Download FUNDAMENTALS OF CLINICAL MEDICINE

FUNDAMENTALS OF CLINICAL MEDICINE
FINAL EXAMINATION
Version A
TRUE / FALSE
1. Automatisms are involuntary automatic behaviors that occur when consciousness is impaired,
either during or after a seizure.
A. True
B. False
2. When treating a patient with an acute ischemic stroke blood pressure should not be lowered acutely.
A. True
B. False
MULTIPLE CHOICE; SLNGLE BEST ANSWER:
3. Among the reasons HIV infection is likely to be a major wealth problem for years to come is/are:
A. The long time between infection and symptoms of disease (median time 11.3 years).
B. Antigen stimulation of infected CD4 causes HTV production.
C. Age groups at risk for acquiring HIV have little experience with AIDS in their peer
group of friends.
D. All of the above.
4. All of the following are modifiable risk factors for stroke except:
A. Smoking
B. Diabetes
C. Hypertension
D. Coronary Heart Disease
E. Family history
5. Advers effects that may be associated with Tegretol include:
A. Diplopia
B. SIADH
C. Vertigo
D. All of the above
6. Indications for treatment of arrhythmias include all of the following except:
A. Relief of symptoms that interfere with a patients lifestyle.
B. Prevention of potentially life-threatening arrhythmias.
C. Prevention of asymptomatic frequent premature ventricular contractions.
D. Prevention of embolic events with atrial fibrillation.
7. You are assigned a consult on the Nephrology Consult Service. On your way to the bedside you
learn that the patient has an elevated plasma bicarbonate. Which one pair of acid-base disorders
listed below correctly lists two causes of an elevated bicarbonate?
A. Metabolic alkalosis and severe lactic acidosis.
B. Respiratory acidosis or metabolic alkalosis.
C. Respiratory acidosis or metabolic alkalosis.
D. Metabolic alkalosis or respiratory alkalosis.
8. You determine that a metabolic alkalosis is present in a patient on whom you are consulting.
From the following list, which answer below represents the most likely (common) scenario
leading to the development of a metabolic alkalosis in hospitalized patients.
A. N-G suction or the use of diuretics in a patient with effective volume depletion and
a low urine chloride concentration.
B. Hypertension in a volume expanded patient with a high urine chloride
concentration.
C. Congenital chlorhidorrhea.
D. Vomiting in a patient receiving large doses of cimetidine or omeprazole and an
acid urine pH.
9. A first year medical student presents to the clinic with a complaint of gnawing epigastric pain
relieved by eating. The remainder of the history and physical are unremarkable. Your
recommendation as his physician would be:
A. Buy more life insurance before any diagnostic testing is done.
B. Avoid fatty, greasy food
C. UGI endoscopy
D. A course of an H-2 blocker (e.g. Ranitidine)
E. UGI series
10. A retired physician presents to the clinic with a complaint of gnawing epigastric pain relieved by
eating. He has lost 20 pounds. The remainder of the history in unremarkable. Physical
examination is unremarkable except for heme + (guaiac +) stool. Your recommendation as his
physician would be:
A. Avoid fatty, greasy food
B. UGI endoscopy
C. A course of an H-2 blocker (e.g. Ranitidine)
D. UGI series
11. During the workup of a macrocytic anemia, a 62-year-old woman is determined to have an
intrinsic factor deficiency during a Schilling test. A serum gastrin is markedly elevated. Which
ONE of the following is a likely explanation'?
A. A gastrin-producing rumor
B. Achlorhydria
C. Cholera
D. Celiac sprue
E. Gallstones
12. To examine a program for educating health professionals in a sports injury clinic about the
importance of keeping detailed records, a researcher does a controlled trial in which the
dependent variable is a range of motion of injured joints, which is classified as (a) worse, (b)
same, or (c) better, and the independent variable is (a) program or (b) no program. What kinds of
variables are they'?
A. Dependent is categorical (nominal); independent is ordinal.
B. Dependent is ordinal: independent is categorical
C. Dependent is continuous; independent is categorical.
D. Dependent is ordinal: independent is continuous.
E. None of the above.
13. Also referring to the above question (number 15), are these variables appropriate?
A. Both are appropriate.
B. Neither is appropriate.
C. The dependent variable should be measured continuously, rather than collapsing
data.
D. Choosing the type of variable is unimportant in medical research.
14. The Lipids Research Clinics Trial screened 300,000 men to find 3,000 with cholesterol in the top
1 percent, no heart disease, and compliance with their treatment regimen. They randomized the
population to active drug (cholesterol lowering) and placebo regimens and, after 10 years, found
38 cardiac deaths in the controls and 30 in the drug group (p < .05). A Margarine company then
proclaimed that everybody should switch from butter to low cholesterol margarine to prevent
heart disease. You must decide what to recommend to your patients. What would be your
considerations with regards to a large clinical trial?
A. In large sample studies, statistical significance is very important.
B. In large sample studies, clinical significance is very important.
C. No matter how small a result, you should recommend dietary modifications to your
patients.
D. Even though few of your patients are similar to the study populations, it is a simple
task to extrapolate the results of the study to the general population.
15. A common omission in reports of studies is the "power" of the statistical tests to discover a
difference between the treatment and the placebo. The power of a test is related to the size of the
effect and the size of the sample. true or false'?
A. True
B. False
16. A 58-year-old male, with a history of hypertension and hypercholesterolemia, with no prior
history of dyspnea or exertional chest pain, presents with crushing retrosternal chest pain which
waxes and wanes, radiates down his left arm, and is associated with some diaphoresis. The most
likely diagnosis is:
A. Critical aortic stenosis with hypertensive crisis.
B. Hypertrophic cardiomyopathy.
C. Unstable angina or acute myocardial infarction.
D. Acute pericarditis.
17. The electrocardiogram is the single most useful tool for diagnosing acute myocardial infarction.
The single MOST specific pattern associated with acute myocardial infarction is:
A. ST depression across the pericardial leads.
B. A rapid and irregular rhythm.
C. Hyperacute ST elevation in at least two adjacent leads representing an anatomic
region (such as V1 and V2).
D. Hyperacute ST elevation in at least two leads representing an anatomic region,
such as leads 3 and AVF, with accompanying reciprocal ST depressions in a
anatomically opposite region such as leads VI and V2.
18. Your best friend has fallen in love with an exotic dancer. He is about to get married even though
you have tried to talk him out of such a rash decision since he has know her for only one week.
To make matters worse, she has informed your friend that she has chronic hepatitis B and her
doctor has told her it is actively replicating. Your advice to your friend would be the following:
A. HBIG (hepatitis B immune globulin) and hepatitis B vaccine
B. Hepatitis B vaccine only
C. HBIG (hepatitis B immune globulin) only
D. Check liver function tests and, if elevated, begin interferon treatments
MATCHING QUESTIONS 19 - 21
EACH CHOICE MAY BE USED ONLY ONCE
Match the following hepatitis B serology to the correct diagnosis:
HBsAg
A. +
B. C. +
D. E. +
HBsAb
+
+
-
HBcAB-IgM
+
-
HBcAb(total)
+
+
+
+
HBeAb
+
HBeAg/HBV-DNA
+
+
-
19. Acute hepatitis B.
20. Past infection with the appropriate antibody response.
21. Active (replicating) hepatitis B that is chronic (>6 months).
MULTIPLE CHOICE, SINGLE BEST AIN'SWER:
22. A 5 month old child is brought to your office because of fever (40° C), vomiting and irritability.
He has been febrile and irritable for one week. Examination shows positive Kernig and
Brudzinski signs. The initial CSF shows:
WBC 825/mm3 (99% mononuclear leukocytes)
RBC 10/mm'
protein 120 mgidL
glucose 35 mg- dL (blood glucose 85 mg/dL)
Gram stain - no organisms seen
Your interpretation of these data, and your treatment based on this interpretation, is:
A. probable viral meningitis; observe
B. probable tuberculous meningitis; give INH, Rifampin. Streptomycin.
pyrazinamide. and glucocorticosteroids
C. probable bacterial meningitis: give cefotaxime intravenously
D. probable non-infectious CSF pleocytosis; observe closely and repeat CSF later.
E. probable fungal meningitis; begin amphotericin B
23. An eight year old infant is brought to the hospital in respiratory distress. The emergency room
physician notes that the child has large liver and spleen. Which of the following would not be in the
differential diagnosis of neonatal hepatosplenomegaly and respiratory distress?
A. Congenital Treponema pallidus infection
B. Congenital cytomegalovirus infection
C. Congenital Toxoplasma gondii infection
D. Hepatitis B
E. Listeria monocytogenes sepsis
24. The natural history of AIDS differs in adults and children. Which of the following is a very
common problem in children but uncommon in adults?
A. Kaposi's sarcoma
B. Invasive bacterial infections (e.g. pneumococcal sepsis)
C. Mycobacterium avium-intracellulare blood stream infection
D. Pneumocystis carinii pneumonia
E. Cryptosporidiosis
QUESTION 25 - 26, CASE OF MR. KAPLAN:
Mr. Kaplan presents with a history of severe chest pain for 3 hours. The electrocardiogram shows
ST segment elevation with T wave inversion in leads I, II, AVL and V2 - V6. The most likely
pathological changes in the patient's heart are:
A. Atherosclerosis of the right coronary artery and subendocardial ischemia of the
posterior left ventricle.
B. Vasospasm of the left circumflex coronary artery and subendocardial ischemia of
the lateral left ventricle.
C. Acute thrombus of the left anterior coronary artery and evolving transmural
myocardial infarct of the anterior and lateral left ventricle.
D. Organizing thrombus of the left anterior descending artery and healing transmural
myocardial infarct of the anterior left ventricle.
E. Atherosclerosis of the left anterior descending coronary artery and
subendocardial infarct of the anterior left ventricle.
26. In the case of Mr. Kaplan, the most likely finding with serial measurements of serum levels of
creatine kinase (CK), CK-MB. and troponin - T (T) is:
(Normal values: CK. 12-191 V/L; CK-MB. 0 - 2.5 index; T. 0 - 0.5 MG/ml)
A.
B.
C.
D.
E.
CK
CK-MB
T
CK
CK-MB
T
CK
CK-MB
T
CK
CK-MG
T
CK
CK-MB
T
Admission
400
10
25
190
2
1
200
2
2
150
0
1
190
2
0
6 hours later
1000
20
50
600
5
10
700
6
12
180
1
2
650
5
1
2 days later
300
4
10
200
2
5
2000
20
20
140
0
1
800
8
0
27. In the case of Mr. Kaplan the most appropriate therapy (excluding any major contraindications) is:
A. Sublingual nitroglycerin only.
B. Intravenous nitroglycerin and beta-adrenergic blocker only.
C. Aspirin by mouth.
D. Intravenous heparin.
E. All of the above, plus an intravenous thrombolytic agent such as tissue
plasminogen activating factor.
QUESTION 28 - 30, CASE OF MRS. SEARS:
28. Following recovery from a syncopal episode, Mrs. Sears was admitted to the Coronary Care Unit.
She was a 35-year-old woman previously in good health except for a flu-like illness over the
previous two weeks. Her blood pressure was 80 / 20 mm Hg. Hemodynamic monitoring
revealed: Right atrial pressure. 20 mm HG: pulmonary artery pressure, 60 / 36 mm HG;
pulmonary capillary wedge pressure, 34 mm HG: cardiac index, 1 9 L 'nun / m
The findings support a diagnosis of :
A. Cor pulmonale
B. Aortic Stenosis
C. Hyperdynamic left ventricle
D. Left ventricular failure
E. Neurogenic pulmonary edema
29. The most appropriate pharmacologic therapy for Mrs. Sears is:
A. Diuretics alone
B. Beta adrenergic blocker
C. Calcium channel blocker
D. Dobutamine and beta adrenergic blocker
E. Dobutamine, dopamine, with or without diuretic
30. Likely pathological findings in the case of Mrs. Sears INCLUDE:
A. Left ventricular dilation
B. Lymphocytic infiltrates in the myocardium
C. Centrilobular congestion of the liver
D. Congestion of the pulmonary capillaries
E. All of the above
QUESTION 31 - 33; CASE OF MIELVIN BELL
31. M. Bell, a 24-year-old Gym teacher, was hospitalized because of marked shortness of breath. His
temperature was 101 degree F, blood pressure was 100 / 60 mm Hg, and pulse was 130 bp and
irregularly irregular. He was given intravenous digoxin and a beta-adrenergic blocker. His heart
rate decreased to 100 bp with symptomatic improvement. Despite the symptomatic improvement.
on physical examination, he had persistent rales bilaterally, and on cardiac exam, an accentuated
P. right ventricular lift. loud opening snap and diastolic rumble at the apex. The most likely
pathogenesis of his signs and symptoms is:
A. Acute rheumatic fever with mitral regurgitation
B. Acute bacterial endocarditis with mitral regurgitation
C. Rheumatic mitral stenosis with fever of uncertain origin
D. Congestive cardiomyopathy with mitral stenosis
E. Ischemic heart disease with papillary muscle rupture
32. With regard to the treatment of Mr. Bell's arrhythmia the one most CORRECT statement is:
A. No attempt should have been made to control the heart rate
B. Lidocaine without digoxin should have been given
C. Beta-adrenergic blockers are contraindicated
D. Dopamine is the drug of choice
E. Intravenous administration of a beta-adrenergic blocker and digoxin is appropriate.
33. Mr. Bell is likely to have each one of the following pathological changes EXCEPT:
A. Chronic passive congestion of the lungs
B. Fibrotic mitral valve with marked commissinal fusion
C. Dilated left atrium
D. Hypertrophied right ventricle
E. Dilated left ventricle
QUESTIONS 34 - 36, CASE OF SIRS. GORDON:
34. Mrs. Gordon is a 72 y.o. woman who has been in good health. She was told on a physical
examination 2 years ago that her blood pressure was normal. Last week she was seen by Dr.
Rosenfelder for the first time and was told that she now had high blood pressure. Her blood
pressure in his office was recorded as 180 systolic / 65 diastolic.
Which one statement regarding Mrs. Gordon's blood pressure isTRUE?
A. Since her blood pressure is "so high," Dr. Rosenfelder can make an accurate diagnosis of
high blood pressure on the basis of the BP measured on a single office visit.
B. If Mrs. Gordon has high blood pressure, it is likely to be "isolated systolic hypertension"
which is entirely benign in elderly women.
C. The incidence of isolated systolic hypertension increases with age and is associated with
an increased risk of congestive heart failure (hypertensive cardiomyopathy).
D. Any blood pressure elevation in an elderly woman is most probably secondary to intrinsic
renal disease and her evaluation should focus on the assessment of her renal function.
E. Mrs. Gordon must be obese and weight reduction will cure her hypertension.
35. Dr. Rosenfelder elects to treat her blood pressure with a thiazide diuretic. She has removed all
salt from her diet of salad without dressing and raw vegetables. She follows the advise of her
friend to drink plenty of fluids to avoid dehydration. She presents 2 weeks later with severe
symptomatic hyponatremia and is admitted to the hospital.
The following laboratory values are obtained:
Sodium 112 mEq/1 (normal 135 - 145), potassium 2.5 mEq/l (normal 3.5 - 4.7), Serum
Osmolality 240 mOsm/ kg water (normal 285 - 300), Urine osmolaliry 75 mOsm/kg H2O,
24 hour urine Volume 6 liters. UNA, 5 mEq/I
Her admission laboratory values indicate that her hyponatremia is due to:
A. Facticious hyponatremia secondary to the accumulation of an unmeasured osmolyte (e.g.
mannitol, glucose) in the serum.
B. Excessive water intake in the presence of an elevated serum ADH (Anti-diuretic Hormone)
level.
C. Elevated serum ADH level because of volume contraction.
D. Serum ADH levels increased inappropriately due to some underlying pulmonary or CNS
lesion, (SIADH).
E. Psychogenic polydipsia, water intoxication where the capacity of the kidney to excrete a dilute
urine is overwhelmed despite the elaboration of a "maximally"
dilute urine
36. Mr. Gordon is treated with fluid restrictIon. Dr. Rosenfelder stops the thiazide diuretics and
increases Mrs. Gordon's salt allowance. Her serum osmolality and sodium normalize over the
next 5 days. Mrs. Gordon's potassium level, however, remains low. To determine the reason
for the decreased serum potassium level. Dr. Rosenfelder orders a series of tests.
The following are her test results:
Serum:
Potassium 2.7 mEq/l (3.5 - 4.7)
Osmolality 290 mOsm/kg H2O
Urine:
Potassium 15 mEg/l
Osmolality 870 mOsm/kg H2O
Which one statement regarding her hypokalemia is TRUE?
A. The urine K+ is greater than the serum K+, therefore, indicating ongoing renal potassium
wasting.
B. The TTKG (transtubular potassium gradient) is appropriately low indicating renal
conservation of potassium.
C. The urine K+ levels indicate that ongoing potassium losses in the stool must be occurring.
D. Thiazide diuretics are not responsible for Mrs. Gordon's hypokalemia since they were
discontinued 5 days earlier.
E. Mrs. Gordon's low serum K+ level does not indicate a total body potassium deficient since
approximately 85% of total body K` is intracellular.
37. Dr. Rosenfelder is visited by Guy Enthusiasm, pharmaceutical agent, who details Dr. R on the
wonders of angiotensin converting enzyme inhibition for the treatment of hypertension without
hypokalemia. Which one statement regarding the use of ACE inhibitors in Mrs. Gordon is
TRUE ?
A. She has documented severe hypertension and will, therefore, require high doses of ACE
inhibitors.
B. ACE inhibition will worsen her hypokalemia by blockade of angiotensin's effect on
aldosterone.
C. Since optimal distal nephron regulation of K+ and hydrogen ion depends on aldosterone,
ACE inhibition will result in impaired K and H ion secretion and in a hyperkalemic nonanion gap metabolic acidosis.
D. ACE inhibitors should be given along with a cyclo-oxygenase inhibitor (e.g. NSAID).The
latter will offset the effects of angiotensin inhibition on K+ metabolism.
38. Off of the diuretics. Mrs. Gordon reports ankle edema. On physical examination, she has a JVP
of 5 cm. cardiac exam is normal without an S3 present. She has 2 + pretibial edema. What one
statement regarding Mrs. Gordon's edema is TRUE?
A. A measure of her serum albumin would help determine the role of a decreased oncotic
pressure at the level of the capillaries (Starling's forces) in the pathogenesis of the
dependent edema.
B. The edema indicates a problem with the central circulation (heart function). Mrs. Gordon
must have CHF (congestive heart failure).
C. Mrs. Gordon must have effective intravascular volume overload from excessive NaCl
retention.
D. Pretibial edema never occurs in states where effective intravascular volume is diminished.
E. Increased NaCl retention (or lack of adequate NaCl excretion) do not participate in the
formation of edema in cirrhosis, CHF, or nephrosis.
39. Mrs. Gordon presents with a renal tubular acidosis (Type IV) two weeks after beginning the ACE
inhibitor. Her urine electrolytes in mEq/l are:
UNA
24. UK 12, UCl 24
Dr. Rosenfelder calculates a urine anion gap (net negative charge) = + 12.
Which one statement regarding this urine anion gap is TRUE?
A. It indicates diminished renal NH4+ production and excretion despite a systemic acidosis.
B. It indicates increased renal net acid excretion as a result of decreased HCO3- in the final
urine.
C. It indicates specifically increased HCO3- in the final urine resulting in the systemic
Acidosis.
D. It indicates excessive Cl- wasting in the urine resulting in volume contraction and an anion
gap acidosis (e.g. lactic acidosis).
40. A patient presents in the emergency room stating that he has just invented the perpetual motion engine
and others are attempting to steal his invention from him. The patient's s relatives accompany him and
upon questioning them, you find that the patient has been gainfully employed as a dishwasher for the past
fifteen years. He has no mechanical ability, no background in theoretical and applied mechanics, and the
patient’s report would appear to be inaccurate. You would say the patient is experiencing:
A. ambivalence
B. delusions
C. depersonalization
D. hallucinations
E. illusions
41. Which of the following is a major alcohol-associated illness (due directly to the toxic effects of
alcohol)
A. endocarditis
B. renal calculi
C. Horner's syndrome
D. cirrhosis
E. meningitis
42. Antipsychotics may be useful in all of the following diagnostic classifications, EXCEPT:
A. dysthymic disorder
B. mania
C. organic brain syndrome
D. paranoia
E. schizophrenia
43. With regard to the broad classification of neuroleptics, each one of the following statements is true,
EXCEPT:
A. Some patients are more responsive to one versus another of the neuroleptics
B. These medications have some effect on the pattern of thinking.
C. These medications have their main effect in the synaptic cleft
D. These medications sometimes help control subjective pain which is not equivalent to physical
cause.
E. These medications usually take a minimum of 7 days to be effective.
44. With regard to an antidepressant medication, in which one of the following disorders is it NOT
recommended?
A. bipolar disorder, depressive phase
B. bipolar disorder, manic phase
C. dysthymic disorder
D. major depression with melancholia
E. panic disorder
45. Of the following treatment modalities, which is the LEAST indicated modality of treatment for a
Major Depressive Disorder'?
A. electroconvulsive therapy
B. hospitalization for suicidal behavior
C. lithium carbonate
D. psychologically working through a reaction to loss
E. tricyclic medication
46. A patient presents to the Emergency Room with the complaint that six months earlier he took LSD
and has not ingested any since that time. His presenting complaints at this time revolve around
walls not maintaining their perpendicular, assuming a waving shape, and objects in the
environment which he knows to be stationary, appearing to move. This man is experiencing:
A. illusions
B. delusions
C. autisms
D. concretisms
E. confabulations
47. Which of the following neurotransmitter systems is MOST involved in schizophrenia?
A. acetylcholine
B. endorphin
C. epinephrine
D. histamine
E. dopamine
48. The Thematic Apperception Test (TAT) is an example of what type of psychological test'?
A. ability
B. achievement
C. intelligence
D. interest
E. personality
49. Each one of the following is descriptive of persons with a schizophrenic diagnosis EXCEPT:
A. are found in all cultures
B. one-third get better, one-third stay the same, one-third get worse
C. do not respond to drug therapy
D. have a better prognosis if associated with affective symptoms
50. On the mental status examination, we speak of orientation in four spheres. Each one of the
following is included as part of the mental status assessment of orientation EXCEPT:
A. cultural background
B. person
C. place
D. present situation
E. time
51. On the mental status examination, attention and concentration are usually judged by having the
patient:
A. Interpret proverbs
B. multiply 3 times 4
C. recite 3 non-related words given previously at a later time
D. do serial subtraction
E. recite the alphabet
52. The abused child is most often the victim of its:
A. mother
B. father
C. mother's boyfriend
D. older sibling
E. other individual
53. Characteristics of autism are.
A. inability to relate to people, associated with fascination for objects
B. failure to use language for communication
C. obsessive desire for maintenance
D. all of the above
E. none of the above
54. Which one of the following medications can produce depression?
A. Reserpine
B. Imipramine
C. Fluoxetine
D. Insulin
55. Kibler-Ross has described five major phases that occur in patients' psychological responses to the
knowledge that they are dying. These stages include:
A. acceptance
B. denial
C. anger
D. bargaining
E. all of the above
56. Delirium tremens is characteristically associated with all of the following EXCEPT:
A. bradycardia
B. tremor
C. visions of "pink elephants"
D. disorientation to time and place
E. a typical course of three to ten days
57. Anxiety is often associated with all of the following disorders EXCEPT:
A. pheochromocytoma
B. hyperthyroidism
C. temporal lobe epilepsy
D. hypothyroidism
E. Sydenham's chorea
58. Phenytoin is an effective initial therapy for a generalized convulsive seizure. However, patients
must be monitored for drug toxicity because:
A. Patients often consume extra doses of medication, causing accumulation of drug in the
plasma.
B. Phenytoin saturates enzymes for elimination, causing accumulation of drug in the plasma.
C. Phenytoin interacts with food and fluids and may have enhanced absorption.
D. Renal failure interferes with drug metabolism, making it necessary to reduce the doses of
the drug.
E. Phenytoin is eliminated by first order kinetics, leading to linear responses between levels
and doses.
59. Adults (20-60 years old) may experience an initial convulsive seizure after a life without seizures.
Careful workup is required because:
A. Adults are able to evaluate their physicians and may initiate a law suit if they are not
happy.
B. Metabolic causes for new-onset epilepsy are commonly identified, and appropriate
treatment can be instituted.
C. A treatable cause, such as a brain rumor, may present with a generalized tonic-clonic
seizure.
D. Genetic information will be important for family planning.
E. Specific drug therapy can be selected if all data from a complete workup is available for
review.
60. Alzheimer's disease is a slowly progressive (years) dementing illness. Diagnosis and treatment
include:
A. magnetic resonance imaging and expectant care
B. angiogram and vitamin B-12 injections
C. brain biopsy and anti-epileptic medications
D. pneumoencephalogram and carotid endarterectomy
E. upper GI series and motor reprogramming exercises
61. Patients with dementia are an increasing problem in the general population. Families are stressed
by this illness because:
A. Automobile insurance rates are increased as the degree of dementia worsens.
B. members are concerned because the patient tends to forget recipes for favorite foods
C. The patient needs increasing quantities of care that eventually becomes constant.
D. The specific treatment for the disorder is so expensive.
E. The most common cause. Alzheimer's disease is familial in 80% of cases.
62. Parkinson's Disease is associated with loss of cells in the pars compacta of the substanta nigra.
A. requires administration of serotonin precursors
B. is challenging because L-DOPA has little if any effect on the progression of the disease
C. requires titration of initial doses of L-DOPA with greatly reduced doses as the disease
progresses
D. is best handled by transplantation of fetal adrenal tissue into the head of the caudate
nucleus.
E. is challenging because nothing alters the tremor and bradykinesia
63. All of the following represent causes of an anion gap metabolic acidosis EXCEPT:
A. Chronic diarrhea.
B. Alcoholic ketoacidosis.
C. Ethylene glycol intoxication.
D. Starvation ketoacidosis.
E. Aspirin intoxication.
64. In obstructive lung disease the forced vital capacity (FVC) is commonly reduced for which ONE
of the following reasons?
A. Fatigue of the inspiratory muscles.
B. Fatigue of the expiratory muscles.
C. Insufficient time to fully exhale at the termination of the test.
D. A low diffusing capacity.
65. A patient has a one-second forced expiratory volume (FEV 1) of 62% of that predicted, a forced
vital capacity (FVC) of 66% of that predicted, and an FEV I/FVC ratio of 81%. Which statement
is TRUE?:
A. Her response to methacholine should be studied to make the diagnosis of asthma.
B. Her response to a beta-2 agonist should be studied to make the diagnosis of asthma.
C The low FVC makes the diagnosis of restrictive lung disease.
D. To make the diagnosis of restrictive lung disease, studies of lung volumes (e.g., body
Plethysmography) are needed.
66. Which one of the following statements is TRUE regarding an acute exacerbation of asthma?
A. Most of the work of breathing by the respiratory muscles is on expiration.
B. In addition to bronchodilator therapy patients should be taught to breathe out more
forcefully.
C. Hypoxia is largely due to ventilation-perfusion mismatch.
D. HYPERventilation is virtually never observed.
67. Which of the following mechanisms of arterial hypoxemia responds LEAST well to breathing
oxygen at 100% (F1O2 = 1.00)?
A. Shunt.
B. Hypoventilation.
C. Diffusion limitation.
D. Ventilation/perfusion mismatch.
68. Risk factors for the development of venous thrombosis include all of the following EXCEPT:
A. Stasis of blood.
B. Injury to vessels/endothelium.
C. Hypercoagulable states.
D. Pulmonary infection.
69. All of the following are secondary causes of pulmonary hypertension. Which is the most common
cause in the U.S.?
A. Obstructive airways disease.
B. Chronic pulmonary thromboembolism.
C. Schistosomiasis.
D. Interstitial fibrosis.
70. Mr. H. is a 27 year-old Caucasian man. He is not obese, and has no first-degree relative with diabetes.
Over a few days, he has developed extreme thirst, nausea and polyuria. He is admitted to the hospital with
severe volume depletion and metabolic acidosis.
Laboratory findings:
Serum ketones strongly positive (normal, negative)
Serum glucose = 1500 mg/dL (normal, 60 - 110 mg/dL)
Serum potassium = 4.9 mEq/L (normal, 3.5 - 5.0 mEq/L)
Which statement is regarding treatment to be given during Mr. H's hospitalization?
A. Insulin should be infused continuously, until the ketoacidosis has cleared
B. The patient should be fed, and given moderate doses of Regular insulin subcutaneously before
meals; physiological compensatory mechanisms will correct the ketoacidosis over the next 72
hours.
C. Following correction of the ketoacidosis, the patient should be fed a diet low in simple
sugars
D. Intravenous saline solution should be given immediately
E. It is likely that administration of supplemental potassium will be required within
the first 24 hours
71. Mr. A. is a 32 year-old Mexican-American man, born in South Texas. His mother and two of her
sisters have diabetes. The patient is obese. He has no complaints. On admission to the hospital for routine
herniorrhaphy, he is found to have a fasting serum glucose of 265 mg/dL (normal. 55 to 100 mg/dL).
Which is true regarding Mr. A's diabetes'?
A. This form of diabetes is rare among Mexican-Americans
B. The patient is likely to have a substantial level of circulating insulin
C. A small dose of insulin will cause profound hypoglycemia
D. By means of HLA typing, one can determine which of Mr. A's children will be at high
risk for development of diabetes
E. The pathogenesis of his diabetes is related to infiltration of the pancreatic islets with activated
T lymphocytes.
72. Which is TRUE of the endocrine system?
A. Peptide hormones cannot enter target cells
B. Feedback regulatory systems allow the circulating concentrations of peptide hormones to
be kept constant at all times
C. Insulin binds glucose, in order to transport it into cells
D. Cyclic AMP is an important intracellular mediator of the action of several hormones
E. Hormones are irreversibly inactivated by their interactions with receptors
73. A patient presents with diarrhea. The stool studies reveal:
Volume
Osmolality (mOsm/kg H2O)
Na+ (mEq/1)
K+ (mEq/1)
FED
3300 ml
310
90
60
FASTING
2100 ml
290
100
40
The most likely diagnosis is:
A. Pancreatic insufficiency
B. Pernicious Anemia
C. Lactase deficiency
D. Carcinoid
QUESTION 74 - 75, CASE OF JASON:
Jason, a 4-year-old boy injured while playing outside with his older sister, presents with a large
hematoma of the right thigh. He has several episodes of bleeding into his knee joints in the past.
His maternal uncle had similar bleeding problem, but parents and sisters do not have any history
of abnormal bleeding.
74. Jason most likely has a (an):
A. Congenital platelet abnormality
B. Acquired platelet abnormality
C. Congenital factor VIII abnormality
D. Acquired factor VIII abnormality
E. Fibrinogen abnormality
75. Which of the following tests will likely be abnormal in this patient (Jason)?
A. Platelet count
B. Template bleeding time
C. PT
D. aPTT
E. Fibrinogen level
76. Sickling of red cells is:
A. Enhanced by the presence of bicarbonateB. Related to the age of the cell
C. Related to the amount of oxygen bound by the red cell
D. Of clinical importance in jaundice of the newborn
77. Each of the following coagulation factors is dependent on the availability of vitamin K, EXCEPT.
A. Fibrinogen
B. Factor VII
C. Factor IX
D. Factor X
E. Prothrombin
78. In articular hyaline cartilage matrix, the collagens:
A. Cannot be degraded and so remain behind when proteoglycans are lost.
B. Are predominantly composed of TYPE IV collagen.
C. Mutations in these molecules do not cause inherited human disease
D. Form a structural framework which constrains the matrix proteoglycans in a tightly packed
state.
79. Each one of the following could predispose a 50-year-old woman to infectious arthritis EXCEPT:
A. A furuncle
B. Rheumatoid arthritis
C. Corticosteroid therapy
D. Non-steroidal antiinflammatorv therapy
80. In a 25-year-old white male, which one of the following is the most likely cause of an acute arthritis
involving one knee accompanied by severe pain in the heel?
A. Neisseria gonorrhea
B. Staphylococcus aureus
C. Ch1amydia trachomatis
D. Streptococcus pyogenes
E. Parvovirus B19
81. Which one of the following diseases is not classified as a spondyloarthropathv?
A. Reiter's syndrome (reactive arthritis)
B. Rheumatoid arthritis
C. Psoriatic arthritis
D. Ankylosing spondylitis
E. Arthritis secondary to Crohn's disease
82. Which of the following is not a potential adverse effect associated with the administration of
cyclophosphamide?
A. Hemorrhagic cystitis
B. Gonadal failure
C. Peripheral neuropathy
D. Neutropenia
E. Skin cancer
83. Which of the following is one of the American College of Rheumatology criteria for the diagnosis
of rheumatoid arthritis?
A. Morning stiffness of 30 minutes duration
B. Elevated erythrocyte sedimentation rate
C. Bony overgrowth of the small joints of the hand
D. Arthritis of 3 or more joint areas
E. Positive ANA test
84. Rheumatoid factors are.
A. IgM anti-IgG antibodies
B. a subset of antinuclear antibodies
C. not found in the sera of lupus patients
D. found in the sera of all rheumatoid arthritis patients
E. associated with more benign disease course in rheumatoid arthritis
85. Rheumatoid factors may be present i in the sera of patients with all of the following diseases
EXCEPT:
A. Sjogren's syndrome
B. bacterial endocarditis
C. sarcoidosis
D ankylosing spondylitis
E. chronic liver diseases
86. Which of the following is not a complication of the use of oral steroid therapy?
A. Osteopenia
B. Thickening of the skin
C. Increased blood sugar
D. Cataracts
E. Increase in blood pressure
87. Photoprotection is helpful in preventing which of the following parameters in lupus patients?
A. Weight loss
B. Weight gain
C. Malar rash
D. Oral ulceration
E. Neutropenia
QUESTIONS 88 - 90; MATCHING.
EACH CHOICE MAY BE USED ONLY ONCE:
Match the best answer on the below with the skin lesion above:
88. Toxic Epidermal Necrolysis in adult
89. Facial rash, photosensitivity, nail fold changes
90. Camper with petechiae on wrists, ankles, and flu like illness
A. Staphylococcal Scalded skin syndrome
B. Rocky mountain spotted fever
C. Dilantin
D. Systemic lupus erythematosus
E. Meningococcemia
MULTIPLE CHOICE, SINGLE BEST ANSWER:
91. Tinea versicolor
A. Is contagious
B. Infection confers lifetime immunity
C. Is caused by Pitvrosporum furur
D. Invokes cell - mediated immunity
E. Is caused by Pityrosporum orbiculare
92. Most physiological coagulation is initiated by:
A. Factor XII and contact activation factors
B. Factor IX and factor VIII
C. Factor X and factor V
D Factor VII and tissue factor
E. Factor VII, factor X and TFPI
93. Each of the following would prolong an activated partial thromboplastin time (aPTT) EXCEPT:
A. a 20% level of factor XI
B. a 15 % level of factor VII
C. an autoantibody against factor VIII
D an autoantibody against phospholipid
QUESTION 98 - 99, CASE OF JW.
94. You are called to see JW, a 45 year old man for a prothrombin time of 16 seconds (Normal is
10.5 to 12.5 seconds). Six days ago he had an uneventful laparotomy for a small bowel
obstruction. He has been on cephalosporins and nasogastric suction since the operation. He has
improved and the wound is healing well. The most likely cause of his elevated prothrombin time
is:
A. hemophilia A
B. congenital factor VII deficiency
C. disseminated intravascular coagulation
D. liver disease
E. acquired vitamin K deficiency
95. The best treatment for JW would be:
A. Recombinant factor VIII concentrate
B. Fresh frozen plasma
C. Cryoprecipitate
D. Vitamin K, 10 mg IV
E. Observation because this is a benign condition and he is asymptomatic
Questions 96 - 97 are based on the following case scenario:
Mr. S. H. is a 44 year old Caucasian man who is followed in the outpatient clinic. He was first
seen 6 months previously, after he had a generalized (grandmal) seizure that appeared to follow
closely a brief incarceration for intoxication and acute withdrawal from alcohol. He was placed on
phenobarbital for treatment of the seizures and was told to abstain from alcohol.
He now returns because of nausea and vomiting and is found to have elevated hepatic
transaminase enzyme levels in the serum 12 times normal). He appears withdrawn. He states that
he has abstained from alcohol for the last 6 months. He reports that he has felt lousy as if he had the
"flu." He has been taking one bottle nightly of Nyquilt (containing acetaminophen) for these flu-like
symptoms. In the last few days, he has doubled the dose.
96. In evaluating the elevated hepatic transaminases (liver enzymes, ALT. AST) you consider the
possibility of a toxic hepatitis. Which ONE of the following statements regarding possible liver
damage and hepatotoxicants is MOST CORRECT for this case:
A. Since SH denies alcohol consumption, hepatic damage from ethanol is unlikely.
B. SH is protected from liver damage by excessive doses of acetaminophen because of
phenobarbital induction of the liver cytochrome P450 system.
C. Once liver failure occurs. Mr. H is protected from liver damage from other hepatotoxicants
since they MUST all be metabolized first by the hepatic cytochrome P450 system to more
toxic metabolites.
D. Many "over the counter" liquid cold and cough remedies contain significant quantities of
alcohol and acetaminophen that in overdose can cause tissue (liver) damage.
97. You reason that S H may have taken acetaminophen. To determine his risk of liver damage from
acetaminophen, you draw a serum acetaminophen level. Which ONE of the following statements
represent information in addition to the single serum level that is MOST necessary in estimating
his risk of acute liver damage. (Acetaminophen is cleared normally by the liver).
A. The rate of renal clearance of the drug.
B. The rate of hepatic clearance of the drug.
C. The duration of previous nontoxic exposure to acetaminophen prior to the recent overdose.
D. Cumulative life time acetaminophen dose.
98 - 101 are based on the following case:
During routine mammography, a breast lesion is detected in 57 year-old Mattie Bowen. You learn
from Mrs. Bowen that she does self breast exams infrequently, but has not noticed any lumps or
other breast changes during the last 6 months. Her menses began at age 11, and her periods were
very regular with 28 day cycles until about 2 years ago when she went through menopause. She
has four children, ages 34, 30, 27 and 22. She had one miscarriage. Between pregnancies she used
an intrauterine device (IUD) for contraception.
98. Which ONE of the following is a positive risk factor for breast cancer in Mrs. Bowen's case?
A. Early age at first pregnancy
B. Multiparity
C. Early age of beginning menses
D. Not using combination estrogen/progesterone oral contraceptives
E. All of the above
99. You learn that Mrs. Bowen's sister had breast cancer diagnosed at age 55, and Mrs. Bowen is very
worried that she might have breast cancer, too. There are no other family members who have
cancer as far as she knows. Based on this family history, which of the statements below is TRUE?
A. There is no increased risk of breast cancer in a patient who has a first degree relative with
breast cancer.
B. The risk of Mrs. Bowen having breast cancer are increased by 50-fold since she has a first
degree relative with breast cancer.
C. There is a twice normal risk increased of breast cancer in a patient who has one first degree
relative with breast cancer.
D. Since Mrs. Bowen's mother is still alive at age 80 with no evidence of breast cancer. Mrs.
Bowen does not need to worry about breast cancer.
E. Mrs. Bowen is likely part of a "cancer" family, and other family members should be screened
with serum tumor markers to allow early detection of their tumors.
100. The breast lesion was biopsied and sent to surgical pathology. A diagnosis of infiltrating
adenocarcinoma was made. The tumor strongly expressed estrogen receptor antigens. The radical
mastectomy specimen contains three lymph nodes positive for metastatic adenocarcinoma. Other
evaluation for metastatic disease is negative. Mrs. Bowen is scheduled for chemotherapy
including an anti-estrogen drug, rationale for using anti-estrogen therapy is:
A. Women with estrogen receptor positive breast cancer may respond to hormonal therapy.
B. Since she is postmenopausal, conventional chemotherapy is not effective.
C. Any patient without evidence of hematogenous metastases should get Tamoxifen.
D. Using an anti-estrogen in this patient will counteract the effect of the ovaries on growth of the
tumor.
101. In searching the medical literature, you discover 225 recent journal articles that by their titles imply
that they address the issue of prognosis in women with breast cancer. You select the 50 articles
that provide sufficient information on their methods to allow you to make a "quick and dirty"
validity check before you study them in detail. Which ONE of the following methodologic
criteria would you require for a article on breast cancer prognosis?
A. Was an inception cohort assembled?
B. Was there a gold standard of diagnosis?
C. Is the association significant and strong?
D. Were the patients really randomized?
E. Was the pattern of referral defined?
102. The development of a metastatic lesion by hematogenous spread from a primary lung
adenocarcinoma would depend on which ONE of the following?
A. Development of a subclone of tumor cells capable of infiltrating and degrading
extracellular matrix material.
B. Having a very anaplastic tumor.
C. Invasion of lymphatic vessels first.
D. Having a tumor with a very high growth fraction.
103. The Positive predictive value represents:
A. The percent of persons with the disease who test positive.
B. The percent of people who test positive that actually have the disease.
C. The percent of people who test positive divided by the percent who test negative.
D. A property of a diagnostic test that is unaffected by prevalence of the disease.
104. For the following (hypothetical) diagnostic study what are the sensitivity and specific' ity of the
CPK levels for the diagnosis of acute myocardial infarction?
ACUTE
MYOCORDIAL
INFARCTION
Serum CPK (Creatine
Phosphokinase) levels
YES
NO
YES
NO
30
70
250
750
A. Sensitivity = 0.10 / Specificity = 0.9
B. Sensitivity = 0.12 / Specificity = 0.5
C. Sensitivity = 0.3 / Specificity = 0.75
D. Sensitivity = 0.38 / Specificity = 0.25
105. Among the complications of HIV infection occurring in persons with CD4 counts above 200
include:
A. Cytomegalovirus retinitis
B. Mycobacterium tuberculosis
C. Mycobacterium avium-intracellulare
D. Toxoplasmosis
QUESTION 106 - 107, CASE OF JG:
JG, a fifty year-old male smoker complains to you (the doctor) of cough and "not feeling well”.
Further questioning reveals that he is producing copious amount of greenish sputum and that the
cough and sputum production are much worse than usual.
106. Which of the following diseases are associated with smoking?
A. Small cell carcinoma.
B. Centriacinar emphysema.
C. Chronic bronchitis.
D. All of the above
E. None of the above.
107. Which of the following is the least likely cause of abundant sputum production'?
A. Lobar pneumonia.
B. Bronchitis.
C. Interstitial pneumonia.
D. Bronchial obstruction by tumor with post-obstructive pneumonia.
E. Bronchopneumonia.
108. Each one of the following statements regarding exogenous pyrogens is true EXCEPT:
A. Cause fever by release of interleukin 1 from various cells
B. May contaminate solutions in microgram quantities and cause fever
C. Act directly on the hypothalamus
D. Include synthetic peptides as well as molecules derived from bacterial cell wails
109. Fever
A. Causes tachycardia
B. Causes increased oxygen consumption and metabolic requirements
C. Can be deleterious in patients with myocardial ischemia, cerebral edema and decreased
pulmonary reserve
D. Enhances many immune functions in vitro
E. All of the above are correct.
110. A history of prolonged FUO is compatible with
A. Drug induced fever
B. Malignancy
C. Collagen vascular disease
D. Endocarditis
E. All of the above are correct.
111. Which one of the following is a true statements about the pathogenesis of septic shock?
A. The endogenous mediators represent normal defense mechanisms in excess
B. Shock is defined as a blood pressure <90/60 or ≥ 40 mm Hg drop in systolic blood
pressure
C. The causative bacterial organism releases endogenous pyrogen (ILl) producing fever and
changes in blood pressure
112. Well-defined mechanisms of diarrhea (passage of watery stools) include each one of the following
EXCEPT:
A. Abnormal electrolyte and water transport
B. Disaccharidase deficiency
C. Malabsorption
D. Increased gastric emptying
ANSWERS
1. A
2. B
3. D
4. E
5. D
6. C
7. B
8. A
9. D
10. B
11. B
12. B
13. C
14. B
15. A
16. C
17. D
18. A
19. C
20. B
21. A
22. B
23. D
24. B
25. C
26. B
27. E
28. D
29. E
30. E
31. C
32. E
33. E
34. C
35. E
36. B
37. C
38. A
39. A
40. B
41. D
42. A
43. E
44. B
45. C
46. A
47. E
48. E
49. C
50. A
51. D
52. A
53. D
54. A
55. E
56. A
57. D
58. B
59. C
60. A
61. C
62. B
63. A
64. C
65. D
66. C
67. A
68. D
69. A
70. B
71. B
72. D
73. D
74. C
75. D
76. D
77. A
78. D
79. D
80. C
81. B
82. C
83. D
84. A
85. D
86. B
87. C
88. C
89. D
90. B
91. E
92. D
93. B
94. E
95. D
96. D
97. B
98. C
99. C
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
A
A
A
A
C
B
D
C
C
E
E
A
D