Day 6 Flashcards
Q1-A 55-year-old man who has been smoking 20 cigarettes a day for the last 30 years has been diagnosed with a right-sided pleural effusion following admission with a week’s history of shortness of breath. From the list below, select the most likely findings that one would ascertain during examination of the chest wall:
A-Decreased air entry coupled increased vocal fremitus and resonant percussion on the right side of the chest
B-Normal air entry coupled decreased vocal fremitus and resonant percussion on the right side of the chest
C-Normal air entry coupled increased vocal fremitus and dull percussion on the right side of the chest
D-Decreased air entry coupled decreased vocal fremitus and dull percussion on the side of the chest
E-None of the above
Ans: D. On examination of the chest wall, one would typically find the following
signs in a patient with a right-sided pleural effusion:
• Decreased air entry on the affected side
• Decreased vocal fremitus (which occurs as a result of decreasedconduction of sound waves through liquid media)
• Dullness (‘stony’) on percussion on the affected sideTherefore (D) is the correct answer.
Q2-The single blood test performed by a good laboratory that would be expected to be the most sensitive for determining whether the patient is euthyroid, hypothyroid or hyperthyroid is:
A-T3 uptake B-Total T3 C-Total T4 D-TSH (thyroid stimulating hormone) E-Free T4
Ans: D
Q3-A 34-year-old diabetic woman attends your hypertension clinic to discuss her
Blood pressure control. She is currently following lifestyle advice and has started to lose weight and maintain good glycaemic control. Her blood pressure was 155/93 mmHg at her last clinic appointment and is now 150/90 mmHg. She informs you that she has recently became pregnant, which was planned and intends to keep the baby. The most appropriate first-line therapy is:
A-ACE-inhibitor B-Angiotensin II receptor blocker C-Calcium channel blocker D-Diuretics E-β-blocker
Ans: C. A calcium channel blocker (C) is first-line therapy in a female who intends
to/or has become pregnant, as well as in patients who are of African-Caribbean descent (with an ACE inhibitor). In a normal patient followinglifestyle therapy ACE inhibitors (A) are first line, calcium channel blockers(C) are second line followed by a combination of diuretics (D) and calciumchannel blockers.
-blockers (E) are used if despite the aforementionedtherapy target blood pressure is not met. If there are any contraindicationsor poor compliance with ACE inhibitors, angiotensin II receptor blockers(B) are used instead.
Q4-The most common cause of hypercalcaemia in a hospitalized patient is:
A-Dietary, such as milk-alkali syndrome B-Drug related, such as the use of thiazide diuretics. C-Granulomatous disease D-Cancer E-Dehydration
Ans: D.Primary hyperparathyroidism (hyper-PTD) represents 90% of mild hyper-Ca (serum Ca 10.5-11.5 mg/dL), mostly due to one gland hyperplasia or adenoma and accidentally found in mid-aged women. Parathyroid adenoma is also part of MEN-1 and MEN-2.
Essentials of diagnosis
- Clinical features:
(1) Most patients are asymptomatic with mild hypercalcemia. When serum Ca is over 11.5 mg/dL, typical symptoms will appear as “Bones (pain and fractures with osteitis), Groans (PUD, pancreatitis), Stones (nephrolithiasis), and Psychic overtones (anxiety, depression, irritability and sleep disturbances).”
(2) CVS: Hypertension and arrhythmias (short QT).
(3) UT: polyuria, polydipsia, and nephrocalcinosis with renal failure.
(4) GI: anorexia, weight loss, constipation, nausea/vomiting, thirst, abdominal pain.
(5) NS: Neuromuscular weakness, psychosis, or mental disturbances. - Lab tests: Serum Ca > 10.5 mg/dL and PO4 < 2.5 mg/dL with elevated PTH can be diagnostic.
Differential diagnosis High oral Ca-intake, secondary hyper-PTD, tertiary hyper-PTD, sarcoidosis, MEN syndrome, etc.
Q5-A 5-year-old boy is seen for routine examination by his doctor, but his parents have stated that lately he becomes short of breath while playing with his friends, and has a bluish hue to his lips when coming back from playing. The boy’s teacher also says he finds the boy squatting while playing outside during recess. Which of the following is the most likely diagnosis?
A-Atrial septal defect B-Patent foramen ovale C-Hypertrophic obstructive cardiomyopathy D-Tetralogy of Fallot E-Restrictive cardiomyopathy
Ans: D. The history of exercise intolerance and squatting while playing outside (tet spells) is pathognomonic for tetralogy of Fallot. The remainder of choices do not present with tet spells such as squatting during exertion.
Q6-A case of pleural effusion, pleural tapping done and fluid sent for evaluation. report comes a s Protein level less than 50 percent of serum level and LDH level less than 60 percent of serum level. What would be the most probable diagnosis?
A-Cancer
B-Infection
C-Congestive heart failure
D-None of above
Ans: C. it’s a classical description of Transudate.seen in CHF.
Exudate - Transudate
Cancer and infection - Congestive heart failure
Protein level high(>50% of serum level) - Protein level low(<50% of serum level)
LDH level High(>60% of serum level) - LDH level low(<60% of serum level)
Q7-The best indicator of obesity related health risks can be obtained by
A-Measuring hip circumference B-Measuring BMI C-Measuring waist circumference D-Measuring waist circumference and BMI E-Measuring size of adipose cells
Ans: D
Q8- A 65 y/o man presents with urinary hesitancy, intermittent stream, and terminal dribbling and retention for the past 2 months. He smoked for 5 years before stopping 10 years ago. DRE (digital rectal exam) reveals a smoothly enlarged mass on the front wall without tenderness. Urine analysis shows protein (1+). What’s the best next step?
A-Ultrasound-guided biopsy of the mass B-PSA testing C-Terazosin D-Tamsulosin E-Finasteride F-Surgical resection
Ans: D.This is most likely moderate BPH, best treated with a new alpha-R blocker (tamsulosin) with high selectivity and least S/E. Terazosin is old and has more S/E. Finasteride (5-alpha-reductase Inh) is also effective in reducing blood flow and obstruction. Milder cases can be best managed by watchful waiting for shrinkage. Prostectomy is indicated after the above medications fail to alleviate symptoms. ‘A and B’ are indicated when prostate cancer is suspected.
Q9-You are told by your registrar that a 66-year-old woman from a residential home has been admitted with a right mid-zone community-acquired pneumonia. She is very drowsy and her CURB-65 score is 4. On admission, the patient’s oxygen saturations are 91–92 per cent on room air, respiratory rate of 20,and temperature of 37.7°C, PO2 7.1 kPa and PCO2 4.7 kPa. Her oxygen saturations have improved to 95 per cent on 15 L O2 via a non-rebreather oxygen mask. From the list below, which is the most appropriate management plan for this patient?
A-Oral antibiotics and alert the ITU SpR
B-Intravenous antibiotics and transfer to respiratory ward
C-Intravenous antibiotics and alert the ITU SpR
D-Oral antibiotics and transfer to the respiratory ward
E-Alert ITU SpR
Ans: C. This patient has a CURB-65 score of 4. The BTS guidelines state that aCURB-65 score between 3 and 5 indicates severe pneumonia and requires
hospitalization with the possibility of escalation to ITU. In this question,the patient has developed a secondary type-1 respiratory failure. Despitehaving 15 L of oxygen, her oxygen saturations have not vastly improved.This patient will therefore require review by the ITU team with thepossibility of mechanical ventilation. In addition, severe pneumoniae arenot usually treated with oral antibiotics; intravenous antibiotics areindicated due to quicker onset of action.
Q10- A 65 y/o man presents with status epilepticus after progressive headache for the past 3 months. He has years of history of smoking, alcohol drinking, and 3-4 hour’s daily use of cellular phone. P/E shows that his vital signs are about normal, his muscles are tender, and urine is dark. The best next step is to perform
A-ECG B-CT scan of the head C-Serum CPK test D-Urine myoglobin test E-Dipstick urinalysis
Ans: A. The patient is in status seizure with rhabdomyolysis–myoglobinuria most likely induced by an intracranial tumor. ECG is the best initial step here to detect the life-threatening hyperkalemia. Other options all need to be performed to confirm the diagnosis but hyperkalemia is a riskier and more urgent issue in this patient
Q11-60- year male Patient with Known case of BPH (Beingn Prostatic Hypertrophy) stable on medications. On examination prostate was smooth with no nodularity, He asked for PSA screening. What will you till him?
(PSA=Prostate Specific Antigen)
A-No need for PSA
B-Explain pros and cons of PSA
C-Order other advanced Investigations (biopsy)
D-Abdominal ultrasound
Ans: B as patient wish
Q12-You see a 57-year-old man who has been diagnosed with hepatocellular carcinoma (HCC). You are asked about risk factors in HCC by your consultant. Which of the following is not a known predisposing factor for developing hepatocellular carcinoma?
A-Hepatitis B virus B-Liver cirrhosis C-Hepatitis C virus D-Hepatitis A virus E-Aflatoxin
Ans: D Chronic Hepatitis B (A) and C (C) infections, liver cirrhosis (B) and aflatoxin (E) (a carcinogen from the mould Aspergillus flavus) are all known
Predisposing factors for developing hepatocellular carcinoma. Chronic inflammatory changes results in hepatocyte damage and mutation in the
cellular reparation machinery. Hepatitis A (D) does not usually lead tochronic infection and thus is not deemed to be a predisposing factor tohepatocellular carcinoma.
Q13-A 69-year-old man, who is recovering from an emergency laparotomy for a
Ruptured duodenal ulcer develops profuse offensive diarrhoea. His postoperative
Course has been complicated by chest infections and he has just been stepped downOnto the main wards from the intensive care unit. Stool cultures have revealed C.difficiletoxin. What is the most appropriate treatment?
A-Oral metronidazole B-Intravenous fluids C-Intravenous hydrocortisone D-Oral aciclovir E-Oral co-amoxiclav
Ans: A Clostridium difficilecolitis is a hospital-acquired infection that is caused by
the use of broad-spectrum antibiotics. The use of these antibiotics causes eradication of normal gut flora and subsequent colonization of the gut by C.difficile.Patients may present with profuse, offensive diarrhoea. This is treated with a course of oral metronidazole (A). Intravenous fluids (B) maybe required if the diarrhoea has resulted in significant dehydration. However, management with fluids alone does not eradicate the bacteria. Intravenous hydrocortisone (C) is not a treatment for C. difficilecolitis. Oral acyclovir (D) is an anti-viral agent that is not useful in the treatment of C. difficile colitis. Oral co-amoxiclav (E) is a broad-spectrum antibiotic that may result in C. difficile colitis. Therefore, this is the incorrect answer.
Q14-A 28-year-old woman in her 27th week of gestation presents fora routine prenatal visit. She doesn’t have any complaints. Onphysical examination her temperature is 37.2 C (99 F), bloodpressure is 120/80 mm Hg, and heart rate is 87 bpm. The patientis asked to ingest 50 mg of glucose and have her blood glucose
Checked in one hour; it returns as 145 mg/dL.
Which of the following is the best next step in the managementof this patient?
A-Treat with insulin
B-Treat with sulfonylurea
C-Do a fasting blood glucose level
D-Perform oral glucose tolerance test
Ans: D. An oral glucose tolerance test should be done after a positive glucose load test (described in the question). Fasting blood glucose is not used to diagnose gestational diabetes. Treatment with insulin is premature without a diagnosis of gestational diabetes. Sulfonylurea has been used, but it does not have better pregnancy outcomes than insulin.
Q15-A 69-year-old man presents with confusion. His wife reports he has become
Increasingly depressed and confused in the last month. Prior to this, he had been
Complaining of pain in his right arm and abdomen but he refused to visit his GP.
The patient has brisk reflexes, reduced skin turgor, sunken eyes and an x-ray of his
Right arm shows lytic lesions. The most appropriate management is:
A-Calcitonin B-Non-steroidal anti-inflammatory drugs (NSAIDs) C-Intravenous bisphosphonates D-Stem cell transplant E-Intravenous saline
Ans: E. This patient is most likely suffering from hypercalcaemia due to an underlying condition of untreated multiple myeloma. Patients therefore suffer from symptoms that include dehydration, depression, bone and abdominal pain and increased risk of renal stones. Although the underlying disease is multiple myeloma, the patient must first be stabilized against the effects of hypercalcaemia. Intravenous saline (E) over several days stabilizes the patient and replaces any lost fluid volume. Calcitonin (A) has a short duration of action and is not particularly effective in lowering calcium levels and would not help with the patient’s fluid loss. Intravenous bisphosphonates (C) are appropriate once the patient has been stabilized and is not dehydrated, especially important in a patient with myeloma to stem the excess serum calcium levels. Stem cell transplantation (D) would be aimed at trying to improve the patient’s prognosis but would not be suitable or safe in an unstable patient. NSAIDs (B) would be helpful in alleviating the patient’s pain, however, due to the production of Bence–Jones proteins they should be avoided as they might precipitate renal failure.
