Day 5 Flashcards
Q1-A premature infant born at 28 weeks is in respiratory distress, with grunting, nasal flaring, and the use of accessory muscles. Bowel sounds are heard upon auscultation of the back and chest x-ray shows air fluid levels are seen in the chest. Which of the following is the most likely diagnosis?
A-Hydrocele B-Gastroschisis C-Diaphragmatic hernia D-Hiatal hernia E-Omphalocele
Ans: C. A hernia in the diaphragm will allow for bowel contents to move into the chest and impair ventilation. Hydrocele is a urinary defect and is not seen on x-ray. It cannot be gastroschisis or omphalocele, as those are defined as an extrusion of abdominal contents outside of the body. Hiatal hernia is a benign finding most commonly seen in elderly or obese patients.
Q2-A 23- year girl presented with perioral paresthesia and carpopedal spasm 20 mins after a huge argument with her boyfriend. What is the next step for this patient?
A-SSRI B-Diazepam C-Rebreath into a paper bag D-Propranolol E-Alprazolam
Ans: C. As part of the mechanism creating panic attack symptoms; hyperventilation in particular, a sharp fall in blood carbon dioxide levels occurs. The theory behind rebreathing your exhaled air through a paper bag is that you are able to reabsorb the carbon dioxide back into the bloodstream that you would otherwise have lost in breathing out.
The main theory is that depleted carbon dioxide in the blood stream alters the bloods pH, making it more alkaline, moving towards a state known as alkalosis. Higher alkalinity of the blood, can give rise to dizziness, tunnel vision, fainting and some of the other panic attack symptoms. Paper bag rebreathing reverses this carbon dioxide deficiency and so alleviates this situation.
Q3-Young female with BMI 18, fine hair all over body, feeling of she is fat, does not eat well with excessive exercise.
A-Anorexia nervosa
B-Body dysmorphic disorder
C-Bulimia nervosa
Ans: A. Anorexia Nervosa .it’s an eating disorder characterized by failure to maintain a normal eating habit and body weight, fear and preoccupation with overweight. Patient has an unrealistic self-evaluation as overweight and disturbed body image, and usually loses weight by maintaining strict caloric control, excessive exercise, purging, fasting, and abusing laxative and diuretics. It mostly occurs in young females (F:M = 10:1). Average onset age is 17 years; the later the onset, the worse the prognosis.
Treatment 1. First hospitalize the patient and correct metabolic imbalance to prevent dehydration, starvation, electronic imbalances, and death. 2. Weight gain is the therapeutic target. It’s important to have psychotherapy and behavior therapy (with rewards or punishments) based on weight, and family therapy to reduce conflicts with parents. Antidepressants (SSRIs) may have some effects on promoting weight gain. Patient is usually not distressed by the disorder and may be resistant to treatment. 3. Prognosis/outcome: The course is fluctuating; long-term mortality rate of hospitalized patients is 10%, resulting from the effects of starvation (electrolyte disorders) and purging or suicide.
Q4- Which of the following is the most common cause of impotence due to a medical condition?
A-Alcohol B-CAD C-Drugs D-Diabetes E-Hypertension
Ans: D. Diabetes. Alcohol and drugs are also very common causes, but they are not “medical conditions.”
Q5- A 62 y/o man with recurrent and exacerbated COPD is hospitalized for evaluation for lung resection. He has a history of heavy smoking and alcoholism. His daily activities have been affected by the status of the disease. Which of the following is most useful in the evaluation for his surgery?
A-Result of exercise testing B-Arterial PO2 level C-Arterial PCO2 level D-Predicted postoperative EFV1 E-PAO2-PaO2 gradient
Ans: D. PFT-predicted postoperative EFV1 is the most useful means to evaluate the benefit from lung resection. ABG is not of much value for this purpose.
Q6-At which chromosome is the cystic fibrosis gene?
A-Long arm chromosome 7 B-Short arm chromosome 7 C-Long arm chromosome 8 D-Short arm chromosome 8 E-Long arm chromosome 17
Ans: A. An autosomal recessive disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) gene (chloride channel) on chromosome 7 and characterized by widespread exocrine gland dysfunction. Cystic fibrosis (CF) is the most common severe genetic disease in the United States and is most frequently found in persons of white ethnicity.
Q7-A 41-year-old woman with type 2 diabetes attends a hypertension clinic. She has been doing well on metformin and has maintained good glycaemic control
Along side dietary changes and regular physical exercise. She has been meeting herHbA1c targets consistently. However, her blood pressure has been poorly controlled despite lifestyle changes and is currently 157/97 mmHg. The most appropriate first line therapy is?
A-Diuretics B-Angiotensin II receptor blocker (ARB) C-Calcium channel blocker D-β-blocker E-Angiotensin-converting enzyme (ACE) inhibitor
Ans: E in type 2 diabetics blood pressure is monitored monthly if above150/90 mmHg, bimonthly if above 140/80 mmHg and bimonthly if bloodpressure is above 130/80 mmHg with renal, ophthalmic or cerebrovascular pathology. First-line therapy in type 2 diabetes patients with hypertension and no other abnormalities are ACE inhibitors (E) due to good blood pressure control and their renal and ophthalmic protective effects. Anangiotensin II receptor antagonist (B) may be used if there is intoleranceto an ACE inhibitor. Second-line therapy should be a calcium channelblocker (C) or a diuretic (A) if blood pressure remains high despite ACE inhibitor or angiotensin II blocker therapy. If this also fails to provide adequate control, B-blocker (D) therapy is used.
Q8-Treatment of Tinea Versicolor is?
A-Topical Ketoconazole or Selenium Sulphite
B-Oral Fluconazole
C-Doxycycline
D-Erythromycin
Ans: A. Tinea Versicolor Caused by Malassezia species, a yeast that is part of normal skin flora. Humid and sweaty conditions as well as oily skin can make the organism pathogenic. Cushing syndrome and immunosuppression are also risk factors. History/PE ■ Presents with small scaly patches of varying color on the chest or back ■ Patches can be hypopigmented as a result of interference with melanin production, or hyperpigmented/pink due to inflammation.
Diagnosis ■ Characteristic exam findings and history are sufficient. ■ Best initial test: KOH preparation of the scale revealing “spaghetti and meatballs” pattern of hyphae and spores.
Treatment-Treat lesions with topical ketoconazole or selenium sulfide.
Q9-Patient came with total bilirubin: 5.8 & direct bilirubin: 0.4, hemoglobin is normal. Patient telling during illness bilirubin increases. What is the likely diagnosis?
A-Guillain–Barré syndrome B-Dubin-junson syndrome C-Biliary sclerosis D-Crigler-Najjar syndrome E-Gilbert Syndrome
Ans: E. Gilbert syndrome (disease) -It’s the most common genetic cause of indirect bilirubinemia, a benign autosomal recessive or dominant disease due to a mild deficiency of glucuronosyltransferase. The jaundice fluctuates and is exacerbated by physical stress, infection, fasting, fever, surgery, or ethanol, and alleviated by barbital use. Elevated bilirubin is mostly <5 mg/dL. Patient usually has no other abnormalities and requires no special treatment.
Q10-A 72- year man is receiving chemotherapy for lung cancer. He has his last chemotherapy 8 days ago. He has now cough with some green sputum but feels well. Temp=38C. Chest exam showed few coarse crepitations in the right base. HR=100/min. CBC: Hgb=12.5g/dL, WBC=1100/cumm, Neutrophils-60%, Platelet 90,000/cumm. Sputum, urine and blood culture sent for microbiology. What is the most appropriate management?
A-Broad spectrum antibiotics IV B-Broad spectrum antibiotics PO C-GCSF (growth factor) D-Postpone treatment until bacteriology results available E-Reassure and send home
Ans: A-IV not oral as age, likely pneumonia very low neutrophil -cefepime is prefered antibiotic as per the guideline.no need to wait for any culture report first start treatment and then adjust according to culture.its febrile neutropenia a medical emergenct,if not treated propmptly they may die because of septicaemia or may end up with long term hospitalization or organ failure due to septecemia.
Q11-A 46-year-old woman with atrial fibrillation is seen in clinic following an episode of syncope while shopping. She has a family history of epilepsy and a past medical history of breast cancer. She remembers feeling dizzy for a couple of seconds then waking up on the floor. What is the most useful step in management?
A-Lying–standing blood pressure B-A collateral history C-An ECG D-An MRI brain E-A CT head
Ans: B The most important management step for any episode of loss ofnsciousness is to obtain a full history (B), including details before, during and after the event. Elicit the events just before the collapseincluding the activity, position (e.g. sitting versus standing), associatedsymptoms such as aura or palpitations and whether there were anywitnesses. The patient should be able to describe events after they awake, including any post-ictal symptoms such as confusion or sleepiness. The
patient will not know what happened while they were unconscious, although sometimes this can be inferred if they noticed incontinence, asore tongue/muscles or bruising. A collateral history from a witness is keyin determining the duration of the event, any colour changes or movements.
The history often makes the diagnosis, investigations confirm it. Lying–standing blood pressure (A) is helpful in orthostatic hypotension, an ECG(C) or echo for cardiogenic causes, brain imaging (D and E) may detectstructural abnormalities responsible for an epileptic focus.
Q12- A 2months baby who has ambiguous genitalia presents to the Emergency room with vomiting. Labs: Na+-125mmol/L, K+=6mmol/L. What is the most likely diagnosis?
A-Fragile X syndrome
B-Turners syndrome
C-Noonan syndrome
D-Congenital adrenal hyperplasia
Ans: D. Congenital adrenal hyperplasia
Autosomal recessive disorder characterized by the partial or total defect of various synthetic enzymes of the adrenal cortex required for cortisol and aldosterone production
Clinical Presentation
- Classic presentation: vomiting, dehydration, Hyperkalemia, Hyponatremia, hypoglycemia, and female haveAmbiguous genitalia at birth.
Treatment Is-Hydrocortisone
Q13-A 23year male has a tonic clonic seizure. His GCS score is 12, BP=120/77mmHg, HR=99bpm. What is the most appropriate investigation for his condition?
A-CT head
B-MRI head
C-Serum blood glucose
D-Serum drug levels
Ans: B. first time seizure needs to be screened for epilepsy, MRI investigation of choice, blood glucose should be checked but without history of Diabetes, decent vitals, its not the most appropriate single option.
Minimum Workup in a young person with 1st Time Seizure
• CBC and differential
• Electrolytes including Ca2+, Mg2+, P04
• HeadMRI
Q14-A 35 y/o female comes to the physician with dyspnea on exertion, chest pain, lethargy, fatigue, and lower limb edema for the past month. She has had an occasional cough for the past month and takes no medicine except an OCP. P/E shows a loud split S2 and a systolic ejection murmur. CXR shows enlarged central pulmonary arteries. ECG and arterial blood gas (ABG) are ordered. Her RR is 25/min and pulse is 105/min. What’s the most likely diagnosis?
A-Pulmonary embolism B-CAD with right heart failure C-COPD D-Primary pulmonary hypertension (HTN) E-Secondary pulmonary HTN
Ans: D. This patient has manifestations of pulmonary hypertension but no history of related causes. CXR demonstrates enlarged central pulmonary arteries. ECG and Echocardiogram will demonstrate R-Ventr hypertrophy and signs of R-Ventr overload. PE usually occurs suddenly with similar symptoms and may not show R-Ventr hypertrophy and failure so early. CAD is less likely because the patient has low-risk for her age and history.
Q15- A 60 y/o man complains of lower limb pain and easy bruising for the past 3 days. The pain is not relieved by rest. He has 4-5 years of history of smoking, hyperlipidemia, and vasculitis and was on heparin for DVT prophylaxis 2 weeks ago. P/E finds stable vital signs and multiple bruises on the lower limbs. Lab tests reveal normal RBC and WBC; platelets = 50 x 103/uL, aPTT = 30 sec, PT = 20 sec, BT = 8 min, and LDL = 200 mg/dL. The best next step is to
A-start warfarin B-start lovastatin C-start lepirudin D-stop heparin E-infuse platelets
Ans: D. This is an uncommon case of heparin-induced thrombocytopenia due to anti-platelet factor 4 complex causing decreased platelets and increased BT. The first step is to stop heparin and wait for the platelets to recover to > 100 x 103/uL before adding warfarin. Warfarin alone without heparin may induce limb gangrene in a patient with DVT. “C and B” should be the next step after heparin is stopped. ‘E’ is reserved for more severe bleeding.
