Medicine 6th Year Exam 5-5-2020

Medicine 6th year exam , 5-5- 2020 ** Endocrinology : 1) patient found to have 2 cm nodule on left side , TSH is 10 , thyroglobulin is increased , which one of the following is the least likely cause ? 1. MTC *********************************** 2. benign thyroid adenoma *** 3. papillary thyroid CA 4. follicular thyroid CA 5. anaplastic CA .... 2) pregnant in 22 weeks GA patient with dizziness , fatigue , tremor , paplitation , soft bruit is heared over the left thyroid ,TSH is .04 (0.5-5.0) , T4 23 (9-20) , the MANS : 1. radioiodine ablation 2. carbimazole *** 3. observe then repeat TFT in 4 weeks 4. 5. .... 3) patient underwent transphenoidal surgery for tumor removal , the MANS to assess his thyroid function is : 1. measure TSH 2. measure T4 *** 3. measure T3 4. measure alpha-subunit of TSH 5. measure thyroglobulin .... 4) patient with DM , HTN , hypercholestrolemia , he is on gliplizide , metformin , enalpril and simvastatin . if he developed B12 deficiency due to drug , it will be most likely due to : 1. gliplizide 2. metformin *** 3. enalapril 4. simvastatin 5. .... 5) a cushing syndrome patient , which of the following will confirm adrenal tumor : 1. low ACTH *** 2. Increased urinary cortisol 3. 4. 5. .... 6) diabetic patient on metformin and glimeperide , developed sweating and confusion , his measured glucose was 25mg/dl , of the following the least likely to be a cause of his decreased glucose is : 1. acute kidney injury 2. poor oral intake 3. drug overdose 4. adrenal insufficiency 5. pheochromcytoma *** .... 7) diabetic patient with ED , you decided to start him on Viagra, what drug will be contraindicated to be given with it : 1. Aspirin 2. hydrochlorathiazide 3. simvastatin 4. isosorbide dinitrate *** 5. .... 8) patient with episodic HTN , headaches , palpitation , sweating , for his HTN , which of the one of the following drugs shouldn't be given for this patient : 1. Propanolol *** 2. ACE 3. thiazide 4. alpha blocker 5. .... 9)female patient presented with hypoglycemia SxS and episodic sweating , she noticed weight gain lately , FBG : 40 , MANS : 1. 24 ECG 2. 72 fasting glucose 3. Fasting insulin & C-peptide *** 4. ACTH stimulation test 5. .... 10) 70 year old Female presented with back pain , constipation , and abdominal pain , decreased urinary frequency , her PTH was high , CA high, PO4 low , the most likely diagnosis : 1. multiple myeloma 2. primary hyperparathyroidism*** 3. Paget's disease 4. osteomalacia 5. ** Nephro : (note for 4th year : the Qs were very hard, it's unlikely that you will have them in your exam .. good luck) ..... 1)40 year old male patient known to have alcoholic liver cirrhosis. He is maintained on spironolocatone 100mg daily and furosemide 40mg daily. He has been sober since 4 months. He is being discussed as a candidate for liver transplantation. He notes that he is compliant with his drug regimen, but without any improvement. He has long standing ascites which has progressed over this period of time. He notes increased lower limb swelling and gaining of 3 kg in the past month. Which of the following is the most appropriate next step in the management of this patient? Na: 136 ?? mEq/L K: 3.9 mE/L Cr: 0.6 mg/dl Urine Na 126 mEq/L Urine K 36 mEq/L (a) Fluid restriction of <1L/day *** (b) Admit for albumin infusion (c) Increase dose of spironolactone (d) Advise dietary sodium restriction *** ........... 2)70 year old male patient with history of DM, HT and CKD stage 3 underwent CABG for 2 vessel disease yesterday. 1 week ago he presented with angina and underwent coronary angiography. His surgery today was uneventful. Post-operatively he required mechanical ventilation and administration of vasopressors. He total urine output declined to 300ml/24 hours. His total input was estimated to be positive 10L even though he is on furosemide. On physical examination he had bilateral dependent edema. HR 74 bpm and BP 94/60 mmHg. What is the most appropriate next step to assess the cause of his acute kidney injury? (a) Fractional excretion of sodium *** (b) Adminstration of 1.5% of albumin (c) Urine sediment and cellular/cast study *** (d) Determination of complement (C3) level (e) Measure central venous pressure ....... 3) Patient is referred from the nephrology clinic and said to have nephritic syndrome and his renal biopsy shows (AA) amyloid plaques. Which of the following will most likely associated this presentation? (a) SLE (b) Multiple Myeloma (c) Monoclonal gammopathy of unknown significance (d) RA*** (e) ....... 4) case of Aspirin overdose (Resp. alkalosis , high level of aspirin and hemodyamically stable ) , MANS 1. acetazolamide 2. alkalinization with NaHCO3 *** 3.hemodiaysis ........ 5) 70 year old female hypertensive , had gastroenteritis , admitted with suspicion of prerenal azotemia , after 2 days se devloped bradycardia with regular rhythm and no ECG abnormalities and hypotension , patient is on bb and diuretic , what is the best treatment ( BB toxicity ) : 1. 5% dextrose & insulin 2. IV glucagon *** 3. IV MgSO4 4. IV NahCO3 5. IV Ca gluconate ......... 6) untreated Hep C patient presented with isolated persistent proteinuria , what is the most likely association : 1. MPGN type 1 2. PAN 3. Cryoglobulinemia *** 4. MCD 5. ......... 7) female patient with met alkalosis (PH not shown , but HCO3 >30) , patient has low K+ and low Cl , on urine patient has Cl<10 , what is the most likely diagnosis 1. surreptitious vomiting *** 2. gittelman syndrome 3. diuretic abuse 4. barter 5. primary hyperaldosteronism .......... 8) female in her 30s presented with HTN (very high) , metabolic alkalosis , low K+ , nl Na+ , on PE CVS and RS were normal , and she does have strong and intact pulses , most likely diagnosis : 1. primary hyperaldosteronism 2. Fibromuscular dysplasia *** 3. 4. 5. ......... 9) patient in his 30s bilateral cystic kidney with 2 distinctive masses , his father died of BRAIN TUMOR , he does have family history of father's 2 sister of similar problem one of them has also hearing loss , what is your diagnosis 1. ADPCK *** 2. ARPCK 3. VHL *** 4. Tuberous sclerosis 5. ........ 10) elderly male was bought by his wife to ED after falling , he has neurological Sxs (confusion , agitation , drowsiness) , his Na was 118 , MANS : 1. desmopressin analog (tolvaptan) 2. 100 mg bolus of 3% hypertonic Na *** 3. 4. 5. ....... 11) all of the following will cause renal glycosuria except : 1. Addison's *** 2. pregnancy 3. Fanconi 4. lead posioning 5. cystinosis ...... 12) 31 y/o female with bloody diarrhea, went to a party 3 days ago .. Diarrhea started today .. Also she has hematuria .. Her platelet count was 78k (hus) Best thing to confirm diagnosis: 1. Rectal exam 2. look for schistocytes in blood film ** 3. ..... Rheumatology : 1- 50 year-old female patient presented with proximal muscle weakness, difficulty standing and climbing stairs, she also complained of shortness of breath when lying flat. On P/E, there is proximal weakness but her strength is preserved distally, cardiac exam revealed tachycardia, gallop rhythm, and displaced apical impulse. Which of the following antibodies is likely to be present in this patient: A) Anti-M2 B) Anti Jo C) Anti SRP D) Anti SSA E) Anti RNP-1 2- Female patient, diagnosed with diffuse SSc 2 years ago. She presented to the clinic complaining of headache and impaired visual acuity. On P/E, she has papilledema, her HR 88 bpm, BP 180/118 mmHg, neurological exam was normal. Which of the following is the most appropriate investigation: A) Head CT and then LP B) Urinary analysis and blood smear C) MRV with antiphospholipid antibodies D) MRA with HLA-B51 E) Temporal artery biopsy and steroids 3- 70 year-old female patient, complaining of painful proximal and distal interphalangeal joints for the last 2 years which has worsened in the last few months, she has mild tenderness on palpation. She also has osteoarthritis of the right knee that was diagnosed 1 year ago. Which would be your first treatment option? A) Paracetamol B) Diclofenac C) Prednisone D) Methotrexate E) Knee joint replacement 4A) B) C) D) Male patient with recurrent sinusitis, skin rash, nasal septal perforation. Dx? EGPA GPA Relapsing polychondritis SLE 5- Patient with lupus nephritis class IV, what would you give her in addition to steroids? A) Cyclophosphamide B) Cyclosporine C) Methotrexate D) Leflunomide E) Rituximab 6A) B) C) D) E) Which one of the following is not seen in Behcet’s disease? Scleritis Erythema nodosum Acneiform lesions Genital ulcers Oral ulcers 7- Patient presented with painful acute swelling and redness in the right big toe, her past medical history is significant for hypertension, diabetes, and bleeding peptic ulcer. What would be your management for his painful joint? A) Diclofenac B) Colchicine C) Prednisone D) Allopurinol E) Rasburicase 8- A female patient complaining of xerostomia and xerophthalmia, she also has anti-SSA and anti-SSB. Which one of the following is a risk that this patient might develop in the future? A) Sepsis B) Lymphoma C) Interstitial lung disease D) Renal failure E) Colon cancer 9- Which of the following is likely to have a positive HLA-B27? A) 25 year-old male complaining of early morning back pain that improves with exercise B) 72 year-old male with chronic back pain C) 67 year-old female with painful knee joints that worsens with activity D) 62 year-old female with swollen PIPs and MCPs E) 19 year-old female with photosensitive rash on her cheeks 10- All of the following are features of reactive arthritis except A) Conjunctivitis B) Penile ulcers C) Keratoderma blenorrhagicum D) Tenosynovitis E) Circinate balanitis Infectious : 1- A female who went to a restaurant and presented with vomiting for 5 hours, Dx : Staph? 2- True about Hepatitis B vaccine > protective against hepatitis D 3- All of the following are considered +ve PPD tests except: (a) HIV patient with 3mm induration*** (b) Healthy person with 17mm induration (c) Patient with household contact of TB with 7mm induration (d) Patient with renal transplant with 12mm induration (e) Patient with prior negative PPD test with 13mm induration*** (both A & E work) 4- 70 year old patient started complaining of cough, SOB and weakness of 3 days duration. He was suspected to have been infection with H1N1 infleunza A strain. All of the following are applicable except? (a) He should be given oseltamivir (b) He should be started on antibiotics (c) His household contacts should be started on oseltamivir (d) H1N1 diagnosis can be confirmed with nasopharyngeal swab PCR (Note: oseltamivir is used only if <48 hours since exposure). 5- Most serious type of malaria; P.falciparum 6- True about brucellosis: Add gentamicin if resistant 7- HIV pt CD4 < 150: Give Cotrimoxazole prophylaxis against PCP 8- Disorder of phagocytosis? chronic granulomatous disease 9- True about rubella :transmission is most commonly in the first month of gestational age more than 90 % ** Cardiology : 1- 30 year old female presents with new onset chest pain that is not relieved by rest. She also complains of SOB and fatigability. On physical examination she is febirle (38.4C), has an S3 and bilateral basal crackles. CXR shows cardiomegaly and bilateral pleural effusions are present. Echocardiography shows a LVEF of 30%, global dyskinesia and a gallop rhythm. There are no valvular abnormalities. Which of the following is indicated in this patient? (a) Methylprednisolone (b) Captopril and carvedilol*** (c) Vancomycin and ceftriaxone 2- Pt presented with dizziness, pulse rate 35, blood pressure 70/50. He is on b-blocker and hydrochlorothiazide. ECG shows sinus bradycardia and no ST o T wave changes. Glucose:95. What to give him: 1- IV glucagon** (bblocker antidote) 2- IV calcium gluconate 3- dextose with insulin 4- IV magnesium sulfate 3- ECG showing ventricular tachcardia. Pt presented with palpitation then suddenly collapse while talking to him. What to do: 1- defibrillation** 2synchronized cadioversion 3- IV digoxen 4- IV adenosine Pt presented with palpitaton, heart rate: 160. ECG showing SVT. Pt is hemodynamically stable (no chest pain, SOB, hypotension, confusion). What to do 1- IV adenosine** 2- IV digoxen 3- defibrillation 4synchronized cardioversion Pt presented with chest pain stabbing in nature increased by laying flat and relieved by leening forward. ECG showing diffuse ST. Which of the following is not correct about this pain: Steroids is rthe first line therapy Pt after 3 days of acute anterior MI. Presented with chest pain and dysnea. PO2 80% not corrected by 100% O2. On exan: systolic murmur with thrill, pulmonary crackles. What to do: 1- VSD repair** 2- mitral valve repair Female 30 years presented 6 weeks after giving birth with progressive SOB, signs and symptoms of heart failure (S3, crackles...) dx: Preipartum cardiomopathy Pts presented with palpitations, ECG showing wide QRS, pulse irregularly irregular, pt is stable hemodynamically. Drug of choice Procainamide**(WPW syndrome) Which of the following causes short QT: Digoxen 4- 5- 6- 7- 8- 91011- 12- 13- 14- 15- Which of he following is contraindicated wth sildenafil: Isosorbide dinitrate Pt pesented with chest pain. He has hx of lymphoma treated. HR: 120. Otherwise PE normal. What to do: pericardiocentesis** Pt presented with severe epigastric abdominal pain with nausea, abdominal exam showing tenderness but no gaurding or other signs of peritonitis. Pulse irregularly irregular. What to do: CT angio** (mesentric ischemia) Which of the following does not cause severe acute chest pain: Papillary muscle dysfunction Pt presented with chest pain consistent with MI, ECG showing ST depression o cardiac markers are positive. What not to give to this pt: Thrombolytics** Pt presented with STEMI. What not to do? Wait cardiac biomarkers to do PCI ** GI 1. Elevated liver enzymes + dm + elevated ferritin . Most appropriate next step ? - Liver bx - transferrin saturation ** 2. Case of bloody diarrhea after coming back from a journey to europe ,he also complains of right knee pain and swelling , dx ? - nongonococcal arthritis - campylobacter infection ** 3. Young male with chronic bloody diarrhea + abdominal pain + RLQ mass + anal skin tags ? Dx? - crohn's ** - UC - chronic pancreatitis 4. Chronic diarrhea + microcytic anemia (mcv 77) + low ferritin +low b12 +low folate , serum antibody you will most likely find ? - anti ttg** -Anti intrinsic factor 5. A patient diagnosed to have UC 10years ago in remession with drugs , regarding the screening for colon cancer which is true : - every year ** 6. Known case of UC presented with acute flare , we use all of the following except : - LMWH - azathioprone * - iv steroid - oral mezalamine - mesalamine enema 7. Chronic diarrhea with wt loss in chronic alcohol abuser , previous hx of terminal ileum resection due to acute appendicitis with rupture , most appropriate next step ? -fecal elastase * -endoscopic capsule 8.young patient with chronic diarrhea and anal skin tags , next step? - colonoscopy 9. Dysphagia for both solid and liquids for 18 months , dx? - achalasia** - esophageal cancer -esophageal webs - trachial cancer 10. Young female , obese , ocp , presented with ascitis , which of the following if presents will support the diagnosis of Budd chiari syndrome ? -liver tenderness ** - ascitis protein 35 g/L 11. Female with elevated liver enzyme and ferritin level 400 , dx? - NASH - hemochromatosis ** hemato : 1-a case describing a pt developed fever, confusion, renal insufficiency ,thrombocytopenia and anemia (ttp), whats wrong: -the pt will need plasmapheresis -the pt will require hemodialysis because he's going to develop renal failure soon ** 2-31 y/o female with bloody diarrhea, went to a party 3 days ago .. Diarrhea started today .. Also she has hematuria .. Her platelet count was 78k (hus) Best thing to confirm diagnosis: -Rectal exam - look for schistocytes in blood film** 3- a case describing pt with normal platelet count,normal pt,normal ptt and abnormal aggregation of platelets with adp: glansman thropasthenia** 4-Patient with thalasaemia was started on chelation therapy , which of the following is true : - Chelation therapy cannot be started before age of 7 years - Chelation therapy is given with vit c bacause it increases iron secretion -before giving therapy , if organ damage was established it cannot be reversed when iron chelation therapy is started -deferoxamime is first line of ttt -oral defrasirox is first line of ttt 5-a jordanian soldier was given anti malarial prophylaxis, then he developed symptoms of anemia, on blood smear was found to have heinz bodies, whats the most likely dx : -Heridetary spherocytosis -G6PD deficiency** 6- a pt with hb of 14.5, platelets= >800,000 , wbcs: 54,000 , neutrophils 80%, basophils: 3%, what is the most likely dx -polycythemia vera -CML, chronic phase*** -CML, blastic phase -essential thrombocytosis 7- what is the most CURABLE non hodgkin lymphoma: -follicular -diffuse large b cell*** -burkitts 8- a pt was diagnosed with lymphocyte-depleted hodgkin lymphoma, all of the following are part of staging except: -serum B2 microglobulin -brain ct ** 9- a female pt with hx of recurrent abortions and 2 previous episodes of DVT and current episode of PE, all of the following are true except: -her aPTT will correct in mixing study 10- a case describing pt with bone marrow findings of fibrosis and teardrop cells: -idiopathic myelofibrosis 11- a pt with chronic low back pain of 6 months duration, his prostate is enlarged and his prostate specific antigen is elevated, he's having pancytopenia, his bone marrow biopsy revealed abnormal dysplastic cells, whats the cause of his pancytopenia: -infiltration of the bone marrow by metastatic prostate cancer -myelodysplastic syndrome*** 12- a pt developed hit after using heparin, which drug can't be used for anticoagulation: -argatroban -LMWH** 13- One of the following is a mutation thrombophilia causing VTE: Protein C def Protein A def Anticardiolipin Lupus anticoagulant Factor V leiden** ** Respiratory : 1- a patient with ARDS, not likely to find : -normal p CO2 -increased left atrial pressure ** -bilat infiltrates 2- compliance curve (restrictive lung disease), all the following are correct except : * a- decrease FEV1 /FVC b- dec FEV1 c- 3- one of the following enhance lifestyle a- pulmonary rehabilitation b- salmetrol c- albetrol + tiotropium d- long term oxygen therapy . 4- COPD patient with pneumonia , given numbers (atm 680 ) to calculate A-a gradient , the mechanism of pulmonary failure is : hypoventilation + v/q mismatch 5- Flow-volume loop , (a) represents which of the following : answer : peak expiratory flow . 6- The best predictor for sepsis in pneumonia : Procalcitonin . 7- Asthmatic patient , his regular Pa CO2 38 one of the following represents the most severe asthma : PaCO2 43 ** neuro (6) **psychiatry (3) ** Derma (3)