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

End of Rotation Exam
October 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, 2 and 3

A 91 year old man is brought to the emergency department form local ALF because of weakness and diarrhea of several days duration. The patient has a history of prostate cancer treated with radiation therapy years prior to entry. At this time, he is also complaining of dysuria and nausea. On physical examination, the temperature 97.8 deg F (36.6 deg C), blood pressure 95/60, pulse rate 68, and the respiratory rate was normal without labored respirations. The mucous membranes were dry. The neck was supple. The chest was clear. The heart rate was regular. There was mild abdominal distension and the bowel sounds were decreased. The initial laboratory studies revealed the following data:
WBC 37,500/mL with 80% segmented neutrophils, 12% bands, 3% lymphocytes. Hct 35%.

Na 138 mEq/L, K 3.0 mEq/L, Cl 105 mEq/L, HCO₃^– 18 mEq/L, BUN 30 mg/dl, creatinine 1.6 mg/dl, and glucose 78 mg/dl.

UA spec. gravity 1.016, protein 100 mg/dl, neg. leukocyte esterase and nitrite. RBCs 50-100/hpf. WBC 10-20 /hpf.

1. Which of the following is the MOST APPROPRIATE admitting diagnosis?

2. Which of the following statements is true?

2.-

a.There are signs of metabolic acidosis
b.There are signs of compensated respiratory acidosis
c.There are signs of acute, uncompensated respiratory alkalosis

3. Which of the following intravenous fluid regimens is MOST APPROPRIATE?

3.

a.D5W 0.45 NS with 40 mEq/KCl per liter at 80 ml per hour.
b.D5W with 40 mEq/L KCl per liter at 45 ml/hr.
c.D5W NS with 20 mEq/L KCl per liter at 80 ml/hr.
d.Normal Saline at 125 mg/hr.

4. Which of the following statements IS NOT true?

a.Avian influenza A (H5N1) has resulted in more than 150 deaths in humans throughout the globe.
b.Avian influenza (H5N1) has been shown to be able to be transmitted from human-human rapidly and effectively.
c.Avian influenza (H5N1) cannot be prevented through the standard influenza vaccination being administered presently in the United States.
d.Human cases of avian influenza (h5N1) have been reported from Africa, Europe and Asia.

5. An 80-year-old man is brought into the emergency department because of shortness of breath. He has been complaining of cough for a few days at home. The family denies fever and notes the presence of scant sputum production. The patient, despite his age, has been active in his condominium association and in his church until this time. On examination he appeared to be in mild respiratory distress. His vitals signs were as follows: Blood pressure 108/79, pulse 110, respiratory rate 24, temperature 99.4 deg F (37.4 deg C). Chest exam revealed rales posteriorly. Heart sounds were irregular. Abdomen is mildly distended. Extremities revealed mild edema. An EKG was performed and is available for your review. Which of the following IS TRUE?

a.Patient has congestive heart failure and sinus tachycardia
b.Patient has signs of left ventricular dysfunction and atrial fibrillation.
c.The patient has congestive heart failure and an acute anterior wall myocardial infarction.
d.The patient has complete right bundle branch block and ventricular tachycardia.

6. A 58-year-old man is referred from the emergency department to your primary care medical practice. He was seen in the ER one week prior because of the acute onset of abdominal pain. An emergency work up for the latter revealed a small, fibrotic liver on a sonogram. He reports that the pain has resolved with a prescription for a proton pump inhibitor. The patient denies risk factors for hepatitis B or C, or a family history of chronic liver disease. On examination, the patient is not jaundiced but has gynecomastia. The abdomen is entirely negative for ascites or organomegaly. The ER records reveal an elevation of serum aspartate transaminase (AST) and alanine transaminase (ALT) levels in a 2:1 ratio. Which one of the following diagnoses is most likely at this time?

a. Biliary cirrhosis
b. Hemochromatosis
c. Non-alcoholic fatty liver disease.
d. Wilson’s Disease

7. A 52-year-old woman is seen in the outpatient service because of headaches. She has a history of migraines since she was in her twenties. At this time, 2 weeks prior, she began to have severe headaches, non-lateralizing, associated with visual changes. Her usual migraines were associated with menstruation but she has been menopausal since about 2 years prior. On examination, her temperature is 102.2 deg F (39.0 deg C), pulse 103 reg, respiratory rate 18, and blood pressure 150/83. The physical examination revealed the tympanic membranes to be somewhat retracted, otherwise unremarkable. Her WBC was 11,500 / mL. Erythrocyte sedimentation rate was 97 mm/hr. Which of the following course of action IS MOST APPROPRIATE?

a.Begin treatment with Ampicillin and nasal steroids and refer the patient to otolaryngology in two weeks for outpatient evaluation.
b.Admit patient to hospital and perform a lumbar puncture to rule out meningitis.
c.Begin prednisone orally, obtain outpatient ophthalmology consultation and follow patient in 2 weeks.
d.Admit patient to hospital, order blood cultures, CT head, begin steroid treatment intravenously, and antibiotic coverage.

8. A 64-year-old woman with a well-documented history of chronic hepatitis C disease is hospitalized for a 2-week history of abdominal pain. She has been worked up in the outpatient service with a CT of the abdomen and pelvis with contrast and the liver appeared small, the spleen enlarged but no filling defects or fatty stranding of the pericolic fat were noted. The presence of ascites was documented. She developed fever, and worsening ascites over the course of the next week. In the past several days the patient has developed nausea. An abdominal paracentesis revealed cloudy ascetic fluid with Gram-negative bacilli on Gram-stain. Which one of the following courses of action is most appropriate at this time?

a.Refer patient to oncologist for evaluation of abdominal carcinomatosis.
b.Begin treatment with cefotaxime (Claforan) intravenously
c.Consult surgery for immediate laparotomy to seal presumed perforation of the bowel.
d.Repeat abdominal paracentesis with careful attention to the preparation of the abdominal wall in order to avoid contaminants.

9. A 71-year-old man is seen in the outpatient service because of abdominal pain. The pain is described as 7-8/10, mid-abdominal and radiating to the back. It is associated with nausea but the patient has not vomited before seeing you. He denies fever. The patient has no history of alcohol use. He has carbohydrate intolerance in a 3-hour test performed one-month prior. He is on metoprolol and hydrochlorothiazide for blood pressure control. He has no history of peptic acid disease but takes a baby aspirin daily. His past surgical history reveal a cholecystectomy 20 years ago without complications. On examination, he appears in mild distress without jaundice. His vital sings are as follows: Temperature 96.7 deg F (35.9 deg C ), pulse 101 reg, blood pressure 106.88. The abdomen is slightly full with minimal tenderness at the epigastrium. His laboratory studies reveal the following:

WBC of 7,100 / mL, Hct 37.8%.

Na 132 mEq/L, K 4.5 mEq/L, Cl 100 mEq/L, HCO₃^– 26 mEq/L, BUN 19 mg/dl, creatinine 1.2 mg/dl, and glucose 166 mg/dl.

Serum triglyceride 998 mg/ml.

Which of the following is the most likely diagnosis?

9.

a.Acute cholangitis.
b.Acute pancreatitis
c.Gastritis
d.Gastroenteritis

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10. Which of the following therapeutic approaches is contraindicated in the management of hepatic encephalopathy?

10.

a.Provide a balanced diet containing at least 80 grams of protein per day.
b.Use non-absorbable broad-spectrum antibiotics such as neomycin orally.
c.Provide lactulose orally.
d.Restrict the sodium intake.

11. Which of the following is THE LEAST COMMON cause of death in a patient who has been treated for diabetic ketoacidosis?

11.

a.Cerebral edema
b.Hypokalemia
c.Hyperglycemia
d.Hypoglycemia

12. Diabetic ketoacidosis is characterized by all of the following except?

12.

a.Ketoacidosis ensues from a state of catabolism and insulin deficiency.
b.Rising blood glucose results in hyperosmolar state, diuresis and dehydration.
c.Due to elevated glucose levels, there is rapid lipogenesis.
d.Fatty acid break down in the liver leads to free fatty acids in the circulation.

13. A 45-year-old woman is brought by fire rescue to the emergency room with history of chest pain. She apparently was donating blood at a community center when she felt weak and nearly passed out. According to the patient’s daughter who arrived at the hospital with her, she turned pale, ashened, cold, diaphoretic and weak soon after the blood donation began. The patient denies dyspnea. She has no history of heart disease or angina. She exercises rarely like 80 percent of Americans.

On physical examination, she appears apprehensive but in no acute distress. Blood pressure after receiving 500 ml of normal saline intravenously is 114/72, pulse rate 52 reg, and respirations unlabored. The chest, heart and neurologic physical exams are otherwise normal. An EKG is obtained and is available for your review. Which of the following diagnoses is MOST APPROPRIATE?

13.

a.Acute antero-septal-lateral myocardial infarction
b.Pulmonary embolism
c.Air embolism
d.Vasovagal Attack

14. A 96-year-old woman is brought into the emergency department because of shortness of breath and weakness. The symptoms have been creeping up since 12 hours according to a relative who has accompanied her in the fire rescue vehicle. There is no history of chest pain cough or fever. The patient has a history of hypertension and leg swelling. On examination, she appears oriented but in mild distress. Her vital signs are as follows: Blood pressure 164/66, pulse 72 reg, respirations 18 unlabored, temperature 98.2 deg F (36.8 deg C). The chest reveals fine rales posteriorly. The heart sounds are distant. Laboratory studies reveal:

WBC 6,600 /mL. Hct 39 %

Na 140 mEq/L, K 5.0 mEq/L, Cl 103 mEq/L, HCO₃^– 28 mEq/L, BUN 52 mg/dl, creatinine 1.8 mg/dl, and glucose 181 mg/dl.

UA spec. gravity 1.010.

Pro-BNP 2712 ng/ml.

Which of the following diagnosis is most likely?

14.

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

15. A 62-year-old man who works as a driver for the hospital transportation system presented to the emergency department with complaints of slurred speech for 2 hours the night prior to entry. He denies a history of drug use, head trauma, headaches or visual symptoms. He does not smoke and drinks rarely during the holydays. He is monogamous and faithful. He takes no medications. On examination he appears concerned but in no distress. The blood pressure is 160/95, the pulse 90 regular and the respirations unlabored. His speech is normal. The face is symmetrical. There are no lateralizing signs in the neurologic examination. The plantar response is downward. Which of the following course of action is MOST APPROPRIATE?

15.

a.Obtain baseline laboratory studies and refer patient for cardiac outpatient work up
b.Admit the patient to hospital and perform lumbar puncture to rule out a CNS inflammatory process.
c.Observe and work up patient in hospital with a diagnosis of TIA and high risk for stroke.
d.Admit patient to hospital and immediately observe for CVA and perform cardiac and neurologic work up.

16. A 38-year-old man presents with one-week history of sore throat. He complains of fever to 101 deg F (38.3 deg C) and cough. He has a history of mild dyslipidemia but denies smoking, drugs, multiple sexual partners, exposure to environmental toxins or travel. On examination, he appears somewhat ill but in no acute distress. He has 1-2 cm cervical nodes that are tender and yellowish tonsillar exudates. Chest exam is clear and the heart reveals no murmur or rub. Which of the following courses of action is most appropriate?

16.

a.Treat with amoxicillin
b.Throat culture and treat with amoxicillin if positive
c.Rapid strep test and if positive, treat with amoxicillin

17. A 71-year-old man is brought to the outpatient clinic because of shortness of breath and dizziness. His symptoms have been noted since about two days. He suffers from high cholesterols and has had two TIA’s in the past 5 years. He drinks alcohol occasionally and denies drugs and recent medication history except for a statin. On examination, he appears to be in no acute distress. His blood pressure is 138/78, the pulse is 63 reg. An EKG is performed and it is available for your review. Which of the following courses of action seems MOST APPROPRIATE?

17.

a.Obtain echocardiogram
b.Obtain Electrolytes
c.Refer patient to cardiology for cardiac catheterization.
d.Manage for Acute Coronary Syndrome.

18. You are preparing a set of policies and procedures for your new practice. The issue is medication adherence. Which of the following IS NOT something you would recommend in your pamphlet or in your policies?

18.

a.Try to prescribe medications that can be given once a day.
b.Have your medical assistant and receptionist read the prescriptions and emphasize to the patient and the family the need to comply with the instructions.
c.To expedite time in the office, avoid involvement of your staff and recommend that the patient discuss the medication and the reason for using it in this case with the pharmacist.
d.Consider financial costs and “preferred lists” when prescribing.

19. Syphilis is known to affect all organs of the body throughout its acute, latent and chronic phases. Which of the following cardiac structures and/or pathological entities is most commonly associated with syphilitic infection?

19.

a.Conduction system disease
b.Mitral valve myxomatous degeneration
c.Aortitis
d.Myocarditis

20. Which of the following statements IS NOT TRUE regarding bronchogenic carcinoma?

20.

a.Patients may be asymptomatic at the time of diagnosis
b.About 70% of bronchial carcinomas arise in the hilar region.
c.Like other cancers, bronchial carcinoma has now a prognosis that is 5 times better than what it used to be 20 years ago.
d.Full respiratory and pulmonary evaluation is needed before surgery. An FEV 1 equal or less than 1.5 is not compatible with life post pneumonectomy.

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