Download Fundamentals of Clinical Medicine / Problem Based Learning

Fundamentals of Clinical Medicine / Problem Based Learning
Version B
Part A:
MULTIPLE CHOICE
SINGLE BEST ANSWER
QUESTIONS 1 - 6
CASE OF MRS. LUDAR:
Mrs. Ludar is a 27-year-old woman who is concerned about irregular menses. She underwent
menarche at age 14 and had normal menses until eleven months ago. Her last interval between
menses was 46 days, and the last menses consisted of spotting for 2 days. She reports significant
lower abdominal pain during menses for the last two years. She had a normal pregnancy at age
21, otherwise used oral contraceptives to prevent pregnancy. She discontinued these 14 months
ago since she and her husband were ready for another child. History reveals that they have been
trying to conceive but have been unsuccessful to date. The thought of the weight she gained with
her first pregnancy prompted her to loss 20 kg approximately one year ago, and she has
maintained this weight with vigorous daily exercise since.
Physical Exam:
Thin 27-y.o. woman, 20% below ideal body weight
Skin: Fine
Hair: Scanty facial hair visible
Breasts: Slightly tender without galactorrhea
Pelvic examination: Normal bimanual examination
Remainder of physical examination normal
The MOST appropriate first step in evaluating Mrs. Ludar is:
A. Have her keep a daily record of her temperature
B. A pregnancy test
C. Obtain a progesterone level 10 days after her next menstruation.
D. An endometrial biopsy
E. A head CT scan for evidence of a pituitary tumor
2. An evaluation is initiated for the infertility. This evaluation reveals that her basal body
temperature does not change over the next 4 weeks and her progesterone level at 21 days
is < 2 ng/ml (normal luteal phase > 5). Which one of the following might account for
these findings:
A. Inability of the fertilized ovum to implant in a diseased endometrium
B. Failure of the ovum to undergo fertilization due to a defect related to the sperm
C. Absence of the mid-cycle prolactin surge
D, Absence of ovulation related to vigorous exercise
E. High levels of progesterone concurrent with the secretory (luteal) phase of the
endometrium
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3. Mrs. Ludar is begun on clomiphene citrate and she becomes pregnant after three months.
The infertility and subsequent successful pregnancy indicate best that:
A. The Ludars' infertility is due to Mrs. Ludar's guilt and subconscious wish not to
become pregnant.
B. Mrs. Ludar has an intact hypothalamic pituitary axis.
C. Mrs. Ludar's ovaries are resistant to normal levels of luteinizing hormone (LH) during
the mid-cycle surge.
D. Mrs. Ludar does not have endometriosis.
4. hMG (human menopausal gonadotropin) works by:
A. Increasing estrogen's effects on the hypothalamic pituitary axis
B. Mimicking the actions of luteinizing hormone
C. Mimicking the action of follicle stimulating hormone
D. An anti-androgen effect on the ovary
E. Increasing the central release of luteinizing hormone
5. Four months after delivering her second child, Mrs. Ludar returns because she has had
only one menstrual period post-partum. Her weight is now normal and she has no other
complaints. She elected not to breast feed her child. Her amenorrhea is MOST LIKELY
due to:
A. Premature menopause
B. Hypothalamic failure
C. Polycystic ovarian disease
D. Pregnancy
E. Pituitary tumor
6. The single MOST COMMON cause of hyperthyroidism in pregnancy is:
A. Single toxic adenoma
B. An autoimmune disease (autoimmune thyroiditis)
C. Molar pregnancy
D. Subacute thyroiditis
E. Iodine deficiency
7. Which one of the following laboratory tests is MOST LIKELY in women with normal
pregnancies?
A. Low T4 levels
B. High free T3 levels
C. Decreased Thyroxine Binding Globulin
D. Decreased Free thyroxine index (FTI)
E. Normal TSH (Thyroid Stimulating Hormone)
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8. Hyperthyroidism in otherwise normal pregnancies:
A. Significantly affects fetal growth and development since T3 and T4 readily cross the
placenta
B. Increases the risk of growth retardation
C. Never complicates parturition
D. Can be safely treated with anti-thyroidal medications
E. Can be distinguished easily on the basis of symptoms from normal pregnancy
9. Placental transfer of Thyroid Stimulating Immunoglobulin (TSIG) from the mother to the
fetus MOST LIKELY will:
A. Cause fetal goiter
B. Result in fetal hyperthyroidism
C. Be predictable on the basis of the mothers serum total T4
D. Increase fetal TSH
E. Decrease placental transport of T4 and T3
QUESTION 10 - 13,
CASE OF MM:
MM is a 26-year-old woman on chronic hemodialysis as a consequence of cocaine induced focal
glomerular sclerosis and accelerated hypertension. Two weeks after beginning dialysis she
develops jaundice. She has received 6 units of blood in the last 4 months to treat the
complications of her cocaine usage and her renal failure. She reports unprotected sex with
multiple partners in conjunction with cocaine usage. Her current labs are: bilirubin 4.6 (n10.2 1.0 mg/dl), AST 864 (nl 7-40 U/1), and her ALT is 946 U/l (n1 1-40).
10. Her hepatitis serologies are:
Mrs. MM
positive
negative
negative
negative
positive
Hepatitis B surface antigen
Hepatitis B surface antibody
IgM Hepatitis A antibody
Hepatitis C antibody
Hepatitis B core antibody
These serologies indicate that:
A. She has been exposed to Hepatitis A in the past
B. She does not have an chronic infection with Hepatitis B
C. She is immune to further infection with Hepatitis B
D. She does not have an acute infection with Hepatitis A
E. She does not have an infection with Hepatitis C
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Normal
negative
negative
negative
negative
negative
11. Her physicians consider the time course for viral hepatitis and conclude that if this is
hepatitis B, she MOST LIKELY acquired the hepatitis through:
A. Contaminated needles in the Dialysis Unit
B. Sexual transmission from an infected partner
C. A contaminated unit of transfused blood in the hospital
D. Eating food prepared in a local seafood restaurant
E. Immunization with the Heptavac (Hepatitis B) vaccine
12. Chronic hepatitis after infection with the hepatitis B virus:
A. Develops very rarely
B. Is not associated with the hepatocellular carcinoma
C. Is more likely to occur with Hepatitis B than with the Hepatitis C virus
D. Results in fibrosis and ultimately cirrhosis in patients with chronic active disease
E. Does not respond to treatment with anti-viral agents
13. A liver biopsy performed on Mrs. MM two weeks after the onset of jaundice would
MOST LIKELY reveal:
A. Hepatocellular necrosis and diffuse lymphocytic inflammation
B. Lymphocytic portal tract infiltration
C. Portal tract fibrosis with hepatocyte necrosis and inflammation with pericellular
fibrosis
D. Hepatocytes with ground glass inclusions
14. Which of the following is a true statement regarding the control of esophageal variceal
hemorrhage in patients with chronic liver disease and portal hypertension?
A. The use of endoscopic sclerotherapy is inferior to endoscopic band ligation and
thus should never be performed.
B. Endoscopic evaluation should be performed 36 - 48 hours after the onset of bleed
in order to properly stabilize the patient.
C. Endoscopic band ligation carries a slightly better side effect/complication rate
compared to endoscopic sclerotherapy.
D. Balloon tamponade of esophageal or gastric varices is the initial treatment of
choice in all patients with variceal hemorrhage.
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15. Advanced chronic obstructive pulmonary disease may be complicated by cor pulmonale.
In such patients the right heart failure is due to:
A. Myocardiopathy of the right ventricle due to chronic hypoxia within the myocardium
B. Gradual stiffening of the pulmonic valve, caused by years of respiratory acidosis
C. Pulmonary arterial hypertension
D. Systemic arterial hypertension
16. The cyanosis-that occurs in advanced chronic obstructive pulmonary disease is BEST
explained by:
A. Anemia of chronic disease, which decreases O2 carrying capacity
B. Poor perfusion of peripheral tissues due to cor pulmonary
C. Excessive carbon monoxide, from smoking, which prevents binding of O2 to
hemoglobin
D. Substantial amounts (e.g., > 5 g/dl) of reduced hemoglobin in arterial blood
17. A patient with chronic obstructive pulmonary disease is admitted to the intensive care unit
with respiratory failure and anasarca (severe total body edema). In addition to inhaled
bronchodilators, she is given several medicines intravenously. An elevated concentration
of hemoglobin is noted on routine blood tests, for which the MOST LIKELY
explanation is:
A. Chronic hypoxia
B. Chronic respiratory acidosis
C. A "dilution effect" from the multiple intravenous medicines
D. Infection, causing a "left shifted" differential cell count
18. A 62-year-old patient with chronic obstructive pulmonary disease has a recent onset of
increased cough, purulent sputum, fever, and dyspnea. A marked increase in neutrophilic
leukocytes is noted in the blood. A chest radiograph shows a dense alveolar infiltrate,
with "air bronchograms," throughout the right lower lobe. The MOST LIKELY
explanation is:
A. Acute bronchitis
B. Bronchiectasis with alveolar hemorrhage
C. Tension pneumothorax, due to rupture of an emphysematous bleb near the pleural
surface.
D. Pneumonia due to S. pneumoniae
19. The hyperinflation of the chest in patients with chronic obstructive lung disease is caused by:
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A. The trapping of gas in the alveoli due to obstruction of the airways
B. Chronically weakened expiratory muscles
C. Corticosteroid-induced osteopenia which results eventually in deformity of the
thoracic cage
D. An unconscious effort by the patient to increase lung volumes in order to increase
the oxygen reservoir
20. Suspected obstructive lung disease in a new patient can be diagnosed BEST by:
A. Chest radiograph
B. Peak expiratory flow rate
C. Spirometry measurement of maximum forced expiratory flow to determine the
ratio of forced expiratory volume at 1 s to the force vital capacity (FEV1/FVC).
D. Diffusing capacity (DLco):
21. During the GI component of PBL, a second-year medical student's roommate develops a
gnawing epigastric pain relieved by drinking milk but exacerbated by chili dogs. He also
takes 4 - 6 aspirins daily for tension headaches. Having completed physical diagnosis
successfully, you assure him that his physical exam is unremarkable. Your BEST
recommendation to him would be:
A. An empiric course of antibiotics and ranitidine to eradicate H. pylori
B. Diet modification, with avoidance of fatty foods
C. H. pylori serology and an upper GI endoscopy
D. Discontinuation of the 4 - 6 aspirins that he had been taking daily for headaches
E. Psychotherapy
22. Your other roommate, a law student, also develops similar epigastric pain. He is not
taking aspirin but is drinking two martinis a night, smokes cigars and wears red
suspenders. He confides that his stools have become black and tarry. Your
recommendation to him as the MOST appropriate course of action would be:
A. Obtain an H. pylori serology; if positive, a course of antibiotics and omeprazole
B. Undergo an upper GI endoscopy
C. Undergo an upper GI series
D. Obtain a serum gastrin level
E. To stop smoking the cigars and to wear a belt instead of those tacky-looking red
suspenders
23. H. pylori is NOT associated with:
A. Gastric cancer
B. Gastritis
C. Duodenal ulcer
D. Esophagitis
24. The major benefit of treating an H. pylori-associated ulcer with antibiotics (in addition to
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acid suppression) is:
A. More rapid ulcer healing
B. More effective pain control
C. Prevention of GI bleeding
D. Reduction of ulcer recurrence
E. Prevention of colitis
Part B:
25. The risk of colorectal cancer in a cohort (population) is DECREASED by:
A. Migration from Japan to the United States
B. A diet low in fiber and high in fat
C. Regular aspirin usage
D. Residence in an industrial "westernized" nation
E. Male gender
26. All of the following statements regarding patients with colorectal cancer are TRUE
EXCEPT:
A. Patients whose tumors involve regional lymph nodes benefit from adjuvant
chemotherapy.
B. Disease stage, i.e., Dukes' stage, is the most important determinant of patient
outcome.
C. Colorectal cancers are believed to develop from adenomatous polyps
D. All colorectal polyps are precancerous lesions.
27. Which one of the following describes BEST a feature of Hereditary Nonpolyposis
Colorectal Cancer (HNPCC):
A. Extracolonic cancers are uncommon until late in the course of HNPCC
B. Hundreds of adenomatous polyps are found in these patients
C. Early age of onset of colorectal cancer (generally less than 50 years old)
D. Most commonly diagnosed in individuals without a family history for colorectal
cancer
E. Colorectal Cancers of HNPCC are most commonly found in the distal colon
28. An elderly woman is found to have a macrocytic anemia. A Schilling test is performed,
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which demonstrates cobalamininalabsorption that corrects with intrinsic factor. The
MOST LIKELY explanation for the anemia is:
A. Dietary folate deficiency
B. Atrophic gastritis
C. Real resection
D. Bacterial overgrowth in the small intestine
E. Strict vegetarian diet
29. A 14-year-old girl is referred because of growth retardation, weight loss and diarrhea.
The following tests have already been performed: timed stool collection demonstrated 21
gin fat/24 hr on a 100 gm fat diet (nl <7 gm/24 hr); a D-xylose demonstrated a 5 hr urine
collection of 1.5 gm (nl > 5 gm). The most appropriate next step to confirm your
suspected diagnosis is a(n):
A. Small bowel biopsy
B. Schilling test
C. Secretin stimulation test of pancreatic function
D. ERCP (endoscopic retrograde cholangiopancreatography)
E. Serum gastrin, VIP and serotonin
30. A 25-year-old medical student presents to the Student Health Office because of diarrhea.
Over the last several weeks he has been under increasing stress because of a particularly
egregious instructor in his PBL class. He has noted some vague abdominal pain and has
been drinking milk and Mylanta to ease the pain. A timed stool collection yields the
following information:
Stool volume:
Stool Na:
Stool K:
Stool Mg:
Stool osmolarity:
Stool pH:
525 cc
29 meq/1
30 meq/1
63 meq/1
299 mosm
6.0
The MOST LIKELY explanation for the above scenario is:
A. Peptic ulcer caused by excess gastric acid secretion due to a gastrin-producing tumor
B. Osmotic diarrhea secondary to lactase deficiency and Mg malabsorption
C. Irritable bowel syndrome
D. H. pylori infection
31. A 63-year-old man comes to your office with a complaint of diarrhea. He first noted the
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diarrhea after a business trip to Bangladesh approximately six months ago. He initially
ascribed his symptoms to "traveler's diarrhea" but it has become progressively more
severe. The diarrhea wakes him up at night; however, he has noted no weight loss. He
has noted an occasional flush over his face and upper trunk. He has changed his diet and
is now drinking approximately one quart of milk/day.
His stool studies included:
Stool volume:
Stool Na:
Stool K:
Stool Mg:
Stool Osmolarity:
Stool pH:
2300 cc
00 meq/1
35 meq/1
12 meq/1
301 mosm
7.2
The MOST LIKELY diagnosis is:
A. Cholera
B. Carcinoid syndrome
C. Lactose malabsorption
D. Irritable bowel disease
E. Pernicious anemia
32. A 68-year-old man presents to your office complaining of abdominal pain and weight loss.
He developed a gnawing mid-epigastric pain not relieved by eating. He has noted an
increased frequency of bowel movements, but no blood. The following test results are
available:
Stool volume: 625 cc
Stool Na: 85 meq/1
Stool K: 40 meq/1
Fecal fat: 25 gm/24 h (nl< 7)
D-xylose: 6.0 gm/5 h urine collection (nl > 5 gm)
The MOST LIKELY diagnosis is:
A. Pancreatic insufficiency
B. Carcinoid syndrome
C. Pernicious anemia
D. Colon carcinoma
E. Crohn's disease
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33. Ulcerative colitis is NOT associated with:
A. Increased risk of colon cancer
B. Sclerosing cholangitis
C. Peripheral arthritis
D. Increased risk of gall stones
34. Which of the following is a risk factor for inflammatory bowel disease (IBD):
A. Diet low in fiber
B. Family history of IBD
C. Stress
D. Non-tropical spree
35. Which metabolic/nutritional abnormality is MOST LIKELY to occur in Crohn's disease:
A. Hypercalcemia
B. Vitamin B 12 deficiency
C. Hypergastrinemia
D. Hyperthryroidism
E. Decreased gastric acid secretion
36. A 24-year-old asthmatic patient presents to the emergency room with a severe
exacerbation. The arterial blood gas is: pH 7.24, PCO2 50 Torr, PO2 60 Torr. Your
fellow student reminds you about the "0.08 rule." The BEST diagnosis for this patient's
acid-base problem is:
A. Pure respiratory acidosis
B. Pure metabolic acidosis
C. Mixed: respiratory acidosis and a compensating metabolic alkalosis
D. Mixed: respiratory acidosis and a metabolic acidosis
37. In the adult respiratory distress syndrome (ARDS), the mechanism of the pulmonary
edema is:
A. Hypoproteinemia, resulting in decreased oncotic pressure within the pulmonary
capillaries
B. Increased permeability of the alveolar-capillary interface
C. Abnormally elevated hydrostatic pressure within the pulmonary capillaries
D. Positive end-expiratory pressure or PEEP
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38. The pulmonary artery (Swan-Ganz) catheter enables the intensive care physician to obtain
an estimate of the left ventricular end-diastolic pressure (an index of ventricular
"preload") by allowing measurement of
A. Pressures in the left ventricle after insertion into a systemic artery and retrograde
passage into the left ventricle
B. Pulmonary capillary and left atrial pressures after insertion into a systemic vein and
anterograde passage into the distal pulmonary artery with the balloon inflated to
achieve a wedged position
C. Cardiac output, which is directly dependent on ventricular preload
D. Right atrial pressure, which always closely approximates left atrial and thus left
ventricular end diastolic pressure
39. What type of pulmonary hypertension results from an impedance of pulmonary venous
drainage?
A. Passive caused by mitral stenosis or pulmonary veno-occlusive disease
B. Hyperkinetic caused by an atrial or a ventricular septal defect
C. Obstructive caused by pulmonary embolism
D. Obliterative caused by primary pulmonary hypertension
E. Vasoconstrictive caused by sleep apnea
40. Cor pulmonale:
A. Is characterized by Left Ventricular Hypertrophy and congestive heart failure
B. Can occur with primary lung disease in the absence of pulmonary hypertension
C. Can be caused by congenital or acquired forms of heart disease that produce
pulmonary hypertension
D. Is caused commonly by chronic hypoxia from intrinsic lung disease or chronic
pulmonary embolism
E. Does not occur with acute pulmonary embolism
END OF EXAMINATION
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ANSWERS:
1. B
2. D
3. B
4. C
5. D
6. B
7. E
8. A
9. B
10. D
11. B
12. D
13. A
14. C
15. C
16. D
17. A
18. D
19. A
20. C
21. D
22. B
23. D
24. D
25. C
26. D
27. C
28. B
29. A
30. B
31. B
32. A
33. D
34. B
35. B
36. D
37. B
38. B
39. A
40. D
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