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03-31-2005, 01:23 AM
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set of 2 questions(Nasi)
q435. A 71 yo man with carotid artery stenosis develops severe depression with anergy& hypersomina.The best choice for initial Rx?
A:amitriptyline B:doxepine C:nortriptyline D  henelzineE:trazodone Ans: C:nortriptyline elderly pts r often sensitive to the hypotensive,sedative and anticholinergic effects of antidepressants,this pt is at special risk for hypotension bcoz of his carotid artery stenosis,Nortryptiline is least likely to cause these SEs Q An 85yo widow who lives alone presents with weight loss,decreased energy,insomnia and a lack of interest in her usual activities.Her PMH is positive for HTN,AF,urge incontinence and contact dermatitis.She’s taking oxybutynin that she refuses to discontinue bcoz of its effectiveness.With diagnosis of depression and excluding other possible diagnosis,which drug is the best choice for this pt? a:thioridazine b:amitriptyline c:imipramine d:doxepine e:trazodone f:either d or e Ans: e:trazodone trazodone without anticholinergic effects(to avoid cumulative anticholinergic interaction effect with oxybutynin),its sedative SE may also be helpful in managing her insomnia.other antidepressants without anticholinergic effects r:fluoxetine,bupropion if the pt accepts to discontinue oxybutyn in,imipramine a good choice,bcoz its anticholinergic effect could be useful in controlling incontinence Q.A 43 yo woman has depressive rumination,hypersomnia,hyperphagia and a subjective sense of heaviness in her limbs that have not responded to trials of fluoxetine& nortriptyline.The most appropriate next step of management of this case is initiate: A:desipramine B:methylphenidate C:sertaline D:tanylcypromine E:trazodone Ans  :tanylcypromineagain case of MDD with atypical features Q. a 26 yo woman complains of binge eating& chronic depression that becomes worse when she feels rejected.She has not responded to a trial of sertraline.Rx: a:methylphenidate b:fluoxetine c henelzined:ECT Ans: c henelzineMDD with atypical features,may respond particularly well to MAOIs Q. a 54 yo hospitalized woman who has severe recurrent MDD improves dramatically after her first 2Rx with bilateral ECT.after the 4th ECT she's disoriented to the date.The best choice for furthur Rx? a:administer 2more ECT and then initiate antidepressant medications b:discontinue ECT&treat with antidepressant medication c:discontinue ECT until her cognitive status improves and then resume ECT d:initiate a mood stabilizing medication and continue ECT e:switch to unilateral ECT for 4 additional Rx Ans: a:administer 2more ECT and then initiate antidepressant medications the pt is responding well to ECT but needs atleast 2 additional Rx to minimize the risk of a quick relapse.some degree of transient cognitive impairment is common with ECT& often becomes more severe as Rx progresses,but it usually resolves within wk following the conclusion of a course of ECT and in this case doesn’t preclude 2 additional Rx.After conclusion of Rx,antidepressant usually continued for 6mo to lessen the chance of relapse. unilateral ECT less effective&often reserved for pts at special risk for severe cognitive compromise like elderly indivisuals,not indicated in this case! Q. Atropine is administered before the sessions of ECT,why? Ans: atropine is administered 30min before each session of ECT to reduce oral secretions that may interfere with airway maintenance& to reduce the postconvulsive bradychardia caused by vagal stimulation. Q. Which condition is not associated with abnormal maternal alpha-FP levels? A:maternal liver disease B:multiple gestation C:intrauterine fetal death D:fetal congenital nephrosis E:fetal hydrocephalus F  mphaloceleG:fetus-to-mother bleeding H:trisomy 18 I:trisomy 21 A: E:fetal hydrocephalus closed NTD including those associated with hydrocephalus in the fetus,r not *** with abnormal AFP levels in maternal serum. Q. which of the following can’t be used in the emergency Tx of acute toxic reaction secondary to PCP? A:alkalinization of the urine B hentolamine dripC:benzodiazepines D:haloperidol E:gastric lavage Ans: A:alkalinization of the urine phentolamine to treat serious HTN,acidification of urine to a PH less than 5 will decrease the T1/2 of PCP from 72 to 24hr. Q. A 37 yo male hunter from a rural area of South Carolina presents with fever and headache for 7days.Ph.E unremarkable,WBC:2800,plt:102,000.The most likely cause of illness? a:Ehrlichia canis b:Borrelia burgdorferi c:Rickettsia rickettsii d:Neisseria meningitides e:Parvovirus B19 Ans: a:Ehrlichia canis mild version of RMSF(spotless RMSF):with leucopenia,thrombocytopenia Q. A 55 yo married professor without a previous psychiatric history is early in her menopause.In addition to experiencing hot flashes&some irritability,she complains of episodes of dizzy spells&memory lapses which she had experienced on several occasions early in life.She denies depressive symptoms either now or in the past.Next step of management? Ans: EEG to rule out possible temporal lobe epilepsy,her symptoms r consistent with psychomotor epilepsy:that’s exacerbated at menopause Q. A 37 yo man develops arthralgias,fever,urticaria 2wk after a heart transplant.The immunosuppressive agent most responsible is: a:azathioprine b:cyclosporine c rednisoned:antitymocyte globulin Ans: d:antitymocyte globulin serum sickness Q. A 45yo man has an excretory urogram for investigation of microscopic hematuria discovered on a routine U/A(with no protein).He’s healthy without complaints.Kidneys r of normal size with calcification& dye collection in dilated medullary structures.Serum electrolytes,BUN,Cr,Ca,P,UA normal.Cr clearance:103ml/min.Which one is not true about this condition? A:there’s significant chance that symptomatic renal stones will develop B:there’s significant chance that he has hypercalciuria C:there’s significant chance of UTI D:He’s likely to have impaired urine concentrating ability E rogression to renal sufficiency is uncommonF:His children each have a 50% chance of experiencing the same condition Ans: F:His children each have a 50% chance of experiencing the same condition case of medullary sponge kidney,it’s congenital not heredity disease Q. A 55 yo woman is being treated for ARDS with mechanical ventilation.She has gradually improving gas exchange,is afebrile & has minimal sputum.She’s receiving no antibiotics& a routine sputum culture,obtained on the 10th day of mechanical ventilation shows gr- rods,non-lactose fermenters.Her Cxray unchanged from 3days earlier.What’s the most appropriate management for this pt? Ans: case of psedomonas do nothing,in the absence of clinical signs of invasive infection,this represents colonization,Ab therapy could predispose to superinfection with resistant gr- organisms or fungal agents Q. which one is not a feature of analgesic associated nephropathy? A:normal-sized kidney B:anemia out of propotion to azotemia C:strile pyuria D apillary necrosisE:female predominance Ans: A:normal-sized kidney anemia due to chronic GI blood loss,so out of propotion to azotemia Q. A 25 yo homosexual man presents with diarrhea.Acid-fast stain of stool reveals large acid fast+ oval organisms,culture negative for enteric bacterial pathogens.An assay for Clostridium difficile toxin is normal.Treatment? Ans: isospora belli,TMP-SMZ diff diagnosis:cryptosporidium also acid fast with no response to TMP-SMZ,size less than 1/4 size of isospora,so may be the answer but bcoz of large cysts isospora most likely MAV complex also acid fast,but rods not cysts Q. A 20yo woman resuscitated after multiple organ trauma sustained in an auto accident,requiring over 30units of packed RBCs and volume expanders within 24hr.She now develops spontaneous bruising,bleeding at venipuncture sites,and GIB.Rx? a DAVPb lt transfusionc:aminocaproic acid d:IV gammaglobulin e:FFP Ans: b lt transfusion dilutional thrombocytopenia Q. Which of the following pharmacokinetic factors is least affected by age? A:GI absorption B lasma protein bindingC:tissue distribution D:hepatic metabolism E:renal excretion Ans: A:GI absorption Age-related changes r:increased gastric PH,decreased gastric emptying:could potentially affect the absorption of medications,but GI absorption overall is changed little,bcoz most drugs r absorbed through passive diffusion and their bioavailability is unchanged Q: A 68 yo white man is reffered to u for evaluation of renal failure.Lab: Na:135,K:4.2,Cl:109,HCO3-:24,glucose:101,Ca:10.9,P:4.3,Albumin:4,Hct:29% Cr clearance:55ml/min,urine protein:6.2g/day Next step of Mx? Ans: this pt has multiple myeloma and his renal failure most likely is related to overproduction of Ig light chains.the pt has anemia,he has significant proteinuria WITH NORMAL serum albumin so nephrotic syndrome excluded!and the presence of LMW protein that's readily filterated at glomerulus such as Ig light chain,could explain the proteinuria first step of Mx:immunofixation electrophoresis of the serum&urine confirmation by BMA&biopsy&bone survey Q. Which one is not a side effect of cyclosporine? A:HTN B:hyperkalemia C:hypoglycemia D:nephrotoxicity E:tremor Ans: C:hypoglycemia Q. A 54 yo woman presents with abrupt decline in urine output& RF.Her PMH is positive only for hysterectomy 1mo earlier& chronic migraine headaches controlled with methysergide.Lab: Na:130,K:6.2,Cl:99,HCO3-:16,glucose:101,Ca:7.9,P:6.3,Albumin:4,Cr:3.2 U/A:PH:1.010,protein&Hgb:trace,sediment:unremark able Urine output over the past 12hr:60cc Next step of Mx? Ans: this pt has a presentation typical of retroperitoneal fibrosis:clear association with methysergide CT generally confirms the Dx by showing medial deviation&extrinsic compression of the ureters,so diagnostic test of choice Q. A 24 yo man known to be HIV+,currentlt receiving no treatment,develops the acute onset of petechiae and oropharyngeal bleeding.Plt count:2000,No RBC fragmentation is noted on exam of peripheral blood smear.Rx? a DAVPb lt transfusionc:aminocaproic acid d:IV gammaglobulin e:FFP Ans: d:IV gammaglobulin acute thrombocytopenia:ITP Q. A previously well 24 yo woman from Colorado presents with high fever,headache and large ecchymoses on the buttocks and trunk.Her BP is 90/60mmHg,WBC:6000,PLT:75000,PT:18s(control 12s),ESR:3mm/hr.The most likely cause of illness? a:Ehrlichia canis b:Borrelia burgdorferi c:Rickettsia rickettsii d:Neisseria meningitides e:Parvovirus B19 A: d:Neisseria meningitides fever,hypotension,DIC due to bacteriemia Q. a 34yo African-American woman,who’s G4P3 at 36wk gestation,presents with complaints of worsening shortness of breath&fatigue of 2wk duration.She has noticed swelling in her legs and exacerbation of the dyspnea when she lies flat.On exam:u detect an extra heart sound following S2 at the apex,jugular venous distention and bilateral basilar rales.The most likely Dx? A: peripartum cardiomyopathy seen commonly from the last mo of pregnancy until 6mo postpartum with a peak incidence at 2mo postpartum RFs:increasing age,multiparity,African-American race,HTN,multiple gestation Q. which one is not capable of increasing plasma levels of lithium? A henylbutazoneB:thiazide diuretics C:indomethacin D:high intake of coffee E:fasting&low salt diet A: D:high intake of coffee All increase plasma levels of lithium,high intake of coffee interferes with achieving therapeutic levels of lithium Q. A 37 yo man presents to the ER with a history of alcoholism& recent onset of obtundation.He lives alone and can provide no other information.On arrival he has a grand mal seizure that lasts for 2 minutes.Ph.E:BP:120/70,HR:110,and no evidence of head trauma,papilledema or focal neurologic findings.His mental status doesn’t change with IV injections of thiamine& 50% dextrose.Lab:Na:136,K:5,Cl:99,HCO3-:12,BUN:42,Cr:4.2,Arterial PH:7.10,PaCO2:40,PO2:85. Next step of Mx? A: Classic presentation of ethylene glycol ingestion(methanol toxicity in diff diagnosis but acute renal failure due to oxalate deposition and tubular obstruction).the case is an alcoholic pt who substituted ethanol with antifreeze,symptoms like alcohol intoxication but with progression to stupor,obtundation,coma and seizures.There’s also a severe anion gap metabolic acidosis,bcoz ethylene glycol is metabolized to glycolic acid&oxalate. Tx:alkaline diuresis,IV infusion of ethanol:now fomepizole is prefered,it's more expensive but doesn't cause CNS depression or metabolic abnormalities seen with ethanol,hemodialysis in cases fail to respond to antidotal therapy. Q. A 10 yo girl presents to the ER with polyuria,polydipsia,nausea and vomiting for 2 days,9hrs after Tx for DKA,she’s complaining of a severe diffuse headache and she becomes stuporous within minutes.No electrolyte abnormality is seen.Next step of Mx? A:emergent head CT B:head xray C rder EEGD rder LPE:IV heparin F:IV naloxane G:IV mannitol infusion H:start IV antibiotics immediately after taking B/C I:IV corticostroids A: G:IV mannitol infusion cerebral edema is a feared complication of DKA Tx in children.The pathogenesis is ill-defined but correlates with aggressive fluid replacement,especially with hypotonic fluids.Typicaly children have headaches that progress to obtundation&coma,focal neurologic defecits r rare.therapy must be initiated immediately before any diagnostic tests. Tx:reduction of ICP with mannitol,raising the head of the bed,hyperventilation and if needed neurosurgical decompression Q. A 32yo man was treated with doxycyline for Lyme disease 2mo ago and now completely recovered.Now he wants to donate blood.What do u say? A: He can donate 12mo after the last dose of Abs was taken Q. A 27yo woman G2P1 at 34wk gestation presents for prenatal visit.She had a primary outbreak of herpes at 26wk gestation.She has no complaint now,her Ph.E and fetus condition all normal.The next step of Mx? A: recommend acyclovir prophylaxis starting at 36wk gestation to prevent another outbreak that may lead to do C/S(ONLY INDICATION OF C/S IS resence of active lesions at birth)it’s safe drug during pregnancy Q. Which of the following lab abnormalities is not present with lead poisoning? A:microcytic anemia B:basophilic stippling on the peripheral smear C roteinuriaD:elevated ALP E:elevated erythrocyte protoporphyrin A: D:elevated ALP both glycosoria&proteinuria r seen Q. A 34yo schoolteacher woman with history of hepatitis(asymptomatic)due to blood transfusion in the past,now feels well,with no complaints,Ph.E nomal,LFTs all normal. Her medical records show: Hepatitis A Ab -,HBs Ag -,HBs Ab+,Hepatitis C Ab+ Next step of Mx? A:hepatitis A vaccination B:hepatitis B vaccination C:liver biopsy D:abdominal US E:referral for interferon/ribavirin Tx F:do nothing,just disease education&consuling A: A:hepatitis A vaccination case of chronic asymptomatic hepatitisC,she’s schoolteacher at high risk for hepatitis A,if infected at much higher risk for fulminant liver disease,so needs protection Q. A 18 yo woman without any significant PMH presents for pre-college Ph.E.She’s healthy with no complaints.On Ph.E u find a single nodule on the left lobe of thyroid gland,all other Ph.E r normal.First step of Mx? A rder TSHB rder thyroid uptake scanC:fine needle biopsy D:repeat exam in 6mo A. A rder TSHfirst TSH,if normal then needle biopsy Q. In the dark,a pt’s right pupil is 3mm greater in diameter than the left pupil.In bright light,the right pupil is only 1mm larger than the left pupil.Which pathway contains the lesion? a:afferent sympathetic b:efferent sympathetic c:afferent parasympathetic d:efferent parasympathetic A. b:efferent sympathetic anisocoria Q. A 2yo child has a 2day history of fever&pain in the right ear.Ph.E reveals bulging&marked erythema of the right tympanic membrane as well as bilateral scleral injection and purulent conjunctivitis,what’s the pathogen most likely responsible? A: nontypable H.influ Q. U visit a 5day old son who brings by her mother bcoz of red,tearing eyes with yellow sticky discharge that prevents him from opening his eyes after sleeping.A Gr stain of purulent material show gr- diplococci.Next stp of Mx? A:topical silver nitrate B:topical erythromycin C:systemic ceftriaxone D:systemic erythromycin A: C:systemic ceftriaxone gonococcal conjunctivitis topical silver nitrate&erythro for prophylaxis at birth systemic erythro for chlamydial conjunctivitis that usually occurs 5-14days after birth Q. A 52 yo recipient of a cadaveric renal graft develops bleeding gums and easy bruising.The immunosuppressive agent most responsible is: a:azathioprine b:cyclosporine c rednisoned:antitymocyte globulin A: a:azathioprine with BM suppression Q. a 33yo woman,G4P4 presents to the ER with abdominal pain.She has a history of asthma,tobacco and alcohol abuse&STD.She had a cholecystectomy 7mo ago and a tubal ligation after the birth of her 4th child.On exam the pain is primarily located in the right lower quadrant,it increases when a hand is quickly removed from the abdomen.The pt has a positive Rovsing sign.Next step of Mx? A:abdominal xray B:US C:CBC D:serum beta-HCG E elvic exam A: D:serum beta-HCG abdominal pain in sexually active women should always raise the suspicion of EP.RFs include:a history of salpingitis or EP,increasing age,multiparity&African American or Hispanic race.A history of tubal ligation may increase risk Q. A pt with GIB on postoperative day 1 after repair of an AAA.What’s the diagnostic study of choice for this condition? A:esophagogastroduodenoscopy B:barium enema C:colonoscopy D:abdominal CT E:upper GI series A: C:colonoscopy the common cause of GI hemorrhage after an AAA repair is colonic ischemia.The inf mesenteric A is often sacrificed during the procedure,if the pt doesn’t have adequate collaterals from the left colon,ischemia will occur. Colonoscopy is the diagnostic study of choice for colonic ischemia Stress gastritis may occur post op but on post-op day1 the problem is likely colonic ischemia Q. A 67 yo man presents with midabdominal colicky pain,nausea,anorexia and vomiting for the past 48hr.T:37C,BP:100/60,HR:103.On Ph.E he has a distended&tympanic abdomen.Abdominal Xray shows multiple distended loops of small bowel and distention of the right colon,up to the middle of the transverese colon.Stool is positive for occult blood.What's the most appropriate next diagnostic step? a:doppler US b:abdominal CT c:laparoscopy d:exploratory laparotomy e:upper GI endoscopy A: b:abdominal CT mesentric venous thrombosis Q. A 19yo woman with 2 previous episodes of mania develops a major depressive episode.Which of the following is the most appropriate initial pharmacologic management? A:imipramine B:lithium C:divalproex D:venlafaxine E:venlafaxin&divalproex A: E:venlafaxin&divalproex CASE OF BIPOLAR DISORDER,DEPRESSED PHASE the depressive episode should be treated with an antidepressant:venlafaxine,and a mood-stabilizing agent:divalproex should also be initiated to minimize the risk of inducing a manic episode Q. Which of the following ECG findings is most characteristic of carbamazepine toxicity? A:QRS duration of 0.160 msec B:QT interval of 310 msec C:PR interval of 0.210 msec D:ST elevation E eaked T waves A: A:QRS duration of 0.160 msec carbamazepine a tricyclic compound has Na channel blocking characteristics,QRS prolongation&QT interval lengthening the most characteristic ECG changes seen in carba toxicity Q. A 16yo high school student presents with a syphilitic chancre for 8 days.He currently has 3sexual partners and doesn't use protection with any of them.Mx for the pt and his partners? A: treat him with benzatine penicillinG 2.4million units IM in a single dose,bcoz sexual partners might be infected even if seronegative,presumptive Tx should be given to those who were exposed within 90days. Q. A 42yo woman is referred for evaluation of a liver mass that was found on a CT ordered as a part of nephrolithiasis work up.The 3cm mass has a central hypodense region with progressive peripheral to central enhancement.Her medical history includes only nephrolithiasis,and her medications include OCPs and multivitamins.The most appropriate next step of Mx? A:FNA B:CT-guided biopsy C bservation with a follow up CTD:hepatic artery ligation E:surgical removal A: Cavernous hemangioma:the most common benign livr tumor These tumors may enlarge over time,if greater than 4cm in size they r termed giant hemangiomas.in some cases they r hormone-responsive& occasionally undergo spontaneous thrombosis& lead to pain&elevated liver transaminases.But most of these tumors r asymptomatic& spontaneous rupture is rare.surgical removal is recommended if they r associated with pain. so the ans in this case is:C bservation with a follow up CT Q. A 34 yo primigravid woman at 10wk gestation has a urine dipstick positive for nitrates&leukocyte esterase and a U/C:50,000 CFU/ml of E.coli.Next step of Mx? A: according to BRS the definition of asympto bacteriuria is CFU>100,000 of single organism,but kaplan says that Tx indicated in this case...??? Q. A 4 yo boy falls from the jungle gym at preschool.He sustains minor abrasions& contusions and is taken care of by the school nurse.He presents with his parents for a complete check up for possible internal injuries.Comple Ph.E is normal,Hgb:14g/dl,U/A:microhematuria.What's the most appropriate next step of Mx? a:US b:CT of abdomen& pelvis c:IVP d:retrograde urethrogram&cystogram e:serial Hct&Hgb f:reassurance the parents A: a:US microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable,The first noninvasive test should be the US Q. The most common cause of thyrotoxicosis in pregnancy is: a:subacute thyroiditis b:hydatiform mole c:thyrotoxicosis factitia d:toxic diffuse goiter e:choriocarcinoma A: d:toxic diffuse goiter Q. A 33 yo male recent immigrant from Mexico presents with multiple white spots on his arms&legs that slowly appeared over the past 2yr.The spots used to be reddish& scaly but were replaced by patches without any pigment.He's otherwise healthy with no FH of skin disease&no medication.Ph.E all normal except skin lesions:multiple confluent vitiligolike depigmented macules and patches over the elbows,shins and ankles,VDRL postivie.The most likely Dx? A: PINTA spirochetal disease caused by Treponema carateum,endemic in Mexico,Central&South America Q. The drug used in Tx of autonomic symptoms of heroin withdrawal is: a:methylphenidate b:diphenhydramine c:alprazolam d:clonazepam e:flumazenil A: b:diphenhydramine Q. which of the following electrolyte abnormalities is not associated with ALL or its Tx? A:hypokalemia B:hyperphosphatemia C:hyperuricemia D:hypercalcemia E:hyperkalemia A: D:hypercalcemia Q. A 1400 gr infant born at 35wk gestation,is 42cm in length and has a head circumference of 28cm.One day after birth she becomes very irritable,tremulous and inconsolable.Her cry is high-pitched.Her pulse is 174/min.There r no dysmorphic facial features.Her mother had inconsistent prenatal care and has a history of multiple inpatient hospitalizations for substance overdoses.The infant was most likely exposed to which substance in utero? A: The most commonly abused drug by pregnant mothers is cocaine,infants r usually SGA &sometimes have microcephaly and neurodevelopmental abnormalities.Exposed infants r very irritable and inconsolable to the withdrawal period,the cry is often high pitched,they r also at increased risk of SIDS,periventricular leukomalacia is also associated with cocaine exposure Q. a 27 yo woman G2P1 at 26wk gestation,comes for routine care.Her pregnancy has been without complications.She feels consistent fetal movement,has had no contractions and has experienced no bleeding.She complians of burning chest pain that worsens at night and after meals.Lab:AST:50U/L,ALT:55U/L,ALP:125U/L,Albumin:3.5gr/dl.The next most appropriate step of Mx? A:RUQ US B:esophagogastroduodenoscopy C:ERCP D:abdominal CT E:reassurance A: E:reassurance GER ALP normally elevated in pregnancy AST,ALT may be slightly elevated in normal pregnancy Q. A term male infant is found to be cyanotic shortly after birth and requires endotracheal intubation.On Ph.E his BP:65/30mmHg(equal in 4 extremities)PR:175,RR:30.His precordium is dynamic,has a grade III sys murmur and a single S2.Cxray shows a normal heart size and increased pulmonary vascular markings.ABG on an FIO2 100%shows:PH:7.34,PaCO2:47,PaO2:46.What’s the most likely Dx? A: total anomalous pulmonary venous return with obstruction of course,pls read the explanation from blue print:good explanation  Q. A 47yo man complains of numbness&pain in the lower extremities.He works as a pipe fitter.His PMH is positive for HTN for the past 7yr&consumption of 6 to 8 beers/day for the past 25yr and 50 pack-yr of cigarette use.He also complains of frequent urination.On Ph.E he has 5-/5 strenght in plantar& dorsiflexion,with diminished light touch distally.What’s the likely cause of his complaint? A MB:Alcohol abuse C:Hypothyroidism D:Tobacco abuse E:Asbestosis A: B:Alcohol abuse alcoholic neuropathy:damage to both sensory&motor fibers,initial symptoms r plantar pain&paresthesia often described as burning.distal weakness can occur&ankle jerks r first reflexes lost. this condition is unlikely to be due to DM,diabetic polyneuropathy is uncommon at the time of diabetes Dx,it usually begins with sensory loss in the feet. Q. A 34yo woman presents with a dry,hacking cough of 6mo duration.The cough initially began after an URI but has never completely improved.It’s particularly bad at night and in the early morning.The woman doesn’t complain of rinorrhea,dyspnea,fatigue,fever or weight loss.Her PMH positive for an appendectomy at age12.Her FH significant for lung cancer in her father and maternal grandfather.She doesn’t smoke and works as a secretory for a software manufacture.OTC cough syrups have provided only minimal relief.Ph.E&Cxray r normal.The first step of Mx? A:PFTs B:Chest CT C:PPD D:trial of antihistamine or decongestant with intranasal steroid E:upper endoscopy A: D:trial of antihistamine or decongestant with intranasal steroid case of chronic cough:more than 3wk in nonsmoking pts the first most common cause of chronic cough is PND,if this pt doesn't show improvement with trial of Tx PFTs is done,bcoz the second most common cause of chronic cough is asthma Q. A 59yo woman who’s hospitalized for palliative Tx(chemo+radiation Tx)of metastatic laryngeal carcinoma develops a fever,T:39,BP:105/60,HR:114,RR:16.Ph.E completely normal(no localizing symptom,no site of infection identified),no foreign indwelling cathaters.Lab:Hgb:9,WBC:800(neutrophil:46%,lymphoc yte 32%,bands:12%)plt:19000.Pan culturing was done.Next step of Mx? A:start Tx with ceftazidime B:start Tx with vancomycin C:start Tx with ceftazidime&vancomycin D:start Tx with ceftazidime,vancomycin& amphotericinB E:wait for culture results A. A:start Tx with ceftazidime neutrophils:[800x(46+12)(<500)]=464 case of neutropenia(<500) fever greater than 100.9F,or 100.4F>1hr:IS SIGNIFICANT IN NEUTOPENIC PTS If pt continues to be febrile after 72hr Tx with ceftazidime,then Tx with vanco should be started,ampho after 5days if unresponsive Q. A 22yo woman G1P0 at 12wk gestation with an intrauterine pregnancy,complains of burning when she urinates,she also has increased urgency&frequency.A urine dipstick shows leukocyte esterase& a small amount of blood.Which of the following steps should be next? A:urine microscopy B:Antibiotics C:urine culture D:CBC E:renal US F elvic exam A: A:urine microscopy although CBC,U/C,Antiniotic Tx all necessary urine microscopy is essential to assess for WBC casts,it may also suggests an atypical cause of infection Q. A 77yo woman has widely disseminated breast cancer.She's being followed at home bcoz she has refused any furthur specific anti-cancer therapy.Her Hct drops from a previously stable 43% to 26% over a 2mo period.Review of the blood smear shows normochromia,anisocytosis,poikilocytosis and nucleated RBCs,rare immature cells r also seen in the smear.What’s the most likely cause of her anemia? A: myelophtisic anemia the underlying disease process here is an end-stage cancer Q. A 62yo woman presented with closed communicated femur Fxs and underwent operative fixation with an intramedullary nail.On postoperative day 2 she’s confused,oriented only to name,has diffuse rales&scattered petechiae on the upper chest&arms.T:39C,BP:120/90mmHg,PR:135regular,RR:30 with O2 saturation 85% on room air,wound is clean&dry.Which of the following tests would be likely to yield the most diagnostic information? A oppler US of the lower extremitiesB:U/A&CBC C:Abdominal CT D:Pulmonary angiogram E:radiograph of the femur A: B:U/A&CBC serum&urine eosinophilia,as well as fat droplets in the urine&blood also trombocytopenia Q. What’s the underlying cause that leads to hypokalemia in pts with ALL? A: hypokalemia secondary to a renal tubular defect hyperkalemia as a part of tumor lysis syndrome:a complication of Tx Q. U see a 6yo boy at ur office for the first time.His parents note that he seems to tire easily and complain of weakness in his legs,they have attributed this to his shyness and his preference for watching videos rather than playing outside.Ph.E reveals a healthy-apearing boy with a BP:138/94mmHg in his right arm.His lower extremities r slightly atrophic and mottled-appearing.What’s the pathophysio mechanism of HTN in this pt? A: HTN secondary to decreased renal blood flow Q. Which of the following agents would not be expected to increase HDL? A:simvastatin B:niacin C:Gemfibrozil D:Alcohol E:Vit E A: E:Vit E Q. A 76 yo woman is admitted to ICU for respiratory failure.She requires 100% fractional concentration of O2 & has a PaO2 of 56mmHg.A central venous catheter indicates a PCWP of 8mmHg.Her Cxray is notable for a bilateral alveolar filling process.What’s the most likely cause of the woman’s respiratory failure? A:aspiration B:sepsis C:trauma D:multiple transfusions E neumoniaF:MI A: B:sepsis case of ARDS:it’s defined by the presence of the following 3 criteria: 1-bilateral diffuse opacities on Cxray 2-PCWP<18mmHg 3-PaO2/FIO2<200mmHg the most common causes in descending order r:sepsis,aspiration,multiple transfusions,pneumonia,near-drowning,pancreatitis,cardiopulmonary bypass Q. A 23 yo woman presents with severe LLQ abdominal pain of 6hr duration that’s associated with some moderate vaginal bleeding.She’s sexually active&she doesn’t use contraception.Her last period was 6,1/2wk ago. Which of the following provides the least help in confirming ur clinical Dx? A:quantitative beta-HCG B:vaginal US C:abdominal US D:culdocentesis E:laparascopy A: C:abdominal US abdominal US can identify a tubal gestational sac in only 25%of cases Q. A 52 yo man with a long history of alcohol dependence,characterized by frequent binge drinking,is started on 50mg/day of naltrexone and has no binges during the next 6mo. By which mechanism naltrexone decreased his binge drinking? A: Naltrexone ia an opoid antagonist,it's most likely effective in the Tx of alcohol dependence bcoz it blocks the euphoric effects of alcohol-mediated release of endogenous opoids. Q. A 25yo woman complains of severe anexiety when she has to speak at business meetings or attend social events.She’s unable to host or attend even small parties and this has narrowed her social life&decreased her chances of networking in her carrier.She feels isolated and inadequate.What’s the best choice of Tx? A:assertiveness training&paroxetine B:supportive psychotherapy&lorazepam C sychodynamic psychotherapy&imipramineD:stimulus flooding and lorazepam E:systemic desensitization A: A:assertiveness training&paroxetine case of social phobia assertive training a version of cognitive psychotherapy includes educating the indivisual about anexiety-controlling techniques,role playing and desensitizing the indivisual to anexiety provoking social stimuli. Q. The brain structure most closely associated with sleep architecture is: a:hypothalamus b:amygdale c:dorsl raphe nucleus d:hippocampus e:cingulated gyrus A: c:dorsl raphe nucleus Q. A 22 yo woman G1P0 32wk pregnant complains of bilateral kneepain&hip pain.At 28wk she had contractions that were controlled with terbutaline.On furthur questioning she complains of shortness of breath while lying flat.Ph.E:BP:150/90mmHg,tachycardia,lungs clear,neck exam normal.Homans sign negative,no lower extremity swelling or edema is present.Hyperpigmentation is apparent on her nose&cheeks.Lab:ESR:65,HCT:31%,Hgb:10,plt:300, 000.Next step of Mx? A:ANA B:Echocardiogram C:Anti-dsDNA D:V/Q scan E:reassurance A: E:reassurance knee&hip complaints r common as pregnancy proceeds and the exam is normal,so a rheumatologic disease unlikely.the facial hyperpigmentation is melasma due to elevated estrogen&MSH levels.ESR is elevated in normal pregnancy.dyspnea is a common complaint secondary to diaphragmatic displacement(cardiovascular exam is normal)so peripartum cardiomyopathy unlikely,based on Ph.E pulmonary TE is unlikely too. Tachycardia a side effect of terbutaline(beta-agonist) Q. A newborn girl is evaluated for jaundice.At the age of 4days,her bilirubin is 8mg/dl and nearly all unconjugated.Which of the following tests is most appropriate? A:CBC B:blood smear C:blood culture D:ALT,AST E:TSH A: B:blood smear this pt has primarily unconjugated bilirubin& the most important next step is a peripheral smear to evaluate for hemolysis. if hemolysis is present the most likely causes includes a congenital erythrocyte disorder,an erythrocyte enzyme defect,or a blood group incompability. if no hemolysis exists and no infection is evident,the probable Dx is either physiologic jaundice or breastmilk-induced jaundice after ruling out hemolysis TSH,ALT,AST would be useful to rule out hypothyroidism&liver disease. Q. A 63 yo pt presents with left leg pain after fa,lling.the leg is abducted,externally rotated and shortened.The most likely Dx? A ost.hip dislocationB:ant.hip dislocation C:femoral neck Fx D:knee lateral dislocation A: C:femoral neck Fx both ant.hip dislocation& femoral neck Fx can present in this way but fx more common Q: A 74yo man has pain,swelling and redness of the right hand 2wk after a stroke involving the left hemisphere.The hand is warm and has pitting edema.Any motion of the wrist and shoulder produces pain.Radiographs of the shoulder,wrist and chest r normal.Mx? A: shoulder-hand syndrome:reflex sympathetic dystrophy can occur following stroke,MI,trauma to shoulder.it’s characterized by pain,swelling,erythema,increased skin T and limitation range of motion of shoulder,arm and hand on affected side,usually unilateral.Tx hysical therapy to the arm Q. A 76 yo woman admitted to the ICU with diagnosis of ARDS.After approximately 10days on a ventilator,she develops fever&RUQ pain.On Ph.E:vital signs normal,she has lost 7kg during hospitalization.US shows pericholecystic fluid&a thickened gallbladder wall with no visible stones.The next step of Mx? A:cholecystostomy B:Antibiotics&observation C:ERCP with sphincterotomy D:cholecystectomy E:CT scan A: D:cholecystectomy case of acalculous cholecystitis Q.A 19yo white male has periapism of 12hr duration.He has no history of trauma or drug use.His Ph.E except for his periapism is unremarkable.The lab study which will most likely establish the etiology of periapism is: a lt countb:Hgb electrophoresis c:sickle cell prep d:BT e:CBC A. e:CBC leukemia a well-recognized cause of periapism in young men,in the absence of an obvious etiology for the periapism,WBC count should be performed to rule out leukemia.he’s white&sickle cell unlikely Q. A 48 yo man complains of left shoulder pain.He has no associated trauma.On Ph.E,he experiences the most pain with crossed arm adduction with applied resistance.The most likely Dx is: a:acromioclavicular join inflammation b:subacromial bursitis c:supraspinatous syndrome d artial rotator cuff teare:biceps tendinitis A. a:acromioclavicular join inflammation Q. A 31 yo man presents to the ER after a head on collision in which he was a front seat passenger wearing a seatbelt.On Ph.E he’s conscious,BP:110/70mmHg,PR:96,RR:14.The most appropriate method for suspecting the Dx of injury to the small bowel is: a:abdominal exam b:supine&upright abdominal xray c:abdominal CT d PLe:serum amylase measurment A: a:abdominal exam he’s conscious!!!so the first step is exam Q. Which of the following adverse effects occurs most frequently during Tx with clozapine? A:seizure B:renal failure C:agranulocytosis D igmentary retinopathyE:anticholinergic delirium A: A:seizure the incidence of seizure with a daily dosage of clozapine greater than 600mg is more than 5%.Agranulocytosis incidence is 1% Q. A 55 yo white man presents for routine sigmoidoscopy to screen for colon cancer.A single 3mm sessile polyp is found,biopsy performed and pathology reports hyperplastic polyp.Next step of Mx? A:colonoscopy B:Air-contrast barium enema C:repeat sigmoidoscopy in 6mo to evaluate for recurrence D:continued regular sigmoidoscopic screening at the usual interval A: D:continued regular sigmoidoscopic screening at the usual interval hyperplastic polyp<5mm no potential risk of malignancy Match 1-10 with A-J 1) Continuous murmur 2) Left parasternal heave 3) Midsystolic click 4) Paradoxical spliting of S2 5) paradoxical pulse 6) Canon a waves 7) Low ejection fraction Normal ejection fraction 9) Pitting edema 10) Improves stroke volume A) digoxin B) LBBB C) Status asthmaticus D) Systolic dysfunction E) Dialysis pt. F) R vent. hypertrophy G) Mitral valve prolapse H) Complete heart block I) Diastolic dysfunction J) left heart failure 1) Continuous murmur -dialysis 2) Left parasternal heave -right ventricular hypertrophy 3) Midsystolic click -mitral valve prolapse 4) Paradoxical spliting of S2 -LBBB 5) paradoxical pulse -status asthamaticus 6) Canon a waves - complete heart block 7) Low ejection fraction - systolic dysfunction Normal ejection fraction -diastolic dysfunction 9) Pitting edema -left heart failure 10) Improves stroke volume- digoxin 1.Girl 5 yo with IQ 60 starts to eat food from other children plate ( nothing else was given)she has : Down syndrom, trisomy 18, trisomy 13 down syndrome b/c t18,t13 never reach 5 years t18,t13 svere mental ratardation not mild like here t21 mild m.r like here with av iq 60-70 down mcc m.r 2.Which of the listed effects belong to hormone replacement therapy and which to Tamoxifen (SERM) treatment? 1. Cause hot flashes 2. Prevents hot flashes 3. Cause Endometrial hyperplasia 4. Prevents Endometrial cancer 5. Prevents osteoporosis 6. Contraindicated with thrombophlebitis 7. Prevents breast cancer 8. predisposes to breast cancer 9. increases LDL 10. increases HDL Tamoxifen as far as i know is not contraindicated with thrombophlebitis Both ERT and Tamoxifen decrease LDL, but only ERT increase HDL!!! These two facts i got from Kaplan Q-Bank.. I checked there.. If you have other references please tell me... The other things absolutely correct 3.A patint suspected to have a PE. The V/Q scan is interpreted as intermediate probability.. What is the next step of diagnosis? a. CT scan with contrast b. CT scan without contrast c. Angiography d. Doppler US of legs Follow Ups: couldnt solve this questions myself. Different books have different opinions..Seems Doppler US of the legs is the best answer.. 4.There is a patient with symptoms of renal colic. On the CT scan a stone is found in the ureteropelvic junction. The size of stone is 2.5 cm. What should you do with this patient? a. Provide successive analgesia and send him home with scheduling an appointment in a week b. Do extracorporeal shock wave litho c. Do percutaneous lithotomy d. Antibiotics and prepare for urgent operation C. Percutaneous nephrolithotomy.. Because Stones larger than 1 cm unlikely to pass spontaneousely and ESWL is used for stones less than 2 cm - it's better to use pervaginaaneous lithotomy Follow Ups: 5. Why increase of Calcium in Squamous Cell CA??? [ Follow Ups ] [ Post Followup ] [ Forum 2 ] -------------------------------------------------------------------------------- Posted by ah from IP 68.74.70.11 on November 12, 2003 at 11:04:02: In Reply to: Why increase of Calcium in Squamous Cell CA??? posted by img on November 12, 2003 at 10:38:09: Squamous cell Carcinoma, has paraneoplastic syndrome where is produces a PTH like hormone, that causes hypercalcemia.. Follow Ups: 6.Treatment for Achlasia and Schatzki Ring...??? [ Follow Ups ] [ Post Followup ] [ Forum 2 ] -------------------------------------------------------------------------------- Posted by img from IP 64.107.143.3 on November 12, 2003 at 10:37:21: The treatment for both is Pneumatic Dilation....what is that exactly how do they do that? Follow Ups: Put a balloon in their and dilate(pneumatic dialation) for achalasia, it has other treatment options like, boutox injection, and CCA and nitrates(palliative treatments), and also surgical myotomy (definitive treatment) i was told the treatment for schatzi's ring was to do endoscopy and push the scope through to break the ring open (from kaplan videos) hope this helps Follow Ups: 7.A 50 y/o woman presents with double vision for three days. She denies nausea or vomiting. On P/E, vitals are normal, ptosis and slight divergence of the right eye is noted. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Fundus examination shows no papilledema. Which of the ffg is the most likely underlying condition? A. Aneurysm of the post. communicating artery B. Carcinoma of the Rt. pulmonary apex C. Diabetes mellitus D. Giant cell arteritis E. Syphilis F. Systemic hypertension Answer is A. Aneurysm of the posterior communicating artery This px shows signs of oculomotor palsy, with restriction of the eye movements in all directions (except laterally, due to preservation of the sixth cranial nerve), and ptosis. Dilatation of the pupil, which fails to react to light, is a sign of intracranial compression of oculomotor nerve. Uncal herniation and aneurysm of the posterior communicating artery are the two most common surgical conditions leading to oculomotor palsy. Cerebral angiography is the investigation of choice to confirm the diagnosis. All of the most common medical causes of oculomotor nerve palsy result in paresis of extraocular movements and ptosis, but the pupillary light reflex is preserved. These conditions include diabetes mellitus, giant cell arteritis, syphilis and systemic HTN 8.-A 45 y/o woman attempted suiside with imipramine ingestion. Which of the ffg would most likely reflect possible cardiac toxicity? A. Left deviation of the QRS axis B. Prolongation of the QRS interval C. Shortening of the QT interval D. ST segment depression E. T wave inversion Answer is B. Prolongation of the QRS interval. A prolongation of the QRS interval is highly predictive of both cardiac and CNS toxicities from tricyclic antidepressant ingestion. Follow Ups: 9.-GVHD after bone marrow transplantation is principally mediated by which of the following cells? A. B-lymphocytes of bone marrow graft B. Leukemic cells C. Natural killer cells of recipient D. T-lymphocytes of bone marrow graft E. T-lymphocytes of recipient Answer is D- T-lymphocytes of bone marrow graft In GVHD, T cells (both helper and suppressor cells) of the engrafted marrow react against the recipient's antigens, thus triggering inflammation and injury to the host tissues. The most severely affected organs include the immune system, gastrointestinal tract, liver, skin, and lungs. 10.A 39 y/o male presents with chronic pain and tingling of the buttocks. The pain is exacerbated when the buttocks are compressed by sitting on a toilet seat or chair for long periods. No lumbar pain is noted. Pain is elicited with Freiberg's maneuver (forceful internal rotation of the extended thigh). Which of the following is the most likely Dx? A. Disk compression of the sciatic nerve B. Piriformis syndrome C. Popliteus tendinitis D. Posterior femoral muscle strain Answer is B. Piriformis syndrome The sciatic nerve comes out of the greater sciatic foramen below the piriformis muscle, and is liable to compression by the muscle. Symptoms are as described above; bicycle riding and running may also set off the symptoms, which may take the form of chronic nagging ache, pain, tingling, or numbness. 11.A 50 y/o woman with a remote hx of blood transfusions is found on a screening physical examination to have spider angiomas and palpable splenomegaly. She is otherwise healthy. Laboratory test abnormalities are limited to mild aminotransferase elevations and a platelet count of 110,000/µL. Subsequent evaluation reveals that she is positive for anti-HCV Abs, and liver biopsy reveals cirrhosis. Screening endoscopy demonstrates large distal esophageal varices. The most appropriate treatment recommendation would be: A. Nonselective beta-blocker B. Band ligation C. Band ligation and sclerotherapy D. Dietary protein restriction E. Isosorbide mononitrate Answer is A. Nonselective beta-blocker The American College of Gastroenterology recommends that all patients with cirrhosis who have not had a bleeding episode and who have no contraindications to beta-blockade should be screened by endoscopy to detect the presence of gastroesophageal varices. If large esophageal varices are detected, patients should then be treated with nonselective beta-blockers. Several large, randomized, controlled trials of nonselective beta-blockers in patients with esophageal varices have demonstrated their superiority over placebo in preventing initial variceal hemorrhage, particularly in patients with large varices. Follow Ups: 12.A 70 y/o woman is hospitalized with pulmonary edema. She has no previous history of pulmonary edema or CHF. An echocardiogram shows significant left ventricular systolic dysfunction. After 5 days of treatment in the hospital, her symptoms improve and she is discharged to home. She is examined in the office 1 week later; although her pulmonary examination and chest radiograph still show crackles and mild congestive heart failure, respectively, her symptoms are markedly improved. Which one of the following medications can be safely discontinued without compromising patient survival? A. Digoxin B. ACE inhibitor C. Spironolactone D. ß-blocker Answer is A. digoxin Although the use of digoxin may significantly reduce hospitalization rates and the need for other interventions in patients already receiving diuretics and ACE inhibitors, it has not been shown to confer a survival advantage in any large randomized controlled clinical trial. Follow Ups: 13.On screening flexible sigmoidoscopy, a 60 y/o man is found to have a 5-mm polyp in the rectum. Histopathologic examination of biopsy specimens demonstrates a hyperplastic morphology. He has no symptoms, no family history of colorectal cancer, and no significant medical history, and takes no medications. A six-window fecal occult blood test is negative. What is the most appropriate follow-up for this patient? A. Repeat sigmoidoscopy in 1 year B. Colonoscopy C. Barium enema D. Yearly fecal occult blood testing and sigmoidoscopy in 3 to 5 years Answer is D. Yearly fecal occult blood testing and sigmoidoscopy in 3 to 5 years This asymptomatic, average-risk patient had a hyperplastic polyp found at screening sigmoidoscopy and a negative fecal occult blood test. Hyperplastic polyps are not associated with an increased risk of neoplasia, and routine screening is recommended. This includes yearly fecal occult blood tests on dietary and medication restrictions and flexible sigmoidoscopy every 3 to 5 years. If an adenomatous polyp is found at sigmoidoscopy, colonoscopy is recommended, because 50% of such patients will have neoplasms beyond the reach of the sigmoidoscope. Barium enema is reserved for those patients who are unable undergo endoscopic evaluation. source: mksap 14.A patient with isolated systolic hypertension. Which is the drug of choice? a) Ca channel blockers b) beta-blockers c) Thiasides d) ACE inhibitors e) Loop diuretics Follow Ups: emedicine & harrisons both say the first line therapy for systolic htn is ca channel blockers ( like nifidipine ) the results of the SYST-EUR (Systolic Hypertension in Europe) trial documented that a long-acting calcium channel antagonist reduced mortality to an extent equivalent to that previously reported for diuretics and beta blockers. Thus, long-acting calcium channel antagonists are often used as first-line therapy. harrison's 15.A hemodinamically stable pateint with confusion and vague symptoms.. Laboratory tests show hypernatremia. What is the best treatment option? a) Dextrose-5%-water b) normal saline c) Ringer solution d) half-normal saline e) hypertonic saline Kaplan says when the patient is hemodinamically stable - give D5W, otherwise - normal saline... Crash the board says - NEVER give D5W to patients with hypernatremia.. Give just water orally.. If hemodinamically unstable - give normal saline, when the patient becomes stable- switch to half-normal saline (0,45%. What to answer on the exam? Harrisons recommends that either 5% dextrose in water or half-isotonic saline can be given intravenously in Tx os hypernatremia. and current surgery says: Treat the patient with 5% dextrose in water unless hypotension has developed, in which case hypotonic saline should be used. Follow Ups: 16.A 52-year-old woman presents to her physician's office complaining of an enlarging nose, thickening of her tongue, and coarsening of her facial features. She had started noticing the gradual change 2-3 years earlier, accompanied by soreness of the hands. No change in shoe size or enlargement of the limbs was reported. The patient denies having headaches. When she was 42 years old, she was diagnosed with chronic bronchitis. At the age of 51, she underwent thyroid surgery for multinodular goiter. On examination, her blood pressure is 140/90 mm Hg and her pulse is 68/min. A chest x-ray film shows a welI-demarcated opacity, 5 cm in diameter, Iocated in the posterobasal part of the right pulmonary lobe. Question 1 of 5 Which of the following is the most likely diagnosis? / A. Gigantism / B. McCune-AIbright syndrome / C. NAME syndrome / D. Paraneoplastic syndrome / E. Pituitary adenoma Question 2 of 5 The pituitary cells that normally produce the hormone involved in this patient's disease process belong to which of the following types? / A. Corticotrophs / B. Gonadotrophs / C. Mammotrophs / D. Somatotrophs / E. Thyrotrophs Question 3 of 5 Which of the following is the major inhibitor of the release of the hormone in question? / A. Gastrin / B. GHRH (growth hormone releasing hormone) / C. GIP (gastric inhibitory peptide) / D. Secretin / E. Somatostatin Some of the involved hormone's actions are mediated by somatomedins (IGFs). Which of the following effects would most likely be a result of the action of IGFs (insulin-Iike growth factors)? / A. Decreased insulin sensitivity / B. Epiphyseal growth / C. Increased GI absorption of Ca2+ / D. Lipolysis / E. Na+retention Question 5 of 5 The lung carcinoma seen on the chest x-ray film is most likely which of the following pathologic types? / A. Adenocarcinoma / B. Large cell carcinoma / C. Pancoast tumor / D. Small cell carcinoma / E. Squamous cell carcinoma In Reply to: Re: Re: q...ans is D,D,E,B,E posted by prr on November 13, 2003 at 21:16:44: The correct answer is E. Paraneoplastic syndromes are clinical syndromes resulting from tumor-produced hormones and occur in 10-15% of cancer patients. Lung cancers can cause several paraneoplastic syndromes based on the humoral factor being produced. Squamous cell carcinomas are one of the most common primary malignancies of the lung and are often seen in smokers. They usually arise from central bronchi, producing a hilar mass. Hypercalcemia, caused by the secretion of parathyroid hormone-related peptide (PTHrP), and acromegaly, caused by an ectopic secretion of growth hormone, are endocrine paraneoplastic syndromes associated with squamous cell carcinoma of the lung. 17.A 45-year-old man visits his primary care physician because of discharge, tearing, and discomfort in the left eye that has lasted 3 days. He has no history of trauma. Examination of the left eye reveals conjunctival edema and vascular congestion with stringy discharge. When fluorescein dye is placed in the eye, no areas of staining are found, but a number of white spots appear in the superior aspect of the cornea. What is the diagnosis? Follow Ups: the s/s sounds like viral conjunctivitis, but those white spots are marginal ulcers ( toxin-related complication of staph ) which may indicate an allergic reaction to staphylococcal antigen. So Dx could be blepharitis due to Staph. infection. 18.In a study of relationship between aluminium toxicity and devalopment of dementia, Alzheimer type, 400 patients with disease and 400 unaffected controls was interviewed about the use of aluminium cookware in the fourth decade of life. Results indicate that relative risk of the disease in aluminium cookware users is 2.6 (95% confidence interval 1.9-3.2)> Researchers conclude that aluminium cookware cause dementia Alzheimer type.Which of the following potential flaws invalidate this conclusion? a. diagnostic bias b. ecologic fallacy c. inadequate statistical power d. lack of statistical significance e. recall bias I can't get several things in this Q. 1. Why the calculate relative risk as it's case-control study and Odd's ratio should be calculated.. 2. What is diagnostic bias - and why this answer is wrong here? 3. whats this deal with recall bias? just picking this choice by the method of exclusion? Follow Ups: use logic if you ask a patient if he or she used to cook using al cookware 40 years ago, they probably do not remember, and if those patients already have Alheimer your chances to remember are very few. Follow Ups: 19.A 41-y-old woman has taken aspirin for chronic headaches and phenytoin for seizures for 2 years. PE shows epigastric tenderness and bilateral 3 cm nontender axillary lymph nodes. A lymph nodes biopsy shows hyperplasia. What is the cause of patient's lymphoadenopathy? lymphadenopathy as a reaction to Phenytoin phenytoin-induced hypersensitivity reaction 20.A 52 yo African-American male has a pedunculated colon polyp detected in his descending colon during screening sigmoidoscopy.Follow-up colonoscopy reveals no other lesions and the polyp is completely removed by snare biopsy.The pathologic examination shows well-differentiated adenocarcinoma in situ without invasion of the submucosa and no extension into the stalk. Which one of the following would be most appropriate at this time? A:Hemicolectomy with colostomy B:Segmental colon resection with examination of regional lymph nodes and intraoperative liver biopsy C:Segmental colon resection with examination of regional lymph nodes D:Repeat endoscopy immediately with fulguration of the stalk remnant E:No further procedures at this time,repeat examinations of the colon at regular intervals E:No further procedures at this time; repeat examinations of the colon at regular intervals Even when a pedunculated adenoma contains focal invasive cancer,endoscopic removal is generally considered adequate treatment if the endoscopist is satisfied that excision has been complete,the margin is clear,and the histology is not poorly differentiated or indicative of lymphatic or vascular invasion 21.Which one is markedly decreased in PCO syndrome? A:estradiol B:androgens C:SHBG D:FSH E:LH C:SHBG findings in PCO syndrome:estradiol&LH high normal,mild elevation of androgens,low normal FSH,decreased SHBG Follow Ups: 22.A 27yo man presents to the ED with acute shortness of breath,which has progressed over the past several months.His PMH is significant for a stab wound to the left groin area 5yr ago,which was treated with observation.He has no other illness.On Ph.E:BP:120/80mmHg,HR:125/min,bilateral rales,and jugular venous distention.Cardiac exam reveals a systolic ejection murmur and an S3 gallop. What’s the next diagnostic step of Mx? a case of high-output cardiac failure due to undiagnosed traumatic AV fistula from the injury. at the time of injury the fistula was small,but over time it has enlarged and become hemodynamically significant. on Ph.E:the pt would most likely have a palpable thrill& audible bruit over the fistula.Occlusion of the fistula with direct pressure leads to an expected significant drop in HR as a result of rise in peripheral resistance.A drop of 10beats/min or more is thought to be significant& is termed Branham's sign.A duplex study or angiogram could confirm the dx. Follow Ups: 23.A 35 yo woman G4P2A1 with a 5yr Hx of chronic HTN presents to the maternity unit at 29wk GA,reports that she has not felt the baby move in 12hr and expresses concern that her baby might be dead.A 3-hr 100-gr OGTT shows 3 elevated values.Her blood glucose values have been within the target range.Which of the ffg methods most accurately confirms fetal demise? A:absence of fetal movement by maternal report B:absence of fetal cardiac motion on sonography C:absence of fetal cardiac activity by external sonocardiography D:absence of fetal heart tones by Doppler auscultation E:absence of fetal movement by sonography B:absence of fetal cardiac motion on sonography assessment of cardiac activity by a skilled sonographer is the most accurate method of confirming fetal demise 24.Cervical exploration is performed to evaluate a thyroid nodule that was read as hypercellular and follicular on the FNA.After exposing the thyroid gland at surgery,what’s the diagnostic procedure of choice? A:incisional biopsy of the nodule B:excisional biopsy of the nodule C:thyroid lobectomy D:near total thyroidectomy E:total thyroidectomy C:thyroid lobectomy A FNA has revealed a hypercellular or follicular lesion. this finding mandates surgical exvision because cytopathology can't determine either capsular or vascular invasion,which r the 2 hallmarks of malignancy in a follicular neoplasm.The surgical biopsy technique involves a total lobectomy on the side of the lesion.Incisional or excisional biopsies r not appropriate for evaluation of well-diff thyroid cancers& may result in furthur dissemination of a potential malignancy.A near total or total thyroidectomy would be appropriate if a maligannt lesion is confirmed histologically 25.A 45 yo man presents to the office with a tender left breast mass 1cm in size.He has no nipple discharge.His mother died of breast cancer at 41yo.What’s the appropriate next step in the Mx of this pt? A:FNA B:mammography C:US of the lesion D:US of the testicles E:excisional biopsy B:mammography The work up of a palpable breast mass in a male pt is the same as for a female pt. Bilateral mammography is necessary to characterize the lesion as well as evaluate the opposite breast.Breats US can then be done if indicated by mamo characteristics. As in female pts,FNA should not be performed until after mammo,as it will change the characteristics of the lesion.Excisional biopsy should not be done until after mammo. Testicular US is generally done if there’s concern for a testicular tumor which can cause gynecomastia. 26.A 55 yo man who was in an automobile crash undergoes exploration for abdominal injury.He has a significant contusion to his bowel with intramural hematomas and several areas of perforation.The bowel is repaired but is very edematous.Post-op,u decide that enteral feeding is not safe and that TPN is appropriate during the post-op period.10 days after starting TPN a pt has elevated bilirubin,AST,ALT,ALP& dry scaly skin. What’s ur Mx for this pt? LFTs become abnormal in as many as 30% of pts on TPN.During the first 2wk,transaminases rise& a gradual increase in ALP occurs.Rising enzyme levels normally respond to a modest REDUCTION IN THE RATE OF INFUSION! Failure of the serum enzymes to plateau or return to normal within 7-14days should suggest another etiology.Fatty liver& structural liver damage can be induced by TPN.Prolonged TPN can cause cirhosis,but this usually occurs over years of TPN. dry,scaly skin is indicative of free fatty acid defeciency. Administeration of LIPIDS correct the problem! 27.A 18 yo woman presents to the ED for unilateral left-sided abdominal-pelvic pain.A quantitative serum beta-HCG level is 4500mIU/ml.No intrauterine gestational sac is apparent on transvaginal sonography.However,on sonogram a left-sided pelvic mass is noted consistent with an unruptured ampullary EP measuring 4cm in length. Which of the ffg is the surgical procedure of choice? A:laparoscopic salpingectomy B:laparatomy with linear salpingostomy C:laparascopic segmental resection of oviduct D:laparascopic linear salpingostomy D:laparascopic linear salpingostomy linear salpingostomy for those unruptured&<5cm 28.A 65 yo woman complains of vulvar itching.On exam u find a 6x8mm left vulvar lesion.The pathology report of biopsy describes full-thickness involvement of epithelium with basal cells.The basement membrane is intact without any invasion.Which mode of Tx is recommended? A:skinning vulvectomy B:simple vulvectomy C:radical vulvectomy D:radiation therapy A:skinning vulvectomy case of:CIS or stage0 vulvar carcinoma Skinning vulvectomy which removes only the epithelium is the Tx of choice for Vulvar CIS. Radiation Tx is of limited value in vulvar cancer Simple vulvectomy for Paget’s disease,radical vulvectomy for invasive vulvar carcinoma. 29.Which one of the following is appropriate in the management of acute vertebral fracture in a patient with osteoporosis? A:raloxifene B:alendronate C:intranasal calcitonin D:vitD C:intranasal calcitonin Several modalities have been found to be helpful for managing the pain ***/ acute osteoporotic vertebral compression Fx.Analgesics,bed rest,and lumbar corsets can all be beneficial,with calcitonin reserved for resistant cases due to its analgesic effect.The other options listed r all for long-term Mx of osteoporotic and high-risk pts. 30.A 24yo woman comes to the office with concerns about excessive dakly pigmented hair on her chin,upper lip,abdomen and thighs.Onset of excessive hair has been gradual since puberty.Her mother&sister have similar findings.Exam doesn’t show evidence of virilization.What’s the most appropriate next step of Mx? A btain serum testosterone& DHEASB btain serum testosterone& 17-OH progesteroneC btain serum FSHD btain pelvic USE rescribe OCPF rescribe spironolactoneG rescribe GnRH agonistsH:use conservative management B btain serum testosterone& 17-OH progesteroneit’s important to rule out late-onset CAH which results in increased levels of 17-OHP levels obtain serum testosterone&DHEAS if pt presents with RAPID onset of hair growth+virilization(enlarged clitoris):case of androgen-producing ovarian:sertoly-leidig(if increased testosterone& adnexal mass)or adrenal tumor(if increased DHEAS) 31.A 6yo girl is brought to the office by her concerned mother,who states that she has seen pubertal changes in her daughter.The girl hasn’t had any bleeding.On exam pubic hair but     
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