Im Boards Rationalized Exam

1 .You’ve been seeing Mrs. Reyes, 42/F at theOPD for chronic heart failure and she has been minimally symptomatic on a beta blocker. She comes back to you with acute decompensated heart failure. Which of the following might have triggered her decompensation? A. Alcohol abuse B. Smoking C. Pregnancy D. Fluid restriction

4. Diagnostic feature of cardiac tamponade I. Kussmaul’s sign J. Pulsus Paradoxus K. Thickened/calcified pericardium L. Incresed myocardial thick ness

Alcohol and Smoking – acute renal failure Pregnancy – fetus added to blood volume which causes decompensatory heart failure Fluid restriction is a treatment.

**Cardiac Tamponade  Too much fluid in the Pericardial sac  Beck’s Triad o Hypotension o Soft/muffled heart sound o Distended neck veins  Pulsus Paradoxus (HALLMARK): greater than normal (10mmHg) inspiratory decline in systolic arterial pressure  Prominent x descent  Electrical alternans  Pericardial effusion  Equalization of diastolic pressures

2.

You remember that Mrs. Reyes has rheumatic heart disease since she was 25 years old. On examination, she has an accentuated S1, a diastolic rumble over the apex and a wide notched P wave on 12L ECG. Which valvular lesion does she most probably have? A. Mitral stenosis B. Mitral regurgitation C. Aortic stenosis D. Aortic regurgitation

. Accentuated S1 – mitral valve Mitral Stenosis  Most common in RHD  Others congenital dse, SLE and RA  Left atrial myxoma mimics symptoms  Accentuated S1, Diastolic rumble and opening snap 3. Which ECG findin distinguishes acute MI from pericarditis? E. ST elevations are concave F. Development of Q Waves G. Tall P waves H. T wave inversiotns usually seen within days before ST segments become isoelectric ECG on Myocardial Ischemia:  Aggravated by effort or activity The diagnosis of acute myocardial infarction is not only based on the ECG. A myocardial infarction is defined as:  Elevated blood levels of cardiac enzymes (CKMB or Troponin T) AND  One of the following criteria are met: o The patient has typical complaints, o The ECG shows ST elevation or depression. o Pathological Q waves develop on the ECG. o A coronary intervention had been performed (such as stent placement) ECG on Pericarditis:  Aggravatesd by lying on supine In pericarditis four stages can be distinguished on the ECG:  stage I: ST elevation in all leads. PTa depression (depression between the end of the P-wave and the beginning of the QRS- complex)  stage II: pseudonormalisation (transition)  stage III: inverted T-waves  stage IV: normalization Keep into account that in stage I pericarditis, ST-elevation is present in all leads except in aVR, V1 and III. **Dressler’s Syndrome – Pericarditis after MI  triad of features: o fever, o pleuritic pain and o pericardial effusion

** Kussmaul's sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration. Usually present in: Constrictive pericarditis and restrictive cardiomyopathy

** See also figure 1 5.Initial anti-hypertensive therapy with Thiazide diuretic should be given to which patient: A. 48/MCHF Functional Class III, BP 160/90 B. 50/M BP 140/90 with gouty arthritis C. 23/F with CKD stage 5 from chronic glomerilonephtitis BP 150/90 D. 55/F with dyslipidemia and bronchial asthma, BP 150/90 ** (seefigure 2) 6.Treatment of choice for acute pericarditis occurring post-STEMI A. Ibuprofen 20mg 3 times daily B. Aspirin 650mg 4 times daily C. Prednisone 1mg/kg daily D. Warfarin 2.5 to 5mg daily ___________ Syndrome Initial dose for MI: Aspirin 80 mg tab 2nd choice: Ibuprofen (studies show it increases 2nd chances of MI again.) Prednisone is contra-indicated due to this thinning effect on the pericardial sac Warfarin is also CI due to its effect on the sac to bleed. 7.A 64/M came to the ER for chest heaviness starting 3 hours prior, unrelieved by nitrates given to him at the previous hospital On PE, BP 80/50 HR 64 RR20 neck veins were flat, breath sounds clear while heart sounds were distinct. On 12L ECG, ST elevation was seen in leads II, III and AVF. What is the next step in stabilizing this patient? A. Give morphine B. Give intravenous fluid C. Start dopamine drip D. Start dobutamine drip The patient has Inferior wall MI so the preload is not enough going to the heart which causes the hypotension. Dobutamine and Morphine nitrate – not given due to its vasodilation effects which can even worsen the low BP status Dopamine – not given due to the ST elevations on ECG finding which could worsen due to effects of increase cardiac activity.

8.Fibrinolytic therapy can be given to which of the following patients as treatment for STEMI A. 64/M presenting with severe, tearing chest pain. B. 49/M diabetic with BP 190/110 C. 45/F with lupus nephtritis and active menses. D. 40/M who had ischemic stroke months ago.

Acute Myocardial Infarction  Symptoms: o Chest pain o Dyspnea o Diaphoresis o Light-headedness o Weakness o Palpitations o Nausea and vomiting

Absolute Contraindications to Fibrinolysis:  History of Cerebrovascular hemorrhage at any time  Non-hemorrhagic stroke or other Cerebrovascular event within the past year  Marked hypertension (SBP>180 mmHg and/or a DBP>110mmHg) at any time during the acute presentation  Suspicion of aortic dissection (tearing chest pain)  Active internal bleeding (excluding menses)

Pulmonary Embolism Symptoms of pulmonary embolism include  difficulty breathing,  chest pain on inspiration, and  palpitations. Clinical signs include  low blood oxygen saturation  cyanosis,  rapid breathing, and a  rapid heart rate. **Severe cases of PE can lead to collapse, abnormally low blood pressure, and sudden death.

9. In assessment of blood pressure, using an inappropriately small BP cuff will result in: A. Overestimation of the true blood Pressure B. Underestimation of the true blood Pressure C. No change in the true blood pressure D. Overestimation only of the systolic blood pressure. 10. A 59 year old male presents with chest pain. On auscultation, you were able to appreciate a midsystolic murmur radiating to the carotids. You also noted a weak and delayed pulse. Your likely diagnosis is: A. Aortic stenosis B. Aortic regurgitation C. Acute myocardial infarction D. Pulmonary embolism Aortic Stenosis - The three cardinal symptoms of aortic stenosis are:  syncope,  anginal chest pain and;  dyspnea Other symptoms of heart failure such as:  orthopnea,  exertional dyspnea,  paroxysmal nocturnal dyspnea, or  pedal edema. It also has Pulsus parvus et tardus which is may be a slow and/or sustained upstroke of the arterial pulse, and the pulse may be of low volume It also has the apical-carotid delay which is the pulse radiating to the carotid artery. Aortic Regurgitation: aka Aortic Insufficiency  The leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole  Auscultation of the heart to listen for the murmur of aortic insufficiency and the S3 heart sound o S3 gallop correlates with development of LV dysfunction  Early diastolic and decrescendo, which is best heard in the third left intercostal space and may radiate along the left sternal border. Symptoms of Aortic Reg are same as Heart Failure such as:  orthopnea,  exertional dyspnea,  paroxysmal nocturnal dyspnea,

11.A 75 year old male comes in for angina. He is a heavy smoker and alcoholic beverage drinker. He was also said to have a “fatty liver” by ultrasound. On further history, he admits to have been taking the “the blue pill” (sildenafil) for erectile dysfunction (last intake was the day prior). Which anti-anginal drug is absolutely contraindicated for this patient: A. Metoprolol B. Diltiazen C. Nitroglycerin D. Aspirin Since the patient is taking in Sildenafil, we should not give Nitroglycerin for his angina because the BP will decrease lower than the normal and cause significant hypotension. 12. A 35 year old male with a heavy smoking history develops claudication on the right foot with gangrene on the tips of tips of the toes. Popliteal pulses on both extremities are normal. Your likely diagnosis is: A. Atheroembolism B. Deep venous thrombosis C. Fibromuscular dysplasia D. Thromboangiltis obliterans 13. A 65 year old male was hospitalized for stroke 8 months prior and was subsequently bedridden after. He was rushed to the emergency room for sudden onset difficulty of breathing. Upon arrival at the emergency room there was note blood-tinged sputum, with the following vital signs BP:110/70 HR: 72 regular, RR:34 and there was clear breath sounds. Emergency 2D echo showed McConnell’s sign. What is the most common cause of death for patients with this condition? A. Pump failure from myocardial ischemia B. Progressive right heart failure C. Respiratory failure from hypoxemia D. Sudden cardiac death from cardiac dysrhythmia Pulmonary Embolism  Dyspnea is the most common symptom  Tachypnea is the most common sign  Risk Factors: o Bedridden > 3 days o Active Cancer o Major Surgery < 12 weeks  Progressive right heart failure is the usual cause of death ** Mc Connel’s Sign:  This is the finding of akinesia of the mid-free wall but normal motion of the apex  Right side of heart is failing

14. A 54 year old diabetic male, with a 60 pack year smoking history sought consult at the OPD 1 week ago for exertional dyspnea and cough with whitish sputum which started 8 months ago. He was rushed to the emergency room for a 3 day history of worsening difficulty of breathing, cough and decreased sensorium. Upon arrival, he was seen drowsy with absent breath sounds and bipedal edema. Which of the following should be the next step in managing this patient? A. Intubate the patient B. Nebulize with Salbtamol C. Start theophylline drip D. Give Furosemide IV boluses 15.A diagnostic thoracentesis is warranted for which of the following situations? A. Pleural effusions are equally present on both lung fields B. Patient is febrile C. Isolated left sided effusion D. Sputum AFB is positive Light’s Criteria: Transudative vs Exudative  Pleural Fluid protein/serum protein >0.5  Pleural fluid LDH/serum LDH > 0.6  Pleural fluid LDH > 2/3 normal upper limit for serum Factors indicating the likely need for a procedure more invasive than a thoracentesis (increasing order of importance)  Loculated pleural fluid  Pleural fluid pH < 7.20  Pleural fluid glucose < 3.3 mmol/L (180mmHg) Present with Neutros predo. (10000/uL)

TB Meningitis Not increased Present first is neutro then lymphocytes increase Very low to none

5 minutes  Less muscle aches post-attack  Post-ictal confusion  Can have urinary incontinece  Rarely preceded by emotion or pain  Autonomic manifestations  Urinary and fecal incontinence  Usually preceded by emotion or pain  Autonomic manifestations

94. A 45 year old male sought consult at OPD because of multiple sharply demarcated, erythematous plaques with scaling located predominantly in the elbows and knees as well as occasional shoulder and knee pains. What is your diagnosis? A. Lichen planus B. Pityriasis rosea C. Psoriasis D. Tinea versicolor **Psoriasis • Multiple sharply demarcated erythematous plaques with scaling = CLASSIC CHARS. • Locations o Elbows o Knees o Navel lesions o Shoulders + knee pain

96. True regarding Type Lepra reaction or ENL? A. The most dramatic manifestation is footdrop B. Edema is the most characteristic microscopic feature C. Fever is not common D. Other symptoms include neuritis, lymphadenitis, uveitis, orchitis, and glomerulonephritis Lepra Reactions Type 1  

95. Which primary skin lesions is correctly paired with its description? A. Macule: Flat, colored lesion, 5m firm lesion raised above the surface of the surrounding skin C. Plaque: >1cm, flat-topped, raised lesionwith edes that are always distinctly demarcated D. Vesucle: small, fluid-filled lesion, >0.5cm in diameter, raised above the plane of surrounding skin. Primary Skin Lesions: Macule Flat, colored lesions, < 2c in diameter Tumor > 5cm, firm lesion raised above the surface of surrounding skin Plaque >1cm, flat-topped raised lesion with edges that are sometimes distinctly demarcated. Vesicles Small, fluid-filled lesion, 0.5cm

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Occurs in borderline forms of leprosy Classic signs of Inflammation within previously involved macules, papules and plaques Most Dramatic manifestation isFOOTDROP EDEMA is the most characteristic microscopic feature

Type 2 or Erythema Nodosum Leprosum (new lesions)  Lepromatous end of the leprosy spectrum  Crops of painful erythematous papules that resolve spontaneously in a few days  With systemic manifestations: Profound fever, neuritis, lymphadenitis, uveitis, orchitis and glomerulonephriti s  Skin biopsy of ENL papules reveals vasculitis or panniculitis  Anemia, leukocytosis and abnormal liver function tests

97. This test is performed on scaling skin lesions when a fungal infection is suspected A. Tzanck smear B. Diascopy C. KOH preparation D. Patch testing Tzanck test is for Herpes dermal infection Diascopy is a test for blanchability performed by applying pressure with a finger or glass slide and observing color changes.  It is used to determine whether a lesion is vascular (inflammatory), nonvascular (nevus), or hemorrhagic (petechia or purpura).  Hemorrhagic lesions and nonvascular lesions do not blanch; inflammatory lesions do.  Diascopy is sometimes used to identify sarcoid skin lesions, which, when tested, turn an apple jelly color. Patch Test is a method used to determine whether a specific substance causes allergic inflammation of a patient's skin. Any individual suspected of having allergic contact dermatitis and/or atopic dermatitis needs patch testing.

98. Am exa,[;e pf a category A bioterrorist agent A. E. coli 0157:H7 B. Extremely-drug resistant (XDR) M. tuberculosis C. SARS coronavirus D. Variola major Micro Bioterrorism A Anthrax, Botulism, Plague, Smallpox and Tularemia Arenaviruses: Lassa, New World (Machupo, Junin, Guanarito, and Sabia) Bunyaviridae: Crimean-Congo, Rift Valley Filoviridae: Ebola, Marburg B Brucellosis Epsilon toxin of Clostridium perfringens, Glanders Melioidosis Psittacosis Q fever Ricin toxin from Ricinus communis Typhus Fever Staphylococcal entertoxin B; Viral Enceph Water safety threats (Vibrio cholerae, Cryptosporidium parvum) Food safety threats (Salmonella spp. Escherichia coli 0157:H7, Shigella toxin) C Emerging infectious diseases threats such as Nipah, hantavirus, SARS coronavirus and pandemic influenza. 99. Best preventive measure for high altitude pulmonary edema A. Acetazolamide B. Nifedipine C. Limitation of fluid intake prior to ascent D. Gradual ascent 100. Mrs. C is a 48 y/o female who consulted you a few years back for dyspepsia. She comes to your clinic now with easy fatigability, weakness, incoordination and memory disturbances. She claims she cannot tolerate eating withough taking antacids. Physical and neurologic exams are unremarkable. Among the labs you ordered, only her CBC is abnormal showing red blood cells with high MCV and high MCH. Which of the following nutrients is she most likely deficient with? A. Iron B. Folate C. Cyanocobalamin D. Vitamin D 101. Cause of normal anion gap metabolic acidosis: A. Diarrhea B. Alcoholic Ketoacidosis C. Uremia D. Salicylate ingestion **Urine Anion Gap = Na +K – Cl RTA Type 1 Type 2 Distal tubule Proximal tubule Decrease K Decrease K Failure of acid FANCONI secretion by syndrome alpha (osteomalacia) intercalated cells of cortical **ricketts due to collecting duct of wasting distal nephron Metabolic acidosis Hypoalbunemia Hypocalcemia Hyperchloremia Nephrocalcinosis

Type 3 Adrenals Increase K

High Anion Gap Metabolic Acidosis • Lactic acidosis • Ketoacidosis • Ingestion of alcohol INH methanol ethylene glycol • Renal Failure • Massive rhabdomyolysis 102. Which of the following is a risk factor for stroke in a patient with atrial fibrillation? (HPIM p1428 table 226-1) A. B. C. D.

Age more than 65 years old Mitral regurgitation Diabetes Mellitus Marked right atrial enlargement

**Risk Factors for stroke in a patient with atrial fibrillation  History of CVA or TIA  Mitral stenosis  Hypertension  DM  > 75 years old  CHF  Left Ventricular dysfunction  Marked Left atrial enlargements > 5.0  Spontaneous echo contrast 103. True of Manifestations of Myxomas A. Most appear singly B. Most are pedunculated on a fibrovascular stalk C. Most are located in the left atrium D. They have characteristic “tumor plop” appreciated during diastole ** ALL OF THE CHOICES are CORRECT!!!!!!! 104. Which of the following medications should not be started in patients with hyperkalemia? A. Carvedilol B. Dobutamine C. Captopril D. Furosemide ** Drugs that cause HYPERKALEMIA • ACE I and ARBs • K-sparing diuretics (amiloride and spironolactone) • NSAIDs • Tacrolimus • Timetoprim, Pentamide 105. For angina, nitrates may be administered. Nitroglycerin is most commonly administered sublingually in what dose? A. 5mg B. 10mg C. 0.4mg D. 4mg 106. A 19 year old female comes in for dyspnea. As a child, she had cyanosis, selectively involving the toes only (but not the fingers). She was said to have a “defect in her heart”, but was lost to follow up. On auscultation, you should expect: A. A fixed splitting of S2(ASD L to R shunt) B. A holocystolic murmur(Mitral Regurgitation, Pulmonic Stenosis) C. A continuous machinery murmur D. Early diastolic murmur(MR, MVP)

107. The most common congenital heart valve defect is: A. Pulmonic stenosis B. Mitral stenosis C. Bicuspid aortic valve D. Mitral regurgitation 108. A 40 years old female came in for dyspnea. Blood pressure on admission was 120/20 mmHg. Auscultation revealed a high-pitched, blowing, decrescendo diastolic murmur at the right sternal border. You also noted capillary pulsations (alternate flushing and paling of the skin) at the root of the nail while pressure is applied to the tip of the nail. This is called? A. Corrigan’s pulse B. Quincke’s pulse C. Traube’s sign D. Duroziez’s sign 

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Large-volume, 'collapsing' pulse also known as: o Watson's water hammer pulse o Corrigan's pulse - rapid upstroke and collapse of the carotid artery pulse Low diastolic and increased pulse pressure de Musset's sign - head nodding in time with the heart beat Quincke's sign-pulsation of the capillary bed in the nail Traube's sign - a 'pistol shot' systolic sound heard over the femoral artery Duroziez's sign - systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope

109. A 35 years old male comes in for dyspnea and orthopnea. On examination, he had a heart rate of 110 with an irregularly irregular rhythm. An opening snap, followed by a diastolic rumble was audible on auscultation. You requested a chest x-ray and expect to find: A. Widening of the carinal angle B. Left ventricular enlargement C. Tubular heart with a widened mediatinum D. Paucity of pulmonary vasculature ** SSx pertains to Mitral stenosis 110. Most common parasitic cause of cardiomyopathy is Chagas’ disease. What is the etiology? A. Trypanosoma cruzi transmitted by the reduviid bug B. Trypanosoma brucei transmitted by the Tsetse fly C. Toxoplasmosis transmitted by cysts D. Trichinella spiralis caused by ingestion of larva of undercooked meat 111. A 35 years old male came in for dyspnea. He had a blood pressure of 60/40 mmHg with muffled heart sounds and distended neck veins. Your acute management is: A. Immediately start intropic support B. Place in Trendelenberg position and observe C. Give Furosemide 40 mg IV stat bolus D. Do 2D Echo-guided pericardiocentesis 112. Most out of the hospital deaths from STEMI is due to: A. Heart Failure B. Ventricular fibrillation C. Premature ventricular contractions D. Pulmonary edema

113. A 22 years old male will be working abroad as a construction worker in Dubai. This patient came in tor your clinic for clearance. He is asymptomatic. On PE, you noted grade II/IV midsystolic murmur at the apex. Chest X-ray and ECG were normal. What would be your next step? A. Reassure and clear him for work, no further tests B. Dela giving of clearance and schedule for 2D Echocardiography C. Refer to cardiologist for clearance D. Admit for further work-up: Holter monitoring, cardiac enzymes and possible coronary angiography ** Only the DIASTOLIC murmur is pathologic! 114. What is a relative contraindication of thrombolysis in ST-segment elevation myocardial infarction? A. History of Cerebrovascular hemorrhage B. Suspicion of aortic dissection C. Active internal bleeding D. Pregnancy 115. Presents as refractory hypertension, mostly asymptomatic but infrequently may have paresthesias, polyuria, or muscle weakness secondary to hypokalemic alkalosis. A. Cushing’s syndrome B. Phaeochromocytoma C. Primary aldosteronism D. Aortic coarctation 116. Abdominal aortic aneurysm repair is indicated for asymptomatic patients if the diameter is: A. > 4.5 cm B. > 5.5 cm C. > 6.0 cm D. > 7.0 cm 117. Which of the following physical examination findings, if present in COPD suggest advanced disease? A. Barrel chest B. Temporal wasting C. Clubbing of the digits D. Cyanosis 118. The standard monotherapy for lung abscess A. Ceftriaxone B. Metronidazole C. Clindamycin D. Ampicillin-Sulbactam 119. Which of the following points to an exacerbation in a patient with established COPD? A. Exertional dyspnea B. Increased dyspnea C. Presence of airflow obstruction D. Resting hypoxemia 120. The following are true regarding non-imaging tests in diagnosisng pulmonary embolism EXCEPT: A. The D-dimer is a useful “rule in” test B. The D-dimer has a limited role in hospitalized patients C. Arterial blood gas lacks diagnostic utility for pulmonary embolism D. Elevated cardia biomarkers predict an increased mortality from pulmonary embolism 121. When after initiation of adequate therapy in pneumonia, when do you expect fever to resolve? A. 24 hours B. 36 hours C. 48 hours D. 72 hours

122. Among COPD patients, supplemental oxygen should be provided to maintain arterial oxygen saturation at what level? A. 80% B. 85% C. 90% D. 95%

129. Type of emphysema usually observed in patients with alpha1-antitrypsin deficiency, which has predilection for the lower lobes: A. Centriacinar emphysema B. Peripheral emphysema C. Lobar emphysema D. Panacinar emphysema

123. Occupational lung disease characterized by the characteristic HRCT pattern known as “crazy paving” A. Chronic beryllium disease B. Coal worker’s pneumoconiosis C. Asbestosis D. Silicosis

** Types of Ephysema:

124. What is the most common cause of repiratory hypoxia, which is usually correctable by inspiring 100% oxygen? A. Hypoventilation B. Intrapulmonary right to left shunting C. Pulmonary atelectasis D. Ventilation perfusion mismatch 125. Which among the following is an example of obstructive lung disease? A. Bronchiectasis B. Asbestosis C. Pulmonary fibrosis D. Gullain-Barre syndrome Obstructive Lung

Restrictive Lung Diseases

Diseases • Chronic obstructive pulmonary disease (COPD), which includes emphysema and chronic bronchitis • Asthma • Bronchiectasis • Cystic fibrosis.

•Interstitial lung disease, such as idiopathic pulmonary fibrosis • Sarcoidosis, an autoimmune disease • Obesity, including obesity hypoventilation syndrome • Scoliosis • Neuromuscular disease, such as muscular dystrophy or amyotrophic lateral sclerosis (ALS)

126. An asthmatic patient was given ipratropium bromide for rescue medication. What is its most common side effect? A. Tachycardia or palpitations B. Tremors C. Dry mouth D. Urinary retention 127. What is the most common cancer associated with asbestos exposure? A. Lung cancer B. Mesothelioma C. Tumors of the pericardium D. Laryngeal carcinoma 128. A 60 years old male presented with cough and dyspnea of three days duration. You requested for a sputum gram stain and culture. An adequate sputum sample has: A. Presence of organisms B. Presence of >25 neutrophils C. Presence of >25 squamous cells D. Presence of >25 white blood cells

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Centriacinar emphysema begins in the respiratory bronchioles and spreads peripherally. Also termed centrilobular emphysema, this form is associated with longstanding cigarette smoking and predominantly involves the upper half of the lungs.

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Panacinar emphysema destroys the entire alveolus uniformly and is predominant in the lower half of the lungs. Panacinar emphysema generally is observed in patients with homozygous alpha1-antitrypsin (AAT) deficiency. In people who smoke, focal panacinar emphysema at the lung bases may accompany centriacinar emphysema.

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Paraseptal emphysema, also known as distal acinar emphysema, preferentially involves the distal airway structures, alveolar ducts, and alveolar sacs. The process is localized around the septae of the lungs or pleura. Although airflow frequently is preserved, the apical bullae may lead to spontaneous pneumothorax. Giant bullae occasionally cause severe compression of adjacent lung tissue

130. During the natural course of ARDS, which phase do we expect clinical recovery wherein patients are usually liberated from mechanical ventilation? A. Proliferative phase B. Fibrtoic phase C. Recovery phase D. Exudative phase **Phases of ARDS Exudative

Proliferative

Fibrotic

Alveolar Edema Neutrophil-rich leukocytosis Subsequent formation of hyaline membranes from diffuse alveolar damage 7 days after Exudative stage Prominent interstitial inflammation Early fibrotic changes Substantial fibrosis Bullae formation Recovery stage

131. Chest radiograph finding specifically indicating past exposure to asbestos and not pulmonary impairment: A. Pleural plaque B. Pleural Effusion C. Pleural fibrosis D. Pleural mesothelioma 132. A 30 year old male comes in for dyspnea. Examination on the right basal lung field revealed: dullness on percussion, increased fremitus and crackles. Your diagnosis is probably: A. Asthma B. Pneumothorax C. Pleural effusion D. Consolidation / pneumonia **See Figure 6 in attached paper

133. The following cause of ARDS is due to a direct lung injury: A. Sepsis B. Chest trauma C. Near drowning D. Multiple blood transfusion

139. Most common mode of transmission of HIV in developing countries such as the Philippines: A. Perinatal transfer B. Homosexual transmission C. Heterosexual transmission D. Contaminated IV drug paraphernalia

**Direct Lung Injury • Pneumonia • Aspiration of gastric contents • Pulmonary contusion • Near drowning • Toxic inhalation injury

140. The heart valve most commonly affected with infective endocardidtis among IV drug users is: A. Mitral valve B. Tricuspid valve C. Pulmonic valve D. Aortic valve

134. What is the prevailing mechanism for the development of emphysema? A. Dutch hypothesis B. British hypothesis C. Hygiene hypotsesis D. Elastase: Anti-elastase hypothesis

141. Most common clinical manifestation of Infective Endocarditis: A. Fever B. Chills C. Heart murmur D. Janeway lesions

** Dutch / British hypothesis  provides one of several biologically plausible explanations for the pathogenesis of chronic obstructive pulmonary disease (COPD), a progressive disease known to be aetiologically linked to environmental insults such as tobacco smoke

**SSx of IE:  Fever occurs in 97% of people; malaise and endurance fatigue in 90% of people.  A new or changing heart murmur, weight loss, and coughing occurs in 35% of people.  Vascular phenomena: septic embolism (causing thromboembolic problems such as stroke in the parietal lobe of the brain or gangrene of fingers),  Janeway lesions (painless hemorrhagic cutaneous lesions on the palms and soles),  intracranial hemorrhage,  conjunctival hemorrhage,  splinter hemorrhages,  renal infarcts, and  splenic infarcts.  Immunologic phenomena: Glomerulonephritis which allows for blood and albumin to enter the urine, o Osler's nodes (painful subcutaneous lesions in the distal fingers), o Roth's spots on the retina, o positive serum rheumatoid factor  Other signs may include; night sweats, rigors, anemia, splenomegaly

** Hygiene hypothesis • allergen / germ theory 135. The CURB-65 criteria is used in pneumonia as a severity of illness score. Which is INCORRECTLY paired? A. C: Creatinine > 250 B. U: Urea > 7mmol/L C. R: Respiratory rate > 30/ min D. B: Blood pressure < 90/60 **CURB scoring:     

Confusion of new onset (defined as an AMT of 8 or less) Urea greater than 7 mmol/l (19 mg/dL) Respiratory rate of 30 breaths per minute or greater Blood pressure less than 90 mmHg systolic or diastolic blood pressure 60 mmHg or less age 65 or older

136. What is the most common cause of hemoptysis worldwide? A. Pneumonia B. Tuberculosis C. Bronchogenic carcinoma D. Upper respiratory tract infection 137. A 60 year old male was previously diagnosed with tuberculosis but was never compliant to medications. He presented with three month history of productive cough and dyspnea. Chest x-ray revealed presence of tram tracks. What is your diagnosis? A. Asbestosis B. Emphysema C. Brochiectasis D. Lung Abscess 138. A 45 year old female with an ovarian malignancy comes in for dyspnea and hemoptysis. On examination, she was tachycardic and tachpneic, but with stable blood pressure. Her entire left lower extremity is swollen and tender with erythema. To confirm your diagnosis you would request for: A. D-dimer B. Pelvic CT scan C. Chest CT scan D. Venous duplex scan, lower extremity

Diagnosis of infective endocarditis can only be said to be "possible" if only 1 major and 1 minor criteria are fulfilled or if only 3 minor criteria are fulfilled. Major criteria include:  

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Positive blood culture with typical IE microorganism, defined as one of the following: Typical microorganism consistent with IE from 2 separate blood cultures, as noted below: o Viridans-group streptococci, or o Streptococcus bovis including nutritional variant strains, or o HACEK group, or o Staphylococcus aureus, or o Community-acquired Enterococci, in the absence of a primary focus Microorganisms consistent with IE from persistently positive blood cultures defined as: o Two positive cultures of blood samples drawn >12 hours apart, or o All of 3 or a majority of 4 separate cultures of blood (with first and last sample drawn 1 hour apart) o Coxiella burnetii detected by at least one positive blood culture or antiphase I IgG antibody titer >1:800

Evidence of endocardial involvement with positive echocardiogram defined as  Oscillating intracardiac mass on valve or supporting structures, in the path of regurgitant jets, or on implanted material in the absence of an alternative anatomic explanation, or  Abscess, or  New partial dehiscence of prosthetic valve or new valvular regurgitation (worsening or changing of preexisting murmur not sufficient) Minor criteria include:     

Predisposing factor: known cardiac lesion, recreational drug injection Fever >38°C Evidence of embolism: arterial emboli, pulmonary infarcts, Janeway lesions, conjunctival hemorrhage Immunological problems: glomerulonephritis, Osler's nodes Positive blood culture (that doesn't meet a major criterion) or serologic evidence of infection with organism consistent with IE but not satisfying major criterion

142. True about the diagnosis of Infective Endocarditis (IE): A. Diagnosis is based on the Jones Criteria B. Organisms can often be cultured from blood despite prior antibiotic therapy C. Diagnosis of IE is rejected if fever and symptoms resolve in less than 4 days of therapy D. Typical organism recovered in blood culture are E. coli and S. viridans 143. Which sexually transmitted disease is associated with gummas? A. Syphilis B. Human papilloma virus C. HIV D. Donovanosis 144. Pasteurella multocida is known to commonly infect dog and cat bites. What is the antibiotic of choice for this organism? A. Cloxacillin B. Penicillin G C. Co-amoxiclav D. Clindamycin 145. Remains the standard and recommended duration of IV antibiotic therapy for osteomyelitis. A. 2-4 weeks B. 4-6 weeks C. 8-12 weeks D. 3-6 months 146. Antibiotics that may be used for only 3 days in acute uncomplicated cystitis in women A. TMP-SMX B. Nitrofurantoin C. Quinolones D. All of the above 147. Dramatic but mild reaction consisting of fever, chills, myalgias, tachycardia with mild hypotension noted after initiation of antibiotic therapy for leptospirosis A. Lucio reaction B. Weil’s Syndrome C. Nicolandi Branham Sign D. Jarisch-Herheimer Reaction

** Lucio reaction  It is characterized by recurrent crops of large, sharply demarcated, ulcerative lesions, affecting mainly the lower extremities, but may generalise and become fatal as a result of secondary bacterial infection and sepsis. ** Weil’s Syndrome  Leptospirosis + Kidney failure, Jaundice and Lung bleeding ** Nicolandi Branham Sign  the slowing of the heart rate in response to (manual) compression of an arteriovenous fistula.

148. Most important risk factor associated with the development of perinephric abscesses A. Diabetes mellitus B. Prior urologic surgery C. Chronic kidney disease D. Nephrolithiasis with obstruction 149. Most commonly implicated organism/s in Primary Bacterial Peritonitis: A. Escherichia coli B. Pseudomonas aeruginosa C. Anaerobic bacteria D. Mixed infection **Primary Bacterial Peritonitis = E. coli ** Secondary Bacterial Peritonitis = Mixed Infection 150. Single most reliable laboratory parameter in liver abscess A. Increased AST and ALT B. Increased alkaline phosphatase C. Normocytic, normochromic anemia D. Increased direct bilirubin 151. Most common extrapulmonary manifestation of tuberculosis A. TB meningitis B. TB adenitis C. Pott’s disease D. Genitourinary TB 152. In which tuberculous infection are systemic steroids like dexamethasone proven to positively influence outcomes? A. TB meningitis B. Pott’s disease C. Tuberculous pericardial effusion D. Miliary TB 153. The single most important agent of Traveler’s diarrhea A. Enterotoxigenic E. coli B. Salmonella typhi C. Campylobacter jejuni D. Rotavirus 154. Least common but the most severe of the pneumonic complications of influenza. A. Secondary bacterial pneumonia B. Primary influenza viral pneumonia C. Mixed viral and bacterial pneumonia D. Chronic bronchitis with aspiration pneumonia Secondary Bacterial pneumonia = Most common complication of influenza

155. Which Plasmodium species has 72-hour duration of erythrocytic stage, 15 day duration of intrahepatic phase and prefernce for older red cells A. P. vivax B. P. ovale C. P. malariae D. P. falciparum 156. A 30 year old male comes in for agitation and hydrophobia. On further probing, his relative recall a history of dog bite 2 weeks prior. The most characteritic pathologic finding in this disease is: A. Nigiri body B. Amyloid body C. Babes nodules D. Filamentous virion 157. Largest intestinal nematode parasite of humans, reaching up to 40 cms in length A. Trichuris trichiura B. Ascaris lumbricoides C. Strongyloides stercoralis D. Enterobius vermicularis 158. A 30 year old commercial sex worker comes in for recurrent whitish material on her tongue. She has had weight loss, daily febrile episodes, and generalized lymphadenopathies. To confirm your diagnosis, you will request for: A. ELISA(Screening for HIV) B. RNA PCR C. Western blot (Confirmatory test for HIV) D. P24 antigen capture 159. Mainstay preferred diagnostic test for Leptospirosis A. Culture assays B. Serologic tests C. PCR identification D. Dark-field microscopy 160. Condition with increased susceptibility to Salmonella infections A. Alcoholism B. Antacid ingestion C. Age less than 5 years D. Maternal colonization 161. Best diagnositic test for localized and generalized tetanus infection A. Wound culture B. Tetanus toxin PCR C. Clostridium IgM D. None needed 162. Preferred antibiotic for tetanus infection A. Ceftriaxone B. Penicillin G C. Clindamycin D. Metronidazole 163. Infection predominantly transmitted by sexual intercourse A. Hepatitis C virus B. Sarcoptes scabiae C. Chlamydia trachomatis D. Gardnerella vaginalis 164. Most common cause of acute epididymitis in sexually active men less than 35 years old A. Chlamydia trachomatis B. Neisseria gonorrhea C. Enterobacteriaceae D. Herpes simplex virus type 2

165. Most common manifestation of infection with Clostridium difficile A. Fever B. Diarrhea C. Abdominal pain D. Leucocytosis 166. What is the normal mean annual decline in glomerular filtration rate with age in ml/min/body surface area? A. 0.5 B. 1.0 C. 1.5 D. 2.0 167. Which of the following suggest a chronic etiology for the kidney disease? A. Bilateral size of kidney on ultrasound 10 cm B. Elevation of serum creatinine > 6 weeks C. Osteitis fibrosa cystica D. Presence of oliguria

** Chronic etiology for the Kidney Disease • Kidney size > 10 cm on UTZ • Elevation of Serum Creatinine > 6 months • Osteitis Fibrosa Cystica is present • Anemia is present 168. This diuretic reversible inhibit the resoption of NaK-Cl in the thick ascending limb of Henle’s loop? A. Bumetanide B. Thiazide C. Metolazone D. Spironolactone **Bumetanide = loop diuretic which inhibits NKCCC • Na-K-Cl symporter in the thick ascending limb of loop of Henle ** Metolazone, thiazide, spironolactone • dCT – NaCl symporter ** Triamterene = K sparing • blocks epithelial sodium channel in the collecting tubule 169. Which of the following diuretics can retain potassium? A. Furosemide B. Chlorthalidone C. Triamterene D. Ethacrynic acid 170. The pentad of thrombotic thrombocytopenia includes the following, EXCEPT: A. Hemolytic anemia B. Thrombocytopenia C. Neurologic symptoms D. Hepatic failure 171. Primary renal pathophysiologic lesion in acute leptospirosis is injury of the: A. Glomerulus B. Ascending loop of henle C. Descending loop of henle D. Proximal convoluted tubule 172. Most common cause of nephritic syndrome in the elderly A. Minimal change disease B. Memranous glomerulonephritis C. Focal segmental glomerulocsclerosis D. Membranoproliferative glomerulonephritis 173. Kimmelstiel-Wilson nodules are seen in: A. Fabry’s disease B. Urate nephropathy C. Diagbetic nephropathy D. Analgesic nephropathy

174. First line of therapy for the management of hypertension in CKD A. Salt restriction B. ACE inhibitors C. Loop diurectics D. Calcium channel blockers

181. Microadenomas differ from macroadenomas in size. What is the cut off? A. 5mm B. 10mm C. 15mm D. 20mm

175. Diagnosis for thyroid biopsy revealing psammoma bodies with Orphan Annie appearance A. Anaplastic thyroid cancer B. Follicular thyroid cancer C. Papillary thyroid cancer D. Thyroid lymphoma

182. A 35 year old female presents with amenorrhea, infertility, and galactorrhea. Prolactin level was significantly elevated at >200 g/L. An MRI revealed findings suggestive of microadenoma. The mainstay of therapy is: A. Dopamine agonist B. Surgical debulking C. Transphenoid resection D. Radiotherapy

176. A 55 year old diabetic female came in for decrease in sensorium. CBG showed 780mg/dl, ABG done showed pH of 7.32, HCO3 20 pO2 92 pCO2 30. On further inquiring, she was poorly compliant to her medications and was complaining of cough with yellowish sputum for 3 days, vomiting abdominal pain for 1 day. There was glucosuria and +1 ketonuria on urinalysis. What is the most likely diagnosis? A. Diabetic ketoacidosis B. Hyperglycemic hyperosmoloar state C. Cerebral infarct D. Sepsis syndrome **HHS Dx:  Plasma glucose level of 600 mg/dL or greater  Effective serum osmolality of 320 mOsm/kg or greater  Profound dehydration, up to an average of 9L  Serum pH greater than 7.30  Bicarbonate concentration greater than 15 mEq/L  Small ketonuria and absent-to-low ketonemia  Some alteration in consciousness ** Diabetic ketoacidosis

177. What is appropriate initial resuscitation step? A. Give insulin IV bolus with potassium B. Hydrate with plain NSS C. Order for STAT plain cranial CT D. Start broad spectrum IV antibiotics 178. What BP level is considered hypertension in diabetic patients? A. >120/80 B. >125/75 C. >130/80 D. >140/90 179. Which of the following insulin preparation provide basal insulin? A. NPH insulin B. Insulin aspart C. Regular insulin D. Insulin glargine 180. Diabetes medications that can cause hypoglycemia even if used alone A. Metformin B. Alpha-glucosidase inhibitor C. Thiazolidinediones D. Sulfonylureas

183. A 20 year old male was found to have a parathyroid adenoma, pituitary adenoma, and pancreatic tumor. This familial pituitary syndrome is called: A. MEN 1 B. MEN 2A C. MEN 2B D. MEN 3 ** MEN 1 – Parathyroid tumors, Pancreatic tumors and Pituitary tumors MEN 2A – Meduallary thyroid cancers, Phaeochromocytoma and Parathyroid tumors MEN 2B – Medullary thyroid cancers, Phaeochromocytoma and Neuroma ** MEN 3 – no such thing!!! 184. A 46 year old female has a 3cm thyroid nodule at the isthmus. Which feature is a risk factor for thyroid carcinoma for this patient? A. Age B. Sex C. Nodule size D. Nodule location 185. A 35 year old female with palpitations has low TSH and a normal FT4. Your next approach to management: A. Treat as Grave’s disease with methimazole B. Get an MRI to rule out a TSH secreting pituitary adenoma C. Treat as subclinical hyperthyroidism and observe D. Measure FT3 to rule out T3 toxicosis 186. A 28 year old prenant female was diagnosed with Graves disease. You prefer propythiouracil for this patient because: A. Has better bioavailability during pregnancy B. It has low transplacental transfer C. It is more effective than methimazole in prenant patients D. Methimazole does not cross the placenta during pregnancy 187. Screeing for diabetes mellitus is recommended for all individuals who are: A. > 25 years old B. > 35 years old C. > 45 years old D. > 55 years old 188. Which of the following finding is consistent with portal hypertension? A. Hypoalbuminemia B. Obliterated Traube’s space C. Spider angioma D. AST:ALT ratio more than 2

189. What is the role of lactulose in patients with hepatic encephalopathy? A. Evacuate blood for the gastrointestinal tract B. Inactivate colonic bacteria C. Induce diarrhea D. Promot colonic alkalanization 190. Associated with increased risk of peptic ulcer disease: A. Atopic disease B. Nephrolithiases C. Blood group A D. Acute renal failure 191. Least common complication of pertic ulcer A. Gastric outlet obstruction B. Perforation C. Bleeding D. Gastritis 192. A 20 year old female comes in for abdominal pain occurring 3 days per month in the last three months. Associated symptoms include improvement of pain with defecation and soft frequent stools. She most likely has: A. Irritable bowel syndrome B. Inflammatory bowel disease C. Gastrointestinal tuberculosis D. Intestinal parasitism 193. A 50 year old male, smoker, alcoholic drinker comes in for sudden severe non-remitting abdominal pain. Heart rate was noted to irregularly irregular. There was only very minimal tenderness, our of proportion to the symptoms. The gold standard of diagnosis is: A. Radiograph showing bowel-wall edema (“thumbprinting”) B. Demonstation of pneumatosis intestinalis C. Oral and IV dynamic CT scan D. Laparotomy 194. Single most common risk factor for hepatitis C A. HIV B. Blood transfusion C. Injection drug use D. Risky sexual behavior 195. Best therapy for hepatorenal syndrome A. Dialysis B. Ocreotide C. Midodrine D. Liver transplant 196. Most common cause of rectal bleeding in infancy A. Trauma B. Anal fissure C. Hemorrhoids D. Imperforate anus 197. Best imaging study for initial evaluation of a suspected pancreatic disorder and for the complications of acute and chronic pancreatitis A. CT B. MRI C. ERCP D. Ultrasound 198. Leading cause of acute pancreatitis A. Idiopathic B. Alcoholism C. Cholelithiases D. Hypertriglyceridemia

199. Which of the following lab tests used in the diagnosis of acute pancreatitis remain elevated for 7 to 14 days after the initial bout? A. Lipase B. Calcium C. Amylase D. Hematocrit 200. Hallmark of anaphylaxis A. Vascular collapse leading to hypotension B. Urticarial eruptions which are intensely pruritic C. Respiratory Distress from laryngeal edema D. Rapid onset after introduction of antigen 201. Chronic Urticaria is define as attacks lasting more than A. 2 weeks B. 4 weeks C. 6 weeks D. 8 weeks 202. Key effector cell of the biologic reponse in allergic rhinitis, urticarial, anaphylaxis and systemic mastocytosis A. Mast cell B. Basophil C. Eosinophil D. Dendritic cell 203. A 20 year old patient develops severe maculopapular rashes all over after a bee sting. Associated signs and symptoms include dyspnea, wheezing, vomiting, and dizziness. Drug of choice is: A. Diphenhydramine B. Hydrocortisone C. Norepinephrine D. Epinephrine 204. Most common pulmonary manifestation of SLE A. Pleuritis B. Pneumonia C. Pleural effusion D. Pulmonary fibrosis 205. “Salt and pepper” appearance of the skin is seen in: A. Systemic Lupus Erythematosus B. Systemic Sclerosis C. Ankylosing Spondylitis D. Becet’s Syndrome 206. The pathergy test is used in the diagnosis of: A. Henoch Schonlein purpura B. Takayasu Arteritis C. Behcet’s syndrome D. Ankylosing spondylitis 207. Accounts for most non-gonococcal isolates in infectious arthritis in adults of all ages A. Staphylococcus aureus B. Gram negative bacilli C. B-hemolytic streptococci D. Mycobacterium tuberculosis 208. Most common varity of psoriasis A. Guttate B. Pustular C. Plaque-type D. Inverse 209. Most common dermatophyte infection A. Tinea corporis B. Tinea cruris C. Tinea capitis D. Tinea pedis

210. this differentiates primary from secondary causes of polycythemia A. RBC mass B. EPO levels C. Arterial O2 saturation D. Carboxyhemoglobin levels 211. Most convenient laboratory test to diagnose iron deficiency anemia A. TIBC B. Serum iron C. Serum Ferritin D. Serum Transferrin 212. Thalassemia might favor a natural protection agains which infection: A. Malaria B. Dengue Fever C. Typhoid Fever D. HIV 213. Mainstay of treatment for sickle cell anemia A. Hydration B. Hydroxyurea C. Red Cell transfusion D. Bone marrow transplant 214. Osmotic fragility test is used to diagnose: A. G6PD deficiency B. Sickle cell anemia C. Hereditary spherocytosis D. Paroxysmal nocturnal hemoglobinuria 215. Most common physical finding in Chronic Myelogenous Leukemia: A. Pallor B. Petechiae C. Lymphadenopathy D. Splenomegaly 216. A 50 year old female diagnosed with leukemia showed “smudge” or basket cells on perpheral blood smear. Your diagnosis is: A. Acute promyelocytic leukemia B. Chronic lymphocytic leukemia C. Acute lymphoblastic leukemia D. Mantle cell lymphoma 217. Most rapidly progressive lymphoma A. Diffuse large B-cell lymphoma B. Burkitt’s lymphoma C. Mantle cell lymphoma D. Follicular lymphoma 218. Given with Cyclophophamide chemotherapy to reduce the risk of bladder damage A. N-acetylcysteine B. Mesna C. Acrolein D. Leucovorin 219. Coadministered with 5-fllurouracil to enhance cytotoxicity in the treatment of GI cancers A. N-acetylcysteine B. Mesna C. Acrolein D. Leucovorin

220. Hematologic malignancy associated with an increased risk for Disseminated Intravascular Coagulation A. Chronic Myeloid Leukemia B. Acute Promyelocytic Leukemia C. Non-hodgkin’s Lymphoma D. Multiple myeloma