a. There is a suggestion of an infiltrate in the right base next of the heart.
b. There is blunting of both costophrenic angles
c. the cardiac silhouette is not enlarged
d. There is a right-sided pneumothorax.

8. Diabetic ketoacidosis (DKA) is associated with all of the following except:

a. acidemia
b. insulin deficiency
c. anabolism
d. hepatic ketogenesis

9. In DKA, hyperglycemia leads to osmotic diuresis, loss of fluid and electrolytes and dehydration. In parallel, rapid lipolysis occurs, and free fatty acids are eventually broken in the liver to so-called "ketone bodies." Which of the following is not a "ketone body"?

a  acetone
b. beta-hydroxybutyrate
c. acetyl-Coenzyme A
d. acetoacetate

10. A 77-year-old woman presented to the ER with worsening dementia. Her initial labs revealed the following chemistries:

Na   152 mEq/L
K     5.3
Cl    117
HCO3       12
BUN  247 mg/dl
Glu  530 mg/dl

These data suggest that the primary acid base disturbance is:

a. respiratory acidosis from coma
b. respiratory alkalosis from panic attack
c. metabolic alkalosis from renal wasting
d. metabolic acidosis from diabetes

11. The osmolality of the serum from the sample reported in item 10 is:
a. 280
b. 304
c. 421
d. 530

12. The patient whose chemistries were presented in item 10 above requires therapeutic attention. Which of the following treatment would you initiate first?

a. 10 units R human insulin intravenously and normal saline at 250 cc/hr
b. 20 units N human insulin subcutaneously and normal saline 500 cc/hr
c. 15  units R human insulin subcutaneously and Half normal saline 200cc/hr
d. 10 units R human insulin intramuscularly and D5W at 250 cc/hr



13. The sin qua non  of asthma, a condition of the lungs and airways, include all of the following except for:

a. airflow limitation
b. airway hyperresponsiveness
c. viral infection
d. inflammation of the bronchial mucosa

14.  A 20-year-old man presents to the emergency room because of what he termed, a heavy feeling in his chest. He gave a history of chest heaviness for about 6 hours during which time he attempted to take antacids and bicarbonate of soda on the advice of an old retired Cuban physician who lives next door. He complained of shortness of breath and denied palpitations, syncope or radiation of the heavy feeling. He denied fever but complained of some cough two days prior to this complaint. He has no hx of heart disease,
high cholesterol or high blood pressure. His mother is diabetic and lives while his father had heart failure and has been dead for 4 years. The patient occasionally smokes tobacco and marijuana. His EKG is shown in another page.
Which of these diagnoses best describes the clinical picture?

a. acute pericarditis with cardiac tamponade
b. acute inferior and possibly posterior wall myocardial ischemia
c. inferior wall infarction of undetermined age (not acute)
d. antero-lateral myocardial ischemia


15. Which of the following diagnostic tests would you want to perform immediately?

a. echocardiography
b. right side cardiac catheterization 
c. coronary arteriogram
d. cardiac enzymes and isoenzymes

16. The patient has a blood pressure of 105/60 mmHg, a pulse of 58 per minute and 18 resp per minute. His temperature is 99.0 deg F. A hemoccult test is negative. There is no sign of internal hemorrhage or headache. All of the following drugs may be used in the clinical setting described except for one. Identify the drug not indicated in this case:

a.  metoprolol intravenously
b.  tissue-type plasminogen activator
c.  aspirin
d.  pravastatin

17. The Killip classification of heart failure in acute myocardial infarction is as follows:
                               Approx.
        Killip Class    Description Incidence   Mortality
                                        with therapy       
        I           No heart failure        40%     5%

        II          Mild Lt ventr. fail.    40%     20%

        III         Pulmonary edema 10%     40%

        IV          Cardiogenic shock   10%     90%

The patient does not have an S4 or S3 gallops, is satisfactorily saturated according to a pulse oxymetry of 100% on 2 L nasal  oxygen, and has now a pulse rate of 65 per minute without chest pain. A chest radiograph of the pertinent patient is demonstrated in the view box. On your way out of the CCU/ICU you encounter a relative who has spoken to the attending minutes before. What sort of a mortality would the attending most likely have quoted
for the relative given the data gathered and demonstrated?

a. 90 %
b. 50 %
c. 20%
d. 5%




18. A 63-year-old woman comes into the ER because of increasing dizziness. She has a history of atherosclerotic disease and right carotid surgery several years ago. Her physical exam reveals signs of bilateral hemispheric disease. A CT of the brain without contrast is obtained. The films are available for you to review. Which of the following statements is true regarding the films shown?

a. there are bilateral subdural hematomata.
b. there are wedge shaped defects in the cortices.
c. there is a shift of the midline.
d. there is a hemorrhage in the ventricles.

19. The most common microorganism cultured from the urine in patients diagnosed with pyelonephritis is:

a. Chlamydia pneumonia
b. Chlamydia trachomitis
c. Escherichia coli
d. Klebsiella pneumonia

20. An 87-year-old woman (SR 589440177) presents to the ER brought in by her family. The patient suffers from diabetes and hypertension. She experienced a syncopal attack on the day of admission. While a complete history is obtained and a thorough physical exam is completed, an EKG is available from a
friendly technician. You review the tracing. Which of the following
statements is true?

a. the rhythm is sinus with frequent PAC's.
b. there are clear signs of transmural inferior wall infarction.
c. there is left anterior hemiblock or left anterior fascicular block
d. the rhythm is atrial fibrillation and there are up sloping ST's in V5-6.


END OF THE July 2001 EXAM.

ANSWERS


1. c) In a number of studies where the serology of ER patients and impatients
was assayed, the HIV seropositivty was found to be 2 to 5% in the mid
nineties. These were urban centers in NY. South Florida is a metropolitan
area with a particularly high rate of HIV.

2. d) family medicine resident. All of these health care workers may be at
risk of HIV in the work place. However, of these listed, the family medicine
trainee is the least likely to get into trouble here.

3. c) urosepsis. Nosocomial infection means "hospital acquired infection."
The most common nosocomial infection is urosepsis.

4. b) 270. This is the closest number to the estimated osmolality. See
discussion on question 11 below.

5. d) NS. Given that the patient is slightly hyposmolar and there is a
negative test for ketones in the urine, NS is the most reasonable choice.

6. a) metabolic alkalosis and respiratory acidosis. These are the possible
primary acid-base disturbances when the bicarbonate level is elevated in
serum.

7. a) there is a suggestion of an infiltrate in the right base. The other
choices are not present in the radiograph.

8. c) anabolism. All other choices are part and parcel of DKA.

9. c) acetyl coenzyme-A. The other three choices are the classical ketone
bodies.

10. d) metabolic acidosis associated with diabetes. The patient has diabetic
ketoacidosis. The anion gap is elevated at 22. Therefore one of the high
anion gap acidoses must be present.

11. c) 421 mOsm/L. The serum osmolality is estimated by the following
formula: 2 x the sodium concentration, plus the serum BUN /2.8, plus the
serum glucose / 18.


12. a) 10 units of regular human insulin intravenously and NS infusion at 250
cc/hr. In the acute treatment of diabetic ketoacidosis the only insulin
indicated in regular insulin, that is fast acting insulin. All others are not
used. A minimum of 6 u of insulin R are given IV but most physicians use 10
units loading dose. This loading dose may be given IM, however, the
intravenous fluids listed in choice (d) do not have normal saline.



13. c) viral infection. The other three choices are part and parcel of
asthma. However, viral infections are not. Notice that not infrequently a
viral infection may be the stimulus that decompensates an asthmatic patient.


14. b) acute inferior wall myopcardial infarct and possible extension to
posterior wall. Notice that there are ST elevations in II, III and avF. These
leads are associated with the inferior wall. There are reciprocal changes
(inverse) in I and avL. The abnormalities in the precordial leads may be due
to posterior wall infarction.


15. d) cardiac enzymes and isoenzymes. The usual profile nowadays consists of
CPK, Troponin, LDH. Of these the troponin appears early and the LDH
disappears last.

16. a) metoproplol is indicated in acute myocardial infarction to decrease
oxygen consumption. However, one important contraindication is bradycardia. A
ventricular rate of 58 would lead most physicians to hold metoprolol until
the rate gives signs of a higher frequency.


17. d) The signs and symptoms do not lead you to think that the patient has
congestive heart failure. The chest radiograph alone may be misleading.

18. b) The CT images of the brain reveal cortical defects that appear as
"wedge defects." These are usually the result of cortical infarcts and or
loss of brain parenchyma from degenerative diseases.

19. c) E. coli. Both in impatient and outpatient urosepsis, the most common
organism is E. coli. The origin of the E. coli is the bowel and perianal area
from whence the microorganisms reach the lower urinary tract. In patients
with lowered immune defenses and or urethral reflux, the infection ascends to
reach the renal pelvis yielding the syndrome of pyelonehritis.

20. d) atrial fibrillation. The lower strips reveal a rhythm that is
irregularly irregular. Note that there are no clear P waves in any lead.