REVIEW EXAM PRIMARY, ACUTE CARE MEDICINE. July 2006. Albarran School of Medicine

End of Rotation Exam
July 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.

The following clinical vignette refers to items 1 and 2 below.

A 31-year-old man presented to the Emergency Department with history of abdominal pain of several days duration. The pain is reported to be 8/10 and associated with nausea and vomiting. There was no history of abdominal or gastrointestinal problems. The patient is an Asian immigrant who works at a local restaurant.

1. On physical examination he appears to be uncomfortable and nauseated. His temperature is 98.0 deg F (36.7 deg C), blood pressure 120/72, and pulse 72 regular. The abdomen is slightly distended, warm and bowel sounds are depressed. There is tenderness to palpation diffusely. Which of the following studies IS NOT indicated immediately in the emergency department?

2. His laboratory studies become available shortly thereafter. His electrolytes are reported as follows:
Na 142 mEq/L, K 3.8 mEq/L, Cl 103 mEq/L, HCO₃ 35 mEq/L
Which of the following statements is true?

a.There is no evidence of an acid base disturbance.
b.There are signs of metabolic acidosis
c.There are signs of metabolic alkalosis
d.There are signs of acute respiratory alkalosis.

The following clinical vignette refers to items 3 and 4 below.

A 51-year-old man is brought to the emergency room by fire rescue because of chest pain. Apparently, the patient was in his usual state of health when be experienced mid sternal and epigastric chest pain while driving to work in the morning. The patient works as a social worker in the US Social Security Office. He has a history of hyperlipidemia diagnosed when he went to donate blood several months ago but has not had time to visit a physician since then. He has no history of diabetes mellitus or hypertension.

3. On arrival at the hospital the patient gives a history of having had pain since about two hours prior after he left his home. He was given one tablet of nitroglycerin (0.4 mg) and the discomfort soon subsided soon. His physical examination revealed a blood pressure of 144/85, pulse rate of 75 regular, respirations unlabored and temperature 99.0 deg F ( 37.2 deg C). The examination of the chest is normal. The heart sounds reveal a soft S4 sound and no murmur or rub. The abdomen is negative for distension or tenderness. An EKG is obtained immediately and the results are shown here in the next page.

Which of the following statements is TRUE regarding the findings?

a. Left anterior fascicular block
b. Right axis deviation.
c. Acute inferior wall infarction.
d. Acute pericarditis.
e. Adequate R wave progression

4. His initial laboratory studies reveal the following data:
Na 138 mEq/L, K 3.4 mEq/L, Cl 100 mEq/L, HCO₃ 28 mEq/L
BUN 13 mg/dl, creatinine 0.9 mg/dl, glucose 242 mg/dl. One hour later, the blood glucose level is measured with a reflectometer and the level is 210 mg/dl.
Which of the following statements is MOST APPROPRIATE?

a.The patient has no signs of myocardial ischemia and may be discharged.
b.The patient has diabetes mellitus.
c.The patient may have hypoaldosteronism.
d.Repeat laboratory studies, since the patient has no history of diabetes mellitus

6. The following diagram summarizes clinical data on a patient suffering with Hepatitis A.

Figure

Which of the following sets of answers IS CORRECT?

	I	II	III	IV
a	Hep A virus in stool	Viremia	IgM	ALT
b	Hep A virus in stool	Viremia	ALT	IgM
c	Viremia	Hep A virus in stool	ALT	IgM
d	Viremia	ALT	Hep A virus in stool	IgM

7. A 36-year-old disabled man is brought to the hospital from a local nursing home. He is reported to have experienced a change in his mental status without obvious cause. The patient has a history of a psychiatric illness. His initial laboratory studies reveal the following data:
Na 128 mEq/L, K 3.6 mEq/L, Cl 91 mEq/L, HCO₃ 29 mEq/L
BUN 11 mg/dl, creatinine 0.9 mg/dl, glucose 103 mg/dl

Which of these is most important to work up and possibly treat as soon as possible?

a.Serum sodium
b.Serum Potassium
c.Serum Bicarbonate
d.Blood urea nitrogen
a.Serum glucose

9. Which one of the following statements about the management of a hip fracture is correct?

a. Antibiotic prophylaxis should be continued for 72 hours after surgery.
b. Rehabilitation may begin one week post-op.
c. Patients should receive thromboprophylaxis.
d. Indwelling urinary catheters should remain in place postoperatively to prevent urinary retention

10. Which of the following statements IS TRUE regarding nutritional support in the hospitalized patient?

a.The preferred route for administering nutritional support is the intravenous route.
b.Peripheral parenteral nutrition is limited to solutions with an osmolality of less than 900 mOsm/L
c.Diabetes mellitus is an absolute contraindication to total parenteral nutrition.
d.In most parenteral nutrition formulations, the fats are utilized to provide most of the Calories provided.

12. Which one of the following statements about the treatment of depression is NOT correct?

a. Selective serotonin reuptake inhibitors (SSRIs) should be used with caution in the first few weeks of treatment because they have been associated with a worsening of suicidal ideations.
b. SSRIs are associated with more adverse effects than tricyclic antidepressants.
c. Venlafaxine (Effexor) is more effective than tricyclic antidepressants.
d. Cognitive therapy has been shown to effectively improve depressive symptoms.

13. A 34-year-old woman is admitted to the hospital because of progressive weakness. She has not been examined in many years after she had her last child more than 10 years ago. She complains of irregular and excessive vaginal bleeding and abdominal pain for several years getting progressively worse. There is no history of chest pain, palpitations, diabetes, hypertension, smoking, or heart disease. She complained in the past week of shortness of breath on exertion. She is a nonsmoker and nondrinker of alcohol. Her physical examination reveals a systolic murmur grade 2/6 in the left sternal border without radiation. A large abdominal mass apparently anchored in the pelvis is easily palpable reaching the mid-epigastrium.

The patient’s laboratory data reveal a hgb of 5.5 gm/dl, serum glucose 96 mg/dl, and serum K of 3.4 mEq/L. An EKG is performed and is available for your review. Her chest film is reported normal without cardiomegaly or pulmonary infiltrates. You are called to clear the patient for surgery. Which of the following statements IS MOST APPRPRIATE?

a.Patient has abnormalities in the EKG that require that we rule out acute myocardial infarction. Surgery must be delayed.
b.Patient must have at least 4 units of packed RBC’s and serum potassium rechecked and/or corrected before surgery.
c.Patient needs to have a full gastrointestinal endoscopy to evaluate her for gastrointestinal blood loss.

14. A 73-year-old woman with a well-documented history of glaucoma, diabetes mellitus, and hypothyroidism is brought to the hospital via Fire Rescue because of shortness of breath. She was in her usual state of health, at home, when she began to have shortness of breath about 5 hours prior to entry. She also complained of diaphoresis. On examination she appears to be in mild respiratory distress. Her respiratory rate at rest is 24 per minute, the pulse is 110 regular and the blood pressure is 190/106. She has rales in both bases and a systolic murmur at the apex in systole. There is also slight tenderness in the left side of the abdomen. Her laboratory studies reveal the following data:
Na 134 mEq/L, K 3.4 mEq/L, Cl 97 mEq/L, HCO₃ 29 mEq/L, BUN 14 mg/dl, creatinine 1.1 mg/dl, serum glucose 112 mg/dl, Hgb 11.8 gm/dl, WBC 14,000, pro-BNP 2,576 ng/dl.

Which of the following diagnostic entities best explains the clinical picture?

a.Congestive Heart Failure
b.Community Acquired Pneumonia
c.Aspiration Pneumonia
d.Pulmonary Embolism

15. An 88-year-old woman is brought to the hospital from the ALF, where she resides since her husband died, because of shortness of breath. She has a history of coronary artery disease manifested by an acute myocardial infarction 2 years prior and cerebrovascular thrombosis in the past resulting in left hemiparesis. Her mini mental exam could not be completed. Her Glasgow Coma Scale was 13/15. On examination, her vitals signs were: pulse 85 irregular, blood pressure 130/80 and temperature 96.2 deg F ( 35.2 deg C). Her chest exam revealed fine rales in both bases. An EKG is obtained and is available for your review. Which of the following statements IS TRUE?

a.Acute inferior wall infarction.
b.Sinus bradycardia with PAC’s.
c.Atrial fibrillation with controlled ventricular response.
d.Left anterior fascicular block.

18. Which one of the following statements about the addition of the Dietary Approaches to Stop Hypertension eating plan to a regimen of low sodium intake, moderate alcohol consumption, weight loss, and increased exercise is correct?

a.There is no additional benefit.
b.There is an additional reduction in blood pressure.
c.There is a reduction in cardiovascular mortality.
d.There is a reduction in all-cause mortality.

19. A 65-year-old man notices a painful cramping sensation radiating down both legs while walking. The pain does not subside rapidly with rest. He has difficulty standing on his heels and tiptoes, stating that he feels weak. His Ankle Brachial Index is 0.92. There is no history of disordered sleep. Which one of the following is the most likely diagnosis?

a.Restless legs syndrome.
b.Peripheral vascular disease.
c.Spinal stenosis.
d.Nocturnal leg cramps.

20. Which one of the following statements about developmental dysplasia of the hip (DDH) is correct?

a.Most infants with hip abnormalities identified by ultrasonography require intervention.
b.Most infants with hip abnormalities identified by screening physical examination require intervention.
c.DDH increases the risk of avascular necrosis of the hip.
d.Most cases of DDH have identifiable risk factors.
e.Most newborn hips identified as abnormal or suspicious for DDH resolve spontaneously

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