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

End of Rotation Exam
November 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. Kawasaki disease (KD, also called mucocutaneous lymph node syndrome) is one of the most common vasculitides of childhood. It is typically a self-limited condition, with fever and manifestations of acute inflammation lasting for an average of 12 days without therapy. Concern exists because complications such as coronary artery aneurysm, depressed myocardial contractility and heart failure, myocardial infarction, arrhythmias, and peripheral arterial occlusion may lead to morbidity and mortality. In which of the following ethnic groups is the incidence of KD highest in the United States?

2. A 44-year-old woman presented to the outpatient service complaining of tremors. She has been diagnosed with a thyroid condition about 2 years prior but had been lost to follow up until this time. She also complained of neck pain, palpitations, chest pain, and anxiety. On physical examination, she appeared her stated age. Her blood pressure 137/73 mm Hg, pulse 100 per min. regular, respirations 18 per minute unlabored. She had no exophthalmos. The examination of the neck anteriorly revealed a \n area of fullness and slight erythema and warmth. Which of the following sets of laboratory studies fits best this clinical description?

2.-

T₄ RIA
(0.8-2.4 ng/ml)

T₃ Uptake 24hr (%)

h-TSH*
(04-4.2mU/ml)

a

22

20

16

b

3

11

2.0

c

24

47

0.0

d

0.5

8

24.0

*- highly sensitive TSH.

3. Which of the following is THE MOST common pathological type of thyroid carcinoma (in the general population – males and females combined)?

3.

a.Lymphomatous
b.Anaplastic
c.Follicular
d.Papillary

5. An estimated 4 percent of visits to primary care physicians involve psychiatric or social crises. A crisis occurs when a person is confronted with a critical incident or stressful event that is perceived as overwhelming despite the use of traditional problem solving and coping strategies. Often it is not the event itself that causes the crisis; rather, it is the appraisal of the event as serious, uncontrollable, and beyond the patient's resources for coping that triggers a crisis response. Which of the following best describes the accepted role of the physician is crisis management?

a.Immediately obtaining a psychiatric consultation, obtaining a history of HIV risk factors, and inquiring about domestic violence.
b.To respond effectively to a patient's crisis providing reassurance and support to the patient, assessing the situation, ensuring the safety of the patient and others, and teaching the patient strategies that will assist him or her to cope more effectively with the current incident and related future critical incidents.
c.Performing a Mini-mental Status examination, assessing the potential of possible psychosis and self-harm and starting benzodiazepine therapy for two weeks.
d.Performing a complete neurological work-up, ordering an EEG, and obtaining a CT of the brain with contrast.

6. A 64-year-old man presents to the emergency room complaining of chest pain. The discomfort was felt intermittently and it was graded 5/10. It was alleviated with sublingual nitroglycerin. The patient also complained of dyspnea associated with the chest pain, orthopnea and dyspnea on exertion. There was no history of syncope, palpitations or digestive problems. On physical examination, he appeared somewhat distressed. His blood pressure was 141/83 mm Hg, the pulse 72 per minute regular, and the respirations unlabored at rest. He was afebrile. The neck was negative for jugular venous distension. The chest exam revealed fine crackles in the bases. The heart sounds were distant. Extremities revealed no edema. An EKG was obtained and is available for your review. Which of the following statement is MOST CORRECT?

a.Acute anteroseptal myocardial infarction
b.Posterior wall myocardial infarction of undetermined age.
c.Acute pericarditis
d.Anxiety reaction

7.A 52-year-old homeless man who resides in Camillus House in downtown Miami, Florida presents to your clinic with fatigue, thirst, and blurred vision of several weeks duration. A random finger stick reveals a blood glucose level of 350 mg per dL (19.4 mmol per L), and the patient recalls a physician telling him a year ago that he had diabetes. You begin treatment with samples of a sulfonylurea drug and explain to the patient the basics of diabetes education. Which one of the following actions is most appropriate now?

a.Provide patient with several telephone numbers for practicing dietitians in the downtown area.
b.Advise the patient to avoid all foods containing fat.
c.Provide the patient with a list of web sites including the ada.org.
d.Obtain a detail history of the foods offered at Camillus house.

8. A 64-year-old man is admitted to the hospital because of angina pectoris. He has a history of coronary artery disease and on admission complained of dyspnea. You are called to evaluate the patient because the nursing staff and the telemetry technicians have seen an abnormal rhythm in the cardiac monitor. The patient has no symptoms at the time. You find him in no acute distress. His vital signs were: blood pressure 130/71 mm Hg, pulse 69 irregular, and temperature 96. 2 deg F (37.5 deg C) . The physical examination was unremarkable in terms of the neck, the chest and the heart exams except for the irregularity in the heart rhythm. You order a 12-lead EKG and the results are available here. Which of the following statements is correct?

a.The rhythm is sinus rhythm with premature atrial contractions.
b.The rhythm is sinus rhythm with left ventricular ectopics.
c.The rhythm is AV dissociation.
d.The rhythm is sinus rhythm with artifactual interference.

9.Which of the following statements IS NOT TRUE regarding our clinical knowledge of Kawasaki’s Disease?

9.

a.The fever of Kawasaki disease is usually higher than 102.2°F (39°C) and often above 104.0°F (40°C).
b.If untreated, the fever lasts for an average of 11 days.
c.Conjunctival injection is typically bilateral and nonpurulent.
d.Photophobia and eye pain are not often present.
e.Swelling or erythema of the hands and feet is characterized by a sharp demarcation at the ankles and wrists; the swelling may be painful.
f.Classic peeling of the fingers and toes (starting in the periungual region) usually does not occur until two to three weeks after onset of symptoms, when fever typically has resolved.
g.Oral mucosal changes can manifest as red and cracked lips, strawberry tongue, or diffuse erythema with no focal lesions, ulcerations, or exudates.
h.Rash tends to appear within the first five days of illness and then it turns into a vesicular eruption resembling small pox.
i.Laboratory and other ancillary studies are nonspecific.

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The following clinical vignette refers to items 10 and 11.

A 63-year-old man is brought to the emergency department by fire rescue. He complained of palpitations in the ALF where he resides. Soon the paramedics arrived and documented the rhythm that is available here.

10. Which of following statements is most appropriate?

10.

a. Atrial fibrillation
b. Atrial flutter
c. Sinus arrhythmia
d. Sinus tachycardia

11. Which of the following EKG findings are also evident in this tracing?

11.

a.Left ventricular hypertrophy by voltage
b.First degree atrio-ventricular block
c.Left anterior fascicular block
d. Complete right bundle branch block

12. A 51-year-old man is brought to your clinic because of weakness and polyuria. He has a recent history of gastroenteritis for which he was admitted to your hospital. The patient has a history of mental illness and lives with his sister and brother in law. The sister is accompanying the patient this afternoon to the clinic. He also suffers from hypertension. Currently he is on glargine (Lantus insulin 30 units subcutaneously at night. The patient is unable to check his blood glucose himself and the family works outside the home. He is allergic to sulfa. On physical examination, the patient has a BMI of 34 kg/m² and seems stable. He has a negative chest, heart and abdominal exam. The blood glucose is 291 mg/dl at 3:00 PM, nonfasted. You decide to engage a home health service to check his blood glucose twice daily and to try to oversee his diet. Which of the following measures is most appropriate also?

12.

a.Start Regular insulin at 5 units in AM and 5 units in PM subcutaneously.
b.Start Glypizide 10 mg. in AM daily.
c.Start Novolog 70/30 Insulin 20 units subcutaneously at hour of sleep.
d.Start pioglytazone (Actos) 15 mg daily in AM.

13. A 57-year-old man with a long history of cigarette smoking presents to the emergency room brought in by fire rescue because of cough and shortness of breath. The patient has had several admissions this year because of decompensated COPD. At this time he comes in with two-week history of increasing cough, low grade fever, and yellow sputum. His vital signs are as follows: Blood pressure 145/90 mm Hg, pulse rate 115 regular, respirations 26 per minute labored. He is afebrile. Chest exam reveals bilateral wheezes and a very poor inspiratory effort. The chest film reveals hyperexpansion without an acute infiltrate. Which of the following regimens IS MOST APPRPRIATE?

13.

a.Theophylline 250 mg intravenously over 20 minutes and then 15 mg per hour, Ceftriaxone 1 gm intravenously, hydrocortisone 300 mg intravenously.
b.Montelukast 10 mg orally, hydrocortisone 300 mg intravenously, diltiazem 20 mg intravenously and 15 mg per hour.
c.Hydrocortisone 300 mg intravenously, levofloxacin 500 mg intravenously, levalbuterol inhalation.
d.Azithromycin 500 mg intravenously, levalbuterol inhalation, morphine sulfate 4 mg intravenously.

14. Which of the following statements IS NOT TRUE regarding adolescents in the United States today?

14.

a.Most adolescents in urban areas – 10 in 12- do not have a primary care physician.
b.More than 40 percent of adolescent deaths from motor vehicle crashes involve alcohol and/or drug use or abuse.
c.More than 75 percent of adolescents in the United States have reportedly used alcohol and more than 25 percent have engaged in binge drinking.
d.Nearly 60 percent of adolescents have used tobacco at least once.
e.Approximately 4 million cases of STDs are reported in the United States annually in adolescents.

15. While examining a one-day-old infant, the physician hears an occasional, faint left hip click when performing the Ortolani test. Which one of the following courses of action is the most appropriate next step?

15.

a.Ultrasound of left hip.
b.X-Ray of left hip.
c.Refer to pediatric orthopedist.
d.Recheck infant in 2 weeks.

16. When performing the Ortolani and Barlow tests, the physician should do which one of the following?

16.

a.Examine each hip separately.
b.Examine the left hip first.
c.Examine the hips simultaneously.
d.Examine the right hip first

17. Which one of the following is the most common clinical form of Hirschsprung’s disease?

17.

a.Long segment, infant onset.
b.Long segment, late onset.
c.Short segment, infant onset.
d.Short segment, late onset.

The following clinical vignette refers to items 18 and 19.

A 65-year-old woman is brought to the emergency department by her family because of nausea and vomiting. The patient was in her home in her usual state of health carrying the diagnoses of GERD, schizophrenia and COPD when several hours before admission began to have these symptoms associated with coffee grounds emesis. The patient’s PIR was zero at the time of the examination. Her blood pressure was 143/78 mm Hg, pulse rate 89 regular, respirations unlabored, and temperature 99.2 deg F (37.3 deg C). The chest and heart examinations were benign. The abdomen revealed mild distension and epigastric fullness. Rectal examination was negative for occult blood. The initial laboratory studies revealed the following data:

Na 139 mEq/L, K 2.9 mEq/L, Cl 95 mEq/L, HCO₃ 35 mEq/L, BUN 9 mg/dl, creatinine 0.7 mg/dl, glucose 95 mg/dl.

18. Which of the following acid base disturbances does this patient probably have?

18.

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

19. You identified hypokalemia as an important medical problem that needs attention. Through what organ has this patient wasted his potassium?

19.

a.The upper GI tract
b.The lower GI tract
c.The kidneys
d.The lungs

20. A 63-year-old black woman who is postmenopausal presents to the emergency department with an acute myocardial infarction. This is her second myocardial infarction in three years. Her medical history also is significant for asthma, hyperlipidemia, depression, and hypertension. Which of the following interventions should NOT be initiated to prevent subsequent cardiovascular events in this high-risk patient?

20.

a.Daily aspirin use.
b.Hormone therapy.
c.Diet modification.
d.Therapy for depression

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