MEDICINE
1ST LONG EXAMINATIONS
1. Mr. Roxas, a 65-‐year old diabetic, noted pus oozing from a wound on his pedicured big toe. After 2 days he was noted to have temperature of 39C. Despite antibiotics he remained highly febrile. On the 3rd day of fever he was brought to the ER because of lethargy. BP was 70 systolic, HR of 130/min and RR of 34/min. What cytokine is responsible for the
manifestations?
A. Tumor necrosis factor B. Interleukin-‐2
C. Interleukin-‐4 D. GM-‐CSF
TNF is resonsible for the inflammatory response to infection up to the point of symptoms of septic shock. IL-‐2, a T cell cytokine signals other lymphocytes to initiate an immune response. IL-‐4, a Th2 cytokine, signals B cells to produce antibodies also for proliferation of mast cells. GM-‐CSF tells granulocytes and macrophages to proliferate.
2. Ms. Sanchez, 25 years old, has been experiencing daily bouts of sneezing and excessive rhinorrhea since she was 9 years old. Likewise she has sneezing and nasal itching whenever she sweeps the floor. What is one cytokine that is responsible for the development of the condition described?
A. Interleukin-‐1 B. Interleukin-‐4* C. Interferon-‐gamma D. TGF-‐beta
IL-‐4 (B) is a product of T helper ceIls that signals B cells to produce especially IgE antibodies is response to allergen exposure; also signals for proliferation of mast cells. IL-‐1 is a macrophage cytokine that tells Th cells to initiate an immune response. IFN-‐γ Th1 cytokine that helps mediate cell-‐mediated immunity. TGF-‐β usually downregulates YH1 or Th2 immune responses.
3. A virus encountered by T/B cells results in an immune response that rids the agent within 5-‐7 days. After 2 weeks the same virus is re-‐encountered. The host does not manifest symptoms of the disease. This property of the adaptive immune response is:
A. Memory * B. Specificity C. Diversity D. Synergy
(A) Memory -‐ non-‐infection during the 2nd encounter is because of the anamnestic response triggered by the memory cells.
4. Adhesion molecules are necessary for the following step involved in the immune response: A. MHC-‐antigen interaction with TCR
B. C3 attaching to cell targeted for destruction C. Phagocytosis of microorganisms
D. Entrance of inflammatory cells into affected tissue *
(D) adhesion molecules attract and mediates adhesion of inflammatory cells onto the vascular wall and the entrance between cell junctions into the site that needs help to fight of
pathogens. Others -‐ no connection to adhesion molecules.
5. The signal(s) that enable T cell activation are: A. TCR interaction with antigen
B. TCR interaction with MHC
C. MHC + antigen interaction with CD4 or CD8
D. TCR + MHC-‐antigen interaction and CD28-‐CD80 interaction*
(D) are the 2 signals that will initiate an acquired immune response. The others are only single signals or the wrong molecules.
6. This process taking place in the thymus chooses for maturation T cells that have low affinity for self peptides attached to self HLA:
A. Positive selection B. Negative selection * C. Double positivity D. Single positivity
The stem is the definition of (B) negative selection. Positive selection is apoptosis of T cell clones that have no or excessive affinity for self HLA. (C,D) are stages in the maturation of T cells.
7. The rhinovirus enters the host via the respiratory system. An immune response against the virus is mounted in the:
A. Thymus B. Peyer’s patches C. Lymph nodes * D. Spleen
Inhaled pathogens are brought to lymph nodes (C) around the respiratory tract for presentation to T helper cells. Thymus is the site of maturation of T cells. Ingested pathogens are presented to Peyer's patches while blood borne pathogens are presented in the spleen.
8. Hepatitis B virus enters the host via shared syringes among IV drug users. An immune response against the virus is mounted in the:
A. Thymus B. Bone marrow C. Lymph nodes D. Spleen *
(D) Spleen is responsible for handling blood-‐borne pathogens. The others-‐ see explanation for No. 10.
9. Mr. Reyes, 29 years old, was found to be HIV+ and suffering from miliary tuberculosis. An expected result from various tests is:
A. Elevated levels of immunoglobulins B. Defective microbicidal action of phagocytes C. Negative PPD *
D. Positive intradermal candida test
(C) is the phenomenon of anergy observed in severe viral diseases as well as in severe forms of mycobacterial infection. (A) By the time HIV patients have AIDS-‐defininig illnesses (e.g., advanced TB), Igs are depressed as well. (B) does not happen. (D), like PPD test, candida test is to test T cell function. It will beexpected to be negative as well.
10. Aside from male-‐male sex, another mode of transmission is showing an increasing trend: A. Heterosexual sex
B. Mother to Child C. Needle prick
D. Intravenous drug use *
Self explanatory
11. You are formulating a new antiretroviral drug that will prevent viral RNA from insinuating itself onto the host DNA. Your target molecule/enzyme is:
A. Chemokine receptor acting as coreceptor for the HIV B. Reverse transcriptase
C. Integrase * D. Protease
(C) Target integrase to prevent viral DNA becoming integrated into host DNA. The rest act on other stages of the life cycle/ enzymes of the virus.
12. Mr. Feliciano experienced fever, fatigue, myalgia, and headaches for a week. Two weeks after the illness, he is worried that he may be contracting HIV infection because he had unprotected sex with a casual male acquaintance. You recommend the following examination to confirm or reassure him:
A. HIV ELISA
B. HIV ELISA then Western Blot if positive C. HIV DNA PCR *
D. Phenotyping of HIV
At 2 weeks after assumed exposure, the anti-‐HIV immune response has not occurred, therefore no antibodes will be detected yet. The virus itself or its components, however will be detectable (C). Phenotyping measures inhibitory action of anti-‐HIV drugs on the isolated HIV strain.
13. Granuloma formation in response to mycobacteria is an example of: A. Type I hypersensitivity
B. Type II hypersensitivity C. Type III hypersensitivity D. Type IV hypersensitivity*
Granuloma formation around the tuberculosis pathogen is cell mediated -‐ Type IV reaction (D).
14. A 43 year old male consulted for hematuria, edema and was found to be hypertensive several months PTC. Anti-‐hypertensives were given and he was lost to follow up until he began developing shortness of breath then a few hours ago, hemoptysis. Immunoglobulins were identified lining basement membranes of the lungs and kidneys. This disease is an example of:
A. Type I hypersensitivity B. Type II hypersensitivity * C. Type III hypersensitivity D. Type IV hypersensitivity
The disease described is Goodpasture's Syndrome with Igs attacking thecells of the basement membrane in the lungs and glomeruli -‐ Type II reaction.
15. Mature T lymphocytes that emerge from the thymus have survived because: A. They have no affinity for self antigens *
B. They have no affinity for self-‐MHC
C. They have escaped cytotoxic action of natural killer cells D. They have non-‐functional CD28
T cells that have undergone positive and negative selection (A) are allowed to mature. The others are not actual events.
16. This autoimmune disease results in the hyperactivity of the affected organ’s physiologic function:
A. Hashimoto’s disease B. Myasthenia gravis C. Type I diabetes mellitus D. Graves’ disease*
All except Graves' disease (D) result in hypofunctioning organs.
17. A 35-‐year old male began experiencing easy bruisability with hematomas appearing over the thighs and medial surface of the upper extremities. A blood exam shows a hemoglobin of 140, hematocrit of 40, WBC 10 with 65% neutrophils, 35% lymphocytes and platelet count of 24,000. You suspect this autoimmune disease:
A. Hemolytic anemia
B. Idiopathic thrombocytopenia* C. Acute myelogenous leukemia D. Aplastic anemia
(B) ITP is a result of autoantibodies against platelets, not rbcs (A). The others are not autoimmune diseases.
18. A 49-‐year old female has been experiencing extreme driness of the eyes and mouth as well as swelling of the parotid glands for the past 4 months. There were no signs of arthritis nor renal involvement. ANA test showed increased levels of the autoantibody SSa. Your diagnosis is:
A. Systemic lupus erythematosus B. Dermatomyositis
C. Scleroderma
D. Sjogren’s syndrome *
(D) is the disease described. SLE -‐ multisystemic with arthritis and nephritis.
Dermatomyositis has a rash and proximal muscle weakness. Scleroderma is waxy appearance of face among others.
19. In atopic individuals, B lymphocytes receives signals from Th2 cells to produce an excessive amount of:
A. IgG B. IgA C. IgM D. IgE *
IgE is the Ig involved in atopy (D), not the others.
20. The following statement about IgE-‐mediated reactions is true:
B. Nasal congestion is characteristic of the early phase allergic reaction.
C. The development of allergic diseases depends on the interaction between genes and the environment. *
D. The mast cell releases inflammatory mediators 48-‐72 hours after allergen attachment to IgE receptors.
Only (C) is true. (A) there has to be a period of sensitization from the first exposure to the reaction. (B) nasal congestion is a reflection of the late phase allergic reaction. (D) Mast cell degranulation occurs in a sensitized individual shortly after reexposure to the same allergen.
21. Ms. Gomez, with a known allergy to seafood, developed wheals within minutes of eating her favorite food – shrimp – despite taking a tablet of an antihistamine before the meal. This was followed by a feeling of a lump in the throat. At the ER, she was found to have wheezing all over lung fields. As the doctor in charge, you will give:
A. Epinephrine 1:1000 dilution, 0.5 ml IM * B. Diphenhydramine 50 mg IM
C. Hydrocortisone 100 mg IV D. Beta-‐2 agonist nebulization
(A) epinephrine, undiluted, is the drug of choice and is life-‐saving. All the others are ancillary measures.
22. Mr. Agulto was injected with benzathine penicillin IM at the OPD. Within seconds, he collapsed. BP was 80/50, HR=128/min. Your drug of choice is:
A. Epinephrine 1:1000 dilution, 0.5 ml IM* B. Diphenhydramine 50 mg IM
C. Dopamine infusion D. Beta-‐2 agonist nebulization
(A) epinephrine is drug of choice inthis situation with hypotension and tachycardia. (B,D) are ancillary. (C) is given for additional CVS support after epinephrine as needed.
23. The following condition is a Type B reaction:
A. Diarrhea and malabsorption after 5 days of co-‐amoxiclav
B. Convulsions and coma after ingestion of 15 tablets of 500mg paracetamol C. Difficulty of breathing after one tablet of ibuprofen *
D. Epigastric pain after ingestion of prednisone
(C) is an idiosyncracy: unpredictable and affecting a small number of individuals only. (A,D) are side effects while (B) is a toxicity, all three of which are Type A drug reactions
24. Which drug is most likely to induce an immune response? A. Insulin *
B. Penicillin C. cefalexin D. Erythromycin
Insulin is a macromolecule which is most likely to induce an immune response compared to the other choices, which are haptens.
25. The following statement best describes an IgE-‐mediated reaction: A. Red, edematous rash over the area 48 hours after using latex gloves B. Group of ten people with diarrhea after eating spaghetti
C. Urticarial rash within an hour of ingesting shellfish *
D. All of the above
(C) is a typical Type I reaction. (A) is a delayed or Type IV reaction. (B) is food poisoning.
26. The following statement is true about the management of drug hypersensitivity: A. Desensitization is indicated in every adverse reaction
B. Stevens-‐Johnson Syndrome due to phenobarbital ingestion is an indication for gradual oral challenge
C. Withdrawal of the suspected drug is the best treatment* D. Cephalosporins are the best alternative for amoxicillin sensitivity
(C) As in any allergic reaction, withdrawal/avoidance is the best treatment. (A) substituting with a drug from a different class is preferrable to desensitization. The latter is done only when the drug is the only appropriate one. (B) Drugs that cause exfoliating reactions should never be tried or rechallenged again. (D) shares the same bicyclic ring structiure of amoxicillin and is not the ideal alternative.
27. A patient started anti-‐tuberculosis drugs 3 months ago. He developed fever and cough around 8 days ago for which he was prescribed amoxicillin and paracetamol (taken for 3 days). A day ago, he developed pruritic, erythematous urticarial rash and swelling of the lips and periorbital area. Upon review, your foremost suspect among the drugs taken is:
A. Rifampicin B. Isoniazid
C. Amoxicillin / 0.25* D. Paracetamol
By review of drug intake and temporal relationship of the exposure and the reaction (C) is the most possible. (A,B) have been given for a long time without problems so unlikely suspects. Amoxicillin and paracetamol taken at the same time but by review of literature, amoxicillin more likely than paracetamol to give the symptoms.
28. Georgia experienced anaphylaxis after eating peanuts and crabs in one meal. A skin prick test was done when the reaction subsided after 2 days. The result was negative. What is your next move?
A. Advice the patient that peanuts and crabs can be returned to her diet. B. Advice the patient that peanuts should not be eaten again.
C. Ideally the skin test is done 2 weeks after the anaphylaxis episode. * D. Request for total IgE.
After an anaphylactic episode, histaminestores in mast cells are depleted. A skin test done shortly after the reaction will be negative. Histamine is restored around 2 weeks after the anaphylactic episode (C). (A,B) is not done. (D) is useless.
For questions 29-‐32, refer to the following case: F.B. is a 25 year-‐old female who consults the out-‐patient clinics because of pruritic lesions for two weeks. Her household members also experienced pruritus. On physical examination, excoriated papules were noted on the fingers, toes, and periumbilical area.
29. This patient is probably suffering from A. scabies*
B. dyshidrotic eczema C. contact dermatitis D. Empitigo
This patient has the typical history and physical examination indicative of scabies.
30. You should advise the patient that the etiologic agent A. is a louse that causes human infestation
B. are typically present in thousands in infected individuals C. can be transmitted by fomites*
D. causes a characteristic itching both day and night
Scabies is caused by a mite. It is only present in thousands in immunocompromised individuals. Nocturnal pruritus is characteristic.
31. Upon physical examination which of the following lesions would be characteristic of the disease?
A. nodule B. burrow* C. crust D. ulcer
Burrows are the characteristic lesions of patients with scabies.
32. The patient wants to be further educated regarding her condition. You can advise that A. sexual transmission of the disease is a very rare occurrence
B. it is more common in the elderly than in young children and adults C. males are more commonly affected than females
D. overcrowding has been associated with this condition*
The disease is sexually transmissible. Its occurrence is seen both in young children, adults, and the elderly. Both males and females are equally affected. Overcrowding is associated with this condition.
33. A 21-‐year old known asthmatic male is brought to the emergency room because of dyspnea and generalized appearance of wheals of 30 minutes duration. History revealed that he took Penicillin V tablets for sore throat as recommended by a classmate. What is your diagnosis?
A. Rubeola B. Acute Urticaria*
C. Erythema Multiforme Minor D. Erythema Multiforme Major
34. A 26-‐year old female presents with erythematous macules and patches on the trunk and extremities of three days duration. These were associated with fever, painful lips and eye discharge. The patient volunteered that she self-‐medicated with cotrimoxazole one week ago because of dysuria and urinary frequency. The resident who saw the patient is suspecting Steven-‐Johnsons Syndrome. What lesion is pathognomonic for this condition?
A. vesicle B. target* C. wheal D. purpura
35. A 50-‐year old female complains of yellowish plaques on both inner upper eyelids of 2 years duration. What is the underlying genetic defect?
A. Familial hypertriglyceridemia
B. Familial hypercholesterolemia C. Alpha-‐1 apolipoprotein deficiency D. Familial lipoprotein lipase deficiency*
36. An 85-‐year old female is diagnosed with Acrodermatitis enteropathica. Which of the following medications will lead to dramatic improvement of her skin condition?
A. zinc sulfate* B. ascorbic acid C. copper sulfate D. beta-‐carotene
37. A 35-‐year old male diagnosed with ulcerative colitis is referred by his gastroenterologist because of sudden appearance of large, extremely painful ulcers and boils on the lower extremities. What is your dermatologic impression?
A. Decubitus Ulcer B. Multiple Furuncolosis C. Ecthyma Gangrenosum D. Pyoderma Gangrenosum*
38. A 5-‐year old male is brought to the Dermatology OPD clinic because of dry skin, brittle hair and edema of the abdomen. What is your diagnosis?
A. Pellagra B. Kwashiorkor* C. Vitamin A deficiency D. Acrodermatitis enteropathica
39. A 63-‐year old male, known diabetic, consults because of shiny yellow plaques on both shins of 2 years duration. Physical examination revealed telangiectasia on the surface of the lesions. What is your diagnosis?
A. Pyoderma gangrenosum B. Granuloma annulare C. Necrobiosis lipoidica* D. Stasis dermatitis
40. An indigent 30 year-‐old pregnant patient consults you with physical findings and history indicative of scabies. Which scabicide would you opt to give her and her six other children?
A. lindane B. sulfur* C. permethrin D. crotamiton
Sulfur is cheap and effective in treating 9 patients, including this pregnant patient. Lindane is not safe for the patient. Permethrin is expensive, considering that this is an indigent patient with 6 other children to be treated. Crotamiton has very low cure rate.
41. A 20-‐year old male presents with skin-‐colored umbilicated papules on the suprapubic and pubic area. He claims to have noted these lesions a month ago. Which is true about his condition?
A. It may have been acquired through sexual contact with another partner.* B. Asymptomatic viral shedding is a feature of his condition.
C. Multinucleated giant cells can be seen on Tzanck smear of typical lesions. D. It can invade the dermis and subcutaneous tissue.
Molluscum contagiosum can be sexually acquired in adult individuals. No asymptomatic viral shedding and multinucleated giant cells are seen. This condition does not invade beyond epidermis.
42. P.C., a 34 year-‐old male, married, with two children, noted lesions on the shaft of his penis. Upon consult, you noted multiple hyperkeratotic papules on the penile shaft and base of the penis. Which is true about his condition?
A. Human Papilloma virus types 16 and 18 are the common etiologic agents. B. Imiquimod applied at night three times a week for 12 to 16 weeks is effective in
treating his condition.*
C. Once treated, he can be assured that he will not have the condition anymore. D. All of the above are true.
HPV types 6 and 11 account for most cases of genital warts. Even after treatment with imiquimod he can still have recurrence of the infection.
43. Which treatment is contraindicated for his wife who has similar lesions but is pregnant? A. Podophyllotoxin*
B. Cryotherapy C. Trichloroacetic acid D. Laser
Podophyllotoxin is contraindicated in pregnant patients.
44. A 24 y/o woman came to your clinic due to multiple, well-‐defined erythematous papules and plaques with thick, loosely adherent silvery white scales on the elbows, knees, trunk and scalp of one year duration. Koebner phenomenon was positive. What clinical sign can you elicit in order to help you with your diagnosis?
A. Darier sign B. Asboe-‐Hansen sign C. Auspitz sign* D. Nikolsky sign
The case described is Psoriasis. In order to aid in its diagnosis, Auspitz sign can be done which is positive if pinpoint bleeding is noted when scales are forcibly removed from a plaque. Darier sign is seen in urticaria pigmentosa wherein a wheal is produced after rubbing the lesion. In the pemphigus group of diseases, an autoimmune blistering disease, the ff. signs are positive: Asboe-‐Hansen sign is lateral extension of a blister with downward pressure on a blister/vesicle. Nikolsky sign is shearing of epidermis upon lateral pressure on unblistered skin.
45. An elderly woman complained of a very pruritic lesion on her nape of two years duration. On physical examination, you see a thick, erythematous plaque measuring 3x5 cm, on the left side of her neck. It had accentuation of skin markings. What is your diagnosis?
A. Psoriasis
B. Lichen simplex chronicus* C. Tinea corporis
D. Lichen planus
Lichen simplex chronicus is an endogenous dermatitis, commonly occurring in the elderly. The lesions are found on accessible areas, such as the neck, hands and legs. The lesions are intensely pruritic, and typically are thickened, with accentuation of the skin lines or markings.
46. An infant was brought in to your clinic due to erythematous thin plaques on her cheeks and on her elbows. Similar lesions are seen on her knees. What is your clinical impression?
A. psoriais vulgaris B. seborrheic dermatitis C. measles
D. atopic dermatitis*
The predilection sites of infantile phase of atopic dermatitis are the face (cheeks, forehead) & extensor surfaces (knees and elbows)
47. A 30 y/o man presented with erythematous plaques and papules in the shape of a dragon on his left deltoid area. Ten days prior to consultation, he had henna tattoo done on the exact area. He wondered why he had this reaction to the tattoo, when he had tattoos done several times in the past, with no untoward reactions. Which of the following does not describe the condition that he has?
A. The dermatitis will initially be sharply confined to site of contact, later spreading beyond area.
B. It is associated with intense pruritus.
C. It is dependent on the concentration of agent* D. It occurs only in sensitized individuals.
This is an allergic contact dermatitis, secondary to paraphenyldiamine found in henna tattoos. ACD is not dependent on the concentration of the agent for a dermatitis to occur, in contrast to irritant contact dermatitis wherein it is dependent on the concentration of the acid or base. In ACD, the lesions or the rash develops after several exposures to the allergen has happened (not during the first time it was introduced, ie, not the first time the patient had a henna tattoo).
48. A 75 y/o man was diagnosed with bullous pemphigoid. Which of the following do you expect to find on physical examination?
A. Flaccid bullae B. Tense bullae* C. Positive Nikolsky sign D. A & C only
The pemphigoid group of diseases present clinically with tense bullae. Both Asboe-‐Hansen and Nikolsky sign will be elicited in the pemphigus vulgaris, and will be negative in bullous pemphigoid.
49. A 35 woman was referred to the Dermatology service due to well-‐defined areas of eroded skin on the chest and back, affecting about 5% of the total body surface area. She also had erosions on her oral mucosa and genitalia. The cutaneous lesions started to appear on her 5th day on antibiotic therapy (co-‐trimoxazole) given for urinary tract infection. What is
your diagnosis?
A. Steven Johnson syndrome* B. Erythema multiforme C. Toxic epidermal necrolysis D. None of the above
In SJS the affected area is less than 10%, in Stevens-‐Johnson syndrome-‐Toxic epidermal necrolysis overlap, epidermal detachment is 10-‐30% while in Toxic epidermal necrolysis it is >30%.
50. A 50 y/o American man came in due to a large ulcer with a rolled border filled with black necrotic debris on his right nasolabial fold. Histopathologic findings were consistent with basal cell carcinoma (BCC). Which of the following statements is/are true of BCC?
A. It is the most common skin cancer B. >90% occur on the face
C. Rarely occurs in dark-‐skinned individuals D. All of the statements are true*
Basal cell carcinoma is the most common type of skin cancer. It is locally invasive but with limited capacity to metastasize. More than 90% occur on the face. It is more common in Caucasians or those with Fitzpatrick skin types 1 & 2.
For questions 51-‐53, refer to the following case: A 41 y.o. laundry woman presents with 5-‐10 mm lesions with overlying honey colored crust on her lower legs of about 1 week duration, with increasing number of lesions.
51. Primary diagnosis would be: A. Hansen’s disease B. Scabies
C. Impetigo* D. Herpes zoster
Lesions are descriptive of impetigo. Frequent exposure to water may compromise barrier function of skin
52. What would be a simple laboratory procedure to help confirm the diagnosis: A. KOH stain
B. Tzanck smear
C. AFB stain D. Gm stain*
Gm stain is a simple procedure that will help determine presence of Gm + bacteria
53. What would be the findings in the test: A. Multinucleated giant cells B. Gm (+) cocci in clusters* C. hyphae
D. Gm (-‐) bacilli
Most probable finding would be Gm+ cocci in clusters (S aureus) or Gm+ in chain (Strep) (not included in choice)
54. A 40 y.o. female, obese, consults for fluctuant, erythematous, tender mass (about 10 mm) on her groin. The most probable diagnosis is:
A. Erythrasma B. Tinea Cruris C. Folliculitis D. Furuncle*
Obesity and site predisposed to friction and clinical description supports probable diagnosis of furuncle
For questions 55-‐56, refer to the following case: A 24 y.o. male consults for very itchy papules and vesicles on ball of plantar area of L foot, with involvement of 2nd and 3rd digital webs
which are also slightly macerated. The lesions are of 4weeks duration and slowly increasing in area of involvement.
55. The most probable etiologic agent involved is: A. Candidia albicans
B. Trichophyton rubrum*
C. Corynebacterium mi nitissumum D. Pityrosporum ovale
Clinical description suggests Tinea pedis especially involvement of interdigital webs. Trichophyton rubrum is one of the more common dermatophytes involved
56. Recommended treatment would be: A. Griseofulvin
B. Azoles* C. Erythromycin D. Selenium sulfide
Azoles are effective for dermatophytes. Griseofulvin , erythromycin, Selenium sulfide and are not.
57. Discrete flaccid bullae with some lesions having crusting on the surface are noted on lower legs, bilateral of a 22 yo female. She also has some inguinal lymphadenopathy and low grade fever. The most probable diagnosis is:
A. Epidermolysis bullosa B. Herpes zoster C. pemphigus D. Bullous impetigo*
Clinical description is suggestive of infectious nature of disease and bilaterality excludes Herpes Zoster; Bullous Impetigo is most probable diagnosis.
58. Testicular pain or tenderness is one of the criteria in: A. Polyarteritis Nodosa *
B. Hypersensitivity vasculitis C. Wegener’s Granulomatosis D. Kawasaki Arteritis
59. Mrs. Delos Reyes, an over weight 65 years old and a previous patient of yours in the OPD has been known to have mild osteoarthritis of the knees. She came in today due to increasing pain on her knees especially when she stands up coming from a prolonged sitting position. She has gained more weight in the last 2 months. The major risk factor for the progression of her knee osteoarthritis is:
A. her age B. her weight * C. her gender
D. she has developed Diabetes
Age is the most potent risk factor for OA. OA occurs in >50% of persons over age 70, and aging increases joint vulnerability, however, obesity is a major risk factor in increasing its prevalence and obesity is the cause of its high rate of disability.
60. Joint injuries, such as what happens in athletes are another risk factor for early OA. Malalignment is another anatomic abnormality that can make one at risk for OA. Among these patients, who has the highest risk of early cartilage loss?
A. a patient with varus deformity* B. a patient with valgus deformity C. a normal patient
D. a patient with polymyositis
Varus (bowlegged) knees w/ OA are exceedingly high risk of cartilage loss in the medial or inner compartment of the knee. This is the usual. Whereas valgus (knock-‐kneed) malalignment predisposes to rapid cartilage loss in the lateral compartment. Patients with polymyositis have proximal muscle weakness, hence would have difficulty standing and would not be able to put weight on their knees.
61. A 57 year old slightly over weight teacher came to you complaining of mechanical pains on her knees. You suspect early stage of knee osteoarthritis. PE of the knees is unremarkable except for some crepitations. You requested XRAY of both knees, upon looking at the film, you see that the joint spaces are still intact, however you already see the Radiologic Hallmark of OA, which is:
A. juxta-‐articular osteopenia B. Osteophytes
C. Bone sclerosis*
D. Decreased medial compartment
Juxta-‐articular osteopenia is the earliest radiographic manifestation of RA. Osteophytes are an important radiographic hallmark of OA, they form near areas of cartilage loss and start as outgrowths of new cartilage. Bone sclerosis is seen in more advanced OA, so as diminution in the space of the medial compartment.
62. Nonpharmacotheraphy has been the mainstay in the management of OA. If you were to provide an exercise program to your patient with knee OA, what would be the most effective exercise regimen?
A. aerobic and/or resistance training* B. range of motion exercises
C. running D. all of the above
Aerobics will build endurance and resistance training focuses on strengthening muscles across the joint. ROM exercises alone will not strengthen muscles and running is impact loading w/c you do not want in a joint w/ OA.
63. You have a patient with mild to moderate OA of the Hands and Knees. She would only have occasional pains with VAS (Visual Analog Scale) pain score of 4/10. Your initial analgesic of choice is:
A. a COX-‐2 inhibitor B. Paracetamol* C. Ibuprofen D. Prednisone
Acetaminophen or Paracetamol is the initial analgesic of choice for patients with OA in knee, hip or hands. Systemic steroids have no role in OA
64. Your 42 year old easy go lucky, bachelor uncle who lives with you and your family awakened you one night because he was in severe pain. He said that the pain and swelling was so dramatic that everything just happened that night, you saw his left big toe very warm, red, swollen and very tender. You thought it was cellulitis and immediately brought him to the ER. At the ER, you realized that your first impression was wrong when you heard the Medical Resident asked this question?
A. Are you a drug addict?
B. Did you have excessive alcohol ingestion?* C. Do you have fever?
D. Have you had this before?
This is obviously gout. And trigger factors are very important to ask, commonly in young males, it is alcohol/ethanol ingestion. Fever is common in acute gout and it doesn’t always mean there is infection. It is also important to ask if the patient had a similar episode already in the past because that would increase the probability that this is really gout. However, in this case, the trigger factor is the most important question. This patient probably had a drinking spree prior to the attack.
65. For question number 64, the Medical resident’s impression is gout. He ordered serum Uric acid level but turned out to be normal. You want to document that this is really gout. The patient’s left first MTP is still swollen. What will you suggest?
A. Repeat the serum Uric Acid after 2 weeks on your uncle’s follow-‐up in the OPD B. Get an XRAY of his big toe
C. Aspirate the First MTP and examine the fluid for MSU crystals*
D. Wait for the next attack, because if this is gout he will certainly have another attack
Even if the clinical appearance strongly suggests gout, the presumptive diagnosis ideally should be confirmed by needle aspiration. Needle-‐shaped MSU crystals are seen both intracellularly and extracellularly. w/ polarized light, these crystals are brightly birefringent w/ negative elongation. Serum Uric acid levels are not diagnostic of gout.
66. L.T., a 21 year old female, now diagnosed to have SLE, was just in Boracay last April for her summer vacation with her friends. Among the pathogenesis of SLE, which do you think was triggered by her vacation in Boracay?
A. genes
B. abnormal immune response*
C. autoantibodies and immune complexes D. Inflammation
This patient’s vacation in Boracay exposed her to sunlight for quite a long period of time. Exposure to UV light causes flares of SLE in approximately 70% of patients, possibly by increasing apoptosis in skin cells or by altering DNA and intracellular proteins to make them antigenic. Because this patient is genetically predisposed, that abnormal response to the UV light made her produce autoantibodies and immune complexes and the subsequent inflammation in SLE.
67. A 30 year old female with SLE comes to you with her urinalysis result that showed: Sp gravity 1.002, (+++) proteins, (-‐) sugar, RBC 30-‐40, WBC 25-‐30, (++) RBC casts, (++) hyaline, coarse and granular casts. You know there is definite nephritis, what will be the next most valuable examination that you will perform to confirm nephritis?
A. kidney Biopsy* B. Renal Ultrasound
C. RBC morphology
D. 24 hour urine collection to measure the patient’s total protein excretion
Nephritis is already evident with presence of +++ proteinuria and casts, we don’t need ultrasound, rbc morphology anymore. We do 24 hour urine for protein measurement if the proteinuria in the urinalysis is not very conclusive. At this stage we should determine the classification of her nephritis, this will help us in the choice of treatment and prognosis of the patient.
68. The earliest lesions in rheumatoid arthritis is: A. Pannus formation
B. Sequestration and destruction of Ig-‐coated circulating cells
C. Microvascular injury and an increase in the number of synovial lining cells * D. Bone erosions
69. A 22 year old female presents with a facial rash on the malar area sparing the naso labial fold. She also has arthritis of the hand joints and hair loss of 3 months duration. Her
laboratory work ups revealed a urinalysis with +++ protein, CBC with hemoglobin of 90. Other indications of disease activity of her SLE may be:
A. high C3 B. low C3* C. thrombocytosis D. Lymphocytosis
In active SLE, we usually encounter decrease levels of blood elements such as thrombocytopenia, lymphopenia, anemia and leukopenia. Complement levels are low especially in cases with nephritis, hence you expect C3 to be low.
70. An 18 year old female college student was brought to the ER after a grand mal seizure. She was diagnosed to have SLE 2 years ago. At that time, she presented with arthralgia, fatigue, alopecia, a butterfly rash, and a positive ANA (titer 1:640). She was started on Hydroxychloroquine 200mg twice a day and was given steroid creams for her facial rash. She seemed to respond well to treatment. 2 months ago, she developed tender black spots on the skin at the base of her fingernails. Her facial rah worsened, and more hair had fallen out. She began to have episodes of throbbing frontal headache, and on the day of admission, she suffered a generalized tonic-‐clonic seizure during a lecture at school and was brought to the ER. Remembering the criteria for SLE, her manifestation now is:
A. idiopathic epilepsy B. CNS infection
C. Intracerebral thrombosis D. CNS lupus *
Neurologic manifestations of SLE may vary from just a simple headache to a frank seizure. This is CNS manifestation of lupus
71. A 40 year old patient with SLE for 10 years has received cyclophosphamide and rituximab for her lupus nephritis class IV in the last 4 years. This patient was rushed to the ER due to difficulty of breathing. On auscultation, there were coarse and wet crackles all over the chest wall. Immediate intubation was done due to impending respiratory arrest. Pulmonary edema and possible pulmonary hemorrhage was the initial reading of the Chest Xray. You know that this is a life-‐threatening condition in SLE. What must be given to this patient?
A. pulse Methylprednisolone*
B. blood transfusion C. pulse Cyclophosphamide D. IVIG
For life-‐threatening conditions in SLE due to disease activity, we give pulse methylprednisolone. This is given at a dose of 1 gm OD for 3 days in the hope of arresting the disease activity.
72. In osteoarthritis, nodes in the distal interphalangeal joints are called: A. Heberden’s nodes *
B. Bouchard’s nodes C. Osler’s nodes D. Erythema nodosum
73. A 32 year old mother presented with an 8 week history of pain and swelling of the small joints of her hands, followed additively by swelling of her knees, shoulders, and ankles. She was experiencing 4 hours of morning stiffness and fatigue during the day. She recalled experiencing a mild sorethroat, low-‐grade fever, and myalgias during the start of her symptoms. Pertinent physical examinations are: tenderness on both shoulders, MCP’s, PIP’s, knees and ankles. Swelling is noted on the MCP’s, PIP’s, knees and ankles. What will be of use for you to document your diagnosis?
A. ANA
B. ASO titer and ECG C. ESR and anti-‐CCP* D. Xray of the joints
The diagnosis here is Rheumatoid arthritis, therefore increase ESR and positive anti-‐CCP will be of benefit for us to document the diagnosis. These 2 are part of the criteria/scoring system for RA
74. A 58 year old female presented to you with a history of left knee pain and swelling of 6 weeks duration. This was followed about a week later by pain and swelling of 3 of her MCP’s and 3 PIP’s on both of her hands. You are thinking of RA but is uncertain, hence, you requested for a CBC, ESR, Rheumatoid Factor (RF), and anti-‐CCP. CBC turned out to be normal, RF was negative, but the ESR was 70mm, and the anti-‐CCP was 3x the upper limit of normal. What is your score now based on the new classification criteria for RA?
A. 5 B. 8 C. 10* D. 12
Knee=1; 3MCP’s=2; 3PIP’s=2; 6 wks duration=1; elevated ESR=1; high positive anti-‐CCP=3 total score: 10; A score of 6 or more is needed for a diagnosis of definite RA
75. A 45 year old patient with RA, considered Methotrexate-‐naïve who has now sustained multiple joint deformities. Her DAS-‐28 score is still high. You worked up the patient for possible initiation of Biologic treatment. Her HBsAg was +, her XCR showed old PTB scar. The patient could not tolerate NSAIDS due to epigastric discomfort. What do you think will be the best combination treatment for this patient?
A. high dose Prednisone, Hydroxychloroquine, and Etanercept B. low dose Prednisone, Hydroxychloroquine, and Rituximab C. low dose Prednisone, Hydroxychloroquine, and Tocilizumab*
