1st LE Medicine

November 10, 2017 | Author: Dia Dimayuga | Category: Gout, Immune System, T Helper Cell, Allergy, Medical Specialties
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MEDICINE   ST 1  LONG  EXAMINATIONS     1.  Mr.  Roxas,  a  65-­‐year  old  diabetic,  noted  pus  oozing  from  a  wound  on  his  pedicured  big  toe.   After  2  days  he  was  noted  to  have  temperature  of  39C.  Despite  antibiotics  he  remained   rd highly  febrile.  On  the  3  day  of  fever  he  was  brought  to  the  ER  because  of  lethargy.  BP  was   70  systolic,  HR  of  130/min  and  RR  of  34/min.  What  cytokine  is  responsible  for  the   manifestations?   A. Tumor  necrosis  factor     B. Interleukin-­‐2   C. Interleukin-­‐4   D. GM-­‐CSF   TNF  is  resonsible  for  the  inflammatory  response  to  infection  up  to  the  point  of  symptoms  of   septic  shock.    IL-­‐2,  a  T  cell  cytokine  signals  other  lymphocytes  to  initiate  an  immune  response.     IL-­‐4,  a  Th2  cytokine,  signals  B  cells  to  produce  antibodies  also  for  proliferation  of  mast  cells.     GM-­‐CSF  tells  granulocytes  and  macrophages  to  proliferate.     2.  Ms.  Sanchez,  25  years  old,  has  been  experiencing  daily  bouts  of  sneezing  and  excessive   rhinorrhea  since  she  was  9  years  old.  Likewise  she  has  sneezing  and  nasal  itching  whenever   she  sweeps  the  floor.  What  is  one  cytokine  that  is  responsible  for  the  development  of  the   condition  described?   A. Interleukin-­‐1   B. Interleukin-­‐4*   C. Interferon-­‐gamma   D. TGF-­‐beta   IL-­‐4   (B)   is   a   product   of   T   helper   ceIls   that   signals   B   cells   to   produce   especially   IgE   antibodies   is   response   to   allergen   exposure;   also   signals   for   proliferation   of   mast   cells.     IL-­‐1   is   a   macrophage  cytokine  that  tells  Th  cells  to  initiate  an  immune  response.    IFN-­‐γ  Th1  cytokine   that   helps   mediate   cell-­‐mediated   immunity.     TGF-­‐β   usually   downregulates   YH1   or   Th2   immune  responses.     3.  A  virus  encountered  by  T/B  cells  results  in  an  immune  response  that  rids  the  agent  within   5-­‐7  days.  After  2  weeks  the  same  virus  is  re-­‐encountered.  The  host  does  not  manifest   symptoms  of  the  disease.  This  property  of  the  adaptive  immune  response  is:   A. Memory  *   B. Specificity   C. Diversity   D. Synergy   (A)  Memory  -­‐  non-­‐infection  during  the  2nd  encounter  is  because  of  the  anamnestic  response   triggered  by  the  memory  cells.       4.  Adhesion  molecules  are  necessary  for  the  following  step  involved  in  the  immune  response:   A. MHC-­‐antigen  interaction  with  TCR   B. C3  attaching  to  cell  targeted  for  destruction   C. Phagocytosis  of  microorganisms   D. Entrance  of  inflammatory  cells  into  affected  tissue  *   (D)  adhesion  molecules  attract  and  mediates  adhesion  of  inflammatory  cells  onto  the  vascular   wall  and  the  entrance  between  cell  junctions  into  the  site  that  needs  help  to  fight  of   pathogens.    Others  -­‐  no  connection  to  adhesion  molecules.  

5.  The  signal(s)  that  enable  T  cell  activation  are:   A. TCR  interaction  with  antigen   B. TCR  interaction  with  MHC   C. MHC  +  antigen  interaction  with  CD4  or  CD8   D. TCR  +  MHC-­‐antigen  interaction  and  CD28-­‐CD80  interaction*   (D)  are  the  2  signals  that  will  initiate  an  acquired  immune  response.    The  others  are  only   single  signals  or  the  wrong  molecules.     6.  This  process  taking  place  in  the  thymus  chooses  for  maturation  T  cells  that  have  low   affinity  for  self  peptides  attached  to  self  HLA:   A. Positive  selection   B. Negative  selection  *   C. Double  positivity   D. Single  positivity   The   stem   is   the   definition   of   (B)   negative   selection.     Positive   selection   is   apoptosis   of   T   cell   clones  that  have  no  or  excessive  affinity  for  self  HLA.    (C,D)  are  stages  in  the  maturation  of  T   cells.     7.  The  rhinovirus  enters  the  host  via  the  respiratory  system.  An  immune  response  against  the   virus  is  mounted  in  the:   A. Thymus     B. Peyer’s  patches   C. Lymph  nodes  *   D. Spleen   Inhaled   pathogens   are   brought   to   lymph   nodes   (C)   around   the   respiratory   tract   for   presentation   to   T     helper   cells.     Thymus   is   the   site   of   maturation   of   T   cells.     Ingested   pathogens  are  presented  to  Peyer's  patches  while  blood  borne  pathogens  are  presented  in  the   spleen.     8.  Hepatitis  B  virus  enters  the  host  via  shared  syringes  among  IV  drug  users.  An  immune   response  against  the  virus  is  mounted  in  the:   A. Thymus   B. Bone  marrow   C. Lymph  nodes   D. Spleen  *   (D)  Spleen  is  responsible  for  handling  blood-­‐borne  pathogens.    The  others-­‐  see  explanation  for   No.  10.     9.  Mr.  Reyes,  29  years  old,  was  found  to  be  HIV+  and  suffering  from  miliary  tuberculosis.  An   expected  result  from  various  tests  is:   A. Elevated  levels  of  immunoglobulins   B. Defective  microbicidal  action  of  phagocytes   C. Negative  PPD  *   D. Positive  intradermal  candida  test   (C)  is  the  phenomenon  of  anergy  observed  in  severe  viral  diseases  as  well  as  in  severe  forms  of   mycobacterial   infection.     (A)   By   the   time   HIV   patients   have   AIDS-­‐defininig   illnesses   (e.g.,   advanced   TB),   Igs   are   depressed   as   well.     (B)   does   not   happen.   (D),   like   PPD   test,   candida   test   is  to  test  T  cell  function.    It  will  beexpected  to  be  negative  as  well.    

10.  Aside  from  male-­‐male  sex,  another  mode  of  transmission  is  showing  an  increasing  trend:   A. Heterosexual  sex   B. Mother  to  Child   C. Needle  prick   D. Intravenous  drug  use  *   Self  explanatory     11.  You  are  formulating  a  new  antiretroviral  drug  that  will  prevent  viral  RNA  from  insinuating   itself  onto  the  host  DNA.  Your  target  molecule/enzyme  is:   A. Chemokine  receptor  acting  as  coreceptor  for  the  HIV     B. Reverse  transcriptase   C. Integrase  *   D. Protease     (C)  Target  integrase  to  prevent  viral  DNA  becoming  integrated  into  host  DNA.    The  rest  act  on   other  stages  of  the  life  cycle/  enzymes  of  the  virus.     12.  Mr.  Feliciano  experienced  fever,  fatigue,  myalgia,  and  headaches  for  a  week.  Two  weeks   after  the  illness,  he  is  worried  that  he  may  be  contracting  HIV  infection  because  he  had   unprotected  sex  with  a  casual  male  acquaintance.  You  recommend  the  following   examination  to  confirm  or  reassure  him:   A. HIV  ELISA     B. HIV  ELISA  then  Western  Blot  if  positive   C. HIV  DNA  PCR  *   D. Phenotyping  of  HIV   At   2   weeks   after   assumed   exposure,   the   anti-­‐HIV   immune   response   has   not   occurred,   therefore  no  antibodes  will  be  detected  yet.    The  virus  itself  or  its  components,  however  will   be  detectable  (C).    Phenotyping  measures  inhibitory  action  of  anti-­‐HIV  drugs  on  the  isolated   HIV  strain.     13.  Granuloma  formation  in  response  to  mycobacteria  is  an  example  of:   A. Type  I  hypersensitivity   B. Type  II  hypersensitivity   C. Type  III  hypersensitivity   D. Type  IV  hypersensitivity*   Granuloma   formation   around   the   tuberculosis   pathogen   is   cell   mediated   -­‐   Type   IV   reaction   (D).     14.  A  43  year  old  male  consulted  for  hematuria,  edema  and  was  found  to  be  hypertensive   several  months  PTC.  Anti-­‐hypertensives  were  given  and  he  was  lost  to  follow  up  until  he   began  developing  shortness  of  breath  then  a  few  hours  ago,  hemoptysis.  Immunoglobulins   were  identified  lining  basement  membranes  of  the  lungs  and  kidneys.  This  disease  is  an   example  of:   A. Type  I  hypersensitivity   B. Type  II  hypersensitivity  *   C. Type  III  hypersensitivity   D. Type  IV  hypersensitivity   The   disease   described   is   Goodpasture's   Syndrome   with   Igs   attacking   thecells   of   the   basement   membrane  in  the  lungs  and  glomeruli  -­‐  Type  II  reaction.    

15.  Mature  T  lymphocytes  that  emerge  from  the  thymus  have  survived  because:   A. They  have  no  affinity  for  self  antigens  *   B. They  have  no  affinity  for  self-­‐MHC   C. They  have  escaped  cytotoxic  action  of  natural  killer  cells   D. They  have  non-­‐functional  CD28   T  cells  that  have  undergone  positive  and  negative  selection  (A)  are  allowed  to  mature.    The   others  are  not  actual  events.     16.  This  autoimmune  disease  results  in  the  hyperactivity  of  the  affected  organ’s  physiologic   function:   A. Hashimoto’s  disease   B. Myasthenia  gravis   C. Type  I  diabetes  mellitus   D. Graves’  disease*   All  except  Graves'  disease  (D)  result  in  hypofunctioning  organs.     17.  A  35-­‐year  old  male  began  experiencing  easy  bruisability  with  hematomas  appearing  over   the  thighs  and  medial  surface  of  the  upper  extremities.  A  blood  exam  shows  a  hemoglobin  of   140,  hematocrit  of  40,  WBC  10  with  65%  neutrophils,  35%  lymphocytes  and  platelet  count  of   24,000.  You  suspect  this  autoimmune  disease:   A. Hemolytic  anemia   B. Idiopathic  thrombocytopenia*     C. Acute  myelogenous  leukemia   D. Aplastic  anemia   (B)   ITP   is   a   result   of   autoantibodies   against   platelets,   not   rbcs   (A).     The   others   are   not   autoimmune  diseases.     18.  A  49-­‐year  old  female  has  been  experiencing  extreme  driness  of  the  eyes  and  mouth  as   well  as  swelling  of  the  parotid  glands  for  the  past  4  months.  There  were  no  signs  of  arthritis   nor  renal  involvement.  ANA  test  showed  increased  levels  of  the  autoantibody  SSa.  Your   diagnosis  is:   A. Systemic  lupus  erythematosus   B. Dermatomyositis   C. Scleroderma   D. Sjogren’s  syndrome  *   (D)  is  the  disease  described.    SLE    -­‐  multisystemic  with  arthritis  and  nephritis.     Dermatomyositis  has  a  rash  and  proximal  muscle  weakness.    Scleroderma  is  waxy  appearance   of  face  among  others.     19.  In  atopic  individuals,  B  lymphocytes  receives  signals  from  Th2  cells  to  produce  an   excessive  amount  of:   A. IgG   B. IgA   C. IgM   D. IgE  *    IgE  is  the  Ig  involved  in  atopy  (D),  not  the  others.     20.  The  following  statement  about  IgE-­‐mediated  reactions  is  true:   A. An  allergen  is  capable  of  causing  mast  cell  degranulation  on  first  exposure  

B. C.

Nasal  congestion  is  characteristic  of  the  early  phase  allergic  reaction.   The  development  of  allergic  diseases  depends  on  the  interaction  between  genes   and  the  environment.  *   D. The  mast  cell  releases  inflammatory  mediators  48-­‐72  hours  after  allergen   attachment  to  IgE  receptors.   Only   (C)   is   true.     (A)   there   has   to   be   a   period   of   sensitization   from   the   first   exposure   to   the   reaction.    (B)  nasal  congestion  is  a  reflection  of  the  late  phase    allergic  reaction.    (D)  Mast  cell   degranulation  occurs  in  a  sensitized  individual  shortly  after  reexposure  to  the  same  allergen.     21.  Ms.  Gomez,  with  a  known  allergy  to  seafood,  developed  wheals  within  minutes  of  eating   her  favorite  food  –  shrimp  –  despite  taking  a  tablet  of  an  antihistamine  before  the  meal.  This   was  followed  by  a  feeling  of  a  lump  in  the  throat.  At  the  ER,  she  was  found  to  have  wheezing   all  over  lung  fields.  As  the  doctor  in  charge,  you  will  give:   A. Epinephrine  1:1000  dilution,  0.5  ml  IM  *   B. Diphenhydramine  50  mg  IM   C. Hydrocortisone  100  mg  IV   D. Beta-­‐2  agonist  nebulization   (A)  epinephrine,  undiluted,  is  the  drug  of  choice  and  is  life-­‐saving.    All  the  others  are  ancillary   measures.     22.  Mr.  Agulto  was  injected  with  benzathine  penicillin  IM  at  the  OPD.  Within  seconds,  he   collapsed.  BP  was  80/50,  HR=128/min.  Your  drug  of  choice  is:   A. Epinephrine  1:1000  dilution,  0.5  ml  IM*   B. Diphenhydramine  50  mg  IM   C. Dopamine  infusion   D. Beta-­‐2  agonist  nebulization   (A)   epinephrine   is   drug   of   choice   inthis   situation   with   hypotension   and   tachycardia.     (B,D)   are   ancillary.    (C)  is  given  for  additional  CVS  support  after  epinephrine  as  needed.     23.  The  following  condition  is  a  Type  B  reaction:   A. Diarrhea  and  malabsorption  after  5  days  of  co-­‐amoxiclav   B. Convulsions  and  coma  after  ingestion  of  15  tablets  of  500mg  paracetamol   C. Difficulty  of  breathing  after  one  tablet  of  ibuprofen  *   D. Epigastric  pain  after  ingestion  of  prednisone   (C)  is  an  idiosyncracy:  unpredictable  and  affecting  a  small  number  of  individuals  only.    (A,D)   are  side  effects  while  (B)  is  a  toxicity,  all  three  of  which  are  Type  A  drug  reactions     24.  Which  drug  is  most  likely  to  induce  an  immune  response?   A. Insulin  *   B. Penicillin   C. cefalexin   D. Erythromycin   Insulin   is   a   macromolecule   which   is   most   likely   to   induce   an   immune   response   compared   to   the  other  choices,  which  are  haptens.     25.  The  following  statement  best  describes  an  IgE-­‐mediated  reaction:   A. Red,  edematous  rash  over  the  area  48  hours  after  using  latex  gloves   B. Group  of  ten  people  with  diarrhea  after  eating  spaghetti   C. Urticarial  rash  within  an  hour  of  ingesting  shellfish  *  

D. All  of  the  above   (C)  is  a  typical  Type  I  reaction.    (A)  is  a  delayed  or  Type  IV  reaction.  (B)  is  food  poisoning.     26.  The  following  statement  is  true  about  the  management  of  drug  hypersensitivity:   A. Desensitization  is  indicated  in  every  adverse  reaction   B. Stevens-­‐Johnson  Syndrome  due  to  phenobarbital  ingestion  is  an  indication  for   gradual  oral  challenge   C. Withdrawal  of  the  suspected  drug  is  the  best  treatment*     D. Cephalosporins  are  the  best  alternative  for  amoxicillin  sensitivity   (C)  As  in  any  allergic  reaction,  withdrawal/avoidance  is  the  best  treatment.    (A)  substituting   with   a   drug   from   a   different   class   is   preferrable   to   desensitization.     The   latter   is   done   only   when  the  drug  is  the  only  appropriate  one.    (B)  Drugs  that  cause  exfoliating  reactions  should   never   be   tried   or   rechallenged   again.     (D)   shares   the   same   bicyclic   ring   structiure   of   amoxicillin  and  is  not  the  ideal  alternative.     27.  A  patient  started  anti-­‐tuberculosis  drugs  3  months  ago.  He  developed  fever  and  cough   around  8  days  ago  for  which  he  was  prescribed  amoxicillin  and  paracetamol  (taken  for  3   days).  A  day  ago,  he  developed  pruritic,  erythematous  urticarial  rash  and  swelling  of  the  lips   and  periorbital  area.  Upon  review,  your  foremost  suspect  among  the  drugs  taken  is:   A. Rifampicin   B. Isoniazid   C. Amoxicillin  /  0.25*   D. Paracetamol   By  review  of  drug  intake  and  temporal  relationship  of  the  exposure  and  the  reaction  (C)  is  the   most  possible.    (A,B)  have  been  given  for  a  long  time  without  problems  so  unlikely  suspects.     Amoxicillin   and   paracetamol   taken   at   the   same   time   but   by   review   of   literature,   amoxicillin   more  likely  than  paracetamol  to  give  the  symptoms.     28.  Georgia  experienced  anaphylaxis  after  eating  peanuts  and  crabs  in  one  meal.  A  skin  prick   test  was  done  when  the  reaction  subsided  after  2  days.  The  result  was  negative.  What  is  your   next  move?   A. Advice  the  patient  that  peanuts  and  crabs  can  be  returned  to  her  diet.   B. Advice  the  patient  that  peanuts  should  not  be  eaten  again.   C. Ideally  the  skin  test  is  done  2  weeks  after  the  anaphylaxis  episode.  *   D. Request  for  total  IgE.   After   an   anaphylactic   episode,   histaminestores   in   mast   cells   are   depleted.     A   skin   test   done   shortly   after   the   reaction   will   be   negative.     Histamine   is   restored   around   2   weeks   after   the   anaphylactic  episode  (C).    (A,B)  is  not  done.    (D)  is  useless.       For  questions  29-­‐32,  refer  to  the  following  case:  F.B.  is  a  25  year-­‐old  female  who  consults  the   out-­‐patient  clinics  because  of  pruritic  lesions  for  two  weeks.  Her  household  members  also   experienced  pruritus.  On  physical  examination,  excoriated  papules  were  noted  on  the   fingers,  toes,  and  periumbilical  area.         29.  This  patient  is  probably  suffering  from   A. scabies*   B. dyshidrotic  eczema   C. contact  dermatitis   D. Empitigo  

This  patient  has  the  typical  history  and  physical  examination  indicative  of  scabies.     30.  You  should  advise  the  patient  that  the  etiologic  agent   A. is  a  louse  that  causes  human  infestation   B. are  typically  present  in  thousands  in  infected  individuals   C. can  be  transmitted  by  fomites*   D. causes  a  characteristic  itching  both  day  and  night   Scabies   is   caused   by   a   mite.   It   is   only   present   in   thousands   in   immunocompromised   individuals.  Nocturnal  pruritus  is  characteristic.     31.  Upon  physical  examination  which  of  the  following  lesions  would  be  characteristic  of  the   disease?   A. nodule   B. burrow*   C. crust   D. ulcer   Burrows  are  the  characteristic  lesions  of  patients  with  scabies.       32.  The  patient  wants  to  be  further  educated  regarding  her  condition.  You  can  advise  that   A. sexual  transmission  of  the  disease  is  a  very  rare  occurrence   B. it  is  more  common  in  the  elderly  than  in  young  children  and  adults   C. males  are  more  commonly  affected  than  females     D. overcrowding  has  been  associated  with  this  condition*   The  disease  is  sexually  transmissible.  Its  occurrence  is  seen  both  in  young  children,  adults,  and   the  elderly.  Both  males  and  females  are  equally  affected.  Overcrowding  is  associated  with  this   condition.     33.  A  21-­‐year  old  known  asthmatic  male  is  brought  to  the  emergency  room  because  of   dyspnea  and  generalized  appearance  of  wheals  of  30  minutes  duration.  History  revealed  that   he  took  Penicillin  V  tablets  for  sore  throat  as  recommended  by  a  classmate.  What  is  your   diagnosis?   A. Rubeola     B. Acute  Urticaria*   C. Erythema  Multiforme  Minor   D. Erythema  Multiforme  Major     34.  A  26-­‐year  old  female  presents  with  erythematous  macules  and  patches  on  the  trunk  and   extremities  of  three  days  duration.  These  were  associated  with  fever,  painful  lips  and  eye   discharge.  The  patient  volunteered  that  she  self-­‐medicated  with  cotrimoxazole  one  week  ago   because  of  dysuria  and  urinary  frequency.  The  resident  who  saw  the  patient  is  suspecting   Steven-­‐Johnsons  Syndrome.  What  lesion  is  pathognomonic  for  this  condition?   A. vesicle   B. target*   C. wheal   D. purpura     35.  A  50-­‐year  old  female  complains  of  yellowish  plaques  on  both  inner  upper  eyelids  of  2   years  duration.  What  is  the  underlying  genetic  defect?   A. Familial  hypertriglyceridemia    

B. C. D.

Familial  hypercholesterolemia     Alpha-­‐1  apolipoprotein  deficiency   Familial  lipoprotein  lipase  deficiency*  

  36.  An  85-­‐year  old  female  is  diagnosed  with  Acrodermatitis  enteropathica.  Which  of  the   following  medications  will  lead  to  dramatic  improvement  of  her  skin  condition?   A. zinc  sulfate*   B. ascorbic  acid   C. copper  sulfate   D. beta-­‐carotene     37.  A  35-­‐year  old  male  diagnosed  with  ulcerative  colitis  is  referred  by  his  gastroenterologist   because  of  sudden  appearance  of  large,  extremely  painful  ulcers  and  boils  on  the  lower   extremities.  What  is  your  dermatologic  impression?     A. Decubitus  Ulcer   B. Multiple  Furuncolosis   C. Ecthyma  Gangrenosum   D. Pyoderma  Gangrenosum*     38.  A  5-­‐year  old  male  is  brought  to  the  Dermatology  OPD  clinic  because  of  dry  skin,  brittle   hair  and  edema  of  the  abdomen.  What  is  your  diagnosis?   A. Pellagra   B. Kwashiorkor*   C. Vitamin  A  deficiency   D. Acrodermatitis  enteropathica     39.  A  63-­‐year  old  male,  known  diabetic,  consults  because  of  shiny  yellow  plaques  on  both   shins  of  2  years  duration.  Physical  examination  revealed  telangiectasia  on  the  surface  of  the   lesions.  What  is  your  diagnosis?   A. Pyoderma  gangrenosum   B. Granuloma  annulare   C. Necrobiosis  lipoidica*   D. Stasis  dermatitis     40.  An  indigent  30  year-­‐old  pregnant  patient  consults  you  with  physical  findings  and  history   indicative  of  scabies.  Which  scabicide  would  you  opt  to  give  her  and  her  six  other  children?   A. lindane   B. sulfur*   C. permethrin   D. crotamiton   Sulfur   is   cheap   and   effective   in   treating   9   patients,   including   this   pregnant   patient.   Lindane   is   not  safe  for  the  patient.  Permethrin  is  expensive,  considering  that  this  is  an  indigent  patient   with  6  other  children  to  be  treated.  Crotamiton  has  very  low  cure  rate.     41.  A  20-­‐year  old  male  presents  with  skin-­‐colored  umbilicated  papules  on  the  suprapubic  and   pubic  area.  He  claims  to  have  noted  these  lesions  a  month  ago.  Which  is  true  about  his   condition?   A. It  may  have  been  acquired  through  sexual  contact  with  another  partner.*   B. Asymptomatic  viral  shedding  is  a  feature  of  his  condition.  

C. Multinucleated  giant  cells  can  be  seen  on  Tzanck  smear  of  typical  lesions.   D. It  can  invade  the  dermis  and  subcutaneous  tissue.   Molluscum  contagiosum  can  be  sexually  acquired  in  adult  individuals.  No  asymptomatic  viral   shedding   and   multinucleated   giant   cells   are   seen.   This   condition   does   not   invade   beyond   epidermis.     42.  P.C.,  a  34  year-­‐old  male,  married,  with  two  children,  noted  lesions  on  the  shaft  of  his   penis.  Upon  consult,  you  noted  multiple  hyperkeratotic  papules  on  the  penile  shaft  and  base   of  the  penis.  Which  is  true  about  his  condition?   A. Human  Papilloma  virus  types  16  and  18  are  the  common  etiologic  agents.   B. Imiquimod  applied  at  night  three  times  a  week  for  12  to  16  weeks  is  effective  in   treating  his  condition.*   C. Once  treated,  he  can  be  assured  that  he  will  not  have  the  condition  anymore.   D. All  of  the  above  are  true.   HPV   types   6   and   11   account   for   most   cases   of   genital   warts.   Even   after   treatment   with   imiquimod  he  can  still  have  recurrence  of  the  infection.     43.  Which  treatment  is  contraindicated  for  his  wife  who  has  similar  lesions  but  is  pregnant?   A. Podophyllotoxin*   B. Cryotherapy   C. Trichloroacetic  acid   D. Laser   Podophyllotoxin  is  contraindicated  in  pregnant  patients.     44.  A  24  y/o  woman  came  to  your  clinic  due  to  multiple,  well-­‐defined  erythematous  papules   and  plaques  with  thick,  loosely  adherent  silvery  white  scales  on  the  elbows,  knees,  trunk  and   scalp  of  one  year  duration.  Koebner  phenomenon  was  positive.  What  clinical  sign  can  you   elicit  in  order  to  help  you  with  your  diagnosis?   A. Darier  sign   B. Asboe-­‐Hansen  sign   C. Auspitz  sign*   D. Nikolsky  sign   The  case  described  is  Psoriasis.  In  order  to  aid  in  its  diagnosis,  Auspitz  sign  can  be  done  which   is  positive  if  pinpoint  bleeding  is  noted  when  scales  are  forcibly  removed  from  a  plaque.  Darier   sign  is  seen  in  urticaria  pigmentosa  wherein  a  wheal  is  produced  after  rubbing  the  lesion.  In   the  pemphigus  group  of  diseases,  an  autoimmune  blistering  disease,  the  ff.  signs  are  positive:   Asboe-­‐Hansen   sign   is   lateral   extension   of   a   blister   with   downward   pressure   on   a   blister/vesicle.  Nikolsky  sign  is  shearing  of  epidermis  upon  lateral  pressure  on  unblistered  skin.     45.  An  elderly  woman  complained  of  a  very  pruritic  lesion  on  her  nape  of  two  years  duration.   On  physical  examination,  you  see  a  thick,  erythematous  plaque  measuring  3x5  cm,  on  the  left   side  of  her  neck.  It  had  accentuation  of  skin  markings.  What  is  your  diagnosis?   A. Psoriasis   B. Lichen  simplex  chronicus*   C. Tinea  corporis   D. Lichen  planus   Lichen  simplex  chronicus  is  an  endogenous  dermatitis,  commonly  occurring  in  the  elderly.  The   lesions   are   found   on   accessible   areas,   such   as   the   neck,   hands   and   legs.   The   lesions   are   intensely  pruritic,  and  typically  are  thickened,  with  accentuation  of  the  skin  lines  or  markings.  

46.  An  infant  was  brought  in  to  your  clinic  due  to  erythematous  thin  plaques  on  her  cheeks   and  on  her  elbows.  Similar  lesions  are  seen  on  her  knees.  What  is  your  clinical  impression?   A. psoriais  vulgaris   B. seborrheic  dermatitis   C. measles   D. atopic  dermatitis*   The   predilection   sites   of   infantile   phase   of   atopic   dermatitis   are   the   face   (cheeks,   forehead)   &   extensor  surfaces  (knees  and  elbows)     47.  A  30  y/o  man  presented  with  erythematous  plaques  and  papules  in  the  shape  of  a  dragon   on  his  left  deltoid  area.  Ten  days  prior  to  consultation,  he  had  henna  tattoo  done  on  the   exact  area.  He  wondered  why  he  had  this  reaction  to  the  tattoo,  when  he  had  tattoos  done   several  times  in  the  past,  with  no  untoward  reactions.  Which  of  the  following  does  not   describe  the  condition  that  he  has?   A. The  dermatitis  will  initially  be  sharply  confined  to  site  of  contact,  later  spreading   beyond  area.   B. It  is  associated  with  intense  pruritus.   C. It  is  dependent  on  the  concentration  of  agent*   D. It  occurs  only  in  sensitized  individuals.   This   is   an   allergic   contact   dermatitis,   secondary   to   paraphenyldiamine   found   in   henna   tattoos.    ACD  is  not  dependent  on  the  concentration  of  the  agent  for  a    dermatitis  to  occur,    in   contrast  to  irritant  contact  dermatitis  wherein  it  is  dependent  on  the  concentration  of  the  acid   or  base.    In  ACD,  the  lesions  or  the  rash  develops  after  several  exposures  to  the  allergen  has   happened  (not  during  the  first  time  it  was  introduced,  ie,  not  the  first  time  the  patient  had  a   henna  tattoo).       48.  A  75  y/o  man  was  diagnosed  with  bullous  pemphigoid.  Which  of  the  following  do  you   expect  to  find  on  physical  examination?   A. Flaccid  bullae   B. Tense  bullae*   C. Positive  Nikolsky  sign   D. A  &  C  only   The   pemphigoid     group   of   diseases   present   clinically   with   tense   bullae.   Both   Asboe-­‐Hansen   and   Nikolsky   sign   will   be   elicited   in   the   pemphigus   vulgaris,   and   will   be   negative   in   bullous   pemphigoid.     49.  A  35  woman  was  referred  to  the  Dermatology  service  due  to  well-­‐defined  areas  of   eroded  skin  on  the  chest  and  back,  affecting  about  5%  of  the  total  body  surface  area.  She   also  had  erosions  on  her  oral  mucosa  and  genitalia.  The  cutaneous  lesions  started  to  appear   th on  her  5  day  on  antibiotic  therapy  (co-­‐trimoxazole)  given  for  urinary  tract  infection.  What  is   your  diagnosis?   A. Steven  Johnson  syndrome*   B. Erythema  multiforme   C. Toxic  epidermal  necrolysis   D. None  of  the  above   In   SJS   the   affected   area   is   less   than   10%,   in   Stevens-­‐Johnson   syndrome-­‐Toxic   epidermal   necrolysis   overlap,   epidermal   detachment   is   10-­‐30%   while   in   Toxic   epidermal   necrolysis   it   is   >30%.    

50.  A  50  y/o  American  man  came  in  due  to  a  large  ulcer  with  a  rolled  border  filled  with  black   necrotic  debris  on  his  right  nasolabial  fold.  Histopathologic  findings  were  consistent  with   basal  cell  carcinoma  (BCC).  Which  of  the  following  statements  is/are  true  of  BCC?   A. It  is  the  most  common  skin  cancer   B. >90%  occur  on  the  face   C. Rarely  occurs  in  dark-­‐skinned  individuals   D. All  of  the  statements  are  true*   Basal  cell  carcinoma    is  the  most  common  type  of  skin  cancer.    It  is  locally  invasive  but  with   limited   capacity   to   metastasize.     More   than   90%   occur   on   the   face.   It   is   more   common   in   Caucasians  or  those  with  Fitzpatrick  skin  types  1  &  2.     For  questions  51-­‐53,  refer  to  the  following  case:  A  41  y.o.  laundry  woman  presents  with  5-­‐10   mm  lesions  with  overlying  honey  colored  crust  on  her  lower  legs  of  about  1  week  duration,   with  increasing  number  of  lesions.     51.  Primary  diagnosis  would  be:   A. Hansen’s  disease   B. Scabies   C. Impetigo*   D. Herpes  zoster   Lesions   are   descriptive   of   impetigo.     Frequent   exposure   to   water   may   compromise   barrier   function  of  skin     52.  What  would  be  a  simple  laboratory  procedure  to  help  confirm  the  diagnosis:   A. KOH  stain   B. Tzanck  smear         C. AFB  stain   D. Gm  stain*   Gm  stain  is  a  simple  procedure  that  will  help  determine  presence  of  Gm  +  bacteria     53.  What  would  be  the  findings  in  the  test:   A. Multinucleated  giant  cells   B. Gm  (+)  cocci  in  clusters*   C. hyphae   D. Gm  (-­‐)  bacilli   Most  probable  finding  would  be  Gm+  cocci  in  clusters  (S  aureus)  or  Gm+  in  chain  (Strep)  (not   included  in  choice)     54.  A  40  y.o.  female,  obese,  consults  for  fluctuant,  erythematous,  tender  mass  (about  10   mm)  on  her  groin.  The  most  probable  diagnosis  is:   A. Erythrasma     B. Tinea  Cruris     C. Folliculitis   D. Furuncle*   Obesity  and  site  predisposed  to  friction  and  clinical  description  supports  probable  diagnosis  of   furuncle     For  questions  55-­‐56,  refer  to  the  following  case:  A  24  y.o.  male  consults  for  very  itchy  papules   and  vesicles  on  ball  of  plantar  area  of  L  foot,  with  involvement  of  2nd  and  3rd  digital  webs  

which  are  also  slightly  macerated.  The  lesions  are  of  4weeks  duration  and  slowly  increasing  in   area  of  involvement.         55.  The  most  probable  etiologic  agent  involved  is:   A. Candidia  albicans   B. Trichophyton  rubrum*   C. Corynebacterium  mi  nitissumum   D. Pityrosporum  ovale   Clinical   description   suggests   Tinea   pedis   especially   involvement   of   interdigital   webs.   Trichophyton  rubrum  is  one  of  the  more  common  dermatophytes  involved     56.  Recommended  treatment  would  be:   A. Griseofulvin   B. Azoles*   C. Erythromycin   D. Selenium  sulfide   Azoles   are   effective   for   dermatophytes.   Griseofulvin   ,   erythromycin,   Selenium   sulfide   and     are   not.       57.  Discrete  flaccid  bullae  with  some  lesions  having  crusting  on  the  surface  are  noted  on   lower  legs,  bilateral  of  a  22  yo  female.  She  also  has  some  inguinal  lymphadenopathy  and  low   grade  fever.  The  most  probable  diagnosis  is:   A. Epidermolysis  bullosa   B. Herpes  zoster   C. pemphigus   D. Bullous  impetigo*   Clinical   description   is   suggestive   of   infectious   nature   of   disease   and   bilaterality   excludes   Herpes  Zoster;  Bullous  Impetigo  is  most  probable  diagnosis.     58.  Testicular  pain  or  tenderness  is  one  of  the  criteria  in:   A. Polyarteritis  Nodosa  *   B. Hypersensitivity  vasculitis   C. Wegener’s  Granulomatosis   D. Kawasaki  Arteritis     59.  Mrs.  Delos  Reyes,  an  over  weight  65  years  old  and  a  previous  patient  of  yours  in  the  OPD   has  been  known  to  have  mild  osteoarthritis  of  the  knees.  She  came  in  today  due  to  increasing   pain  on  her  knees  especially  when  she  stands  up  coming  from  a  prolonged  sitting  position.   She  has  gained  more  weight  in  the  last  2  months.  The  major  risk  factor  for  the  progression  of   her  knee  osteoarthritis  is:     A. her  age   B. her  weight  *   C. her  gender     D. she  has  developed  Diabetes   Age   is   the   most   potent   risk   factor   for   OA.   OA   occurs   in   >50%   of   persons   over   age   70,   and   aging   increases   joint   vulnerability,   however,   obesity   is   a   major   risk   factor   in   increasing   its   prevalence  and  obesity  is  the  cause  of  its  high  rate  of  disability.      

60.  Joint  injuries,  such  as  what  happens  in  athletes  are  another  risk  factor  for  early  OA.   Malalignment  is  another  anatomic  abnormality  that  can  make  one  at  risk  for  OA.  Among   these  patients,  who  has  the  highest  risk  of  early  cartilage  loss?     A. a  patient  with  varus  deformity*     B. a  patient  with  valgus  deformity     C. a  normal  patient     D. a  patient  with  polymyositis   Varus   (bowlegged)   knees   w/   OA   are   exceedingly   high   risk   of   cartilage   loss   in   the   medial   or   inner   compartment   of   the   knee.   This   is   the   usual.   Whereas   valgus   (knock-­‐kneed)   malalignment   predisposes   to   rapid   cartilage   loss   in   the   lateral   compartment.   Patients   with   polymyositis  have  proximal  muscle  weakness,  hence  would  have  difficulty  standing  and  would   not  be  able  to  put  weight  on  their  knees.     61.  A  57  year  old  slightly  over  weight  teacher  came  to  you  complaining  of  mechanical  pains   on  her  knees.  You  suspect  early  stage  of  knee  osteoarthritis.  PE  of  the  knees  is  unremarkable   except  for  some  crepitations.  You  requested  XRAY  of  both  knees,  upon  looking  at  the  film,   you  see  that  the  joint  spaces  are  still  intact,  however  you  already  see  the  Radiologic  Hallmark   of  OA,  which  is:     A. juxta-­‐articular  osteopenia     B. Osteophytes     C. Bone  sclerosis*     D. Decreased  medial  compartment   Juxta-­‐articular   osteopenia   is   the   earliest   radiographic   manifestation   of   RA.   Osteophytes   are   an  important  radiographic  hallmark  of  OA,  they  form  near  areas  of  cartilage  loss  and  start  as   outgrowths   of   new   cartilage.   Bone   sclerosis   is   seen   in   more   advanced   OA,   so   as   diminution   in   the  space  of  the  medial  compartment.     62.  Nonpharmacotheraphy  has  been  the  mainstay  in  the  management  of  OA.  If  you  were  to   provide  an  exercise  program  to  your  patient  with  knee  OA,  what  would  be  the  most  effective   exercise  regimen?     A. aerobic  and/or  resistance  training*     B. range  of  motion  exercises     C. running     D. all  of  the  above   Aerobics  will  build  endurance  and  resistance  training  focuses  on  strengthening  muscles  across   the   joint.   ROM   exercises   alone   will   not   strengthen   muscles   and   running   is   impact   loading   w/c   you  do  not  want  in  a  joint  w/  OA.     63.  You  have  a  patient  with  mild  to  moderate  OA  of  the  Hands  and  Knees.  She  would  only   have  occasional  pains  with  VAS  (Visual  Analog  Scale)  pain  score  of  4/10.  Your  initial  analgesic   of  choice  is:     A. a  COX-­‐2  inhibitor     B. Paracetamol*     C. Ibuprofen     D. Prednisone   Acetaminophen  or  Paracetamol  is  the  initial  analgesic  of  choice  for  patients  with  OA  in  knee,   hip  or  hands.  Systemic  steroids  have  no  role  in  OA    

64.  Your  42  year  old  easy  go  lucky,  bachelor  uncle  who  lives  with  you  and  your  family   awakened  you  one  night  because  he  was  in  severe  pain.  He  said  that  the  pain  and  swelling   was  so  dramatic  that  everything  just  happened  that  night,  you  saw  his  left  big  toe  very  warm,   red,  swollen  and  very  tender.  You  thought  it  was  cellulitis  and  immediately  brought  him  to   the  ER.  At  the  ER,  you  realized  that  your  first  impression  was  wrong  when  you  heard  the   Medical  Resident  asked  this  question?     A. Are  you  a  drug  addict?     B. Did  you  have  excessive  alcohol  ingestion?*     C. Do  you  have  fever?     D. Have  you  had  this  before?   This   is   obviously   gout.   And   trigger   factors   are   very   important   to   ask,   commonly   in   young   males,   it   is   alcohol/ethanol   ingestion.   Fever   is   common   in   acute   gout   and   it   doesn’t   always   mean   there   is   infection.   It   is   also   important   to   ask   if   the   patient   had   a   similar   episode   already   in   the   past   because   that   would   increase   the   probability   that   this   is   really   gout.   However,   in   this   case,   the   trigger   factor   is   the   most   important   question.   This   patient   probably   had   a   drinking  spree  prior  to  the  attack.     65.  For  question  number  64,  the  Medical  resident’s  impression  is  gout.  He  ordered  serum   Uric  acid  level  but  turned  out  to  be  normal.  You  want  to  document  that  this  is  really  gout.   The  patient’s  left  first  MTP  is  still  swollen.  What  will  you  suggest?     A. Repeat  the  serum  Uric  Acid  after  2  weeks  on  your  uncle’s  follow-­‐up  in  the  OPD     B. Get  an  XRAY  of  his  big  toe     C. Aspirate  the  First  MTP  and  examine  the  fluid  for  MSU  crystals*     D. Wait  for  the  next  attack,  because  if  this  is  gout  he  will  certainly  have  another  attack   Even   if   the   clinical   appearance   strongly   suggests   gout,   the   presumptive   diagnosis   ideally   should   be   confirmed   by   needle   aspiration.   Needle-­‐shaped   MSU   crystals   are   seen   both   intracellularly   and   extracellularly.   w/   polarized   light,   these   crystals   are   brightly   birefringent   w/  negative  elongation.  Serum  Uric  acid  levels  are  not  diagnostic  of  gout.     66.  L.T.,  a  21  year  old  female,  now  diagnosed  to  have  SLE,  was  just  in  Boracay  last  April  for   her  summer  vacation  with  her  friends.  Among  the  pathogenesis  of  SLE,  which  do  you  think   was  triggered  by  her  vacation  in  Boracay?     A. genes     B. abnormal  immune  response*     C. autoantibodies  and  immune  complexes     D. Inflammation   This   patient’s   vacation   in   Boracay   exposed   her   to   sunlight   for   quite   a   long   period   of   time.   Exposure   to   UV   light   causes   flares   of   SLE   in   approximately   70%   of   patients,   possibly   by   increasing  apoptosis  in  skin  cells  or  by  altering  DNA  and  intracellular  proteins  to  make  them   antigenic.  Because  this  patient  is  genetically  predisposed,  that  abnormal  response  to  the  UV   light   made   her   produce   autoantibodies   and   immune   complexes   and   the   subsequent   inflammation  in  SLE.     67.  A  30  year  old  female  with  SLE  comes  to  you  with  her  urinalysis  result  that  showed:  Sp   gravity  1.002,  (+++)  proteins,  (-­‐)  sugar,  RBC  30-­‐40,  WBC  25-­‐30,  (++)  RBC  casts,  (++)  hyaline,   coarse  and  granular  casts.  You  know  there  is  definite  nephritis,  what  will  be  the  next  most   valuable  examination  that  you  will  perform  to  confirm  nephritis?     A. kidney  Biopsy*     B. Renal  Ultrasound    

C. RBC  morphology     D. 24  hour  urine  collection  to  measure  the  patient’s  total  protein  excretion   Nephritis   is   already   evident   with   presence   of   +++   proteinuria   and   casts,   we   don’t   need   ultrasound,   rbc   morphology   anymore.   We   do   24   hour   urine   for   protein   measurement   if   the   proteinuria   in   the   urinalysis   is   not   very   conclusive.   At   this   stage   we   should   determine   the   classification   of   her   nephritis,   this   will   help   us   in   the   choice   of   treatment   and   prognosis   of   the   patient.     68.  The  earliest  lesions  in  rheumatoid  arthritis  is:   A. Pannus  formation   B. Sequestration  and  destruction  of  Ig-­‐coated  circulating  cells   C. Microvascular  injury  and  an  increase  in  the  number  of  synovial  lining  cells  *   D. Bone  erosions     69.  A  22  year  old  female  presents  with  a  facial  rash  on  the  malar  area  sparing  the  naso  labial   fold.  She  also  has  arthritis  of  the  hand  joints  and  hair  loss  of  3  months  duration.  Her   laboratory  work  ups  revealed  a  urinalysis  with  +++  protein,  CBC  with  hemoglobin  of  90.  Other   indications  of  disease  activity  of  her  SLE  may  be:     A. high  C3     B. low  C3*     C. thrombocytosis     D. Lymphocytosis   In   active   SLE,   we   usually   encounter   decrease   levels   of   blood   elements   such   as   thrombocytopenia,   lymphopenia,   anemia   and   leukopenia.   Complement   levels   are   low   especially  in  cases  with  nephritis,  hence  you  expect  C3  to  be  low.       70.  An  18  year  old  female  college  student  was  brought  to  the  ER  after  a  grand  mal  seizure.   She  was  diagnosed  to  have  SLE  2  years  ago.  At  that  time,  she  presented  with  arthralgia,   fatigue,  alopecia,  a  butterfly  rash,  and  a  positive  ANA  (titer  1:640).  She  was  started  on   Hydroxychloroquine  200mg  twice  a  day  and  was  given  steroid  creams  for  her  facial  rash.  She   seemed  to  respond  well  to  treatment.  2  months  ago,  she  developed  tender  black  spots  on   the  skin  at  the  base  of  her  fingernails.  Her  facial  rah  worsened,  and  more  hair  had  fallen  out.   She  began  to  have  episodes  of  throbbing  frontal  headache,  and  on  the  day  of  admission,  she   suffered  a  generalized  tonic-­‐clonic  seizure  during  a  lecture  at  school  and  was  brought  to  the   ER.  Remembering  the  criteria  for  SLE,  her  manifestation  now  is:     A. idiopathic  epilepsy     B. CNS  infection     C. Intracerebral  thrombosis     D. CNS  lupus  *   Neurologic   manifestations   of   SLE   may   vary   from   just   a   simple   headache   to   a   frank   seizure.   This  is  CNS  manifestation  of  lupus     71.  A  40  year  old  patient  with  SLE  for  10  years  has  received  cyclophosphamide  and  rituximab   for  her  lupus  nephritis  class  IV  in  the  last  4  years.  This  patient  was  rushed  to  the  ER  due  to   difficulty  of  breathing.  On  auscultation,  there  were  coarse  and  wet  crackles  all  over  the  chest   wall.  Immediate  intubation  was  done  due  to  impending  respiratory  arrest.  Pulmonary  edema   and  possible  pulmonary  hemorrhage  was  the  initial  reading  of  the  Chest  Xray.  You  know  that   this  is  a  life-­‐threatening  condition  in  SLE.  What  must  be  given  to  this  patient?     A. pulse  Methylprednisolone*    

B. blood  transfusion     C. pulse  Cyclophosphamide     D. IVIG     For   life-­‐threatening   conditions   in   SLE   due   to   disease   activity,   we   give   pulse   methylprednisolone.  This  is  given  at  a  dose  of  1  gm  OD  for  3  days  in  the  hope  of  arresting  the   disease  activity.     72.  In  osteoarthritis,  nodes  in  the  distal  interphalangeal  joints  are  called:   A. Heberden’s  nodes  *   B. Bouchard’s  nodes   C. Osler’s  nodes   D. Erythema  nodosum     73.  A  32  year  old  mother  presented  with  an  8  week  history  of  pain  and  swelling  of  the  small   joints  of  her  hands,  followed  additively  by  swelling  of  her  knees,  shoulders,  and  ankles.  She   was  experiencing  4  hours  of  morning  stiffness  and  fatigue  during  the  day.  She  recalled   experiencing  a  mild  sorethroat,  low-­‐grade  fever,  and  myalgias  during  the  start  of  her   symptoms.  Pertinent  physical  examinations  are:  tenderness  on  both  shoulders,  MCP’s,  PIP’s,   knees  and  ankles.  Swelling  is  noted  on  the  MCP’s,  PIP’s,  knees  and  ankles.  What  will  be  of  use   for  you  to  document  your  diagnosis?     A. ANA     B. ASO  titer  and  ECG     C. ESR  and  anti-­‐CCP*     D. Xray  of  the  joints   The  diagnosis  here  is  Rheumatoid  arthritis,  therefore  increase  ESR  and  positive  anti-­‐CCP  will   be  of  benefit  for  us  to  document  the  diagnosis.  These  2  are  part  of  the  criteria/scoring  system   for  RA     74.  A  58  year  old  female  presented  to  you  with  a  history  of  left  knee  pain  and  swelling  of  6   weeks  duration.  This  was  followed  about  a  week  later  by  pain  and  swelling  of  3  of  her  MCP’s   and  3  PIP’s  on  both  of  her  hands.  You  are  thinking  of  RA  but  is  uncertain,  hence,  you   requested  for  a  CBC,  ESR,  Rheumatoid  Factor  (RF),  and  anti-­‐CCP.  CBC  turned  out  to  be   normal,  RF  was  negative,  but  the  ESR  was  70mm,  and  the  anti-­‐CCP  was  3x  the  upper  limit  of   normal.  What  is  your  score  now  based  on  the  new  classification  criteria  for  RA?     A. 5     B. 8     C. 10*   D. 12   Knee=1;   3MCP’s=2;   3PIP’s=2;   6   wks   duration=1;   elevated   ESR=1;   high   positive   anti-­‐CCP=3   total  score:  10;    A  score  of  6  or  more  is  needed  for  a  diagnosis  of  definite  RA     75.  A  45  year  old  patient  with  RA,  considered  Methotrexate-­‐naïve  who  has  now  sustained   multiple  joint  deformities.  Her  DAS-­‐28  score  is  still  high.  You  worked  up  the  patient  for   possible  initiation  of  Biologic  treatment.  Her  HBsAg  was  +,  her  XCR  showed  old  PTB  scar.  The   patient  could  not  tolerate  NSAIDS  due  to  epigastric  discomfort.  What  do  you  think  will  be  the   best  combination  treatment  for  this  patient?     A. high  dose  Prednisone,  Hydroxychloroquine,  and  Etanercept     B. low  dose  Prednisone,  Hydroxychloroquine,  and  Rituximab     C. low  dose  Prednisone,  Hydroxychloroquine,  and  Tocilizumab*    

D. low  dose  Prednisone,  Methotrexate,  and  Tocilizumab     Letter  C  will  be  the  ideal  combination.  She  would  not  be  able  to  tolerate  high  dose  Prednisone   due  to  epigastric  discomfort,  Rituximab  may  not  be  the  ideal  Biological  agent  for  her  due  to   the  positive  HBsAg.  She  is  considered  Methotrexate-­‐naïve,  hence  you  wont  use  Methotrexate   anymore.     76.  The  new  criteria  for  Rheumatoid  Arthritis  include  this  antibody  which  carries  greater   specificity  for  the  diagnosis  of  RA  than  a  positive  test  for  Rheumatoid  Factor:   A. TNF-­‐  alpha   B. Serum  anti-­‐  CCP*   C. ANA   D. GM-­‐CSF     For  questions  77-­‐78,  refer  to  the  following  case:  A  16  year  old  female  was  brought  into  the   ER  by  her  mother  due  to  fever  and  migratory  polyarthritis.  You  suspected  Acute  rheumatic   fever  (ARF).         77.  You  know  that  ARF  is  a  reaction  to  infection  with  group  A  streptococcus,  and  this  is  a   result  of:     A. genetic  disorder     B. cross-­‐reactivity*     C. hypersensitivity  reaction     D. over-­‐production  of  antibodies     When   a   susceptible   host   encounters   a   group   A   streptococcus,   an   autoimmune   reaction   results,   which   leads   to   damage   to   human   tissues   as   a   result   of   cross-­‐reactivity   between   epitopes  on  the  organism  and  the  host.     78.  For  the  above  patient,  you  would  ask  about  a  history  of  sore  throat  or  an  upper   respiratory  tract  infection,  since  for  ARF  there  is  a  precipitating  group  A  streptococcal   infection  before  the  appearance  of  the  clinical  features.  In  this  case,  you  would  suspect  that   the  infection  happened  approximately  about:     A. 2  months  ago     B. 3  days  ago     C. 6  months  ago     D. 3  weeks  ago  *   There   is   a   latent   period   of   approx.   3   weeks   (1-­‐5   wks)   between   the   precipitating   grp   A   strep   infection   and   the   appearance   of   the   clinical   features   of   ARF.   Exceptions   are   chorea   and   indolent  carditis,  w/c  may  follow  prolonged  latent  periods  lasting  up  to  6  months.     79.  An  elderly  male  came  in  due  to  a  new-­‐onset  headaches.  On  PE,  his  temporal  artery  on  the   left  is  very  prominent  and  tender.  Your  impression  is  Giant  Cell  Arteritis.  This  condition  is   closely  associated  with:     A. Polymyalgia  rheumatic*     B. Rheumatic  fever     C. Temporal  arteritis     D. Takayasu  arteritis   Giant   cell   arteritis   is   closely   associated   with   polymyalgia   rheumatica   ,   w/c   is   characterized   by   stiffness,  aching,  and  painin  the  muscles  of  the  neck,  shoulders,  lower  back,  hips,  and  thighs.   It   may   be   seen   in   40-­‐50%   of   patients   w/   giant   cell   arteritis.   In   addition,   10-­‐20%   of   patients  

who   initially   present   w/   polymyalgia   rheumatica   may   later   go   on   to   develop   giant   cell   arteritis.  Temporal  arteritis  is  another  name  for  giant  cell  arteritis.   Takayasu   arteritis   is   another   type   of   large   vessel   vasculitis,   it’s   also   called   the   pulseless   disease.       80.  A  23  year  old  male  was  admitted  in  the  ward  due  to  palpable  purpura  on  his  lower   extremities.  Your  differential  diagnoses  are  Hypersensitivity  Vasculitis,  Henoch-­‐Schonlein   Purpura,  and  Churge-­‐Strauss  Syndrome  because  all  of  these  are  small  vessel  vasculitis  and   may  present  as  palpable  purpura  on  the  lower  extremities.  For  small  vessel  vasculitis,   common  histopathological  finding  on  skin  biopsy  is:     A. fibrinoid  necrosis     B. aneurysm  formation     C. leucocytoclasis*     D. Thrombosis   Leucocytoclasis,  a  term  that  refers  to  the  nuclear  debris  remaining  from  the  neutrophilsthat   have   infiltrated   in   and   around   the   vessels   during   the   acute   stages.   This   is   typical   feature   of   cutaneous  vasculitis  of  small  vessels.     81.  A  30  year  old  male  is  being  seen  by  a  Rheumatologist  due  to  an  axial  arthritis.  His  history   started  as  a  dull  pain,  insidious  in  onset,  felt  deep  in  his  lumbar  and  gluteal  area,   accompanied  by  low-­‐back  morning  stiffness  that  improves  with  activity.  The  hallmark  in  this   patient  is:     A. muscular  spasm     B. sacroilitis*     C. syndesmophyte     D. bamboo  spine   This   patient   has   Ankylosing   spondylitis.   Sacroilitis   is   usually   the   earliest   manifestation,   and   this  is  the  explanation  for  the  initial  low  back  pain  and  stiffness.  The  muscular  spasm  may  be   just   secondary,   syndesmophytes   are   the   bony   excrescences   that   are   formed   when   the   outer   annular   fibers   are   already   eroded,   then   you’ll   see   bamboo   spine   because   the   spine   has   already  ankylosed.     82.  A  25-­‐year-­‐old  graduate  student  presents  with  a  10-­‐day  history  of  arthritis.  She  developed   a  fever  of  39  degrees  Celcius  with  chills,  followed  by  pain  and  swelling  in  the  2nd  and  3rd   MCP  and  PIP  joints  of  her  left  hand  and  the  2nd,  3rd,  and  4th  MCP  joints  of  her  right  hand,   which  lasted  3  days.  As  the  small  joint  swelling  disappeared,  her  left  wrist  became  slightly   red,  warm,  swollen,  and  very  painful  to  flex  or  extend  for  2  to  3  days.  As  the  wrist  became   normal,  her  left  knee  became  red,  swollen,  tender,  and  warm,  and  has  remained  so  now  for  4   days.  She  has  a  mild  sore  throat  and  has  also  noticed  small  skin  lesions  on  her  arms.  Which   characterization  best  describes  the  presentation  and  evolution  of  this  patient’s  illness?   A.  Chronic  Polyarthritis   B.  Acute  migratory  Polyarthritis  *   C.  Acute  Intermittent  Monoarthritis   D.  Nonarticular  Pain  Syndrome     83.  A  32-­‐year-­‐old  mother  presented  with  an  8  week  history  of  pain  and  swelling  of  the  small   joints  of  her  hands,  followed  additively  by  similar  involvement  of  her  knees,  shoulders,  and   ankles.  She  was  experiencing  2  hours  of  morning  stiffness  and  fatigue  during  the  day.  She   recalled  experiencing  a  mild  sore  throat,  moderate-­‐grade  fever,  and  myalgias  a  week  before.  

Pertinent  physical  examinations  are:  tenderness  on  both  shoulders,  MCP’s,  PIP’s,  knees  and   ankles.  Swelling  is  noted  on  the  MCP’s,  PIP’s,  knees  and  ankles.  Most  likely  diagnosis  is:   A. Rheumatic  fever   B. Rheumatoid  Arthritis  *   C. Reactive  Arthritis   D. Viral  Arthritis       84.  Which  of  the  following  is  most  specific  for  the  diagnosis  of  gout?   A. elevated  serum  uric  acid   B. monosodium  urate  crystals  in  the  synovial  aspirate  *   C. calcium  dihydrophosphate  crystals  in  the  synovial  aspirate   D. radioluscent  bone  erosions  on  the  sites  of  tophi     85.  A  30  year  old  female  diagnosed  with  SLE  came  to  you  for  follow-­‐up.  You  diagnosed  her   with  nephritis  based  on  her  urinalysis  which  showed:  +++  proteins,  5-­‐10  RBC,  and  RBC  casts.   To  monitor  the  activity  of  the  nephritis,  the  marker  antigen  that  you  will  use  is:   A. Anti-­‐histone   B. Anti-­‐Sm   C. Anti-­‐DsDNA  *   D. ANA     86.  As  a  measure  of  toxicity,  the  LD50  of  a  substance  is  defined  as:   A. The  maximum  dose  at  which  50%  of  the  known  adverse  effects  are  expressed.   B. The  dose  expected  to  cause  50%  mortality  among  test  animals.*   C. The  ability  of  the  substance  to  kill  test  animals  at  50%  the  specified  dose.   D. The  probability  that  50%  of  the  maximum  recommended  dose  will  cause  death  on  a   test  animal.     87.  A  class  of  insecticide  sprays  is  being  evaluated  for  its  safety  for  use  in  homes.  However   toxicity  of  inhaled  microscopic  droplets  to  humans  becomes  an  issue  for  all  of  them.  Which  of   the  ff.  statements  is  true?   A. The  one  with  the  highest  LC50  is  the  least  potent,  but  safest  to  humans.*   B. The  one  with  the  highest  LC50  is  the  most  toxic  to  both  insects  and  humans.   C. The  one  with  the  lowest  LC50  is  the  least  potent  insecticide  but  safest  for  humans.   D. The  one  with  the  lowest  LC50  is  the  most  toxic  to  insects  but  safest  for  humans.     88.  Miosis  is  an  expected  finding  among  patients  with  toxic  exposures  to:   A. Amphetamines   B. Beta  blockers*   C. Ethanol   D. carbamate     89.  In  which  of  the  following  poisoning  by  ingestion  is  gastric  lavage  CONTRAINDICATED?   A. Paracetamol  overdose   B. Malathion  ingestion   C. NaOH  (lye)  ingestion*   D. Isoniazid  overdose    

90.  The  resulting  phocomelia  from  intake  of  thalidomide  during  the  1st  trimester  of   pregnancy  is  the  result  of  the  expression  of  the  toxic  effect  of  the  drug  as  a:   A. Mutagen   B. Teratogen*   C. Carcinogen   D. Cytotoxin     91.  A  5  year  old  kid  ingested  kerosene  contained  in  a  bottle  of  Seven-­‐up®  which  he  mistook   for  the  soda  drink.  He  promptly  vomited  and  the  frantic  mother  brought  him  to  your   attention.  You  should:   A. Do  a  chest  x-­‐ray  to  check  for  chemical  pneumonitis.*   B. Insert  an  NGT  and  do  gastric  lavage.   C. Give  activated  charcoal  to  get  rid  of  the  remaining  kerosene  ingested.   D. Give  the  child  a  cathartic  to  hasten  elimination  of  the  ingested  kerosene.     92.  This  morning  over  breakfast,  a  26  y/o  male  cousin  casually  told  you  his  migraine   headache  was  at  its  worst  the  day  before,  he  took  a  total  of  no  less  than  twenty  500  mg   tablets  of  acetaminophen  in  the  last  24  hours.  He  took  four  Mefenamic  Acid  500  mg  capsules   with  a  midazolam  (a  short  acting  benzodiazepine)  tablet  last  night  to  put  him  to  sleep.  He   claims  he  feels  fine  and  cursory  neurologic  examination  seems  normal.  Which  of  the   following  should  be  your  course  of  action  –  toxicology-­‐wise?   A. Prudent  observation  should  be  enough,  he  is  asymptomatic.   B. He  should  undergo  gastric  lavage.   C. He  should  be  given  pyridoxine  as  antidote.   D. He  should  be  in  the  hospital  immediately  and  the  antidote  started.*     93.  After  discovering  that  her  husband  was  having  an  affair,  a  29  y/o  housewife  took  a  250  ml   bottle  of  muriatic  acid  and  drank  it  in  front  of  him.  The  husband  claims  she  was  able  to  take   three  gulps  before  screaming  in  pain  and  throwing  up.  She  is  now  in  your  care  at  the  ER.   Which  of  the  following  is  appropriate  for  this  patient?   A. Gastric  lavage  with  plain  water   B. Activated  charcoal  administration   C. Mg(OH)2-­‐Al(OH)3  antacid  to  neutralize  the  ingested  acid.   D. Stabilize  patient  &  refer  the  patient  for  endoscopy.*     94.  A  36  year  old  known  drug  pusher  was  brought  to  jail  shortly  after  a  buy-­‐bust  operation.   Three  hours  later  he  started  to  manifest  signs  of  amphetamine  toxicity.  Witnesses  claim  they   saw  the  suspect  swallow  several  plastic  packets  before  police  caught  up  with  him.  He  was   brought  to  the  hospital  for  two  reasons:  the  police  wanted  the  evidence  retrieved,  and   wanted  him  well  enough  so  he  could  pinpoint  his  source.  The  best  thing  to  do  is:   A. Obtain  gastric  aspirate  for  analysis,  start  lavage,  and  treat  the  toxicity.   B. Collect  urine  sample  for  assay,  do  whole  bowel  irrigation  and  start  treatment  of   toxicity.*   C. Extract  blood  samples  for  assay  and  start  your  treatment.   D. Collect  urine  sample  for  analysis  and  start  treating  the  toxicity.     95.  Poisoning  patients  who  go  into  protracted  episodes  of  seizures  may  go  into   rhabdomyolysis.  Expected  sequelae  in  these  patients  include:   A. Hypokalemia  with  cardiac  compromise  

B. C. D.

Hyperkalemia  and  renal  failure*   Undue  diuresis  and  dehydration   Hypercalcemia    

  96.  Patients  of  poisoning  often  have  temperature  homeostasis  problems  as  part  of  the   toxidrome.  Which  of  the  following  statements  is  true?   A. Hypothermic  patients  must  have  their  body  temperature  raised  rapidly  to  prevent   end  organ  damage.   B. Ice  baths  are  indicated  for  hyperthermic  patients.  *   C. Hypothermia  usually  persists  even  if  the  toxin  has  been  eliminated.   D. Hyperthermia  may  be  seen  in  oral  hypoglycemic  and  sedative  hypnotic  overdose.     97.  Activated  charcoal  is  sometimes  referred  to  as  the  “universal  antidote”  in  poisonings  by   ingestion.  This  is  because:   A. The  GIT  absorbs  it,  goes  into  enterohepatic  circulation  and  picks  up  toxins  on  its   way  out.   B. It  neutralizes  a  lot  of  toxic  substances  in  the  GIT.   C. It  is  inert  and  adsorbs  a  variety  of  poisons  in  the  GIT.*   D. It  is  a  cathartic  and  an  antidote  to  a  variety  of  poisons.     98.  Atropine  reverses  the  toxic  effects  of  anticholinesterases  like  carbamates  &   organophosphates  by:   A. Accelerating  their  urinary  excretion.     B. Competitive  inhibition  at  the  receptor  sites.*   C. Bypassing  the  physiologic  effects.   D. Forming  an  inert  complex  with  the  poison.     99.  A  depressed  post-­‐partum  26  y/o  female  ingested  some  43  (potentially  fatal  number  of)   iron  fumarate  pills  and  was  brought  to  your  attention.  She  was  also  on  antidepressant   medications.  The  patient  claims  she  feels  fine.  Abdominal  x-­‐ray  verified  the  presence  of  the   radio-­‐opaque  tablets  and  has  entered  the  small  intestines.  Deferroxamine,  will  not  be   available  until  72  hours  later.  The  best  thing  to  do  is  to:   A. Induce  vomiting.   B. Insert  NGT  and  give  repeated  doses  of  activated  charcoal  slurry.   C. Wait  until  deferroxamine  is  available   D. Start  whole  bowel  irrigation*     100.  The  effect  of  a  potentially  fatal  ingested  poison  may  be  mitigated  by  forcing  the  poison   to  form  inert  complexes  with  the  “antidote”.  This  is  exemplified  by:   A. Administering  starch  slurry  in  Lugol’s  iodine  solution  ingestion.*   B. IV  ethanol  administration  in  methanol  poisoning   C. Use  of  atropine  in  carbamate  inhalation.   D. Use  of  flumazenil  in  benzodiazepine  overdose.    

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