Practice Test 2013

Question 1

Levels of glucose, anion gap, insulin, renin, glucagon, b-hydroxybutyrate, and catecholamines in DKA:

Answer 1

Elevated: glucose, anion gap, renin, glucagon, b-hydroxybutyrate, and catecholamines

Low: Insulin

Question 2

Diagnosis of delirium:

Answer 2

Confusion assessment method

Question 3

MOA of acetaminophen in reducing fever:

Answer 3

Increased arachadonic acid in OVLT endothelial cells. Acetaminophen blocks COX which increases arachadonic acid and decreases PGE2 which causes a decrease in cAMP.

Question 4

Ciprofloxacin BBW:

Answer 4

arthropathy in children

Question 5

College grad uses liquor, cocaine, and marijuana at a party. Which substance will be in urine 2 days later?

Answer 5

Benzolyecognine from cocaine. Alcohol and marijuana are cleared more quickly.

Question 6

Rocky Mountain Spotted Fever treatment:

Answer 6

Doxycycline

Question 7

Antiphospholipid syndrome:

Answer 7

may have family member with SLE: thrombembolic event, family hx of autoimmune disease, false positive RPR, mild to severe thrombocytopenia

Question 8

Increased resistance of gram negative drugs, ventilator associated pneumonia, which abx is most effective?

Answer 8

Cefipime with greatest activity against gram negatives and most resistance to beta-lactamases

Question 9

Western blot confirmatory test detects:

Answer 9

antibody against HIV antigens

Question 10

Man with HF has SOB, JVD, peripheral edema, what PE sign related to liver is most likely?

Answer 10

Large tender liver

Question 11

Removal of necrotic mass, found unresponsive days later, echo showed large RV, small hypercontractile LV with interventricular flattening:

Answer 11

pulmonary thrombo-embolism (Trousseau’s syndrome and immobility)

Question 12

Prolonged abx needed in:

Answer 12

febrile pts where it is hard to get adequate levels such as endocarditis and osteomyelitis

Question 13

Managing behavioral and safety concerns in pts with dementia:

Answer 13

caregiver and pt education

Question 14

True/False

Any child can consent to medical treatment for drug or chemical dependence in Texas.

Answer 14

True

Question 15

Mom wants you to do a drug screen on daughter without telling her:

Answer 15

Assess daughter and obtain whatever tests are needed, need trusting relationship with the patient

Question 16

Daughter with sclerae injection and mild expiratory wheezes, cough, most likely cause is:

Answer 16

marijuana

Question 17

DKA, metabolic acidosis from acetyl CoA in the mitochondria:

Answer 17

The metabolic acidosis in this patient is most likely due to DKA. Ketones such as beta-hydroxybutyrate accumulate as a result of lack of an insulin signal to oppose stress –induced fuel mobilization. This ultimately can result in acidemia. In this situation, triglycerides are rapidly broken down to fatty acids (just the opposite of option a). The mobilized fatty acids are then rapidly activated by the addition of coenzyme A so the resulting acyl CoA molecule can enter the mitochondria to be converted acetyl CoA, which can be completely oxidized by the TCA cycle. However, under these conditions, acyl CoA metabolism (beta-oxidation) occurs so rapidly that the end-product, acetyl CoA, is produced faster than it can enter the TCA cycle. Consequently, acetyl CoA accumulates to high enough levels to condense to beta-hydroxybutyrate. The beta-hydroxybutyrate accumulates, then diffuses out of the cell in the protonated form (beta-hydroxybutyric acid). Once in the blood, the beta-hydroxybutyric acid de-protonates , resulting in acidemia. Options c, d and e are incorrect since a decrease in any of those (glucagon production, carnitine and carnitine palmitoyl transferase ) would likely decrease the rate of transfer of fatty acyl CoA into the mitochondria, and consequently would decrease the production of beta-hydroxybutyrate.

Question 18

Cocaine and substernal chest pain, effect mediated by:

Answer 18

indirect stimulation of alpha adrenergic receptors

Question 19

Cirrhosis, Kayser-Fleischer rings, dysarthria, and spacticity:

Answer 19

Wilson Disease

Question 20

Woman with muscle aches, fatigue, arthralgia and thinks she has lupus, has malar rash, non deforming arthritis, thrombocytopenia, what else would increase likelihood of lupus?

Answer 20

2+ protein on urine dipstick

4 criteria required for dx of Lupus

Question 21

Discharge, dysuria, intracellular gram-negative diplococci, best abx regimen is:

Answer 21

Ceftriaxone 125 mg IM once

Question 22

NV fatigue, hepatic transaminases and bilirubin, hep B surface antigen positive, core antibody IgM positive, hep C antibody positive, so patient has

Answer 22

hep c and acute hep B

Question 23

Glucocorticoids interfere with ability to mount fever by

Answer 23

inhibition of phospholipase A2

Question 24

Peripheral edema, 12g protein in urine, bx shows glomerulonephritis, what is likely to be increased

Answer 24

serum lipid levels (nephrotic syndrome – hyperlipidemia from increased hepatic lipoprotein from decreased oncotic pressure)

Question 25

FNVD, BUN 70, CR 2.1, no blood, casts, protein, glucose or cells, most likely

Answer 25

increased water permeability in the collecting duct (hypovolemic – pre renal – increase ADH – increase water permeability in collecting ducts)

Question 26

Drug-induced Lupus

Answer 26

will see anti-histone antibodies

Question 27

Self imposed diet for 6 mo, macrocytic anemia

Answer 27

from folate deficiency (vitamin b12 stores can last years)

Question 28

Bleeding ulcer, what does CBC look like?

Answer 28

IDA so microcytic anemia

Question 29

Hypercalcemia

Answer 29

reduce with furosemide

Question 30

Cirrhosis and edema, increased body sodium and water so

Answer 30

increased plasma ADH

Question 31

Dyspnea, orthopnea, pedal edema, elevated neck veins, crackles, 3rd heart sound

Answer 31

CHF

Question 32

Decreased energy, dyspnea, orthopnea, pedal edema, elevated neck veins, crackles, 3rd heart sound so HF and HTN, cause is

Answer 32

ischemic cardiomyopathy

Question 33

60 yo male with social withdrawal, used to be normal now has social problems and is acting weird, 29/30

Answer 33

atrophy of fronto-temporal brain regions

Question 34

Hematemesis, low BP, duodenal ulcer, give blood, BUN 80 and Cr 2.5 (very increased from admission), brown muddy casts and FENa of 3.5%, what is mechanism

Answer 34

ATP depleition in renal tubular epithelia (ATN)

Question 35

Dyspnea and orthopnea, dullness on percussion on right, thoracentesis on PE, pleural effusion/serum LDH ratio < 0.6 so transudate so etiology

Answer 35

CHF

Question 36

Cause of death of man is MI, he had dx of vascular dementia, what is consistent:

Answer 36

multiple lacunar infarcts

Question 37

Diphenhydramine taken for surgery after rotator cuff tear then has AMS

Answer 37

diphenhydramine is cause

Question 38

Mitral regurg and LV dysfunction (CHF) will show

Answer 38

blowing holosystolic murmur and gallop during phase of rapid ventricular filling (S3)

Question 39

Donepezil MOA

Answer 39

inhibition of acetylcholinesterase

Question 40

Diagnostic study to determine etiology of confusion in patient who fell

Answer 40

CT of the head (hematoma or stroke)

Question 41

Positive for cocaine, lab shows elevated creatinine kinase, HTN, tachycardia, visual hallucinations

Answer 41

muscle damage from cocaine induced rhabdomyolysis

Question 42

Blockage of cytokines will not affect:

Answer 42

LPS stimulation of OVLT endothelium via TLR/CD14 complex

Question 43

IL-1 and LPS can be suppressed by COX inhibitors because

Answer 43

IL-1 and LPS both stimulate PGE2 release from the basal side of the OVLT endothelial cells

Question 44

Amphotericin B

Answer 44

Binds to sterols in the cell membrane

Question 45

Erythromycin

Answer 45

54. Erythromycin

Question 46

Rifampin

Answer 46

binds to beta subunit of DNA dependent RNA polymerase thereby blocking RNA transcription

Question 47

Levofloxacin

Answer 47

inhibits bacterial topoisomerase IV and DNA gyrase

Question 48

Sulfamethoxazole

Answer 48

inhibits enzymes in the folic acid synthesis pathway

Question 49

Cephazolin

Answer 49

inhibits 3rd and final stage on bacterial cell wall synthesis by binding with specific penicillin binding proteins

Question 50

Fluconazole

Answer 50

interacts with 14 alpha demethylase preventing the conversion of lanosterol to ergosterol

Question 51

Ritonavir used for AIDS, PI, how does it work?

Answer 51

virus assembly affected so lack of mature cleaved forms of viral proteins

Question 52

Hypovolemic shock, metabolic acidosis, DKA, volume status is from

Answer 52

osmotic diuresis

Question 53

Diabetes insipidus

Answer 53

decreased ADH or decreased effect leads to dilute urine, concentrated serum so increase in Na

Question 54

Monitoring SLE

Answer 54

anti-double stranded DNA antibody

Question 55

Not responsible for pleasurable effects of drugs like cocaine

Answer 55

dopamine, pleasure center in brain and cocaine inhibits dopamine

Question 56

Buddhist

Answer 56

religion where final moment of consciousness is important, body should remain undisturbed for 3-8 hours after breathing stops so would be upset about operation soon after death

Question 57

Serum albumin to ascites albumin is 1.9

Answer 57

cause of ascites is portal hypertension from cirrhosis | >1.1 = transudate

Question 58

IV drug user with bibasilar pulmonary crackles, aortic valve vegetations, moderate aortic valve insufficiency, describe murmur

Answer 58

decrescendo diastolic murmur at right second intercostal space and left sternal border – aortic regurg

Question 59

GSW, ruptured colon, lacerated liver, high risk for infection, abx reginmen?

Answer 59

piperacillin plus taxobactam since it covers gram positive, negatives and anaerobes

Question 60

Acute HIV syndrome

Answer 60

burst in plasma viremia, decline in CD4 THEN clinical latency and AIDS

Question 61

A 10‐year‐old boy presents with abdominal pain that began periumbilically but has now moved to the RLQ. What types of bacteria do you worry about? What drugs might work?

Answer 61

Appendicitis is going to involve bowel flora, so predominantly Gram negatives and anaerobes, with a few Gram positives such as Enterococcus thrown in for fun. The good news is that this is a previously healthy child with an intact immune system who will have the infected body part removed surgically, so almost anything will help. Every surgeon has their own favorite regimen. Here, what is usually started is piperacillin/tazobactam (Zosyn), which is active against Pseudomonas, anaerobes and most Gram negatives. Ampicillin with sulbactam (Unasyn) has been used alone – it covers most Gram negatives and anaerobes but not Pseudomonas. Cefotetan is a cephalosporin with reasonably good anaerobe coverage; some surgeons like that. If the kid has a periappendiceal abscess or operative complications, I would not use monotherapy – I would definitely add gentamicin in that case.