Day 15

Question 1

Q1-70-year woman comes to the emergency room with crushing substernal chest pain for 1 hour.
What is the most appropriate next step in management of this patient?

A-CKMB level
B-Morphine
C-Oxygen therapy
D-Aspirin
E-Angioplasty OR hrombolytics

Answer 1

Ans: D. Aspirin lowers the mortality with acute coronary syndrome.and it is critical to administer asprin as soon as possible.with 1 hour of chest pain neighther cardiac enzyme like CK MB or Troponin would be elevated yet,Morphine,Nitrates and oxygen also should be administered but but they would not reduce mortality and are therefore not as important as Aspirin. Aspirin should be given simultaneously with activating for cardiac catheterization.
Clopidogrel is indicated when aspirin is intolerant or has undergone angioplasty with stenting.
The patient should nbe transferred to Intensive Care Unit (ICU) ,but you must always initiate the therapy and testing before you simply move the patient to another part of hospital.it is much more important to start treatment then just to move the patient,even is it is a area of better observation and intervention/proper treatment.thrombolytic or Angioplasty is important to do quickly,However Aspirin is recommended first.Aspirin is then followed with another form of acute revascularization.

Question 2

Q2-70-year woman comes to the emergency room with crushing substernal chest pain for the last hour. An ECG showing ST segment elevation in Segment V2 to V4. Aspirin has given the patient to chew.
Now what is the most appropriate next step in management of this patient?

A-CK MB level
B-Nitrates-sublingual
C-Thrombolytics
D-Angioplasty

Answer 2

Ans: D. Angioplasty is associated with greatest mortality benefits amongst all options given in question. Again Morphine, oxygen and Nitrates are important but not clearly lower the mortality. Enzyme test can be done but it can be normal in first 4 hours and donor changes the management in such classical MI and even if elevated CK-MB or troponin it wil not alter the Acute MI management.
Beta blockers are associated with decrease mortality, but they are not critically dependent upon time.as long as patient receives metoprolol during hospital stay and at time of discharge, she will get benefit. And same is true for use of statins and ACEI.

Question 3

Q3-which of the following is most important in decreasing risk of restenosis after coronary artery PCI?

A-Multistage procedure.i.e.Doing 1 vessel at a time with multiple procedures
B-Use of heparin for 3-6 months after procedure
C-Warferin use after procedure
D-Placement of drug eluting stent (Paclitaxel, sirolimus)

Answer 3

Ans: D. placement of drug eluting stent that inhibits local T cell response has markedly reduced the rate of restenosis. Heparin is used at the time of procedure but not used continuously post procedure for long time. Warferin has no role to play in management of CAD.warferin is useful for clot on venous side of the circulation like DVY or Pulmonary embololus.

Question 4

Q4-A patient comes to a rural hospital without cardiac catheterization facility. He has chest pain and ST Segment elevation. What is the appropriate next step in management of this patient?

A-Transfer for angioplasty
B-Thrombolytic therapy now
C- Refer to cardiology

Answer 4

Ans: B. Immediate thrombolytic are far more beneficial to the patient then several hours’ delay angioplasty. Remember consultation is never a correct answer in most cases.
The mortality benefit of thrombolytic are extends up to 12 hours’ form onset of chest pain. In other words, you can answer thrombolytic in first 12 hours of chest pain and ST segment elevation. The mortality benefit is as much as 50% relative risk reduction within the first 2 hours of onset of chest pain. This is why patient with chest pain who arrives in emergency department should receive thrombolytic therapy within 30 minutes of coming through doors.
(Door to needle time under 30 minutes)

Question 5

Q5-A man comes to the emergency department with chest pain that is for last 30 minutes and crushing in nature. And does not change with respiration or position of the body. An ECG showed ST segment depression in V2 to V4 leads.an Aspirin is given to the patient.
What is the next most appropriate step in management of this patient?

A-Low molecular weight heparin
B-Thrombolytics
C-GPII/IIIB inhibitors
D-Nitrates

Answer 5

Ans: A. Heparin will prevent a clot from forming in coronary arteries. heparin does not desolved clot that already formed. when the patient has ACS(Acute coronary syndrome) and NO ST segment ST segment elevation. Thrombolytics will not benefit.
Nitroglycerine, morphine and oxygen are not clearly associated with reduction in mortality.
ACE inhibitors and statin are used but the mortality benefit again is based on either low ejection fraction or high LDL respectively.
Metoprolol should be used but it has not been proven that it matters wether we give beta blockers immediately or at the time before discharge.in other words there is no urgency in time of time of prprenolol to give. There is tremendous urgency to give heparin immediately because we want to prevent clot from growing further and closing off coronary arteries.

Question 6

Q6-Which of the following is the most common cause of death from CHF (congestive Heart Failure)?

A-Pulmonary edema
B-Myocardial infarction
C-Arrythmia/Sudden death
D-Myocardial rupture

Answer 6

Ans: C. ischemia provokes ventricular arrhythmia leads to sudden death.over 99.9% of CHF patients are at home and not acutely short of breath.if they dies of sudden death.physician never sees them.Betablockers are antiarrythmic and anti ischemic so they prevents sudden death.donot give beta blockers in Acute treatment of CHF.

Question 7

Q7-74 years’ African American man with history of dilated cardiomyopathy deconadary to MI in the past is seen in the office for routine evaluation. he is asymptomatic and maintained on Lisinopril, metoprolol, Asprirn, furosemide and digoxin.lab test persistently showed elevated potassium level.ECG is unchanged.
What is the most appropriate next step in management of this patient?

A-Switch Lisinopril to Candisartan
B-Stop Lisinopril
C-Refer to Hemodialysis
D-Switch Lisinopril to Hydralazine and nitroglycerine.

Answer 7

Ans: D. Hydralazine is direct arteriolar vasodilator. there is definitive survival advantage of usin hydralazine with nitroglycerine in systolic dysfunction. Candisartan is also associated with hyperkalemia. dialysis is also sometime used for hyperkalemia but usually when associated with renal failure.

Question 8

Q8-74 year’s old woman comes to emergency department with acute shortness of breath, Respiratory rate-38/minute, S3 gallop, rales in lungs and jugulovenous distension.
What is the best initial step in management of this patient?

A-Pusle oximeter
B-Echocardiography
C-Intravenous furosemide
D-Ramipril
E-Metoprolol

Answer 8

Ans: C. All the answers are partially correct because they all can be used in CHF at some point. However, the best initial treatment for acute pulmonary edema is to remove large volume of fluid from vascular space with a loop diuretic. Oximetry should be done but should not alter acute management because we now must give oxygen because patient complains of shotness of breath and she is hyperventilating.
Echocardiography should be done bit it should not have to done urgently. Ramipril or any other form of ACEI or ARBS, should be used if there is systolic dysfunction or low ejection fraction.but it doesn’t make difference in acutely unstable patient.the same is true for metoprolol.
Nesiritide is a therapeutic, intravenous form of atrial natriuretic peptides. nesiritide function is much same as nitrates. because it is a weak diuretic, there is no proven mortality benefits.

Question 9

Q9-A 85 years of old man comes to the emergency, known case of lung cancer with increasing sudden shortness of breath from last several days. he bacame somewhat lightheaded today.and that is what has brought him to the hospital today. on examination his pulse rate 112/min, BP-92/58mmof hg on inspiration, Chest-clear, Jugulovenous distension.
Which of the most appropriate to confirm the diagnosis?

A-ECG/EKGChest x ray
B-Echocardiogram
C-Cardiac catheterization
D-Cardiac MRI
E-Chest X ray

Answer 9

Ans: B. Echocardiogram.(Diagnosis of this case is Acute cardiac Temponade). The phrase most appropriate can be very difficult to interpret. It is not always clear whether “appropriate means first, best or most reliable.in this case the reason Echocardiogram is most appropriate is because EKG show nothing except tachycardia. The chest x ry is normal in acute Temponade(X ray can show globular heart).and although right cardiac cathetrrisation is the most accurate to decide precise pressure, it would never be appropriate to do cardiac catheterization first without doing echocardiogram first.

Question 10

Q10-A 60years old man comes to the emergency department with acute chest pain. he also has pain between his scapulae. He has history of hypertension and tobacco smoking. His blood pressure is 170/100mmof hg.
What is the best initial test?

A-Chest X ray
B-Trabsesophageal echocardiogram
C-EKG
D-CT chest
E-Transthoracic echocardiogram

Answer 10

Ans: A. Chest x ray (diagnosis is Aortic dissection). widening of mediastinum is excellent clue for presence of aortic dissection.

Question 11

Q11-A 65 years old man comes to the emergency department with acute chest pain. He also has pain between his scapulae. He has history of hypertension and tobacco smoking. His blood pressure is 170/100mmof hg.
Which is the most accurate test?

A-Chest X ray
B-Trabsesophageal echocardiogram
C-EKG
D-CT angiogram
E-Transthoracic echocardiogram

Answer 11

Ans: D-CT Angiogram (A case of Aortic dissection)

Question 12

Q12-which of the following is most appropriate screening for aortic aneurysm (AA)?

A-Everyone above 50 with CT angiogram
B-Men who ever smoked and over 65 with Ultrasound
C-Everyone above 65 with ultrasound
D-Everyone above 50 with ultrasound
E-Men above 65 with ultrasound

Answer 12

Ans: B. when the with of AAA(abdominal aortic Anurysm) exceed more than 5 cm in diameter,surgical or catheter directed repair of the aneurysm is indicated.the incidence of AAA is less in women and non smokers,so there is no recommendation of screening for those groups.new onset of backache in elderly(over 65 years) should screen fro AAA by ultrasound.

Question 13

Q13-Which of the following is the most dangerous to a pregnant woman?

A-Mitral stenosis
B-Peripartum cardiomyopathies
C-Eisenmenger phenomenon
D-Mitral valve prolapsed
E-Atrial septal defect

Answer 13

Ans: B. worst form of heart disease in pregnancy is peripartum cardiomyopathy with persistent ventricular dysfunction. If a woman with peripartum cardiomyopathy and persistent ventricular dysfunction becomes a pregnant again, she has very high chances of worsening of cardiac functions.
Peripartum cardiomyopathy develops in most woman after delivery so its acceptable to use ACEI and ARBs in such patients.
Pregnancy increases plasma volume by 50%. Mitral stenosis is worsen in pregnancy but not as much as Eisenmenger phenomena or peripartum cardiomyopathy.

Question 14

Q14-A 50years’ asymptomatic woman comes o the office for small mass she found on thyroid by palpation. There is no tenderness and she is not on any medication.
What is the next most appropriate step in management of this patient?

A-Fine Needle Aspiration
B-TSH and T4 level
C-Ultrasound thyroid
D-Radionuclide iodine uptake scan
E-Surgical removal

Answer 14

Ans: B.If the patient has hyperfunctioning thyroid, means elevated T4 or Low TSH, patient doesnot need immediate biopsy. Malignancy is not hyperfunctioning. Ultrasound of thyroid is done to access the size of the lesion but it doesnot change/eliminate need of Thyroid function test or needle aspiration Approach for all-when a patient has thyroid nodule-do

1) -perform Thyroid function test-TSH and T4
2) -if thyroid function test is normal do biopsy of thyroid lesion/gland.

Question 15

Q15-A 46 year’s woman with thyroid nodule is found to have normal thyroid function testing. Fine needle aspiration report comes as “indeterminant for follicular adenoma”.
What is the most appropriate next step in management of the patient?

A-Neck CT
B-Surgical removal (excision biopsy)
C-Ultrasound
D-Calcitonin level

Answer 15

Ans: B. follicular adenoma is histological findings and it does not exclude carcinoma. The only way to exclude cancer is to remove entire nodule. This is an indeterminate finding on FNA. A sonography cannot exclude cancer and calcitonin is useful if biopsy showed medullary carcinoma.

Question 16

Q16-75 year’s old man with history of malignancy admitted with complains of lethargy, confusion and abdominal pain. He is found to have marked elevated calcium level. He has given 3 liters of Normal saline and and pamidronate.his calcium level is still markedly elevated on following day.
What is the most appropriate next step in management of this patient?

A-Calcitonin
B-Zoledronic acid
C-Plicamycin
D-Dialysis

Answer 16

Ans: A. Calcitonin.calcitonin inhibits osteoclasts.the onset of action of calcitonin is very rapid and it wears off rapidly. Bisphosphonate takes several days to to work. Plicamycin and gallium are older therapies for hypercalcemia that no longer have role in management. When they are given as a choice of therapy itsalways wrong.Zoledronic acid is bisphosphonate and doesnot add anything to pamidronate.
Cinacalcet is inhibitor of PTH release.
If hypercalcemia is due to malignancy PTH shouldalready maximally suppressed.
Dialysis only for those who in renal failure.
Prednisolone controls hypercalcemia when it is because of sarcoidosis or any granulomatous disease.

Question 17

Q17-patient is brought to the emergency department after motor vehicle,in which he sustained severe abdominal trauma.on the second day patient became marked hypotensive without evidence of bleeding.there is a fever,high eosiniphil count,hyperkalemia,hypoglycemia and hyponatremia.
What is the most next appropriate step in the management?

A-CT scan of adrenal
B-Draw cortisol level and administer hydrocortisone
C-Dexamethasone suppression test
D-ACTH level
E-Cosyntropin stimulation testing

Answer 17

Ans: B. this is suspected case of acute adrenal insufficiency and it’s critical to administer hydrocortisone. This is more important than diagnosing etiology. Hydrocortisone possesse sufiicient mineralocorticoid activity to be life saving.in addition hydrocortisone increases blood pressure because there is a permissive effect of glucocorticoid on vascular reactivity effect of catecholamines. BP will come up fast with steroid because norepinephrine will be more effective on constricting blood vessels.

Question 18

Q18-60 year’s old man admitted to emergency department with altered mental status, hyperventilation and marked elevated blood glucose level.
Which of the following is most accurate measure of severity of his condition?

A-Glucose level
B-Serum bicarbonate
C-Urine ketone
D-Serum ketone
E-Blood gas-PH level

Answer 18

Ans: B. Hyperglycemia is not the measure of severity of diabetic keto acidosis (DKA). The glucose level can be markedly elevated without the presence of ketoacidosis. Although Blood ketones are important, they all are not detected.
If serum bicarbonate is very low, patient is at risk of death. if serum bicarbonate is high it doesnot matter how high serum glucose is, in term of severity. Serum bicarbonate is way of saying “anionic gap “if the bicarbonate level is low, the anion gap is increased.

Question 19

Q19-15-year-old boy comes to the office because of occasional shortness of breath every few weeks. Currently he feels well. he uses no medication and denies any other medical problems.his vitals stable and chest examination is normal.
Which of the following is single most diagnostic test at this time?

A-Peak expiratory flow
B-Increase in FEV1 with albuterol
C-Diffusion capacity of carbon monoxide
D->20% decrese in FEV1 with use of methacholine
E-Increase alveolar arterial oxygen difference (A-a gradient)
F-Increased in FVC with albuterol

Answer 19

Ans: D. when a patient is currently asymptomatic, it is less likely to find increase in FEV1 with short acting bronchodilator like albuterol. This test when patient is asymptomatic can be false negative.
When the patient is asymptomatic, most accurate test of reactive airway disease is 20% decrease in FEV1 with the use of methacholine or histamine.
CT chest or x ray shows nothing except hyperinflation.
The ABG and PEF helpful when patient in acute exacerbation.
Flow volume loops are best for fixed lesion like trancheal obstruction or copd.

Question 20

Q20-A 47 year’s male with history of asthma came to emergency room with increasing acute shortness of breath, cough and sputum production for several days. His respiratory rate is 32/minute; diffuse expiratory wheeze and prolonged expiratory phase. Which of the following would use as the best indicator of severity of his asthma?

A-Respiratory rate
B-Pulse rate
C-Pulse oxymeter
D-Use of accessory muscle
E-Pulmonary function test

Answer 20

Ans: A. a normal respiratory rate is 10 to 16 per minute. By itself a respiratory rate 32/minute indicates severe shortness of breath. Accessory muscle use is hard to assess and it’s subjective.
Pulse oxymeter will not show hypoxia until patient is nearly at the point of imminent respiratory failure. Oxygen saturation can be maintained more than 90% by hyperventilation of patient.
Pulmonary function testing cannot be when patient is acutely short of breath.

Question 21

Q21 -65 years old woman admitted to hospital with CAP (community acquired pneumonia) sputum gram stain showed gram positive diplococcic but culture does not show any organism. Chest x ray showed lobar infiltrates and large effusion.
She is placed on ceftriaxone and azithromycin. Thoracocentesis reveals marked elevated LDH and protein and white cells 17000 micro liter.
Blood culture grows streptococcus pneumonie with MIC (minimal inhibitory concentration) to penicillin is less than 0.1Microgram/ml.
Her-Temperature -102F, Pusle 114/minute, BP-110/70mmof hg and Spo2 is 96% at room air. What is the most appropriate next step in management of this patient?

A-Repeted thoracocentesis
B-Placement of chest tube for suction
C-Add ampicillin to treatment
D-Place patient in intensive care unit
E-Consult pulmonologist

Answer 21

Ans: B. infected pleural effusion or empyema best responded by chest tube or thoracostomy.
Large effusion is acts like abscess and hard to sterilize. Each side of chest can accommodate 2-3 liter of fluid.
There is no benefit of adding ampicillin to ceftriaxone. a low MIC to penicillin automatically means that organism is sensitive to ceftriaxone and in fact all cephalosporin.
There is no need to keep her in ICU just because of large effusion or chest tube.
Except pulse her vitals otherwise stable and pulmonary consult will not add anything, though it is practiced commonly.
Important notes
• Hypoxia and hypotension as single fare a reason to hospitalize patient.
• Notice that chest x ray does not guide hospitalization and x ray not tells about severity of hypoxia
• Admission criteria-CURB65(C=confusion= uremia, R=respiratory distress=BP low and 65=65 years or more age)

Question 22

Q22-A patient is admitted to the hospital for head trauma and subdural hematoma.the patient is intubated for hyperventilation and subsequent craniotomy.several days after patient admission patient starts blood in vomiting,he was evaluated and found to have stress ulcer.lansoprazole was started.patient then developed VAP(ventilator associated pneumonia),he put on imipenum,linezolid and gentamycin.phenytoin started prophylactically.three days later the creatinine is rising and patient starts having seizures.repeat CT scan shows no changes compared to earlier scan.
What is the most appropriate next step in management of this patient?

A-Switch Phenytoin to carbamazepine
B-Stop Lansoprazole
C-Stop Linezolid
D-Stop imipenum
E-Perform EEG

Answer 22

Ans: D. Imipenum can cause seizures. Imipenum is excreted through kidneys.the renal failure has causes imipenum level to rise leading to toxicity. This is much more likely than failure of phenytoin.Carbamazipine is not much stronger as phenytoin to stop seizure.

Question 23

Q23- An HIV positive African American man admitted with history of dyspnea, dry cough and, high LDH and paO2 of 65 mmof hg. He is started on Sulphomethoxasole and trimethoprim (SMX/TMP) and prednisone. On the third day of hospital he developed severe rash and neutropenia. He has anemia and there are bite cells on peripheral smear.
What is the most appropriate next step in management of this patient?

A-Stop TMP/SMX
B-Begin antiretroviral therapy
C-Switch TMP/SMX to intravenous pentamidine
D-Switch TMP/SMX to aerosol therapy
E-Switch TMP/SMX to clindamycin and primaquin

Answer 23

Ans: C. Rash is most common and neutropenia/bone marrow supression is second most common side effect of TMP/SMX.Although clindamycin and primaquin may have has more efficacy than pentamidine.here we choose option C because this patient looks G6PD deficient and primaquin is contraindicated.bite cells are suggestive of G6 PD deficiency.for active disease Intravenous pentamidine is used not aerosol.starting antiretroviral done eventually.in additional antiretroviral therapy is relatively contraindicated in acute opportunistic infection because of the possibilities of immune reconstitution syndrome.

Question 24

Q24- An HIV positive woman with CD 4 cell count 22cells/microliter is admitted with PCP and treated successfully with TMP/SMX.prophylactic TMP/SMX and azithromycin are started.she is then started on antiretroviral drug and her CD 4 cell count raises to 430cell/microliter for last 6 months.
Now what is the next most appropriate management for this patient?

A-Stop TMP/SMX
B-Stop TMP/SMX and azithromycin
C-Stop all drugs and monitor
D-Continue all medication
E-Stop azithromycin

Answer 24

Ans: B. if CD 4 cell count is maintained more than 200 for several months then you can stop TMP/SMX prophylaxis.Azithromycin is used as prophylaxis for atypical mycobacterium and its used when CD 4 cell count is below 50 cells/microliter.you can not stop anti retroviral therapy otherwise her CD 4 cell count drops.it is the anti retroviral therapy which maintains her CD 4 cel counts.if the CD 4 cells are persistently high no need for any prophylaxis.these cells are fully functional and able to prevent opportunistic infection.the use of prophylaxis medicine is on CD 4 cell count not on viral load. Ref MTB Q bank step 2 CK-pulmonology pages 152.

Question 25

Q25-A 65-year-old woman who recently underwent hip replacement comes to the emergency department with the acute onset of shortness of breath and tachycardia. The chest x-ray is normal, with hypoxia on ABG, an increased A-a gradient, and an EKG with sinus tachycardia.
What is the most appropriate next step in management?

A-Intravenous unfractionated heparin
B-Thrombolytics
C-Inferior vena cava filter
D-Embolectomy
E-Ventilation/perfusion (V/Q) scan
F-Lower-extremity Doppler studies

Answer 25

Ans: A. When the history and initial labs are suggestive of PE (Pulmonary Embolism), it is far more important to start therapy than to wait for the results of confirmatory testing such as thespiral CT or V/Q scan. D-dimer is a poor choice when the presentation is clear because its specificity is poor. Embolectomy is rarely done and is performed only if heparin is ineffective and there is persistent hypotension, hypoxia, and tachycardia.