Download FUNDAMENTALS OF CLINICAL MEDICINE PROBLEM BASED

FUNDAMENTALS OF CLINICAL MEDICINE
PROBLEM BASED LEARNING
BLOCK EXAMINATION IV
VERSION D
MULTIPLE CHOICE; SINGLE BEST ANSWER:
1. A 24 year-old woman was given large doses of oral Cytomel® (triiodothyronine) to promote weight loss.
On examination, she is tremulous and tachycardic. Each one of the following studies would be consistent with
the effects of Cytomel® EXCEPT:
A. elevated radioiodine uptake
B. undetectable TSH
C. low total T4 levels
D. elevated total T3 levels (triiodothyronine)
2. A 16 year-old boy develops nephrotic syndrome. Laboratory studies indicate low TBG levels due to loss of
TBG into the urine. Which one of the following laboratory studies would be MOST consistent with this boy's
clinical picture.
A. elevated radioiodine uptake
B. elevated T3 Resin uptake
C. elevated total T4 levels
D. elevated total T3 levels
3. Which one of the following physician actions would NOT be helpful when dealing with couples with
infertility?
A. Discuss normal psychological responses to infertility at the beginning of treatment
B. Inquire about patients' emotional responses regularly during the course of treatment
C. Tell patients their fears are unfounded; there is nothing to worry about
D. Educate patients about treatment options and procedures so they can participate in the treatment
planning
E. Refer to support group
4. Insulin does not
A. inhibit hepatic glycogenolysis
B. inhibit proteolysis in skeletal muscle
C. promote entry of glucose into skeletal muscle cells
D. promote synthesis of glycogen in skeletal muscle
E. promote breakdown of stored triglycerides in adipose tissue
5. Which one of the following statements BEST describe the pathophysiology of noninsulin-dependent
diabetes mellitus (NIDDM)?
A. Mutations of the insulin receptor are present in the great majority of patients.
B. The pancreas is infiltrated with polymorphonuclear neutrophils.
C. The pancreas is infiltrated with sensitized lymphocytes.
D. At the time of diagnosis, circulating antibodies to insulin are present in easily detectable amounts.
E. At the time of diagnosis, circulating insulin is present in easily detectable amounts.
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QUESTION 6 - 8 ARE BASED ON THE FOLLOWING CASE:
A couple complains of infertility despite concerted efforts to achieve pregnancy for a period of
three years. The husband was in an automobile accident two and one half years ago and has had
severe headaches since.
6. To assess the possible role of the husband in the genesis of the problem you suggest an initial:
A. LH and FSH assay
B. Measurement of plasma testosterone
C. Semen analysis
D. Serum prolactin assay
E. Assessment of his GnRH pulse generator
7. His wife has had irregular menstrual cycles. Her work up is MOST LIKELY to show which one of the
following:
A. A flat basal body temperature chart
B. Low plasma progesterone levels
C. Normal LH concentrations
D. Normal estrogen levels
E. All of the above
8. If a mid cycle rise in basal body temperature is observed, her work up might also reveal
each one of the following EXCEPT:
A. An elevated plasma progesterone level on day 9 of the cycle
B. An elevated plasma estradiol level on day 12 of the cycle
C. An elevated plasma FSH level on day 13 of the cycle
D. An elevated plasma progesterone level on day 20 of the cycle
E. An elevated plasma estradiol level on day 22 of the cycle
9. Cor pulmonale is BEST defined as:
A. pulmonary hypertension and right ventricular hypertrophy or dilatation secondary
to some form of respiratory or pulmonary artery disease.
B. right ventricular hypertrophy or dilatation that may occur in the absence of pulmonary
hypertension; as might occur following a right ventricular infarction.
C. pulmonary artery hypertension caused by congenital or acquired heart disease
D. pulmonary hypertension always in association with (caused by) a pulmonary embolus
10. Which one of the following mechanism contributes MOST IMPORTANTLY to acute pulmonary
hypertension following acute pulmonary embolism?
A. Acute mitral valve insufficiency induced by papillary muscles dysfunction.
B. Mechanical blockage of pulmonary arteries by the embolus and pulmonary artery
vasoconstriction.
C. Pulmonary artery intimal hyperplasia.
D. Pulmonary artery medial necrosis.
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11. Which one of the following mechanisms BEST accounts for the hypoxemia produced by acute pulmonary
embolism?
A. rightward shift of the oxyhemoglobin dissociation curve.
B. acute interstitial edema that increase the diffusion path length for oxygen in the alveolus.
C. intrapulmonary shunt and ventilation-perfusion (VA /Q) mismatch.
D. hypoventilation
12- Which one of the following mechanisms BEST explains the reduction in the forced vital capacity (FVC)
commonly seen in obstructive lung disease?
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. low diffusing capacity
13. Which one of the following is the BEST way to establish the diagnosis of hypoventilation?
A. history
B. physical examination
C. arterial blood gas
D. spirometry
14. A patient has a one-second forced expiratory volume (FEV1) of 62% of the predicted normal value, a
forced vital capacity (FVC) of 66% of predicted, and an FEV1 /FVC ratio of 81 %. Which one of the
following statements is MOST LIKELY TO BE TRUE for this patient?
A. Her response to a 13-2 agonist should be studies to make the diagnosis of asthma.
B. Her response to methacholine should be studies to make the diagnosis of asthma.
C. The low FVC is sufficient to confirm 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.
15. The nurse calls you about an arterial blood gas (ABG) that was obtained on your patient while breathing
room air. Your patient, a previously healthy college student, has been admitted to the Intensive Care Unit for
progressive neuromuscular weakness due to the Guillain-Barre syndrome. The ABG is:
pH 7.24,
PaCO2
60 Torr,
PaO2
70 Torr.
Which one of the following mechanisms of arterial hypoxemia BEST explains his PaO2?
[For reference:
PAO2 = F1O2 x (Pbarometric – PH2O) - PaCO2 / R,
where Pbarometric = 760, PH2O = 47 Torr, and R = 0.8]
A. hypoventilation
B. diffusion limitation
C. shunt
D. ventilation / perfusion mismatch
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16. Which one of the following is LEAST LIKELY to be a cause of insufficient secretion of growth
hormone?
A. Trauma
B. Hypoglycemia
C. Irradiation of the anterior pituitary
D. Granulomatous disease of the anterior pituitary
E. Immunologically mediated damage to somatotrophs (hypophysitis)
17. Recall that serum cortisol normally is highest between 6 and 9 a.m., then declines to low and often
undetectable levels during the afternoon and evening. Consider now a 54 year old homeless man with
advanced tuberculosis. He complains of faintness and vomiting. Examination shows hypotension. You suspect
tuberculous destruction of the adrenal cortices. The MOST APPROPRIATE test for confirmation of this
suspicion would be
A. Serum aldosterone level, drawn after infusion of 2 liters of isotonic saline solution
B. Plasma norepinephrine level, drawn with patient in the supine position
C. Ratio of serum cortisol levels at 4 p.m. and 10 p.m.
D. Serum cortisol level at 7 p.m.
E. Serum cortisol level at 7 a.m.
18. Which one of the following statements BEST describes atherosclerosis among patients
with diabetes mellitus.
A. it affects the aorta and peripheral vessels, but not coronary arteries
B. it tends to be widespread but does not usually cause death or disability
C. it occurs only in patients with cardiovascular autonomic neuropathy
D. it occurs in noninsulin-dependent diabetes (NIDDM) but not in Type I diabetes
E. it is more severe than in persons without diabetes
19. A normal 25 year old medical student takes no food after eating dinner at 6 p.m. one night. The next
morning he awakens, skips breakfast and goes to class. What physiological mechanism MOST
IMPORTANTLY ensures that his brain will have an adequate supply of energy for the 9 a.m. lecture?
A. Fivefold reduction in cerebral metabolic rate, to match the declining supply of glucose
B. Conversion of adipose tissue triglyceride to circulating glucose, under the influence of insulin
C. Continued slow gastrointestinal absorption of nutrients from the previous night's meal
D. Slow breakdown of cerebral glycogen stores
E. Regulated conversion of hepatic glycogen into circulating glucose
20. Many factors can influence thyroid function tests and thyroid hormone binding. Which on of the following
factors affect LEAST thyroid hormone levels?
A. pregnancy
B. oral contraceptives
C. emergency abdominal surgery
D. iodinated contrast for radiologic tests
E. physical examination (palpitation) of the thyroid
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21. Which one of the following is NOT associated with infertility?
A. previous use of the diaphragm
B. increased circulating "androgens" (e.g., DHEA-S and T)
C. previous pelvic infections
D. hyperprolactinemia
E. dramatic changes in body weight (female)
22. The menopause is caused by:
A. Reduced GnRH pulse generator frequency
B. Reduced gonadotropic hormone secretion
C. Ovarian failure
D. Increased prolactin secretion
E. Increased autonomic nervous system activity
23. Male factor infertility accounts for infertility in approximately what percentage of couples?
A. 2%
B. 10%
C. 40%
D. 75%
E. 95%
24. Which one of the following statements BEST describes the most likely mechanism for
the destruction of alveolar walls in centriacinar emphysema?
A. Necrosis of alveolar septa initiated by bacterial infection.
B. Metaplasia of bronchial epithelium.
C. Increased pressure on alveolar septa by expanded airspaces.
D. Decreased surfactant production by Type 1 pneumocytes.
E. Increased elastase and decreased alpha,-antitrypsin activity.
25. Cigarette smoking predisposes or is associated with each of the following EXCEPT:
A. cor pulmonale
B. recurrent respiratory infections
C. laryngeal carcinoma
D. recurrent pulmonary emboli
E. obstructive airway disease
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QUESTION 26 - 28 ARE BASED ON THE CASE OF James Blair.
Mr. Blair, a 62-year-old man with a 40-year, 2 pack/day smoking history is seen in the clinic
for increasing dyspnea. He has had no fever, and his persistent cough is about the same as usual.
Chest x-ray shows increased lucency of the lung fields and increased chest diameter.
LAB RESULTS:
White blood cell count (WBC): 7,000
normal a differential
Hemoglobin (Hgb): 16.3
Hematocrit (Hct): 48.9
Platelet count: 318,000
(normal 4,800-10,800/mm3)
(normal 12.5-15.5 gm/dl)
(normal 34.5-46.5%)
(normal 130,000-365,000/mm3)
26. Based on the above information, Mr. Blair MOST LIKELY has:
A. bronchogenic carcinoma
B. bacterial pneumonia
C. centriacinar emphysema
D. acute bronchitis
E. bronchiectasis
27. Pulmonary function studies in patient like Mr. Blair would MOST LIKELY show predominantly:
A. slowing of forced expiration
B. reversible airway hyperactivity
C. markedly decreased vital capacity
D. increased diffusion capacity (DLCO)
28. The increased hemoglobin and hematocrit in Mr. Blair is MOST LIKELY due to:
A. an underlying hematologic malignancy
B. a compensatory response to decreased oxygenation
C. a concentration effect due to decreased plasma volume
D. iron overload in a chronically ill patient
E. compensated anemia of chronic disease
29. A 72-year-old female presented with uterine bleeding that started a week ago. The best diagnostic test to
perform on this patient is:
A. Pap smear
B. Ultrasound of the uterus
C. Pelvic CT scan
D. Endometrial biopsy
E. serum CA-125
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30. Each one of the following conditions has been reported to raise serum CA-125 EXCEPT:
A. Cervical carcinoma
B. Ovarian carcinoma
C- Pelvic inflammatory disease
D. Severe endometriosis
E- Severe liver disease with ascites
31. Women on unopposed estrogen therapy are at the greatest increased risk for developing
which one of the following carcinomas?
A. Cervical
B. Endometrial
C. Ovarian
D. Vaginal
E. Vulvar
32. Which one of the following is most useful in distinguishing Grave's disease
(thyrotoxicosis)in pregnancy from the "normal" signs and symptoms of pregnancy?
A. fatigue
B. palpitations
C. tachycardia
D. exophthalmos
E. nausea and vomiting
33. The most common diagnosis in a pregnant woman with thyrotoxicosis is:
A. Grave's disease
B. Hashimoto's thyroiditis
C. toxic adenoma
D. struma ovarii
E. gestational trophobiastic disease (molar pregnancy)
34. Which one of the following in NOT consistent with normal changes in thyroid function testing in
pregnancy?
A. the total T4 is increased
B. the total T3 is increased
C. the free T4 is unchanged
D. the free T3 is decreased
E. the thyroid stimulating hormone (TSH) is unchanged.
35. The placenta is relatively permeable to all of the following except:
A. thyroxine (T4)
B. propylthiouracil (PTU)
C. methimazole (Tapazol)
D. thyroid stimulating immunoglobulin (TSI)
E. thyroid stimulating hormone (TSH)
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36. Neonatal Grave's disease (from transplacental passage of thyroid stimulating immunoglobulin) occurs in
approximately what percentage of infants whose mothers have maternal Grave's disease.
A. 1.0%
B. 10.0%
C. 30.0%
D. 50.0%
E. 90.0%
37. Which one of the following statements is NOT true of diabetic neuropathy?
A. The onset of symptoms can be delayed by near-normalization of glycemia
B. Lower extremities are more often affected than upper extremities
C. It can cause postural hypotension
D. It is usually painless
E. It can cause impotence
38. A 62 year-old woman consults her physician because of constipation. Routine laboratory tests disclose a
fasting serum glucose of 275 mg/dl (normal, 75-115 mg/dl). Which form of treatment is least likely to lower
the blood sugar?
A. Injections of insulin
B. Oral administration of sulfonylureas
C. Hypocaloric diet
D. Immunosuppression
E. Oral administration of metformin
39. Which one of the following is the MOST IMPORTANT therapeutic advantage of sulfonylurea drugs
when compared with insulin?
A. A greater retardation of progression of nephropathy
B. No need for injections
C. Minimal risk of hypoglycemia
D. Promotion of weight loss
E. Effectiveness in patients with both Type I and Type II diabetes
40. The Diabetes Control and Complications Trial (DCCT) demonstrated that meticulous control of blood
sugar in patients with Type I diabetes significantly reduced the risk of development of:
A. Gangrene
B. Embolic strokes
C. Albuminuria
D. Insulitis
E. Myocardial infarction
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41. A 13 year-old boy, previously healthy, has felt weak and nauseated for two days. On examination, he is
hyperventilating and clinically dehydrated. Laboratory analysis discloses diabetic ketoacidosis. The
pathogenesis of this patient's diabetes is most likely related to:
A. Deposition of amyloid in the islets of Langerhans
B. Resistance to the action of insulin
C. Immunologically mediated damage to the beta cells of the endocrine pancreas
D. Immunologically mediated damage to the alpha, beta and delta cells of the endocrine pancreas
E. Obesity
42. Which one of the following statements is NOT true, regarding the management of noninsulin-dependent
diabetes mellitus?
A. Proteinuria is not clinically significant, as long as the glomerular filtration rate is greater than 130
ml/min m2
B. Diabetic retinopathy is an important cause of visual loss
C. Treatment with sulfonylureas can cause hypoglycemia
D. Sulfonylureas will lose their effectiveness over 5-10 years, in over 20% of patients initially treated
successfully with one of these drugs
E. Adherence to proper diet can significantly improve glycemia, in the majority of patients
END OF EXAMINATION
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ANSWERS:
1. A
2. B
3. C
4. E
5. E
6. C
7. E
8. A
9. A
10. B
11. C
12. C
13. C
14. D
15. A
16. B
17. E
18. E
19. E
20. E
21. A
22. C
23. C
24. E
25. D
26. C
27. A
28. B
29. D
30. A
31. B
32. D
33. A
34. D
35. A
36. A
37. D
38. D
39. B
40. C
41. C
42. A
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