questions(Nasi)

[cyrus1345]

1.Which of the following vaccines is not routinely recommended in HIV infected asymptomatic children?
. . . . a. IPV
. . . . b. MMR
. . . . c. Hib
. . . . d. Pneumococcal
. . . . e. Varicella


e


2,Which one of the following is not a finding in HIV wasting syndrome?
. . . . a. <5th percentile on weight-for-height chart on 2 consecutive measurements.
. . . . b. Chronic diarrhea.
. . . . c. Temperature of 38.5 °C, intermittently during the last 2 months.
. . . . d. Persistent weight loss.
. . . . e. Thrombocytopenia

e



3.Diagnosis of HIV infection in newborns and infants <18 months of age requires which tests:
a. ELISA confirmed with Western Blot
b. PCR or viral culture ( two positive assays on two separate specimens )
c. Use of plasma viral load (PVL)
d. Indirect immunofluorescence assay

b

4.The following statements of pediatric HIV clinical manifestations/ management are true EXCEPT:

PCP occurs most frequently in infants between 3 and 6 months of age who acquire infection before at birth.

Lymphoid interstitial pneumonitis (LIP), is fairly uncommon manifestation in children infected HIV.

Leiomyosarcomas, CNS lymphomas, and Burkitt lymphomas occur much more frequently in children with HIV infection.

Combination therapy with either ZDV and 3TC or ZDV and ddI is clinically, immunologically, and virologically superior to monotherapy

MMR, pneumococcal vaccine and influenza vaccine can be given to patients who are not severely immunocompromised.


Follow Ups:


Lymphoid interstitial pneumonitis (LIP), is fairly uncommon - ACE 19:36:18 08/26/03 (0)




5.An active 75 yo woman with no complains presents for general Ph.E.20 yr ago she had a complete hysterectomy for being uterine fibroids and she hasn’t had a pap smear since then.
Her Ph.E unremarkable:lungs clear,no breast mass,o abdominal mass,no rectal mass.
2yr ago she had a screening flexible sigmoidoscopy with a normal result.Last yr she had a normal mammogram.2mo ago she had an influ vaccine and 5yr ago pneumonia vaccine.
Which of the ffw preventive measures is now indicated in this pt?
A:repeat pneumonia vaccine
B:stool guaiac for OB times 3
C:mammography
Dap smear
E:lipid profile


B:stool guaiac for OB times 3

the generally accepted age cutt off point for screening mammo is 70-75yo.hysterecomy was for benign condition and there’s no need to repeat Pap smear.pneumonia vaccine is effective for at least 6-7 yr in immunocompotent pts.for a 75yo pt,change in lipid profile with diet or drug is not likely to alter life expectancy.


6.A 59 yo woman inquires about screening for cervical cancer.Her medical Hx is significant for menorrhagia secondary to fibroids and she underwent a total abdominal hysterectomy 3yr ago.She’s married and has 2 children.Her only medication is atenolol for HTN.She doesn’t smoke or drink alcohol.In repose to her concern about cervical cancer screening which of the ffw is most correct?
A:she should have pap smears annually
B:she should have pap smears every 3yrs
C:she should have pap smears every 5yrs
D:she only needs annual pelvic exam
E:she should have annual vaginal US



D:she only needs annual pelvic exam

if total hysterectomy is done in pts with cervical cancer or dysplasia,they need pap smear to take from vaginal cuff.But in this pt total hysterectomy was done for a benign condition and there's no need to take Pap smear.Annual pelvic exam recommended to detect ovarian cancer or other gynecologic problems.


Follow Ups:


7.A healthy 40 yo Cacausian woman who’s married,monogamous & has had 3 normal consecutive annual pap smear.How often should u recommend she return for pelvic exam and pap smear?
A:every 6mo
B:every 1yr
C:every 2yr
D:every 3yr
E:every 4yr



d

8.What’s ur suggestion for colon cancer screening for this pt?
A healthy 45 yo man whose father died of colon cancer at 60yo.
ARE&FOBT now,if negative repeat every 3-5yr
B:colonoscopy now if negative repeat every yr
C:FOBT every yr
DRE,FOBT& flexible sigmoidoscopy every yr for 2yr,if negative repeat every 3-5yr
E:flexible sigmiodoscopy and barium enema very 2yr



DRE,FOBT& flexible sigmoidoscopy every yr for 2yr,if negative repeat every 3-5yr


Follow Ups:


9.A 67 yo woman returns to ur office 10 yr after being treated for advanced left breast cancer(with radical mastectomy+radiotherapy to her axilla).For the last 4yr,she has noticed swelling in her left hand and now there seems to be a rash progressing up her arm.Ph.E:4+pitting edema in her hand as well as multiple painless purplish red nodules that seem to be spreading up her arm.What’s he most likely Dx?
lyphonjoamasarcoma

Follow Ups:


10.A 25 yo man presents with a 4-day Hx of frontal headache&purulent rinorrhea.He had clear rhinorrhea and a sore throat 5days earlier with initial improvement followed by the presenting symptoms.
Which of the ffw tests/methods of evaluation is most sensitive for securing a Dx?
A:culture
B:radiograph
C:CT scan
D:US
E:history



C:CT scan

THE Dx of sinusitis is primarily clinical,but imaging can be useful.Plain Xrays of the sinuses r sufficiently sensitive to rue out frontal and maxillary sinusitis,but their ability to detect sinusitis in ethmoid or sphenoid sinuses is poor.CT is extremely sensitive but it may often overcall sinus disease:false+ result.To decrease the false+ result as with any test CT is necessary only in pts with a high pretest probability.US has a lower sensitivity than radiography or CT but has good specificity.Sinus& nasal culture has a high rate of false-&false+ results.


Follow Ups:

11.A 36yo woman develops a 6cm mass on her ant.thigh over the past 9 mo.The mass appears to be fixed to the underlying muscle,but the overlying skin is movable.The next most appropriate step in Mx is:
a:abdominal CT
b:bone scan
c:excisional biopsy
d:incisional biopsy



d:incisional biopsy

most likely Dx is benign soft tissue tumor,but risk of malignancy is increased for tumors>5cm,as well as those lesions that r symptomatic or have enlarged rapidly over a short period of time.excisional biopsies good option for small lesions.


Follow Ups:


12.A 56 yo woman post-breast conservative Tx for DCIS develops a large,fixed node in her right axilla.No breast mass on Ph.E.bilateral mammogram no abnormality.FNA from axillary mass shows adenocarcinoma cells.
What’s the most appropriate next step of Mx?
A:axillary node dissection for staging& radiotherapy to the breast
B:axillary node dissection for staging alone
C:radical mastectomy
D:modified radical mastectomy
E:radiation to the axillary mass witout surgery



D:modified radical mastectomy

13.An 8yo girl with recurrent episodes of pneumonia.The consolidations which have occurred in various lung segments have cleared with ab therapy.Occasional wheezing has responded to inhaled bronchodilators.Findings today include rhonchi and rales at the base of the left lung and an infilterate in the left lower lobe.The most appropriate study for this pt is:
a:barium swallow
b:bronchoscopy
c:radionuclide scan of the lung
d:spirometry
e:skin test for allergy


d:spirometry

the recurrent diffuse pulmonary disease described for this pt is more likely to have a viral or noninfectious inflammatory etiology than a bacterial etioliogy.Asthma is the most common cause of noninfectious inflammatory disease and the most common underlying cause of any type of recurrent pulmonary infilterates in children.




14.which one can be a physiologic response to acute injury?
A:increased secretion of insulin
B:increased secretion of thyroxine
C:decreased secretion of ADH
D:decreased secretion of glucagons
E:decreased secretion of aldosterone



A:increased secretion of insulin

although the immediate release of cathecholamines causes a transient drop in the insulin levels,shortly thereafter there's a significant rise in plasma insulin levels in injured humans.Since injured pts r highly hypermetabolic,it might be expected that the activity of the thyroid hormones would be increased ffw injury but increased levels of the thyroid hormones r not seen.
glucagon,ADH,aldosterone increased.



15.2 hour old, 38 week gestation, 3 kg male infant was born to a 25 year old G1P1 A+, VDRL negative, Hepatitis B negative, GBS unscreened, Rubella immune, woman who had an uncomplicated pregnancy, labor and delivery. Apgar scores were 9/9. He was sent to the newborn nursery. He breast fed 1 hour ago without concerns. He now presents with respiratory distress.

Exam: VS T 37, HR 160, RR 80, BP 60/35 (mean 45), oxygen saturation 95% in 2 L/min oxygen via mask. Wt 3kg (50%), Lt 48cm (50%), HC 33.5 cm (50%). He is a term male with obvious respiratory distress and tachypnea.Laboratory results: CBC: WBC 15,000, 8% bands, 50% segs, 40% lymphs, 2% monos, Hct 55%, Plt 250,000. No toxic granulations or vacuoles of the neutrophils are noted. ABG: pH 7.35, PCO2 55 torr, PO2 70 torr, BE -7 in a 30% oxygen hood. CXR: 10 ribs of inflation, streaky linear perihilar densities, and small scattered patchy densities bilaterally. No areas of consolidation. Over the next hours, infant remained stable and begin to improve.
What is the diagnosis ?

Respiratory distress Syndrome (RDS)
Transient tachypnea of the newborn (TTN)
Meconium aspiration
Pneumonia
Pneumothorax
Cyanotic congenital heart disease

b



16.The sudden onset of significant respiratory distress and hypotension should suggest what respiratory disorder?

Respiratory distress Syndrome (RDS)
Transient tachypnea of the newborn (TTN)
Meconium aspiration
Pneumonia
Pneumothorax
Cyanotic congenital heart disease




pneumothorax

17.In Respiratory Distress Syndrome what is the radiographic manifestation of this deficiency?

CXR: Ground glass appearance
CXR: Fluid in the fissures, central/perihilar congestion
CXR: Infiltrates or hazy lungs (may be identical to RDS).
CXR is often normal


Follow Ups:


a

18.The earliest way to diagnose an anterior abdominal wall defect is:
. . . . . a. by physical exam
. . . . . b. by history
. . . . . c. by fetal ultrasound
. . . . . d. by fetal CT scan



C as early as 12 wks can see abdominal wall defect!!


19.Treatment of abdominal wall defects in neonates includes:
. . . . . a. immediate surgical repair
. . . . . b. pushing the intestines back into the abdominal cavity while still in the delivery room
. . . . . c. provide immediate optimal resuscitation and stabilization first, and then surgery
. . . . . d. always do primary closure in both lesions



c. provide immediate optimal resuscitation and stabilization


20.The following are correct regarding omphaloceles except:
. . . . . a. is usually covered by a translucent membrane
. . . . . b. is frequently associated with other congenital malformations
. . . . . c. is lateral to the umbilical stump
. . . . . d. is within the umbilical ring



Follow Ups:


c. is lateral to the umbilical stump


21.Newborn male infant is born to a 21 year old G2P1 mother at 36 weeks gestation via cesarean section. Appropriate antenatal care and monitoring occurred throughout the pregnancy. Prenatal ultrasonography was done at 32 weeks gestation revealing what appeared to be free intestine floating in the amniotic fluid, coming from the anterior abdominal wall. The mother elected for a cesarean section delivery after fetal lung maturation was assured (at 36 week gestation in this case scenario). The baby looks normal at birth except for matted intestinal loops coming through an anterior abdominal wall defect just to the right of the umbilical cord. The loops are very edematous and do not resemble normal intestines. Dx ?


Follow Ups:


yes all got it=gastrochisis


22.Which of the following sets of electrolytes could be seen with Hypertrophic Pyloric Stenosis (Na, K, Cl, bicarb):
. . . . . a. 130, 2.7, 90, 28
. . . . . b. 130, 5.8, 94, 22
. . . . . c. 130, 3.9, 98, 17
. . . . . d. 148, 4.1, 108, 13



Follow Ups:


HPS=hypocl, hypok, metab alk. so A



23.12 month old female who presents for a well child check. Within the past 4 months, her weight has fallen from the 25th percentile to significantly less than the 5th percentile. Her height has dropped from the 10th percentile to slightly less than the 5th percentile, while her head circumference has remained at about the 25th percentile. Her language, motor, cognitive, and social development are normal. She seems to eat appropriate foods for her age, but the her mother notes that she tends to be restless and fidgety while eating, and that she does not like the texture of certain foods, often leading to parental frustration at mealtimes. Her stools tend to be frequent, with particles of food seen. Urine is normal. There are no symptoms of respiratory or neurological disease, and her review of systems is otherwise negative.

Her past medical history is entirely unremarkable. She was born at term, weighing 3.0 kg (6 pounds, 10 ounces), without any perinatal complications. Her family history is negative for any endocrinopathies or chronic illnesses. Mother is 155 cm (5 feet, 1 inch) 61 inches tall, and father is 168 cm (5 feet, 6 inches). Mother experienced menarche at age 12.5 years and recalls that there were other children in the family who were deemed small as young children but who caught up later in childhood. Mother describes a history of increased sadness and worry since her child was born. Parents are married, and there is no history of abuse or violence in the household. Which of the following (2) statements are false?

All children with FTT should be hospitalized to distinguish between "organic" and "non-organic" etiologies.

Blood pressure is useful in evaluating young children with FTT.

If both parents are of short stature, then the child must have genetic short stature.

History, growth chart review, and physical are key in the evaluation of FTT.

Hospitalization must be considered in cases where a child is at risk of serious medical morbidity as a result of either malnutrition or the condition underlying the FTT or at risk of neglect or abuse.





Follow Ups:


A + B FALSE - ACE 16:00:57 08/27

24.12 year old male soccer player who comes into the office with a chief complaint of pain to both knees. He reports a gradual onset of knee pain in the front of both of his knees that started about one year ago. The pain seems to be in the same spots and is worse after a hard practice or game and with running up and down hills. He noticed a "bump" on both of his knees recently that is tender if he falls or accidentally bangs them. The patient does not remember an initial history of trauma or injury. He is otherwise healthy with normal birth and development. Examination is unremarkable with the exception of his knees. He is comfortable, in no significant acute pain. His right and left knee findings are identical. A mild prominence over the tibial tuberosity is visible. No erythema, edema or effusions are noted. No patellar grind is noted. The patella is normally placed and there is no tenderness over the patella. He has localized tenderness over the tibial tuberosity. His knee range of motion is good, but he experiences pain over the tibial tuberosity. McMurray, anterior drawer, Lachman, and posterior drawer tests are all negative.
What is the most common management for this disease?



Corticosteroids

Surgery

Conservative ( Rest and NSAIDs as needed )

Radiographs of the knee


Follow Ups:


CONSERVATIVE- ( radigraphs are unnecessary


25.13 year old boy who presents to the office with a chief complaint of right heel pain. The patient states he has gradually noticed this pain since the beginning of basketball season 2 weeks ago. The pain is a dull, 5/10 ache over his right heel that is worse with running, especially when running on the hardwood floor. He has tried ice, which provides only temporary relief until the next practice. He is not taking any pain medications. There is no history of trauma or known injury and he is otherwise healthy. Birth and developmental history are unremarkable.

Examination is unremarkable except for his right lower extremity. He is comfortable in no acute pain. There is no visible deformity, muscle atrophy, or erythema. There is minimal soft tissue swelling and moderate tenderness to palpation over the back of the right calcaneus. Ankle range of motion is normal. He ambulates normally and he is even able to jump up and down. He does have an open growth plate (apophysis) over the achilles tendon insertion region, but this is noted to be normal for his chronologic and bone age. Bone scan normal.
Radiographs normal.
What is your diagnosis?

Osgood-Schlatter Disease

Avulsion fracture of the calcaneus

Brodie's abscess

Bone cyst

Sever's disease

Stress fracture




e
26.13 year old right handed boy who presents to the clinic with a chief complaint of right elbow pain. The patient has noticed a gradual onset of pain over the past two months since baseball season started. He is the star pitcher for his little league team and pitches full games twice per week. He also practices a lot during the week. He has complained of pain during practices, but has been told to continue practicing; "no pain, no gain." The pain is most severe over the medial aspect of his right elbow and does not radiate. He is able to do normal activities of daily living. His wrist and shoulder are unremarkable. Radiographs of his right elbow are obtained and show a >2mm ** displaced right medial epicondyle fracture. What is the recommended next step in management ?

Open reduction with internal fixation hardware is performed with early ROM exercises at 1-2 weeks

Single posterior splint for 1-2 weeks then progression to active ROM exercises

Conservative ( rest and NSAIDs )

Corticosteroids

Surgery




a

27.A 60 y/o Japanese man visiting US with excellent health until 6 months ago, when he first noted mild upper abdominal fullness after meals. On P/E hyperpigmented, heaped-up velvety lesions in the neck, axillae, and groin is noted. Which of the following conditions is associated with the skin findings?
a- Non-Hodgkin's lymphoma
b- Anorexia nervosa
c- Acute leukemia
d- Adenocarcinoma of the stomach
e- Addison's disease

d

28.Which of the following should be done annually after age 40 in the asymptomatic, average- risk man in order to promote the early detection of cancer?
a- Colonoscopy
b- Sigmoidoscopy
c- Digital rectal examination with palpation of the prostate
d- Digital rectal examination with palpation of the prostate and stool guaiac
e- Digital rectal examination with palpation of the prostate, stool blood test, and chest x-***



c
29.During a routine checkup, a 65 y/o man is found to have a level of serum Alk Ph. three times the upper limit of normal. Serum Ca and ph. concentrations and LFT results are normal. He is asymptomatic. The most likely diagnosis is
a- metastatic bone disease
b- primary hyperparathyroidism
c- occult plasmacytoma
d- Paget's disease of bone
e- osteomalacia



Follow Ups:


answer is d. - SN 07:52:25 08/28/03 (0)
Re: Q3 - d dox 15:14:41 08/27/03 (0)
Re: Q3 - chomi 10:53:17 08/27/03 (0)
Re: Q3 - ACE 08:55:44 08/27/03 (0)
Re: Q3 - img03 08:49:38 08/27/03


30.Which of the following is NOT a predisposing factor for the development of a hernia?
a- Ascites
b- Obesity
c- Cystic fibrosis
d- Chronic obstructive pulmonary disease
e- Peritoneal dialysis

b

31.A 5-month-old infant has had several episodes of wheezing, not clearly related to colds. The pregnancy and delivery were normal; the infant received phototherapy for 1 day for
hyperbilirubinemia. He had an episode of otitis media 1 month ago. There is no chronic runny nose or strong family history of asthma. He spits up small amounts of formula several times a day, but otherwise appears well. His growth curve is normal. An examination is unremarkable except for mild wheezing. Which one of the following is the most likely diagnosis?
A) Benign reactive airway disease of infancy
B) Cystic fibrosis
C) Unresolved respiratory syncytial virus infection
D) Early asthma
E) GE reflux



Follow Ups:


answer is E. - SN 07:54


32.Other non-sports related causes of hyphema include the following EXCEPT :

diabetes causing neovascularization
retinal ischemia
carotid stenosis
post-intraocular surgery
sickle cell disease
pupillary microhemangiomas
iritis
intraocular tumors


What is the most severe complication of a hyphema and how can you prevent this?






rebleeding...prevention is limitaion of daily activities...

33.This is one of the most common elbow injuries in young children between the ages of 1-5 years. The child may complain of pain in the elbow following a traction (pulling) injury. No significant swelling or angular deformity should be visible. They do not use their upper extremity and will hold their elbow at the side with their forearm on their lap. Radiophrags normal. A classical physical exam finding is pain with attempted forearm supination.

Nursemaid's elbow

greenstick fracture of the distal humerus

Little League Elbow

None of the above


Follow Ups:


Nursemaid's elbow - ACE

34.If you suspect an ACL knee injury in a patient, what specific test can you do to assess ACL laxity.

Anterior drawer test
McMurray's test
Apley's grind test
Valgus and varus stress tests
None of the above


Follow Ups:


anterior drawer test - ACE 15


35.which of the following in bio physical profile gives info regarding long term placental function?
a.gross movement
b.heart rate
c.breathing
d.amniotic fluid index
e.nst
2.which corelates with immediate placental functin? same options


Follow Ups:


D AND E

36.in iugr amniotic fluid is decreased
a.in symmetric
b.assymetric
c.both
d.neither


Follow Ups:


ASSYMETRIC IUGR

fetal cause syymetric iugr so normal AF
assym iugr due to placental causes so decreased AF
and also HC CRL BPD AND AC are all decreased in symm iugr
only AC decreased in assyn iugr the rest normal


37.diff bet progesterone withdrawl normal mensturation and estrogen assoc dub?
THE ENTIRE DECIDUA FUNCTIONALIS IS SHEDED IN NORMAL MENSTURATION.IN ESTROGEN ASSOC DUB ONLY RANDOM AREAS ARE SHEDDED

38.which drug of abuse is assoc with bowel atresia?
cocaien


39.what is the risk of loosing a pregnancy ina pt with 2 spont abortions and a normal preg earlier?
a.15%
b.25%
c.40%
d.20%



Follow Ups:


ANS 25% NO MSG

40.1.at what gestational age cervical cerclage done?
2.which inv is necassary bfore cervical cerclage?
3.if pt doesnt desire c sectin later which procedure is done?


Follow Ups:


YES THE CERCLAGE IS REMOVED AT 36 WEEKS FOR SPONT DELIVERY IN MCDONALDS
IN SHIRODKARS THE CERCLAGE IS LEFT AND CAESAREAN DONE


41.A 63-year-old woman is admitted to the hospital after an acute inferior myocardial infarction. She is noted to be oliguric, and has a blood pressure of 80/55 mm Hg. A Swan-Ganz catheter is placed, revealing a diminished pulmonary capillary wedge of 4 mm Hg, normal pulmonary artery pressure of 22/4 mm Hg, and an increased mean right atrial pressure of 11 mm Hg. Which of the following is the most appropriate next step in management?
A. Balloon angioplasty
B. Digoxin
C. Fluids
D. Intraaortic balloon counterpulsation
E. Vasopressors


ya its fluid /fluid /fluid bcz in inf ami th e preload is low dec heart rate and dec bpwe need to load pt up so ist thingis since wedge is low to bring it up we need to gine a litre bolus then i more if required we dont give any thing that dec preload in this in the ist place like nitrate will make situation worse or balooon is not the ans here volume willl take care of the pt...and then we can takle care of it as managemantof inf ami bcz if heart rate is always low bcz eith ist or sec degree block is there with this kind of ami so we need tc pacing then trans venus once pt is stable..goood q...


42.26 yr old presents for routine gyne exam. Last Pap smear was 3 yrs ago. Currently sexually active uses OCPs. She complains of episodes of spotting and white , thin vaginal discharge. As part of the routine exam, you collect a Pap smear. 2 wks later lab reports a LGSIL ( low grade squamous intraepithelial lesion ).

What is your recommendation?

Repeat Pap smear immediately
Repear Pap smear in 6-8 months
Colposcopic ecam of cervix with directed biopsies
Loop electrosurgical excision procedure ( LEEP )



Colposcopic exam of cervix with directed biopsies
source blueprints
43.A 16-year-old girl comes to the adolescent health clinic for a routine examination. She has no complaints at this time. Physical examination is unremarkable. Her record indicate that she has an incomplete measles, mumps, and rubella (MMR) vaccination history. In addition to appropriate counseling, she is given one dose of the MMR vaccine. One month later, she learns that she is 9 weeks pregnant, and returns to the clinic concerned about potential birth defects resulting from the MMR vaccine. Which of the following most closely approximates the risk of birth defects secondary to MMR vaccine exposure during the first trimester?

A. <1%

B. 3%

C. 5%

D. 8%

E. 10%



Explanation:
The correct answer is A. There are no reported cases of congenital rubella syndrome (CRS) caused by exposure to the rubella vaccine during pregnancy. Among 226 pregnant women known to have received the rubella vaccine from 1971 to 1986, none of the infants developed any congenital malformation that is compatible to or similar to CRS.
It is recommended, however, that women of childbearing age should receive the rubella vaccine only if they state that they are not pregnant and that they have been counseled not to become pregnant for 3 months because of the theoretical risk of exposure to the rubella virus through vaccination. Should pregnancy occurs within 3 months after vaccination, the woman should be counseled about the theoretical risk. But, this is not an indication or a reason to terminate the pregnancy.


44.A 69-year-old retired physician is brought to the emergency department by his wife because of the onset of severe midabdominal pain. He awoke at approximately 4:00 AM with severe pain, which has gradually become "unbearable." He has a history of rheumatic fever, acute cholecystitis resulting in cholecystectomy, and a gastric ulcer. On physical examination, he appears acutely uncomfortable and complains of increasing pain with any movements. His temperature is 38.7 C (101.6 F), blood pressure is 160/90 mm Hg, and pulse is 104/min. He is anicteric and has dry mucous membranes. On abdominal examination, there is reduction in bowel sounds and diffuse tenderness and involuntary guarding to mild palpation. A rectal examination reveals brown stool that is negative for occult blood. Upright chest x-*** and plain abdominal films reveal free air underneath the left hemidiaphragm. Which of the following is the most appropriate next step in management?

A. Abdominal CT scan

B. High-dose oral omeprazole

C. Histamine-2 receptor antagonist

D. Observation after placement of a nasogastric tube

E. Emergent laparotomy



Explanation:
The correct answer is E. This patient has evidence of a perforated viscus, as demonstrated by the free air under the left hemidiaphragm. With a history of gastric ulcer, it is possible that he has perforated a recurrent ulcer. Plans should be made immediately for emergent exploratory laparotomy to prevent progression of his peritonitis. Peptic ulcers that perforate, producing free air in the abdominal cavity, are usually located in either the anterior wall of the duodenum or in the stomach. The description of the pain illustrated in the question stem is typical. The abdominal findings following perforation may be misleading, as diffuse abdominal pain, sometimes with prominent right lower quadrant involvement or radiation to either or both shoulder, may dominate the clinical picture rather than pain localized to the epigastrium. Breathing may exacerbate the pain. Prompt diagnosis with emergent laparotomy will lessen the risks of shock and establishment of a disseminated chemical (or superinfected) peritonitis.
An abdominal CT scan (choice A) would merely delay the definitive laparotomy.
Oral omeprazole and histamine-2 receptor antagonists (choices B and C) are effective medical therapies for gastric ulcer; however, they are superfluous in the management of a perforated ulcer.
Observation after placement of a nasogastric tube (choice D) is inappropriate given the obvious findings of a perforated viscus. Although a nasogastric tube may be placed prior to surgery, there is no role for conservative management for this patient.



45.Generally seen in post menopausal women appearing as diffure ERYTHEMATOUS ECZEMATOID LESION. Red backgorund is mottled with white hyperkeratotic islands. This disease is frequently associated with other invasive carcinomas. 90% intraepithelial and large pale apocrine cells involve the entire epithelium. Dx?

Cevical carcinoma
Vulvar carcinoma
Paget's disease
Bartholin's cyst


Paget's disease see BRS


Follow Ups:


46.Management or motor urge incontinence include all EXCEPT:

Flavoxate
Oxybutynin
Propantheline
Phenoxybenzamine
Ibuprofen


never use a alpha blocker like Phenoxybenzamine
in motor urge incontinence...Phenoxybenzamine
used for overflow incontinence....

recommended trt for motor urge incontinence is
anticholi like oxybutynin, propantheline
beta adrenergic agonist like flavoxate
nsaids like ibuprofen


47.What is the recommended med for prophylaxis of pyelonephritis?

Nitrofurantoin
TMPSMX
Cephalexin
Erythomycin
Amoxi-clavulanic



a

48.What is the recommended trt for pyelonephritis during pregnancy?

IV Cefazolin, ampicillin, ceftriazone
IV Ampicillin, clindamycin, penicillin
Oral Ampicillin, Clindamycin and gentamicin
none of the above


cc to washington manual and NMS, cefazolin sodium and ampicillin plus gentamicin ( or clinda + genta for allergic ) are the most commonly used and should be continued until the pt is afebrile 48hrs

49.Which of the follwing oral antibiotics given for UTI in pregnancy carry risk of kernicterus in last 6 weeks (NMS) ?

Nitrofurantoin
TMPSMX
Cephalexin
Erythomycin
Amoxi-clavulanic


TMPSMX CAUTION USE ALSO IN FIRST TRIMESTER



50.This is a 4 week old female who presents to the office with parental reports of increasing jaundice over the last week. Her parents report that 2 weeks ago, she began to have yellowing of her eyes with subsequent yellowing of her skin when she was diagnosed with physiologic jaundice. After persistent jaundice for 5 days, her parents changed her from breast-feeding to a commercial formula. Since the jaundice appears to be worsening, her parents decided to bring her in for re-evaluation. Her stools have been pale in color for the past 10 days along with darker urine.Laboratory examinations reveal a total bilirubin of 15 mg/dL, direct bilirubin of 12.3 mg/dL, ALT 45 U/L, AST 52 U/L, and an alkaline phosphatase of 2007 U/L. The patient undergoes a DISIDA scan after 5 days of phenobarbital therapy. The scan showed normal uptake by the liver but no excretion of the isotope (i.e., no bile flow) into the bowel even after 24 hours. Dx? What is the next step in management?

a. Laparoscopy
b. Kasai procedure
c. CT
d. Laparotomy + cholangiogram
e. none of the above


CASE OF BILIARY ATRESIA-DO A LAP+CHOLANGIOGRAN THEN LIVER WEDGE THEN HASAI PROCEDURE IF NECESSARY


Follow Ups:


51.Patient with tubo ovarian abscess fails IV cefotetan and doxycycline trt. Next step management:

Expand antibiotic coverage with ampicillin, gentmicin and clindamycin
Laparoscopy for confirmation of diagnosis
Laparotomy with unilateral salpingo-oopherectomy
Laparotomy with hysterectomy and BSO


Follow Ups:


A

ACC TO BLUEPRINTS OBGYN
52.preg pt at term has spont uterine contractions.obs h/o is significant for GBBS sepsis in previos neonate. culture done in third trimester for GBBS is negative.management includes
a.give penG regardless of culture results
b.no prophylaxis necessary
c.give if ROM longer han 18hrs or if mom febrile
d.do culture and give antibiotics accordingly


Follow Ups:


ALL CORRECT GIVE PROPHYLAXIS - CHOMI 05:45:00 08/28/03 (0)


53.which is major reservoir for GBBS?
A.VAGINA
B.CERVIX
C.GI TRACT
D.THROAT
E.SKIN
E.URETHRA


54.in a twin pregnancy with maternal HIV infection.transmission is more in
a.first twin
b.second twin
c.same in both
d.no data available


Follow Ups:


PREP AND PEARL CORRECT FIRST TWIN
DUE TO INCREASED EXPOSURE TIME TO MATERNAL FLUIDS


55.risk of perinatal transmission of HIV with no maternal prophylaxis and previous delivery of an infected infant?
a.50%
b.30%
c.10%
d.1%
e.no risk
WITH AN EARLIER HIV INFECTED BABY THE RISK IS INCREASED WITHOUT PROPHYLAXIS


56..why is hyperpigmentation seen in pregnancy?
2.findings in pregnancy resembling liver failure?


Follow Ups:


DUE TO INCREASED MSH DUE TO INCREASED LEVELS OF ESTROGAN AND PROGESTERONE
SERUM ALUBUMIN IS DECREASED SERUM LIPIDS R INCREASED AND ALK PHOSPHATASE IS INCREASED IN PREG WHICH MIMICKS LIVER DISEASE
THE LIVER ENZYMES AND BILIRUBIN AR NORMAL
ALK PHOSPHATASE IS FROM PLACENTA


57.absence of which layer in placenta leads to placenta accreta?
nitabuch's membrane


58.1.mcc of DIC in obstetrics?
2.pathphysio of DIC in obstetrics?
3.after how many of fetal demise there is significant risk fot DIC?
4.method of choice to diagnose dic?



1.ABRUPTIO PLACENTA
2.RELEASE OF TISSUE THROMBOPLASTIN FRON FETUS AND PLACENTA LEADING TO HYPOFIBRINOGENEMIA
3.4 WEEKS
4.FIBRIN DEGRADATION PRODUCTS


Follow Ups:


58.all r assoc with HDN except
a.anti rh
b.anti *****
c,anti kell
d.anti kidd
e.anti fuffy


Follow Ups:


Re: q? - ACE 13:39:04 08/27/03 (2)
Re: Re: q? - mu 14:06:05 08/27/03 (1)
CORRECT ANTI LEWI
THE REST R ASSOC WITH HDN
IF POSITIVE DO TITRE
IF ITS MORE THAN 1:8 DO AMNIOTIC BILIRUBIN
IF LESS REGULAR TITRING TO BE CONTINUED

59/.lack of cephalad closure of ectomesodermal folds result in?
2.lateral closure?
3.caudad closure?
a.bladder exstrophy
b.omphalocoel
c.ectopia cordis
d.encephalocoel

.LATERAL CLOSURE OMPHALOCOEL
2.CEPHALAD ECTOPIA CORDIS
3.CAUDAD BLADDER EXSTROPHY


60.classic triad of vasa praevia?
management of vasa pravia?
membrane pupture,vaginal bleeding and fetal bradycardia .mx is emergency c section


61.all the following inf r assoc with second trimester fetal loss except
a.cmv
b.parvo virusc.syphlis
d.toxoplasma.
e.mycoplasmae.
f.listeria


Follow Ups:


TOXOPLASMA -ALSO DEATH IS DUE TO ANEMIA AND CARDIAC FAILUTE IN PARVOVIRUS
IN THE REST ITS DUE TO PLACENTAL INFECTION


Follow Ups:

.mx of apt in zone1 in liley graph who is at 37 wks of gestation?
2.mx of a pt in zone2 in liley graph who is 32 wks of gestation?
3.management of a pt in zone 3 on liley graph who is 32 wks of gestation?


Follow Ups:



62.1.DELIVERY
2.CONSERVATIVE
3.FETAL TRANSFUSION



b

63.post meno pt with hot flashes. whicn drug shouldnt be prescribed to decrease or prev osteoporosis
a.calcium and vit d
b.ert
c.raloxifene
d.aldendronate
e.calcitonin


raloxifene increases hotflashes
it decreases trabecular bone loss similar to estrogen and is antagonistic to breast and endometrium
calcitonin is useful when analgesia is required
the progestin part of ert may adversely affect the benefits of estrogen on lipid profile.it also increases irritability and depression



64.hot flashes due to
a.pulses of LH
b.pulses of FSH
c.estrogen decrease
d.progesterone decrease
e.gnrh


pulses of LH
hot flashes r due to cut vasodilation and decreased core body temp.pts feel hot flashes in face arms and upper trunk followed by profuse sweating
hot flashes adversely affect REM sleep


Follow Ups:


65.All the following are indications for cervical cone bipsy EXCEPT:

The cervical cone biopsy cant be fully visualized
a hx of cervical dypslasia
Endocervical curettage ECC is positive
biopsy reveaels microinvasive squamous cell ca
biopsy reveals adenocarcinoma in situ

a


66.Atypical squamous cells of undetermined significance (ASCUS) are found in approximately 5% of Pap smear results. Usually, they represent squamous metaplasia and HPV lesions. What is the recommended trt for a complaint pt ?

Smears should be performed every 4-6 months for 2 years until negative

Colposcopy and biopsy should be performed

Immediate colposcopy with biopsy or repeat Pap smear every 4-6 months

Excisional or ablative therapy is indicated.

Dilatation and curettage


Smears should be performed every 4-6 months for 2 years until negative


http://www.emedicine.com/med/topic324.htm

67.The following are correct EXCEPT:

Inhibit thyroid function - Iodine, lithium, and sulfonylureas

Inhibit thyroxine (T4) and triiodothyronine (T3) conversion - Glucocorticoids, propranolol, amiodarone, and propylthiouracil (PTU)

Increase TSH - Iodine, lithium, dopamine antagonists, and cimetidine

Decrease TSH - Glucocorticoids, dopamine agonists, and somatostatin

Inhibit T4 and T3 binding to transport proteins - Phenytoin, sulfonylureas, diazepam, furosemide, and salicylates

Inhibit gastrointestinal absorption of thyroid hormones - Cholestyramine, ferrous sulfate, aluminum hydroxide, and sucralfate

All are correct


All are correct

SOURCE EMEDICINE.COM
68.Which of the following organs is involved in the metastatic spread of - chorionic carcinoma most fregently?
A) the vagina
B) the lung and brain
C) the liver and the kidneys -
D) all of the above
E) the vagina, lung and brain only


Follow Ups:


yes all the above
69.Which of the following cyst types can develop in chorionic carcinoma?
A) follicular cysts
B) hemorrhagic corpus luteum cysts
C) lutein cysts
D) endometriotic (chocolate) cysts
E) polycystic degeneration


C) lutein cysts

info on chorionic carcinoma:

http://www.ecu.edu/intmedresidency/C...c%20Tumors.pdf



70.Which of the following gynecological malignancies are associated with the positivity of pregnancy tests?
A) endometrial carcinoma
B) cervical carcinoma
C) chorionic carcinoma
D) hormonally active ovarian tumors
E) ovarian cystadenocarcinomas

) chorionic carcinoma

71.Which of the following laboratory tests should be performed in hyperemesis of pregnancy?
A) urine volume; specific gravity; protein, acetone and urobilinogen content
B) urinary sediment examination
C) measurement of the hematocrit and hemoglobin levels
D) measurement of the serum bilirubin level
E) all of the above


E) all of the above


Initial lab studies for HEG should include the following:
Urinalysis for ketones and specific gravity: A sign of starvation, ketones may be harmful to fetal development. High specific gravity occurs with volume depletion.
Serum electrolytes: Assess electrolyte status to evaluate for low potassium or sodium, identify hyperchloremic metabolic alkalosis or acidosis, and evaluate renal function and volume status.
Liver enzymes and bilirubin: Elevated transaminase levels may occur in as many as 50% of patients with HEG.
Amylase: This is elevated in approximately 10% of patients with HEG.
TSH: HEG is associated with hyperthyroidism and suppressed TSH levels in 50-60% of cases.
Calcium level: Consider measuring Ca++ levels. Some rare cases have been reported of hypercalcemia being associated with HEG, resulting from hyperparathyroidism.
Hematocrit: This may be elevated because of volume contraction.



Follow Ups:


72.Which of the following justifies surgery for ovarian neoplasms during pregnancy?
A) only if malignancy is suspected
B) surgery is indicated in all cases, preferably in the first 1-2 months of pregnancy
C) surgery is indicated in all cases, preferably during weeks 10-14 of pregnancy
D) in cases where the lesion may hinder delivery
E) the myoma is removed during cesarean section performed at full term

C) surgery is indicated in all cases, preferably during weeks 10-14 of pregnancy

73.The therapy of hyperthyroidism during pregnancy includes:
A) mild sedation, bed rest
B) the administration of antithyroid agents in low doses
C) combination therapy with antithyroid agents and T3 or T4
D) only answers (A) and (C) are true
E) the administration of T3 or T4


Simultaneous administration of L-thyroxine or L-triiodothyronine is contraindicated because these hormones may mask the effects of excessive doses of propylthiouracil on the mother and may cause hypothyroidism in the fetus


74.You are attending to an 18-year-old unmarried girl admitted to the intensive care unit with shaking chills, 39.4 °C fever, 80/40 mmHg blood pressure, moderate vaginal bleeding, abdominal tenderness and a history of having lost her consciousness twice. The pelvic examina-tion denotes a slightly enlarged and softened uterus. Which of the following procedures is not indicated?
A) a complete blood count
B) a blood culture and peripheral blood smear
C) a chest x-*** and plain abdominal x-*** in the standing position
D) dilation and curettage
E) laparoscopy

E) laparoscopy


In gynecology, the most commonly suggested contraindication of laparoscopy is hemodynamic instability resulting from an unruptured ectopic pregnancy..high index of suspicion for ectopic pregnancy in any woman who presents with these symptoms and who presents with physical findings of pelvic tenderness, enlarged uterus, adnexal mass, or tenderness

EMEDICINE.com


75.Which of the following conditions is characterized by the classic syn-.drome of amenorrhea with or without abnormal vaginal bleeding, pelvic-abdominal pain and an adnexal mass?
A) a tubo-ovarian abscess
B) intermenstrual pain (Mittelschmerz)
C) an ectopic pregnancy
D) a twisted ovarian cyst
E) diverticulitis


c
76.All of the following statements are valid regarding puerperal mastitis, EXCEPT:
A) it is treated by antibiotic therapy
B) the source of the infection is usually the nose and pharynx of the infant
C) abscesses may develop and require surgical drainage
D) Escherichia coli is the most common pathogen
E) its symptoms include shaking chills, fever and tachycardia


D) Escherichia coli is the most common pathogen

m/c Staph aureus but also Staph epidermidis and strep


77.All the following statements are valid regarding hysterosalpingography (a test for verifying the patency of the Fallopian tubes), EXCEPT:
A) both oily and water-soluble contrast materials can be used
B) nodular isthmic salpingitis is ususally detectable by this method
C) this procedure also denotes any intrauterine abnormalities
D) the volume of the contrast material should not exceed 3 ml in order to avoid spillage from the Fallopian tube into the peritoneal cavity
E) this procedure may have a therapeutic effect in infertility



D) the volume of the contrast material should not exceed 3 ml in order to avoid spillage from the Fallopian tube into the peritoneal cavity

http://www.1uphealth.com/health/hyst...ngography.html


Follow Ups:


78.All of the following statements are valid regarding polyhydramnios, EXCEPT:
A)acute polyhydramnios is a frequent cause of premature deliv- ery occurring before the 28th week of pregnancy
B) polyhydramnios is associated with congenital abnormalities in 20% of cases
C) edema is common, particularly of the lower extremities and of the vulva
D) polyhydramnios is associated with ureteral obstruction in al-most 50% of cases
E) it can be complicated by the premature separation of the pla-centa,uterine dysfunction and postpartum hemorrhage




D) polyhydramnios is associated with ureteral obstruction in al-most 50% of cases


79.AT a grocery store an old lady fell down on the floor you went to aid her and your step in her CPR wud be?
a . check her carotid pulses .
b . assess her breathing and give mouth to mouth.
c .establish airway
d .determine her responsiveness..
e.chest compressions


u wont assume every one who falls down needs to establish an airway.. first thing u will do is check her for her responsiveness.by shaking her shoulder and asking q... like are you okay? and then the ABC way

80.All of the following thyroid function tests yield elevated values dur-ing pregnancy, EXCEPT:
A) the basal metabolic rate
B) the total thyroxine level (T4)
C) the total triiodothyronine level (T3)
D) the radioiodine uptake (%)
E) the free thyroxine level

e

81,A 19-year-old woman is referred to the emergency room for a sudden loss of consciousness at her job. The examination reveals slight vaginal bleeding; the abdomen is distended and diffusely tender. The patient complains of shoulder- and abdominal pain. Body temperature: 36.4 °C; heart-rate: 120/min; blood-pressure: 96/50 mmHg. Which of the following diagnostic procedures should be performed to verify the tenta-tive

diagnosis established by evaluating the available clinical data?
A) a pregnancy test
B) posterior colpotomy
C) dilation and curettage
D) diagnostic puncture of the cul-de-sac
E) hysteroscopy

D) diagnostic puncture of the cul-de-sac

question is which test used to VERIFY the tentative diagnosis ( ie ectopic pregnancy ) hence a diagnostic puncture of cul de sac..this what emedicine.com says
Culdocentesis can be performed to help diagnose blood in the cul-de-sac. Ultrasound is relatively noninvasive, and findings are more sensitive for cul-de-sac fluid but cannot be used to distinguish between peritoneal fluid and blood.

82.During the first 24 hours following delivery, the blood glucose level of a neonate born to a diabetic mother is:
A) normal
B) hyperglycemia is common
C) hypoglycemia is common
D) no characteristic changes occur


c

83.Characteristic features of latent (gestational) diabetes include?
A) the presence of symptoms; high blood-glucose levels
B) the absence of clinical symptoms; normal blood-glucose levels, impaired glucose tolerance
C) the absence of clinical symptoms; normal blood-glucose levels and glucose tolerance, however, the enhanced glucose tolerance test yields abnormal results
D) clinical symptoms are absent; blood-glucose levels and the re-sults of both the glucose tolerance test and .the enhanced glu-cose tolerance tests are normal


c


84.Which of the following demonstrate the diabetogenic effect of pregnancy?
A) estrogen, prolactin and cortisol are insulin-antagonists.
B) the blood glucose level is elevated by growth hormone, prolactin and TSH
C) the placenta metabolizes a portion of circulating insulin
D) all of the above
E) only answers (A) and (B) are true


d

85.Which of the following drugs is appropriate for the treatment of listeriosis?
A) penicillin and sulfonamides
B) tetracycline
C) quinacrine (Daraprim) and sulfonamides.
D) chloramphenicol


a

86.In which weeks of pregnancy is ultrasonography recommended for monitoring the condition and development of the fetus?
A) on weeks 8 and 32
B) on weeks 24 and 32
C) on weeks 8, 24 and 38
D) on weeks 8, 24 and 32
E)on weeks 8, 18, 28 and 32

e
87.Which of the following is an indication for the termination of a preg-nancy in patients with underlying heart disease?
A) circulatory insufficiency developing during the first trimester
B) acute endocarditis
C) atrial fib
D) recurrent episodes of cardiac decompensation occurring before pregnancy
E) all of the above

e

88.Which region is the point of maximum tenderness of appendicitis in pregnancy?
A) right above the adnexes
B) at McBurney's point
C) laterally in the upper abdomen, almost in the right hypochondrium because the growing uterus displaces the cecum upwards and laterally
D) in the medial thirds of the imaginary line connecting the umbilicus to the anterior iliac spine.



C) laterally in the upper abdomen, almost in the right hypochondrium because the growing uterus displaces the cecum upwards and laterally

89.A 24-year-old pregnant woman is in the 8th week of gestation. Her medical history includes a pulmonary embolism that occurred 7 years ago during her previous pregnancy. She was given intravenous heparin at that time followed by oral warfarin (coumarin) therapy for several months. The patient has not experienced any signs of thromboembolism for the last 6 years. Which of the following statements is correct re-garding the current condition of the patient?

A) considering the 5-year-long disease-free period, the risk of a re-current thromboembolism is not higher than in normal cases

B) in pregnancy, impedance plethysmography is unsuitable for the evaluation of deep-vein thrombosis

C) in pregnancy, Doppler -ultrasonography is unsuitable for the evaluation of deep-vein thrombosis

D) low-dose heparin therapy should be started and continued throughout the pregnancy and puerperium

E) the risk of a recurrent thromboembolism is the highest in the second trimester of pregnancy



D) low-dose heparin therapy should be started and continued throughout the pregnancy and puerperium

http://www.emedicine.com/med/topic1958.htm


90.What is the earliest time when a multiple pregnancy can be detected by ultrasonography?
A) between the 4th and 6th week of gestation
B) between the 8th and 10th week of gestation
C) between the 14th and 15th week of gestation
D) between the 15th and 16th week of gestation
E) between the 15th and 16th week of gestation



b

91.Radiological fetures of intrauterine fetal death include:
A) the skull is collapsed and the cranial bones override each other
B) an angulated spine
C) exaggerated lordosis; steeply inclined ribs
D) all of the above
E) only answers (A) and (B) are true



d

92.What is hysterosalpingography used for?
A) for the diagnosis of ectopic pregnancy
B) to assess the patency of the Fallopian tubes and detect the morphologic abnormalities of the uterine cavity
C) for the diagnosis of ovarian neoplasms
D) to assess the motility of the Fallopian tubes
E) to measure the size of the ovaries



b
93.Which of the following urinary parameters is/are mandatory when being tested at follow-up visits during pregnancy?
A) the presence of any pus
B) the glucose level
C) the concentration of protein
D). all of the above
E) only answers (A) and (C) are true


Follow Ups:


d

94.A 74 yo man complains of vision loss in his right eye.He has no pain.A fundoscopic exam reveals a pale fundus with a red spot in the macular region.
What’s the most important next step?
Ailocarpine eye drop
Bcular massage
C:IV acetazolamide
D:fluorescein exam
E:emergency iridectomy


Bcular massage


central retinal artery occlusion secondary to an embolic event is the most likely Dx.The primary Tx is ocular massage to try to dislodge the clot.It’s also possible to improve perfusion by lowering the IOP.The pt should be refered emergently to an ophthalmologist.Later he will need a cardiovascular work up to search for an embolic source.

95.A 18yo girl develops a painful vesicular rash around her left eye.This is followed by blurry vision that occurs only when both the eyes r open.Which ocular motor nerve is most likely to be affected?
A:superior devision of the 3rd CN
B:inferior devision of the 3rd CN
C:4th CN
D:6th CN
E:long ciliary nerve

C:4th CN

Varicella-Zoster spreads to the face along the CN V.The CN IV is presumbly involved because it shares its nerve sheath with the ophtalmic division of the 5th CN.


96.A 19 yo man is hit in the face with a lead pipe.The ocular motor muscles most likely to be injured in this case is that inervated by the:
A:superior devision of the 3rd CN
B:inferior devision of the 3rd CN
C:4th CN
D:6th CN
E:long ciliary nerve



C:4th CN

The CN IV innervates the sup.oblique muscle because this muscle extends far anterior in the orbit,it's at high risk of injury with trauma to the orbit or the full face.


97.pleomorphic adenomas(mixed tumors)of the salivary glands r characterized by:
a:they occur most commonly on the lips,tongue,plate
b:they rarely recur if simply enucleated
c:they present as rock-hard masses
d:they grow rapidly
e:they have no malignant potent


a:they occur most commonly on the lips,tongue,plate
they r ruberry,slow-growing,potentially malignant


Follow Ups:


98. 52 yo woman began complaining of double vision& blurry vision 3mo ago and has since had decrease in interaction with her family.There’s paucity of thought and expression and unsteadiness of gait.Her whole body appears to jump in the presence of a loud noise.MRI& routine CSF exam unremarkable.The most likely Dx?
the most likely Dx is:
Creutzfeldt-Jakob disease

99.A 66yo woman presents to the ED with sudden onset of painless loss of vision.On exam the pt has hand motion vision in the right eye and 20/20 vision in the left eye.The cornea is clear and slit lamp exam of the anterior segment is unremarkable.The IOP:20mmH2O.
What’s the most likely Dx?
A:retrobulbar hemorrhage
B:retinal detachment
C:acute angle closure glaucoma
D:herpetic keratitis
E:endophtalmitis



B:retinal detachment

the only painless one in options!
endophtilmitis is painful in most cases,although can be the ans...but the q asked about the most likely Dx!


Follow Ups:


100.A 14 yo girl presents with a red eye.Pain in the right eye is exacerbated with light shone in either eye.What’s the most appropriate intervention?
A:topical steroids
B:sympathomimetic eyedrops
C:cholinesterase inhibitors
D:slit lamp exam
E:eye patch


D:slit lamp exam

the most likely Dx is ant.uveitis(iritis),a slit lamp exam discloses cells in the ant.chamber:cell& flare


Follow Ups:


1. 54 yo woman presents with 6mo of progressive memory loss.She has limited vertical eye movements and on exam she has rhythmic synchronous grimacing and eye closure movements(oculomasticatory myorhythmia)Jejunal biopsy reaveals PAS+ cells.
What’s the most likely Dx?Whipple's disease



2.A 52 yo woman complains of a swollen leg.The swelling began approximately 48 hr ago.The woman has never had anything like this before.On exam:the right lower extremity is 4cm larger than the left with warmth and redness but no open cuts or lymphangitis.Lymphadenopathy of 1cm is apparent in the inguinal regions bilaterally.Homans sign is negative.
What’s the most appropriate next step?
AenicillinG
B:radiography(plain film)
C:US
D:amoxi-clavulanate
E:MRI


C:US

with high suspection of DVT,Doppler US should be done.(more than 90% sensitive)
Inguinal lymphadenopathy up to 1cm is considered normal.But,if this LAP is new,fixed or tender it's more likely to be pathologic.
Homans sign is only 10-50% sensitive for DVT Dx.


Follow Ups:


3.The wk before a 16yo boy left for vacation he had a cold.His mother gave him some antibiotics she had at home so he could enjoy swimming.When the plane descended on the return trip,he developed a severe headache.He now reports having difficulty thinking and feeling awful.What’s the most appropriate study to confirm the cause of this pt’s symptoms?
A:blood culture
B:head CT with contrast
C:sinus aspiration and culture
D:CSF culture


B:head CT with contrast

A history of URI and swimming in an adolescent who then develops severe headache and a change in sensorium is highly suggestive of an intracranial complication of frontal sinusitis.CT may show ring-enhancing lesion consistent with a brain abscess or empyema.



4.A 34 y f with HIV and active pcp is admitted to the hospital. Her last CD4 count was 44 cells/mm3. She has been doing reasonably well since admission with a stable course on appropriate antibiotics. Two days into the hospitalization, she is found to be hypotensive and tachycardic. Her blood pressure is 80/40 mm Hg and her pulse is 110/min. Her temperature is 38.3 C (101 F) orally. Her extremities are cool and damp. Her mental status is normal. The remainder of her physical examination is unchanged. most appropriate therapy?

A. Intravenous fluids
B. Intravenous pressor support
C. Central venous pressor support
D. Add additional antibiotics to treat empiric sepsis
E. Blood transfusion

A. This patient is hypotensive but has minimal effects from the hypotension such as altered mental status or signs of shock. This blood pressure, however, is still not acceptable and the cause for it must be determined. In the interim, the symptom (low BP) must be treated. The standard therapy in all such situations is volume. This is a concept that ALL physicians must understand. Many times, newly graduated physicians worry about "CHF" or "wet lungs" with aggressive IV fluid support. Although in a non-emergent situation when a patients' blood pressure is not dangerously low, these are appropriate concerns, they are irrelevant in this situation. The key principal to understand is volume above all else. Since she is mentating well, there is no urgent indication for pharmacological blood pressure support and IV fluids are the absolute essential initial management tools for this patient


Follow Ups:


5.A 57y man has colon cancer screening examination. He has been in good health There is no family history of colonic polyps or gastrointestinal malignancy. His physical examination is unremarkable. A rectal examination reveals no masses, and his stool is guaiac negative. A sigmoidoscopy reveals a 4-mm polyp in the mid-rectum. It is removed with a forceps, and the histology reveals it to be a tubular adenoma. Which of the following is the most appropriate next step in management?

A. Schedule colonoscopy in 3 years
B. Schedule colonoscopy now
C. Schedule colonoscopy in 5 years
D. Schedule sigmoidoscopy in 1 year
E. Schedule a barium enema in the immediate near future



b


6.51y man undergoes a barium enema as a colon cancer screening examination. A 3-mm polyp is found in the ascending colon. It is rounded and smooth and has met all the radiographic criteria of a benign sessile polyp. No other lesions are seen within the colon. Which of the following is the most appropriate management?

A. Repeat the barium enema in 1 year
B. Schedule a colonoscopy in 1 year
C. Schedule a sigmoidoscopy now
D. Schedule a colonoscopy now
E. Schedule a CT scan to rule out nodal involvement

d


7.Morphological changes of the placenta in toxemia of pregnancy include:
A) infarcts
B) syncitial degeneration and hypertrophy of Langhans' cells
C) a thickening of the basal membrane
D) all of the above
E) only answers (A) and (B) are true

d

8.Symptoms of late toxemia of pregnancy include:
A) hypertension
B) proteinuria
C) edema
D) all of the above
E) only answers (B) and (C) are true



d


9.Which of the following auxiliary symptoms may accompany the essential manifestations of toxemia of pregnancy?
A) headache, dizziness, restlessness
B) visual disturbances, flashes of "sparks", diplopia and blurred vision
C) pruritus
D) only answers (A) and (B) are true


D) only answers (A) and (B) are true


10.The stages of eclamptic seizures are as follows:
A) tonic-clonic seizures
B) prodromal stage, tonic-clonic seizures, coma
C) tonic-clonic seizures, coma
D) clonic seizure, coma
E) prodromal stage, clonic seizure, coma



B) prodromal stage, tonic-clonic seizures, coma

Convulsions are usually generalized tonic-clonic in nature. Usually a brief, single seizure occurs. Multiple seizures also can occur; however, status epilepticus is rare.
Prodromal signs of impending eclampsia: 20% of eclamptics do not have hypertension as defined for severe pre-eclampsia. Subtle alterations in consciousness, for example impaired concentration and amnesia may be present for one or more days and be followed by severe headaches, epigastric pain, vomiting, visual disturbance and photophobia. The objective signs of clonus and hyper-reflexia indicate central nervous system irritability and /or cerebral oedema. Coma: It is a dreaded complication in eclampsia. Most women lapse into coma following a convulsion or repeated convulsions. Others may never suffer a seizure prior to coma. It may be a result of intracerebral hemorrhage that, at times, may dissect into the ventricular system or over the surface of the brain, creating a massive subarachnoid hemorrhage. Coma also can follow a sudden rise in blood pressure, with resultant cerebral edema without hemorrhage.



11.In severe, late occurring toxemia of pregnancy as well as in eclampsia, the pregnancy should be terminated if the following occur despite therapy:
A) if blood pressure is permanently high or rises abruptly
B) if significant or increasing proteinura is present
C) if oligo-anuria or signs of renal parenchymal damage occur
D) if the severe objective signs are accompanied by subjective complaints
E) if all of the above conditions occur alone or in combination



E) if all of the above conditions occur alone or in combination


Follow Ups:


12.Which type of abortion is characterized by cramping lower abdomi-nal pain, vaginal bleeding and a closed cervix?
A) incipient abortion
B) imminent abortion
C) incomplete abortion
D) missed abortion
E) post-abortion residue




Follow Ups:


imminent and threatned abortion not same ( see expl ) - ACE 07:26:08 08/29/03 (0)
Re: Q6 - r 03:34:17 08/29/03 (0)
Re: Q6 - prep 21:07


ANS is THREATNED ABORTION

Source: Dorland and emedicine.com
Imminent abortion, impending abortion in which the bleeding is profuse, the cervix softened and dilated, and the uterine contractions approach the character of labor pains.


Threatened abortion is a clinically descriptive term that applies to women who are at less than 20 weeks' gestation, have vaginal spotting or bleeding, a closed cervical os, and, possibly, mild uterine cramping.

Inevitable abortion

Vaginal bleeding is accompanied by dilatation of the cervical canal, no passage of fetal tissue, and, occasionally, gross rupture of the membranes. Bleeding is usually more severe than with threatened abortion and is often associated with abdominal pain.

Incomplete abortion

Vaginal bleeding is usually heavy and accompanied by abdominal pain. The cervical os is open, with passage of only part of the products of conception. Incomplete abortion is more likely to occur at 6-14 weeks of pregnancy. Ultrasonography (if used) reveals that some products of conception are still present in the uterus; these typically appear as echogenic material

incipient abortion
An impending abortion characterised by copious vaginal bleeding, uterine contractions, and cervical dilation.
Synonym: imminent abortion.




13.Which of the following is the most important feature for distinguish-ing between imminent and incipient abortion?
A) the volume of blood loss
B) cramps
C) the bore of the dilated cervix
D) the results of the biological pregnancy test
E) serum progesterone level
c


14,When does the 2nd stage of labor start and end?
A) from the time of full cervical effacement to the delivery of the fetus
B) from the delivery of the fetus to the expulsion of the placenta
C) from the start of uterine contractions to the effacement of the cervix
D) this period corresponds to the first 2 hours following the deliv-ery of the placenta
E) from the start of uterine contractions to the delivery of the fe-tus




a

15.Progesterone reduces the intensity of uterine contractions by:
A) reducing the resting membrane potential of the myocytes
B) hyperpolarizing the membrane of the myocyte
C) stimulating the synthesis of actomyosin in the muscle
D) increasing the conversion of ATP to ADP



b

16.The optimal frequency of uterine contractions during the 1st stage of labor is:
A) 0-1 contraction/ 10 minutes
B) 3-4 contractions/ 10 minutes
C) 6-8 contractions/ 10 minutes
D) 10-12 contractions/ 10 minutes
E) 15-20 contractions/ 10 minutes

b

17.In the case of head presentation and cephalic position delivery, which of the following describes the rotations of the fetal head cor-rectly?

A) rotation, deflexion, flexion, external rotation
B) flexion, rotation, deflexion, external rotation
C) deflexion, rotation, flexion, external rotation
D) rotation, deflexion, flexion, externa