Day 14

Question 1

Q1-A man is admitted with E Coli Bacteremia.Which of the following is the most appropriate therapy?

A-Vancomycin
B-Linezolid
C-Quinolones, aminoglycosides, carbepenum, piperacillin
D-Doxycyclin

Answer 1

Ans: C. all of the agent listed under “gram negative bacilli” could be the right answer. Choice C is the only agents which cover gram negative bacilli…

Question 2

Q2-A man comes to emergency room with complain of fever, severe head ache, neck stiffness and photophobia. On examination he has weakness in left arm and leg. What is the most appropriate next step in management of this patient?

A-Ceftriaxone, vancomycin, steroid
B-Head CT scan
C-Ceftriaxone
D-Steroids

Answer 2

Ans: A. when there is contraindication of immediate Lumbar puncture, most important step is to initiate treatment. Ceftriaxone or steroid alone is not sufficient. This patient’s presentation is clear for meningitis. Although antibiotic may reduce the sensitivity of CSF culture, it is more important to prevent further neurological damage from untreated meningitis then it is to have a microbiological diagnosis. You can also use gram stain and bacterial antigen detection method to establish a diagnosis after start of antibiotics. Although they cannot tell sensitivity pattern. A head CT is important for this patient because of neurological damage BUT it is more important to initiate first treatment. In addition, if the head CT show a mass lesion may never be able to perform lumbar puncture.

Question 3

Q3-What is the most accurate test for herpes encephalitis?

A-Brain biopsy
B-PCR for CSF
C-MRI brain
D-Viral culture of CSF
E-Serology for herpes

Answer 3

Ans: B. PCR is more accurate than brain biopsy. serology for herpes is useless.95% of the population will be positive. Since blood serology cannot distinguish oral herpes from a routine cold sore, genitalherpes or encephalitis. Tzanck prep test can be done as initial test on a genital ulcerative lesion. Viral culture is most accurate test of genital or skin lesion BUT not of CSF or Brain lesion.

Question 4

Q4-A woman is admitted for herpes encephalitis, confirmed by PCR.after 4 days of acyclovir her creatinine level begin to rise. What is the most appropriate next step in management?

A-Stop acyclovir
B-Reduce dose of acyclovir and Hydrate
C-Switch to oral famciclovir or valciclovir
D-Switch to foscarnet

Answer 4

Ans: B. Oral medication like famciclovir or valcyclovir is insufficient for herpes encephalitis. Although acyclovir may be occasionally renal toxic because acyclovir precipitates in renal tubules. Foscarnet has far more renal toxic.

Question 5

Q5-Which of the following is most sensitive physical finding of Otitis media?

A-Redness
B-Immobility
C-Bulging
D-Decrease hearing

Answer 5

Ans: B. immobility is so sensitive physical finding that a fully mobile tympanic membrane esentiall to exclude the Otitis media. Ref MTB Q bank step 2 CK-ID page 13

Question 6

Q6- 34 year’s woman presents with facial pain, discolored nasal discharge, bad taste in her mouth and fever. On physical examination she has facial tenderness.
Which of the following is the most accurate test in diagnosis?

A-Sinus biopsy or aspirate
B-CT scan
C-X ray
D-Culture of discharge

Answer 6

Ans: A, this is a case of sinusitis. Remember that in infectious disease, radiological test never the accurate test. Only biopsy or aspirate gives you precise microbiological diagnosis. There is a difference between a question that says” what’s most accurate test” and one that ask “what will youdo? CT scan is most common wrong answer to this question. You cannot stain or culture on CT scan.

Question 7

Q7-34 years’ woman presents with facial pain, discoloured nasal discharge, bad taste in her mouth and fever on physical examination she has facial tenderness.
What is the most appropriate next step or action or management?

A-CT scan
B-Linezolid
C-X ray
D-Amoxicillin/clavulinic acid and a decongestant

Answer 7

Ans: D. when the diagnosis is clear as in this case, radiological test is unnecessary.
Amoxicillin/Clavulinic acid, doxycyclin or sulphomethoxasole and trimethoprime remains first line treatment for sinusitis or otitis media. The efficacy of this agent is same as newer ormore broad spectrum antibiotics like quinolones. Imaging is done if diagnosis is equivocal. A decongestant is used in all cases to promote sinus drainage.
Erythromycin is inadequate because of poor coverage of streptococcus pneumonia. Linezolid, althougha excellent for resistant gram positive organism, would not cover hemophilus.

Question 8

Q8-Which of the following correlates best with an increase likelyhood of mortality in acute hepatitis patient?

A-Bilirubin
B-Prothombine time
C-ALT
D-AST

Answer 8

Ans: B. all of the test can be markedly elevated with acute hepatitis with little adverse significance except prothombine time. if PT is elevated there is a marked increase risk of fulminant hepatic failure and death.

Question 9

Q9-Which of the following will become abnormal first after acquiring acute hepatits B infection?

A-Anti Hepatitis B e antibody
B-Surface antigen
C-E antigen
D-Core IgM antibody

Answer 9

Ans: B. Surface antigen is measure of acute viral particles. Bilirubin, Alt and antibody production are measure of body’s response to infection.

Question 10

Q10-Which of the following indicates that a person is no longer a risk for transmitting infection to another person (Active infection has resolved?) in Acute hepatitis?

A-Bilirubin normalize
B-No surface antigen found
C-No E antigen found
D-No Core IgM antibody found
E-Anti Hepatitis B e antibody

Answer 10

Ans: B. as long as surface antigen is present, there is still some viral replication potentially occurring. Even if surface antibody were one of the choices, the correct answer would still be surface antigen. Transmissibility stops when DNA polymerase stops, not when surface antibody appears. Jaundice (increase bilirubin) and ALT normalizes long before viral replications stops.you can definitely have viral replication, elevated DNA polymerase and positive surface antigen with normal ALT.Hepatitis B e antibody will appear before resolution of all DNA polymerase activity.it is an indication that the acute infection is moving towards resolution.but it doesnot conclusively prove that resolution has occurred.

Question 11

Q11-Which of the following is the best indication of need for treatment with antiviral medication in chronic hepatitis?

A-Anti Hepatitis B e antibody
B-Surface antigen
C-E antigen
D-Core IgM antibody

Answer 11

Ans: C, E.antigen, the person most likely to be benefit from anti viral medication is the one with greatest degree of viral replication. Hepatitis B e antigen is strongest indicator of active viral replication. Though surface antigen means there is atleast some active disease. It might be on the way to spontaneous resolution and would not benefit.
Everyone with E antigen also has surface antigen. The person with worst disease (Highest DNA polymerase) will benefit most from the treatment.

Question 12

Q12-Which of the following is the best indicator that pregnant woman will transmit hepatitis infection to her child?

A-Anti Hepatitis B e antibody
B-Surface antigen
C-E antigen
D-Core IgM antibody

Answer 12

Ans: c. E antigen. your question may offer DNA polymerase as a choice instead of E antigen.any time you would say E antigen; you would also say DNA polymerase.
The only difference is that E antigen is qualitative test means it’s simply positive or negative.DNA polymerase is quantitative test, meaning you get a level that can have lot of variability. It is like a gas tank in your car…E antigen tells you about Only presence or absence of gas which DNA polymerase gives amount of gas in tank of car.
If woman is positive for surface antigen, but the E antigen is negative there is only 10% risk of transmission of infection means only 10% child will have infected hepatitis B at birth.
When both surface antigen and E antigen are present there will be 90% of children will be infected at birth.
This is why perinatal transmission is most common mode of transmission worldwide.

Question 13

Q13-A woman comes to clinic with multiple painful genital vesicles.
What is the next step in management?

A-Acyclovir orally
B-Acyclovir topically
C-PCR
D-Viral culture

Answer 13

Ans: A, if the presentation is clear for herpes with multiple vesicles of the mouth or genitalias, diagnostic test is not necessary.Acyclovir, famciclovir or Valacyclovir are all equal in efficacy, so any of them could be right choice. Viral culture is most accurate test but not necessary if vesicles are clear. Serology is always worthless. Since it cannot distinguish an acute genital infection from an oral herpes infection in past.

Question 14

Q14-A 39 years old generally healthy woman comes to OPD with complain of urinary frequency and burning.
The urinalysis showed more than 60 WBC per high power field.
What is the appropriate next step in management?

A-Nitrofurantoin for 3 days
B-Nitrofurantoin for 7 days
C-Urine culture
D-Ultrasound of urinary system
E-CT scan of urinary system

Answer 14

Ans: A, when the symptoms of cystitis are clear and White cells in urine, no need of culture or imaging studies. Culture and imaging are done when there are frequent episode of cystitis or failure to respond to therapy. Three days is sufficient for uncomplicated cystitis. Seven days is given when there are anatomical abnormalities.

Question 15

Q15-A man comes in emergency department with fever and murmur. Blood culture showed streptococcus bovis. Transthoracic echocardiography shows vegetations.
What is the appropriate next step in management of this patient?

A-Colonoscopy
B-Tran esophageal echocardiography
C-Repeat blood culture
D-CT scan of abdomen
E-Surgical valve replacement

Answer 15

Ans: A. Streptococcus bovie is associated with colonic pathology ranging from diverticulitis to polyp to colon cancer. If strep bovie grows do colonoscopy. CT scan will not show diverticuli. There is no point repeating blood culture if already positive. Surgical valve replacement is premature at this stage.

Question 16

Q16-A 55 year’s woman comes to the office with chest pain that has been occurring since last several weeks. The pain is not reliably related to excertion.she is comfortable now. The location of pain is retrosternal.the pain is sometime associated with nausea. There is no shortness of breath and pain does not radiate beyond the chest. She has no past medical history.
What is the most likely diagnosis?

A-Gastro esophageal reflux disease (GERD)
B-Unstable angina
C-Pericarditis
D-Pneumothorax

Answer 16

Ans: A. when a patient has chest pain and the etiology is not likely to be cardiac ischemia then most likely cause is some kind of gastrointestinal disorder such as GERD.the most common GI disorders are associated with chest pain is ulcer disease, cholelithiasis, gastritic, duodinitis etc.
If a 48 years’ female with chest pain and no risk factor it would be very unlikely that her chest pain is related to ischemic heart disease.by the time woman is 55-60 years of age, the protective effect of menstruation and natural occurring estrogen is worn off and risk of CAD is equal rates of the man.

Question 17

Q17-Which of the following is the most likely to benefit a patient’s risk of coronary heart disease?

A-Administration of estrogen at the time of menopause
B-Stopping tamoxifen
C-Stopping aromatase inhibitors
D-Regular exercise

Answer 17

Ans: D. Increase heart rate through regular exercise or even taking the stairs instead of using an elevator shows clear benefit in cardiac outcome.
Although myocardial infarction is extremely rare in woman below 50 years of age, which is average age of menopause, this does not translate into a beneficial effect of administrating estrogen replacement therapy. estrogen replacement may improve LDL but does not help CAD.
Meditation, yoga and relaxation may help but not as much as regular exercise.

Question 18

Q18-Which of the following is most dangerous to patient in terms of risk of coronary artery disease (CAD)

A-Elevated Cholesterol
B-Elevated triglyceride
C-Low HDL (High Density Lipoprotein)
D-Elevated LDL (Low Density Lipoprotein)
E-Obesity

Answer 18

Ans: D. Marked elevation in LDH is by far most dangerous portion of a lipid profile for a patient.A low HDL is also associated with a poor long term prognosis but it is not as dangerous as high LDL.although elevation in triglyceride levels are potentially dangerous ,this is not as reproducible in terms of poor outcome as elevated LDL.the proper treatment of elevated triglyceride is not clearly beneficial as elevated LDL.obesity particularly that resulting in increase abdominal girth, is associated with increased cardiac mortality. However much of the danger of the obesity is from its association with other abnormalities like dyslipedemia, hypertension and diabetes.

Question 19

Q19-Postmenopausal woman develops chest pain immediately on the hearing news of death of her son in war. She develops acute chest pain; dyspnea and ST segment elevation in lead V2 to V4 on ECG.elevated level of troponin confirms the myocardial infarction. Coronary angiogram is normal including absence of vasospasm on provocating test. Echocardiography showing apical left ventricle ballooning.
What is the presumed mechanism of this disorder?

A-Absence of estrogen
B-Massive catecholamine release
C-Plaque rupture
D-Platelet aggregation
E-Emboli to coronary arteries

Answer 19

Ans: B, Tako-Tsubo is acute myocardial damage most often occurs in post menopausal woman immediately following an overwhelming, stressful emotional event. Examples are divorce, earthquack, financial issue, lightning strike and hypoglycemia. This lead to ballooning and left ventricular dyskinesia.as with ischemic disease manage with beta blockers and ACEI.Revascularization will not help, since the coronaries are normal.

Question 20

Q20-Correcting which of the following risk factors for Coronary Artery disease(CAD) result in most immediate benefit to the patient?

A-Hypertension
B-Diabetes
C-Dyslipedemia
D-Tobacco smoking
E-Weight loss

Answer 20

Ans: D, smoking cessation results in the greatest immediate improvement in patient’s outcome for CAD. Within a year after stop smoking risk of CAD reduce by 50% and 2 years after stop smoking reduce risk of CAD by 90%.

Question 21

Q21-A 46years’ woman comes to the office with chest pain that has been occurring since last several weeks. The pain is not reliably related to exertion. She is comfortable now. The location of pain is retrosternal.She has no hypertension and ECG is normal.What is the most appropriate next step in management?

A-CK-MB
B-Troponin
C-Echo cardiogram
D-Exercise tolerance test (ETT)
E-Angiography

Answer 21

Ans: D, enzymes are done to evaluate acute coronary syndrome. Serial troponin levels are done prior to stress test. Echocardiography is done to know motion wall abnormalities, valvular function and ejection fraction. Exercise tolerance test is to evaluate stable patient with chest pain whose diagnosis are not clear.ETT is not done for patient who has acute coronary syndrome in which patient having currently chest pain and diagnosis is clear. also do not put patient on treadmill who are having currently the chest pain.

Question 22

Q22-A 64 year’s old man is placed on Lisinopril as a part of managing CAD in association of ejection fraction 25% and symptoms of breathlessness. Although he has rales some times in the lung examination. Patient is asymptomatic now. Physical examination showed minimal pedal edema. His Potassium level is high which is high on repeat examination. His ECG is normal.
How would you best manage this patient?

A-Add kayexalate (Potassium binding resin)
B-Insulin glucose
C-Stop Lisinopril
D-Switch Lisinopril to candisartan
E-Switch Lisinopril to Hydralazine and nitrates

Answer 22

Ans: E. Although cough is the most common adverse effect of ACEI (Lisinopril), they may also cause hyperkalemia.you can not just switch ACEI to ARBs, since both medication cause Hyperkalaemia because of their effect on inhibiting aldosterone. Aldosterone normal function to excrete potassium from distal tubules.
Hydralazine is direct acting arteriolar vasodilator. Hydralazine will decrease afterload and has been shown to clear mortality benefit in patient with systolic dysfunction. Hydralazine should be used with nitrates to dilate the coronary arteries so the blood is not stolen away from coronary perfusion when after load is decrease with use of hydrazine.

Question 23

Q23-Which of the following is most common adverse effect of statin medication?

A-Rhabdomyolysis
B-Liver dysfunction
C-Renal dysfunction
D-Encephalopathy
E-Hyperkalaemia

Answer 23

Ans: B. at least 1% of patient taking statin will develop elevation of liver transaminase to the level where you will need to discontinue the medications.elevation of CPK level,rhabdomyolysis and or myositis occurs in less than 0.1% patients and rare to have stop medication because of myositis.there is no recommendation to routinely monitor all patient with CPK in absence of symptoms.on the other hand all patients on statin should be monitore routinely for liver enzymes even in absence of any symptoms.

Question 24

Q24-70 year’s old woman comes to the emergency room with crushing substernal chest pain for the last hour. The pain radiates to left arm and associated with anxiety, diaphoresis and nausea. She describes pain as “sore” and dull and clinches her fist in front of her chest. She has a history of hypertension.
What is most likely to be found in this patient?

A->10 mmof hg decrease blood pressure on inspiration
B-Increase jugualar venous pressure on inhalation
C-Triphasic scratchy sound on auscultation
D-S4 gallops

Answer 24

Ans: D. Acute coronary syndrome associated with S4 gallops because of ischemia leading to noncompliance of left ventricle. The S4 gallop is the sound of atrial systole as blood is ejected from atria into a stiff ventricle.
A decrease in blood pressure more than 10mmof hg during inspiration is pulsus paradoxus and is associated with cardiac temponade.
An increase in JVP on inspiration is kussmaul sign seen in most oftenly seen with constrictive pericarditis or restrictive cardiomyopathies.
A triphasic patchy sound seen in pericardial rub.
Although pericarditis can occur as a complicationof myocardial infarction (Dressler’s Syndrome), this would not occur for several days after Myocardial infarction and is much rarer than simple ventricular ischemia.

Question 25

Q25-70 year’s old woman comes to the emergency room with crushing substernal chest pain for the last hour. Which of the following ECG finding is associated with worst prognosis?

A-ST elevation in lead II, II, AVF
B-PR interval more than 200ms
C-ST elevation in lead V2-V4
D-Frequent premature ventricular contractions (PVCs)
E-ST depression in lead V1 and V2

Answer 25

Ans: C. Lead V2to V4 is corresponds to anterior wall of left ventricle.ST segment elevation most often signifies acute myocardial infarction.
ST segment elevation in lead II, III, AVF signifies –inferior wall MI.
Untreated case of acute inferior wall MI –mortality is less than 5% at 1-year post MI and mortality is around 30-40% in acute anterior wall MI.
PR interval greater than 200ms is first degree AV block has little pathological potentials, and when isolated requires no additional treatment.
Ectopics sch as PVCs and APCs (Atrial premature contraction) are associated with later development of more serious arrhythmia.but no additional therapy is needed for them if magnesium and potassium is in normal limits. We don’t like to see PVCS but their presence doesnot requires additional treatment.
ST depression in lead V1 and V2 signifies posterior wall MI. these leads are read in opposite direction of the rest of the leads.in other words ST depression in lead V1 and V2 would be like ST segment elevation elsewhere-Acute myocardial infarction. Infarction of the posterior wall is associated with a very low mortality and again there is no additional therapy needed because of this.
RBBB is relatively benign compared to LBBB.