IM Flashcards by Giselle Celine Cerrillo

For the past 2 weeks, your 55 year old uncle had BP in the range of 130-138 mmHg systolic /
82-86 mmHg diastolic. His height is 160 cm and weight is 55 kg. His waist circumference is 32
inches.

His blood chemistry is as follows: FBS 114 mg/dl, cholesterol 190 mg/dl, HDL 32 mg/dl, LDL 99
mg/dl, triglycerides 130 mg/dl.

What advice will you give him?
A. Undergo aerobic exercises 150 minutes per week
B. Increase his weight since he has a low BMI
C. Limit salt intake to less than 2 g/day
D. Drink a maximum of 2 bottles of beer per week

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Which of the following health interventions has the greatest impact on reducing morbidity and
mortality?
A. Control of blood pressure to less than 140/90 mmHg
B. Achieving HbA1c less than 7%
C. Maintaining BMI less than 24
D. Targeting LDL below 70 mg/dl

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Which of the following, when clustered with Type 2 diabetes, increases an individual’s risk for
cardiovascular disease?
A. Fasting triglcerides of 140 mg/dl
B. BP of 130/90
C. HDL cholesterol of 55 mg/dl in a female patient
D. Waist circumference of 70 cm in a male patient

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Mang Tonio, a 60 year old tricycle driver, consults for sudden onset shortness of breath
associated with severe epigastric pain and cold swears. He has been having intermittent attacks
of mild chest discomfort especially when climbing stairs and after eating since 2 weeks ago. He is
a diabetic with poor compliance to medications. He is also a smoker, but does not drink alcohol.
On PE, BP is 110/80, HR 86/min, 18 RR, BMI 28. The rest of the PE is normal.

What test would you order to confirm your diagnosis?
A. EGD
B. Chest x-ray
C. Exercise stress test
D. 12-L ECG

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Mang Tonio’s ECG shows:
Acute STEMI ECG
What is your diagnosis?
A. Acute myocardial infarction
B. Costochondritis
C. Acute pericarditis
D. Atrial fibrillation

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Mang Tonio says that the physician at the health center gave him a table that relieved his
chest pain. He cannot recall the name of the drug but remembers that he developed a headache
after taking this medication. What best describes the mode of action of this drug?
A. It decreases myocardial oxygen demand
B. It dilates the coronary arteries
C. It inhibits the conversion of angiotensin I to angiotensin II
D. It inhibits thromboxane synthesis by platelets

The medication is probably sublingual nitrates, a potent vasodilator.

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After 1 month of taking his medications, Mang Tonio reports that although he noted
improvement in his symptoms, he still occasionally experiences chest pain. On PE, BP 140/90,
HR 80/min regular. You review his medications and increase the dosage of which of the following:
A. Metoprolol
B. Simvastatin
C. Ramipril
D. Clopidogrel

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Ben, a 55 year old jeepney driver, complains of easy fatigue and dyspnea on exertion. He is a
chronic smoker and a heavy alcohol drinker. Which of the following would make you consider a
right-sided heart failure in this patient?
A. Crackles
B. Displaced apex beat
C. Fluid wave
D. S3 gallop

C
Left-sided heart failure involves signs of pulmonary congestion such as crackles, rales, and
wheezing, as well as left ventricular dysfunction or remodeling, as in a displaced apex beat or S3
gallop. Right-sided heart failure signs include a heightened JVP, ascites, edema, and other signs
of portal hypertension, among others.

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Which of the following drugs belongs to the class of medication that has been shown to relieve
symptoms of heart failure in a patient with depressed ejection fraction, reverse cardiac
remodeling, prevent hospitalization, and prolong life?
A. Atorvastatin
B. Digoxin
C. Captopril
D. Furosemide

C – ACE inhibitors is the drug class the question is talking about

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Chest pain that presents as a severe “ripping” and “tearing” pain or a sudden severe sharp
pain in the front of the chest that extends into the back, between the shoulder blades, can be
correctly diagnosed by what test?
A. Electrocardiogram
B. Chest computed tomography
C. Esophageal manometry
D. Creatine kinase MB isoform

B
The described chest pain pertains to aortic dissection, which can be correctly diagnosed by CT
scan.

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Aling Sonia, 74/F, consults at the OPD for swelling in her legs and feet. She says that this is
absent when she wakes up in the morning and is most noticeable late in the day. She uses 3
pillows behind her head when she sleeps and would often wake up at night with a sense of
drowning. Which of the following signs would you expected to find on PE?
A. Elevated JVP
B. Weak dorsalis pedis pulses
C. Pallor
D. Pursed lip breathing

A
The edema, 3-pillow orthopnea, and paroxysmal nocturnal dyspnea all point to CHF. B can be
expected in peripheral arterial occlusive disease, although severe pedal edema can also make it
difficult to appreciate dorsalis pedis pulses. Pallor may be seen in CKD and other chronic
diseases. Pursed lip breathing is usually associated with COPD.

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This is Aling Sonia’s chest x-ray. Which cardiac chamber is enlarged?

A. Right ventricle
B. Right atrium
C. Left atrium
D. Left ventricle

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Who among the following has a risk factor for diabetes that warrants early screening?
A. Carla, 32, with a waist circumference of 70 cm
B. Alan, 40, with a BMI of 28
C. Mark, 38, with an HDL cholesterol of 55
D. Donna, 29, whose first cousin has diabetes

B
Cut-off for DM screening is a waist circumference of >102 cm in males and >80 cm in females,
BMI > 25, HDL

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Linda, a 45 year old executive, consults you for a random blood sugar of 230 mg/dl. A
diagnostic center near her office offered discounted rates for lab tests so she had her blood sugar
tested. You will diagnose Linda with diabetes if she also presents with which of the following
symptoms?
A. Polyuria, polydipsia, and weight loss
B. Polyuria, polydipsia, and blurring of vision
C. Polyuria, polydipsia, and polyphagia
D. Polyuria, polydipsia, and parasthesia

A – blurring of vision and parasthesia are signs of end-organ damage and are late
complications of DM. According to our resident monitor, polyphagia is no longer strongly
associated with DM, at least compared to weight loss

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On review of systems, you elicit that Linda complains of tingling sensation on her hands and
feet. What is the most common pattern for diabetic neuropathy?
A. Distal sensorimotor polyneuropathy
B. Segmental sensorimotor polyneuropathy
C. Proximal motor polyneuropathy
D. Multifocal neuropathy with autonomic involvement

A – the so-called “glove and stocking” distribution of diabetic neuropathy

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You diagnose Linda with type 2 DM. She is overweight and has mild to moderate
hyperglycemia. The drug of choice is
A. Insulin
B. Metformin
C. Sitagliptin
D. Acarbose

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Treatment goals for Linda include the following EXCEPT

A. HbA1c 50 mg/dl

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A 54/F consults your clinic for depression, constipation, memory loss, and fatigue. She
reports having received treatment for hyperthyroidism in the past but she could not recall the
details. There was no goiter and there was no neck scar. She had a rounded face. Her speech was slow and her voice was low-pitched. You noted a slow return phase of her deep tendon
reflexes. What results do you expect to find on her thyroid function tests?
A. Elevated FT4, elevated TSH
B. Low FT4, low TSH
C. Elevated FT4, low TSH
D. Low FT4, elevated TSH

D – she now has hypothyroidism

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Ana, a 32 year old housewife, consults at the OPD for palpitations. She claims to have lost
weight over the past few months despite an increased appetite. PE revealed HR of 110/min,
irregularly irregular rhythm. Her thyroid scan show this:

How will you manage this patient?
A. Refer to ENT for FNAB
B. Start glucocorticoid therapy
C. Start anti-thyroid medication
D. Start thyroid hormone replacement therapy

C
The scan shows a diffusely “hot” or active thyroid, pointing to a hyperthyroid condition, probably
Grave’s disease

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You prescribe Ana with medications and advice follow-up in 4 weeks. Which lab test would
you request to monitor her response to treatment?
A. Free T3
B. Repeat thyroid scan
C. TSH
D. Free T4

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Ana returns to the OPD complaining of epigastric pain. She reports improvement in her
symptoms after 1 month intake of propylthiouracil and propranolol. She also admits to selfmedicating
with multivitamins and ferrous sulfate upon the advice of her neighbor. You tell Ana
that her new symptoms may possible be from an adverse effect of which medication?
A. Ferrous sulfate
B. Propranolol
C. Multivitamins
D. PTU

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Ariel, 50/M, consults at the OPD for parasthesias 1 week after undergoing thyroidectomy for
thyroid CA. You lightly tapped on the right side of his face and note this:
What is the explanation for this finding?
A. Beginning hypothyroidism
B. Low parathyroid hormone level
C. Persistent hyperthyroidism
D. Recurrent laryngeal nerve injury

B
This is the Chvostek sign, indicative of hypocalcemia. This may be secondary to inadvertent
removal of the parathyroids during thyroidectomy.

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Amy, a 19 year old college student, consults the OPD for chest tightness. She was diagnosed
with bronchial asthma when she was 8 years old but was lost to follow-up because her symptoms
occurred only a few times a year. In the last 3 months, she began to experience more frequent
attacks of shortness of breath and cough. She now notes chest tightness and wheezing at least
once a day, relieved by salbutamol inhaler, but denies any night symptoms. What would be your
next step in management?
A. Leukotriene antagonists
B. Inhaled glucocorticoids
C. Long-acting beta-agonists
D. Oral corticosteroids

B – we need to give her controller meds in addition to her reliever meds

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Which of the following is an effect of beta-adrenergic agonists on airways?
A. Control of inflammation over time
B. Contraction of airway smooth muscle
C. Decreased mucociliary clearance
D. Inhibition of mast cell mediator release

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65/M consults for a 1 month history of persistent productive cough, occasionally with bloodtinged sputum, but no fever. He has lost his appetite and noticed his pants becoming loose around the waist. He also complains of exertional dyspnea. He has been smoking 1-2 packs of cigarettes a day for the last 40 years. On PE, patient is cachectic with note of decreased breath sounds on all lung fields and occasional wheezes. Which of the following is the LEAST likely diagnosis? A. Lung cancer B. Pneumonia C. Emphysema D. Tuberculosis

B TB and lung cancer can explain the symptoms, especially weight loss. Smoking is also a risk factor for lung cancer. Emphysema can occur secondary to COPD, which the patient possibly has because of the symptoms and the history of smoking.

Which of the following interventions is proven to reduce mortality in patients with COPD? A. Leukotriene receptor antagonists B. Inhaled LABA + corticosteroid combination C. Systemic corticosteroids D. Oxygen

``` What diagnosis should you consider when you see the following PE finding in patients with COPD? A. Cor pulmonale B. Lung cancer C. TB D. Reactive erythrocytosis ```

A 75/F with diabetes has had cough and fever for the past 3 years. On PE: HR 84, RR 22, BP 120/70, T 38.1 C. You hear crackles on the right lower lung field. What would be your choice of antibiotic treatment based on the 2010 Philippine Guidelines on the Management of Community- Acquired Pneumonia in Immunocompetent Adults? A. Claithromycin B. Cefuroxime C. Levofloxacin D. Amoxicllin

B Actually given her age and concomitant DM, she may be considered immunocompromised, necessitating the use of a cephalosporin.

``` Which of the following would you expect to find in sputum microscopy? A. Legionella pneumophilia B. S. aureus C. Pseudomonas aeruginosa D. Enteric gram-negative bacilli ```

``` Identify the organism in the sputum gram stain below: A. H. influenza B. M. tuberculosis C. P. aeruginosa D. S. pneumonia ```

D – these are gram-positive diplococci

Which of the following statements is TRUE about the treatment of pulmonary TB? A. It is important that the patient is compliant with all his medications during the first 2 months in order to prevent relapse B. The treatment regimen of choice for PTB consists of a 4 month intensive phase and 2 month continuation phase C. Cough that persists until 5 months of treatment in a patient adherent to medications is indicative of treatment failure D. Fixed dose combinations of anti-TB drugs improves compliance

A 35/M being treated for PTB develops cute pain on the 1st metatarsophalangeal joint. You noted erythema, swelling, and tenderness. Which of the following drugs is responsible for this event? A. Isoniazid B. Pyrazinamide C. Rifampicin D. Ethambutol

``` Which of the following drug and adverse effect pairs are CORRECTLY matched? A. Pyrazinamide: jaundice B. Isoniazid: Vitamin B1 depletion C. Rifampicin: color blindness D. Streptomycin: arthritis ```

A 25/F consults at the OPD for a 3 month history of non-productive cough, with weight loss, night sweats, and fatigue. She does not smoke. Chest examination is normal. What would be your first step in the management of this patient? A. Start treatment with a 1 week course of antibiotic B. Refer for bronchoscopy C. Send sputum for microscopy D. Therapeutic trial with antihistamine-decongestant combination

``` In what phase of pneumonia is there predominance of neutrophils and deposition of fibrin? A. Resolution B. Red hepatization C. Edema D. Grey hepatization ```

Which of the following is TRUE regarding atypical pathogens in pneumonia? A. They are difficult to grow on standard culture media B. They are generally susceptible to beta-lactam antibiotics C. They are generally resistant to macrolides D. They are easily visualized on gram stain

The following are criteria of a good screening test in healthy adults EXCEPT A. The burden of illness is high B. The screening strategy is safe and cost-effective C. Early treatment is more effective than late treatment D. Prognosis of the disease being screened, if missed, is poor

``` This 55 year old laundrywoman consults you for weight gain. She says that her pants have gotten tighter around the waist. What is your primary diagnosis? A. Hypothyroidism B. Cushing’s syndrome C. Nephrotic syndrome D. Polycystic ovary syndrome ```

B – the classic moon facies of Cushing’s is evident here

20/M known to have asthma since childhood, consults for recent weight gain. He is taking various oral and inhaled medications to control his asthma. On PE, his abdomen appeared like this: Which one of his medications most likely caused this finding? A. Oral montelukast B. Inhaled salmeterol C. Oral prednisone D. Inhaled budesonide

C – These violaceous striae are indicative of Cushing’s, most likely due to his intake of steroids.

A 24/F consults at the OPD for left-sided chest pain, which is more apparent when she inhaled deeply. She has no other illnesses, is a non-smoker, and has no family history of heart disease. PE reveals an area of point tenderness on the 4th rib along the LMCL. There was no erythema or warmth of the overlying skin. What is the most likely diagnosis? A. Costochondritis B. Herpes zoster C. Myofascial pain syndrome D. Angina pectoris

A 35/M complains of retrosternal chest pain that usually manifests when he lies down after a heavy meal. This is usually accompanied by a sour taste in the mouth. The pain is not worsened by effort nor by coughing. What treatment will you prescribe? A. Omeprazole B. Ibuprofen C. Isosorbide dintrate D. Aspirin

A – the symptoms point to GERD, which is treated by PPIs | 42)

In which of the following patients would you consider treatment for Hepatitis B infection? A. 35 year old nurse who is anti-HBs reactive, anti-HBe reactive, with ALT that is 1.5x the upper limit of normal B. 45 year old executive who is HBsAg negative, anti-HBc reactive, with ALT 4x the upper limit of normal C. 28 year old seaman who is HBsAg negative, HBeAg negative, with ALT 3x the upper limit of normal D. 33 year old lab technician who is HBsAg reactive, HBeAg reactive, with ALT 3x the upper limit of normal

D (+) HBsAg indicates an acute infection. (+) HBeAg means that he is infective. When combined with his sensitive work as a lab technician, handling blood samples etc., we should treat him.

28/M seaman came to your clinic to have the results of his hepatitis profile interpreted as part of preemployment check-up. PE is unremarkable. His results are positive anti-HAV IgG, reactive Anti-HBs IgG, negative anti-HBc, and negative anti-HCV. How would you interpret these results? A. Acute hepatitis A and past hepatitis C B. Acute hepatitis A and chronic hepatitis B C. Past hepatitis A and chronic hepatitis B D. Past hepatitis A and vaccinated against hepatitis B

D A is false because hep B is an inactivated vaccine. B is false because you also administer the full series of 3 doses of hep B vaccine as part of post-exposure prophylaxis.

A 52 year old business man consults for persistent abdominal discomfort described as an aching sensation usually on the epigastric area that often worsens after meals. The pain would sometimes wake him up at night. He mentioned that he has been having black stools the past 3 days. You note slight pallor and direct epigastric tenderness on PE. What would be the next step in your management of this patient? A. Order an abdominal CT scan with triple contrast B. Refer for esophagogastroduodenoscopy C. Check for fecal occult blood D. Start therapeutic trial with omeprazole

B | To confirm the diagnosis of PUD (peptic ulcer disease)

You took home some fried rice which was leftover during a dinner party held in a Chinese restaurant. You ate this for breakfast the next morning together with fried egg and hotdog. By 11 AM you experienced vomiting and abdominal pain. What is the most probably pathogen? A. Non-typhoidal Salmonella B. Shigella dysenteriae C. Bacillus cereus D. Vibrio cholerae

A 40/M consulted you for jaundice. You noted that the sclerae were yellowish. The abdomen was flat and nontender. There was no Murphy’s sign. Lab tests revealed high total bilirubin, normal direct bilirubin, high indirect bilirubin, and normal alkaline phosphatase. What is the most probable diagnosis? A. Hypercarotenemia B. Hemolytic anemia C. Periampullary carcinoma D. Choledocholithiasis

B A is ruled out because icteric sclerae indicates real jaundice. C is ruled out because alkaline phosphatase is normal, indicating a non-obstructive lesion. D is less likely because there is no Murphy’s sign.

A 75/M patient consults your clinic for vomiting of previously ingested food associated with bloatedness, flatulence, and weight loss. He also complains of nocturia, dizziness upon getting up from bed, and tingling of the fingers and toes. PE reveals anhidrosis and areas of hyperpigmentation over both lower extremities. Which of the following medications would you prescribe to relieve his symptoms? A. A non-absorbable carbohydrate laxative B. A 5-HT 1 receptor antagonist C. A proton pump inhibitor D. A prokinetic agent

D This patient has DM and shows signs of DM gastropathy (the favorite diagnosis of 1B during the first week of the rotation haha). DM gastropathy results in increased gastric emptying times, leading to vomiting and bloatedness. Prokinetics (ex. domperidone) will hasten gastric emptying and reduce the symptoms

A 57/M consults you for yellow discoloration of his skin. He does not complain of abdominal pain, nausea, or vomiting, but reports that he has lost about 5 kg in the past month. On PE, you note a vague epigastric mass on deep palpation and excoriations on his skin. There is no Murphy’s sign. Which of the following abnormalities do you expect to see on blood chemistry? A. Increased serum albumin B. Elevated indirect bilirubin C. AST/ALT ratio of >2 D. Elevated gamma-glutamyl transferase

D The patient has obstructive jaundice, probably secondary to a periampullary mass. GGT is a more accurate version of alkaline phosphatase, a liver enzyme test that is elevated when obstruction is present

This peripheral blood smear was taken from a patient being worked up for anemia. Which of the following is a possible cause of the anemia? A. Chronic kidney disease B. Pernicious anemia C. Heavy menstrual bleeding D. Folate deficiency

Which of the following is TRUE regarding the lab evaluation of patients with jaundice? A. A normal serum albumin suggests an acute process such as viral hepatitis B. Normalization of a prolonged prothrombin time after IV vitamin K suggests a chronic process such as liver cirrhosis C. A disproportionately high level of liver enzymes compared to alkaline phosphatase suggests a cholestatic process D. A disproportionately high level of alkaline phosphatase compared to liver enzymes suggests a hepatocellular dysfunction

A 65/F with recurrent abdominal pains has been having postprandial vomiting for the past week, occurring within 1 hour of eating. What is the most probably diagnosis? A. Colonic obstruction B. Meckel’s diverticulum C. Ileus D. Pyloric stricture

D | Since the vomiting occurs within an hour of eating, pick the most proximal lesion.

Your 43 year old aunt has sore throat and fever, and self-medicated with clindamycin. After taking this for 2 weeks, she developed bloody diarrhea. The most probably cause for her diarrhea is A. Shigella sp. B. Clostridium difficile C. Cryptosporidium D. Camplyobacter jejuni

B | Clindamycin is notorious for causing C. difficile colitis

A 67/M comes to your clinic for burning epigastric pain that radiates to the retrosternal area, exacerbated by meals and sometimes awakens him from sleep, leaving a sour taste in his mouth. Which of the following signs would warrant further evaluation prior to empiric treatment? A. Early satiety B. Odynophagia C. Bloatedness D. Occasional vomiting

A 19/M student was brought to your clinic for sudden onset abdominal pain which started on the epigastric area and is now localized in the RLQ. Which of the following PE findings suggests a surgical abdomen? A. Hypoactive bowel sounds B. Direct abdominal tenderness C. Rebound tenderness D. Succussion splash

C | This suggests appendicitis, a condition needing surgery

23/F arrives at your clinic with severe RLQ abdominal pain, radiating to the inguinal area with sudden onset. She has dysuria and gross hematuria since yesterday. Her last menstrual period was 4 weeks ago. On PE, she is tachycardic but the abdomen was soft and nontender. What is your diagnosis? A. Urolithiasis B. Ruptured ectopic pregnancy C. Acute appendicitis D. Incarcerated hernia

A A and B are the most likely diagnoses. The clincher is that B would present with an extremely tender abdomen.

A 39/F has been complaining of belching, dyspepsia, and abdominal enlargement. On PE, the abdomen was round with no abdominal striae. It was tympanitic on percussion. There was no fluid wave. No masses were palpable. Which of the following is causing her symptoms? A. Ascites B. Increased intestinal gas C. Fecal impaction D. Ovarian new growth

A 21/M Red Cross volunteer consults you for fever of 1 week duration, sometimes with chills, associated with headache, malaise, and muscle pains. He had just arrived from a relief mission in the flooded areas of Mindanao when symptoms began and remembers having waded in flood water, drank unsterilized water from a stream, and had bitten by mosquitoes. On PE, you note that he had conjunctival suffusion, icteric sclerae, and calf tenderness. What is your primary impression? A. Malaria B. Typhoid fever C. Dengue fever D. Leptospirosis

D (It’s the flood-wading)

Which of the following reasons explains why there is anemia in CKD? A. There is a low production of erythropoietin B. 25-hydroxy Vitamin D is not converted to 1,25 dihydroxy Vitamin D C. Ferrous iron is not converted to the ferric state D. There is decreased GI absorption of Vitamin B12

``` Which of the following conditions will present with WBC casts on urinalysis? A. Acute cystitis B. Acute pyelonephritis C. Ureterolithiasis D. CKD ```

Ana, 35 year old midwife, consults for a periodic health exam. She is a non-smoker. Diet consists mainly of fried food. No family history of hypertension and DM. BP 120/80, BMI 28, normal systemic PE. The screening exams recommended for Ana include A. Mammogram B. Lipid profile C. Fecal occult blood D. Chest x-ray

Juanito, 45 year old bus driver, consults at the health center for a required periodic health exam. He is a heavy smoker but does not drink alcohol. He claims that he is in perfect health just like his parents and siblings. BP 130/80, BMI 22, normal systemic PE. Which of the following screening tests is recommended for Juanito? A. Fecal occult blood B. Visual acuity with Snellen Chart C. 12L-ECG D. DRE

The General Health Questionnaire screens for depression, anxiety disorder, and psychosis. It is recommended that it be administered to which of the following populations? A. School teachers B. Retirees C. Security personnel D. Health care workers

Adult immunization is as important as childhood immunization. Varicella is given two doses one month apart for adults. It is contraindicated in patients with A. Diabetes B. Immunocompromised conditions C. Chronic kidney disease D. Chronic liver disease

``` Which of the following conditions may be responsible for a urine specimen that appears like this? A. Chronic glomerulonephritis B. Ischemic nephropathy C. Diabetic nephropathy D. Renal cell carcinoma ```

A 73/M consults you for dysuria of 1 month duration. He also mentions the need to strain to urinate, feeling of urinary retention, and a weak urinary stream. He has already been treated with ciprofloxacin for 1 week with no improvement. Which of the following conditions should you consider in this patient? A. Bilateral ureteral obstruction B. Acute bacterial cystitis C. Bladder outlet obstruction D. Acute urethritis

C | Probably secondary to BPH

A 60/M consults you for an incidental finding of an elevated serum creatinine of 200 umol/L. Which of the following findings, if present in this patient, will make you suspect that he has CKD? A. Concentrated urine B. Osteodystrophy C. Oliguria D. Hypertension

B This would manifest only in CKD because of the important role the kidney plays in calcium metabolism. This is akin to hypoalbuminemia occurring due to chronic liver disease

This 50 year old traffic aide consults for a chronic non-healing wound on his right leg. He denies any trauma to the area, but says that he experiences on and off bipedal edema associated with a dull ache that worsens with prolonged standing. He was diagnosed with diabetes 10 years ago. You inspect his leg and find: What is the probably cause of his wound? A. Autonomic dysfunction B. Peripheral arterial occlusive disease C. Loss of protective sensation D. Chronic venous insufficiency

A 20/F consults for periorbital edema. She submits a urine specimen immediately after voiding. Which urine abnormality do you expect to find? A. WBC casts B. Albuminuria C. RBC casts D. Glucosuria

75/F is brought to you by her daughter for weight loss. According to her daughter, the patient experiences difficulty in eating due to pain in the mouth. You note this on PE What is your diagnosis? A. Tongue CA B. Oral lichen planus C. Oral candidiasis D. Leukoplakia

46/M diabetic consults for periorbital edema. He also complains of frothy urine. PE: BP 160/100, pale conjunctivae, pitting bipedal edema. What is the pathophysiologic mechanism underlying this patient’s edema? A. Increased capillary pressure B. Renal hypoperfusion C. Decreased oncotic pressure D. Increased sodium reabsorption

C | The patient is probably hypoalbuminemic given the albuminuria

This is the chest x-ray of a patient with dyspnea for the past 1 month. What PE findings on the right chest would you be able to elicit? A. Decreased breath sounds, decreased vocal fremiti, resonant B. Decreased breath sounds, increased vocal fremiti, dullness C. Decreased breath sounds, increased vocal fremiti, resonant D. Decreased breath sounds, decreased vocal fremiti, dullness

``` Which of the following causes of anemia is compatible with this peripheral blood smear? A. Iron deficiency anemia B. Vitamin B12 deficiency C. CKD D. Microangiopathic hemolytic anemia ```

A 29 year old farmer consulted you for weight loss. You noted that he had a BMI of 17. Aside from this, the rest of his PE is normal. All lab tests are unremarkable except for the stool exam which showed this: What medication will you give your patient? A. Metronidazole B. Mebendazole C. Ciprofloxacin D. Cotrimoxazole

B | He has ascariasis

``` What is the drug of choice for UTI among pregnant women? A. Ciprofloxacin B. Doxycycline C. Cotrimoxazole D. Amoxicillin ```

``` Mila, 45/F consults for shortness of breath with occasional cough. She underwent a modified radical mastectomy for invasive ductal carcinoma last year and was lost to follow-up. Chest x-ray reveals: What is your impression? A. Lobar pneumonia B. Multiple lung abscess C. Pulmonary metastases D. Miliary TB ```

``` This 45 year old farmer consults for abdominal enlargement and jaundice. He consumes about 400 ml of lambanog 3x weekly. What would you expect on lab work up? A. Prolonged protime B. Direct bilirubinemia C. Hypernatremia D. Albuminuria ```

Thyroid function tests and clinical manifestations are reviewed 3 to 4 weeks after starting treatment and the dose of antithyroid drugs are titrated based on which of the following tests? A. Total T3 B. Free T4 C. Total T4 D. TSH

Your 57 year old aunt tells you that she recently completed her annual executive check-up at work and was diagnosed to have diabetes. She is obese, does not smoke, fairly active, and manages her own business. What examinations would you recommend to screen for complications of diabetes? A. Electrocardiography B. Lipid profile C. Glycosylated hemoglobin D. Urinalysis

``` What vaccinations would you recommend for your 57 year old aunt? A. HPV vaccine, 3 doses B. Influenza vaccine annually C. Hepatitis A vaccine, 3 doses D. Pneumococcal vaccine every 5 years ```

``` Your aunt was started on oral hypoglycemic agents. What test would you recommend to monitory adequacy of diabetes treatment? A. Random capillary blood glucose B. Oral glucose tolerance test C. Glycosylated hemoglobin D. Fasting blood sugar ```

A 60/F came into your clinic complaining of exertional chest pain. The pain is substernal, lasts about 2-3 minutes, radiates to both arms, and is relieved with rest. She is a non-smoker and does not drink alcohol. Her BMI is 22. Her BP is 120/80 and her PE is normal. Which of the following drugs would you prescribe to reduce her risk for a coronary event? A. Digoxin B. Nitrates C. NSAIDs D. Aspirin

A 54/M came in complaining of dyspnea on exertion. About 6 months ago he began to develop dyspnea on exertion, later progressing to 2 pillow orthopnea and occasional edema. PE shows a displaced apex beat to the 6th intercostal space at the left anterior axillary line, normal S1 and S2, an S3 gallop, fine crackles at both lung bases, and bipedal edema. What should be your primary therapeutic goal for this patient at this point? A. Reduce risk of further disease progression B. Alleviate fluid retention C. Prevent cardiac remodeling D. Lessen disability

The following interventions have been proven to slow the progression of CKD EXCEPT A. Use of ACE inhibitors among patients with proteinuria B. Anti-hypertensive treatment among normotensive diabetics C. Aggressive glycemic control among diabetics D. Dietary protein restriction at 0.90 g/kg per day

A 67/M patient is brought to your clinic by his relatives for sudden onset of weakness of the right lower extremity. Which of the following signs will point to an upper motor neuron problem? A. Hyperactive tendon reflexes B. Decreased muscle tone C. Proximal muscle weakness D. Presence of fasciculations

Which of the following agents used in the management of allergic rhinitis is the most potent in providing relief of established rhinitis? A. Oral antihistamines B. Intranasal steroids C. Cromolyn sodium D. Phenylephrine

``` The following medications may be used for prophylaxis against NSAID-related mucosal injury EXCEPT A. Selective COX-2 inhibitor B. Misoprostol C. Bismuth D. Proton pump inhibitor ```

A 35/F has been having recurrent epigastric pain, described as burning, for the past 3 months. An endoscopy is done revealing (+) gastric ulcers. H. pylori testing was positive. Eradication of H. pylori infection has had the greatest impact on which of the following treatment goals for peptic ulcer disease? A. Reduce risk for ulcer perforation B. Prevent ulcer recurrence C. Promote ulcer healing D. Provide relief of pain

``` Which of the following features can distinguish central from peripheral vertigo? A. Response to visual fixation B. Presence of nystagmus C. Tendency to fall after a spin D. Character of dizziness ```

A 65/M consults your clinic for loss of consciousness. His son found him seated on the bathroom floor the night before, looking confused. When asked what happened, all he could remember was that he had difficulty emptying his bladder. There were no prior episodes reported. He takes hydrochlorothiazide daily for hypertension. There was no deficits on neurologic exam. Which of the following would you LEAST consider in this patient? A. Micturition syncope B. Vasovagal syncope C. Arrhythmia D. Stroke

An 80/F consults your clinic for constipation that has gradually worsened over the past couple of years. She denies anorexia or vomiting but reports that she has had difficulty passing stool for years. She would take lactulose regularly but recently it does not seem to work. She is generally healthy, does not smoke, and is fairly active. She has 10 children, all of whom were delivered at home. Which of the following conditions would you LEAST consider? A. Laxative abuse B. Malingering C. Descending perineum syndrome D. Pelvic floor dysfunction

A 55/M consults you for weight loss. He claims that he has not modified his diet but noticed that he lost 2 inches from his waistline. He does not complain of any other symptoms. Family history reveals that his brother recently underwent bowel resection for polyposis coli. What test would you request in order to arrive at a diagnosis? A. Colonoscopy B. FBS C. FOBT D. Abdominal CT

Your 30 year old cousin asks your advice regarding an executive check up because she is getting married and plans to get pregnant soon after. She is generally healthy, has never been hospitalized, and has no known drug or food allergies. Her father is diabetic, and her mother has hypertension. She has been smoking 3-5 cigarettes daily for the past 10 years and drinks wine on occasion. Based on the Philippine Guidelines on Periodic Health Examinations, you would recommend the following examinations EXCEPT A. Fasting blood glucose B. Total cholesterol C. Chest radiography D. Mammography

She also asks your advice regarding what vaccinations she needs prior to getting pregnant. Which of the following would you advise her? A. Hepatitis B vaccination is recommended prior to pregnancy for all women of child-bearing age B. Vaccination against Rubella should not be given to women who might get pregnant within 4 weeks of receiving the vaccine C. Varicella vaccination is recommended for nonpregnant women of child-bearing age anytime before pregnancy D. A complete course of HPV vaccination is recommended for all women who are sexually active

``` 45 year old farmer. What is the most likely etiologic agent? A. Paragonimus westermanii B. Wuchereria bancrofti C. Trichenella spiralis D. Schistosoma japonicum ```

B | He has filiariasis

A 57 year old farmer consults for chronic productive cough with occasional hemoptysis, associated with anorexia and weight loss, but no fever. He is a 40-pack-year smoker. Which would you LEAST consider? A. COPD B. Atypical pneumonia C. Pulmonary TB D. Bronchogenic CA

Nonito reports that he was diagnosed with TB 6 months earlier. However, he took his medications for 2 weeks only. During this consult, his sputum AFB smear shows: How would you manage Nonito? A. Refer to TB diagnostic committee B. Request for TB culture C. Prescribe 2 HRZE/4HR D. Prescribe 2 HRZES/5HRE

C | Nonito is considered a new case of TB. Start with the standard treatment regimen

Which among the following adult patients with pneumonia would warrant hospital admission? A. Pleural effusion B. Chronic renal insufficiency C. CXR findings of infiltrates, R lower lobe D. Vital signs: BP 90/60, PR 120, RR 24

``` 64/M suddenly develops vertigo, diplopia, and blindness. What should be your primary diagnosis? A. Posterior circulation stroke B. Cerebellar stroke C. Multiple sclerosis D. Meniere’s disease ```

According to the 2006 update of the Philippine Guidelines for the Diagnosis, Treatment, Prevention, and Control of Tuberculosis in Adult Filipinos, which of the following tests should be ordered after 2 months of treatment among newly diagnosed smear-positive patients? A. Uric acid B. Chest x-ray C. AST D. Sputum AFB smear