Day 23 Flashcards
Q1-A 65-year-old woman comes to the emergency department with acute, severe shortness of breath; rales on lung exam; S3 gallop; and orthopnea. Which of the following is the most important step?
A-Chest x-ray B-Oxygen, furosemide, nitrates, and morphine C-Echocardiogram D-Digoxin E-ACE inhibitors
Ans: B. Oxygen, furosemide, nitrates, and morphine are the mainstay of therapy for acute pulmonary edema. Although they are not associated with a concrete mortality benefit, they are the standard of care for pulmonary edema, which is the worst manifestation of CHF. Removing volume from the vascular system and, therefore, the lungs is more important than any form of diagnostic testing. Pulmonary edema is a clinical diagnosis. Shortness of breath, rales, S3, and orthopnea are more important in establishing the diagnosis than any single test.
Q2-A 78-year woman is admitted to the intensive care unit for acute pulmonary edema. She has rales to the apices and jugulovenous distention. Her EKG shows ventricular tachycardia. Which of the following is the best therapy?
A-Synchronized cardioversion B-Unsynchronized cardioversion C-Lidocaine D-Amiodarone E-Procainamide
Ans: A. Synchronized cardioversion is used when ventricular tachycardia is associated with acute pulmonary edema. The same answer would be used if the acute pulmonary edema was associated with the onset of atrial fibrillation, flutter, or supraventricular tachycardia. Unsynchronized cardioversion is used for ventricular fibrillation or ventricular tachycardia without a pulse. Medical therapy, such as lidocaine, amiodarone, or procainamide, can be used for sustained ventricular tachycardia that is hemodynamically stable.
Q3-A 75 years male presents with history of enuresis and change in behavior. Exam: waddling gait. What is the most likely diagnosis?
A-Subdural hemorrhage
B-Brain tumor
C-Normal pressure hydrocephalus
D-Psychotic depression
Ans: C,Normal Pressure Hydrocephalus (NPH)
It’s a potentially treatable form of dementia probably due to impaired CSF outflow in the brain.
Essentials of diagnosis
1. Classic triad: dementia, gait disturbance (“shuffling gait”), and urinary incontinence. There are generally no signs of elevated ICP and headaches.
2. Diagnosis is mostly made by clinical features and LP (lumbar puncture), which will usually show normal or mildly elevated CSF-P (pressure), and will improve symptoms. CT or MRI may reveal ventricular enlargement out of proportion to sulcal atrophy.
Treatment 1. Repeated spinal taps to remove large-volume CSF is the initial helpful therapy. 2. The preferred treatment is ventricular shunting, although variances and complications are common and potentially severe, which require vigilance in the follow-up.
Q4-A 53-year male complained of right iliac fossa dull aching pain. Exam showed that he had right iliac fossa mass with positive cough impulse. The examining doctor found a bluish tinge on the mass surface & the percussion tab was positive. The most likely diagnosis is:
A-Right inguinal hernia B-Right femoral hernia C-Right Vaginal Hydrocele D-Cyst of morgagni E-Saphenavarix
Ans: D
Q5-A 70-year man is seen in the office for further management of congestive heart failure. He currently has no symptoms and good exercise tolerance. He has been on lisinopril, metoprolol, spironolactone, and furosemide for the last 6 months. His ejection fraction is 23 percent. Which of the following is most likely to benefit this patient?
A-Intermittent dobutamine therapy B-Digoxin C-Cardiac transplantation D-Implantable cardioverter/defibrillator E-Chlorthalidine
Ans: D. Implantable cardioverter/defibrillators are indicated in dilated cardiomyopathy. The most common cause of death in CHF is sudden death from arrhythmia.Those with an ejection fraction below 35 percent that persists are candidates for implantable defibrillator placement.
Q6- A 28 y/o man is brought to the clinic for “strange behavior.” He is recently unemployed, and now has changes in mood and irrational behavior (such as discarding his favorite books and collections). His wife notices that he occasionally has 2-3 min spells in which he is unresponsive and remains motionless. A physician gave him an antipsychotic but this only made the spells worse. He sometimes complains of smelling an unpleasant odor. This condition is best treated with
A-Carbamazepine B-Phenytoin C-Haloperidol D-Valproic acid E-Ehosuximide
Ans: A. Carbamazepine is the #1 medicine for complex partial seizures. Phenytoin is the #1 drug for simple partial and all generalized seizures except Petit Mal. ‘E’ is best for absence seizure.
Q7-An old man comes to the doctor complaining that a part of this body is rotten and he wants to remove it. What is the most likely diagnosis?
A-Guilt B-Hypochondriasis C-Munchausen syndrome D-Nihilism E-Capgras syndrome
Ans: D. Nihilism-part of the body do not exisats or are deadGuilt-its an emotion that occurs when person feels that they have violated a moral standard.
Hypochondriasis-worry about having a serious illnessMunchausen’s-Psychiatric factitious disorder wherein those affected feigndisease, illness or psychological trauma to draw attention, sympathy or reassurance to them selves.
Capgras syndrome-A delusion that a friend, spouse, parent or other close family member (or pet) has been replaced by an identical-looking impostor.
Q8-A 32-year woman who is 32 weeks pregnanat attends the antenatal clinic. Lab shows HB-10.8gm/dl, MCV-95fl, what is the most appropriate management for this patient?
A-Oral iron
B-IV Iron
C-Folic acid Supplementation
D-No treatment requires
Ans: D. No treatment is required according to Nice guideline
Cut off for iron supplement:
1- At 8-10 weeks-if HB less than 11
2- At 28 weeks and further-if Hb less than 10.5
So this patient has 10.8 Hb at 32 weeks so no treatment is required.
Q9-A 66-year-old Hispanic man is seen in the office for follow-up. He was placed on metformin for type 2 diabetes after not responding to modifications of diet and exercise several months ago. Despite maximal doses of metformin, his blood glucose is > 150 mg/dL, and his HgA1c is above 7 percent. What is the next best step in management?
A-Add glyburide B-Add insulin subcutaneously C-Add insulin pump D-Add rosiglitazone E-Add acarbose or miglitol F-Switch to a sulfonylurea
Ans: A. If a patient with type 2 diabetes cannot be adequately controlled with metformin, then add a second medication. The greatest efficacy and safety is with a sulfonylurea. If the question describes a patient originally placed on a sulfonylurea but not adequately controlled, then add metformin. There are several options before having to start insulin.
Q10-A 65-year-old man with longstanding diabetes comes to the office with a “pins and needles” sensation in both his feet. He is also chronically bloated and constipated. On review of systems, you find he cannot maintain erection sufficiently to complete intercourse. Urinalysis shows microalbuminuria. His LDL is 147. What is the best management for this patient?
A-HgA1c
B-Nerve conduction studies
C-Hydralazine and sildenafil
D-Ramipril, erythromycin, atorvastatin, and pregabalin
E-Gastric-emptying study and penile tumescence studies
Ans: D. Prescribe ACE inhibitors for the proteinuria, erythromycin for the diabetic gastroparesis and to increase GI motility, atorvastatin to decrease the LDL level to < 100 for a patient, and pregabalin for diabetic neuropathy. No further specific diagnostic tests are required when you see this collection of abnormalities.
Q11-A resident of a nursing home presented with rashes in his finger webs and also on his abdomen, with complaints of itching which is severe at night. He was diagnosed with scabies. What the best treatment for his condition?
A-0.5% permethrin B-Doxycycline C-5% permethrin D-Reassure E-Acyclovir
Ans: C. The key is C. 5% permethrin. Scabies outbreaks in nursing homes and cases of crusted scabies may require combination therapy consisting of topical application of permethrin and 2 oral doses of ivermectin at 200 mcg/kg (administered 1 wk apart).
Q12-Known case of penicillin allergy with active rheumatic fever involving valve. What is the drug of choice?
A-Oral Doxycycline
B-IV Vancomycin
C-Cephalosporin
Ans: C.
Q13-A man with hypercortisolism is found to have an elevated ACTH level that suppresses with high-dose dexmethasone. MRI of this pituitary shows no visible lesion. What is the next best step in management?
A-Remove the pituitary B-Repeat the dexamethasone suppression test C-Use ketoconazole D-Do petrosal venous sinus sampling E-Order a PET scan of the brain
Ans: D. MRI and CT of the brain lack both sensitivity and specificity in diagnosing endocrine disorders. It is important to confirm the identity of an adrenal disorder functionally prior to scanning the patient. This patient has high cortisol with a high ACTH, indicating either the pituitary or an ectopic source of hyperadrenalism. The fact that the ACTH levels suppress with high-dose dexamethasone indicates a pituitary adenoma, which is the cause of Cushing syndrome in about 45 percent of patients. If the tests point to a pituitary source but the scanning is indeterminant, inferior petrosal sinus sampling is used to confirm it. Petrosal sinus sampling is also used to localize the lesion, as well to see which half of a pituitary should be removed.
Q14-A 35 year’syoung man comes to the clinic for evaluation of intermittent episodes of shortness of breath. Currently he is not short of breath. What is the best test to determine a diagnosis of reactive airway disease?
A-Chest x-ray
B-Diffusion capacity of carbon monoxide (DLCO)
C-High-resolution CT scan
D-Methacholine stimulation testing
E-Pre- and post bronchodilation pulmonary function testing (PFT)
Ans: D. Methacholine stimulation testing looks for a decrease in FEV1 in response to synthetic acetylcholine. Methacholine will decrease FEV1 if the patient has asthma. The DLCO is a good test of interstitial lung disease, in which it is decreased. Asthmatic patients may have an increased DLCO from hyperventilation. High-resolution CT scanning is a test for interstitial lung disease and for bronchiectasis. Pre- and postbronchodilation PFTs are an appropriate assessment if the patient is currently short of breath to see if there is improvement, but they are of no value in an asymptomatic patient. Chest x-ray is not specific enough to be the “most accurate test.”
Q15-Which of the following lowers mortality in COPD?
A-Smoking cessation
B-Home oxygen therapy (continuous)
C-Both of above
Ans: C. Both of these therapies reduce mortality in COPD.
