1. A 48 year old female came into your office for a routine checkup. Her BP is 180/100. During her previous checkups, her BP has been 110-120/80. Her BMI is 27. She is a nonsmoker and drinks 2 glasses of wine a few ti mes a week. Her father died of a heart attack at 68 years old. What should be your recommendations to her during this initial visit? a.She should limit her alcohol intake to 2 glasses o f alcohol per day. b.She should start anti-hypertensive medications immediately. c.She should be encouraged to lose weight with a target BMI of less than 25. d.She should start engaging in resistance training on most days of the week. Health-promoting lifestyle modifications are recommended for individuals with pre-hypertension (120-13 9 / 80-89) and as an adjunct to drug therapy in hypertensive individuals. weight loss and reduction ofdietary NaCl have been shown to prevent the development of hypertension. Drug therapy is recommended for individuals with blood pressures 140/90 mmHg. HPIM, 17 th ed. Chapter 241 Hypertensive Vascular Disease > Treatment: Hypertension 2. At what blood pressure levels is maximum protect ion against combined cardiovascular endpoints achieved? a.<120-125 systolic and <75-80 diastolic b.<135-140 systolic and <80-85 diastolic c.<140-145 systolic and <90-95 diastolic d.<100-115 systolic and <75-80 diastolic Maximum protection against combined cardiovascular endpoints is achieved with pressures <135140 mmHg for SBP and < 8085 mmHg for DBP.... More aggressive blood pressure targets for blood pressure control (< 130/80 mmHg) may be appropriate for patients with diabetes, CHD, chronic kidney disease, or with additional cardiovascular disease risk factors HPIM, 17 th ed. Chapter 241 Hypertensive Vascular Disease > Treatment: Hypertension 3. Which of the following lipid profile abnormalities are most commonly seen in type 2 DM patients? a.high LDL, low HDL b.High triglycerides, low HDLc.Low LDL, low HDL d.Low triglyceride, high HDL Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalentpattern of dyslipidemia in people with type 2 diabetes. ADA Standards of Medical Care in Diabetes 2010 Part VI. Prevention and Managemen t of Diabetes Complications 4. What is the target BP of hypertensive patients with type 2 DM and macroalbuminuria? a.< 120/80 mm Hg b.<125/75 mm Hg c.< 130/75 mm Hg d.< 140/90 mm Hg Many individuals with type 1 or type 2 DM develop hypertension. Numerous studies in both type 1 and type 2 DM demonstrate the effectiveness of strict blood pressure control in reducing albumin excretion and slowing the decline in renal function. Blood pressure should be maintained at <130/80 mmHg in diabetic individuals without proteinuria. A slightly lower blood pressure (125/75) should be considered for individuals with microalbumin uria or macroalbuminu ria HPIM, 17 th ed. Chapter 338 Diabetes Mellitus
1. A 48 year old female came into your office for a routine checkup. Her BP is 180/100. During herprevious checkups, her BP has been 110-120/80. Her BMI is 27. She is a nonsmoker and drinks 2 glassesof wine a few times a week. Her father died of a heart attack at 68 years old. What should be yourrecommendations to her during this initial visit?
a. She should limit her alcohol intake to 2 glasses of alcohol per day.b. She should start anti-hypertensive medications immediately.
c. She should be encouraged to lose weight with a target BMI of less than 25.d. She should start engaging in resistance training on most days of the week.
Health-promoting lifestyle modifications are recommended for individuals with pre-hypertension (120-139 / 80-89) and as an adjunct to drug therapy in hypertensive individuals. weight loss and reduction of dietary NaCl have been shown to prevent the development of hypertension. Drug therapy isrecommended for individuals with blood pressures 140/90 mmHg. HPIM, 17th ed. Chapter 241 Hypertensive Vascular Disease > Treatment: Hypertension
2. At what blood pressure levels is maximum protection against combined cardiovascular endpointsachieved?
a. <120-125 systolic and <75-80 diastolicb. <135-140 systolic and <80-85 diastolic
c. <140-145 systolic and <90-95 diastolicd. <100-115 systolic and <75-80 diastolic
Maximum protection against combined cardiovascular endpoints is achieved with pressures <135140mmHg for SBP and <8085 mmHg for DBP.... More aggressive blood pressure targets for blood pressurecontrol (< 130/80 mmHg) may be appropriate for patients with diabetes, CHD, chronic kidney disease, orwith additional cardiovascular disease risk factors HPIM, 17th ed. Chapter 241 Hypertensive Vascular Disease > Treatment: Hypertension
3. Which of the following lipid profile abnormalities are most commonly seen in type 2 DM patients?a. high LDL, low HDLb. High triglycerides, low HDL c. Low LDL, low HDLd. Low triglyceride, high HDL
Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in people with type 2 diabetes. ADA Standards of Medical Care in Diabetes 2010 Part VI. Prevention and Management of DiabetesComplications
4. What is the target BP of hypertensive patients with type 2 DM and macroalbuminuria?a. < 120/80 mm Hgb. < 125/75 mm Hgc. < 130/75 mm Hgd. < 140/90 mm Hg
Many individuals with type 1 or type 2 DM develop hypertension. Numerous studies in both type 1 andtype 2 DM demonstrate the effectiveness of strict blood pressure control in reducing albumin excretionand slowing the decline in renal function. Blood pressure should be maintained at <130/80 mmHg indiabetic individuals without proteinuria. A slightly lower blood pressure (125/75) should be considered forindividuals with microalbuminuria or macroalbuminuria HPIM, 17th ed. Chapter 338 Diabetes Mellitus
5. A 42 year old female from the Cordilleras consults at the OPD for an anterior neck mass that hasenlarged slowly over the past 10 years. History reveals that she has a daughter with developmentalabnormalities. What is the expected thyroid function test of this patient?
In areas of relative iodine deficiency, there is an increased prevalence of goiter and, when deficiency issevere, hypothyroidism and cretinism. Cretinism is characterized by mental and growth retardation andoccurs when children who live in iodine-deficient regions are not treated with iodine or thyroid hormoneto restore normal thyroid hormone levels during early life. These children are often born to mothers withiodine deficiency, and it is likely that maternal thyroid hormone deficiency worsens the condition. HPIM,17th ed. Chapter 335. Disorders of the Thyroid Gland > Hypothyroidism
6. Which of the following is the preferred treatment for Graves disease in pregnant women?a. Methimazoleb. Propylthiouracilc. SSKI (Saturated solution Potassium Iodide)
d. RadioiodineD is an absolute contraindication to pregnancy and breastfeeding moms. - HPIM 17th ed. Chapter 335.Some clinicians prefer propylthiouracil (PTU) because it crosses the placenta less readily thanmethimazole. Although not definitely proven, methimazole in early pregnancy rare methimazoleembryopathy (esophageal or choanal atresia, aplasia cutis).PTU still is the preferred thionamide in the United States Williams Obstetrics, 23rd ed. Chapter 53. Thyroid and Other Endocrine Disorders. (wala sa Harrisonseh, except for the one about RAI contraindications)
7. A patient you are treating with methimazole comes to your clinic complaining of oral ulcers, fever, andsore throat 1 week after you prescribed the medication. What would you do?
a. Observe closely and reassure patient b. Continue methimazole at a lower dosec. Shift her to another anti-thyroid drugd. Stop medication and do CBC
Common side effects of antithyroid drugs: rash, urticaria, fever, and arthralgia (15% of patients)which may resolve spontaneously or after substituting an alternative drug. Rare but major sideeffects: hepatitis, SLE-like syndrome, and, most importantly, agranulocytosis (<1%). It is essential that antithyroid drugs are stopped and not restarted if a patient develops major side effects. Writteninstructions should be provided regarding the symptoms of possible agranulocytosis (e.g., sore throat,fever, mouth ulcers) and the need to stop treatment pending a CBC to confirm that agranulocytosis. But its not useful to monitor blood counts prospectively, as the onset of agranulocytosis is idiosyncratic andabrupt.- HPIM 17th ed. Chapter 335 Chapter 335 Disorders of the Thyroid Gland
8. According to the Philippine Guideline on Periodic Health Examination, screening of all individuals fortype 2 Diabetes Mellitus should begin at what age?
a. 35b. 40 c. 45d. 50
9. In what phase of pneumonia do we see predominance of neutrophils, fibrin deposition, disappearanceof bacteria, and improvement of gas exchange?
a. Edemab. Red hepatizationc. Gray hepatizationd. Resolution
Classic Pneumonia phases:1) edema- proteinaceous exudates + bacteria in alveoli. This phase is rarely evident in clinical or
autopsy specimens because it is so rapidly followed by2) red hepatization phase: erythrocytes in the intraalveolar exudates + neutrophils (important from
the standpoint of host defense). Bacteria occasionally seen in cultures3) gray hepatization, no new erythrocytes are extravasatingold ones have been lysed and degraded
+ pinakasikat ang NEUTROPHILS + abundant fibrin deposition + bacteria disappeared Thisphase = successful containment of infection and improvement in gas exchange.
4) resolution, macrophage is dominant cell type in the alveolar space+ debris of neutrophils,bacteria, and fibrin has been cleared
HPIM 17th d. Chapter 251 Pneumonia
10. What is the major risk factor for asthma?a. Atopyb. Family history of asthma
c. Aged. Environmental setting
Atopy is the major risk factor for asthma. whether or not the genes predisposing to asthma are similar or in addition to those predisposing of atopy is not yet clear. It is likely that environmental factors in early life determine which atopic individuals become asthmatic. HPIM 17th ed., Chapter 248 Asthma
11. Which finding, if found in a COPD patient, should make you suspect a lung malignancy?a. Cyanosisb. Clubbingc. Hemoptysisd. Muscle wasting
Clubbing of the digits is not a sign of COPD the development of lung cancer is the most likelyexplanation for newly developed clubbing.- HPIM 17th ed, Ch. 254, Physical Findings
12. What is the main preventive measure for community-acquired pneumonia?a. Avoidance of self-medication with antibioticsb. Healthy diet and smoking cessationc. multivitamins with zincd. Vaccination
The main preventive measure is vaccination. HPIM 17th ed. Chapter 251 Pneumonia The mainstays of CAP prevention are pneumococcal and influenza vaccination.
PSMID CAP 2010
13. What is the most common etiology of secondary hypertension?a. Medicationsb. Vigorous coughingc. Primary renal diseased. Phaeochromocytoma
Primary renal disease is the most common etiology of secondary hypertension.- HPIM 17th ed, Ch. 241 Hypertensive Vascular Disease
14. What is the most widely used test for both the diagnosis of ischemic heart disease and estimating theprognosis?
a. Treadmill Stress testb. 2D echocardiography with Doppler studies
c. Thallium perfusion scand. Coronary angiography
The most widely used test for both the diagnosis of IHD and estimating the prognosis involvesrecording the 12-lead ECG before, during, and after exercise, usually on a treadmill- HPIM 17th ed, Ch. 237, under Stress Testing
15. A 50 year old female comes to your clinic wanting to know about her risk of having a heart attack.She is a smoker. Her last menstrual period was about 8 years ago. Her BP is 120/80 and her BMI is 21.Physical Examination is unremarkable. The following factors increase her risk for ischemic heart diseaseEXCEPT:
a. postmenopausalb. cigarette smokingc. family history
d. AgeRisk factor: Age (men 45 years; women 55 years)HPIM 17th ed, Ch. 235, Table 235-1 Major Risk Factors
16. What is the LDL goal for patients with acute coronary syndrome or coronary heart disease withdiabetes or multiple coronary risk factors?
a. < 70 b. < 100c. < 130d. < 160
In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high doseof statin, is an option. ADA 2010Less than 70 mg/dL for those with heart or blood vessel disease and for other patients at very high riskof heart disease (those with metabolic syndrome)National Cholesterol Education Program's (NCEP's) Expert Panel Guidelines
17. A 54 year old male consults for dyspnea on exertion that started 6 months ago. Physical examinationshows the apex beat displaced to the 6th intercostal space, left anterior axillary line; Gr. 3/6 systolicmurmur at the midaxillary line; and fine crackles, both lung bases. What should be your primarytherapeutic goal for this patient at this point?
a. Alleviate fluid retentionb. Prevent cardiac remodeling with medicationsc. Control blood pressured. Reduce risk of further disease progression
For patients who have developed symptoms (class IIIV NYHA Classification), the primary goal should beto alleviate fluid retention, lessen disability, and reduce the risk of further disease progression and death.These goals generally require a strategy that combines diuretics (to control salt and water retention) withneurohormonal interventions (to minimize cardiac remodeling).- HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale
18. Which of the following drugs used for patients with heart failure is NOT correctly matched with thespecial population for which it is indicated?
b. Warfarin dilated LV with depressed LV functionc. Angiotensin Receptor Blocker ACE intolerant d. Spironolactone renal insufficiency (Creatinine clearance <30 ml)
A. Digoxin: symptomatic LV systolic dysfunction + concomitant atrial fibrillation; should be considered forthose with Sx and symptoms of HF while receiving standard therapy, including ACEI and B-blockers.B. Warfarin [goal NR: 2.03.0]: HF + chronic or paroxysmal a. fib, or with history of systemic or
pulmonary emboli (stroke or TIA). Patients with symptomatic or asymptomatic ischemic cardiomyopathyand documented recent large anterior MI or recent MI with documented LV thrombus should be treatedwith warfarin.C. ARBs are well tolerated in patients who are intolerant of ACE inhibitors because of cough, skin rash,and angioedema.D. Aldosterone antagonists are not recommended when serum Cr is >2.5 mg/dL (Cr clearance is <30mL/min) or when the serum K is >5.0 mmol/L.- HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale
19. What is the most common cause of Cor Pulmonale?a. Chronic Bronchitisb. Recurrent pulmonary embolismc. RV failure
d. Pulmonary Hypertension Cor pulmonale develops in response to acute or chronic changes in the pulmonary vasculature and/orthe lung parenchyma that are sufficient to cause pulmonary hypertension. COPD and chronic bronchitis are responsible for approximately 50% percent of the cases of corpulmonale in North America. According to Dr. Palileo, the root cause is COPD which leads to pulmonary hypertension (the pathologicmechanism) which then results to cor pulmonale. The question is pertaining to the root cause.
b. - HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale
20. Which of the following is NOT an effect of B adrenergic agonists on airways:a. Relaxation of airway smooth muscleb. Inhibition of mast cell mediator releasec. Increased mucociliary clearanced. Decrease of chronic inflammation when used over time
Table 248-3 Effects of B2-Adrenergic Agonists on Airways
Relaxation of airway smooth muscle (proximal and distal airways)
Inhibition of mast cell mediator release
Inhibition of plasma exudation and airway edema
Increased mucociliary clearance
Increased mucus secretion
Decreased cough
No effect on chronic inflammation
- HPIM 17th ed. Chapter 248 Asthma
21. Which of the following is a cardinal symptom of heart failure?a. Shortness of breathb. Palpitationc. Chest paind. Bipedal edema
The cardinal symptoms of HF are fatigue and shortness of breath.- HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale
22. Which of the following has been shown to reduce mortality in patients with COPD?
a. Oral glucocorticoidsb. Inhaled glucocorticoidsc. Supplemental oxygend. Long-acting Beta agonists
Supplemental O2 is the only pharmacologic therapy demonstrated to decrease mortality in patients withCOPD. For patients with resting hypoxemia (O2 saturation <88% or <90% with signs of pulmonary HTNor RHF), O2 has been demonstrated to have a significant impact on mortality.
23. The major features of Metabolic Syndrome are the following EXCEPT:a. peripheral obesityb. hypertensionc. hyperglycemiad. dyslipidemia
Features of Metabolic Syndrome:1) Central obesity: Waist circumference >102 cm (M), >88 cm (F)2) Hypertriglyceridemia: Triglycerides >150 mg/dL or specific medication
Low HDL cholesterol: <40 mg/dL and <50 mg/dL, respectively, or specific medication3) Hypertension: Blood pressure >130 mm systolic or >85 mm diastolic or specific medication4) Fasting plasma glucose >100 mg/dL or specific medication or previously diagnosed type 2
diabetes- HPIM 17th ed., Chapter 236. The Metabolic Syndrome
24. A previously healthy 19-year-old consults you for productive cough and fever of 3 weeks duration. You diagnose him with community-acquired pneumonia. Based on the 2010 Philippine Guidelines, whichantibiotic would you prescribe?
a. Amoxicillinb. Levofloxacinc. Cefuroximed. Cotrimoxazole
For low-risk CAP without comorbid illness, amoxicillin remains the standard drug of choice (Grade A) PSMID CAP 2010
25. A 65 year old male comes to your clinic complaining of persistent productive cough with whitishsputum but no fever. For the last 2 months he has noted increasing dyspnea on exertion. He has beensmoking 1-2 packs of cigarettes a day for the last 40 years. Physical examination is normal. You wouldexpect to find the following on the chest x-ray EXCEPT:
a. Cardiomegalyb. flattening of the diaphragmc. Hyperlucencyd. bullae
In COPD: Obvious bullae, paucity of parenchymal markings, or hyperlucency suggest the presence of
emphysema. Increased lung volumes and flattening of the diaphragm suggest hyperinflation but do not provide information about chronicity of the changes.- HPIM 17th ed., Chapter 254 Chronic Obstructive Pulmonary Disease
26. What is the drug of choice for Prinzmetals Variant Angina?a. ACE-inhibitorb. Beta Blockerc. Diureticsd. Calcium Channel Blocker
EXPLANATION: Nitrates and CCBs are the main treatments for patients with variant angina. SL or IV nitroglycerin oftenabolishes episodes of variant angina promptly, and long-acting nitrates are useful in preventingrecurrences. Calcium antagonists are extremely effective in preventing the coronary artery spasm of variant angina, and they should be prescribed in maximally tolerated doses.
HPIM 17th
ed., Chapter 238. Unstable Angina and Non-ST-Elevation Myocardial Infarction
27. Resistant hypertension refers to patients with BP persistently _______ despite taking 3 or more anti-hypertensive agents, including diuretics, in combination and at full doses.
a. > 140/90 mm Hgb. > 160/90 mm Hgc. > 180/100 mm Hgd. > 200/100 mm Hg
EXPLANATION: Verbatim from Chapter 241. Hypertensive Vascular Disease > Blood Pressure Goals for HypertensiveTherapy
28. What test differentiates obstructive lung disease from restrictive lung disease?a. Chest X-rayb. Spirometryc. Chest CT scan with Contrast d. History and Physical Examination
EXPLANATION: The two major patterns of abnormal ventilatory function, as measured by static lung volumes andspirometry, are restrictive and obstructive patterns . . . . In the obstructive pattern, the hallmark is adecrease in expiratory flow rates. The hallmark of a restrictive pattern is a decrease in lung volumes,primarily TLC and VC.
- HPIM 17th ed., Chapter 246. Disturbances of Respiratory Function
29. In which of the following patients would you consider treatment for Hepatitis B infection?a. 28 year old seaman who is HBsAg reactive, HBeAg negative, with normal ALT (3rd row)b. 35 year old laboratory technician who is HBs reactive, HBe reactive, with elevated ALT
(2.5x the upper limit of normal) (Acute or Chronic)c. 45 year old executive who is HBsAg reactive, anti-HBe reactive, with ALT 1.5x the normal value
(3rd row)d. 43 year old nurse who is anti-HBS reactive, anti-HBe reactive, with elevated ALT (2x the upper
limit of normal)4th row, or recovery from Hep B
EXPLANATION: A. Late acute or chronic hepatitis, low infectivityB. Acute or Chronic Hepatitis B, high infectivityC. Late acute or chronic hepatitis, low infectivityD. Recovery from Hep B/ HBsAg of one subtype and heterotypic anti-HBs (common)
30. The following are considered first line anti-TB drugs EXCEPT:a. Rifampicinb. Isoniazidc. Pyrazinamided. Streptomycin
EXPLANATION: Four major drugs are considered the first-line agents for the treatment of TB: isoniazid, rifampin,pyrazinamide, and ethambutol HPIM 17th ed., Chapter 158 Tuberculosis
31. Which of the following is the most potent anti-TB drug?a. Rifampicinb. Isoniazidc. Pyrazinamided. Streptomycin
Rifampin, a semisynthetic derivative of Streptomyces mediterranei, is considered the most important andpotent antituberculousagent. It is also active against a wide spectrum of other organisms, including some gram-positive and
gram-negative bacteria, Legionella spp., M. kansasii, and M. marinum.- (HPIM 17th
ed)
32. Which is the most common extrapulmonary site for tuberculosis?a. Liverb. Larynxc. Lymph noded. Spine
In order of frequency, most common extrapulmonary sites of TB: lymph nodes (40%) > pleura > GUT >bones and joints > meninges > peritoneum > pericardium
33. The following adverse drug reactions are correctly matched to the known anti-TB meds EXCEPT:a. Isoniazid - Seizuresb. Rifampicin - Hyperuricemiac. Pyrazinamide Hepatotoxicity
d. Streptomycin - Ototoxicity A. Isoniazid: The two most important adverse effects of isoniazid therapy are hepatotoxicity andperipheral neuropathy.Other adverse reactions are either rare or less significant and include rash (2%), fever (1.2%), anemia,acne, arthritic symptoms, a systemic lupus erythematosuslike syndrome, optic atrophy, seizures, andpsychiatric symptoms.B. Rifampin: rashes, thrombocytopenia, nephritis, cholestatic jaundice, occasionally, hepatitis, light-chainproteinuria. If administeres less often than 2x weekly, it causes a flu-like syndrome (fever, chills, myalgia,anemia, thrombocytopenia, sometimes associated with acute tubuar necrosis)C. Pyrazinamide: hepatotoxicity, nausea, vomiting, drug fever, hyperuricemia. Optic neuritis is anadverse effect of Ethambuto/Streptomycin.D. Streptomycin: ototoxic, nephrotoxic, vertigo, hearing loss. Pyrazinamide is the one that usuallycauses hyperuricemia.
- Katzung Basic and Clinical Pharmacology 11th ed.. Chapter 47 Antimycobacterial Drugs (Wala saHarrisons, or at least, hindi in depth ang discussion)
34. A 67 year old male patient is brought to your clinic by his relatives for sudden onset of weakness of the right lower extremity. Which of the following signs will point to an upper motor neuron problem?
a. Decreased muscle tone
b. Presence of fasciculations
c. Proximal muscle atrophy
d. H
yperactive tendon reflexes
- HPIM 17th ed. Chapter 23 Weakness
35. The following medications may be used for prophylaxis against NSAID-related mucosal injuryEXCEPT:a. Misoprostolb. Bismuthc. Proton pump inhibitord. Selective COX-2 inhibitor
-HPIM 17th ed. Chapter 287 Peptic Ulcer Disease, Table 5 contains Prophylactic therapy (w/c include the 3above)
36. Chest pain that presents as a severe ripping and tearing pain or a sudden severe sharp pain in thefront of the chest that extends into the back, between the shoulder blades is characteristic of what condition?
a. Acute pericarditisb. Pulmonary embolism
c. Aortic dissection d. Acute myocardial infarction
Unlike the pain of IHD, symptoms of AD tend to reach peak severity immediately, often causing patient tocollapse from intensity. The classic teaching is that the adjectives used to describe the pain reflect theprocess occurring within the wall of the aorta"ripping" and "tearing"but more recent data suggest that the most common presenting complaint is sudden onset of severe, sharp pain.- HPIM 17th ed. Chapter 13. Chest Discomfort
37. A 65 year old male consults your clinic for loss of consciousness. His son found him seated on thebathroom floor this morning, looking confused. When asked what happened, all he could remember wasthat he was turning his head to the side while shaving. There were no prior episodes reported. He takeshydrochlorothiazide daily for hypertension. There were no deficits on neurologic exam. Which of thefollowing would you LEAST consider in this patient?
a. Cardiac arrhythmiab. Ischemic stroke c. Orthostatic hypotensiond. carotid sinus hypersensitivity
"A stroke, or cerebrovascular accident: abrupt onset of neurologic deficit attributable to focal vascularcause..." "call emergency medical services immediately if they experience or witness the sudden onset of any of the following: loss of sensory and/or motor function on one side of the body (~85% of ischemicstroke patients have hemiparesis); change in vision, gait, or ability to speak or understand; or if theyexperience a sudden, severe headache. HPIM 17th edition, Ch. 364 Cerebrovascular disease
38. A 40 year old female comes to your clinic for right leg edema, gradually worsening over the past fewmonths. There was initially no limitation in her daily activities, but recently, she has started to havedifficulty walking long distances because of heaviness of the right leg. There were no other symptoms. You note erythema, warmth and tenderness on examination of the right leg with hyperpigmentation of the skin and ulceration near the malleoli. What is your primary impression?
a. lymphedema tardab. chronic venous insufficiency c. cellulitisd. peripheral arterial occlusive disease
Patients with venous insufficiency often complain of a dull ache in the leg that worsens with prolongedstanding and resolves with leg elevation. Examination demonstrates increased leg circumference, edema,and superficial varicose veins. Erythema, dermatitis, and hyperpigmentation develop along the distalaspect of the leg, and skin ulceration may occur near the medial and lateral malleoli.- HPIM 17th ed. Chapter 243 Vascular Diseases of the Extremities
39. Chest pain that presents as a sharp retrosternal chest pain that sometimes radiates to the left shoulder and is relieved by sitting up and leaning forward is characteristic of which of the followingconditions?
a. Pulmonary embolismb. Esophageal refluxc. Acute pericarditis d. Acute myocardial infarction
Perdicarditis: most typically, pain is retrosternal, aggravated by coughing, deep breaths, or changes inposition (movement of pleural surfaces). Pain often worse while supine, and relieved by sitting upright and leaning forward- HPIM 17th ed. Chapter 13. Chest Discomfort
40. Which of the following laboratory findings may distinguish a cardiac from a renal cause of edema?
a. Hyponatremiab. Azotemiac. Pulmonary congestion on chest x-rayd. Elevated liver transaminases
- AST is also elevated in cardiac conditions, unaffected in renal diseases.
41. What is the initial analgesic of choice for patients with osteoarthritis?a. tramadolb. celecoxibc. ibuprofend. acetaminophen
answer: D
42. A 57 year old male patient consults you for yellow discoloration of his skin. He does not complain of abdominal pain, nausea or vomiting but reports that he has lost about 5 kg in the past month. Onphysical exam, you note a vague epigastric mass on deep palpation and excoriation on his skin. There isno Murphy's sign. Which of the following abnormalities do you expect to be on blood chemistry?
a. prolonged protimeb. decreased serum albuminc. elevated alkaline phosphatased. normal total bilirubin
Answer: C. The patient has cholangiocarcinoma
43. A 67 year old man comes to your clinic for burning epigastric pain that radiates to the retrosternalarea, exacerbated by means and sometimes wakens him from sleep, leaving a sour taste in his mouth.Which of the following signs would warrant further evaluation prior to empiric treatment?
a. occasional vomitingb. pallorc. early satietyd. bloatedness
answer: B. Pallor is a danger sign
44. In which of the following conditions would emesis relieve abdominal pain?a. renal colicb. acute pancreatitisc. esophageal refluxd. small bowel obstruction
answer: D
45. A 75 year old male consults your clinic for vomiting of previoiusly ingested food associated withbloatedness, flatulence, and weight loss. He also complains of nocturia, dizziness upon getting up frombed, and tingling of the fingers and toes. Physical examination reveals anhidrosis and areas of hyperpigmentation over both lower extremities. Which of the following medication would you prescribeto relieve his symptoms?
d. metoclopromide Answer: DOndansetron is used to relieve chemotherapy induced vomitingLorazepam is used to relieve anticipatory vomiting in chemotherapyMeclizine is used for motion sicknessMetoclopromide is used as a prokinetic drug.
Patient has gastroparesia from Diabetes Mellitus type 2
46. What is the leading cause of mortality and morbidity in patients with CKD?a. Cerebrovascular diseaseb. Significant uremiac. Cardiovascular disease d. Infectious disease
Since diabetes mellitus and hypertension are the two most frequent causes of advanced CKD, it is not surprising that cardiovascular disease is the most frequent cause of death in dialysis patients. HPIM 17th ed. Chapter 274 Chronic Kidney DIsease
47. The following conditions may produce vomiting within 1 hour of eating EXCEPT:a. Diabetic gastropathyb. Food poisoningc. Gastric carcinomad. Chemotherapy
Pyloric obstruction and gastroparesis produce vomiting within 1 h of eating Chemotherapy causesvomiting that is acute (within hours of administration), delayed (after 1 or more days), or anticipatory. HPIM 17th ed. Chapter 39 Nausea, Vomiting and Indigestion
48. The reason for the secondary anemia in patients with CKD isa. Intermittent GI blood lossb. Iron deficiencyc. Loss of bone marrow stimulation d. Vitamin deficiency
A normocytic, normochromic anemia is observed as early as stage 3 CKD and is almost universal by stage4. The primary cause in patients with CKD is insufficient production of erythropoietin (EPO) by thediseased kidneys. Additional factors include iron deficiency, acute and chronic inflammation with impaired iron utilization,severe hyperparathyroidism with consequent bone marrow fibrosis, and shortened red cell survival in theuremic environment. Less common causes include folate and vitamin B12 deficiency and aluminumtoxicity.- HPIM 17th ed. Chapter 274 Chronic Kidney Disease
47. What is the cornerstone of diagnosis in patients suspected to have acute severe infectious diarrhea?a. proctosigmoidoscopyb. abdominal CT scanc. stool microbiologic studies d. serology
The cornerstone of diagnosis in suspected severe acute infectious diarrhea is microbiologic analysis of thestool. Workup includes cultures for bacterial and viral pathogens, direct inspection for ova and parasites,
and immunoassays for certain bacterial toxins (C. difficile), viral antigens (rotavirus), and protozoalantigens (Giardia, E. histolytica). HPIM 17th ed., Chapter 40. Diarrhea and Constipation
50. Which of the following nephrolithiasis is associated with Proteus infection?a. Calcium
b. Uric Acidc. Struvite d. Cysteine
Struvite stones are common and potentially dangerous. These stones occur mainly in women or patientswho require chronic bladder catheterization and result from urinary tract infection with urease-producingbacteria, usually Proteus species. The stones can grow to a large size and fill the renal pelvis and calycesto produce a "staghorn" appearance. HPIM 17th ed. Chapter 281 Nephrolithiasis
51. The following conditions are common causes of involuntary weight loss among elderly patientsEXCEPT:
a. Hyperthyroidismb. Depression
c. Malignancyd. Acid peptic disease
In the elderly, the most common causes of weight loss are depression, cancer, and benigngastrointestinal disease. HPIM 17th ed. Chapter 41. Weight Loss
52. Majority of urolithiasis will pass out from urine spontaneously without any intervention when thestone size is
a. < 0.5 cmb. < 1.0 cmc. < 1.5 cmd. < 2.0 cm
The vast majority of ureteral stones <0.5 cm in diameter will pass spontaneously. HPIM 17th ed, Chapter 281 Nephrolithiasis
53. Pregnant women with cystitis should be treated with any of the following antibiotics EXCEPT:a. Amoxicillinb. Cefuroximec. Ofloxacind. Nitrofurantoin
In pregnancy, acute cystitis can be managed with 7 days of treatment with amoxicillin, nitrofurantoin, ora cephalosporin. HPIM 17th ed. Chapter 282 Urinary Tract Infections, Pyelonephritis, and Prostatitis. Of the fluoroquinolones, ofloxacin (300 mg by mouth bid for 7 days) and levofloxacin (500 mg/d bymouth for 7 days) are as effective as doxycycline for the treatment of chlamydial infection and appear tobe safe and well tolerated. These drugs cannot be used in pregnancy. HPIM 17th ed. Chapter 169
Chlamydial Infections Ofloxacin should be avoided during pregnancy in the absence of specific data documenting their(fluoroquinolones) safety. Katzung 11th ed.
54. A 21-year-old male medical student consults your clinic for fever of 1-week duration associated withchills and sweating. Fever would resolve spontaneously but would return again after 36 hours. Medicalstudent just came from a mission in Cagayan Valley where they slept in the community with locals forseveral days. Temperature is 37.3oC. What is your primary impression?
a. Malariab. Typhoid feverc. Leptospirosisd. Dengue
Some infections have characteristic patterns in which febrile episodes are separated by intervals of normal temperature. For example, Plasmodium vivax causes fever every third day
HPIM 17th
ed. Chapter 17 Fever and Hyperthermia
55. A 65-year-old female patient consults your clinic for fever which began 3 weeks ago. She reports that her temperature was usually between 38-38.3°C. She claims that she would often feel tired andsometimes experience muscle aches, but no cough, dysuria, diarrhea or abdominal pain. All laboratorytests done in the past week were negative (CBC, urinalysis, septic work-up, blood chemistry). Which of the following would you LEAST consider as the probable cause of fever in this patient?
a. Factitious feverb. Colon cancerc. Giant cell arteritisd. Tuberculosis
In the elderly, multisystem disease is the most frequent cause of FUO, giant-cell arteritis being theleading etiologic entity in this category. In patients >50 years of age, this disease accounts for 1520%
of FUO cases. Tuberculosis is the most common infection causing FUO in the elderly, and colon cancer isan important cause of FUO with malignancy in this age group. A significant proportion (9%) had factitiousfeversi.e., fevers due either to false elevations of temperature or to self-induced disease. A substantialnumber of these factitious cases were in young women in the health professions. HPIM 17th ed. Chapter 19 Fever of Unknown Origin
56. A 65-year-old female patient consults your clinic for fever which began 3 weeks ago. She reports that
her temperature was usually between 38-38.3°C. She claims that she would often feel tired and
sometimes experience muscle aches, but no cough, dysuria, diarrhea or abdominal pain. All laboratory
tests done in the past week were negative (CBC, urinalysis, septic work-up, blood chemistry). Which of
the following would you LEAST consider as the probable cause of fever in this patient?
a. Factitious fever
b. Colon cancer
c. Giant cell arteritis
d. Tuberculosis
In the elderly, multisystem disease is the most frequent cause of FUO, giant-cell arteritis being the
leading etiologic entity in this category. In patients >50 years of age, this disease accounts for 1520%
of FUO cases. Tuberculosis is the most common infection causing FUO in the elderly, and colon cancer is
an important cause of FUO with malignancy in this age group.
HPIM 17th ed. Chapter 19 Fever of Unknown Origin
57. The emphasis in patients with classic fever of unknown origin is on continued observation and
examination, with the avoidance of shotgun empirical therapy. In which of the following patients is
empiric therapy indicated?
a. 75 year old male with leukocyte count of 15,000 cells/ L
b. 20 year old female with hemoglobin level of 90 g/L
c. 35 year old male with absolute neutrophil count of 300 cells / L
d. 55 year old female with platelet count of 20,000 cells/ L
Vital-sign instability or neutropenia is an indication for empirical therapy with a fluoroquinolone +
62. In a patient who has been on a strict vegan diet for more than 20 years, what findings would youexpect on peripheral blood smear?
a. Normocytic, normochromic anemiab. Macrocytic, hypochromic anemia
c. Microcytic, normochromic anemiad. Microcytic, hypochromic anemia
Severe ID A: microcytic and hypochromic RBCs smaller than nucleus of a lymphocyte associated withmarked variation in size and shape. HPIM 17th ed. Chapter 58 Anemia and Polycythemia
63. All of the following clotting factors are produced exclusively by the liver EXCEPT:a. Factor 7b. Factor 8 c. Factor 9d. Factor 5
With the exception of factor VIII, the blood clotting factors are made exclusively in hepatocytes.- HPIM 17th ed. Chapter 296 Evaluation of Liver Function
64. The following are used as a standard therapy for H. pylori infection EXCEPT:a. Proton pump inhibitorsb. Ceftriaxonec. Amoxicillind. Clarithromycin
Multiple drugs have been evaluated in the therapy of H. pylori. No single agent is effective in eradicatingthe organism. Combination therapy for 14 days provides the greatest efficacy. The agents used with thegreatest frequency include amoxicillin, metronidazole, tetracycline, clarithromycin, and bismuthcompounds. HPIM 17th ed. Chapter 286 Diseases of the Esophagus
65. What is the most common complication observed in patients with peptic ulcer disease?a. Anemiab. Gastric outlet obstructionc. Bleedingd. Perforation
Bleeding (15%, more often in individuals >60 years old) > Perforation (6-7%) > Gastric Outlet Obstruction (1-2%)HPIM 17th ed. Chapter 287 Peptic Ulcer Disease and Related Disorders
66. What is the most consistent clinical feature in irritable bowel syndrome?a. Abdominal painb. Alteration in bowel habitsc. Gas, bloatedness, and flatulence
d. Vomiting According to current IBS diagnostic criteria, abdominal pain or discomfort is a prerequisite clinical featureof IBS. Highly variable in intensity and location, pain in IBS is hypogastric in 25% > right side 20% > left side in 20% > epigastric 10%- HPIM 17th ed. Chapter 290 Irritable Bowel Syndrome
67. What is the hallmark of all forms of intestinal obstruction?a. Abdominal distentionb. Abdominal tenderness
Abdominal distention is the hallmark of all forms of IO. It is least marked in cases of obstruction high inthe small intestine and most marked in colonic obstruction. HPIM 17th ed. Chapter 293 Acute Intestinal Obstruction
68. Which of the following etiologic agents causes acute onset watery diarrhea, abdominal cramping andhigh-grade fever within a few hours of ingestion?
a. Bacillus cereusb. Escherichia colic. Giardia sp.d. Vibrio parahaemolyticus
See Table 40.2 Pathobiology of Causative Agents and Clinical Features in Acute Infectious Diarrhea inHPIM 17th ed. Chapter 40 Diarrhea(sorry, too big to Print Screen)Essentially the deciding factor was the high-grade fever.
IncubationPeriod
Vomiting
Ab.Pain
Fever
Diarrhea
Bacillus Cereus 1-8h 3-4+ 1-
2+
0-
1+
3-4+,
waterE. Coli 872 h 24+ 1
2+01+
34+,watery
Giardia sp. 18 d 01+ 13+
02+
12+,watery,mushy
V. parahaemolyticus 12 h11d
03+ 24+
34+
14+,wateryorbloody
69. Interpret the following Hepatitis profile: HBsAg (-); Anti-HBs (+), AntiHBc total (-):
a. Past Hepatits B infectionb. Previous immunizationc. Chronic Hepatitis B infectiond. Acute Hepatitis B infection
Please see Chart in # 29. Thanks.
70. Cornerstone in the treatment of alcoholic liver diseasea. Silymarinb. No treatment availablec. Alcohol abstinenced. Vitamin B complex
Complete abstinence from alcohol is the cornerstone in the treatment of ALD. HPIM 17th ed. Chapter 301 Alcoholic Liver Disease
71. Which hepatitis virus is the major cause of liver cirrhosis worldwide?a. Hepatitis Ab. Hepatitis Bc. Hepatitis Cd. Hepatitis D
In the 2013 samplices, the answer is Hep C, however according to Dr. Palileo and Dr. Lo, the questionemphasized liver cirrhosis WOLDWIDE and not just in the US, and worldwide there are more Hep B
cases. According to harrisons (excerpts found below), about 170M have hepatitis C and 20-30% of themwill develop cirrhosis, thus 51M cases (170Mx0.3) of liver cirrhosis will be /is caused by the HepC virus. Meanwhile 300-400M worldwide have Hepatitis B and 25% may ultimately develop cirrhosis,meaning 100M cases (400 x 0.25) of liver cirrhosis will be / is caused by the HepB virus.HPIM excerptsOf patients exposed to the Hep C virus (HCV), approx. 80% develop chronic Hep C, and of those, about
20 30% will develop cirrhosis over 2030 years. In the United States, approximately 5 millionpeople have been exposed to the hepatitis C virus, with about 3½4 million who are chronically viremic.Worldwide, about 170 million individuals have hepatitis C, with some areas of the world (e.g.,Egypt) having up to 15% of the population infected.
Of patients exposed to hepatitis B, about 5% develop chronic hepatitis B, and about 20% of thosepatients will go on to develop cirrhosis. In the United States, there are about 1.25 million carriers of hepatitis B, whereas in other parts of the world where hepatitis B virus (HBV) is endemic (i.e., Southeast Asia, sub-Saharan Africa), up to 15% of the population may be infected having acquired the infectionvertically at the time of birth. Thus, over 300 400 million individuals are thought to havehepatitis B worldwide. Approximately 25% of these individuals may ultimately developcirrhosis. HPIM 17th ed. Chapter 302 Cirrhosis and its Complications
72. A 50 year-old male came in for consult of a 3 month history of painless jaundice associated withweight loss. Labs showed elevated CA 19-9. What would be the expected liver function test of thispatient?
a. Low ALT, High AST, Low Alk phosb. Normal ALT, Normal AST, Normal Alk phosc. High ALT, Low AST, Low Alk phosd. High ALT, High AST, High Alk phos
During the feedback, it was emphasized that the liver function test of someone with elevated CA 19-9(with cholangiocarcinoma) may have normal or minimally elevated Aminotransferases (AST, ALT),however ALP is always elevated since it rises with bilirubin, thus the best answer is D.
Cholangiocarcinoma- most typically presents as painless jaundice, often with pruritus or weight loss, andacholic stools. Serologic tumor markers appear to be nonspecific, but CEA, CA 19-9, and CA-125 are oftenelevated in CCC patients and are useful for following response to therapy. HPIM 17th ed. Chapter 88. Tumors of the Liver and Biliary Tree
73. A 35 year old female patient consulted you for jaundice 3 days ago. She is back at your clinic withthe following test results: AST 1232 mmol/L, ALT 1889 mmol/L. You expect to find these results in thefollowing conditions EXCEPT:
a. Drugsb. Acute Viral hepatitisc. Hypotensiond. Choledocholithiasis
Striking elevationsi.e., aminotransferases > 1000 U/Loccur almost exclusively in disorders associatedwith extensive hepatocellular injury such as (1) viral hepatitis, (2) ischemic liver injury (prolongedhypotension or acute heart failure), or (3) toxin- or drug-induced liver injury. HPIM 17th ed. Chapter 296 Evaluation of Liver Function
74. A 26 year old female came in at the OPD for her complaint of an anterior neck mass not associatedwith any symptoms. You decided to do an FNAB which showed papillary thyroid cancer. Several work upsdone showed multiple lung masses. What would be her stage?
Stage II for those <45 is any T, any N, basta may mets (M1).
- HPIM 17th ed. Chapter 335. Disorders of the Thyroid Gland
75. What is the hallmark of proliferative diabetic retinopathy?a. Blot hemorrhageb. Macular edemac. Neovascularizationd. Retinal microaneurysms
The appearance of neovascularization in response to retinal hypoxia is the hallmark of proliferativediabetic retinopathy. These newly formed vessels appear near the optic nerve and/or macula and ruptureeasily, leading to vitreous hemorrhage, fibrosis, and ultimately retinal detachment.
HPIM 17th
ed. Chapter 338 Diabetes Mellitus
76. A 33-year-old female consults you for dysuria of 1 week duration associated with frequencyoccasionally with vaginal discharge. She has already been treated with antibiotics for urinary tract infection thrice in the past 2 months for the same symptoms. Which of the following conditions shouldyou consider in this patient?
a. Acute bacterial cystitisb. Acute urethritis c. Acute pyelonephritisd. Acute urinary tract infection
Cystitis: Patients with cystitis usually report dysuria, frequency, urgency, and suprapubic pain. If agenital lesion or a vaginal discharge is evident, especially in conjunction with <105 bacteria per mL on
urine culture, then pathogens that may cause urethritis, vaginitis, or cervicitis (e.g., C. trachomatis, N.gonorrhoeae, Trichomonas, Candida, and HSV) should be considered.Urethritis: Of women with acute dysuria, frequency, and pyuria, ~30% have midstream urine cultureswith either no growth or insignificant bacterial growth. Clinically, these women cannot always be readilydistinguished from those with cystitis Chlamydial or gonococcal infection should be suspected in womenwith a gradual onset of illness, no hematuria, no suprapubic pain, and >7 days of symptoms. Theadditional history of a recent sex-partner change, especially if the partner has recently had chlamydial orgonococcal urethritis, should heighten the suspicion of a sexually transmitted infection, as should thefinding of mucopurulent cervicitis
77. A 45 y.o. patient came to the OPD with symptom of weight loss. He also presented withtachyarrhythmia and easy fatigability. What would you request to confirm your most likely impression?
a. Fasting blood glucoseb. Thyroid stimulating hormone
c. Complete blood count d. 2D-echocardiogram
Thyrotoxicosis may cause unexplained weight loss, despite enhanced appetite, due to the increasedmetabolic rate. Other prominent features include hyperactivity, nervousness, and irritability, ultimatelyleading to a sense of easy fatigability in some. The most common cardiovascular manifestation issinus tachycardia, often associated with palpitations, occasionally caused by supraventriculartachycardia.- HPIM 17th ed. Chapter 335. Disorders of the Thyroid Gland
78. Hepatitis B virus can be acquired through the following mode of transmission EXCEPT:a. Sexual intercourseb. Blood contamination
c. Oro-fecal contamination d. Maternal transmission via vaginal delivery
Transmission HBV
Fecal-oral
Percutaneous +++
Perinatal +++
Sexual ++
- HPIM 17th ed, Chapter 298 Acute Viral Hepatitis > Table 298.2 Clinical and Epidemiologic Features of Viral Hepatitis
79. Estrogen replacement therapy has been found to be beneficial for:a. Cognitive function
b. Sexual desiresc. Osteoporosis d. Cardiovascular disease
A large body of clinical trial data indicates that various types of estrogens reduce bone turnover,prevent bone loss, and induce small increases in bone mass of the spine, hip, and total body. HPIM 17th ed. Chapter 348 Osteoporosis
80. Your classmate tells you that he was absent for the past 3 days because he had a high grade fever. You notice that he has generalized rashes so you do a Tourniquet test, which turned out positive. Hesays he is worried because he had episodes of epistaxis this morning. What would you do next?
a. Reassure your classmateb. Advise CBC monitoring every 12 hours on OPD basis
c. Tell him to proceed to the ER immediately.d. Request for further tests to confirm diagnosis.
Dengue HF is identified by the detection of bleeding tendencies (tourniquet test, petechiae) or overt bleeding in the absence of underlying causes such as preexisting gastrointestinal lesions. We want toprevent Dengue shock syndrome, which is usually accompanied by hemorrhagic signs, is much moreserious and results from increased vascular permeability leading to shock. HPIM 17th ed. Chapter 189Infections Caused by Arthropod- and Rodent-Borne Viruses
81. What is the most effective means of controlling allergic rhinitis?a. Allergen avoidanceb. Oral anti-histaminesc. Intranasal steroidsd. Mast cell stabilizer
Nasal corticosteroid sprays are the most effective treatment for allergic rhinitis.
Although allergen avoidance helps, the question was about control.
82. What is the most dreaded complication of warfarin therapy?a. Allergic reactionb. Bleedingc. Hepatotoxicityd. GI disturbances
Warfarin may cause severe bleeding that can be life-threatening and even cause death.
83. A 19 year old male student was brought to your clinic for sudden onset abdominal pain which startedon the epigastric area and is now localized in the right lower quadrant in the abdomen. Your physicalexamination revealed direct epigastric tenderness with guarding and generalized rebound tenderness.What is the next step in managing this patient?
a. Start the patient on acid suppressive agents.b. Refer the patient for emergency surgeryc. Advise the patient to increase dietary fiberd. Observe and reassure
Patient probably has appendicitis. The goal is to remove an infected appendix before it breaks open(ruptures).
84. A 55 year old male came to your clinic complaining of recurrent retrosternal chest pain usuallyoccurring in the early morning, does not radiate to either arm and is worse on lying down. He denies anychest pain or dyspnea on exertion but notes similar pain after drinking a few beers or sodas and aftereating spicy food. What is the most likely diagnosis?
a. Stable anginab. Esophageal refluxc. Aortic dissectiond. Acute pericarditis
Because of burning pain in the chest which was increased by bending, stooping, lying down, or eating.
85. A 43 year old obese woman consults you for on and off abdominal pain of 1 month duration,described as crampy, usually occurring after meals. She has no other associated symptoms. Which of thefollowing diagnostic tests would you order?
a. hepatobiliary ultrasoundb. abdominal CT scanc. serum lipased. serum bilirubin
Patient likely has biliary tree pathology. Ultrasound is better at visualizing the hepatobiliary tree (if there
are stones) than CT scan (according to Dr. Palileo)
86. A 23 year old female arrives at your clinic with severe right lower quadrant abdominal pain, suddenonset. Her last menstrual period was 5 weeks ago. On physical examination, she is tachycardic,tachypneic, and pale, with generalized direct and rebound tenderness over her abdomen. Which of thefollowing conditions should you primarily consider?
a. Acute Calculous Cholecystitisb. Ruptured ectopic pregnancyc. Acute Gastroenteritis
d. Renal colic from nephrolithiasisSymptoms and Signs of ectopic pregnancy
1. Pain. Pelvic and abdominal pain are reported by 95 percent of women with tubal pregnancy.2. Abnormal bleeding. Amenorrhea with some degree of vaginal spotting or bleeding is reported by
60 to 80 percent of women with tubal pregnancy.3. Abdominal and pelvic tenderness. With rupture, exquisite tenderness during abdominal and
vaginal examination is demonstrable.4. Uterine changes. Although minimal early, later the uterus may be pushed to one side by an
ectopic mass.5. Vital signs. Birkhahn and colleagues (2003) noted that in 25 women with ruptured ectopic
pregnancy, the majority on presentation had a heart rate of less than 100 beats per minute and asystolic blood pressure greater than 100 mm Hg.
- Williams Obstetrics, 23rd ed. Chapter 10. Ectopic Pregnancy
87. Your 30-year-old cousin asks your advice regarding an executive check up because she is gettingmarried and plans to get pregnant soon after. She is generally healthy, has never been hospitalized, andhas no known drug or food allergies. Her father is diabetic, and her mother has hypertension. She hasbeen smoking 3-5 cigarettes daily for the past 10 years and drinks wine on occasion. Based on thePhilippine Guidelines on Periodic Health Examinations, you would recommend the following examinationsEXCEPT
a. Fasting blood glucoseb. Total cholesterolc. Chest radiographyd. Mammography
PHEX
88. She also asks your advice regarding what vaccinations she needs prior to getting pregnant. What would you advise her?
a. A complete course of HPV vaccination is recommended for all women who are sexually active.b. Hepatitis A vaccination is recommended prior to pregnancy for all women of childbearing age.c. Tetanus toxoid vaccine should be administered to pregnant women during the first trimester.d. Vaccination against Varicella should not be given to women who might get pregnant
within 4 weeks of receiving the vaccine.Before PregnancyOf particular importance are:
y Tdap (tetanus, diphtheria, pertussis) this is important for preventing pertussis (whoopingcough). It should be given in place of Td vaccine, when tetanus protection is indicated
y MMRy Varicella
y Influenza- especially important if your patient might be pregnant during flu season, but recommended for all adults
y Hep B, if indicatedLive vaccines (including MMR and varicella) should be given a month or more before pregnancy.Inactivated vaccines can be given before or during pregnancy, as needed.
* HPV recommended for F from 11-26 years of age. More research is needed about HPV vaccine andpregnancy. For now, pregnant women should wait until their pregnancy is over before getting thevaccine.
89. A 20 year-old female came to your clinic for a check-up prior to starting classes the followingsemester. She is apparently healthy with no known comorbidities. Past medical history and family medicalhistory are unremarkable. She denies smoking or alcohol use but admits to unprotected sexualintercourse with 3 promiscuous partners in the last 3 years. She is a nursing student and will be starting
to work in the hospital the following month. You would recommend the following EXCEPT:a. Pap smearb. HIV screeningc. Hepatitis B vaccined. Pneumonococcal vaccine
90. The treatment goals for adults with diabetes include which of the following?a. Preprandial capillary glucose 140-160 mg/dlb. A1C < 7 c. Peak postprandial capillary plasma glucose < 200 mg/dld. Blood pressure < 120/80
- ADA 2010
91. A 52-year old woman consults at the outpatient clinic for progressive weakness. She noticed that symptoms began about3 months ago, described as a feeling of being tired easily. She alsocomplained of blurring of vision, gradual loss of weight, thirst, and frequent urination. She has threechildren, the last of whom was delivered via Caesarean section because of cephalopelvicdisproportion. What laboratory test will help you confirm your initial impression?a. Chest radiographb. Fasting blood glucosec. Thyroid stimulating hormoned. Electrocardiography
CS due to CPD may have be a history of GDM or delivery of baby >4 kg (>9 lb), which is a risk factor forT2DM. Symptoms of hyperglycemia: polyuria, polydipsia, weight loss, fatigue, weakness, blurry vision, frequent superficial infections, and slow healing of skin lesions after minor trauma. Metabolic derangements relatemostly to hyperglycemia (osmotic diuresis, reduced glucose entry into muscle) and to the catabolic stateof the patient (urinary loss of glucose and calories, muscle breakdown due to protein degradation anddecreased protein synthesis). Blurred vision results from changes in the water content of the lens andresolves as the hyperglycemia is controlled. (HPIM 17th ed. Chapter 338 Diabetes Mellitus)
92. A 25 year old female consults at the OPD for a 1-month history of non-productive cough usualyoccurring early in the morning. She denies any episode of fever, and claims that several chest x-raysdone in the past 4 weeks have all been normal. She does not smoke. Chest examination is normal.What is the next step in the management of this patient?a. Treat with an anti-histamine-decongestant combinationb. Treat with a proton-pump inhibitor
c. Refer for bronchoscopyd. Request for chest CT scan
Hallmarks of allergic rhinitis: Episodic rhinorrhea, sneezing, obstruction of the nasal passages withlacrimation, and pruritus of the conjunctiva, nasal mucosa, and oropharynx All occurring in temporalrelationship to allergen exposure. Although commonly seasonal due to elicitation by airborne pollens, it can be perennial in an environment of chronic exposure (HPIM 17th ed. Chapter 311 Allergies, Anaphylaxis, and Systemic Mastocytosis)
93. A 55 year old female consults you for gradual abdominal enlargement. She reports that she limits herdaily activities because she easily tires even with light chores and has lost her appetite. There was noorthopnea or PND, but her duaghter noted that seemed to have gained weight in the past fewweeks. On physical examination, you note that she is lethargic with heart rate of 55/min. There is nofluid wave on abdominal examination, but there was bilateral non-pitting edema on both legs. What test would you order to confirm your diagnosis?
a. Holoabdominal ultrasoundb. Thyroid stimulating hormonec. Colonoscopyd. Fasting blood glucose
Table 335-5 Signs and Symptoms of Hypothyroidism (Descending Order of Frequency)
Symptoms Tiredness, weaknessDry skinFeeling coldHair lossDifficulty concentrating and poor memory
ConstipationWeight gain with poor appetiteDyspneaHoarse voiceMenorrhagia (later oligomenorrhea or amenorrhea)ParesthesiaImpaired hearing
(HPIM 17th ed. Chapter 335. Disorders of the Thyroid Gland)
94. Which of the following conditions wil present with red blood cell casts on urinalysis?a. Poststreptococcal glomerulonephritisb. Acute pyelonephritisc. Renal tubular acidosisd. Nephrolithiasis
In general, RBC casts indicate glomerular injury or, less often, acute tubulointerstitial nephritis. (HPIM17th ed. Chapter 273 Acute Renal Failure).
95. Which of the following examinations is not recommended for initial testing in patients presenting withinvoluntary weight loss?a. Chest radiographb. Abdominal ultrasound c. Fasting blood glucosed. Complete blood count
Table 41-2 Screening for Evaluation of InvoluntaryWeight Loss
96. A 28 year old female consults your clinic for shortness of breath. She said symptoms started about amonth ago, associated with frequent productive cough, anorexia, low-grade fever and weight loss.Physical examination revealed a respiratory rate of 22/min, weight of 40 kg, and height of 5 ft. The rest of the PE was unremarkable. Chest x-ray showed infiltrates and areas of lucency surrounded by reticulardensities on the R upper lobe. A pre-employment chest X-ray taken 6 months prior was normal. What isyour primary diagnosis?
a. Community-acquired pneumoniab. Atypical pneumoniac. Pulmonary tuberculosisd. Bronchogenic carcinoma
Early in the course of disease, symptoms and signs are often nonspecific and insidious, consisting mainly
of fever and night sweats, weight loss, anorexia, general malaise, and weakness. However, in themajority of cases, cough eventually developsoften initially nonproductive and subsequentlyaccompanied by the production of purulent sputum, sometimes with blood streaking. Essentially normalPE further strengthens diagnosis, and rules out CAP (no crackles/fever, even if Pt is tachypneic).Radiographically speaking, Although the "classic" picture is that of upper-lobe disease with infiltrates andcavities, virtually any radiographic patternfrom a normal film or a solitary pulmonary nodule to diffusealveolar infiltrates in a patient with ARDSmay be seen. HPIM 17th ed. Chapter 158 Tuberculosis
97. A 26 year old female consults at the OPD for recurrent productive cough. The cough is morecommon in the early morning hours and is associated with chest tightness but no fever. She iscomfortable, not in distress with no retractions. Chest auscultation reveals inspiratory and expiratoryrhonchi at the bases but good air entry. What test will you order to confirm your diagnosis?
a. Chest x-rayb. Skin prick test c. Methacholine challenged. Spirometry
The diagnosis of asthma is usually apparent from the symptoms of variable and intermittent airwaysobstruction, but is usually confirmed by objective measurements of lung function Simple spirometryconfirms airflow limitation with a reduced FEV1, FEV1 /FVC ratio, and PEF. HPIM 17th ed. Chapter 248 Asthma
98. A 78 year old female was brought to your clinic by her daughter for a check-up. She was almost hit by a bicycle this morning while crossing the street. She has no known comorbidities and walks to thechurch 4 blocks away from her home without difficulty. She has no vices and no previous hospitalizations.BP is 110/70, BMI is 24 and the physical examination was normal. You would recommend the followingfor this patient except
a. VA testingb. Audiometryc. Functional Reachd. Bone densitometry
PHEX
99. A 24 year old female came to the OPD complaining of chest pain. The pain is on the right side but sometimes on the left, described as sharp, lasting only few minutes. However, the pain sometimes
persists as a dull ache lasting several hours. She has no other illnesses, is a non-smoker and has nofamily history of heart disease. Physical examination is normal except for mild tenderness on palpation of the right anterior chest. What is the most likely diagnosis?
a. Costochondritisb. Chronic stable anginac. Herpes zoster
d. Unstable angina Costochondral and chondrosternal syndromes are the most common causes of anterior chest musculoskeletal pain. ... The pain of such syndromes is usually fleeting and sharp, but some patientsexperience a dull ache that lasts for hours. Direct pressure on the chondrosternal and costochondral junctions may reproduce the pain from these and other musculoskeletal syndromes.- HPIM 17th ed.Chapter 13 Chest Discomfort
100. A 40 year-old female came to your clinic for a routine check-up. She has not seen a doctor in severalyears and denies any symptoms or co-morbidities. She is a non-smoker and denies alcohol intake. Herfamily history is unremarkable. BP is 120/80 and BMI is 24. The rest of the physical exam isunremarkable. What would you recommend for this patient?
