GB Flashcards
A 40-year-old man with a history of recurrent painful attacks affecting the right big toe, was diagnosed with gout and started on allopurinol. He is also a known case of psoriasis for several years. He presented to the clinic with recurrent joint pain affecting the right big toe, left ankle, and bilateral knees. He is using allopurinol regularly as prescribed but has no improvement in his joint pain. Examinations revealed he has active arthritis at the left ankle and knee joints bilaterally (see lab results). Which of the following is the most likely cause for his joint pain?
A. Active pseudogout arthritis.
B. Active gout arthritis.
C. Psoriatic arthritis.
D. Osteoarthritis.
C. Psoriatic arthritis.
A 28-year-old woman with systemic lupus erythematosus for 2 years on hydroxychloroquine 200 mg/day, prednisone 5 mg/day, and azathioprine 100 mg/day presented to the Emergency Room with sudden onset of lower limb weakness and urinary incontinence. Examination revealed she has paraplegia and hyperreflexia (see lab results). Which of the following is the most appropriate test to be done immediately?
A. Lumbar puncture, MRI brain
B. Lumbar puncture, CT brain
C. Lumbar puncture, MRI spinal cord
D. Lumbar puncture, MRI, MRA, and MRV of the brain
C. Lumbar puncture, MRI spinal cord
A 50-year-old man is complaining of pain affecting the wrist joints bilaterally, second and third proximal interphalangeal joints, and right knee joint for the last 4 months. His examination revealed active arthritis at both wrists and second and third proximal interphalangeal joints (see lab results). Which of the following is the most appropriate treatment?
A. Methotrexate
B. Methotrexate and sulfasalazine
C. Methotrexate and hydroxychloroquine
D. Methotrexate, hydroxychloroquine, and prednisone
D. Methotrexate, hydroxychloroquine, and prednisone
A 30-year-old woman with systemic lupus erythematosus is evaluated for right hip pain that started 3 weeks ago and occurs at night and with walking. Her current medications are azathioprine, hydroxychloroquine, prednisolone, and lisinopril for the last 5 years. Her examination was normal except for pain on internal rotation of the right hip. Laboratory tests including pelvic and left hip radiographs were normal. Which of the following is the most likely cause of hip pain?
A. Active lupus arthritis
B. Septic arthritis affecting right hip
C. Avascular necrosis affecting right hip
D. Degenerative changes affecting right hip
C. Avascular necrosis affecting right hip
A 60-year-old man complaining of right knee pain for several years that has increased over the last few months. He also has noticed frequent knee clicks. A diagnosis of osteoarthritis is suspected. Which of the following is the most appropriate to confirm the diagnosis?
A. Bilateral knee X-rays.
B. MRI of the right knee.
C. No further investigation.
D. Arthroscopy for the right knee.
C. No further investigation.
A 52-year-old man with rheumatoid arthritis for 12 years. His current treatment consists of methotrexate 15 mg weekly and adalimumab 40 mg/2 weeks. He presented to the clinic complaining of fever and shortness of breath for 1 week. His chest examination revealed coarse crackles over the lower part of the right lung (see lab results). Which of the following is the most appropriate action to be taken on this visit?
A. Hold adalimumab and start antibiotics
B. Hold methotrexate and start antibiotics
C. Hold his current treatment and start antibiotics
D. Continue his current treatment and start antibiotics
C. Hold his current treatment and start antibiotics
A 30-year-old man presented to the Emergency Department with an acute monoarthritis where joint aspiration was performed. Based on the presence of crystals in the synovial fluid, he was diagnosed with gout. Which of the following is the most likely type of the crystals seen?
A. Needle-shaped, negatively birefringent
B. Needle-shaped, weakly positively birefringent
C. Rhomboidal-shaped, negatively birefringent
D. Rhomboidal-shaped, weakly positively birefringent
A. Needle-shaped, negatively birefringent
A 30-year-old woman with a diagnosis of systemic lupus erythematosus who was maintained on mycophenolate mofetil 1 gm/day, hydroxychloroquine 200 mg/day, and prednisone 5 mg/day for the last 1 year. She has had inactive disease for more than 6 months. She is planning to get pregnant (see lab results). Which of the following is the most appropriate action at this time?
A. Discontinue prednisone and start cyclosporine
B. Discontinue hydroxychloroquine and start quinacrine
C. Discontinue mycophenolate mofetil and start azathioprine
D. Discontinue mycophenolate mofetil and start methotrexate
C. Discontinue mycophenolate mofetil and start azathioprine
A 61-year-old woman is evaluated for a left pulmonary nodule that was discovered incidentally 2 months ago. She is currently asymptomatic and has not had shortness of breath, fever, chills, weight loss, or night sweats. Medical history is otherwise unremarkable, and she takes no medications. She never smoked. Examination revealed no cervical or supraclavicular lymphadenopathy, and the lungs are clear to auscultation (see report). CT scan chest: Showed an 8 mm left lung nodule. Which of the following is the most appropriate next step in management?
A. PET/CT scan
B. Bronchoalveolar lavage
C. Transthoracic lung biopsy
D. Observation and regular follow-up
D. Observation and regular follow-up
A 63-year-old woman presented with exertional dyspnea for 8 months. She was diagnosed with COPD 3 years ago and has had 4 exacerbations in the last year. She completed pulmonary rehabilitation and quit smoking 2 years ago. Medications include long -acting B2 agonist, inhaled glucocorticoid, roflumilast, and albuterol as needed. Examination revealed no jugular venous distention; decreased breath sounds, a loud pulmonary component of S1 (see lab results and reports). Chest radiograph: Normal. Echocardiogram: Ejection fraction of 60%, no valvular or wall motion abnormalities, and estimated mean pulmonary artery pressure is 55 mmHg. Which of the following is the most appropriate treatment?
A. Daily prednisone
B. Long-term oxygen therapy
C. Overnight pulse oximetry
D. Repeat pulmonary rehabilitation
B. Long-term oxygen therapy
A 58-year-old woman presented to the medical clinic complaining of daily wheezing and breathlessness during allergy season. These episodes of wheezing have limited her activities several times a week. She has a long history of seasonal allergies in the form of itchy eyes and runny nose. No other medical history. Medications include loratadine as needed, and antihistamine eye drops. Examination revealed watery eyes with conjunctival irritation, expiratory wheezing, and normal cardiac examination (see reports). Chest radiograph: Unremarkable. Spirometry: FEV1 of 74% of predicted, which improved by 18% with a bronchodilator. Which of the following is the most appropriate treatment?
A. Add a leukotriene antagonist
B. Add a low-dose inhaled glucocorticoid
C. Recommend daily oral antihistamine use
D. Add a low-dose inhaled glucocorticoid and long-acting B2 agonist
D. Add a low-dose inhaled glucocorticoid and long-acting B2 agonist
A 71-year-old man is evaluated after a recent hospitalization 10 days ago for pneumonia and was discharged with a 10-day course of appropriate antibiotics. For the past 5 days, he has had a low-grade fever and increased shortness of breath. Pulmonary examination reveals decreased fremitus, dullness to percussion, and decreased breath sounds over the lower third of the right hemithorax (see lab results and report). Chest radiograph: Moderate right-sided pleural effusion. Which of the following is the most appropriate management?
A. Ceftriaxone and azithromycin
B. Chest tube and levofloxacin
C. Repeat chest radiograph in 2 weeks
D. Small-bore pleural drain and piperacillin-tazobactam
D. Small-bore pleural drain and piperacillin-tazobactam
A 20-year-old man is evaluated for a 6-month history of chest and throat tightness, acute episodes of stridor, and a prolonged wheeze that occur during his college basketball practice. He has a history of moderate persistent asthma, which is controlled. He takes a short-acting B2 agonist inhaler as needed, but this does not relieve his symptoms. In addition to a low-dose inhaled glucocorticoid and a long-acting inhaled B2 agonist, he otherwise feels well. Medical history is otherwise unremarkable. Examination reveals normal vital signs and unremarkable systemic examination (see reports). Chest radiograph: Normal. Spirometry: No evidence of obstruction. Which of the following is the most appropriate next step in management?
A. Echocardiography
B. Allergen immunotherapy
C. Otolaryngology evaluation
D. Switch to a medium-dose inhaled glucocorticoid
C. Otolaryngology evaluation
A 33-year-old man presented with shortness of breath, fatigue, and nighttime cough. He has been working in a car repair shop for the past 1 year and notes that his symptoms began about 8 months ago. He believes his symptoms are associated with his workdays. He is being evaluated after several days off from work and currently has no symptoms or medical concerns. He has an unremarkable medical history and takes no medications. He has never smoked. Physical examination is unremarkable. A chest radiograph and spirometry results are normal. Which of the following is the most appropriate next step in management?
A. High-resolution chest CT
B. Inhaled glucocorticoid daily
C. Advise him to switch employment
D. Repeat spirometry after workplace exposure
D. Repeat spirometry after workplace exposure
A 49-year-old woman is evaluated for a 4-month history of dry cough, which began 4 months ago when she noted a paroxysmal onset of persistent coughing spells that make it difficult to carry on a conversation. She was initially diagnosed with allergic rhinitis and was started on a glucocorticoid nasal inhaler with no improvement. Medical history is otherwise unremarkable except for a history of dust allergies. Examination revealed normal vital signs, slight nasal congestion, and dry cough are noted during the examination. Cardiovascular, pulmonary, and abdominal examination findings are unremarkable (see reports). Chest radiograph: Normal. Spirometry: Slightly reduced FEV/FVC ratio of 70% which increased after bronchodilator challenge by 20%. Which of the following is the most appropriate diagnostic test to perform next?
A. Allergy skin testing
B. High-resolution chest CT
C. Measurement of serum IgE levels
D. Methacholine challenge testing
D. Methacholine challenge testing
A 57-year-old man is evaluated for chronic cough, occasional wheezing, and exertional dyspnea while walking. Medical history includes an episode of bronchitis, for which he underwent outpatient treatment 8 months ago. He has a 20-pack-year smoking history. Examination revealed normal vital signs, mildly decreased breath sounds throughout both lungs, and scattered expiratory wheezes bilaterally. Spirometry shows an FEV1 of 75% of predicted and a post-bronchodilator FEV/FVC ratio of 68%. His modified Medical Research Council (mMRC) symptom score is 2. In addition to smoking cessation, which of the following is the most appropriate long -term management plan?
A. Combination inhaled glucocorticoid and a long-acting bronchodilator
B. Phosphodiesterase-4 inhibitor and combination inhaled glucocorticoid and long-acting bronchodilator
C. Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation
D. Short-acting bronchodilator as needed and an inhaled glucocorticoid
C. Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation
A 42-year-old woman presented to the clinic for follow-up of a 7-month history of chronic, nonproductive cough. She was recently diagnosed with cough-variant asthma after a methacholine challenge test. She was started on inhaled fluticasone and as-needed albuterol 2 months ago. Her cough initially improved; however, her symptoms have not fully resolved and are worsened at times, most notably when she lies down. She also noted that mild hoarseness
occasionally accompanies her cough, especially when she wakes up in the morning. Examination revealed a dry cough with frequent throat clearing. The chest was clear with no wheezing. Which of the following is the most appropriate management?
A. Add a long-acting B2-agonist
B. Add a proton pump inhibitor
C. Start nocturnal antitussive therapy
D. Repeat methacholine challenge testing
B. Add a proton pump inhibitor
A 17-year-old man presented to the Emergency Department with severe asthma exacerbation that began 12 hours ago. He is on an albuterol inhaler and a long -acting glucocorticoid at home without improvement. He was hospitalized and intubated 2 years ago. Examination revealed respiratory distress with diffuse expiratory wheezes. After 1 hour of systemic glucocorticoid and B2 agonist nebulizer, he still appeared in respiratory distress (see lab results and report). Chest X-ray: Hyperinflated lungs. Which of the following is the most appropriate next step in management?
A. Admit to the ICU
B. Reassure him and discharge home
C. Admit to the general medical floor
D. Discharge home the next day with follow-up
A. Admit to the ICU
A 63-year-old man was evaluated in the Emergency Room for 1 week of progressive shortness of breath and found to have right pleural effusion on chest X-ray. Aspiration yielded a clear transudative fluid. Which of the following is the most likely cause?
A. Pancreatitis
B. Pneumonia
C. Heart failure
D. Malignancy
C. Heart failure
A 24-year-old woman is reviewed in the Asthma Clinic. She currently uses a salbutamol inhaler 100 mcg prn combined with a beclometasone dipropionate inhaler 400 mcg bd. Despite this, she is having frequent exacerbations of her asthma that required frequent courses of prednisolone and hospitalization three times in the last 6 months. What is the most appropriate next step in management?
A. Switch beclometasone to fluticasone
B. Start to take the salbutamol regularly
C. Add long-acting B2 agonist (Salmeterol)
D. Add long-acting anticholinergic bronchodilator (Tiotropium)
C. Add long-acting B2 agonist (Salmeterol)
A 63-year-old woman is in the COPD clinic for frequent exacerbations, despite being maintained on a salbutamol inhaler as required and a tiotropium inhaler regularly. She was diagnosed with COPD three years ago and recently quit smoking. Her latest FEV1 was 39% of predicted. Which of the following is the most appropriate next step in her management?
A. Salmeterol inhaler
B. Betamethasone inhaler
C. Long-term oxygen therapy
D. Combined salmeterol + fluticasone inhaler
D. Combined salmeterol + fluticasone inhaler
A 69-year-old smoker presents with a 3-week history of worsening breathlessness. Examination revealed normal vital signs and decreased breathing sounds over the lower left zone (see reports). Chest X-ray: Large left-sided pleural effusion. Pleural tapping: Pending result. Which of the following will most likely indicate that it is an exudative effusion?
A. Pleural fluid LDH / Serum LDH < 0.6
B. Pleural fluid protein / Serum protein < 0.5
C. Effusion LDH level greater than 1/3rd the upper limit of serum LDH
D. Effusion LDH level greater than 2/3rds the upper limit of serum LDH
D. Effusion LDH level greater than 2/3rds the upper limit of serum LDH
A 33-year-old man with a history of severe asthma is admitted to the Emergency Department with an asthma attack. He received high-flow oxygen and nebulized salbutamol. He is unable to complete sentences, has bilateral expiratory wheeze, and is unable to perform a peak flow reading. He was immediately given intravenous hydrocortisone and nebulized salbutamol continuously. After 10 minutes, there is no improvement, and intravenous magnesium sulfate was given. His condition continues to deteriorate (see lab results). Which of the following is the most appropriate management?
A. Non-invasive ventilation
B. Add intravenous aminophylline
C. Add nebulized ipratropium bromide
D. Intubation and mechanical ventilation
D. Intubation and mechanical ventilation