2011 - 6th Flashcards
A 52-year-old male patient was admitted to the hospital after experiencing chest pain. Clinical presentation and subsequent investigations established the diagnosis of ST-elevation myocardial infarction. He was immediately treated with medications and PCI, and now rests in the coronary care unit. Few days after the initial presentation, the patient starts to develop a similar episode of pain and discomfort in his chest. Which of the following tests would be most helpful as an evidence of re-infarction?
A. Creatine kinase-MB isoenzyme
B. Troponin levels
C. Presence of chest pain
D. S3 gallop
E. Myoglobin levels
A. Creatine kinase-MB isoenzyme
Note: The rapid decline of CK-MB to reference values by 48 to 72 hours allows for the discrimination of early re-infarction when symptoms
recur between 72 hours and 2 weeks after the initial acute MI, when troponin, which takes longer time to decline, may still be elevated.
A 35-year-old man has history of leg swelling and low albumin for four years. He suddenly becomes short of breath and hypoxic. Chest auscultation shows no findings. What is the cause of this patients’s presentation?
A. Pulmonary embolism
B. Fluid overload
C. Chest infection
A. Pulmonary embolism
Note: Patients with nephrotic syndrome lose protein C and S in the urine. Both having anticoagulant properties, their loss predisposes to hypercoagulability and puts the patient at risk of developing renal vein thrombosis, deep vein thrombosis and subsequent pulmonary embolism.
A middle-aged woman presented to the cardiology clinic with a complaint of palpitations and chest discomfort of few weeks duration. She occasionally feels dizzy as well. An ECG was done during one of the episodes and is shown below. What is the likely diagnosis?
A. Atrial flutter with 2:1 block
B. AV nodal re-entrant tachycardia
C. Atrial fibrillation
D. Wolff-Parkinson-White syndrome
A. Atrial flutter with 2:1 block
A 25-year-old patient has a recent history of developing epileptic seizures.
Each seizure is characterized by a preceding aura of olfactory or gustatory nature. The patient also reports experiencing moments he is familiar with.
The neurologist decides to obtain a brain MRI for the patient. What would
this imaging modality be helpful at detecting in this patient?
Mesialtempora sclerosis
What is the rationale behind tapering the dose of therapeutic steroids slowly in patients who are steroid dependent?
A. Not to precipitate acute adrenal insufficiency
A young patient who is a known case of asthma is getting worse despite being on medications, including inhaled steroids. His mother says that her son is wheezv almost everday and is having a productive cough
Laboratory investigations show a high WBC count and high eosinophil count. What other investigation would confirm the cause of this patient’s
presentation?
A. IgE antibodies to Aspergillus fumigatus
B. Blood culture
C. HIV test
D. Blood film and bone marrow aspiration
A. IgE antibodies to Aspergillus fumigatus
Note: Allergic bronchopulmonary aspergillosis, or asthmatic pulmonary eosinophilia, is caused by a hypersensitivity reaction to bronchial colonization by Aspergillus, complicating asthma and cystic fibrosis. I is characterized by peripheral eosinophilia and very high levels of IgE.
A 10-year-old child presents with two-day history of dark urine that was
decreased in amount. He was aso found to have lower imo and tacia swellina. Blood pressure was measured and found to be elevated.
Urinalysis shows high RBCs and protein in the urine as well as RBC casts.
What is appropriate management for this patient?
A. Conservative management until the patient improves
B. Start the patient on intravenous antibiotics
C. Administer high-dose intravenous steroids
A. Conservative management until the patient improves
A 36-year-old obese female complains of frequent headaches. On neurological examination, fundoscopy reveals papilledema. She also had signs of sixth cranial nerve palsy. Her BMI is 31. What is the likely diagnosis according to this patient’s presentation?
A. Idiopathic intracranial hypertension
Note: Idiopathic intracranial hypertension is a disorder of unknown etiology that predominantly affects obese women of childbearing age. The primary problem is chronically elevated intracranial pressure, and the most important neurologic manifestation is papilledema.
A flight attendant started to develop chest pain that is pricking in nature. She has a tall stature and a flat chest. She also reports developing palpitations and occasional shortness of breath. An echocardiogram was performed and showed prolapse of the mitral leaflets into the left atrium during systole accompanied by mild mitral regurgitation. What could be done to manage this patient’s symptoms?
A. Administration of beta blockers B. Start her on diuretics
C. Give her aspirin
D. Mitral valve replacement
A. Administration of beta blockers B. Start her on diuretics
A 49-year-old man has a previous history of multiple episodes of chest pain on exertion. They used to last for about 20 minutes and were relieved
by rest. He now reports another episode at rest that is longer in duration. The pain was so severe he had to be taken to the emergency room where
an ECG was performed and showed a normal trace. Blood samples were taken as well for laboratory workup and revealed the presence of elevated levels of cardiac enzymes. What is the likely diagnosis?
A. Non ST-elevation myocardial infarction
B. Unstable angina
C. ST-elevation myocardial infarction
D. Stable angina
E. Prinzmetal’s angina
A. Non ST-elevation myocardial infarction
A 36-year-old female patient is a known case of multiple sclerosis for few
vears. she experienced a demvelinating episode two months back that was characterized ov ed
weakness. visual disturbances and incoordination.she improved and had no svmptoms for tew
weeks until now when she had another episode of worsening symptoms. What clinical pattern of multiple sclerosis does this patient experience?
A. Relapsing-remitting course
B. Primary progressive
C. Secondary progressive
D. Progressive relapsing
E. Clinically-isolated
A. Relapsing-remitting course
A 17-year-old male patient with history of Crohn’s disease for one year develops thin yellow discharge from the perianal area. Barium enema showed an enterocutaneous fistula. Which ot the following imaging modalities is of choice to visualize the structure and anatomy of the fistula?
A. Pelvic MRI
B. Fistulogram
C. Ultrasound
D. CT of the pelvis
A. Pelvic MRI
Note: Pelvic MRI findings show very high concordance with operative
finings compared to the questioned accuracy ot fistulography.
What would be the appropriate antibiotic regimen for the patient in the previous scenario?
Cettriaxone and vancomvcin
What would be found in the cerebrospinal fluid of the patient in the previous scenario?
A. IgG oligoclonal bands
B. Cytoalbuminologic dissociation
A. IgG oligoclonal bands
A 63-year-old gentleman has long history of hypertension on nifedipine and losartan. He also takes alpha antagonists for benign prostate hyperplasia. On a routine urinalysis, he was found to have microalbuminuria. What would be an appropriate step in management at this stage?
A. Start the patient on angiotensin converting enzyme inhibitors
A 25-year-old man with a long history of chronic intermittent bloody diarrhea presents with one week history of exacerbating symptoms. Over the last 24 hours, the severity of diarrhea has decreased, but he now complains of abdominal pain and distention. On physical examination, the patient is extremely ill and pale, abdomen is distended, tympanic to percussion and diffusely tender. His vital signs are as follows: blood pressure 93/60, heart rate 113 beats/min, respiratory rate 18 breaths/min and temperature 37.9 C. His abdominal x-ray is shown. Which of the following should be used as part of management for the of this patient?
A. Infliximab
B. Oral steroids
v. Oral metroniaazole
D. Methotrexate
E. Mercaptopurine-6
A. Infliximab
Note: Initial management of toxic megacolon includes aggressive fluid
and electroive replacement. Intravenous antoiotics as well as intravenous steroids or biologic therapy, e.g. anti-TNF.
A 33-year-old gentleman was brought to the emergency room with a sudden onset of severe headache and periorbital pain. On neurological examination, he was found to have a positive kerning sign, a dilated right pupil and complete posis of the left eyelid.
What is the most likely underlying cause of this patient’s presentation?
A. Subarachnoid hemorrhage
B. Multiple sclerosis
C. Bacterial meningitis
A. Subarachnoid hemorrhage
Note: The development of sudden onset of severe headache accompanied b sians of meningeal irritation should make subarachnoid hemorrhage one of the most likely differentials. Moreover,
paintu thiro crania nerve pasv should point towards a ruptured berr aneurvsm as the cau
such presentation.
A 52-year-old man comes to the neurology clinic with a complaint of
visUal disturbance and ower imo weakness. On examination. he was found to have diplopia. Power of the left lower limb was 4/5, and reflexes were exaggerated. He also seems unable to balance his gait. What is the likely diagnosis in this patient?
A. MUltiple sclerosis
B. Guillain-Barré syndrome
A. MUltiple sclerosis
What is the diagnostic method of choice for the patient in the previous
scenario
A. CT angiography
B. Lumbar puncture
A. CT angiography
Note: The gold standard for diagnosis of intracranial aneurysms is
current intra-arterial digita suotraction andioaraonv. out a diagnosis
can also be provided by CT- and MR angiography.
If the patient in the previous scenario is steroid-resistant and cannot use a drug that suppresses her bone marrow, what medication can be used?
A. Cvclosporine
B. Cyclophosphamide
C. Azathioprine
D. Methotrexate
A. Cvclosporine
Note: Cyclosporine has an advantage over other immunosuppressive medications in that it does not affect the bone marrow.
A 15-year-old Indian child was found positive for tuberculosis when performing a pre-school admission checkup. The doctor put him on a combination of drugs, including isoniazid. What is the mechanism of action of isoniazid?
A. Inhibition of cell wall synthesis of mycobacteria
B. Inhibition of intracellular protein synthesis
C. Inhibition of mitochondrial DNA synthesis
D. Inhibition of mRNA binding to ribosomes
A. Inhibition of cell wall synthesis of mycobacteria
On auscultation of the chest of the patient in the previous scenario, what is expected to be heard?
A. Late systolic murmur
B. Pansystolic murmur
C. Soft S1
D. Opening snap
E. Diastolic rumble
A. Late systolic murmur
Note: During systole, the floppy mitral valve suddenly prolapses, and the chordae tendinae tense producing a mid-systolic click followed by some regurgitation. The latter manifests as a high-pitched late systolic crescendo-decrescendo murmur that is best heard at the apex.
A patient was admitted to the ICU in a coma. He was found to have no sleep-wake cycle. His EEG shows an isoelectric line. Which of the following should first be excluded before announcing brain death?
A. Barbiturate intoxication
B. Vegetative state
C. Locked-in syndrome
A. Barbiturate intoxication
Note: Prior to deciding on a diagnosis of brainstem death, the
poSSIoIlItv that a patent’s apneic coma is due to sedative druas hypothermia or metabolic/electrolyte disturbances should be first excluded.
A 43-year-old woman developed progressive muscle weakness in her upper arms over the last six weeks. She has difficulty getting out of chairs and climbing stairs. She has no muscle pain, however. What is expected to be found in the muscle biopsy of this patient?
A. Infiltration of myocytes by Th1 and cytotoxic T cells
B. Intracellular inclusions
C. Granulomatous reaction
A. Infiltration of myocytes by Th1 and cytotoxic T cells
A 24-year-old woman had an uneventful vaginal delivery a couple of weeks back. She now presents with shortness of breath and easy fatiguability. On examination, she was found to have a raised JVP, S3 gallop and lower limb edema. An echocardiogram was performed and showed a dilated heart and an ejection fraction of 20%. Which of the following pulses is this patient likely to have?
A. Pulsus alternans
B. Pulsus paradoxus
C. Pulsus bisferiens
D. Pulsus parvus et tardus
A. Pulsus alternans
Note: Pulsus alternans occurs in the setting of severe heart failure complicating this case of peripartum cardiomyopathy.
A 76-year-old patient with history of congestive heart failure was admitted to the hospital after experiencing an episode of decompensation and was put on digitalis. Few hours later, the patient was found to have developed a supraventricular arrhythmia as was shown on the ECG trace. What is the
most appropriate step in the management of this condition?
A. Complete cessation of digitalis
B. Decrease the dose of digitalis
C. Add a beta blocker
D. Add a calcium channel blocker
E. Observe the patient until she is symptomatic
A. Complete cessation of digitalis
Note: Digoxin toxicity may cause almost any arrhythmia, classically, those with increased automaticity and decrease atrioventricular conduction. The development of digoxin toxicity warrants the immediate discontinuation of the drug along with observation and supportive care with proper hydration to optimize the real clearance of excess drug, if the patient is hemodynamically stable.
The following day, the patient in the previous scenario has deteriorated with sudden onset of tachycardia and hypotension. The jugular venous pressure was elevated and heart sounds were muffled. The ECG showed low voltage criteria. What is expected to be found on this patient’s chest x-
ray?
A.Enlarged cardiac shadow and clear lung fields B. Infiltrates in both lung fields
C. A rim of calcification around the heart
A.Enlarged cardiac shadow and clear lung fields
Note: If accumulation of pericardial fluid takes place fast enough to impede the pumping function of the heart, cardiac tamponade results. Hence, it is the rate of accumulation and not the quantity of fluid that predicts the development of cardiac tamponade.
A 27-year-old pregnant female started to experience shortness of breath and palpitations during pregnancy. On auscultation of her chest, a mid- diastolic murmur was best heard at the apex with a loud S1. A diagnosis of mitral stenosis was confirmed on echocardiography. What cardiac arrhythmia is most commonly associated with mitral stenosis?
A. Atrial fibrillation
B. Atrial flutter
C. Ventricular tachycardia
A. Atrial fibrillation
A young patient presented to the emergency room with status epilepticus
What is the most common cause of status epilepticus?
A. Non-compliance to anti-epileptic medications
A 52-year-old female comes to her physician with a complaint of change in her urine color. She has a history of hepatitis C infection. Digital infarcts were noted on physical examination as well as gum bleeds and purpura on both of her lower legs. Which of the following is the likely diagnosis in this patient?
A. Cryoglobulinemia
B. Infective endocarditis
C. Henöch-Schonlein purpura
A. Cryoglobulinemia
A young prisoner who has been known to abuse drugs was found short of breath with a fever. He also reports being unusually sweaty at night. When examined, his jugular venous pressure was elevated, and lower limb edema was present. A chest x-ray was performed and is shown below. What diagnosis does this patient has?
A. Tuberculous constrictive pericarditis
B. Lung abscess
C. Right-sided heart failure
D. Cardiac tamponade
A. Tuberculous constrictive pericarditis
Note: Chronic constrictive pericarditis is evident on a chest x-ray by the presence of a calcified rim, i.e. the pericardium, that encases the heart. This takes place as the granulation tissue gradually contracts, forms a scar and eventually calcifies.
A middle-aged male patient comes to the clinic to evaluate his risk for
developing ischemic heart disease. A blood sample was taken for laboratory workup. Which of the following lipid profiles is most protective against ischemic heart disease?
A
