End of Rotation Exam
August 2006
 

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. A 34 year old man with no significant past medical history arrived at the emergency room because of abdominal pain of 12 hours duration. The pain is described as sharp at a level of 8/10 and associated with nausea without vomiting. The patient notices that the pain gets worse when he is driving himself to the hospital and he turns abruptly or goes over a bump on the road. He has no history of weight loss, fever, travel, diarrhea, irritable bowel syndrome, nephrolothiasis or bleeding. On examination is appears uncomfortable when he moves. The abdominal examination reveals right lower quadrant tenderness with rebound. The initial laboratory studies reveal a WBC of 12, 900 per cubic mm. Which of the following studies would you order IMMEDIATELY in the emergency department?

1.-

 

a.Barium enema
 b.Colonoscopy
 c.Renal and bladder ultrasound
 d.CT of abdomen with intravenous contrast.
e.CT abdomen and pelvis without intravenous contrast.

2.Urinary stone disease is a significant health problem in the United States. The prevalence of urinary calculi is estimated to be 5 percent in the general population, with an annual incidence of as much as 1 percent. Men are twice as likely as women to develop calculi, with the first episode occurring at an average age of 30 years. All of the following choices may be associated with nephrolothiasis. Which of the following is least likely to cause renal nephrolothiasis in a particular patient?

2.-

a.Oxalate absorption
b.Hypercalcemia
 c.Suboptimal water intake
 d.Inherited metabolic disorders

3. A 55-year-old diabetic, hypertensive woman was brought to the hospital because of a two-week history of left sided weakness. She has no history of stroke or myocardial infarction. She denies palpitation, angina pectoris or shortness of breath, tonic clonic movements, head trauma, or fever. One week prior to the onset of the left sided weakness she experiences amaurosis on the right for several hours. She follows general guidelines for preventive care and has had negative results in mammography, a colonoscopy, and pelvic exams with PAP tests routinely in the past. On examination she has a blood pressure of 170/76 mm Hg, pulse 76 reg, and she was afebrile. Which of the following clinical entities explains best her presentation at this time?

 

3.

 

a.Acute vascular event in the region of the left hemisphere.
 b.Multiple sclerosis
 c.Brain abscess secondary to hemosepsis.
 d.Subdural hematoma of the occiput.
 e.Acute vascular event in the region of the right hemisphere.

4.  A 40-year-old nonsmoking woman with well-controlled type 1 diabetes mellitus diagnosed in childhood and no vascular disease seeks contraception. She states that she wants “something convenient” that does not require a daily reminder. Which one of the following contraceptive methods is the safest option for this patient following generally accepted clinical guidelines and the World Health Organization (WHO/OMS) criteria ?

 

4.

a. Progestin intrauterine device.
b. Contraceptive ring
c. Copper intrauterine device
d. Combined estrogen-progestin oral agent.

 

5.Women who have had unprotected intercourse within five days of their visit can be offered hormonal emergency contraception that day, after appropriate counseling. Which of the following contraceptive methods seems most logical in this setting?

5.

a.The copper intrauterine device (IUD)
b.The progestin IUD.
c. A combination estrogen-progestin pill.
 d.A progestin-releasing IUD

6. A 54-year-old retired postal worker is brought into the hospital by Fire Rescue because he passed out when he went to get out of bed on the day of entry. He has a history of systemic arterial hypertension treated with amlodipine and is said to be an alcoholic on remission since about 2 years ago.  He dies palpitations, chest pain or history of head trauma, diarrhea, vomiting, or renal disease prior to this. On examination, he appears to be in no acute distress except for a scalp injury in his right forehead. The blood pressure is 150/95 mm Hg, the pulse rate 84 regular and he is afebrile. The neurologic examination is nonfocal.
His laboratory studies reveal the following data:
Na 140 mEq/L, K 3.1 mEq/L, Cl 103 mEq/L, HCO3 24 mEq/L, BUN 4 mg/dl, creatinine 0.7 mg/dl, glucose 136 mg/dl.
 Which of the following treatments seems MOST APPROPRIATE?

6.

a. Administer 40 mEq of KCl intravenously over 5 minutes.
b. Administer 20 mEq KCl orally in 24 hours.
c. Administer 120 mEq KCl orally in 24 hours.
 d  Administer 360 mEq KCl orally over 24 hours
 

7.  A six-month-old infant with generalized seborrheic dermatitis presents with frequent loose bowels and weight loss inconsistent with previous growth trends. Which one of the following would be the most appropriate next step?

7.

a. Reassure the parents that the symptoms are indicative of a self-limited process.
 b.Perform a work-up to detect immunodeficiencies.
 c.Prescribe oral course of steroids and schedule barium enema.
d. Apply a selenium- zinc shampoo twice weekly.

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The following clinical vignette refers to items 8 and 9.

A 43-year-old woman with an unremarkable past medical history was brought to the emergency department because of the acute onset of upper abdominal pain of two days duration. The pain was described as sharp and intermittently intense to a level of 10/10 and waning to 2/10. She complained of nausea but no vomiting. Denies diarrhea or change in bowel habits. On physical examination, she appeared to be uncomfortable because of the abdominal pain. Temperature was 98.5 deg F ( 36.9 deg C) pulse rate 93 regular and blood pressure 110/65 mm Hg. The abdominal examination revealed tenderness to palpation in the epigastrium. Laboratory studies revealed the following data:

Na 141 mEq/L, K 3.6 mEq/L, Cl 102 mEq/L, HCO3 31 mEq/L , BUN 10 mg/dl, creatinine 0.6 mg/dl, glucose 118 mg/dl.

AST 97 U/L, ALT 312 U/L, serum amylase 373 U/L, lipase 2485 U/L .

8. Which of the following diagnoses is MOST LIKELY?

8.

 

 

a.Acute hepatitis
 b.Acute pancreatitis
 c.Acute gastroenteritis
 d.Acute gastritis
 

9. Which of the following acid-base disturbances most likely explains this patient’s clinical data?

9.

 

 

a.Metabolic acidosis
 b.Metabolic alkalosis
 c.Respiratory alkalosis
 d.Respiratory acidosis

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10.Which of the following antihypertensive agents is the only one with proven effectiveness for the development of diabetic nephropathy?

10.

 

 

a.Thiazide diuretics
 b.Calcium channel blockers
 c.Angiotensin-converting enzyme inhibitors
 d.Clonidine

 

11. An 87 year old diabetic woman is admitted via de emergency department because of the acute onset of dyspnea associated with nausea one or two days prior to entry. She complained of chest discomfort that radiated to the left arm. The latter discomforts lasted about 10 minutes and waxed and wane over several hours. On examination, the blood pressure was 150/110 mm Hg. The patient appeared uncomfortable. The chest examination revealed rales in both bases. An EKG is obtained and it is available for your review.
Which of the following statements is TRUE?

11.

 

 

a.Heart rhythm is sinus tachycardia with frequent premature atrial contractions.
b.The admitting diagnosis should be: Community Acquired Pneumonia.
 c.The heart rhythm is atrial fibrillation with a rapid ventricular response.
 d.The electrocardiogram reveals ST changes diagnostic of acute pericarditis.

 

12. The accuracy of A1C testing for the diagnosis of diabetes was first evaluated using pre-1997 World Health Organization (WHO) criteria for a diabetes diagnosis (i.e., OGTT result more than 140 mg per dL [7.8 mmol per L] fasting or more than 200 mg per dL [11.1 mmol per L] at two hours). A meta-analysis1 (including 10 studies that evaluated A1C levels of 8,984 patients) that used a cutoff (i.e., upper limit of normal) A1C level of 6.3 percent (two standard deviations [SD] above the mean) showed that A1C testing was 66 percent sensitive and 98 percent specific for diagnosing diabetes. Which of the following statements is TRUE?

12.

 

 

a.34% of individuals without diabetes mellitus will be correctly diagnosed by the evaluation of A1C at this cut-ff level.
b.98 % of individuals with diabetes mellitus will be correctly diagnosed with diabetes mellitus by the evaluation of A1C at this cut-ff level.
c.2% of diabetics will be missed because their results will be counted by this method as a false negative test.
d.32% of patients will be diagnosed as diabetics by the evaluation of A1C at this cut-ff level.

 

13.  A 69-year-old woman with history of end-stage renal disease maintained on hemodialysis is found to have an abnormal CBC. Her hgb is 15.7 gm/dl, the WBC is 6,000 cells per cubic mm, the MCV is 108 fl, and the platelet count is 127,000 per cubic mm.  Which of the following diagnoses is LEAST LIKELY?

13.

 

 

a.  Iron deficiency
 b. Myelofibrosis
 c. Vitamin B12 deficiency
 d. Folic acid deficiency

 

14.  Which one of the following statements about primary care for lesbians and bisexual women is correct?

14.

 

 

a.Cervical cancer screening should follow screening recommendations for women in general
b.Intracervical insemination is more effective than intrauterine insemination.
c.Screening for domestic violence is not needed.
 d.Hospital visitation, notification, durable power of attorney, and parental rights for nonbiologic partners are granted automatically to same-sex partners in most localities

 

15. Which one of the following statements about enthesitis is correct?

 

15.

 

 

a.Cervical cancer screening should follow screening recommendations for women in general
b.Intracervical insemination is more effective than intrauterine insemination.
c.Screening for domestic violence is not needed.
 d.Hospital visitation, notification, durable power of attorney, and parental rights for nonbiologic partners are granted automatically to same-sex partners in most localities

 

The following clinical vignette refers to items 16 and 17.
You are called to evaluate a 45-year-old woman because of persistently high blood glucose levels. She was admitted to the hospital 2 days prior because of generalized weakness. She has a history of diabetes mellitus and has been on a sliding scale since admission. Currently, she has no new complaints. Her pulse is 55 regular and the blood pressure is 160/70. Her afternoon blood work revealed the following data:
Na 138 mEq/L, K 5.6 mEq/L, Cl 107 mEq/L, HCO3 26 mEq/L , BUN 20 mg/dl, creatinine 1.6 mg/dl, glucose 304 mg/dl.

16. Which of the following therapeutic measures is in order right now in order to attain glycemic control within 2-4 hours?

16.

 

 

a. Administer 20 units of glargine insulin (Lantus) subcutaneously.
 b. Administer 15 units regular insulin subcutaneously.
c.Administer 10 units N insulin intravenously.
 d. Administer 25 units N insulin subcutaneously.

 

17. An EKG is obtained and is available for your review. Which of these measures seems IS CONTRAINDICATED at this time in the management of this patient?

17.

 

 

a. Administer atropine 0.4 mg intravenously.
 b. Administer nitroglycerin ointment 2% one inch.
 c. Administer digoxin 0.25mg intravenously.
 d. Administer 30 grams sodium polysterene sulfonate by enema.

 

18. An 84-year-old man is brought to the hospital because of gross hematuria. He has a history of atrial fibrillation, mitral insufficiency. On arrival he is in no acute distress. His initial laboratory studies reveal a hemoglobin level at 13 gm/dl and a PT INR 4.2. Which of the following management measures is MOST appropriate immediately.

18.

 

 

a.Administer 2 units fresh frozen plasma
 b.Obtain a liver spleen scan
 c. Administer 20 mg vitamin K intravenously
 d.Transfuse two units of packed RBCs.

 

19. Which of the following IS NOT a recognized risk factor for breast cancer?

19.

 

 

a.Late menarche
b.Late menopause
c.Late first pregnancy,
 d.Nulliparity.

20. Which of the following statements IS NOT true regarding prostatic specific antigen (PSA)?

20.

 

 

a.Screening by PSA testing greatly enhances detection of organ-confined prostate cancer.
b.PSA is a member of the kallikrein family.
 c.PSA is a glycoprotein with serine protease activity.
d.PSA is produced only by malignant prostatic epithelial cells.

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