Med 1 - Finals Flashcards
- True statements on the NEW definition of Fever of Unknown origin EXCEPT:
A. fever >38.3C or 101F on at least 2 occasions
B. no known immunocompromised state
C. must be admitted at the hospital for 2 weeks with extensive diagnostic work-up
D. illness duration of 3 weeks or more
C. must be admitted at the hospital for 2 weeks with extensive diagnostic work-up
The definition of Fever of Unknown Origin (FUO) has been updated over time. The typical criteria include a fever of >38.3°C on several occasions, lasting for at least three weeks, with no clear diagnosis after one week of inpatient investigation or two to three outpatient visits. The statement about needing to be hospitalized for two weeks is not a standard part of the definition.
- The following are indications for further evaluation in a patient with dehydration secondary to profuse diarrhea EXCEPT:
A. Bloody stools, elderly, and immunocompromised
B. presence of community outbreaks and failure to improve after 48 hours
C. fever and recent antibiotic use
D. none of the above
D. none of the above.
All options listed are valid reasons for further evaluation in dehydration secondary to diarrhea. These include risk factors and signs of potentially severe or complicated conditions.
- The most common malignant cause of unintentional weight loss is:
A. gastrointestinal malignancy
B. osteosarcoma
C. hematologic
D. breast cancer
A. gastrointestinal malignancy.
Unintentional weight loss is often associated with malignancies, with gastrointestinal cancers such as those of the pancreas, stomach, and esophagus being among the most common causes.
- True or false: A palpable spleen always indicates the presence of a disease.
A. Maybe
B. True
C. False
C. False.
While a palpable spleen can indicate underlying disease, it is not always the case. In some individuals, particularly those who are slim, a normal spleen may be palpable without any disease.
- Hematuria may be caused by:
A. nephrolithiasis
B. tuberculosis
C. prostatitis
D. all of the above
D. all of the above.
Hematuria can be caused by a variety of conditions affecting the urinary tract or kidneys, including nephrolithiasis (kidney stones), tuberculosis affecting the genitourinary system, and prostatitis.
- A patient with diabetes insipidus was admitted due to signs of dehydration secondary to hypovolemia. Serum sodium was elevated at 150 mg/dl. Which resuscitation fluid is most appropriate for this case?
A. D5 water
B. albumin infusion
C. normal saline solution
D. lactated ringer’s solution
A. D5 water.
For a patient with hypernatremia and diabetes insipidus, hypotonic fluids such as D5W (5% dextrose in water) are typically used to carefully correct the sodium imbalance.
- A 29-year-old construction worker sought ER consultation due to vomiting of 3 days duration. He had undocumented weight loss. He claimed he wants to eat but keeps vomiting previously ingested food within one hour of eating. The patient is severely dehydrated with blood pressure of 90/60, tachycardic with thready pulse. The problem is most likely secondary to:
A. gastroparesis with pyloric obstruction
B. colonic and distal intestinal obstruction
C. achalasia
D. Zenker’s diverticulum
A. gastroparesis with pyloric obstruction.
Given the symptoms of persistent vomiting soon after eating, gastroparesis with pyloric obstruction is a likely cause, potentially leading to delayed gastric emptying and mechanical blockage.
- False positive proteinuria on Dipstick test may be secondary to:
A. all of the above
B. pH 7.0
C. blood contamination
D. concentrated urine
A. all of the above.
Dipstick tests for proteinuria can give false positives under several conditions, including alkaline urine (high pH), presence of red blood cells (blood contamination), and highly concentrated urine.
- A patient sought consultation due to three (3) bouts of feculent vomitus. The underlying problem of this patient is:
A. colonic and distal intestinal obstruction
B. achalasia
C. pyloric obstruction with gastroparesis
D. Zenker’s diverticulum
A. colonic and distal intestinal obstruction.
Feculent vomitus, which is vomit with a fecal odor, is typically indicative of a distal intestinal obstruction, where the bowel contents have become stagnant and decomposed.
- Immediate hematologic finding in the first 2 weeks post-splenectomy EXCEPT:
A. thrombocytosis
B. aplastic anemia
C. leukopenia and thrombocytopenia
D. leukocytosis
C. leukopenia and thrombocytopenia.
In the immediate post-splenectomy period, typical hematologic findings include leukocytosis and thrombocytosis, not leukopenia (decrease in white blood cells) and thrombocytopenia (decrease in platelets). These are the opposite of what is commonly observed:
Leukocytosis (an increase in white blood cell count) and thrombocytosis (an increase in platelet count) are typical immediate responses following splenectomy.
Aplastic anemia (B) is a condition where the bone marrow fails to produce sufficient new cells to replenish blood cells and is not a direct or typical immediate consequence of splenectomy.
- Which of the following statements below is true regarding kidney function and creatinine levels?
A. the glomerular filtration rate is directly proportional to the urinary creatinine excretion and inversely proportional to the plasma creatinine.
B. the glomerular filtration rate is inversely proportional to the plasma creatinine and urinary creatinine excretion
C. the glomerular filtration rate is directly proportional to the plasma creatinine and urinary creatinine excretion
D. the glomerular filtration rate is directly proportional to the plasma creatinine and inversely proportional to the urinary creatinine excretion
A. the glomerular filtration rate is directly proportional to the urinary creatinine excretion and inversely proportional to the plasma creatinine.
A. The glomerular filtration rate (GFR) is inversely proportional to the plasma creatinine concentration—meaning, as GFR decreases, plasma creatinine increases. GFR is also directly proportional to urinary creatinine excretion under steady state conditions. This means as GFR increases, more creatinine is cleared from the blood and excreted in the urine.
- The underlying cause of anemia in renal failure is:
A. iodine deficiency
B. folic acid deficiency
C. bone marrow failure
D. inadequate erythropoietin
D. inadequate erythropoietin.
In chronic renal failure, the kidneys’ ability to produce erythropoietin is compromised. Erythropoietin is crucial for the production of red blood cells in the bone marrow. Its deficiency leads to anemia, a common complication in chronic kidney disease.
- A patient sought consultation due to difficulty in swallowing. He was diagnosed with GERD 15 years prior to consultation and has been symptomatic but was lost to follow-up and was self-medicating PRN in between consultations. His last consultation was 10 years ago. The dysphagia is most likely due to:
A. peptic stricture
B. chemical pneumonitis
C. eosinophilic esophagitis
D. Schatzi ring
A. peptic stricture.
Chronic GERD can lead to the formation of a peptic stricture, which is a narrowing of the esophagus due to scar tissue formed as a result of prolonged acid exposure. This would explain the progressive difficulty in swallowing solid foods.
- A 65-year-old male complained of progressive difficulty of breathing aggravated by physical exertion. He had a non-productive cough of 3 months duration. He denies any intake of maintenance medications, no history of diabetes or hypertension. He is a smoker 10 sticks a day for 20 years. On examination, the patient was tachypneic, with wheezes on both lung fields, hyperresonant on both lung fields. Chest x-ray showed widened intercostal spaces, a tubular heart, and flattening of the diaphragm. What is your diagnosis?
A. community-acquired pneumonia
B. Pneumothorax
C. chronic bronchitis
D. emphysema
D. emphysema.
The symptoms and clinical findings—progressive breathlessness, non-productive cough, wheezing, hyperresonance on lung fields, and characteristic X-ray findings of widened intercostal spaces, tubular heart, and flattened diaphragm—are indicative of emphysema, a type of chronic obstructive pulmonary disease (COPD), especially given the history of long-term smoking.
- One of the most common causes of chronic diarrhea in adults is:
A. traveler’s diarrhea
B. lactase deficiency
C. abuse of laxatives for weight control
D. Option 4
B. lactase deficiency.
Lactase deficiency, or lactose intolerance, is a common cause of chronic diarrhea following the ingestion of dairy products in individuals who lack the enzyme lactase.
- Relative bradycardia or temperature-pulse dissociation can be seen in the following EXCEPT:
A. none of the above
B. leptospirosis
C. all of the above
D. brucellosis
E. Typhoid fever
A. none of the above.
Relative bradycardia, also known as Faget’s sign (temperature-pulse dissociation), is seen in conditions like typhoid fever, leptospirosis, and brucellosis. All options listed are correct, and thus, the option “none of the above” is the suitable answer.
- Occlusive or non-occlusive ischemic colitis often presents as:
A. vague abdominal pain localizing to the upper left quadrant of the abdomen
B. upper abdominal pain followed. by alternating diarrhea and constipation
C. lower abdominal pain preceding watery then bloody diarrhea
D. tenesmus with watery mucoid stools followed by constipation
C. lower abdominal pain preceding watery then bloody diarrhea.
Ischemic colitis typically presents with sudden onset of lower abdominal pain followed by the development of bloody diarrhea, reflecting colonic ischemia.
- The major causative factors of abdominal swelling EXCEPT:
A. fetus and fat
B. flatus and feces
C. none of the above
D. fluid and neoplasm
C. none of the above.
The classic causes of abdominal distension include the “Five Fs”: Fluid, Fetus, Fat, Feces, and Flatus. “Neoplasm” is also a recognized cause, so “none of the above” is correct.
- Blood parasite that has cyclical fever every four (4) days is:
A. Trypanosoma cruzi
B. Plasmodium malariae
C. Plasmodium falciparum
D. Plasmodium vivax
B. Plasmodium malariae.
Plasmodium malariae, one of the parasites that cause malaria, is known for causing a fever every 72 hours or every fourth day, known as a quartan fever.
- Which of the following does NOT exhibit volitional control?
A. emesis
B. rumination
C. regurgitation
D. all of the above
A. emesis
- A patient with renal impairment will develop symptoms of uremia when the estimated glomerular filtration rate is:
A. <30 mg/dL
B. <15 mg/dL
C. <45 mg/dL
D. <60 mg/dL
B. <15 mg/dL
Rationale: Uremic symptoms typically become apparent when the glomerular filtration rate (GFR) falls below 15 mL/min/1.73 m², which indicates severe renal impairment or kidney failure.
- Failure of vitamin K to correct prothrombin time in a patient with multiple petechiae, palmar erythema, and jaundice is:
A. severe biliary obstruction
B. pancreatic head carcinoma
C. hemolysis
D. severe hepatocellular injury
D. severe hepatocellular injury
Rationale: In the presence of severe hepatocellular damage, such as in advanced liver disease, the liver’s ability to utilize vitamin K to synthesize clotting factors is compromised, hence vitamin K will not correct the prolonged prothrombin time.
- Indications for splenectomy include the following EXCEPT:
A. correction of cytopenias in immune-mediated hypersplenism
B. for diagnosis in unexplained splenectomy
C. for symptom control
D. staging in Hodgkin’s disease for stage I and II where radiotherapy is contemplated
B. for diagnosis in unexplained splenectomy
- A 55-year-old patient complained of sudden onset of difficulty of breathing. He was diagnosed with pulmonary tuberculosis two (2) weeks prior to consultation and was taking quadruple anti-TB medications with good compliance. On examination, the patient was in distress, tachypneic, clear breath sounds on the right lung, absent breath sounds on the left lung, hyperresonant on the left lung. What is the most likely cause of the problem?
A. pleural effusion
B. pneumothorax
C. pulmonary congestion
D. pulmonary consolidation
B. pneumothorax
Rationale: The clinical findings of distress, tachypnea, absent breath sounds on one side, and hyperresonance suggest pneumothorax, likely a complication related to the underlying lung disease or a side effect of treatment.
- Vaccinations recommended prior to elective splenectomy EXCEPT:
A. Pneumococcal vaccination
B. vaccination against H. influenzae
C. none of the above
D. vaccination against Neisseria meningitidis
C. none of the above
Rationale: Vaccinations against pneumococcal diseases, H. influenzae type b, and Neisseria meningitidis are all recommended prior to splenectomy to prevent severe infections, given the spleen’s role in fighting encapsulated bacteria.
- A patient sought consultation due to coughing of one (1) week duration. He noticed that initially the cough was triggered by food or fluid intake which progressed to coughing even with swallowing without any food or fluid intake. The underlying problem is probably secondary to:
A. gastroesophageal reflux disease
B. tracheobronchial fistula
C. pulmonary malignant new growth
D. achalasia
B. tracheobronchial fistula
Rationale: The progression from cough triggered by food or fluid intake to cough during swallowing suggests a possible tracheobronchial fistula, where there is an abnormal connection between the trachea and the esophagus.
- Neurologic disorder associated with chronic constipation:
A. spinal cord injury
B. all of the above
C. parkinsonism
D. multiple sclerosis
B. all of the above
Rationale: Chronic constipation can be associated with various neurological disorders including spinal cord injuries, parkinsonism, and multiple sclerosis due to effects on autonomic and voluntary control of bowel movements.
- A 25-year-old student sought consultation due to generalized body weakness. She is complaining of progressive easy fatigability with ordinary physical activities of 3 months duration. She denies any change in bowel or bladder habits, no weight change, no change in menstrual cycle. She has insomnia but attributes the lack of sleep from studying for the finals. On examination, she has pale palpebral conjunctivae, anicteric sclerae, with a grade 3/6 murmur at the fourth intercostal space parasternal border. Her palms and soles are pale, with good +2 pulses. Her palmar crease is lighter than the surrounding skin. What is the possible hemoglobin level of this patient?
A. 12 g/dL
B. 10 g/dL
C. 8 g/dL
D. 14 g/dL
C. 8 g/dL
Rationale: The description of progressive easy fatigability, pale conjunctivae and palmar creases, along with a murmur suggest significant anemia. A hemoglobin level of 8 g/dL is consistent with moderate anemia, which aligns with these clinical signs.
- Minimental status examination should be given to elderly patients with unintentional weight loss to identify the presence of:
A. schizophrenia
B. anorexia nervosa and bulimia
C. dementia
D. major depressive disorder with suicidal ideation
C. dementia
Rationale: A Mini-Mental State Examination (MMSE) is a brief test used to screen for cognitive impairment and is appropriate to identify dementia in elderly patients presenting with unintentional weight loss, among other symptoms.
- Non-gastrointestinal disorders that may cause nausea and vomiting include the following:
A. meningitis and intracranial hemorrhage
B. myocardial infarction with or without symptoms of heart failure
C. orthopedic surgery
D. all of the above
D. all of the above
Rationale: Nausea and vomiting can be caused by a variety of non-GI conditions including central nervous system issues such as meningitis, cardiovascular events like myocardial infarction, and even post-operatively, such as after orthopedic procedures.
- The most common cause of ascites is:
A. kwashiorkor
B. nephrotic syndrome
C. cirrhosis
D. cardiac ascites
C. cirrhosis
Rationale: Cirrhosis is the leading cause of ascites. It results from increased pressure in the blood vessels of the liver (portal hypertension) and a decrease in albumin synthesis, which disturbs the fluid balance, leading to fluid accumulation in the abdominal cavity.
- Most common cause of fever of unknown origin is:
A. atypical presentation of an infection
B. vasculitis
C. neoplasm
D. rheumatoid arthritis
A. atypical presentation of an infection
Rationale: Infections are the most common cause of fever of unknown origin (FUO), particularly when they present atypically. This can include infections hidden in the abdomen, pelvis, or bone that are not immediately evident.
- Jaundice is a sign of the following conditions EXCEPT:
A. none of the above
B. hemolytic disorders
C. liver disease
D. disorders of bilirubin metabolism
A. none of the above
Rationale: Jaundice can indeed be a sign of hemolytic disorders, liver disease, and disorders of bilirubin metabolism. All of these conditions can cause an increase in bilirubin levels, leading to jaundice.
- A patient with lymphadenopathy can be given steroids when:
A. reduction in size is necessary prior to excision biopsy
B. there is pharyngeal obstruction that interferes with respiration
C. steroids can alleviate the pain
D. diagnosis is uncertain
B. there is pharyngeal obstruction that interferes with respiration
Rationale: Steroids can be used to quickly reduce inflammation and swelling in cases where lymphadenopathy causes acute complications such as airway obstruction. It’s crucial to manage such life-threatening conditions swiftly.
- Chylous ascitic fluid during paracentesis means:
A. lymphatic damage due to trauma
B. lymphatic disruption from cirrhosis, tumor, or tuberculosis
C. all of the above
D. triglyceride level >200mg/dl and often >1000mg/dL
C. all of the above
Rationale: Chylous ascites indicates lymphatic damage or disruption, which can be caused by trauma, tumors, cirrhosis, or infections such as tuberculosis. It’s characterized by a milky appearance of the ascitic fluid and high triglyceride levels.
- A patient with fever, abdominal pain, and jaundice sought consultation at the ER. The gold standard for identifying choledocholithiasis is:
A. endoscopic retrograde cholangiopancreatography
B. endoscopic ultrasound
C. whole abdominal ultrasound
A. endoscopic retrograde cholangiopancreatography (ERCP)
Rationale: ERCP is the gold standard for diagnosing and often treating choledocholithiasis as it allows both visualization and intervention, such as stone removal.
- A patient complained of epigastric pain radiating to the back. The patient was positive for Murphy’s sign. What is the cause of the abdominal pain?
A. glomerulonephritis
B. nephrolithiasis
C. alcoholic liver disease
D. Acute cholecystitis
D. Acute cholecystitis
Rationale: A positive Murphy’s sign is indicative of acute cholecystitis, which is inflammation of the gallbladder. This condition typically presents with epigastric pain radiating to the back.
- Signs of advanced alcoholic liver disease include:
A. asterixis, spider nevi, parotid gland enlargement
B. testicular atrophy and palmar erythema
C. all of the above
D. gynecomastia, Dupuytren’s contracture
C. all of the above
Rationale: Advanced alcoholic liver disease can manifest with a variety of signs including asterixis (flapping tremor of the hands), spider nevi, parotid gland enlargement, testicular atrophy, palmar erythema, gynecomastia, and Dupuytren’s contracture.
- A 45-year-old female was complaining of multiple palpable nodes at the supraclavicular area. Transvaginal ultrasound was normal and negative pregnancy test. She has no cough, no fever, denies any weight loss. She does not have diabetes or hypertension. What is the possible cause of the supraclavicular lymphadenopathy?
A. Sister Mary Joseph’s nodes indicative of Laennec’s cirrhosis
B. Virchow’s nodes suggestive of intraabdominal malignancy
C. None of the above
D. Sister Mary Joseph’s nodes suggestive of intraabdominal malignancy
B. Virchow’s nodes suggestive of intraabdominal malignancy
Rationale: Virchow’s nodes, found in the left supraclavicular area, are classically associated with intraabdominal malignancies, particularly those of the stomach, as part of the lymphatic drainage from the abdominal cavity.
- Which of the medications listed is associated with chronic constipation?
A. calcium channel blockers
B. angiotensin receptor blockers
C. aspirin
D. nitrates
A. calcium channel blockers
Rationale: Calcium channel blockers are known to cause constipation as a side effect. They reduce the contraction of the smooth muscles in the intestines, thereby slowing intestinal motility.
- Endocrine disorders that will lead to unintentional weight loss EXCEPT:
A. pheochromocytoma
B. Grave’s disease
C. hypothyroidism
D. diabetes mellitus
C. hypothyroidism
Rationale: Hypothyroidism typically causes weight gain, not loss, due to reduced metabolic rate. In contrast, conditions like pheochromocytoma, Grave’s disease, and diabetes mellitus can lead to weight loss.
- Osmotic diuresis in the presence of endogenous solutes namely glucose and urea occurs by:
A. impaired tubular sodium reabsorption
B. all of the above
C. impaired tubular chloride reabsorption
D. impaired tubular water reabsorption
D. impaired tubular water reabsorption
Rationale: Osmotic diuresis, often caused by high levels of glucose or urea in the blood, results from the osmotic pull of these solutes, which impairs the renal tubules’ ability to reabsorb water, leading to increased urine output.
- Which of the findings listed below is highly indicative of glomerulonephritis?
A. microalbuminuria 100 mg/day with muddy casts
B. presence of dysmorphic RBCs, RBC casts, and protein excretion of >500mg/day
C. hyaline casts and WBC 1-3/HPF
B. presence of dysmorphic RBCs, RBC casts, and protein excretion of >500mg/day
Rationale: The presence of dysmorphic red blood cells (RBCs) and RBC casts in the urine are hallmark signs of glomerulonephritis, indicating glomerular damage.
- Medications most commonly associated with cholestasis are:
A. anabolic steroids and contraceptive steroids
B. piperacillin-tazobactam
C. cephalosporins
D. proton-pump inhibitors
A. anabolic steroids and contraceptive steroids
Rationale: Anabolic steroids and contraceptive steroids are well-documented to potentially cause cholestasis, a condition where bile cannot flow from the liver to the duodenum.
- In a patient with hyponatremia and hypovolemia, the appropriate resuscitation fluid to be given is:
A. lactated ringer’s solution
B. normal saline solution
C. albumin infusion
D. D5 water
B. normal saline solution
Rationale: Normal saline is typically used in hypovolemic and hyponatremic patients as it helps restore sodium levels and expand blood volume effectively.
- The following are true of heat stroke EXCEPT:
A. patient can have nausea and vomiting
B. patient can be given paracetamol every 4 hours
C. patient has throbbing headache and confusion
D. rapid rise in body temperature without sweating and unable to cool down
B. patient can be given paracetamol every 4 hours
Rationale: In heat stroke, paracetamol or acetaminophen is ineffective and not recommended because the high body temperature is due to excessive external heat and failed thermoregulation, not due to inflammation or infection.
- The most common cause of hyperpyrexia is:
A. CNS hemorrhage
B. local trauma to the thermoregulatory center
C. cerebral tumor
D. severe infection
D. severe infection
Rationale: Severe infections, such as sepsis, are common causes of hyperpyrexia, a very high fever that is typically above 41.1°C (106°F).
- The thermoregulatory center of the body is located at the:
A. thalamus
B. hypothalamus
C. posterior pituitary
D. anterior pituitary
B. hypothalamus
Rationale: The hypothalamus is responsible for regulating the body’s temperature, acting as the body’s thermostat.
- Where should you place your hands on the chest of a victim when you are performing chest compressions?
A. over the very bottom of the breastbone on the xyphoid
B. on top of the breastbone
C. over the heart on the left side of the chest at the nipple line
D. on the lower half of the breastbone at the center of the chest
D. on the lower half of the breastbone at the center of the chest
Rationale: Effective chest compressions are performed by placing the heel of the hand on the lower half of the sternum, avoiding the xiphoid process to minimize the risk of injury.
- Which of the following is a non-shockable rhythm?
A. ventricular tachycardia
B. supraventricular tachycardia with hemodynamic instability
C. pulseless electrical activity
D. ventricular fibrillation
C. pulseless electrical activity
Rationale: Pulseless electrical activity (PEA) is a non-shockable rhythm because there is electrical activity in the heart but no pulse, and defibrillation is not effective. Instead, immediate CPR and addressing the underlying cause are recommended.
- You are treating a cardiac arrest patient. The AED is malfunctioning. Which of the following is the correct response?
A. Pause CPR to troubleshoot
B. Call for help
C. Go find another AED
D. Continue chest compressions
D. Continue chest compressions
Rationale: When an AED is malfunctioning, the priority remains providing continuous chest compressions to maintain circulation until a functioning AED is available or advanced care arrives.
- What is the correct depth for chest compressions in an adult victim or patient during CPR?
A. at least 2.5 inches
B. at least 2 inches
C. at least 1.5 inches
D. at least 3 inches
B. at least 2 inches
Rationale: According to current CPR guidelines, the recommended depth of chest compressions for adults is at least 2 inches (5 cm) but not greater than 2.4 inches to optimize cardiac output while minimizing the risk of complications.
- What is the correct rate of compressions during cardiopulmonary resuscitation?
A. 80
B. 100
C. 50
D. 60
B. 100
Rationale: The recommended rate of chest compressions during CPR is 100 to 120 compressions per minute. This rate maximizes the chances of return of spontaneous circulation.
- What is your first step if you are alone and find a potential victim?
A. open the airway and give 2 breaths
B. Begin chest compressions
C. Ensure scene safety
D. Check for responsiveness
D. Check for responsiveness
Rationale: The first step when finding a potential victim is to check for responsiveness, typically by tapping and shouting, which helps determine if the victim is conscious and requires further immediate interventions.
- A 45-year-old female was referred to your clinic because of a murmur with an ECG showing frequent premature ventricular contractions. Physical examination showed a soft blowing diastolic murmur grade 3/6 with an opening snap best appreciated at the apex. Which of the following is the cause of the murmur?
A. mitral regurgitation
B. aortic stenosis
C. mitral stenosis
D. mitral valve prolapse
C. mitral stenosis
Rationale: A soft blowing diastolic murmur with an opening snap best appreciated at the apex is characteristic of mitral stenosis, typically resulting from the valve’s narrowing that impedes blood flow from the left atrium to the left ventricle.
- A 24-year-old patient complained of recurrent palpitations and shortness of breath of 3 months duration. She has on and off bipedal edema, easy fatigability, and 2 pillow orthopnea. Physical examination revealed a holosystolic murmur at the apex. What is the cause of the murmur?
A. mitral valve prolapse
B. mitral regurgitation
C. tricuspid regurgitation
D. aortic stenosis
B. mitral regurgitation
Rationale: A holosystolic murmur heard best at the apex is indicative of mitral regurgitation, where there is backflow of blood from the left ventricle into the left atrium during systole.
- A 64-year-old hypertensive, diabetic patient complained of body weakness and decrease in appetite from 4-5 meals a day to a meal a day in 2 days. He had dizziness aggravated by change in position from supine to standing. On PE, the patient was positive for orthostatic hypotension. Which of the statements below indicates orthostatic hypotension?
A. Drop in SBP >10 mmHg or drop in DBP >5 mmHg in 3 minutes after change in position
B. Drop in SBP >10 mmHg and increase in HR >20 beats/min in 5 minutes after change in position
C. Drop in SBP >20 mmHg or drop in DBP >10 mmHg in 3 minutes after change in position
D. Drop in SBP >20mmHg or drop in DBP >10 mmHg in 5 minutes after change in position
C. Drop in SBP >20 mmHg or drop in DBP >10 mmHg in 3 minutes after change in position
Rationale: Orthostatic hypotension is defined as a significant drop in blood pressure when standing from a sitting or lying position, typically a decrease in systolic blood pressure of at least 20 mmHg or a decrease in diastolic blood pressure of at least 10 mmHg within three minutes of standing.
- A 36-year-old male diabetic complained of pain and tingling sensation on his fingers on his left hand. To check for the integrity of the arcuate system, the bedside maneuver to be done is:
A. ABI test
B. ESR and CRP
C. Valsalva maneuver
D. Allen’s test
D. Allen’s test
Rationale: Allen’s test is used to evaluate the patency of the radial and ulnar arteries in the hand and is appropriate for assessing circulation before procedures like arterial blood gas sampling or establishing arterial lines.
- Pulsus paradoxus can be seen in the following conditions EXCEPT:
A. cardiac tamponade and hemorrhagic shock
B. severe obstructive lung disease and tension pneumothorax
C. all of the above
D. none of the above
D. none of the above
Rationale: Pulsus paradoxus is a phenomenon where there is an exaggerated decrease in systolic blood pressure during inspiration. It is seen in conditions like cardiac tamponade, severe obstructive lung disease, and tension pneumothorax.
- Because of the absence of a valve and its anatomic connection to the superior vena cava, the vein used to measure the volume status of the patient is:
A. subclavian vein
B. carotid artery
C. internal jugular vein
D. external jugular vein
C. internal jugular vein
Rationale: The internal jugular vein is often used to measure central venous pressure (CVP) due to its direct anatomical route to the superior vena cava and its proximity to the right atrium, facilitating accurate assessments of the patient’s volume status.
- The single most important bedside measurement to assess the volume status of the patient is:
A. examination of the carotid artery pulsations
B. external jugular venous pressure measurement
C. check for orthostatic hypotension
D. internal jugular venous pressure measurement
D. internal jugular venous pressure measurement
Rationale: Measuring the internal jugular venous pressure (JVP) is the most reliable bedside way to assess a patient’s volume status as it provides a direct estimate of the central venous pressure, which correlates with right atrial pressure.
- A 24-year-old construction worker sought consult due to chest pains of 3 days duration with increased severity in the supine position. He had undocumented fever and body malaise. He self-medicated with paracetamol 500mg affording temporary relief. The patient refused to lie on the bed and preferred the tripod position. The most likely cause of chest pains is:
A. Bronchial asthma
B. pericarditis
C. Chronic obstructive lung disease
D. heart failure NYHA I
B. pericarditis
Rationale: Pericarditis often presents with chest pain that worsens in the supine position and improves when sitting up and leaning forward (tripod position). The history provided fits this typical presentation.
- Pseudoxanthoma elasticum is associated with:
A. hyperthyroidism
B. premature atherosclerosis
C. atrial myxoma
D. sarcoidosis
B. premature atherosclerosis
Rationale: Pseudoxanthoma elasticum is a genetic disorder affecting connective tissue, including that of the blood vessels, which can lead to premature atherosclerosis.
- True of the carotid artery pulse EXCEPT:
A. can not be obliterated with gentle pressure at the base of the vein
B. palpable
C. has two peaks and two troughs
D. no respiratory variation
C. has two peaks and two troughs
Rationale: The carotid pulse typically has a single peak per cardiac cycle, unlike the description given. It is characterized by a rapid upstroke and downstroke without bifurcation.
- True of the internal jugular pulse:
A. has two peaks and two troughs
B. no respiratory variation
C. palpable
D. can not be obliterated with gentle pressure at the base of the vein
A. has two peaks and two troughs
Rationale: The internal jugular vein pulse characteristically shows two peaks and two troughs per cardiac cycle, corresponding to the different waveforms (a, c, x, v, y) observed in jugular venous pulse tracing.
- A 23-year-old male sought consultation for pre-employment clearance. On examination of extremities, the patient had cyanotic nail beds on all his toes and pink nail beds on the fingers. Auscultation revealed a machinery-like murmur at the second left intercostal space parasternal border. He denies any chest pains, palpitations, edema, or loss of consciousness. Before requesting a 2D echo and ECG, what is your diagnosis?
A. tetralogy of Fallot
B. atrial septal defect
C. Patent ductus arteriosus
D. Coarctation of the aorta
C. Patent ductus arteriosus
Rationale: A machinery-like murmur at the second left intercostal space and differential cyanosis (blue toes, pink fingers) suggest a continuous flow between the aorta and pulmonary artery, characteristic of patent ductus arteriosus.
- A 38-year-old female sought consultation due to recurrent palpitations of 2 months duration. She had undocumented weight loss, claims her clothes are getting bigger, no fever, no cough, increased bowel movement 2x a day with well-formed stools. On examination, the patient had very moist hands during examination, no fine tremors, no anterior neck mass, no lymphadenopathy, tachycardic, and exophthalmos. What is the most likely cause of her symptoms?
A. hyperthyroidism
B. hypothyroidism
C. Tangier disease
D. rheumatic heart disease
A. hyperthyroidism
Rationale: The combination of weight loss, increased bowel movements, moist hands, tachycardia, and exophthalmos are classic signs of hyperthyroidism.
- A 65-year-old female collapsed at the lobby of the hospital after visiting a friend at the ICU. She was rushed to the ER, BP was 30 palpatory, and the ECG tracing showed the following (see image). What is the first thing that must be done?
A. defibrillation
B. schedule for pacemaker insertion
C. give Atropine 1 mg IV
D. cardioversion
A. defibrillation
Rationale: Assuming the ECG shows a shockable rhythm such as ventricular fibrillation or pulseless ventricular tachycardia, immediate defibrillation is the most critical and lifesaving step.
- An 18-year-old was complaining of recurrent palpitations. During the interview, the patient again had another episode of palpitations. Rhythm strip showed the attached ECG tracing. BP is 120/70mmHg, RR 20 CPM, afebrile, clear breath sounds. What is the first thing that you should do in this case?
A. give isosorbide dinitrate 5 mg sublingual
B. check for absence of carotid bruit and do carotid massage
C. schedule patient for pacemaker insertion
D. schedule patient for implantable cardiac defibrillator
B. check for absence of carotid bruit and do carotid massage
Rationale: Carotid massage can be attempted in a stable patient to assess and potentially terminate certain types of supraventricular tachycardia (SVT) if no carotid bruits are present (which would suggest carotid artery disease).
The ECG strip you provided shows a regular rhythm with each QRS complex being preceded by a P wave, and the rate appears to be relatively fast. The consistent pattern without dropped beats or significant irregularity suggests a tachyarrhythmia, likely a supraventricular tachycardia (SVT) given the age and symptoms of the patient.
Given this information and the options provided, the appropriate initial management in this clinical scenario would be:
- Correct Answer: B. check for absence of carotid bruit and do carotid massage.
Rationale:
1. Carotid Massage: This non-invasive procedure can be an effective first-line intervention for certain types of supraventricular tachycardia (SVT). It acts by stimulating the vagus nerve, which can help slow the heart rate and potentially terminate the tachycardia. This maneuver should only be performed after ensuring there is no carotid bruit, which could indicate carotid artery disease, making manipulation of the carotid artery potentially dangerous.
-
Alternative options:
- Isosorbide dinitrate: This would not be appropriate as it is typically used for angina (chest pain due to heart disease) and not for arrhythmias.
- Pacemaker insertion: This is generally used for bradyarrhythmias (slow heart rates) and not for managing acute tachycardia.
- Implantable cardiac defibrillator (ICD): An ICD is for life-threatening ventricular arrhythmias, not typically indicated in the acute management of SVT in a young, otherwise healthy individual.
The use of carotid massage here serves as a diagnostic and potentially therapeutic tool in a controlled setting where the patient can be monitored for response and any adverse effects. If this maneuver fails to resolve the palpitations or if the patient’s condition worsens, immediate medical intervention and further cardiac evaluation might be necessary.
- Identify the attached ECG strip.
A. sinus rhythm with premature atrial contraction with compensatory pause
B. second degree atrioventricular block Mobitz type 1
C. second degree atrioventricular block Mobitz type 2
D. third degree atrioventricular block
B. second degree atrioventricular block Mobitz type 1
This strip demonstrates a pattern where most P waves are followed by QRS complexes, but with some P waves not followed by QRS complexes, suggesting an AV block. The PR interval appears to lengthen progressively until a QRS complex is dropped. This pattern is indicative of a second degree AV block, specifically Mobitz Type I (Wenckebach).
- A patient at the ER suddenly complained of chest pains and palpitations. The patient was immediately hooked to the cardiac monitor which showed the attached tracing. What is the management for this case?
A. magnesium sulfate
B. defibrillation
C. pacemaker insertion
D. esmolol IV
A. magnesium sulfate
Rationale:
Magnesium Sulfate: This is the treatment of choice for Torsades de Pointes, even if blood magnesium levels are normal. Magnesium serves as an effective agent for terminating Torsades de Pointes by reducing the excitability of the myocardium, thereby stabilizing cardiac membranes and helping to restore normal rhythm.
- A patient was sent to your clinic due to ECG findings during her annual physical examination. Attached is the ECG strip. What is the correct management?
A. magnesium sulfate
B. pacemaker insertion
C. defibrillation
D. none of the above
D. none of the above
Rationale:
- A (Magnesium sulfate): There is no indication for magnesium sulfate, as there are no signs of torsades de pointes or hypomagnesemia-related arrhythmias.
- B (Pacemaker insertion): Not indicated as there is no evidence of bradyarrhythmia or heart block that would require pacing.
- C (Defibrillation): Not appropriate as there are no signs of ventricular fibrillation or unstable ventricular tachycardia.
- D (None of the above): This is the correct choice as the ECG shows a normal sinus rhythm without any abnormalities that would require intervention. The patient should continue routine observation and management as per usual health care guidelines, considering this ECG as part of a normal annual examination.
This ECG indicates a healthy heart rhythm, and no immediate cardiac interventions are required. However, it is always important to correlate ECG findings with the patient’s clinical symptoms and medical history to ensure comprehensive care.
- A patient complained of double vision. On examination, the patient had diplopia, pupillary constriction, and upper eyelid ptosis of the right eye. Which cranial nerve is affected?
A. Oculomotor nerve
B. Trochlear nerve
C. Abducens nerve
D. Facial nerve
A. Oculomotor nerve
Rationale: These symptoms are indicative of a third cranial nerve (oculomotor nerve) palsy, which controls most of the eye’s movements and the pupillary reflex.
- Extraocular muscles innervated by Abducens nerve:
A. lateral rectus
B. inferior oblique
C. superior oblique
D. inferior rectus
A. lateral rectus
Rationale: The abducens nerve (sixth cranial nerve) specifically innervates the lateral rectus muscle, which abducts the eye.
SO4 (Trochlear)
LR6 (Abducens)
R3 (Oculomotor)
- A 78-year-old female complained of recurring headache and bitemporal hemianopia. The lesion causing the blindness is located at the:
A. right optic nerve
B. right occipital lobe
C. optic chiasm
D. right perichiasmal area
C. optic chiasm
Rationale: Bitemporal hemianopia, where vision is lost in the outer half of both eyes, is typically caused by a lesion at the optic chiasm, often due to a pituitary tumor impinging on the optic nerves.
- A patient complained of left homonymous hemianopia. The lesion is located at the:
A. right optic tract
B. optic chiasm
C. right optic nerve
D. right occipital lobe
A. right optic tract
Rationale:
- Left homonymous hemianopia refers to the loss of the left visual field in both eyes. This type of visual field loss suggests a lesion that affects the right side of the visual pathway after the optic chiasm. This is because the right optic tract carries all the visual information from the left visual field of both eyes.
- Optic Chiasm (Option B): A lesion here typically causes bitemporal hemianopia (loss of the outer halves of the visual field in both eyes) due to the crossing of the nasal fibers from both eyes.
- Right Optic Nerve (Option C): Damage to the right optic nerve would lead to total blindness in the right eye only, not a field defect in both eyes.
- Right Occipital Lobe (Option D): While damage to the right occipital lobe can indeed cause a left homonymous hemianopia, the optic tract is generally more centrally located in the brain and more likely to affect both eyes uniformly, making it the more precise location for the described symptom.
Thus, a lesion in the right optic tract is the most accurate answer for the described symptom of left homonymous hemianopia, affecting the visual pathway post-chiasm, where fibers are no longer divided by hemifield from each eye but are instead completely contralateral.
- A 65-year-old hypertensive, diabetic, had sudden onset of intense headache of >5 minutes duration followed by nausea and vomiting of previously ingested food. Upon arrival at the ER, the patient was GCS 3 with sluggish pupils. Which of the following is the diagnostic test of choice?
A. Cranial CT scan
B. CSF analysis
C. complete blood count
D. EMG-NCV
A. Cranial CT scan
Rationale: A cranial CT scan is the initial diagnostic test of choice in patients presenting with signs of a possible stroke or subarachnoid hemorrhage, particularly given the described sudden intense headache.
- A 23-year-old patient complained of fever, headache, nausea, and vomiting. He had stiff neck of 5 days duration, PE showed positive Kernig’s sign and Brudzinki’s sign. The diagnostic test of choice is:
A. cranial CT scan
B. complete blood count
C. CSF analysis
D. EMG-NCV
C. CSF analysis
Rationale: Given the symptoms and signs suggestive of meningitis (fever, headache, stiff neck, positive Kernig’s and Brudzinski’s signs), lumbar puncture for cerebrospinal fluid (CSF) analysis is the diagnostic test of choice.
- Which of the following is NOT a pain-producing cranial structure?
A. ventricular ependyma
B. meningeal arteries
C. dural sinuses
D. scalp
A. ventricular ependyma
Pain-Producing Cranial Structures:
- Scalp
- Meningeal arteries
- Dural sinuses
- Falx cerebri
- Proximal segments of the large pial arteries
Non-Pain Producing Structures:
- Ventricular ependyma
- Choroid plexus
- Pial veins
- Brain parenchyma
- Headache is a common complaint of patients. Which of the following is a pain-producing cranial structure?
A. falx cerebri
B. pial veins
C. brain parenchyma
D. choroid plexus
A. falx cerebri
Pain-Producing Cranial Structures:
- Scalp
- Meningeal arteries
- Dural sinuses
- Falx cerebri
- Proximal segments of the large pial arteries
Non-Pain Producing Structures:
- Ventricular ependyma
- Choroid plexus
- Pial veins
- Brain parenchyma
- The following feature/s is found in Broca’s aphasia:
A. impaired comprehension
B. preserved comprehension
C. echolalia
D. increased or preserved fluency
B. preserved comprehension
Rationale: Broca’s aphasia, also known as non-fluent aphasia, is characterized by impaired speech production or fluency but with preserved comprehension of language.
- The following feature/s is found in Wernicke’s aphasia:
A. impaired comprehension
B. preserved comprehension
C. decreased fluency
D. echolalia
A. impaired comprehension
Rationale: Wernicke’s aphasia is marked by fluent but nonsensical speech and significant impairment in understanding language.
- The single most common finding in Aphasic patients is:
A. Anomia
B. paraphasia
C. alexia
D. agraphia
A. Anomia
Rationale: Anomia, difficulty in finding words, is a common feature across different types of aphasia and often the most persistent symptom.
- A patient with pulmonary tuberculosis complained of urinary and fecal incontinence of 3 weeks duration with 1/5 motor weakness and 90% sensory deficit on both lower extremities. Where is the neurologic lesion?
A. parietal lobe
B. thalamus
C. spinal cord
D. cerebellum
C. spinal cord
Rationale: The symptoms described suggest a spinal cord lesion, likely due to spinal tuberculosis (Pott’s disease), which can cause compression of the spinal cord leading to motor and sensory deficits as well as bladder and bowel incontinence.
- Which of the following neurologic findings points to lower motor neuron weakness?
A. (+) fasciculations, decreased muscle tone, severe muscle atrophy, absent Babinski sign
B. (+) spasticity, (+) Babinski sign, no fasciculations
C. no fasciculations, absent Babinski sign, proximal muscle weakness
D. absent Babinski sign, normal muscle stretch reflex, absent muscle atrophy
A. (+) fasciculations, decreased muscle tone, severe muscle atrophy, absent Babinski sign
Rationale: Lower motor neuron signs include fasciculations, decreased muscle tone, muscle atrophy, and a normal or absent Babinski sign.
- Which of the following terminologies is defined by the inability to perform a skilled or learned movement unrelated to a significant motor or sensory deficit?
A. bradykinesia
B. apraxia
C. rigidity
D. paratonia
B. apraxia
Rationale: Apraxia is the inability to perform learned movements despite having the desire and physical ability to perform them, and is not due to a motor or sensory impairment.
- Initial treatment for Meniere’s disease is:
A. Modified Epley Maneuver
B. drugs used for treatment of migraine headaches
C. Dix-Hallpike maneuver
D. Diuretics and sodium restriction
D. Diuretics and sodium restriction
Rationale: Initial management of Meniere’s disease typically involves reducing fluid retention through diuretics and dietary sodium restriction to manage the symptoms of vertigo, tinnitus, and hearing loss.
- The following statements on orthostatic hypotension are true EXCEPT:
A. Orthostatic hypotension is a reduction in systolic blood pressure of at least 20mmHg or 10mmHg in diastolic blood pressure within five (5) minutes of standing
B. symptoms include light-headedness, dizziness, and presyncope
C. Blurred vision may occur due to retinal or occipital lobe ischemia
D. Orthostatic hypotension can be exacerbated by exertion, prolonged standing, increased ambient temperature, or meals.
A. Orthostatic hypotension is a reduction in systolic blood pressure of at least 20mmHg or 10mmHg in diastolic blood pressure within five (5) minutes of standing
Orthostatic hypotension is traditionally defined as a decrease in systolic blood pressure (SBP) of at least 20 mmHg or a decrease in diastolic blood pressure (DBP) of at least 10 mmHg within (3) three minutes of standing or head-up tilt on a tilt table.
The values given in the statement (SBP >30mmHg or DBP >20mmHg) are not standard thresholds for defining orthostatic hypotension, though they do indicate a significant drop in blood pressure.
- The most common cause of syncope is:
A. neurally mediated syncope
B. cardiac syncope
C. orthostatic hypotension due to autonomic failure
D. structural obstruction in severe aortic stenosis
A. neurally mediated syncope
Rationale: Neurally mediated syncope (vasovagal syncope) is the most common type, triggered by a reflex that causes a sudden drop in heart rate and blood pressure, leading to fainting.
- Clinically important weight loss is defined by the following except:
A. 4.5 kgs in 6-12 months
B. 1-2 pounds per 3 months
C. 10 pounds in 6-12 months
D. >5% of body weight in 6-12 months
B. 1-2 pounds per 3 months
Rationale: Clinically significant weight loss is typically defined as a loss of more than 5% of body weight over 6-12 months or as stated in other options. A loss of 1-2 pounds over 3 months is not typically considered clinically significant.
- The greatest incidence of weight loss is seen among patients with:
A. solid tumors
B. Alzheimer’s dementia
C. cystic new growth
D. psychiatric and behavioral disorder
A. solid tumors
Rationale: Patients with solid tumors, such as cancers of the lung, breast, and gastrointestinal tract, often experience significant weight loss due to the metabolic demands of the tumor and the effects of the cancer on the body’s ability to absorb and utilize nutrients.
- Back pain often described as an electrical shock that runs down the spine with neck flexion and involves the cervical spinal cord is called:
A. Spurling’s sign
B. acute brachial neuritis
C. cervical angina syndrome
D. Lhermitte’s sign
D. Lhermitte’s sign
Rationale: Lhermitte’s sign is characterized by a sensation like an electric shock that travels down the spine and into the limbs with neck flexion. It is often associated with multiple sclerosis and other conditions affecting the cervical spinal cord.
- Cancer-related back pains most often involve:
A. cervical spine
B. lumbar spine
C. coccyx bone
D. thoracic spine
D. thoracic spine
Rationalization: Cancer-related back pain most commonly affects the thoracic spine. This area is a frequent site for metastatic disease due to the rich vascular supply and the presence of the vertebral venous plexus, which can harbor metastatic cells from primary cancers located elsewhere in the body.
- Spine disease that involves anterior slippage of the vertebral body, pedicles, and superior articular facets leaving the posterior elements behind is called:
A. degenerative disease of the spine
B. spondylosis
C. spondylolisthesis
D. spondylolysis
C. spondylolisthesis
Rationale: Spondylolisthesis refers to the forward displacement of one vertebra over the one beneath it, typically occurring in the lumbar region. This condition can cause significant back pain and nerve root compression.
- Spondylosis most commonly affects:
A. cervical and lumbosacral spine
B. thoracic and sacral spine
C. cervicothoracic and sacral spine
D. thoracolumbar spine
A. cervical and lumbosacral spine
Rationale: Spondylosis, a degenerative disorder, typically affects the cervical and lumbosacral regions of the spine, areas which undergo significant movement and stress.
- Treatment of choice for Cauda Equina Syndrome:
A. NSAIDs and morphine
B. ice pack, rest, and physical therapy
C. glucocorticoids
D. surgical decompression
D. surgical decompression
Rationale: Cauda Equina Syndrome is a surgical emergency where there is impingement of the nerve roots in the lumbar spine, often requiring prompt surgical decompression to prevent permanent damage such as paralysis or loss of bowel and bladder control.
- The following statements on the anatomy of the spine are true EXCEPT:
A. Discs are responsible for 25% of spinal column length and allow the body vertebrae to move easily upon each other.
B. The nerve roots exit at a level above their respective vertebral bodies in the thoracic and lumbar region.
C. The posterior spine provides an anchor for the attachment of muscles and ligaments.
D. The uncovertebral joint can hypertrophy with age and contribute to neural foraminal narrowing and radiculopathy in the cervical region.
B. The nerve roots exit at a level above their respective vertebral bodies in the thoracic and lumbar region.
Rationale: Nerve roots exit below their respective vertebral bodies in the spinal column. This statement is anatomically incorrect.
- Diseases affecting the upper lumbar spine tend to refer pain to the following areas EXCEPT:
A. lumbar region
B. anterior thighs
C. buttocks
D. groin
C. buttocks
Rationale: Diseases affecting the upper lumbar spine (such as L1-L2) typically cause pain in the anterior thigh and groin region, not typically in the buttocks, which is more commonly associated with lower lumbar spine issues.
- Diseases affecting the lower lumbar spine tend to produce pain in the following areas:
A. buttocks
B. anterior thighs
C. groin
D. lumbar region
A. buttocks
Rationale: Conditions affecting the lower lumbar spine (such as L4-L5, L5-S1) tend to produce symptoms in the lower back and buttocks, often radiating down to the legs due to sciatic nerve irritation.
- A patient complained of low back pain and a straight leg-raising maneuver was done. Which side should the pain be reproduced if the nerve root affected is on the left?
A. ipsilateral
B. contralateral
C. pain is referred to the buttocks
D. none of the above
A. ipsilateral
- Rationale: The straight leg raise test, when positive, typically reproduces pain on the same side (ipsilateral) of the affected nerve root. If the affected nerve root is on the left, pain would be reproduced on lifting the left leg.
