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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 1 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) 2 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 3 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. 4 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: 5 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 6 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, 7 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 8 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 9 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 10 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 11 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 12