SEM - IM Flashcards by

On ECG, there were ST depression on leads II, III, and aVF. The patient was hypotensive upon arrival at the ER. The affected wall(s) is/are:

A. Anterolateral wall
B. Lateral wall
C. Inferior wall
D. Septum

C. Inferior wall

High‐Yield Rationale:
🍎 Inferior leads: Leads II, III, and aVF correspond to the inferior wall of the heart. ST depression (in the setting of hypotension) is consistent with ischemic changes in the inferior region, sometimes indicating a reciprocal change of a posterior infarct or evolving inferior infarction.
🍎 Hemodynamic compromise: Hypotension can be associated with right ventricular involvement in an inferior MI, further emphasizing the significance of the inferior wall in this context.

How well did you know this?

Not at all

Perfectly

The most common form of acute kidney injury is:

A. Postrenal acute kidney injury

B. Prerenal azotemia

C. Intrinsic acute kidney injury

B. Prerenal azotemia

High‐Yield Rationale:
🍎 Perfusion issues: Prerenal azotemia accounts for the majority of AKI cases because it is usually due to decreased renal blood flow from conditions such as dehydration, hypotension, or heart failure, which are common clinical scenarios.

How well did you know this?

Not at all

Perfectly

The most common cause of heart failure in Asia and Africa is:

A. Chagas’ disease

B. Rheumatic heart disease

C. All of the above

D. Coronary artery disease

B. Rheumatic heart disease

High‐Yield Rationale:
🍎 Epidemiology: In many developing regions such as Asia and Africa, rheumatic heart disease remains prevalent due to untreated or recurrent streptococcal infections, leading to valvular damage and subsequent heart failure.

How well did you know this?

Not at all

Perfectly

A 50-year-old diabetic patient was brought to the ER due to changes in sensorium. The patient had nausea, vomiting, and abdominal pain a few hours prior to consultation. Upon arrival at the ER, the CBG was 280mg/dl and the patient was drowsy with ketones ++. The expected derangement in arterial blood gas is:

A. Respiratory alkalosis

B. Respiratory acidosis

C. Metabolic alkalosis

D. Metabolic acidosis

How well did you know this?

Not at all

Perfectly

ST elevation on ECG suggests:

A. Transmural involvement

B. Septal hypertrophy

C. Dilated left atrium

D. Subendocardial involvement

How well did you know this?

Not at all

Perfectly

True or false: Diastolic blood pressure decreases after 55 years old, resulting in wide pulse pressure.

A. True

B. False

A. True

High‐Yield Rationale:
🍎 Arterial stiffness: With aging, increased arterial stiffness leads to a decrease in diastolic pressure while systolic pressure remains high, thus widening the pulse pressure.

Why Not the Other Choice?
🍊 False (B): Contrary to the statement, the physiological changes in the vasculature in older adults do indeed lead to a decrease in diastolic pressure and wider pulse pressure.

How well did you know this?

Not at all

Perfectly

Correction of severe hyperkalemia in chronic kidney disease is done with the following medications:

A. None of the above

B. All of the above

C. 1 ampule Calcium gluconate slow IV push over 5 minutes

D. D50-50 1 vial IV push followed by 10 units of insulin

B. All of the above
(GIC protocol for severe hyperkalemia: Calcium gluconate plus insulin-dextrose)

🍎 High-Yield Rationale:
🔸 GIC Protocol Overview:
🍏 Glucose + Insulin (Option D): Administer D50-50 IV push followed by 10 units of regular insulin to drive serum potassium intracellularly, thereby reducing serum potassium levels rapidly.
🍏 Calcium (Option C): Give 1 ampule of calcium gluconate slow IV push over 5 minutes to immediately stabilize the myocardial cell membranes and lessen the risk of lethal arrhythmias due to hyperkalemia.

🍊 Why Not the Other Choices?
🔹 A. None of the above:
🍎 Incorrect because effective treatments (both calcium gluconate and insulin/dextrose) exist for severe hyperkalemia.
🔹 C. Calcium gluconate slow IV push over 5 minutes (alone):
🍎 Although critical for myocardial stabilization, it does not reduce potassium levels—the shift is achieved by insulin/dextrose.
🔹 D. D50-50 IV push followed by 10 units of insulin (alone):
🍎 While this lowers serum potassium by promoting intracellular uptake, it does not protect the heart from the immediate depolarizing effects of hyperkalemia, which is why calcium is also needed.

How well did you know this?

Not at all

Perfectly

Titration of anti-thyroid medications to assess response or improvement is done every:

A. 1-2 weeks

B. 6-8 weeks

C. 4-6 weeks

D. 2-4 weeks

C. 4–6 weeks

⸻

✅ High-Yield Rationale:
* Antithyroid medications (e.g., Methimazole, PTU) are titrated based on Free T4 levels, not TSH (which remains suppressed for months).
* Dose adjustments should be made every 4–6 weeks during initial therapy until euthyroid state is achieved.
* Monitoring too early (e.g., 1–2 weeks) may not reflect meaningful change, while delaying beyond 6 weeks risks prolonged symptoms or over-treatment.

How well did you know this?

Not at all

Perfectly

A patient was brought to the emergency room due to unresponsiveness. He had febrile episodes for 1 week, with nausea and vomiting. Pupils were sluggishly reactive to light, and there was nuchal rigidity (+) Brudzinski (+) Kernig’s. No rashes were noted during examination. This patient most likely has:

A. Meningitis

B. Subdural hematoma

C. Ischemic stroke

D. Intracerebral hemorrhage

How well did you know this?

Not at all

Perfectly

Asymptomatic bacteriuria generally is not treated except in pregnancy because of the following EXCEPT:

A. Preterm delivery

B. Low birth weights

C. Maternal pyelonephritis

D. None of the above

High‐Yield Rationale:
🍎 Pregnancy risks: In pregnant women, asymptomatic bacteriuria is treated to prevent complications such as preterm delivery, low birth weights, and maternal pyelonephritis. Each of the reasons listed (preterm delivery, low birth weights, maternal pyelonephritis) is a valid concern; therefore, none are exceptions.

How well did you know this?

Not at all

Perfectly

The first-line treatment for acute Gouty arthritis is:

A. Colchicine

B. Febuxostat

C. Warm compress

D. Allopurinol

A. Colchicine

🍎 High-Yield Rationale:
🔸 Rapid Anti-inflammatory Action: Colchicine quickly reduces the inflammatory response associated with the deposition of monosodium urate crystals in joints, making it a first-line option when NSAIDs are contraindicated or not tolerated.

🍊 Why Not the Other Choices?
🔹 B. Febuxostat: This is a urate-lowering agent used for long-term management and prevention, not for acute attacks.
🔹 C. Warm compress: While it may provide symptomatic relief, it is not an evidence-based primary treatment for the acute inflammatory process in gout.
🔹 D. Allopurinol: Like febuxostat, allopurinol is a long-term urate-lowering therapy and can worsen acute attacks if initiated during an acute episode.

How well did you know this?

Not at all

Perfectly

The indications for dialysis are the following EXCEPT:

A. Elevated creatinine levels

B. Exposure to toxins/poisons

C. Intractable acidosis

D. Uremia

A. Elevated creatinine levels

🍎 High-Yield Rationale:
🔸 Clinical Context Is Key: An isolated elevation in creatinine is not sufficient to indicate dialysis. Rather, dialysis is indicated by complications such as severe uremia, intractable acidosis, or exposure to toxins/poisons that lead to life-threatening metabolic disturbances.

How well did you know this?

Not at all

Perfectly

In systemic inflammatory response syndrome, the WBC count requirement is:

A. 5000-10000

B. Only <4000 and >12000

C. >12000

D. <4000

B. Only <4000 and >12000

🍎 High-Yield Rationale:
🔸 Diagnostic Criteria: SIRS is defined by abnormal WBC counts, specifically leukopenia (<4000/mm³) or leukocytosis (>12,000/mm³), among other parameters. This criterion reflects the systemic inflammatory response.

How well did you know this?

Not at all

Perfectly

The most common drug for gout associated with Steven-Johnson’s syndrome is:

A. Colchicine

B. Allopurinol

C. Febuxostat

D. Diclofenac

How well did you know this?

Not at all

Perfectly

Mean arterial pressure is:

A. None of the above

B. All of the above

C. (SBP + 2DBP)/3

D. The product of the cardiac output and systemic vascular resistance

B. All of the above

Rationale:

Mean Arterial Pressure (MAP) can be estimated and understood in two valid ways:
1. Formula estimation:
• MAP ≈ (SBP + 2 × DBP) / 3
• This is a clinically useful approximation used because diastole lasts longer than systole.
2. Physiologic definition:
• MAP = CO × SVR (Cardiac Output × Systemic Vascular Resistance)
• This is based on the hemodynamic equation derived from Ohm’s law in cardiovascular physiology.

So both C and D are correct, making B (All of the above) the best choice.

How well did you know this?

Not at all

Perfectly

A patient underwent TURP for prostatic hypertrophy. He was noted to be persistently hypotensive despite continuous hydration and inotropic support. The patient suddenly complained of chest pains, ECG showed ST elevation in leads V1-V4, and troponin was positive. This patient is category:

A. Type V MI

B. Type II MI

C. Type I MI

D. Type III MI

E. Type IV MI

B. Type II MI

🍎 High-Yield Rationale:
🔸 Supply-Demand Imbalance: Type II MI occurs due to an imbalance between myocardial oxygen supply and demand. In this case, persistent hypotension led to decreased coronary perfusion, triggering ischemia.
🔸 Context of Non-Coronary Stress: Unlike Type I MI (which results from primary coronary thrombosis), this MI is secondary to systemic stress (prolonged hypotension).

How well did you know this?

Not at all

Perfectly

Discoloration of the flanks due to hemoglobin catabolism from severe necrotizing pancreatitis with hemorrhage is called:

A. Quinke’s sign

B. Water’s sign

C. Cullen’s sign

D. Turner’s sign

🍎 High-Yield Rationale:
🔸 Hemorrhagic Pancreatitis Sign: Turner’s sign (more commonly termed Grey Turner’s sign) is the flank discoloration seen in cases of retroperitoneal hemorrhage, such as in severe pancreatitis.

🍊 Why Not the Other Choices?
🔹 A. Quinke’s sign: Typically refers to angioedema, not related to pancreatitis.
🔹 B. Water’s sign: Not a recognized clinical sign in this context.
🔹 C. Cullen’s sign: Denotes periumbilical ecchymosis, not flank ecchymosis.

How well did you know this?

Not at all

Perfectly

A 35-year-old female call center agent sought consultation due to fever, nausea, and vomiting. PE showed bilateral costovertebral tenderness, more on the right. Ultrasound showed staghorn calculi in both calyces. What does this patient have?

A. Uric acid nephropathy

B. Xanthogranulomatous pyelonephritis

C. Calcium phosphate crystals in the urine

D. Uncomplicated pyelonephritis

How well did you know this?

Not at all

Perfectly

Door to balloon time is:

A. 15 minutes or less

B. 90 minutes or less

C. 30 minutes or less

D. 60 minutes or less

How well did you know this?

Not at all

Perfectly

A patient sought consultation due to unilateral facial edema with unilateral periorbital edema. During examination, he had prominent chest wall superficial veins up to the neck. He was previously diagnosed with lymphoma. Chest X-ray was done. What is the expected finding?

A. White out lung

B. Widening of the mediastinum

C. Flattening of the diaphragm, wide intercostal spaces, and elongated heart

D. Pleural effusion

B. Widening of the mediastinum

🍎 High-Yield Rationale:
🔸 Mediastinal Mass Effect: In lymphoma, mediastinal lymphadenopathy can compress the superior vena cava, leading to SVC syndrome. This is reflected on chest X-ray as widening of the mediastinum.

🍊 Why Not the Other Choices?
🔹 A. White out lung: Suggests extensive pulmonary consolidation or collapse, not typical of SVC syndrome.
🔹 C. Flattening of the diaphragm, wide intercostal spaces, and elongated heart: These are signs of conditions such as emphysema, not SVC syndrome.
🔹 D. Pleural effusion: While it can accompany lymphoma, it is not the expected primary finding in SVC syndrome.

How well did you know this?

Not at all

Perfectly

The normal range for fasting blood glucose is:

A. 60-89

B. 80-120

C. None of the above

D. 70-100

D. 70–100

🍎 High-Yield Rationale:
🔸 Accepted Normal Range: Fasting blood glucose is typically defined as 70 to 100 mg/dL, representing normal glycemic control in a healthy individual.

🍊 Why Not the Other Choices?
🔹 A. 60–89: Lower than the standard lower limit; values below 70 are usually considered hypoglycemic.
🔹 B. 80–120: The upper limit of 120 mg/dL exceeds the normal fasting range and would be considered borderline or prediabetic.
🔹 C. None of the above: Incorrect because option D accurately reflects the normal range.

How well did you know this?

Not at all

Perfectly

True or false: The higher the uric acid, the higher the risk of heart attack, heart failure, atrial fibrillation, or irregular heartbeat.

A. True

B. False

How well did you know this?

Not at all

Perfectly

Anti-hypertensive medications recommended for blacks or African-Americans are:

A. CCB and diuretics

B. CCB and ARB

C. BB and ACEI

D. Valsartan and sacubitril

A. CCB and diuretics

🍎 High-Yield Rationale:
🔸 Guideline Recommendations: Current guidelines recommend calcium channel blockers (CCB) and thiazide diuretics as first-line antihypertensive agents for black/African-American patients due to their superior efficacy in reducing blood pressure and cardiovascular risk in this population.

🍊 Why Not the Other Choices?
🔹 B. CCB and ARB: Although ARBs are useful, thiazide diuretics are preferred over ARBs in the initial management.
🔹 C. BB and ACEI: Beta blockers and ACE inhibitors generally have less antihypertensive efficacy in this demographic when used as monotherapy.
🔹 D. Valsartan and sacubitril: This combination (an ARB and neprilysin inhibitor) is used in heart failure, not as first-line antihypertensive therapy for the general hypertensive black population.

How well did you know this?

Not at all

Perfectly

Monsoon rains affected the coastal cities in India and the local government units recruited individuals to clean the rivers and canals to decrease flooding. You were asked to head the task force. What prophylaxis should the street sweepers receive?

A. Penicillin

B. Azithromycin

C. Doxycycline

D. Amoxicillin

How well did you know this?

Not at all

Perfectly

A 34-year-old female had normal blood pressure at the doctor’s clinic, while with elevated blood pressure at home. This patient has:

A. Masked hypertension

B. Secondary hypertension

C. White coat hypertension

D. Essential hypertension

A. Masked hypertension

🍎 High-Yield Rationale:
🔸 Masked Hypertension Defined: Masked hypertension is when a patient has normal blood pressure readings in the clinical setting but elevated values outside (for example, at home). This pattern may lead to underdiagnosis if only clinic measurements are used.

🍊 Why Not the Other Choices?
🔹 B. Secondary hypertension: Implies a specific underlying cause, which is not indicated by this scenario.
🔹 C. White coat hypertension: In white coat hypertension, the opposite occurs: elevated BP in the clinic and normal BP outside the clinical setting.
🔹 D. Essential hypertension: Refers to primary hypertension without a known secondary cause and is typically consistently elevated both in and outside the clinic.

How well did you know this?

Not at all

Perfectly

A 48-year-old tuberculosis patient sought consultation due to numbness of the lower half of his body. On examination, his motor is 5/5 on both lower extremities, and numbness from the umbilicus and below with a 50% sensory deficit. The location of the lesion is most likely at:

A. T12

B. L1 and below

C. T10

D. T8

C. T10

🍎 High-Yield Rationale:
🔸 Dermatome Mapping: The umbilicus corresponds to the T10 dermatome, so a sensory level at the umbilicus indicates a lesion at the T10 spinal segment.
🔸 Tuberculous Myelopathy: Tuberculosis may affect the vertebral column (Pott’s disease) and typically involves the lower thoracic spine, consistent with a T10 lesion.

🍊 Why Not the Other Choices?
🔹 A. T12: A lesion at T12 would present with a sensory level lower than the umbilicus.
🔹 B. L1 and below: Lesions at or below L1 would produce sensory deficits in the lower extremities and pelvic area, not starting at the umbilicus.
🔹 D. T8: A T8 lesion would produce a sensory deficit above the umbilicus.

How well did you know this?

Not at all

Perfectly

Hyperuricemia is associated with the following conditions EXCEPT:

A. None of the above

B. Stroke and hypertension

C. Coronary artery disease

D. Tumor lysis syndrome

How well did you know this?

Not at all

Perfectly

Door to needle time is:

A. 15 minutes or less

B. 30 minutes or less

C. 90 minutes or less

D. 60 minutes or less

B. 30 minutes or less

🍎 High-Yield Rationale:
🔸 Thrombolytic Therapy Target: For patients receiving thrombolytic therapy in acute myocardial infarction, guidelines recommend that door-to-needle time should be 30 minutes or less to rapidly restore perfusion and minimize myocardial damage.

🍊 Why Not the Other Choices?
🔹 A. 15 minutes or less: This is unrealistically short for most clinical settings.
🔹 C. 90 minutes or less: This time frame applies to door-to-balloon time in primary PCI rather than thrombolytic therapy.
🔹 D. 60 minutes or less: Although quicker treatment is ideal, the target is specifically 30 minutes or less for thrombolysis.

How well did you know this?

Not at all

Perfectly

A 60-year-old male complained of epigastric pain followed by hypotension and cold clammy sweats. ECG showed ST elevation in II, III, and aVF. Troponin was positive. This patient has:

A. None of the above

B. Unstable angina

C. ST elevation MI

D. Non-ST elevation MI

How well did you know this?

Not at all

Perfectly

The most common spinal segment involved in malignant spinal cord compression is:

A. Thoracic

B. Lumbosacral

C. Cervical

D. Lumbar

How well did you know this?

Not at all

Perfectly

Which of the statements are FALSE?

A. All of the above are true

B. Pyrazinamide can cause hemolytic anemia and thrombocytopenia

C. Isoniazid can cause hepatitis

D. Ethambutol can cause optic neuritis

E. None of the above are true

B. Pyrazinamide can cause hemolytic anemia and thrombocytopenia

How well did you know this?

Not at all

Perfectly

A 70-year-old male complained of chest discomfort at rest. This indicates:

A. >80% coronary artery stenosis

B. None of the above

C. 50% coronary artery stenosis

D. 80% coronary artery stenosis

🍎 High-Yield Rationale:
🔸 Significance of Rest Pain: Chest discomfort at rest suggests unstable angina, usually caused by critical coronary artery narrowing, typically around 80% stenosis, which reduces coronary flow sufficiently at rest.

🍊 Why Not the Other Choices?
🔹 A. >80% coronary artery stenosis: Although severe, a threshold higher than 80% is not the classical cut-off for unstable angina.
🔹 C. 50% coronary artery stenosis: This degree of stenosis is generally not enough to produce rest angina.
🔹 B. None of the above: This option is incorrect as option D correctly describes the level of stenosis associated with these symptoms.

How well did you know this?

Not at all

Perfectly

Which of the following statements is true?

A. Extrapulmonary TB is treated for 6 months

B. New onset jaundice is an indication to stop anti-TB medications

C. Breastfeeding is not allowed while on anti-TB medications because of toxicity in the newborn

D. Streptomycin is the drug of choice among pregnant TB patients

How well did you know this?

Not at all

Perfectly

Periumbilical discoloration due to hemoperitoneum in pancreatitis is called:

A. Turner’s sign

B. Cullen’s sign

C. Quinke’s sign

D. Water’s sign

How well did you know this?

Not at all

Perfectly

In tumor lysis syndrome, the electrolytes expected to increase are the following EXCEPT:

A. Potassium

B. Phosphate

C. Calcium

D. None of the above

C. Calcium

🍎 High-Yield Rationale:
🔸 Electrolyte Changes in TLS: In tumor lysis syndrome, rapid cell breakdown leads to increases in serum potassium and phosphate. Calcium, however, typically decreases (hypocalcemia) due to precipitation with phosphate.

🍊 Why Not the Other Choices?
🔹 A. Potassium: Expected to be increased due to release from lysed cells.
🔹 B. Phosphate: Also increases as phosphate is released from intracellular stores during cell lysis.
🔹 D. None of the above: Incorrect because calcium does not increase; it decreases.

How well did you know this?

Not at all

Perfectly

Tumor lysis syndrome occurs most frequently among the following EXCEPT:

A. Lymphomas and leukemias

B. All of the above

C. Large tumor burden

D. None of the above

🍎 High-Yield Rationale:
🔸 Risk Factors in TLS: Tumor lysis syndrome typically occurs in patients with hematologic malignancies (lymphomas and leukemias) and those with large tumor burdens. Both A and C are classic risk factors.

🍊 Why Not the Other Choices?
🔹 A. Lymphomas and leukemias: These are well recognized as high-risk for TLS.
🔹 B. All of the above: This would imply that all the listed factors (i.e., lymphomas/leukemias and large tumor burden) predispose to TLS, which is true; however, the question asks for an exception, and none is an exception.
🔹 C. Large tumor burden: Also a common risk factor for TLS.

How well did you know this?

Not at all

Perfectly

A 22-year-old student sought consultation due to calf pain. He went river rafting with his friends one week prior to consultation. He noted dark-colored urine, fever, and chills. This patient most likely has:

A. Tuberculosis

B. Leptospirosis

C. Acute pyelonephritis

D. Dengue fever with warning signs

How well did you know this?

Not at all

Perfectly

True or false: Tuberculosis in diabetes is treated for nine (9) months.

A. False

B. True

C. Maybe

B. True

How well did you know this?

Not at all

Perfectly

Which of the following drugs is the most hepatotoxic?

A. Isoniazid

B. Rifampicin

C. Pyrazinamide

D. Ethambutol

C. Pyrazinamide

🍎 High-Yield Rationale:
🔸 Hepatotoxicity Profile: While isoniazid and rifampicin also carry hepatotoxic risk, pyrazinamide is recognized as the most hepatotoxic agent among the first-line anti-TB medications, often contributing significantly to drug-induced liver injury during TB treatment.

🍊 Why Not the Other Choices?
🔹 A. Isoniazid: Although hepatotoxic, its risk is generally lower than that of pyrazinamide.
🔹 B. Rifampicin: Also associated with liver injury, but not to the same degree as pyrazinamide.
🔹 D. Ethambutol: Known for optic neuritis rather than hepatotoxicity.

How well did you know this?

Not at all

Perfectly

This disease presents with ascending paralysis and may involve the diaphragm, needing respiratory support. It is called:

A. Guillain-Barré syndrome

B. Hypokalemic periodic paralysis

C. Hemorrhagic stroke

D. Ischemic stroke

How well did you know this?

Not at all

Perfectly

Malignancy that often metastasizes to the spinal column is/are the following:

A. Lung

B. Prostate

C. Breast

D. All of the above

🍎 High-Yield Rationale:
🔸 Common Origins: Lung, prostate, and breast cancers are known to metastasize to the spine because of their high prevalence and tendency for bony spread.

🍊 Why Not the Other Choices?
🔹 A. Lung: Although lung cancer does metastasize to the spine, it is not the only one.
🔹 B. Prostate: Prostate cancer commonly spreads to bone, but breast and lung are also significant.
🔹 C. Breast: Breast cancer is well-known for bony metastases; however, all these malignancies contribute.

How well did you know this?

Not at all

Perfectly

Ulnar deviation of the metacarpophalangeal joints will lead to:

A. Heberden nodes

B. Boutonnière deformity

C. Swan neck deformity

D. Subcutaneous nodes

C. Swan neck deformity.

Rationale
Ulnar deviation of the metacarpophalangeal (MCP) joints is a classic finding in rheumatoid arthritis (RA). In RA, chronic synovial inflammation leads to soft tissue damage—including the ligaments and tendons that support the joints. This damage permits a gradual, lateral (ulnar) drift of the fingers at the MCP joints.

Over time, the imbalance in tendon forces—especially those involved in finger extension—leads to a disruption in the normal mechanics of the hand. In many cases, this imbalance results in a swan neck deformity, which is characterized by:

Hyperextension of the proximal interphalangeal (PIP) joints

Flexion of the distal interphalangeal (DIP) joints

This swan neck configuration is essentially a secondary deformity related to the same underlying pathological process (chronic inflammation and ligamentous laxity) that produces the ulnar deviation at the MCP joints.

How well did you know this?

Not at all

Perfectly

Complications of pyelonephritis EXCEPT:

A. Xanthogranulomatous pyelonephritis

B. Abscess

C. None of the above

D. Obstructive uropathy from papillary necrosis

C. None of the above

🍎 High-Yield Rationale:
🔸 Recognized Complications: Pyelonephritis can lead to complications such as xanthogranulomatous pyelonephritis, abscess formation, and even obstructive uropathy due to papillary necrosis. Since all listed complications occur, “None of the above” is the correct answer for the exception.

🍊 Why Not the Other Choices?
🔹 A. Xanthogranulomatous pyelonephritis: A known complication of chronic pyelonephritis.
🔹 B. Abscess: Pyelonephritis can progress to the formation of renal or perinephric abscesses.
🔹 D. Obstructive uropathy from papillary necrosis: Papillary necrosis may cause sloughed tissue to obstruct the urinary tract.

A patient underwent a successful elective angioplasty. Upon transfer to the patient’s room after the procedure, the patient began to complain of chest pains with difficulty in breathing. He was rushed back to the cath lab, and repeat angiogram showed stent thrombosis. Troponin was positive. This patient falls under which category:

A. Type I MI

B. Type II MI

C. Type IV B

D. Type IV A

E. Type III MI

C. Type IV B

🍎 High-Yield Rationale:
🔸 Procedure-Related MI: Type IV MI is associated with percutaneous coronary intervention (PCI). Specifically, Type IVB is used to describe MI resulting from stent thrombosis, a recognized complication after PCI.

🍊 Why Not the Other Choices?
🔹 A. Type I MI: Refers to spontaneous MI due to plaque rupture and thrombosis in native coronary arteries.
🔹 B. Type II MI: Is due to an imbalance in myocardial oxygen supply and demand; not directly applicable to stent thrombosis.
🔹 D. Type IV A: Typically describes periprocedural MI related to the PCI procedure itself (e.g., minor enzyme rises) rather than stent thrombosis.
🔹 E. Type III MI: Involves sudden cardiac death where MI is inferred, which is not the case here.

A 45-year-old with elevated blood pressure at the clinic, and normal blood pressure at home. This is called:

A. White coat hypertension

B. Secondary hypertension

C. Essential hypertension

D. Masked hypertension

A. White coat hypertension

🍎 High-Yield Rationale:
🔸 Measurement Discrepancy: White coat hypertension is characterized by elevated blood pressure in the clinical setting due to anxiety, with normal readings outside the clinic.

🍊 Why Not the Other Choices?
🔹 B. Secondary hypertension: Implies an underlying cause, which is not indicated by this scenario.
🔹 C. Essential hypertension: Typically presents with consistently elevated blood pressure in all settings.
🔹 D. Masked hypertension: Is the opposite, with normal clinic BP and elevated readings at home.

Heberden’s nodes in osteoarthritis affect the following:

A. Proximal interphalangeal joints

B. Distal interphalangeal joints

C. Metatarsal joints

D. Metacarpal joints

B. Distal interphalangeal joints

🧠 Heberden = Higher (DIP) | Bouchard = Below (PIP)

🍎 High-Yield Rationale:
🔸 Classic Osteoarthritic Change: Heberden’s nodes are bony enlargements due to osteophyte formation at the distal interphalangeal (DIP) joints, a common manifestation of osteoarthritis.

🍊 Why Not the Other Choices?
🔹 A. Proximal interphalangeal joints: Bouchard’s nodes, not Heberden’s, affect these joints.
🔹 C. Metatarsal joints: Not typically associated with Heberden’s nodes.
🔹 D. Metacarpal joints: These are not the site of Heberden’s nodes.

A 50-year-old diabetic was brought to the ER due to changes in sensorium. The patient was having nausea, vomiting, and abdominal pain a few hours prior to consultation. Upon arrival at the ER, CBG was 280mg/dl and the patient was drowsy. Diagnostic test(s) to request is/are:

A. Arterial blood gas

B. None of the above

C. Ketones

D. Serum Na, Chloride, potassium

E. All of the above

🍎 High-Yield Rationale:
🔸 Comprehensive Evaluation: In a diabetic with possible diabetic ketoacidosis (DKA), it is essential to request an arterial blood gas (to assess for metabolic acidosis), check ketones (which are key to confirming DKA), and assess serum electrolytes (Na, Cl, K) to guide management.

🍊 Why Not the Other Choices?
🔹 A, C, D individually: Each test is important, making the comprehensive workup (E) the best approach.
🔹 B. None of the above: Incorrect because all of these tests contribute crucial data.

A 24-year-old G1P0 8 weeks AOG was diagnosed with a urinary tract infection. Which of the following antibiotics should NOT be given to this patient?

A. Trimethoprim-sulfamethoxazole

B. Cefipime

C. Ampicillin

D. Nitrofurantoin

A. Trimethoprim-sulfamethoxazole

🍎 High-Yield Rationale:
🔸 Teratogenicity Concerns: Trimethoprim-sulfamethoxazole is contraindicated during the first trimester due to its association with neural tube defects and other teratogenic risks.

🍊 Why Not the Other Choices?
🔹 B. Cefipime: Cephalosporins are generally considered safe during pregnancy.
🔹 C. Ampicillin: A penicillin derivative that is safe for use in pregnancy.
🔹 D. Nitrofurantoin: Although contraindicated near term, it is acceptable in the first trimester.

A patient complained of cardiac symptoms at rest. Using NYHA, this patient is classified as:

A. NYHA IV

B. NYHA III

C. NYHA I

D. NYHA II

A. NYHA IV

🍎 High-Yield Rationale:
🔸 Severity of Symptoms: NYHA class IV describes patients with cardiac symptoms at rest, indicating severe limitations in physical activity and often requiring supportive measures.

🍊 Why Not the Other Choices?
🔹 B. NYHA III: Involves symptoms with minimal exertion, not at rest.
🔹 C. NYHA I: No limitation of physical activity.
🔹 D. NYHA II: Slight limitation with ordinary activity; symptoms are not present at rest.

A 24-year-old medical student sought consult due to recurrent substernal chest pains aggravated by skipping meals. He was given ranitidine 75mg BID. How long should the H2 blocker be given to this patient?

A. 3 weeks

B. 1 week

C. 4 weeks

D. 2 weeks

D. 4 weeks

🧠 High-Yield Rationale:
H₂ blockers like ranitidine are used for functional dyspepsia or mild GERD, especially meal-related.
📌 Standard duration of therapy = 4 weeks
Shorter durations (<2 weeks) often result in incomplete symptom relief.

❌ Why not the others:

🅰️–🅲 1–3 weeks – Insufficient duration for healing and symptom control

🅴 5 weeks – No additional benefit vs 4 weeks; not standard practice

A patient had 75% numbness and 4/5 weakness of the right upper and lower extremities. No history of trauma, no maintenance medications. Symptoms resolved in 24 hours as if nothing happened. Repeat PE showed 100% sensory intact, 5/5 MMT. This patient likely had:

A. Transient ischemic attack

B. Guillain-Barré syndrome

C. Spinal cord compression

D. Transection of spinal cord

A. Transient ischemic attack

🍎 High-Yield Rationale:
🔸 Transient Symptoms: A transient ischemic attack (TIA) is characterized by temporary neurologic deficits that resolve completely within 24 hours.
🔸 No Residual Deficit: The full resolution of both sensory and motor functions supports the diagnosis of a TIA.

🍊 Why Not the Other Choices?
🔹 B. Guillain-Barré syndrome: Typically presents with progressive and symmetric weakness, not an acute, focal, and resolving episode.
🔹 C. Spinal cord compression: Would not resolve spontaneously in 24 hours and is usually associated with trauma or structural lesions.
🔹 D. Transection of spinal cord: Leads to permanent deficits; rapid and complete resolution is not possible.

Rheumatoid arthritis presents as:

A. Migratory polyarthritis

B. Swelling and tenderness of the first metatarsal joint

C. Pain and swelling of weight-bearing joints

D. Symmetrical joint pain and swelling of 3 or more joints

🍎 High-Yield Rationale:
🔸 Characteristic Pattern: RA classically presents with symmetric involvement of multiple joints, frequently affecting the small joints of the hands and feet, accompanied by pain and swelling.

🍊 Why Not the Other Choices?
🔹 A. Migratory polyarthritis: This pattern is more characteristic of conditions like rheumatic fever, not RA.
🔹 B. Swelling and tenderness of the first metatarsal joint: This is more typical of gout than RA.
🔹 C. Pain and swelling of weight-bearing joints: While osteoarthritis affects these joints, RA more commonly involves a symmetrical pattern in multiple joints.

True or false: ACEI and ARB can be combined to dramatically control hypertension.

A. True

B. False

C. Maybe

Dengue complications include the following EXCEPT:

A. Toxic epidermal necrolysis

B. Encephalitis

C. Myocarditis

D. Disseminated intravascular coagulopathy

A. Toxic epidermal necrolysis

🍎 High-Yield Rationale:
🔸 Dengue Spectrum: Dengue fever can cause complications like encephalitis, myocarditis, and disseminated intravascular coagulopathy. Toxic epidermal necrolysis (TEN), however, is not a recognized complication of dengue.

🍊 Why Not the Other Choices?
🔹 B. Encephalitis: This is a known complication of dengue.
🔹 C. Myocarditis: Cardiac involvement can occur in severe dengue.
🔹 D. Disseminated intravascular coagulopathy: DIC can be seen in dengue hemorrhagic fever.

The most frequent cause of heart failure in first-world countries:

A. Rheumatic heart disease

B. All of the above

C. Coronary artery disease

D. Chagas’ disease

C. Coronary artery disease

🍎 High-Yield Rationale:
🔸 Epidemiology: In developed countries, coronary artery disease is the leading cause of heart failure due to ischemic injury to the myocardium over time.

🍊 Why Not the Other Choices?
🔹 A. Rheumatic heart disease: Now uncommon in first-world countries due to early antibiotic treatment of streptococcal infections.
🔹 B. All of the above: Incorrect because not all listed conditions are the most common cause in this setting.
🔹 D. Chagas’ disease: Primarily seen in Latin America, not first-world countries.

The most frequent cause of heart failure in South America is:

A. Rheumatic heart disease

B. Coronary artery disease

C. Chagas’ disease

D. None of the above

C. Chagas’ disease

🍎 High-Yield Rationale:
🔸 Epidemiologic Relevance: Chagas disease, caused by Trypanosoma cruzi, remains a major contributor to cardiomyopathy and heart failure in South America.

🍊 Why Not the Other Choices?
🔹 A. Rheumatic heart disease: While it can cause heart failure, it is not the most frequent cause in South America.
🔹 B. Coronary artery disease: Less common as a primary cause compared to Chagas in endemic areas.
🔹 D. None of the above: Incorrect since Chagas disease is the recognized most frequent cause.

Treatment for white coat hypertension is:

A. Lifestyle modification and dietary restrictions

B. Start antihypertensive medications

C. None of the above

D. All of the above

Follow-up after initiation of medications for hypertension is:

A. After 4 weeks

B. After 1 week

C. After 3 weeks

D. After 2 weeks

Rationale:
The standard recommendation for initial follow-up after starting antihypertensive therapy is usually within 2 weeks, especially if lifestyle changes and medications have been initiated. This allows for early assessment of:
* Blood pressure response
* Tolerance to the medication
* Need for dose adjustment or additional agents

Valvular heart disease that presents with chest pains aggravated by exertion:

A. Tricuspid regurgitation

B. Mitral stenosis

C. Aortic stenosis

D. Mitral regurgitation

C. Aortic stenosis

🍎 High-Yield Rationale:
🔸 Exertional Angina: Aortic stenosis is classically associated with exertional angina due to the increased myocardial oxygen demand in the setting of fixed outflow obstruction.

🍊 Why Not the Other Choices?
🔹 A. Tricuspid regurgitation: More commonly causes signs of right-sided heart failure and does not typically cause exertional chest pain.
🔹 B. Mitral stenosis: Usually presents with dyspnea, fatigue, and sometimes atrial fibrillation, rather than classic angina.
🔹 D. Mitral regurgitation: Although it can lead to heart failure symptoms, it is not typically associated with exertional chest pain as its primary manifestation.

A patient with colon cancer suddenly complained of fecal and urinary incontinence. This patient most likely has:

A. Tumor lysis syndrome

B. Cauda equina syndrome

C. Dawn phenomenon

D. Superior vena cava syndrome

A. 2 weeks

B. 3 weeks

C. 4 weeks

D. 1 week

🍎 High-Yield Rationale:
🔸 Leptospiremia Timing: In leptospirosis, Leptospira organisms are typically present in the blood during the first week (about 7–10 days) of illness. After this period, they may move to urine for a brief period, making early blood culture crucial.

🍊 Why Not the Other Choices?
🔹 A. 2 weeks / B. 3 weeks / C. 4 weeks: These time frames are too late; by then, blood isolation becomes less reliable as the organisms clear from the bloodstream.

Absolute contraindications to fibrinolytic therapy EXCEPT:

A. Ischemic stroke 3 months prior

B. Aortic dissection

C. Active peptic ulcer

D. Intracranial hemorrhage

C. Active peptic ulcer

🍎 High-Yield Rationale:
🔸 Relative vs. Absolute Contraindications: Ischemic stroke within 3 months, aortic dissection, and intracranial hemorrhage are recognized absolute contraindications to fibrinolysis. Although active peptic ulcer disease might pose bleeding risks, it is generally regarded as a relative contraindication rather than absolute, particularly if active bleeding is not present.

🍊 Why Not the Other Choices?
🔹 A. Ischemic stroke 3 months prior: History of recent stroke is an absolute contraindication.
🔹 B. Aortic dissection: This condition is life-threatening and absolutely contraindicates fibrinolysis.
🔹 D. Intracranial hemorrhage: This is a clear absolute contraindication due to high risk of catastrophic bleeding.

Antibiotic considered safe for the treatment of urinary tract infection in pregnancy:

A. None of the above

B. Fluoroquinolones

C. Sulfonamides

D. Nitrofurantoin

🍎 High-Yield Rationale:
🔸 Pregnancy Safety: Nitrofurantoin is widely used and considered safe for treating urinary tract infections during pregnancy (except near term, due to the risk of neonatal hemolysis).

🍊 Why Not the Other Choices?
🔹 A. None of the above: Incorrect because Nitrofurantoin is a safe option.
🔹 B. Fluoroquinolones: These are contraindicated in pregnancy due to potential cartilage toxicity.
🔹 C. Sulfonamides: Especially in the first trimester and near term, they carry risks such as kernicterus and congenital malformations.

Which of the following will cause 8th cranial nerve damage?

A. Quinolones

B. Pyrazinamide

C. Streptomycin

D. Ethambutol

C. Streptomycin

🍎 High-Yield Rationale:
🔸 Ototoxicity: Streptomycin is an aminoglycoside antibiotic that is notorious for its ototoxic effects, leading to damage of the 8th cranial nerve (vestibulocochlear), which manifests as hearing loss and balance issues.

🍊 Why Not the Other Choices?
🔹 A. Quinolones: These may cause tendon issues and, rarely, other effects but not typically ototoxicity of the 8th nerve.
🔹 B. Pyrazinamide: Known mainly for hepatotoxicity rather than ototoxicity.
🔹 D. Ethambutol: Primarily causes optic neuritis, affecting vision rather than hearing.

Most common cause of chronic pancreatitis is:

A. Gallstones

B. Alcohol

C. Phenacetin abuse

D. Smoking

B. Alcohol

🍎 High-Yield Rationale:
🔸 Alcohol Abuse: Chronic alcohol consumption is the leading cause of chronic pancreatitis in most populations worldwide. It leads to repeated pancreatic injury and fibrosis over time.

🍊 Why Not the Other Choices?
🔹 A. Gallstones: Typically associated with acute pancreatitis rather than the chronic form.
🔹 C. Phenacetin abuse: Once implicated, but its use is now uncommon and not the primary cause.
🔹 D. Smoking: While a risk factor and synergistic with alcohol, alcohol remains the predominant cause.

Osteoarthritis presents as:

A. Pain and swelling of the first metatarsal joint

B. Migratory polyarthritis

C. Symmetrical joint pain and swelling of 3 or more joints

D. Pain and swelling of weight-bearing joints

🍎 High-Yield Rationale:
🔸 Degenerative Joint Disease: Osteoarthritis commonly affects weight-bearing joints (such as the knees and hips) and is characterized by pain that worsens with activity, joint stiffness, and bony enlargements (osteophytes).

🍊 Why Not the Other Choices?
🔹 A. Pain and swelling of the first metatarsal joint: More typical of gout rather than osteoarthritis.
🔹 B. Migratory polyarthritis: Associated with rheumatic fever and other inflammatory diseases, not osteoarthritis.
🔹 C. Symmetrical joint pain and swelling of 3 or more joints: This pattern is more in line with rheumatoid arthritis.

Which of the following is safest to use in pregnancy?

A. Isoniazid

B. Pyrazinamide

C. Streptomycin

D. Ethambutol

A. Isoniazid

🍎 High-Yield Rationale:
🔸 Pregnancy Use: Isoniazid is one of the first-line anti-TB medications and is considered safe for use during pregnancy when supplemented with pyridoxine (vitamin B6). It is a cornerstone of TB treatment in pregnant patients.

🍊 Why Not the Other Choices?
🔹 B. Pyrazinamide: Its safety profile in pregnancy is less well established, though many guidelines now endorse its use; however, Isoniazid remains the classic answer.
🔹 C. Streptomycin: Contraindicated in pregnancy due to the risk of ototoxicity in the fetus.
🔹 D. Ethambutol: Although generally safe, Isoniazid is more traditionally recognized as a first-line safe agent.

True or false: Tuberculosis in pregnancy should be treated as non-pregnant.

A. False

B. True

🍎 High-Yield Rationale:
🔸 Standard Regimen: TB in pregnancy is managed using a similar regimen to non-pregnant adults (typically a combination of Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide) with the exception of Streptomycin, which is contraindicated. Current guidelines support treating TB in pregnancy as in non-pregnant individuals.

🍊 Why Not the Other Choices?
🔹 A. False / C. Maybe: The evidence supports using the same treatment regimen (with careful monitoring), so the correct answer is true.

A 55-year-old male complained of chest pains accompanied by difficulty in breathing and cold clammy perspiration. He was immediately brought to the nearest hospital. However, upon arrival at the ER, the patient was unresponsive, CPR was given but to no avail and was declared dead after efforts of resuscitation. Under the universal MI classification, this patient is:

A. Type II

B. Type III

C. Type V

D. Type I

E. Type IV

B. Type III

🍎 High-Yield Rationale:
🔸 Type III MI Definition: Type III MI is defined as sudden cardiac death in which symptoms of myocardial ischemia occur and biomarker evidence of infarction is assumed, but death occurs before blood samples can be obtained or before the full evolution of diagnostic markers. This situation fits the description provided.

🍊 Why Not the Other Choices?
🔹 A. Type II: Pertains to MI resulting from a supply-demand mismatch, not sudden death.
🔹 C. Type V: Relates to MI in the setting of coronary bypass surgery.
🔹 D. Type I: Refers to spontaneous MI from plaque rupture with thrombosis.
🔹 E. Type IV: Is associated with periprocedural MI during PCI, which is not applicable here.

A patient with spinal cord compression complained of numbness at the level of the nipples. The lesion in the spine is located at:

A. T4

B. T12

C. T10

D. T2

A. T4

🍎 High-Yield Rationale:
🔸 The nipple line corresponds to the T4 dermatome, so a patient with numbness at this level most likely has a lesion at the T4 spinal segment.

🍊 Why Not the Other Choices?
🔹 B. T12: A lesion at T12 would result in sensory loss lower than the nipple line.
🔹 C. T10: This dermatome is below the level of the nipples.
🔹 D. T2: Lesions at T2 would affect areas above the nipples.

On ECG, ST elevation was noted at leads V3, V4, V5, and V6. The walls affected are:

A. Inferior wall

B. Anterolateral wall

C. Septum

D. Inferolateral

B. Anterolateral wall

🍎 High-Yield Rationale:
🔸 Leads V3–V6 primarily view the anterior and lateral regions of the left ventricle. Therefore, ST elevation here indicates an anterolateral myocardial infarction.

🍊 Why Not the Other Choices?
🔹 A. Inferior wall: Inferior leads are II, III, and aVF, not the precordial leads mentioned.
🔹 C. Septum: Septal involvement is typically seen in V1–V2.
🔹 D. Inferolateral: Although “inferolateral” can occur with lateral infarctions, the classic description for these lead changes is anterolateral.

A patient had bitemporal hemianopsia. The lesion is located at:

A. Left optic nerve

B. Optic tract

C. Right optic nerve

D. Optic chiasm

🍎 High-Yield Rationale:
🔸 Bitemporal hemianopsia is the classic visual field defect seen with lesions at the optic chiasm, where the nasal retinal fibers cross.

🍊 Why Not the Other Choices?
🔹 A. Left optic nerve / C. Right optic nerve: A lesion of a single optic nerve causes unilateral blindness or visual deficits, not a bitemporal field cut.
🔹 B. Optic tract: Damage here leads to contralateral homonymous hemianopsia, not a bitemporal loss.

A 28-year-old patient with renal failure secondary to chronic glomerulonephritis sought consultation with blood chemistry levels. FBS 98mg/dl, Chole 198mg/dl, LDL 90mg/dl, HDL 50mg/dl, TG 150mg/dl, BUA 40mg/dl (normal range 7-20mg/dl). SGPT and SGOT are 3x the upper limit of normal. Which of the statements are true?

A. There is no need to adjust febuxostat

B. Adjust the dose of febuxostat because of abnormal liver function tests

C. Adjust the dose of febuxostat because of renal failure

D. Adjust the dose of febuxostat to renal and liver dose

D. There is no need to adjust febuxostat

🧠 High-Yield Rationale:
📌 Febuxostat is a non-purine xanthine oxidase inhibitor used for hyperuricemia in gout.
🟢 It does not require dose adjustment in mild to moderate renal impairment.
🟢 However, it is contraindicated in patients with severe hepatic impairment, and caution is advised if liver enzymes are elevated.

In this case, although SGPT/SGOT are 3x ULN, it is still within tolerable limits for close monitoring, especially if there are no clinical signs of liver failure.

❌ Why not the others:

🅰️ Adjust due to renal failure – Febuxostat is renally safe in mild-moderate impairment

🅱️ Adjust to renal + liver dose – Only monitor, not adjust unless liver failure

🅲 Adjust due to abnormal LFTs – No automatic adjustment unless >3x ULN + symptoms

Treatment for tuberculosis WHO category 1:

A. 2 HRZES, 4 HR

B. 2 HRZE, 4 HR

C. 2 HRZE, 1 S, 4 HR

D. 2 HRZE, 10 HR

B. 2 HRZE, 4 HR

🍎 High-Yield Rationale:
🔸 WHO Category 1 TB treatment for new cases involves an intensive phase of 2 months with Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), and Ethambutol (E), followed by a 4-month continuation phase with Isoniazid and Rifampicin (HR).

🍊 Why Not the Other Choices?
🔹 A. 2 HRZES, 4 HR: The “S” typically stands for Streptomycin, which is not used in standard Category 1 treatment.
🔹 C. 2 HRZE, 1 S, 4 HR: Adding Streptomycin is not part of the standard regimen.
🔹 D. 2 HRZE, 10 HR: A 10-month continuation phase is too long for Category 1 TB.

A patient sought consultation due to right-sided facial edema with periorbital edema. During examination, he had prominent chest wall superficial veins up to the neck. He was previously diagnosed with lymphoma. What does the patient have?

A. Spinal cord compression

B. Superior vena cava syndrome

C. Cauda equina syndrome

D. Tumor lysis syndrome

B. Superior vena cava syndrome

🍎 High-Yield Rationale:
🔸 A patient with lymphoma can develop mediastinal masses that compress the superior vena cava (SVC), leading to SVC syndrome characterized by facial/periorbital edema and engorged chest wall veins.

🍊 Why Not the Other Choices?
🔹 A. Spinal cord compression: Would present with neurological deficits, not primarily with facial edema.
🔹 C. Cauda equina syndrome: Involves lower extremity and sphincter dysfunction.
🔹 D. Tumor lysis syndrome: A metabolic complication, not related to venous compression.

True or false: Hyperuricemia is an independent risk factor for cardiovascular disease.

A. False

B. Maybe

C. True

True or false: CKD patients 18 years old and above can be given ACEI or ARB as initial treatment to improve kidney outcomes.

A. False

B. Maybe

C. True

Street sweepers were asked to clean the canals of debris in preparation for a storm. The street sweepers should receive which drug:

A. Levofloxacin 500mg once a day for 7 days

B. Piperacillin tazobactam single dose

C. Clindamycin 650mg once a day for 3 days

D. Doxycycline 100mg 1 tab once a week

Treatment for XDRTB:

A. 2 HRZE, 4 HR

B. 2 HRZE, 10 HR

C. 2 HRZES, 4 HR

D. No effective treatment available

🍎 High-Yield Rationale:
🔸 Extensively drug-resistant tuberculosis (XDR-TB) is resistant to first- and second-line anti-TB drugs, making treatment extremely challenging. Currently, outcomes for XDR-TB are very poor and treatment options are limited, so standard regimens (such as those in options A, B, or C) are not effective.

🍊 Why Not the Other Choices?
🔹 A, B, and C: These represent regimens for drug-sensitive TB and are not applicable to XDR-TB due to its resistance profile.

True or false: GERD can cause sinusitis.

A. False

B. True

🍎 High-Yield Rationale:
🔸 Laryngopharyngeal Reflux Link: Acid reflux can reach the upper airway and sinuses (as in laryngopharyngeal reflux), causing inflammation that may predispose to or worsen sinusitis.

🍊 Why Not the Other Choice?
🔹 A. False: Numerous studies have shown an association between GERD (or LPR) and upper airway inflammation; thus, saying “false” would not accurately reflect the potential role of reflux in causing sinusitis.

The treatment for asymptomatic hyperuricemia is:

A. All of the above

B. Allopurinol

C. Colchicine

D. Febuxostat

E. None of the above

🍎 High-Yield Rationale:
🔸 No Indication for Treatment: Asymptomatic hyperuricemia is generally not treated unless the patient develops gout, uric acid nephrolithiasis, or other complications. Neither allopurinol, colchicine, nor febuxostat is routinely used for asymptomatic hyperuricemia.

🍊 Why Not the Other Choices?
🔹 A. All of the above; B. Allopurinol; C. Colchicine; D. Febuxostat: Each of these options suggests active treatment, which is not indicated in the absence of symptoms or complications.

Indications for dialysis in renal failure include the following except:

A. Uremic symptoms

B. Intractable hypocalcemia

C. Intractable hyperkalemia

D. Volume overload

B. Intractable hypocalcemia

🍎 High-Yield Rationale:
🔸 Standard Indications: Dialysis is indicated for patients with uremic symptoms, refractory (intractable) hyperkalemia, and volume overload. Intractable hypocalcemia is not a typical indication for dialysis.

🍊 Why Not the Other Choices?
🔹 A. Uremic symptoms: A well-established indication for starting dialysis.
🔹 C. Intractable hyperkalemia: A recognized life‐threatening condition warranting dialysis.
🔹 D. Volume overload: Unresponsive to medical therapy is an indication for dialysis.

Tumor lysis can occur in the following conditions EXCEPT:

A. All of the above

B. One week after initiation of therapy and while on steroids

C. Dehydration

D. None of the above

E. Spontaneously before cancer treatment

D. None of the above

High-Yield Rationale:
Tumor Lysis Syndrome (TLS) can occur in ALL the conditions listed:
[E] Spontaneously before cancer treatment – ⚠️ Yes, especially in highly proliferative tumors (e.g., leukemia, lymphoma)
[B] One week after initiation of therapy and while on steroids – ⚠️ Yes, TLS is most common within 1 week of chemo or after steroids
[C] Dehydration – ⚠️ Yes, this is a risk factor due to reduced renal clearance
Thus, NONE of the above choices are incorrect, making D. None of the above the best answer.

Which of the following are NOT true?

A. Mycobacterium bovis is resistant to pyrazinamide

B. Mycobacterium bovis can be transmitted through pasteurized milk

C. None of the above

D. Mycobacterium bovis is resistant to isoniazid

E. Mycobacterium bovis causes 50% of pulmonary tuberculosis in Africa

B, D, and E are NOT true

🍎 High-Yield Rationale:
🔸 True Statement: Mycobacterium bovis is resistant to pyrazinamide (statement A is true).
🔸 False Statements:
🔹 B. Transmission through pasteurized milk: Pasteurization kills the organism.
🔹 D. Resistance to isoniazid: M. bovis is typically susceptible to isoniazid.
🔹 E. Causes 50% of pulmonary tuberculosis in Africa: The vast majority of TB in Africa is due to Mycobacterium tuberculosis.

🍊 Why Not the Other Choices?
🔹 C. None of the above: This option would imply that all statements are true, which is incorrect given that B, D, and E are false.

Coronary artery occlusion brought about by coronary spasm causing chest discomfort is called:

A. Chronic stable angina

B. Prinzmetal angina

C. None of the above

D. Unstable angina

B. Prinzmetal angina

🍎 High-Yield Rationale:
🔸 Variant Angina Mechanism: Prinzmetal angina (variant angina) is caused by coronary artery spasm that transiently occludes the vessel, leading to chest discomfort typically at rest.

🍊 Why Not the Other Choices?
🔹 A. Chronic stable angina: Typically due to fixed atherosclerotic narrowing and symptoms on exertion.
🔹 D. Unstable angina: Usually results from plaque disruption or erosion, not spasm.
🔹 C. None of the above: Incorrect, as Prinzmetal angina is the correct descriptive term.

The three most common oncologic emergencies are the following except:

A. Superior vena cava syndrome

B. Tumor lysis syndrome

C. Dawn phenomenon

D. Spinal cord compression

C. Dawn phenomenon

🍎 High-Yield Rationale:
🔸 Oncologic Emergencies: Superior vena cava syndrome, tumor lysis syndrome, and spinal cord compression are recognized oncologic emergencies. The “Dawn phenomenon” is related to early morning hyperglycemia in diabetics and is not an oncologic emergency.

🍊 Why Not the Other Choices?
🔹 A, B, and D: These are all true examples of oncologic emergencies.

The following statements are true regarding Gestational DM except:

A. None of the above

B. Offspring are at risk of developing metabolic syndrome and DM2

C. Occurs in the 2nd or 3rd trimester

D. Monitor at least every 3 years

A. None of the above

📚 High-Yield Rationale:
B. ✅ True – Offspring of mothers with GDM are at increased risk for metabolic syndrome and Type 2 DM later in life.
C. ✅ True – GDM is defined as glucose intolerance first recognized during the 2nd or 3rd trimester.
D. ✅ True – Women with a history of GDM should be monitored every 1–3 years postpartum due to their elevated risk of developing Type 2 DM.

Regimen for TB relapse or treatment failure is:

A. 2 HRZE, 4 HR

B. 2 HRZES, 1 HRZE, 4 HR

C. 2 HRZES, 4 HR

D. 2 HRZE, 8 HR

B. 2 HRZES, 1 HRZE, 4 HR

🍎 High-Yield Rationale:
🔸 Re-treatment Regimen: In cases of TB relapse or treatment failure, the re-treatment regimen includes an initial intensive phase with Streptomycin (S) added, followed by a continuation phase. Option B reflects this standard approach.

🍊 Why Not the Other Choices?
🔹 A. 2 HRZE, 4 HR: This is the regimen for new cases.
🔹 C. 2 HRZES, 4 HR: Lacks the one-month phase with HRZE after the initial phase.
🔹 D. 2 HRZE, 8 HR: Does not include Streptomycin and uses a longer continuation phase not indicated for relapse.

Small kidneys in chronic renal failure is seen in the following EXCEPT:

A. All of the above

B. None of the above

C. Myeloma

D. Hypertensive nephrosclerosis

E. Diabetic nephropathy

A. All of the above

✅ High-Yield Rationale:
In Chronic Kidney Disease (CKD), kidneys are generally small (<10 cm), echogenic, and show poor corticomedullary differentiation on ultrasound.

However, exceptions (i.e., kidneys may appear normal-sized or enlarged) include:

🟢 Diabetic nephropathy
🟢 Hypertensive nephrosclerosis
🟢 Myeloma kidney

✅ These are the classic exceptions to the “small kidney” rule in CKD.

The lowest platelet count allowed prior to transfusion of platelet concentrate in the absence of bleeding is:

A. 10

B. 100

C. 50

D. 30

A. 10 (×10³/µL)

🍎 High-Yield Rationale:
🔸 In the absence of active bleeding, prophylactic platelet transfusions are typically administered when the platelet count falls below 10,000/µL to reduce the risk of spontaneous hemorrhage.

🍊 Why Not the Other Choices?
🔹 B. 100: This level is far above the threshold for prophylactic transfusion and is used only in bleeding patients or those undergoing invasive procedures.
🔹 C. 50: Too high for prophylaxis in a non-bleeding patient.
🔹 D. 30: Also above the recommended threshold for prophylactic transfusion in the absence of bleeding.

Risk factors for urinary tract infection include the following:

A. Frequent sexual intercourse

B. Diabetes

C. History of prior urinary tract infection

D. None of the above

E. All of the above

🍎 High-Yield Rationale:
🔸 Frequent sexual intercourse, diabetes, and a history of prior urinary tract infection are all recognized risk factors that predispose individuals to UTIs.

🍊 Why Not the Other Choices?
🔹 A, B, or C individually: Each is correct, so the comprehensive answer is “all of the above.”
🔹 D. None of the above: Incorrect because all listed factors are well-established risk factors.

Blood vessel congenital anomaly leading to chest pains and ischemic heart disease:

A. Persistent right superior vena cava

B. Anomalous left coronary artery from the pulmonary artery

C. Anomalous left coronary artery from the pulmonary vein

D. Coarctation of the aorta

B. Anomalous left coronary artery from the pulmonary artery (ALCAPA)

🍎 High-Yield Rationale:
🔸 In ALCAPA, the left coronary artery originates abnormally from the pulmonary artery; as a result, the myocardium is perfused with deoxygenated blood, which can lead to ischemic chest pain and heart failure.

🍊 Why Not the Other Choices?
🔹 A. Persistent right superior vena cava: This anomaly usually does not cause myocardial ischemia.
🔹 C. Anomalous left coronary artery from the pulmonary vein: This is not a recognized anatomical abnormality.
🔹 D. Coarctation of the aorta: This mainly affects blood pressure in the upper versus lower body and does not directly cause coronary ischemia.

True or false: 70/30 insulin is given 2/3 of computed dose in the morning and 1/3 of computed dose in the evening.

A. Maybe

B. False

C. True

🍎 High-Yield Rationale:
🔸 In clinical practice, 70/30 insulin is often dosed so that about two-thirds of the total daily dose is given in the morning and one-third in the evening to match diurnal variations in insulin sensitivity and counteract the morning surge in blood glucose.

🍊 Why Not the Other Choices?
🔹 A. Maybe / B. False: Guidelines and clinical experience support the practice of front-loading the dose with 70/30 insulin.

Factors that contribute to hyperglycemia:

A. Reduced insulin secretion

B. All of the above

C. Decreased glucose utilization

D. Increased glucose production

B. All of the above

🍎 High-Yield Rationale:
🔸 Hyperglycemia results from reduced insulin secretion, decreased glucose utilization in peripheral tissues, and increased hepatic glucose production. All these factors play a role, especially in type 2 diabetes.

🍊 Why Not the Other Choices?
🔹 A. Reduced insulin secretion; C. Decreased glucose utilization; D. Increased glucose production: Each factor contributes, hence the best answer is “all of the above.”

Treatment for CNS tuberculosis is:

A. 2 HRZES, 4 HR

B. 2 HRZE, 4 HR

C. 2 HRZE, 4 H, 4R

D. 2 HRZE, 10 HR

The recommended exercise(s) for osteoarthritis is/are:

A. None of the above

B. All of the above

C. Isometric exercises such as wall sits or planks

D. Isotonic exercises such as yoga and jogging

C. Isometric exercises such as wall sits or planks

🍎 High-Yield Rationale:
🔸 For osteoarthritis, particularly of weight-bearing joints, low-impact exercises that improve muscle strength without excessive joint stress are beneficial. Isometric exercises, which involve muscle contraction without joint movement, can safely strengthen muscles around affected joints.

🍊 Why Not the Other Choices?
🔹 A. None of the above: Not true because exercise is beneficial.
🔹 B. All of the above: Not all isotonic exercises (such as high-impact jogging) are recommended for osteoarthritis.
🔹 D. Isotonic exercises such as yoga and jogging: While yoga (if performed gently) may be acceptable, jogging is high-impact and can worsen joint symptoms.

The following can cause secondary hypertension EXCEPT:

A. None of the above

B. Primary hyperaldosteronism

C. Pheochromocytoma

D. Cushing’s syndrome

E. Obstructive sleep apnea

A. None of the above
All of the listed conditions are known causes of secondary hypertension.

📌 High-Yield Rationale:
Secondary hypertension is elevated blood pressure due to an identifiable underlying cause, and the following are classic examples:

🔹 Primary hyperaldosteronism – causes Na⁺ retention and K⁺ loss → volume expansion and HTN
🔹 Pheochromocytoma – catecholamine-secreting tumor → paroxysmal or sustained HTN
🔹 Cushing’s syndrome – glucocorticoid excess → mineralocorticoid receptor activation and HTN
🔹 Obstructive sleep apnea (OSA) – causes sympathetic activation, RAAS stimulation, and endothelial dysfunction

True of nocturnal angina EXCEPT:

A. It is episodic transient tachycardia

B. None of the above

C. There is decreased oxygenation as respiratory patterns change during sleep

D. There is expansion of the intrathoracic blood volume during recumbency

B. None of the above

📌 High-Yield Rationale:
All the choices (A, C, D) describe true mechanisms contributing to nocturnal angina, which is anginal pain that occurs during sleep due to physiologic changes in the recumbent state and during REM sleep:

✅ True Statements:
🌙 A. Episodic transient tachycardia
→ REM sleep or arousals can trigger bursts of sympathetic activity → transient tachycardia → ↑ myocardial oxygen demand → ischemia

🌙 C. Decreased oxygenation as respiratory patterns change during sleep
→ Hypoventilation or sleep apnea leads to hypoxia → myocardial ischemia

🌙 D. Expansion of intrathoracic blood volume during recumbency
→ Lying flat redistributes venous return → ↑ preload → ↑ wall stress → ↑ oxygen demand

A 41-year-old patient sought consultation for laboratory findings: BUN 10 mg/dl, creatinine 1.2 mg/dl, B/C ratio 8.3, urinalysis dark yellow, granular casts 1-2/LPF, few epithelial cells, 0-1 RBC/HPF, WBC 0-1/HPF. This patient has:

A. Post renal acute kidney injury

B. Chronic renal failure

C. Intrinsic/renal acute kidney injury

D. Prerenal acute kidney injury

C. Intrinsic/renal acute kidney injury

🍎 High-Yield Rationale:
🔸 The laboratory profile shows a low BUN/Creatinine ratio (8.3), which is typical for intrinsic renal damage rather than prerenal azotemia, which usually exhibits a ratio >20.
🔸 The presence of granular casts further supports an intrinsic renal etiology (as seen in acute tubular necrosis).

🍊 Why Not the Other Choices?
🔹 A. Post renal acute kidney injury: Often presents with signs of urinary obstruction.
🔹 B. Chronic renal failure: Typically associated with elevated BUN and creatinine and a higher BUN/Cr ratio, along with other signs like small kidneys on imaging.
🔹 D. Prerenal acute kidney injury: Characterized by a high BUN/Cr ratio and usually absence of granular casts.

A 35-year-old woman presents to the clinic for a routine checkup. She reports feeling slightly fatigued but denies any urinary complaints. Her physical exam is unremarkable. Laboratory results reveal the following: urinalysis shows yellow, slightly turbid urine with pH 6.5, 0–2 WBC/hpf, 0–1 RBC/hpf, few mucus threads, few epithelial cells, and 2–4 hyaline casts per high-power field. Serum BUN is 22 mg/dL, and creatinine is 1.0 mg/dL, yielding a BUN/Cr ratio of 22. What is the most likely diagnosis?
A. Prerenal azotemia
B. Acute tubular necrosis
C. Glomerulonephritis
D. Chronic kidney disease

A. Prerenal azotemia

🍎 High-Yield Rationale:
🔸 BUN/Cr Ratio: A ratio of 22 (BUN = 22 mg/dL, Cr = 1.0 mg/dL) is above the typical cutoff (~20 or higher) for prerenal azotemia.
🔸 Urinalysis Findings: The presence of 2–4 hyaline casts, which are often seen in prerenal states due to concentrated urine, supports a prerenal etiology.
🔸 Clinical Context: The patient is asymptomatic except for slight fatigue, consistent with early or mild prerenal azotemia without intrinsic renal injury.

🍊 Why Not the Other Choices?
🔹 B. Acute tubular necrosis: ATN typically shows granular (“muddy brown”) casts and a BUN/Cr ratio closer to 10–15.
🔹 C. Glomerulonephritis: Usually presents with dysmorphic RBCs or RBC casts, proteinuria, and active urinary sediment.
🔹 D. Chronic kidney disease: Often has additional findings such as smaller kidneys on imaging and more persistent abnormalities; here, the creatinine is normal.

A 47-year-old man is evaluated for worsening weakness and poor appetite over several days. He is mildly hypotensive and appears dehydrated. His urine is yellow and slightly turbid with pH 6.5, showing 0–2 WBC/hpf, 0–1 RBC/hpf, few mucus threads, few renal tubular epithelial cells, and 2–4 granular casts per high-power field. Serum creatinine is 1.8 mg/dL, and BUN is 20 mg/dL (BUN/Cr ratio: ~11.1). What is the most likely diagnosis?
A. Prerenal azotemia
B. Acute tubular necrosis
C. Glomerulonephritis
D. Chronic kidney disease

B. Acute tubular necrosis

🍎 High-Yield Rationale:
🔸 Urinalysis Findings: The presence of few renal tubular epithelial cells and granular casts is classic for ATN.
🔸 BUN/Cr Ratio: A ratio of ~11.1 (BUN = 20 mg/dL, Cr = 1.8 mg/dL) is characteristic of intrinsic renal injury such as ATN.
🔸 Clinical Setting: The patient’s weakness, poor appetite, hypotension, and dehydration suggest a state that can precipitate ischemic ATN.

🍊 Why Not the Other Choices?
🔹 A. Prerenal azotemia: Typically has a higher BUN/Cr ratio (>20) and fewer tubular epithelial cells/granular casts.
🔹 C. Glomerulonephritis: Would more often exhibit dysmorphic RBCs, RBC casts, or significant proteinuria.
🔹 D. Chronic kidney disease: Generally shows a more persistent decline in function and chronic findings rather than the acute scenario described.

A 39-year-old male presents with flank discomfort but no overt urinary symptoms. Urinalysis reveals yellow, slightly turbid urine, pH 6.5, with 0–2 WBC/hpf and 6–8 RBC/hpf. There are few mucus threads and few epithelial cells. No casts were noted. Serum BUN is 20 mg/dL, creatinine is 1.8 mg/dL, with a BUN/Cr ratio of ~11.1. What is the most likely cause of the renal abnormality?
A. Prerenal azotemia
B. Acute tubular necrosis
C. Acute glomerulonephritis
D. Chronic kidney disease

C. Acute glomerulonephritis

🍎 High-Yield Rationale:
🔸 Hematuria: The presence of 6–8 RBC/hpf suggests glomerular bleeding, which is common in acute glomerulonephritis.
🔸 Renal Function: An elevated creatinine (1.8 mg/dL) with a near-normal BUN/Cr ratio (~11.1) supports an intrinsic renal process.
🔸 Clinical Correlation: Flank discomfort in this setting further supports a renal parenchymal etiology, such as acute glomerulonephritis, although often RBC casts are seen, their absence in a single sample does not completely rule it out.

🍊 Why Not the Other Choices?
🔹 A. Prerenal azotemia: Typically would not cause significant hematuria.
🔹 B. Acute tubular necrosis: More commonly shows granular casts and renal tubular epithelial cells rather than a predominant hematuria.
🔹 D. Chronic kidney disease: Would usually present with long-standing abnormalities and not an acute rise in creatinine with active hematuria.

A 28-year-old male street sweeper is admitted with high-grade fever and intense bilateral calf tenderness. He has no known comorbidities. On the first hospital day, he develops headache, abdominal pain, and vomits three times. A microscopic agglutination test (MAT) is positive for leptospira. His labs show a BUN of 24 mg/dL and a serum creatinine of 0.9 mg/dL. What is the most likely renal diagnosis in this patient?
A. Acute kidney injury
B. Chronic kidney disease
C. AKI on top of CKD
D. Normal renal function

A. Acute kidney injury

🍎 High-Yield Rationale:
🔸 Elevated BUN/Creatinine Ratio:
🍏 A BUN of 24 mg/dL with a creatinine of 0.9 mg/dL yields a BUN/Cr ratio of approximately 26.6, which is higher than the normal cutoff (<20). This high ratio is characteristic of a prerenal process, where decreased renal perfusion leads to increased reabsorption of urea.
🔸 Prerenal Azotemia:
🍏 In the context of leptospirosis, especially in someone with symptoms such as high-grade fever, vomiting, and dehydration, the kidneys may suffer from a prerenal injury due to hypoperfusion. This constitutes an acute kidney injury (AKI) rather than normal function, despite the creatinine still being within the “normal” range.
🔸 Acute Process in the Setting of Infection:
🍏 Leptospirosis can cause an acute renal insult. Even if the creatinine appears normal initially, the high BUN/Cr ratio indicates an early acute renal injury, most likely prerenal azotemia.

🍊 Why Not the Other Choices?
🔹 B. Chronic kidney disease:
🍎 CKD generally shows a persistently elevated creatinine, longer duration of renal dysfunction, and additional signs such as small, echogenic kidneys on imaging.
🔹 C. AKI on top of CKD:
🍎 There is no evidence of preexisting chronic kidney impairment in this patient. The laboratory findings are more consistent with an acute prerenal condition.
🔹 D. Normal renal function:
🍎 Although the creatinine is within a normal range, the elevated BUN and high BUN/Cr ratio indicate a prerenal insult leading to early acute kidney injury rather than truly normal renal function.

A 68-year-old man with a known history of diabetes mellitus comes for a follow-up. His weight is 80 kg and height is 164 cm. Routine urinalysis reveals ++ proteinuria, and a micral test shows a level of 100 mg/L. His BUN is 8 mg/dL, and creatinine is 0.9 mg/dL. He is asymptomatic and has no history of recent illness. What is the most likely diagnosis?
A. Acute kidney injury
B. Chronic kidney disease
C. AKI on top of CKD
D. Nephrotic syndrome

B. Chronic kidney disease

🍎 High-Yield Rationale:
🔸 Proteinuria: The presence of ++ proteinuria and a micral test value of 100 mg/L indicate microalbuminuria—a hallmark of early diabetic nephropathy.
🔸 Renal Function: Normal BUN (8 mg/dL) and creatinine (0.9 mg/dL) are consistent with early stages of diabetic nephropathy (i.e., CKD stage 1 or 2).
🔸 Chronic Condition: Diabetic nephropathy is a form of chronic kidney disease rather than an acute process.

🍊 Why Not the Other Choices?
🔹 A. Acute kidney injury: Typically has an abrupt onset with a rise in creatinine and is usually symptomatic.
🔹 C. AKI on top of CKD: There is no evidence of an acute deterioration on top of a chronic decline.
🔹 D. Nephrotic syndrome: Although diabetic nephropathy can progress to nephrotic syndrome, the described proteinuria (100 mg/L on micral test) is indicative of microalbuminuria, not the heavy proteinuria seen in nephrotic syndrome.

A 44-year-old mason was brought to the emergency room due to sudden onset weakness. Neurologic examination reveals that the patient is awake, alert, conversant, and able to follow commands. Motor strength is full (5/5) in both upper extremities but decreased (3/5) in both lower extremities. Cranial nerves are intact, and there are no sensory deficits. Which of the following is the most likely diagnosis?
A. Stroke in the young
B. Transient ischemic attack
C. Cerebrovascular disease (lacunar infarct)
D. Hypokalemic periodic paralysis

D. Hypokalemic periodic paralysis

🍎 High-Yield Rationale:
🔸 Metabolic Etiology:
🍏 Sudden, symmetric lower extremity weakness with preserved upper extremity strength suggests a systemic or metabolic cause rather than a focal neurologic lesion.
🔸 Characteristic Presentation:
🍏 Hypokalemic periodic paralysis typically presents with episodes of muscle weakness triggered by factors like high carbohydrate intake or strenuous activity.
🔸 Normal Sensorium:
🍏 The patient is awake, alert, and cranial nerves are intact, which reinforces a metabolic rather than a central vascular cause.

🍊 Why Not the Other Choices?
🔹 A. Stroke in the young:
🍏 Usually presents with focal deficits affecting one side or one region of the body, not symmetric weakness of both legs.
🔹 B. Transient ischemic attack:
🍏 TIAs are typically brief and focal; they do not cause prolonged symmetric lower extremity weakness without affecting other regions.
🔹 C. Cerebrovascular disease (lacunar infarct):
🍏 Lacunar infarcts produce focal, often unilateral deficits and are less likely to cause symmetric, isolated lower extremity weakness.

A 44-year-old lawyer collapsed during a court hearing and was brought to the emergency room. He is a non-smoker and only occasionally consumes alcoholic beverages. On neurologic exam, he is awake but has slurred speech. Muscle strength is decreased (3/5) in the right upper and lower extremities but preserved (5/5) on the left. Sensory function is 80% intact on the right and fully intact on the left. What is the most likely diagnosis?
A. Stroke in the young
B. Transient ischemic attack
C. CVD infarct (lacunar infarct)
D. Hypokalemic periodic paralysis

A. Stroke in the young

🍎 High-Yield Rationale:
🔸 Focal Deficits:
🍏 The patient’s right-sided weakness, slurred speech (dysarthria), and partial sensory loss point to a focal brain lesion, typical of an ischemic stroke.
🔸 Acute and Persistent Presentation:
🍏 The deficits do not resolve quickly (which would suggest a TIA) and are not symmetric, making a vascular event the most likely cause.
🔸 Demographic Consideration:
🍏 Despite being young (<45 years), strokes can occur in this population due to conditions like hypercoagulability, patent foramen ovale, or arterial dissection.

🍊 Why Not the Other Choices?
🔹 B. Transient ischemic attack:
🍏 TIAs resolve within 24 hours without persistent deficits; here, the deficits are ongoing.
🔹 C. CVD infarct (lacunar infarct):
🍏 Although lacunar infarcts occur in small penetrating arteries, they usually cause pure motor or pure sensory strokes without prominent speech involvement and tend to occur in older patients with chronic hypertension.
🔹 D. Hypokalemic periodic paralysis:
🍏 This condition causes symmetric, not focal, weakness and lacks focal neurologic findings like dysarthria.

A 61-year-old retiree experienced sudden onset left-sided weakness. He has a 20-year history of hypertension and is maintained on atenolol 50 mg once daily with good compliance. He denies any trauma, alcohol use, or smoking. On neurologic examination, he has 4/5 strength in the left upper and lower extremities and 50% sensory loss on the same side. Cardiac exam reveals atrial fibrillation with rapid ventricular response on ECG. What is the most appropriate long-term prophylactic treatment to prevent future strokes in this patient?
A. Aspirin enteric-coated 80 mg once daily after lunch
B. rTPA 10% bolus followed by slow IV infusion of the remaining dose
C. Dabigatran 150 mg twice daily
D. Warfarin 5 mg once daily, with PT and INR monitoring in 1 week

C. Dabigatran 150 mg twice daily

🍎 High-Yield Rationale:
🔸 Anticoagulation in Atrial Fibrillation:
🍏 For long-term stroke prophylaxis in patients with atrial fibrillation, especially following embolic events, direct oral anticoagulants (DOACs) such as dabigatran are preferred in non-valvular AF.
🔸 Efficacy and Safety:
🍏 Dabigatran provides consistent anticoagulation without the need for regular INR monitoring, making it a convenient and effective option.
🔸 Avoiding Suboptimal Options:
🍏 Aspirin is not sufficient for stroke prevention in atrial fibrillation, and rTPA is used only in acute settings.

🍊 Why Not the Other Choices?
🔹 A. Aspirin enteric-coated 80 mg once daily:
🍏 Aspirin is inadequate for stroke prevention in patients with AF, where risk of cardioembolic events is high.
🔹 B. rTPA 10% bolus followed by slow IV infusion:
🍏 rTPA is a thrombolytic agent used in the acute management of ischemic stroke, not for long-term prophylaxis.
🔹 D. Warfarin 5 mg once daily with PT/INR monitoring:
🍏 Warfarin is a valid option but requires frequent monitoring and dose adjustments; DOACs like dabigatran are generally favored when there are no contraindications.