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End of Rotation
Exam
August 2005
Each of the following items has only one correct answer. Read all statements and choices and select the correct answer by clearly marking the letter in front of your choice.
1.-Falls are one of the most common geriatric syndromes threatening the independence of the growing population of older persons. Between 30 and 40 percent of community-dwelling adults older than 65 years fall each year. Which of the following statements IS NOT true?
2.-A 26-year-old woman is admitted to the hospital because of palpitations and weakness. She is found to have profound anemia with a level of hemoglobin of 6.9 gm/dl. She denies menstrual irregularities and her last menstrual period occurred 3 weeks prior to admission. She denies chest pain but has been noted to have shortness of breath on exertion. On examination, she appears chronically ill and pale. Her temperature is 100.4 deg F (38.0 deg C) and her pulse is 102 reg. An electrocardiogram is obtained. Which of the following is correct?
3.-A 56-year-old woman presents to your office because her insurance plan changed and you were recommended by her new health plan. She is postmenopausal and has had diabetes mellitus diagnosed since 3 years ago. Currently she is taking glyburide 5 mg daily. She has no history of kidney disease, hypertension, stroke, or myocardial infarction. She does not smoke or drink alcohol routinely. She brings copies of previous medical records showing a 32 mg albumin per mg creatinine, 2 months prior. On examination she appears to be comfortable and in no acute distress. Her weight is 185 lbs (84 kg) and her height is 64 inches (162.6 cm). Her blood pressure supine is 145/95. The pulse is 80 regular. The respirations are 16 unlabored. Her general physical exam is unremarkable except for a loud S2, an S4 that does not increase with handgrip, and 0/0 ankle jerks. A screening chest film is obtained revealing a normal size heart a widened aorta and clear lung fields.
Assuming that you will evaluate her bone mineral density, gynecological exam, immunization status and mammography. Which of the following medications would NOT be indicated at this time?
4. A 42 year old man presents to the emergency department complaining of substernal chest pressure and dyspnea. He reports experiencing mild chest pain while walking his dog one day prior. On the day of entry into the ED he had sudden onset of chest pain, 10/10 lasting 2 hours. On further questioning, the patient is found to have a 60 pack-year history of smoking and an unknown family history because the patient was adopted.
On physical examination his pulse is 106 regular and the blood pressure is 140/90. Examination of the neck reveals no bruits and a 4 cm jugular venous distension. Chest exam reveals fine rales in both bases. Examination of the heart reveals a loud S4 and no murmur. EKG reveals ST-segment 2 mm elevation in lead III and 1 mm elevation in lead II plus ST-segment depression of 2 mm in lead I and lead aVL. The level CPK MB performed immediately on arrival is negative for injury. Which of the following statements best describes the recommended course of action?
5.-A 53-year-old woman presents to the emergency department with new onset of right-sided abdominal pain. She has a long history of hypertension controlled with an ACE inhibitor. The onset of the pain occurred 4 days prior to admission and since then the pain has increased in intensity and moved towards the lower quadrant. She denies multiple sexual partners or vaginal discharge. During the past day she has felt nauseated, however.
On examination she appears apprehensive and in mild to moderate pain. Her temperature is 98.2 deg F (36.8 deg C), the blood pressure is 140/80 and the pulse is 76 reg. Her chest exam reveals clear breath sounds. Auscultation of the heart reveals an S4 and a soft systolic murmur in the apex 2/6. There is exquisite tenderness in the right lower quadrant to palpation. The rectal exam reveals heme-negative stool and no tenderness elicited on cervical motion from the rectum. An EKG is obtained. Which of the following is INAPPROPRIATE NOW?
6. The Fetal Alcohol Syndrome Disorders (FASD) are characterized by all of the following except:
7. A 21-year-old woman presents to the office after a trip to Delaware where she has relatives complaining of cough, rhinorrhea and low-grade fever. She became ill about 2 weeks prior. She is a nature lover, loves to hike and is on Summer vacation from graduate work at the Marine Biology School of the Univ. of Miami near Key Biscayne. She is otherwise healthy. On examination, she has a temperature of 100.2 deg F (37.9 deg C). She has a slightly reddened oropharynx, and shotty lymph nodes. The chest is clear. The heart is normal. The abdomen is negative. The neurologic exam is also negative. The skin reveals an erythematous lesion shown below.
Which of the following courses of action is indicated?
8. A 63-year-old woman presents with history of postmenopausal vaginal bleeding for 2 weeks. She has not been on hormone replacement therapy. She is a known diabetic with a Glycohemoglobin of 7%. She is also hypertensive maintained on a combination drug, ACE inhibitor and Calcium channel blocker. Her family history is positive for colon cancer and she had had already two negative colonoscopies in the past 10 years. On physical examination she is found to have a weight of 170 lbs (77.2 kg) and 58 inches (147.3 cm) tall. Her BMI is 35.6 kg/m2. Her blood pressure is 130/80. The pulse is 65 regular. She is afebrile. The general physical examination is negative. Which of the following courses of action IS NOT INDICATED NOW?
9. A 72-year-old retired teacher presents for his annual physical examination. He has a history of diabetes controlled on diet alone (glycohemoglobin 6.8%) and mild hypertension. He gets up at nigh once per night on the average. His family history is negative except for a brother who was diagnosed with Hodgkin’s disease at age 60 and is doing well 15 years after treatment. His physical examination is unremarkable. The digital rectal exam reveals a 30-gram gland without nodules. The laboratory panel obtained reveals a normal urine analysis and a PSA level of 3.9 ng/ml.
Which of the following courses of action seems most appropriate?
10. A 50-year-old female geriatrician presents with hearing loss and episodes of vertigo. She also complains of tinnitus. This presentation is most consistent with:
The following clinical vignette refers to items 11 and 12.
A 94-year-old woman is brought to the Emergency Department by her daughter because of epigastric pain of 2 days duration. There is no history of vomiting but the patient has been noted to have dark diarrhea in the past 24 hours. On examination, her temperature is 99.4 deg F (37.4 deg C), the blood pressure is 100/60 and the pulse rate is 72 regular. She is in a fetal position, flexion contracted. The neck is supple to flexion. The chest exam is clear and hyperresonant. The cardiac auscultation reveals no murmur or gallop. The examination of the abdomen reveals left lower quadratant tenderness. The initial laboratory investigations reveal a WBC of 18,000 with 82% segmented neutrophils, 7% bands, and 6 % lymphocytes. The urine analysis reveals a specific gravity of 1.020 and negative glucose, acetone, nitrite and leukocyte esterase.
11. The initial serum chemistries reveal sodium of 142 mEq/L, potassium 4.2 mEq/L, chloride 106 mEq/L, bicarbonate 26 mEq/L, BUN 29 mg/dl, creatinine 1.1 mg/dl, and glucose 190 mg/dl. Which of the following intravenous fluids would be recommended?
12. A stool culture reveals normal flora and negative test for Clostridium difficile toxin. A CT of the abdomen is performed. You walk over to the Radiology Department and review the findings with the attending on duty. The aorta is ecstatic. The appendix is visualized. There is minimal small bowel ileus. The rectal mucosa is thickened measuring 2 cm. Intravenous contrast reveals normal vascularity and parenchymal enhacement. Nasogastric suction and peripheral alimentation are begun. Which of the following courses of action seems most appropriate?
13. A 45-year-old male presents with a 4-week history of recurrent headaches that awaken him nightly and last approximately one hour. He describes the headaches as a deep burning sensation centered behind the left orbit. He rates them as a “15” on a “10 point” pain scale. The headaches are associated with a sensation of heat and warmth in the face, unilateral nasal discharge, and redness of the eye. On examination his blood pressure is120/70 mm Hg, his pulse is 96 and regular, and neurological exam is normal. What is the most likely diagnosis?
14. A 45-year-old woman complains of a throbbing headache 3 to 4 times per month. She describes nausea, photophobia, and no relief with over the counter medications including acetaminophen and aspirin. She has had these headaches for 15 years and denies any focal neurologic symptoms. What is the most appropriate course of action for this patient?
15. A 54 year old male patient presents with a history of chronic tremor. Emotional stress has been shown to exacerbate the movement disorder and this has been evident during the recent pass of hurricane Katrina. Alcohol intake reduces it to the point that it is almost not noticeable. The most likely diagnosis is:
16.A 60-year-old male is evaluated for erectile dysfunction. His libido is normal and his physical examination is unremarkable. He requests sildenafil (Viagra). Which of the following medications would be contraindicated for use with sildenafil?
17. A 74-year-old man with benign prostatic hypertrophy (BPH) complains of increasing trouble urinating. Which of the following medications could contribute to the urinary retention in this patient?
18. A 40-year-old man comes into the emergency room complaining of chest pain. The patient suffers from End-Stage Renal Disease and is dependant on chronic hemodialysis. He has a past medical history of arterial hypertension, hyperlipidemia, and chronic obstructive lung disease. He has a strong history of cigarette smoking and cocaine abuse. His hemoglobin is 10.6 gram/dl. An EKG is performed. Which of the following statements is TRUE?
19. A 25-year-old gay male is evaluated for urethritis. Cultures are positive for gonorrhea and negative for Chlamydia. Of the following treatments, which is the most appropriate?
20. A 55-year-old male presents to your office with a complaint of symmetrical and bilateral finger and hand numbness. When his hands get cold they are painful and change color from white to blue to red. If he keeps his hands warm, he has no problems. Which of the following is the best treatment option for this patient?
21. A 39-year-old female presents with complaints of pain in her hands and knees. She has occasional swelling of knees and finger joints as well as morning stiffness. On exam she has swelling in the knees. The joints of her fingers display swelling and subcutaneous nodules over the PIP and MCP joints. What is the most likely diagnosis?
22. A 30-year-old male complains of lower back pain and stiffness that has been worsening over the past 2 years. The stiffness is worse in the morning, and it improves somewhat with anti-inflammatories and exercise. Palpation shows tenderness over the SI joints bilaterally, and also shows that the PSIS, sacral sulcus and ILA are all level. Lumbar spine exam reveals tenderness to palpation and decreased lordosis. The past medical history is negative except for chlamydial urethritis 10 years ago. Which of the following is the most likely diagnosis for this patient?
23. An 82-year-old woman is brought to the hospital by her daughter because of increasing shortness of breath for one week and recently vomiting. They deny fever, diarrhea, or dysuria. The patient has a long history of multiple medical problems including coronary artery disease, COPD, and hypertension. On examination, her temperature is 99.2 deg F (37.3 deg C), the pulse is 126 per minute, and the blood pressure is 113/69. The respiratory rate is 26 per minute. Chest exam reveals decreased breath sounds in both bases. Her WBC is 10,400. An EKG is performed. Which of the following statements is NOT APPROPRIATE OR TRUE?
26. A 44-year-old female has the following values on thyroid testing: TSH is 0.01 mU/L with T4 and t3 in the normal ranges. The patient denies any symptoms such as tremors, arthritis, visual problems or fever. His physical examination inclusive of a detailed examination of the neck and the nervous system is normal. What is the most likely diagnosis?
27. A 19-year-old female found wandering the streets at 3 AM presents to the emergency room via EMS. She is agitated and disoriented with the following vital signs:
temperature 101.2
pulse regular at 162
respiratory 22
blood pressure 140/90 mm Hg.
She has a prescription bottle of propylthiouracil (PTC) in her purse. Which of the following is the most appropriate treatment regimen for this patient?
28. A 50-year-old female presents to the emergency department with new onset seizures. The following laboratory values are notes.
Na+ 118 mEq/L
K+ 3.5 mEq/L
CL- 90 mEq/L
CO2 25 mEq/L
BUN 18 mg/dL
Creatine 1.0 mg/dL
Serum Osmalality Low
Urine Osmolality High
What is the most likely explanation for these laboratory abnormalities?
29. A 37-year-old male presents via ambulance to the emergency department after being found unresponsive. He has had no prior medical problems. The triage nurse reports a fruity smell to the patient’s breath. Vital signs are:
temperature 98.2
respiratory rate 28
blood pressure 120/80 mm Hg
apical pulse 120 beats/min.
A Foley catheter is placed and urinary output is brisk. Initial lab results are as follows:
Sodium 145 mEq/L
potassium 5.2 mEq/L
chloride 111 mEq/L
CO2 15 mEq/L
glucose 476 mg/dL
Which of the following is correct?
30. A 55-year-old college professor presents for discussion of recently diagnosed type diabetes mellitus. He has a strong family history of coronary artery disease. His father died from a myocardial infarction at age 48. His blood pressure is 140/90 mm Hg and his waist circumference is 105 cm. His physical examination is otherwise normal. Laboratory studies reveal:
BUN 15 mg/dL
Creatinine 0.9 mg/dL
Which one the following statement most accurately represents current recommendations regarding urine screening for proteinuria for this patient?
The following clinical vignette refers to items 31, 32 and 33.
A 66 year old woman with history of breast cancer presents with increasing shortness of breath over a period of about one week duration. She also complains of epigastric discomfort that does not radiate. Her past history is positive for a radical mastectomy on the left and cardiac catheterization twice. She has a history of hypothyroidism and is maintained on thyroid hormone replacement. The patient denies fever, sputum production or smoking. On examination, her temperature is 97.9 deg F (36.6 deg C), the blood pressure is 210/112, the pulse is 102 per minute, and the respirations are 25 per minute. She appeared diaphoretic and in mild respiratory distress. Her chest exam reveals fine rhonchi (wheezes) in the bases.
31. An EKG is obtained. Which of the following statements is TRUE?
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32. Her WBC is 9,800, the hemoglobin is 10.4 gram/dl, the serum Na is 143 mEq/L, serum potassium 4.0 mEq/l, chloride 97 mEq/L, bicarbonate 39 mEq/L, serum creatinine 1.0 mg/dl and serum glucose 335 mg/dl. The urine specific gravity is 1.015 and the acetone is negative. Which of the following IS NOT APPROPRIATE?
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33. A serum TSH test result is made available. The TSH is 0.02 U/L. The digoxin level is 1.05 and the Troponin level is 0.01. Which of the following is appropriate?
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a. Lower digoxin dose b. Increase digoxin dose c. Lower thyroxine dose d. Increase thyroxine dose
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The following clinical vignette refers to items 34 and 35.
A 91-year-old woman is brought into the Emergency Department via Fire rescue. She is said to have been complaining of shortness of breath for one day and weakness for about one week. On examination, the temperature is 100.1 deg F (37.8 deg F), the pulse is 116, the respirations 25 labored, and the blood pressure 139/60. The chest sounds are decreased.
34. Her arterial blood gas is pH 7.59, pCO2 31, pO2 75, HCO3 29 mEq/L. The serum chemistries are: Na 154 mEq/L, K 2.9 mEq/L, Chloride 111 mEq/L, Bicarbonate 34 mEq/L, BUN 49 mg/dl, creatinine 0.9 mg/dl, and glucose 244 mg/dl. Which of the following acid-base disorders explains best the clinical and laboratory data?
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35. The urine specific gravity is 1.020. Protein, nitrite and acetone tests are negative.
Which of the following initial intravenous fluids seems most appropriate?
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