C. Acute myocardial infarction D. Pulmonary embolism
Aortic Stenosis - The three cardinal symptoms of aortic stenosis are:
syncope,
anginal chest pain and; dyspnea
Other symptoms of heart failure such as: orthopnea,
exertional dyspnea,
paroxysmal nocturnal dyspnea, or pedal edema.
It also has Pulsus parvus et tardus which is may be a slow and/or sustained upstroke of the arterial pulse, and the pulse may be of low volume It also has the apical-carotid delay which is the pulse radiating to the carotid artery.
Aortic Regurgitation: aka Aortic Insufficiency The leaking of the aortic valve of the heart
that causes blood to flow in the reverse direction during ventricular diastole Auscultation of the heart to listen for the
murmur of aortic insufficiency and the S3 heart sound
o S3 gallop correlates with development of LV dysfunction Early diastolic and decrescendo, which is
best heard in the third left intercostal space and may radiate along the left sternal border. Symptoms of Aortic Reg are same as Heart Failure such as:
orthopnea,
exertional dyspnea,
paroxysmal nocturnal dyspnea,
Acute Myocardial Infarction Symptoms: o Chest pain o Dyspnea o Diaphoresis o Light-headedness o Weakness o Palpitations
o Nausea and vomiting Pulmonary Embolism
Symptoms of pulmonary embolism include difficulty breathing,
chest pain on inspiration, and palpitations.
Clinical signs include
low blood oxygen saturation cyanosis,
rapid breathing, and a rapid heart rate.
**Severe cases of PE can lead to collapse, abnormally low blood pressure, and sudden death.
11.A 75 year old male comes in for angina. He is a heavy smoker and alcoholic beverage drinker. He was also said to have a “fatty liver” by ultrasound. On further history, he admits to have been taking the “the blue pill” (sildenafil) for erectile dysfunction (last intake was the day prior). Which anti-anginal drug is absolutely contraindicated for this patient:
A. Metoprolol B. Diltiazen C. Nitroglycerin D. Aspirin
Since the patient is taking in Sildenafil, we should not give Nitroglycerin for his angina because the BP will decrease lower than the normal and cause significant hypotension. 12. A 35 year old male with a heavy smoking history develops claudication on the right foot with gangrene on the tips of tips of the toes. Popliteal pulses on both extremities are normal. Your likely diagnosis is:
A. Atheroembolism
B. Deep venous thrombosis C. Fibromuscular dysplasia D. Thromboangiltis obliterans 13. A 65 year old male was hospitalized for stroke 8 months prior and was subsequently bedridden after. He was rushed to the emergency room for sudden onset difficulty of breathing. Upon arrival at the emergency room there was note blood-tinged sputum, with the following vital signs BP:110/70 HR: 72 regular, RR:34 and there was clear breath sounds. Emergency 2D echo showed McConnell’s sign. What is the most common cause of death for patients with this condition?
A. Pump failure from myocardial ischemia B. Progressive right heart failure C. Respiratory failure from hypoxemia D. Sudden cardiac death from cardiac
dysrhythmia Pulmonary Embolism
Dyspnea is the most common symptom Tachypnea is the most common sign Risk Factors:
o Bedridden > 3 days o Active Cancer
o Major Surgery < 12 weeks
Progressive right heart failure is the usual cause of death
** Mc Connel’s Sign:
This is the finding of akinesia of the mid-free wall but normal motion of the apex
14. A 54 year old diabetic male, with a 60 pack year smoking history sought consult at the OPD 1 week ago for exertional dyspnea and cough with whitish sputum which started 8 months ago. He was rushed to the emergency room for a 3 day history of worsening difficulty of breathing, cough and decreased sensorium. Upon arrival, he was seen drowsy with absent breath sounds and bipedal edema. Which of the following should be the next step in managing this patient?
A. Intubate the patient B. Nebulize with Salbtamol C. Start theophylline drip D. Give Furosemide IV boluses
15.A diagnostic thoracentesis is warranted for which of the following situations?
A. Pleural effusions are equally present on both lung fields
B. Patient is febrile
C. Isolated left sided effusion D. Sputum AFB is positive
Light’s Criteria: Transudative vs Exudative Pleural Fluid protein/serum protein >0.5 Pleural fluid LDH/serum LDH > 0.6
Pleural fluid LDH > 2/3 normal upper limit for serum
Factors indicating the likely need for a procedure more invasive than a thoracentesis (increasing order of importance)
Loculated pleural fluid Pleural fluid pH < 7.20
Pleural fluid glucose < 3.3 mmol/L (<60mg/dL) Positive Gram stain or culture of the pleural fluid Presend of gross pus in the pleural space
16.A 50 year old female, on chronic dialysis, was transferred from a nursing home for decreased in sensorium. On history, there was a 1 week history of cough with yellowish sputum, associated with high grade fever and progressive difficulty of breathing. On
examination, she was drowsy, with coarse crackles on the right lower lung field. Vital signs were BP: 70/50 HR 118 and RR 27 and febrile at 39.2°C.
Which of the following would put her risk of Pseudomonas aeruginosa infection?
A. Chronic dialysis
B. Family member with a Pseudomon infection C. Hypotension despite fluid
D. Living in a nursing home **See Figure 3
17. A 30 year old patient sought consult for chronic cough for 3 months. She was previously diagnosed with
pulmonary tuberculosis but only completed treatment 3 months Laboratory test showed positive sputum TB culture and chest x-ray revealed cavitary TB. Which of the following makes patient most likely to transmit PTB?
A. Age of the patient
B. Positive sputum TB culture
C. Presence of cavitary TB on chest ray D. Previous TB treatment
18. When should treatment failure in pulmonary tuberculosis be suspected?
A. Chest x-ray remained unchanged after 6 weeks B. Sputum AFB smears remain post after 5 months.
C. Sputum cultures remain positive after 2 months D. If patient stops medications for 1 week
**TB Treatment Failure/Resistance
If sputum AFB is positive at 3 months and patient is adherent
If sputum cultures remain positive at 3 months In some like extensive cavitary disease and large
numbers of organisms, AFB smear conversion may lag behind culture conversion.
**Cavitary lesions = Increased Bacilli burden 19. What is the mechanism of action of Rifampicin?
A. Inhibits fatty acid synthase and mycolic acid synthesis
B. Inhibits arabinosyltransferases involved in cell wall synthesis.
C. Inhibits mycobacterial
DNA-dependent RNA polymerase, blocking RNA synthesis
D. Mechanism is unclear ***Mechanism of Action of Anti-Koch Drugs Rifampicin – Inhibits mycobacterial DNA-dependent RNA polymerase, blocking RNA synthesis
Isoniazid - prodrug and must be activated by a bacterial catalase-peroxidase enzyme that in M. tuberculosis is called KatG.
KatG couples the isonicotinic acyl with NADH to form isonicotinic acyl-NADH complex.
This complex binds tightly to the enoyl-acyl carrier protein reductase known as InhA, thereby blocking the natural enoyl-AcpM substrate and the action of fatty acid synthase.
This process inhibits the synthesis of mycolic acid, required for the mycobacterial cell wall. Ethambutol - It works by obstructing the formation of cell wall.
Mycolic acids attach to the 5'-hydroxyl groups of D-arabinose residues of arabinogalactan and form mycolyl-arabinogalactan-peptidoglycan complex in the cell wall.
It disrupts arabinogalactan synthesis by inhibiting the enzyme arabinosyl transferase. Disruption of the arabinogalactan synthesis
inhibits the formation of this complex and leads to increased permeability of the cell wall.
Pyrazinamide - Pyrazinoic acid was thought to inhibit the enzyme fatty acid synthase (FAS) I, which is required by the bacterium to synthesize fatty acids and kills dormant bacteria and newly replicated M. tuberculosis Streptomycin- is a protein synthesis inhibitor.
It binds to the small 16S rRNA of the 30S subunit of the bacterial ribosome, interfering with the binding of formyl-methionyl-tRNA to the 30S subunit.
This leads to codon misreading, eventual inhibition of protein synthesis and ultimately death of microbial cells.
20..Which of the following laboratory/imaging finding suggests the presence of chronic hypoxemia?
A. Compensatory increase of bicarbonate In arterial blood gas
B. FEV1/FVC < 0.7 on spirometry C. Low hematocrit
21. A 30 year old female came in for severe abdominal pain radiating to the back. Amylase and lipase were significantly elevated. On the 3rd postoperative day, she
had sudden worsening of dyspnea with a respiratory rate of 34. Arterial blood gas showed a PO2 of 40 with an FiO2 of 40%. Best management for this patient will be:
A. Give stat dose of Furosemide IV bolus with BP precautions
B. Start piperacillin tazobactam and observe after three days for improvements of symptoms
C. Start heparin, aspirin and clopidogrel, and refer for emergent coronary angiography with revascularation D. Institute ventilatory support with a
low tidal volume (6cc/kg) 22.How is Paragonimus westermani (Lung Fluke) transmitted?
A. Respiaratory droplets B. Ingestion of craysfish
C. Transfer from infected blood and body fluids
D. Inhalation of infectious larva
23.A 22 year old college student sought consult for a 7 day history a high grade fever. He also complained of headache, body malaise, and abdominal pain. On physical examination, vital signs were as follows: Bp 110/60 HR 70 RR 18 Temp 39.4°C, the liver was enlarged; there was splenomegaly and blaching, maculapapular rash over the anteriror chest.
A. Dengue hemorrhagic fever B. Leptopirosis
C. Malaria D. Typhoid fever
Typhoid Fever – prolonged high grade fever 1 to 2 weeks duration and continuous; relative bradycardia; relative leucopenia with rashes on the chest. This also has enlarged liver and spleen.
DHF – purpuric rashes are present on the 3rd day of fever
or after lysis of fever
Usually there’s abdominal pain Flu-like symptoms
Bleeding
Platelet count decreases after lysis of fever Leptospirosis
Flu-like symptoms + hepatic damage (jaundice) Malaria
Flu-like symptoms with fever as paroxysmal o The classic symptom of malaria is
paroxysm—a cyclical occurrence of sudden coldness followed by shivering and then fever and sweating, occurring
everytwo days (tertian fever) in P. vivax and P. ovale infections, and every three days (quartan
fever) for P. malariae. P. falciparum infection can
cause recurrent fever every 36– 48 hours or a less pronounced and almost continuous fever 24. Aling Dahlia is a 55 year old diabetic patient you haven’t seen in years. She comes back to you with burning pain when she urinates and vulvar itching. On closer inspection, you note clumped white vaginal discharges on a background of erythematous vaginal epithelium. What is your treatment of choice?
A. Metronidazole 2g orally single dose B. Metronidazole 500mg BID for 7 days. C. Fluconazole 150mg orally single dose D. Azithromycin 2g orally single dose **SSx suggests infection from Candidiasis so an anti-fungal is the drug of choice
25. Your cousin complains to you that she had a episode of vomiting around 10 episodes of watery diarrhea with abdominal cramping for the past 3 hours. She denies any fever and did not notice blood in her vomitus or stools. She tells you that she just come from a friend’s wedding 4 hours ago where she ate fried rice, potato salad, roast beef and prawns.
Which of the following is a reasonable treatment regimen for your cousin in addition to oral rehydration?
A. Bismuth or Loperamide B. Bismuth plus Clindamycin C. Ciprofloxacin plus Metronidazole D. Ciprofloxacin
26.Most common clinical findings in the acute clinical syntdrome of HIV.
A. Mucocutaneous ulceration, Kaposi’s sarcoma
B. Diarrhea, myaldia, urethral discharge C. Pharyngitis, lymphadenopathym fever D. Weight lostm nights swears ,prostration 27. True regarding treatment of schistosomiasis
A.Drug of choice is praziquantel in 2 to 3 doses given in 4 weeks.
B. Early hepatomegaly and bladder lesions Do not resolve with chemptherapy C. Treatment of severe acute schistosomiasis
involves parasite elimination and supportive treatment such as
glucocorticoids.
D. Treatment of schistosmiasis in a patient with co-infection with HIV will reduce
HIV viral load and increase CD4 counts.
28.Which of the following vaccines can be given safely to pregnant women?
A. Measles, mumps, rubella (MMR) B. Varicella
C. Tetanus toxoids D. Herpes zoster
29.Capt. Reyes is a naval officer who is now going to be assigned to Papua New Guinea. He consults you since he is concerned about malaria in the area and intends to bring his pregnant wife and 12 y/o son with him. Which of the following should be your advice to them? A. It is very important to apply anti-mosquito repellants especially in mid-afternoon
when the anopheline mosquitoes most often feed.
B. Travellers should take their Chemoprophylaxis 12-24 hours
prior to departure and continue until 1 week after departure
C. Pregnant women can be given Mefloquine D.Chemoprophylaxis for malaria when
given appropriately assures protection for travelers and diagnosis other than malaria should be sought when they present with fever.
30. Which of the following is true regarding serologic tests for syphilis?
A. RPR remains the standard in examining examining cerebrospinal fluid (CSF)
B. VDRL is the test of choice for rapid Serological diagnosis in clinical setting. C. RPR titers correlate with VDRL titers
during treatment and may be used interchangeably
D. A non-reactive FTA-ABS test on CSF rules out asymptomatic neurosyphilis
**Syphilis Diagnostics: Non-treponemal
RPR test is easier to perform and uses unheated serum; test of choice for rapid serologic
diagnosis in a clinical setting and can be automated.
VDRL test remains the standard for examining CSF.
RPR and VDRL tests are recommended for screening or for quantitation of serum antibody VDRL titers do not correspond directly to RPR
titers
Syphilis Diagnostics: Treponemal
Treponemal antibody-absorbed (FTA-ABS) test and the T. pallidum particle
agglutination (TPPA) test Confirmatory test for syphilis Has high false negative rate
Cannot distinguish between current and treated syphilis
31. Mucocutaneous lesions, generalized non-tender Lymphadenopathy, skin eruptions that involves palms and soles and rarely, lues maligna or severe necrotic lesions, occur in which stage of syphilis infection?
A. Primarily syphilis B. Secondary syphilis C. Latent syphilis D. Late syphilis Stages of Syphilis infection Primary
Gumma
Approximately 3 to 90 days after the initial exposure (average 21 days) a skin lesion, called a chancre, appears at the point of contact. This also has Lymphadenopathy.
This is classically (40% of the time) a single, firm, painless, non-itchy skin ulceration with a clean base and sharp borders between 0.3 and 3.0 cm in size. The lesion, however, may take on almost any form. In the classic form, it evolves from a macule to a papule and finally to an erosion or ulcer.
Secondary
Secondary syphilis occurs approximately four to ten weeks after the primary infection.
symptoms most commonly involve the skin, mucous membranes, and lymph nodes. There may be a symmetrical, reddish-pink,
non-itchy rash on the trunk and extremities, including the palms and soles.
The rash may become maculopapular or pustular. It may form flat, broad, whitish, wart-like lesions known as condyloma latum on mucous membranes. All of these lesions harbor bacteria and are infectious.
Latent
Latent syphilis is defined as having serologic proof of infection without symptoms of disease. It is further described as either early (less than 1
year after secondary syphilis) or late (more than 1 year after secondary syphilis) in the United States.
The United Kingdom uses a cut-off of two years for early and late latent syphilis.
o Early latent syphilis may have a relapse of symptoms.
o Late latent syphilis is asymptomatic, and not as contagious as early latent syphilis
Tertiary
Tertiary syphilis may occur approximately 3 to 15 years after the initial infection, and may be divided into three different forms:
o gummatous syphilis (15%), o late neurosyphilis (6.5%), and o cardiovascular syphilis (10%). Without treatment, a third of infected people
develop tertiary disease.
People with tertiary syphilis are not infectious 32. This blood fluke is now classified as human carcinogen.
A. Schistosoma japonicum B. Schistosoma hematobium C. Schistosoma mekongi D. Schistosoma intercalartum 33. . Most common clinical manifestation of Neisseria meningitides in human:
A. Asymptomatic colonization of the nasopharynx
B. Bacterial meningitis C. Meningococcal septicemia D. Occult bacterermia
34. 40 year old female wondered why despite her appetite she seemed to be wasting away. She has been having vague abdominal pain and watery diarrhea for a month now, despite treatment which Ciprofloxacin. She consults you regarding this wondering if it has anything to do with her love for raw fish. Upon doing a battery tests, you note an albumin level of 12 (normal value: 40).
Fecalysis results showed peanut-shaped eggs. What is your diagnosis?
A. Trichinella B. Capillariasis C. Enterobiasis D. Acariasis
35.A 53 year old male came in at the OPD for jaundice. On history he was a heavy chronic alcoholic beverage drinker and has a strong family history for hepatocellular cancer. On physical examination, he has gynecomastia and a few spider angionata. Hepatitis profile:
HBsAg, anti-HCV: Non-reactive
AST was twice elevated as the ALT, low albumin, prolonged PT
CBC: HGB 92 HCT 0.23 MCV 102 MCH 35 Platelet 166 Which would be the most likely cause of this patient’s chronic liver disease?
A. Alcoholic liver disease B. Chronic hepatitis B infection C. Hepatocellular carcinoma D. Fatty liver
36.What is you interpretation of the following hepatitis profile?
Hbs(·) Anti-HBs (+) Anti-Hbc IgG (+) HBeAg (·) Anti HBe(+/-)
A. Chronic hepatitis B high infectivity B. Late acute or chronic hepatitis B, Low
Infectivity
C. Recovery from hepatitis B D. Vaccination against HBV **See Figure 4
37. A 30 year old female sought consult for mlena. She is complaining of 1 year history of recurrent burning epigastric pain, sometimes awakening the patient in the middle of the night and was relieved by intake of antacids or food. On Physical examination, she has epigastric tenderness, orthostatic hypotension, melena on DRE.
A. Barium swallow B. Abdominal CT scan C. Upper GI endoscopy D. Lower GI endoscopy
38. Mr. Tan is 58 year old male company executive who came in for a preventive check-up. History and physical examination are unremarkable but you noted microcytic, hypochromic anemia in his CBC. Urinalysis, blood
chemistry and chest x-rays are normal. What is next step? A. Reassure him that the anemia might
be from stress
B. Order for abdominal CT scan C. Order PSA, CEA, AFP and LDH
D. Refer to GI for flexible sigmoidoscopy **if age > 50 with microcytic and hypochromic anemia, consider colonic masses possibly malignant, hence, to be checked with sigmoidoscopy.
39. A 30 year old male presents with dysphagia to solid and liquids. A barium swallow x-ray done showed tapering of esophagus with a beak-like appearance. Diagnostic criteria by esophageal manometry would show:
A. Over-activity of peristalsis B. Impalred LES relaxation C. Air fluid level
D. Dilated esophagus Esophageal Disorders
Achalasia
o Barium swallow
Esophageal dilatation Tapering at the GE junction Air-fluid level within the
esophagus
o Manometry: Impaired LES relaxation and absent peristalsis
Diffuse Esophageal spasm
o Corkscrew esophagus on barium swallow
o Manometry: simultaneous contractions, uncoordinated (“spastic”) activity Candida esophagitis
o Characteristic white plaques with friability
40. Which of the following is true of Crohn’s disease ?
A. Usually involves the rectum B. Limited to the mucosa and
superficial subucosa
C. Pathology is segmental with skip areas
D. Backwash ileltis is common Crohn’s vs Ulcerative Colitis
Difference Crohn’s Ulcerative Location Anywhere in GIT Colon usually Inflammation Patches (skip
lesions) Continuous lesions
Pain Lower Right
Abdomen Lower Left Abdomen Appearance Colon may be
thickened and rocky (due to skip lesions) Ulcers are deep and may extend into all layers of the bowel
Colon wall is thinner and with continuous lesions
Mucus lining of large intestine may have ulcers but they do not extend beyond the inner lining Bleeding (From
rectum during bowel
movement is)
NOT COMMON COMMON
Crohn’s Disease Ulcerative Colitis • Abdominal pain, cramping or swelling • Anemia • Fever • Gastrointestinal bleeding • Joint pain • Malabsorption • Persistent or recurrent diarrhea • Stomach ulcers • Vomiting Weight loss • Abdominal pain or discomfort • Anemia caused by severe bleeding • Bloody diarrhea • Dehydration • Fatigue • Fever • Joint pain • Loss of appetite • Malabsorption • Rectal bleeding • Urgent bowel movements • Weight loss
41. Which among these diseases will have a serum-ascites albumin gradient of >1.1g/dL?
A. Cirrhosis
B. Peritoneal carcinomatosis C. Tuberculous peritonitis D. Nephrotic syndrome
42. Mr. Loyola is 34 year old male who came to the ER for abdominal pain. A week ago he has been having vague epigastric pain for which he took antacid but with no relief. He noted the pain to migrate to the right lower part of his abdomen and slight fever. Upon examination, he grimaces with pain after coughing and you note a rigid abdomen with tenderness. Which of the following is the appropriate treatment?
A. Ceftriaxone IV
B. Ceftriaxone plus Metronidazole IV C. Surgery
43. What is the role of lactulose in patients withhepatic encephalopathy?
A. Evacuateblood from the gastrointestinal tract B. Inactivate colonic bacteria C. Induce diarrhea
D. Promote colonic alkalinization
44.Which of the following should you consider accurate in the management of gallstones and its complications?
A. You can employ Ursodeoxycholic Acid
B. Prophylactic cholecystectomy may be considered for those young patientswith low surgical risk
C. Morphine should be employed in the management of severe pain in acute Cholecystitis
D. Cholecystectomy is advised in
allpatients with porcelain gallbladder 45.Which of the following is NOT a criteria inthe Child-Pugh Classification for staging of cirrhosis?
A. Billrubin
B. Partial thromboplastin time C. Serum albumin
D. Ascites Child- Pugh Classification
Serum Albumin Serum Bilirubin Prothrombin time Ascites
Hepatic Encephalopathy
MELD Classification: Internation normalized ratio (INR), serum bilirubin, and serum creatinine
46. A 75 year old male with hypertension and
dyslipidemia presents with hematochezia of about ¼ cup. Which of the following will you consider first as it is the most common cause of hematochezia among the elderly?
A. Bleeding hemorrhoids B. Colon carcinoma C. Peptic ulcer disease D. Diverticular bleeding
47. What is the standard radiological procedurefor diagnosis of nephrellthiasis?
A. Abdominal CT scan with IV contrast B. KUB-IVP
C. Plain helical CT scan of the abdomen D. Ultrasound of the abdomen
48. R.F is a 65 year old male recently admitted for his first cycle of chemotherapy for acute leukemia. Two days after his initial chemo dose, you not that his urine out put has been going down. Physical examination revealed
undistendded bladder and positive Chvostek’s sign, rest is unremarkable
Stat blood chemistry revealed normal creatine kinase, hypocalcemia, hyperphosphatemia, hyperuricemia and mild hyperkalemia. Urinalysis unremarkable except for uric acid crystals.
What is your treatment of choice? A. Glucocorticoids
B. Intravenous crystalloids with allopurinol
C. Intravenous crystalloids only D. Intravenous furosemide
49. In which of the following individuals would you recommend kidney biopsy?
a. 64/M with diabetes and
Hypertension for 15 years, poor
compliance to meds, complains to you of prucitus and insomnia serum
Creatinine 350 mmol/L
b. 21/F complaining of headache and Hypogastric pain. BP 170/100 HR 90, Urinalysis reveals protein 1+RBC 3+, WBC 1+, RBC casts 1 +
c. 23/M complaining of edema. He Claims to be healthy except for a bout sore throat 2 weeks ago. BP
160/90 , HR88, urinalysis reveals protein trace, RBC 2+,WBC1+ d. 25/M came to the ER for no urine
Output. You note stable vital signs and unremarkable physical exam except for multiple bruises on his thighs and legs. Serum BUN 14.0 mmol/L, creatinine 380 mmol/L foley catheter has minimal tea-colored urine.
50. Which of the following features is highly Suggestive of renal disease from multiple myeloma?
a. Hyperuricemia
b. Dipstick negative proteinuria c. Normocytic anemia
d. Hypercalcemia
51. A 45 year old female has been complaining of dysuria and urinary frequency which started 1 week prior to admission. She now presented to the emergency room because of fever, chills, nausea and persistent vomiting and CVA tenderness on the right. When should you contemplate on further imaging studies or urologic consult for this patient?
a. If we find WBC casts on urinalysis b. When fever persists after therapy c. When urine culture does not reveal
any organism
d. Imaging studies and urologic consult are always needed to establish diagnosis in this case 52. Treatment of choice for acute kidney injury
from scleroderma or “scleroderma renal crisis” a. Glucocorticoids
b. ACE inhibitors c. Sildenafil d. Hemodialysis
53. A 57 year old diabetic, weighing 60kg, came to the emergency room for difficulty of breathing. She presented to the emergency room due to difficulty of breathing.
Blood chemistry results are the following (in mmol/L):
BUN 15.56
Creatinine 266 Na 140
Ca 1.45 Alb 14
Which of the following would you expect to see in this patient’s ECG?
A. Peaked T waves B. Prominent U waves C. Prolonged QT interval D. Shortened QT interval
54. 40/M diagnosed with lung cancer Underwent Chest CT with IV contrast. Baseline creatinine prior to introduction of IV contrast was 100 mmol/L. Repeat serum Creatinine determination was 215 mmol/L After 24 hours. What was the best intervention that could have prevented this from occurring?
A. Hydration with saline solution B. N-acetylcsteine
C. IV Sodium Bicarbonate
D. Use of iodinated contrast material 55. Condition characterized by hematuria,thinning and splitting of the GBMs, mild proteinuria, chronic glomerulosclerosis leading to rental failure and sensorineutral deafness
A. Anti-GBM disease B. Alport’s Syndrome
C. Thin Basement Membrane disease D. Nail-Patella Syndrome
56. Most common acute complication of hemodialysis particularly among diabetic
Patients
A. Infection B. Muscle cramps C. Bleeding D. Hypotension
57. Most common type of renal stones A. Calcium stomes B. Uric acid stones C. Cystine stones D. Struvite stones
58. A 22 year old female sought consult at theout-patient department for an enlarging anterior neck masses noted 3 years ago. This was accompanied by heat intolerance,palpitation,tremors. On physical examination there was no exophthalmos, perlorbetal edema, hyperreflexia, enlarged anteriror neck mass that moves with deglutition and absence of cervical lymphadenopathy andtachycardic with and
irregularly irregular rhythm. What is the expected finding for this patient on nuclear imaging?
A. Focal areas of increased uptake B. Homogenous gland with decreased
Uptake
C. Increased tracer uptake distribute Homogenously
D. Normal
59. Which of the following correct regarding radioactive iodine (RAI) therapy?
A. Propylthiouracil should be stopped 2 days before RAI treatment
B. Lactating women may receive RAI treatment with caution
C. .RAI may be given to selected patients with thyroid storm
D. Antithyroid drugs should be given to elderly and those with cardiac diseases before RAI treatment
60. Which of the following clinical features seen in Cushing’s syndrome are considered more specific and more useful in its diagnosis?
A. Facial plethora B. Thin, silvery striae C. Distal myopathy D. Easy bruisability
Cushing’s Syndrome usual SSx: Rapid weight gain Central obesity Buffalo hump Moon facies Hyperhidrosis Telangiectasia
Thinning of skin and mucous mems Purple or red striae
Hirsutism Baldness
Clinical Features More Specific to Cushing’s Syndrome Fragility of the skin, with easy bruising and broad
(>1cm) Purplish striae Proximal myopathy
** If ectopic ACTH production, hyperpigmentation of the knuckles, scars or skin areas exposed to increased friction is seen
Don’t Confused with the ff:
Cushing’s triad (for Increased ICP)is a clinical triad variably defined as having:
o Irregular respirations (caused by impaired brainstem function) o Bradycardia
o Hypertension Cushing’s Disease
o is a cause of Cushing's syndrome characterised by increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary (secondary hypercortisolism)
o Same SSx as Cushing’s Syndrome 61. Which of the following is appropriate precaution regarding exercise in patients with Type 1 diabetes
A. Perform formal exercise testing in Patients with autonomic neuropathy B. Cancel the activity if blood glucose
is less than 100 mg/dl prior to exercise C. Avoid vigorous exercise if there is
untreated nonproliferative DM retinopathy
D. Inject insulin into exercising muscle If blood glucose is more than 300 mg/dl
62. Which of the following is appropriate in the comprehensive management and follow-up of a patient with diabetes?
a. Screening for diabetes at the time of diagnosis
b. Annual monitoring of blood pressure c. Lipid profile and creatinine quarterly d. Eye and foot examination by doctors
annually
63. What is the earliest symptom of pituitary failure (trophic hoemone failure) amongadults?
A. Hypogonadism B. Growth retardation C. Hyperprolactinemia D. Headache
64. Most sensitive hormonal test for
phaeochromocytoma and paragangliomas, that is also considered to be less susceptible to false-positive elevations from stress
a. Plasma metanephrine b. Urine vanillylmandelic acid c. Urine catecholamines d. Plasma catecholamines
65. This agent for dyslipidermia may increase insulin resistance and worsen glycemic control at high doses
a. Simvastatin b. Nicotinic acid c. Gemilbrozil d. Fenofibrate
66.Which of the following represents definite risk from hormone replacement therapy for menopause?
A. Colorectal cancer B. Coronary heart disease C. Endometrial cancer D. Ovarian cancer Hormone Replacement Therapy
Definite Risks Endometrial Cancer Venous thromboembolism Gallbladder disease Breast Cancer
Definite Benefits Symptoms of menopause Osteoporosis
Uncertain Risks and
Benefits Coronary heart Dse Stroke Ovarian Cancer Colorectal Cancer
Diabetes Mellitus Cognitive function
67.A 50 year old patient came for consult for progressive generalized body weakness.Laboratory examination revealed anemia and hypercalcemia and the presence of a Pulmonary mass on chest x-ray. Which of the following will be appropriate differential/s for the case?
A. Squamous cell Lung cancer B. Small cell Lung cancer C. Pulmonary tuberculosis D. All of the above
68.After one week, patient complained of dyspnea, facial swelling, hoarseness, difficulty of breathing. On physical examination, there was dilated neck vein, increased clateral veins over the anterior chest and edema of the face and arms. What is the treatment of choice for his condition?
A. Intravenous diuretics B. Intravenous glucocorticids C. Emergent radiotherapy
D. Emergent surgery and decompression **These are SSx of SVC syndrome among patients with Chest mass especially pulmonary masses.
69. Which of the following suggests a better prognosis for patients with breast cancer?
A. Estrogen/progesterone receptor Positivity
B. High proportion of cells in S-phase C. Overexpression of HER2-neu gene D. Hypernucleated cells
70. Which drug is monoclonal antibody againstHer2/neu and and is being used in treatment of breast and gastric carcinoma?
A. Cyclophosphamide B. Trastuzumab C. Rituximab D. Imatinib mesylate
71 A 45 year old female was brought to theemergency room because of dizziness. On further inquiry, there was note of menorrhagia for the past 4 months. Oncomplete blood count, hemoglobin was 70g/L, hemotocrit was 0.25; the MCVand MCH were low, rest of CBC were normal. What is the most appropriate form of treatment to correct her anemia?
A. Blood transfusion B. Folic acid tablets C. Intravenous iron
D. Intravenous Vitamin B12
72. Hans is a 29 year old who came to the clinic because he passed out blood instead of urine. On further investigation, you note anemia both on physical examination and complete blood count, increased reticulocyte count and LDH levels, hemoglobinuria on urinalysis and normal KUB ultrasound. Bone marrow aspirate microscopy reveals erythroid hyperplasia. Which of the following lab results will confirmthe diagnosis in this case?
A. Decreased bone marrow iron stain B. Undetectable haptoglobulin C. CD 55 and CD 59 cells D. Fetal hemoglobin pattern 73. A 20 year old female presents with pallor,
jaundice and icteric sclerae. Hemoglobin 55g/L, hematocrit 17%, RBC 2.5 x 1012, reticulocytes increased indirect hyperbilirubinemia, positive direct Coomb’s test. Peropheral smear shoes many spherocytes. Polychromatophilic
macrocytes and nucleated red cells. What is your diagnosis?
a. Iron deficiency anemia b. Aplastic anemia c. Megaloblastic anemia
d. Autolmmune hemolytic anemia 74. During your duty in the ER, a patient was referred to you for dyspnea. She is a 40 year old female who was diagnosed with mitral stenosis previously stable on low dose Digoxin. She has a history of fever, malaise And more frequent bowel movement in the Past 2 days. On PE she was agitated, BP 70/40 110 RR24 Temp 39; mucosa was dry neck veins were flat however breath sounds were clear, heart sounds were distinct but irregularly irregular, abdomen was soft.
A. Hydrate the patient with lactated Ringer’s
B. Start low dose dopamine drip C. Start dobutamine drip.
D. Do immediate DC cardioversion at 200J
75. You are making rounds with your OB Consultant. In front of you is a 35week AOG pregnant patient that has been having elevated blood pressure since 2 days ago. Right in front of you, the patient had a seizure. Blood pressure was taken and BP = 200/110mmHg. What do you do?
a. Give Captopril 25mg tab sublingual Stat every 15 minutes
b. Give magnesium sulfate
c. Hook the patient to Nicardipine drip d. Load with Phenytoin IV
76. 60 year old male suddenly had dizziness and diaphoresis. BP id 60/40mmHg with cold clammy extremities. ECG shows the following. What do you do?
a. Give IV Streptokinase b. Give Verapamil 5mgIV STAT c. Provide synchronized electrical c
Cardioversion d. Start CPR
77. A 59 year old male was brought in for drowsiness. Serum calcium was significantly elevated. A malignancy is suspected as an etiliology for the hypercalcemia. Which of the following will you NOT be able to use for this patient?
a. Intravenous furosemide b. Intravenous saline c. Pamidronate d. Calcitonin
78. A 65 year old patient, known hypertensive but poorly compliant to medications, came in for altered mental status severe headache. Blood pressure taken on admission was
260/100mmHg. Management would include: A. Give captopril 25mg sublingually for B. three doses. If there is poor response,
startnicardipine drip
B. Start nicardipine drip immediately C. Give captopril 25mg every 8 hours per
orem
D. Observe for 1 hour. If symptoms resolve, discharge on short acting
antii-hypeersentives.
79. A 60 year old male sought consult for right knee joint pain which started 1 year ago. Now he presents with right knee tenderness and effusin since 4 days ago and he also complains of fever
38.0C. You decided to perform arthrocentesis. Synovial fluid analysis shows 30,000 cells/uL with 70% neutrophils. Positive for rod shaped strongly negative birefringent crystals.
What is your diagnosis? A. CPPD disease B. Gouty asthritis C. Osteoarthritis D. Septic arthritis
80. Which of the following characteristrics
symptoms will favor the diagnosis of rheumatoid arthritis?
a. Migratory polyarthritis
b. Morning stiffness of 10 minutes c. Symmettric involvement d. Subacute monoarticular arthritis 81. Diagnostic test specific for rheumatoid arthritis And useful in predicting its prognosis
A. Rheumatoid Factor B. ESR
C. Anti-CCp antibodies D. CRP
82. Which of the following is an inhibitor of inosine Monophosphate and purine synthesis used in the Treatment of SLE?
A. Cyclophosphamide B. Methotrexate
C. Mycophenolate mofetil D. Allopurinol
83. Autoantibody seen more frequently in drug-induced lupus than in SLE
A. Cyclophosphamide B. Methotrxate
C. Mycophenolate mofetil D. Allopurinol
84. Two weeks after starting allopurinol in your patient with gout, the patient noted development of blisters over 8% of the body with note of oral ulcers and associated diarrhea. Whats is your impression?
A. Toxic Epidermal Necrolysis B. Stevens Johnsons Syndrome C. Staphylococcal Scalded Skin D. Bullous Pemphigoid
85.Nina came to your clinic due to a possible cellulitis. She mentioned that she experienced wheals, chest pain and difficulty of breathing shortly after taking
Amoxicillin. Which of the following antibiotics may still be given safely?
A. Piperacillin-tazobactam B. Cefuroxime
C. Clindamycin D. Co-amoxyclav
Adverse drug reactions to Amoxicillin The answer is Clindamycin because:
There is a cross-reaction between cephalosporin’s and penicillin’s
7-aminocephalospuranic acid closely resembles 6-aminopenicillinic acid
o these both target cell wall of bacteria completely structurally unrelated drugs but can
be used if the one of them has allergic reactions to the patient.
86. Most frequently associated with the transfusion of cellular blood components
A. Febrile nonhemolytic transfusion reaction
B. Graft versus host disease
C. Transfusion – related acute lung injury D. Hepatitis c infection
87.Which of the following patients will you dignose with Anaphylaxis?
A. 45/F with maculpapular rashes 3 weeks after starting Alliopurinol B. 50/M feels light-headed with rashes
After taking Co-amoxyclav BP is 60/40 C. 18/M with hives within minutes after
After eating crabs
D. 28/F OR nurse with rashes on her hands usually noted after her duty
**Anaphylaxis
rapid onset = HALLMARK! Hypotension
Systemic manifestation (cutaneous, GIT, mucosal… etc)
88. Which of the following diseases is the most likely diagnosis for these spinal tap findings:
High leukocyte count (up to 1000/L).
With a predominance of lymphocytes a protein content of 1-8g/L (100-800mg/): and a low glucose concentration
A. Herpes simplex encephalitis B. Tuberculous meningitis C. Streptococcal meningitis D. Gonococcal meningitis **Spinal tap used in CNS infections Parameters Bacterial Meningitis TB Meningitis Opening
pressure Increased (>180mmHg) Not increased Leukocytosis Present with
Neutros predo. (10000/uL) Present first is neutro then lymphocytes increase Glucose <40 mg/dL;
CSF gluc <0.4 Very low to none Protein >45 mg/dL Very high
Culture Gram Stain AFB culture
**TB Men = Cryptococcal Men
Pathognomonic sign = very low to no glucose **S. Pneumoniae = most common pathogen in BacMen 89.What is the most common cause ofsubarachnoid Hemorrhage
A. Bleeding from an AV malformation B. Ruptutre of a saccular aneurysm C. Head trauma
D. Hemiplegia
**Most common cause of subarachnoid hemorrhage Rupture of Saccular Aneurysm
How? HEAD TRAUMA.
** HALLMARK: Blood in CSF so do a plain CT within 72 hours.
90. In a rabies endemic area like the Philippines, the diagnosis of Rabies must be considered even without symptoms of hydrophobia and aerophobia with:
A. Aseptic meningitis
B. “Dumb paralysis” with fever C. Incresed intracranial pressure D. Hemiplegia
**Diagnosis of Rabies Transmission: Bite Incubation: 20-90 days
Prodrome: 2-10 days: constitutional symptoms: o paresthesia,
o pain and
o pruritus in wound site 80% encephalitic: 2-7 days: o anxiety o agitation o hyperactivity o bizarre behavior o hallucinations o autonomic dysfunction o hydrophobia o aerophobia 20% paralytic 2-10 days:
o Flaccid paralysis on limbs (bitten area) o Quadriparesis
o Facial paralysis
Coma then death 0-14 days if left UNTREATED.
91. Kernig sign is performed and elicited by:
A. Patient in supine position thigh, flexed, knee extended. Pain during passive extension of the knee
B. Patient in supine position, thigh flexed, knee extended. Pain during passive flexion of the knee C. Patient in supine position passive fexion of the neckresults in spontaneous extension of the hips and knees
D. Patient in supine position passive extension of the neckresults in spontaneous extensionof the hips and knees
**Kernig Sign
• Knee flexed pain (head jerk) ** Brudzinski’s Sign
• Batok flex lower limb pain
92. A 55 year old male, previously diagnosed with a glioblastoma multiforme came in for decreased
sensorium, imaging revealed perilesional edema. What is the appropriate treatment?
A. Furosemide B. Hypertonic saline C. Hydrocortisone D. Dexamethasone ** Glioblastoma multiforme
• Most common and most aggressive malignant primary brain tumor
** Cerebral Edema
• Vasogenic edema – BBB disruption, Inc vascular permeability
• Cytotoxic edema – Inc in ICF due to neuronal, glial and endothelial cell membrane injury (ex. Tumors)
• Generalized edema – both Vaso and Cyto • Interstitial edema – Inc. Intravascular pressure
o has abnormal flow of fluid from intraventricular CSF across the ependymal injury to periventricular white matter
** DOC:
• Dexamethasone (Cytotoxic edema from TUMORS)
• Mannitol (sugar alcohol) aka Osmotherapy (for Interstitial and Vasogenic edema)
o To decrease re-absorption of water and sodium
o To decrease ECF
93. What feature would favor seizures over syncope? A. No precipitating factor
B. Duration of unconsciousness: seconds C. Less than 15 seconds duration of tonic
movements
D. Duration of diorientation after the even: less than 5 minutes Syncope vs Seizure Syncope Seizure Less common myoclonus Shorter loss of consciousness Less muscle aches
post-attack Can have urinary
incontinece Autonomic manifestations Usually preceded by emotion or pain Typically with myoclonic jerks Loss of consciousness > 5 minutes Post-ictal confusion Rarely preceded by emotion or pain Urinary and fecal
incontinence Autonomic
94. A 45 year old male sought consult at OPD because of multiple sharply demarcated, erythematous plaques with scaling located predominantly in the elbows and knees as well as occasional shoulder and knee pains. What is your diagnosis? A. Lichen planus B. Pityriasis rosea C. Psoriasis D. Tinea versicolor **Psoriasis
• Multiple sharply demarcated erythematous plaques with scaling = CLASSIC CHARS. • Locations
o Elbows o Knees o Navel lesions
o Shoulders + knee pain
95. Which primary skin lesions is correctly paired with its description?
A. Macule: Flat, colored lesion, <2cm in diameter, raised above the surface of the surrounding skin B. Tumor: >5m firm lesion raised above the
surface of the surrounding skin
C. Plaque: >1cm, flat-topped, raised lesionwith edes that are always distinctly demarcated
D. Vesucle: small, fluid-filled lesion, >0.5cm in diameter, raised above the plane of surrounding skin.
Primary Skin Lesions:
Macule Flat, colored lesions, < 2c in diameter Tumor > 5cm, firm lesion raised above the
surface of surrounding skin
Plaque >1cm, flat-topped raised lesion with edges that are sometimes distinctly demarcated.
Vesicles Small, fluid-filled lesion, <0.5cm raised above the plane of surrounding skin Bullae Bigger than a vesicle >0.5cm
96. True regarding Type Lepra reaction or ENL? A. The most dramatic manifestation is footdrop B. Edema is the most characteristic microscopic
feature
C. Fever is not common
D. Other symptoms include neuritis, lymphadenitis, uveitis, orchitis, and glomerulonephritis
Lepra Reactions
Type 1 Type 2 or Erythema
Nodosum Leprosum (new lesions) Occurs in borderline forms of leprosy Classic signs of Inflammation within previously involved macules, papules and plaques Most Dramatic manifestation isFOOTDROP EDEMA is the most characteristic microscopic feature Lepromatous end of the leprosy spectrum Crops of painful erythematous papules that resolve spontaneously in a few days With systemic manifestations: Profound fever, neuritis, lymphadenitis, uveitis, orchitis and glomerulonephriti s
Skin biopsy of ENL papules reveals vasculitis or panniculitis Anemia, leukocytosis and abnormal liver function tests 97. This test is performed on scaling skin lesions when a fungal infection is suspected
A. Tzanck smear B. Diascopy
C. KOH preparation D. Patch testing
Tzanck test is for Herpes dermal infection Diascopy is a test for blanchability performed by applying pressure with a finger or glass slide and observing color changes.
It is used to determine whether a lesion is vascular (inflammatory), nonvascular (nevus), or hemorrhagic (petechia or purpura).
Hemorrhagic lesions and nonvascular lesions do not blanch; inflammatory lesions do.
Diascopy is sometimes used to identify sarcoid skin lesions, which, when tested, turn an apple jelly color.
Patch Test is a method used to determine whether a specific substance causes allergic inflammation of a patient's skin. Any individual suspected of having allergic contact dermatitis and/or atopic dermatitis needs patch testing.
98. Am exa,[;e pf a category A bioterrorist agent A. E. coli 0157:H7
B. Extremely-drug resistant (XDR) M. tuberculosis C. SARS coronavirus
D. Variola major Micro Bioterrorism
A Anthrax, Botulism, Plague, Smallpox and Tularemia
Arenaviruses: Lassa, New World (Machupo, Junin, Guanarito, and Sabia)
Bunyaviridae: Crimean-Congo, Rift Valley Filoviridae: Ebola, Marburg
B Brucellosis
Epsilon toxin of Clostridium perfringens, Glanders Melioidosis
Psittacosis Q fever
Ricin toxin from Ricinus communis Typhus Fever
Staphylococcal entertoxin B; Viral Enceph Water safety threats (Vibrio cholerae, Cryptosporidium parvum)
Food safety threats (Salmonella spp. Escherichia coli 0157:H7, Shigella toxin)
C Emerging infectious diseases threats such as Nipah, hantavirus, SARS coronavirus and pandemic influenza.
99. Best preventive measure for high altitude pulmonary edema
A. Acetazolamide B. Nifedipine
C. Limitation of fluid intake prior to ascent D. Gradual ascent
100. Mrs. C is a 48 y/o female who consulted you a few years back for dyspepsia. She comes to your clinic now with easy fatigability, weakness, incoordination and memory disturbances. She claims she cannot tolerate eating withough taking antacids. Physical and neurologic exams are unremarkable. Among the labs you ordered, only her CBC is abnormal showing red blood cells with high MCV and high MCH. Which of the following nutrients is she most likely deficient with?
A. Iron B. Folate
C. Cyanocobalamin D. Vitamin D
101. Cause of normal anion gap metabolic acidosis: A. Diarrhea
B. Alcoholic Ketoacidosis C. Uremia
D. Salicylate ingestion **Urine Anion Gap = Na +K – Cl RTA
Type 1 Type 2 Type 3
Distal tubule Proximal tubule Adrenals Decrease K Decrease K Increase K Failure of acid secretion by alpha intercalated cells of cortical collecting duct of distal nephron Metabolic acidosis Hypoalbunemia Hypocalcemia Hyperchloremia Nephrocalcinosis FANCONI syndrome (osteomalacia) **ricketts due to wasting
High Anion Gap Metabolic Acidosis • Lactic acidosis
• Ketoacidosis
• Ingestion of alcohol INH methanol ethylene glycol
• Renal Failure
• Massive rhabdomyolysis
102. Which of the following is a risk factor for stroke in a patient with atrial fibrillation? (HPIM p1428 table 226-1)
A. Age more than 65 years old B. Mitral regurgitation C. Diabetes Mellitus
D. Marked right atrial enlargement
**Risk Factors for stroke in a patient with atrial fibrillation
History of CVA or TIA Mitral stenosis Hypertension DM
> 75 years old CHF
Left Ventricular dysfunction
Marked Left atrial enlargements > 5.0 Spontaneous echo contrast
103. True of Manifestations of Myxomas A. Most appear singly
B. Most are pedunculated on a fibrovascular stalk
C. Most are located in the left atrium D. They have characteristic “tumor plop”
appreciated during diastole
** ALL OF THE CHOICES are CORRECT!!!!!!!
104. Which of the following medications should not be started in patients with hyperkalemia?
A. Carvedilol B. Dobutamine C. Captopril D. Furosemide
** Drugs that cause HYPERKALEMIA • ACE I and ARBs
• K-sparing diuretics (amiloride and spironolactone)
• NSAIDs • Tacrolimus
• Timetoprim, Pentamide
105. For angina, nitrates may be administered. Nitroglycerin is most commonly administered sublingually in what dose?
A. 5mg B. 10mg C. 0.4mg D. 4mg
106. A 19 year old female comes in for dyspnea. As a child, she had cyanosis, selectively involving the toes only (but not the fingers). She was said to have a “defect in her heart”, but was lost to follow up. On auscultation, you should expect:
A. A fixed splitting of S2(ASD L to R shunt) B. A holocystolic murmur(Mitral Regurgitation,
Pulmonic Stenosis)
C. A continuous machinery murmur D. Early diastolic murmur(MR, MVP)
107. The most common congenital heart valve defect is: A. Pulmonic stenosis
B. Mitral stenosis C. Bicuspid aortic valve D. Mitral regurgitation
108. A 40 years old female came in for dyspnea. Blood pressure on admission was 120/20 mmHg. Auscultation revealed a high-pitched, blowing, decrescendo diastolic murmur at the right sternal border. You also noted capillary pulsations (alternate flushing and paling of the skin) at the root of the nail while pressure is applied to the tip of the nail. This is called?
A. Corrigan’s pulse B. Quincke’s pulse C. Traube’s sign D. Duroziez’s sign
Large-volume, 'collapsing' pulse also known as:
o Watson's water hammer pulse o Corrigan's pulse - rapid upstroke and
collapse of the carotid artery pulse Low diastolic and increased pulse pressure de Musset's sign - head nodding in time with the
heart beat
Quincke's sign-pulsation of the capillary bed in the nail
Traube's sign - a 'pistol shot' systolic sound heard over the femoral artery
Duroziez's sign - systolic and diastolic murmurs heard over the femoral artery when it is
gradually compressed with the stethoscope 109. A 35 years old male comes in for dyspnea and orthopnea. On examination, he had a heart rate of 110 with an irregularly irregular rhythm. An opening snap, followed by a diastolic rumble was audible on
auscultation. You requested a chest x-ray and expect to find:
A. Widening of the carinal angle B. Left ventricular enlargement
C. Tubular heart with a widened mediatinum D. Paucity of pulmonary vasculature
** SSx pertains to Mitral stenosis
110. Most common parasitic cause of cardiomyopathy is Chagas’ disease. What is the etiology?
A. Trypanosoma cruzi transmitted by the reduviid bug
B. Trypanosoma brucei transmitted by the Tsetse fly
C. Toxoplasmosis transmitted by cysts
D. Trichinella spiralis caused by ingestion of larva of undercooked meat
111. A 35 years old male came in for dyspnea. He had a blood pressure of 60/40 mmHg with muffled heart sounds and distended neck veins. Your acute management is:
A. Immediately start intropic support
B. Place in Trendelenberg position and observe C. Give Furosemide 40 mg IV stat bolus
D. Do 2D Echo-guided pericardiocentesis 112. Most out of the hospital deaths from STEMI is due to:
A. Heart Failure
B. Ventricular fibrillation
C. Premature ventricular contractions D. Pulmonary edema
113. A 22 years old male will be working abroad as a construction worker in Dubai. This patient came in tor your clinic for clearance. He is asymptomatic. On PE, you noted grade II/IV midsystolic murmur at the apex. Chest X-ray and ECG were normal. What would be your next step?
A. Reassure and clear him for work, no further tests
B. Dela giving of clearance and schedule for 2D Echocardiography
C. Refer to cardiologist for clearance
D. Admit for further work-up: Holter monitoring, cardiac enzymes and possible coronary angiography
** Only the DIASTOLIC murmur is pathologic!
114. What is a relative contraindication of thrombolysis in ST-segment elevation myocardial infarction?
A. History of Cerebrovascular hemorrhage B. Suspicion of aortic dissection
C. Active internal bleeding D. Pregnancy
115. Presents as refractory hypertension, mostly asymptomatic but infrequently may have paresthesias, polyuria, or muscle weakness secondary to
hypokalemic alkalosis. A. Cushing’s syndrome B. Phaeochromocytoma C. Primary aldosteronism D. Aortic coarctation
116. Abdominal aortic aneurysm repair is indicated for asymptomatic patients if the diameter is:
A. > 4.5 cm B. > 5.5 cm C. > 6.0 cm D. > 7.0 cm
117. Which of the following physical examination findings, if present in COPD suggest advanced disease?
A. Barrel chest B. Temporal wasting C. Clubbing of the digits D. Cyanosis
118. The standard monotherapy for lung abscess A. Ceftriaxone
B. Metronidazole C. Clindamycin
D. Ampicillin-Sulbactam
119. Which of the following points to an exacerbation in a patient with established COPD?
A. Exertional dyspnea B. Increased dyspnea
C. Presence of airflow obstruction D. Resting hypoxemia
120. The following are true regarding non-imaging tests in diagnosisng pulmonary embolism EXCEPT:
A. The D-dimer is a useful “rule in” test B. The D-dimer has a limited role in hospitalized
patients
C. Arterial blood gas lacks diagnostic utility for pulmonary embolism
D. Elevated cardia biomarkers predict an increased mortality from pulmonary embolism
121. When after initiation of adequate therapy in pneumonia, when do you expect fever to resolve?
A. 24 hours B. 36 hours C. 48 hours D. 72 hours
122. Among COPD patients, supplemental oxygen should be provided to maintain arterial oxygen saturation at what level?
A. 80% B. 85% C. 90% D. 95%
123. Occupational lung disease characterized by the characteristic HRCT pattern known as “crazy paving”
A. Chronic beryllium disease B. Coal worker’s pneumoconiosis C. Asbestosis
D. Silicosis
124. What is the most common cause of repiratory hypoxia, which is usually correctable by inspiring 100% oxygen?
A. Hypoventilation
B. Intrapulmonary right to left shunting C. Pulmonary atelectasis
D. Ventilation perfusion mismatch 125. Which among the following is an example of obstructive lung disease?
A. Bronchiectasis B. Asbestosis C. Pulmonary fibrosis D. Gullain-Barre syndrome Obstructive Lung Diseases
Restrictive Lung Diseases • Chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis • Asthma • Bronchiectasis • Cystic fibrosis.
•Interstitial lung disease, such as idiopathic pulmonary fibrosis • Sarcoidosis, an autoimmune disease • Obesity, including obesity hypoventilation syndrome • Scoliosis
• Neuromuscular disease, such as muscular
dystrophy or amyotrophic lateral sclerosis (ALS)
126. An asthmatic patient was given ipratropium
bromide for rescue medication. What is its most common side effect?
A. Tachycardia or palpitations B. Tremors
C. Dry mouth D. Urinary retention
127. What is the most common cancer associated with asbestos exposure?
A. Lung cancer B. Mesothelioma
C. Tumors of the pericardium D. Laryngeal carcinoma
128. A 60 years old male presented with cough and dyspnea of three days duration. You requested for a sputum gram stain and culture. An adequate sputum sample has:
A. Presence of organisms B. Presence of >25 neutrophils C. Presence of >25 squamous cells D. Presence of >25 white blood cells
129. Type of emphysema usually observed in patients with alpha1-antitrypsin deficiency, which has
predilection for the lower lobes: A. Centriacinar emphysema B. Peripheral emphysema C. Lobar emphysema D. Panacinar emphysema ** Types of Ephysema:
Centriacinar emphysema begins in the respiratory bronchioles and spreads peripherally. Also termed centrilobular emphysema, this form is associated with long-standing cigarette smoking and predominantly involves the upper half of the lungs.
Panacinar emphysema destroys the entire alveolus uniformly and is predominant in the lower half of the lungs. Panacinar emphysema generally is observed in patients with
homozygous alpha1-antitrypsin (AAT)
deficiency. In people who smoke, focal panacinar emphysema at the lung bases may accompany centriacinar emphysema.
Paraseptal emphysema, also known as distal acinar emphysema, preferentially involves the distal airway structures, alveolar ducts, and alveolar sacs. The process is localized around the septae of the lungs or pleura. Although airflow frequently is preserved, the apical bullae may lead to spontaneous pneumothorax. Giant bullae occasionally cause severe compression of adjacent lung tissue
130. During the natural course of ARDS, which phase do we expect clinical recovery wherein patients are usually liberated from mechanical ventilation?
A. Proliferative phase B. Fibrtoic phase C. Recovery phase D. Exudative phase **Phases of ARDS
Exudative Alveolar Edema
Neutrophil-rich leukocytosis
Subsequent formation of hyaline membranes from diffuse alveolar damage Proliferative 7 days after Exudative
stage
Prominent interstitial inflammation Early fibrotic changes Fibrotic Substantial fibrosis
Bullae formation Recovery stage
131. Chest radiograph finding specifically indicating past exposure to asbestos and not pulmonary impairment:
A. Pleural plaque B. Pleural Effusion C. Pleural fibrosis D. Pleural mesothelioma
132. A 30 year old male comes in for dyspnea. Examination on the right basal lung field revealed: dullness on percussion, increased fremitus and crackles. Your diagnosis is probably:
A. Asthma B. Pneumothorax C. Pleural effusion
D. Consolidation / pneumonia **See Figure 6 in attached paper
