IM-B Midterms With Rationale

IM-B Midterms 2012-2014 Cardiology Risk factors for atherosclerosis 1. atherogenic diet- modifiable 2. male- unmodifiable 3. father with CAD- unmodifiable 4. sedentary lifestyle- modifiable 5. hypertension- modifiable 6. obesity- modifiable *unmodifiable includes: AGE, MALE GENDER, GENETICS Case 36y/o with chest heaviness, 15 pack year smoker and alcoholic with a family hx of DM and CAD. His father died of massive MI at age of 45. 7. a. b. c. d.

WHO criteria for the dx of MI: hx of chest pain – dx is based on Hx, ECG and Cardiac biomarkers/enzymes hx of DM LDH determination 2D echo

8. At the ED, ECG should be requested within how many minutes upon the patient’s arrival? a. 60 min b. 15 min c. 10min d. 45min 9. a. b. c. d.

ECG shows *with ST elevation NSTEMI STEMI Normal Ischemia

10. The door to needle time (Fibrinolytic tx) is a. 30min b. 45min c. 60min d. 90min 11. The door to balloon time (PCI) is a. 30min b. 45min c. 60min d. 90min

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

12. The type of atheromatous plaque that can possibly lead to STEMI is a. Stable plaque b. Unstable plaque c. Both d. None of the above 13. The following is an EKG manifestation of ischemia a. T wave inversion- earliest ECG/EKG changes b. ST segment depression c. ST segment elevation d. QT prolongation 14. The following is an advanced PE finding in myocardial ischemia a. Friction rub b. Pulmonary rales c. Accentuated P2 d. Apical diastolic murmur- apical SYSTOLIC murmur if not yet advanced 15. The following is true regarding treadmill exercise test a. Lesser false positive ST depression is > or = 2mm- dapat positive b. Development of acute AF means positive strain test c. Up sloping ST segment is positive –unsloping or junctional ST segment changes do not constitute a positive test d. Increase in BP 10mmHg higher than the predicted BP is positive- wrong 16. The following is not contraindication to the use of beta blocker a. Nightmares and bad dreams b. AV mode dysfunction c. Reynaud’s phenomenon d. COPD -also included: severe bradycaria, hx of depression 17. a. b. c. d.

The ff is a CCB that can be used concomitant with beta blocker or digitalis dihydropyridine- Dihydropyridine= Di heart, actions is on BV only diltiazem- CCB with actions on both BV and Heart verapamil- CCB with actions on both BV and Heart actions captopril- ACEi

18. What antiplatelet acts on the cyclooxygenase activity a. clopidogrel b. aspirin c. ticlopidine d. cilostazol 19. What is the reperfusion of choice for patients with multi-vessel CAD and DM

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

a. b. c. d.

Plain old balloon angiography (POBA) Multiple angioplasty with multiple stenting Coronary artery bypass graft surgery Thrombolysis and triple antiplatelet

20. What is the leading prognostic indicator for IHD a. Presence of left main CAD b. State of LV function c. Complex arrhythmia d. Presence of DM as co-morbidity *others included: location and severity of coronary artery narrowing, severity and activity of myocardial ischemia 21. Which combinations are true, except a. coronary arteries- angina pectoris b. CNS- TIA c. Peripheral circulation-venous insufficiency –if you noticed, others pertains to ischemia..so ito dapat aterial insufficiency not venous d. Splanchnic circulation- mesenteric ischemia 22. Plaque features which makes them vulnerable to rupture, except a. Thin fibrous caps b. Relatively large lipid cores c. High content of macrophages d. None of the above *others include: few smooth muscle cells, eroded endothelium 23. ATP III lipid screening starts at this age, repeated every 5 years a. >20 b. >30 c. >40 d. >50 24. The major determinant of coronary resistance is found in a. Large epicardial arteries (R1) b. Prearteriolar vessels (R2) c. Arteriolar and intrmyocardial capillary vessels (R3) d. R2 and R3 *review anatomy!! reistance vessel= arterioles 25. The ff are true about the effects of ischemia, except a. Failure of normal muscle contraction and then relaxation b. Subendocardium affected more than the subepicardial region c. Transient left ventricular failure d. Mitral regurgitation

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

*A ang sagot sa pinost na ans key pero lahat nasa handout ng ischemic heart disease except for letter B. 26. a. b. c.

False positive stress test can be seen in the following, except Pre-menopausal women with no risk factors for premature atherosclerosis Patients taking cardioactive drugs- digitalis and antiarrhythmic agents Those with intraventricular conduction disturbances, resting ST segment and Twave abnormalities d. Obstructive disease limited to the circumflex coronary artery -also included: abnormal serum potassium levels

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

SECOND PRELIM EXAM SY 2013-2014 PULMONOLOGY 3B A= A correct; B= B correct; C= C correct; D= all correct; E= all incorrect

E 1. Berlin definition of ARDS, following are diagnostic criteria for ARDS a. The onset is within 5 days of a known clinical insult within 1 week b. The PCWP should be less than 18 mm Hg PCWP not included in Berlin criteria. This is American-European Consensus criteria for ACUTE LUNG INJURY c. The respiratory failure can be explained by fluid overload * not fully explained by fluid overload Timing

Within 1 week of a known clinical insult OR new OR worsening respiratory symptoms

Chest Imaging

Bilateral opacities – not fully explained by effusions, lobar/lung collapse, or nodules

Origin of Edema

Respiratory failure not fully explained by cardiac failure or fluid overload; needs objective assessment (eg.: 2DEcho)

Oxygenation Mild

200 mm Hg < PaO2/FiO2 ≤ 300 mm Hg with PEEP or CPAP ≥ 5 cm H2O

Moderate

100 mm Hg < PaO2/FiO2 ≤ 200 mm Hg with PEEP ≥ 5 cm H2O

Severe

PaO2/FiO2 ≤ 100 mm Hg with PEEP ≥ 5 cm H2O

B 2. Which of the following test/s for pleural fluid is/are diagnostic of ARDS a. Pleural fluid/serum LDH ratio >0.6 b. Pleural fluid/serum albumin ratio >0.7 finding in ARDS c. Pleural fluid/serum albumin ration 0.6 This indicates transudate in cardiogenic edema C 3. Which of the following is/are the recommended therapies for ARDS based on strong evidence from randomized controlled trials? a. Glucocorticoids indeterminate b. Mechanical ventilation with high PEEP indeterminate c. Mechanical ventilation with low tidal volume This is the only therapy with strong evidence

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

4- 6 REFER TO CASE IN TEST PAPER E 4. What is the paO2/FiO2 ratio of patient? a. 60 b. 65 c. 80 paO2= in ABG; FiO2= amt. of oxygen you give to patient paO2/FiO2= 65/0.6= 108 should be the answer D 5. What should be the goal for adequacy of oxygenation based on ARDS network protocol? a. PaO2/FiO2 >250 (??? Wala sa handout pero pwede cguro itong iderive n lng from other values b. PaO2 60-80 mmHG 55-80 c. SaO2 >95% 88-95% Other goals for adequate ventilation: PEEP 60 g/L 13. Which of the following is expected to have an elevated NT- proBNP level >150 pg/ml? a. Hepatic hydrothorax

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

b. Congestive heart failure Never ko nabasa ung NT etc..pero based from the choices, all the others are exudative, ito lng ung transudate..nanghula lang ako thru elimination c. Empyema thoracis d. Pulmonary embolism 14. 51 year old male with pnueumonia have massive left-sided pleural effusion. What is the most compelling indication for tube thoracostomy after thoracentesis? a. loculated effusion b. pleural fluid pH less than 7.2 c. gross pus aspirated d. pleural fluid glucose lower than 60 mg/dL 15. previously health 45 year old male in a VA sustaining multiple chest wall injuries. An emergency thoracotomy was done to suture lung parenchymal lacerations. Effusion was noted to be milky white and odorless. Persistenly cloudy after centrifugation a. Chylothorax Wala pong sagot sa answer key but I think this is the answer..it is acute (from VA trauma, emergency, milky white) b. Pseudochylothorax c. Empyema thoracis d. Hemothorax Chylothorax ; Acute disease process; Pleural surfaces not thickened; No cholesterol crystals; Pleural fluid triglyceride >110 mg/dL Pseudochylothorax Chronic disease process; Thickened pleural surfaces; (+) cholesterol crystals; Pleural fluid triglyceride level not elevated 16. 52 year old male with cough of 1 year duration, minimal sputum, shortness of breath, fibrohazed densities on both lung apices and pleural effusion. Pleural fluid protein was at >6 g/dL. What is mechanism of effusion? a. hypersensitivity reaction to TB protein in pleural space Remember that >5 g/dL indicates tuberculous pleurisy.. And there are clues in the cases that this is TB (highlighted in red) b. direct movement of peritoneal fluid through small openings in the diaphragm into pleural space c. inc. amount of fluids in the lung interstitial spaces exit across the visceral pleura d. Pleural inflammation secondary to metastatic disease 17. ??? 18. Which of the following maybe associated with secondary spontaneous pneumothorax? Secondary spontaneous pneumothorax decrease the pulmonary function of a patient with already compromised function a. Marfan Syndrome

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

b. Pulmonary Tuberculosis has already compromised pulm function beforehand…Most common cause of secondary etc..is COPD..pero pwede rin TB, sarcoidosis, cystic fibrosis, tumor, c. Disturbance of collateral ventilation d. Homocysteinuria

A= A correct B= B correct C= both

correct

19. Superior boundary of mediastinum a. Base of brain (obviously hindi)

D= both incorrect

b. Thoracic Inlet

Borders of mediastinum- lateral- parietal pleura Anterior-sternum Posterior- vertebral column and paravertebral gutters Superior- thoracic inlet Inferior- diaphragm 20. Superior vena cava, heart, pericardium, and trachea- Middle mediastinum 21. Which of the following are located in the posterior mediastinum? a. Lower vagus nerve posterior b. upper vagus nerve middle 22. Most valuable imaging technique for mediastinal masses- Chest CT scan a. MRI b. CXR 23. Mediastinal regions of Heitzman? a. Thoracic inlet b. Anterior mediastinum -

Thoracic inlet Anterior mediastinum Supra-aortic area Infra-aortic area Supra-azygos area Infra-azygos area Hila

24. Anterior mediastinal mass, Myasthenia gravis, red cell aplasia, myocarditis, hypogammaglobulinemia a. Neuroblastoma b. Thymoma 25. Anterior mediastinal mass, gynecomastia, elevated AFP, beta hcg a. Germ cell tumors b. Ganglioneuroma Posterior 26. Teardrop-shaped mass in middle mediastinum a. Pericardial cyst b. Bronchogenic cyst

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

SECOND PRELIMS EXAMINATION IM B – ONCOLOGY

1. True of Gompertizian tumor growth a. The growth rate of a tumor peaks the moment it is clinically detectable – the growth rate of tumor peaks BEFORE IT IS CLINICALLY DETECTABLE b. Tumor becomes detectable at a burden of about 10^3 cm3 and kills the patient at a tumor burden about 1kg – tumor becomes detectable at burden of 10^9 (1cm3) and can kill at 10^12 (1kg) c. Efforts to treat the tumor and reduce its size can result in an increase in the growth fraction and an increase in growth rate 2. Benefits of neoadjuvant chemotherapy – neoadjuvant therapy is given after an initial diagnostic biopsy to reduce the size of tumor and clinically control undectected metastatic disease, followed by surgical procedure to remove the residual mass. It is NOT FOR DOWNGRADING TUMORS a. Downgrade the tumor b. Clinically control undetected metastatic disease c. Both A and B 3. Surgery may be curative in the following a. Patients with lung metastases from breast cancer may be cured by resection of the lung lesions -- lung mets from osteosarcoma may be cured by resection of lung lesion b. Patients with an ulcerating breast mass with bone metastases undergoes mastectomy c. Patients with colon cancer who have fewer than five liver metastases restricted to one lobe and no extrahepatic metastases 4. True regarding use of surgery and its systemic effect antitumor effects a. If resection of the primary lesion takes place in the presence of metastases, acceleration of metastatic growth may occur --d/t the removal of the source of angiogenesis inhibitors and mass related growth regulators in the tumor b. Removal of both breasts may prevent breast cancer spread to other organs c. Orchiectomy in male ER (+) breast cancer can prevent recurrence 5. Surgery as palliation can be applied to the following cause/s a. Limb-sparing surgery followed by adjuvant radiation in therapy and chemotherapy for osteosarcoma b. Axillary lymph dissection in breast cancer c. Inferior vena cava filter for recurrent pulmonary emboli, insertion of central venous catheter, control of pleural and pericardial effusions and ascites, stabilization of cancer weakend weight bearing bones, control of hemorrhage 6. Correct about core needle biopsy a. Usually obtains considerably less tissue, but this procedure often provides enough information to plan a definitive surgical procedure b. Wedge of tissue is removed and an effort is made to include the majority of the cross sectional diameter of the tumor in the biopsy to minimize sampling error – Incisional Biopsy c. Both A and B

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

7. The following statements describes the sentinel node approach a. Useful for all malignancies b. The first draining lymph node a spreading tumor would encounter is defined by injecting a dye into the tumor site at operation and then dissecting the first node to turn blue c. Provides reliable information regarding stage of breast cancer but risk of lymphedema lymphangioedema is increased 8. Correct about radioactive therapy a. Is selectivity for cancer cells may be due to defects in a cancer cell’s ability to repair sublethal DNA and other damage b. Radiation damage is dependent on oxygen, hypoxemic cells are more sensitive -Radiation damage is dependent on oxygen, hypoxemic cells are more RESISTANT c. Augmentation of oxygen is the basis for radiation resistance - - HYPOXEMIC CELLS RELATIVELY RESISTANT TO RADIATION , augmenting oxygen makes it relatively sensitive 9. Determinants of radiation dose a. Type of malignancy b. Type of machine c. Total rad, time and number of fractions 10. Drugs used in cancer treatment that may also act as radiation sensitizers a. Compounds that incorporate into DNA and alter stereochemistry I can’t read the other choices due to poor quality of picture :l 11. I can’t read the question due to poor quality of picture :l 12. Development of second solid tumors in or adjacent to the radiation fields a. Acute toxicity of radiation –development of second solid malignancy is a serious LATE toxicity of radiation b. Development is dependent on dose of radiation received c. Occur at a ratio of about 1 ½ per year beginning in the second decade after treatment A for TRUE OR B for FALSE 13. X-rays are generated by linear accelerations, gamma rays are generated from decay of atomic nuclei in radioisotopes such as cobalt and radium 14. In treating mycosis fungoides, electron beam are used because of its high tissue penetrance -- In treating mycosis fungoides, electron beam are used because of its LOW TISSUE PENETRANCE 15. The maximum dose in the target volume is often the cause of complications to tissues in the transit volume 16. Radiation is quantitated is based on the amount of radiation generated by the linear acceleration -- Quantitated on the basis of the AMOUNT OF RADIATION ABSORBED IN THE PATIENT; NOT based on the amount of radiation generated by the machine 17. Patients with colon cancer who have lung metastases restricted to one lung and no extrapulmonary metastases may have long term disease-free survival in 25% if they undergo pneumonectomy - Patients with colon cancer who have 50%), most active and severe clinical features d. Focal proliferative lupus nephritis – lesser glomeruli involved, fewer necrotizing features and less crescents 4. A 24 year old male presented with hemoptysis, anemia, fever, dyspnea and hematuria recurring over 4 days. Creatinine on admission was 3.6 mg/dL. Serologic markers are awaited. What is the most likely diagnosis? a. Microscopic polyangitis –clinically similar to Wegener’s but rarely have significant lung disease or destructive sinusitis b. Goodpasture’s syndrome – males in their 20’s present with hemoptysis, anemia, fever, dyspnea and hematuria c. Churg-Strauss syndrome – hemoptysis not part of lung manifestations d. Wegener’s granulomatosis - -fever, SOB, hemoptysis, nasal ulcer, purulent rhinorrhea, sinus pain, microscopic hematuria, subnephrotic proteinuria, polyarthralgia/arthritis, 5. A patient presented with fever, purulent rhinorrhea, nasal ulcers, sinus pain, arthritis, microscopic hematuria and 1.0gm/24hour of proteinuria. Serial chest xray revealed persistent infiltrates and pulmonary nodule. Renal biopsy was done showing non caseating granuloma. What is the most likely diagnosis? a. Microscopic polyangitis clinically similar to Wegener’s but rarely have significant lung disease or destructive sinusitis b. Goodpasture’s syndrome – males in their 20’s present with hemoptysis, anemia, fever, dyspnea and hematuria c. Churg-Strauss syndrome hemoptysis not part of lung manifestations

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

d. Wegener’s granulomatosis - -fever, SOB, hemoptysis, nasal ulcer, purulent rhinorrhea, sinus pain, microscopic hematuria, subnephrotic proteinuria, polyarthralgia/arthritis, CXR: pulmonary nodules and persistent infiltrates with cavitation, Tissue biopsy: small vessel vasculitis and adjacent noncaseating granuloma

6. Poor prognostic factor in patient with Goodpasture’s syndrome a. Creatinine of 5.5mg/dl at time of diagnosis -- Screat >5-6 mg/dL, >50% crescent on renal biopsy with advanced fibrosis, (+) oliguria, need for acute dialysis b. Hemoglobin of 7.5 gm/dL c. Presence of anti-mpo ANCA d. High titer of anti-GBM antibody 7. Etiologic factor implicated in Type II membranoproliferative GN a. Subacute bacterial endocarditis – an antigen source in Type 1 b. SLE – an antigen source in Type 1 c. C3 nephritic factor-associated nephritis –involved in the pathogenesis of Type 2 d. Cyroglobulinemia nephropathy – an antigen source in Type 1 8. The development of renal vein thrombosis is highest in a. Minimal change disease b. Membranous glomerulopathy –Although thrombotic complications are a feature of all nephrotic syndromes, MGN has the highest reported incidences of renal vein thrombosis, pulmonary embolism, and deep vein thrombosis (Harrisons) c. Focal segmental glomerulosclerosis d. Henoch-Schonlein purpura 9. Recommendation for detection of microalbuminemia in Type 2 DM a. At the time of diagnosis - because the time of onset of type 2 diabetes is often unknown, to test type 2 patients at the time of diagnosis of diabetes and yearly thereafter (Harrisons) b. When creatinine starts to get abnormal c. Five years after diagnosis - It is currently recommended to test patients with type 1 disease for microalbuminuria 5 years after diagnosis of diabetes and yearly thereafter (Harrisons) d. Only when nephropathy is evident

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

10. Which of the following genetically-linked glomerular diseases present with hematuria, proteinuria, lens abnormality and sensorineural hearing loss? a. Fabry’s disease - Classically, Fabry's disease presents in childhood in males with acroparesthesias, angiokeratoma, and hypohidrosis. Over time male patients develop cardiomyopathy, cerebrovascular disease, and renal injury, with an average age of death around 50 years of age b. Alport’s syndrome - Classically, patients with Alport's syndrome develop hematuria, thinning and splitting of the GBMs, mild proteinuria (10 More than 50% washout after contrast CT scan -50%motility b. Gonadotropin therapy for secondary hypogonadism c. Clomiphene citrate for PCOS d. In vitro technique for primary testicular failure 13. 68 y/o male admits to have decreased physical function and muscle strength. Which of the ff describe/s the age related changes in his reproductive function a. Testosterone concentrations increase starting 3rd decade –decrease! b. Reduced LH response to GnRH

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IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)

c. Lower sex hormone binding globulin- higher bec there’s lack of hormone that will bind d. All of the above 14. 50 y/o postmenopausal woman wanted to take hormonal therapy. The ff should be discussed prior to treatment a. Definite benefit is improvement of genitourinary symptoms- highly effective for controlling vasomotor and genitourinary symptoms b. Unproven benefit is decreased risk of diabetes mellitus c. Definite risk is increased ovarian cancer- uncertain risk! d. Probable risk is gallbladder disease- definitive risk! 15. Management of disorders of sex development are the ff, except a. Androgen benefit is improvement of genitourinary symptoms b. Recombinant GH for short stature in 45x c. Estrogen replacement with progesterone in Turner Syndrome d. None of the above Matching type 16. Pubertal failure, aortic root dilatation, hearing loss (turner)= High FSH, low estradiol 17. Fertility wanes, mean duration is 4 yrs, hot flushes (Perimenopause)= FSH, Estradiol not diagnostic 18. Gynecomastia, eunuchoid proportion, small testes (klinefelter) = high FSH, Estradiol 19. Symptoms begin after menarche, slowly progressive (PCOS)= normal FSH, low estrdiol 20. Headache, galactorrhea, short stature, diabetes insipidus (hypothalamic or pituitary cause)= low LH, FSH and estradiol hypothalamic PCOS or pituitary cause FSH Normal/low LH Normal/low Estradiol Low Testosterone

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Perimenopause Premature Klinefelter Ovarian failure (Turner) Normal/low not diagnostic High High High High Low not diagnostic Low High High low

IM-B SY 2013-2014 2nd PRELIM EXAM WITH RATIONALE by Acad. Com. (MHS)