Medicine II First Long Exam 2014A

PLEASE HANDLE THIS WITH CARE. PLEASE DO NOT LEAVE THIS ANYWHERE, YOU KNOW WHAT I MEAN.  FIRST LONG EXAM MEDICINE II, 2014A Note: all text in size 8 are from the recording during the feedback

1.

A 23 year old female is under the care of a dermatologist for acne. She is maintained on benzoyl peroxide gel and intermittent doses of tetracycline capsules for seven months now. She consulted the outpatient dermatology clinic because of recurremce of coin shaped erythematous to violaceous patches on the right forearm of 5 months duration. What is your diagnosis? a. b. c. d.

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Chronic Urticaria Fixed Drug Reaction Nummular Dermatitis Irritant Contact dermatitis

a 19 year old male with epilepsy was given Dilantin three weeks ago. He consults because of erythematous macules and patches on the trunk and extremities of one week duration. These were associated with painful hemorrhagic crusts on the lips and secretions on the eyes. The resident who saw the patient is suspecting StevenJohnsons Syndrome. What type of lesion should he/she look for? a. b. c. d.

bulla wheal target Petechia

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A 25 year old male presents with intensely pruritic blistering lesions with excoriations on the scalp, scapular area and buttocks. Which of the following is the mainstay treatment in this chronic skin condition? a. topical corticosteroids b. dapsone c. gluten free diet d. methotrexate

4.

an 85 year old female is diagnosed with acrodermatitis enteropathica. Which of the following medications will lead to dramatic improvement of the skin condition? a. zinc sulfate b. ascorbic acid c. copper sulfate d. beta carotene

5. A 45-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 the other treatment of choice for this condition? a. corticosteroids b. dapsone c. methotrexate d. sulfasalazine 6. A 58-year old female diagnosed with stage 3 breast cancer has just finished 3 cycles of chemotherapy when she noted the development of complete hair loss. Which of the following is the diagnosis of the hair loss in this patient? a. alopecia areata b. alopecia universalis c. telogen effluvium d. anagen effluvium 7. A 63-year old male with average build is referred because of marked hyperpigmentation and hyperkeratosis of the neck, axilla and flexural areas noted eight months prior to consult. What malignant condition is associated with this presentation? a. breast CA b. gastrointestinal CA c. thyroid CA d. bone CA 8. A 25-year old man presented with a painful ulcer on the shaft of his penis. The ulcer has well-defined borders, and is friable. What is your clinical diagnosis? a. chancroid b. chancre c. herpes simplex 2 infection d. pyoderma gangrenosum

9. A 45-year old woman presented with skin lesions of 3 months duration. Three months prior to consult, she developed erythematous, scaly lesions on the trunk, and later on her extremities. On physical examination, she had thick, scaly erythematous plaques, on her scalp, extending beyond the hairline, on the trunk and extensor areas of her arms and legs. She had onycholysis and nail pitting. For this cutaneous disorder, in what layer of the skin is the primary pathology found? a. epidermis b. dermis c. subcutaneous fat d. hair follicle 10. An elderly man admitted in the Neurology Ward was referred to the Dermatology service. Admitted with a working diagnosis of generalized tonic-clonic seizure, he developed fluid-lesions on his second week in the hospital. He has multiple bullae on the trunk and extremities. There were large areas of exfoliation. There are oral and genital ulcers. CBC shows eosinophilia. Your primary diagnosis is: a. bullous pemphigoid b. Steven Johnson syndrome c. varicella d. herpes zoster 11. A 17-year old with a one month history of intensely pruritic, erythematous patches and plaques on the eyelids, antecubital and popliteal fossa. Other signs, symptoms and conditions that may be associated with this cutaneous disorder would include all EXCEPT: a. orbital darkening b. xerosis c. pityriasis alba d. pitysporum folliculitis 12. An obese woman complains of itchy rashes on the inframammary and crural area. She presented with erythematous patches, with central clearing and scaly, raised borders. What is your clinical diagnosis? a. inverse psoriasis b. tinea corporis c. allergic contact dermatitis d. candidiasis 13. An elderly woman suffers from a non-healing ulcer on the medial, lower aspect of her right leg of 6 months duration. Associated clinical findings that would point to arterial insufficiency as the cause would include: a. varicosities b. dystrophic toenails c. leg pain aggravated by dependence d. all of the above 14. GC is a 35-year old woman who has been having recurrent lesions on her lip area. Every two months, she would have a painful eruption of grouped vesicles on the dry vermillion border of her lips. What is a true statement about this condition? a. it is usually caused by varicella zoster virus b. it is a STD c. it is caused by the herpes simplex virus d. it is drug-induced For questions 15-17, refer to the following case: A 21 yo man presents with 5 mm erosions with honey colored crust on his chin. 15. A simple laboratory procedure to help with the diagnosis would be: a. Tzanck smear b. KOH c. Gram stain d. skin biopsy Lesions are descriptive of impetigo. Gm stain is a simple procedure that will help determine presence of Gm + bacteria.

16. What would be the most probable finding be: a. hyphal elements b. Gm + cocci in clusters c. multinucleated giant cells d. Gm – cocci in clusters

Most probable finding would be Gm + cocci in clusters (S.aureus) or Gm+ in chain (Strep) (not included in choice)

17. What would be the preferred medication to give: a. dicloxacillin b. penicillin c. azoles d. 3rd generation cephalosporin Based on findings of Gm + cocci clusters, indicative S.aureus, dicloxacillin is preferred.

For questions 18-20, refer to the following case: A 35 y/o male, a biking enthusiast, consults for tan colored macules and patches (slightly scaling on surface with distince borders) on his chest. 18. A simple laboratory procedure to do would be: a. Tzanck smear b. KOH c. Gram stain d. Skin biopsy Propensity to sweat and clinical description suggests Tinea versicolor wherein KOH is a simple laboratory procedure to support diagnosis.

19. What would the most probable findings be: a. hyphal elements b. Gm + cocci In clusters c. multinucleated giant cells d. Gm – cocci in clusters Findings would be hyphal elements or specifically spaghetti and meatballs

20. What would be the preferred medication give: a. amphotericin b. azoles c. griseofulvin d. nystatin Azoles are effective for Pityrosporum ovale. Griseofulvin and nystatin are not. Amphotericin is too toxic.

21. A 37 y/o female, on chemotherapy, consults for white plaques on the tongue. Aprobable diagnosis would be: a. thrush b. dermatophysis c. psoriasis d. aphthous ulcers Immunocompromised patients (e.g. on chemotherapy) are more at risk for trush (candidiasis of mouth.)

For questions 22-25, refer to the following case: NA, a 20-year old female who consults the out-patient clincis because of pruritic lesions for two-weeks. Her household members also experienced pruritus. On PE, excoriated papules were noted on the fingers, toes, and periumbilical area. 22. This patient is probly suffering from: a. scabies b. dyshidrotic eczema c. contact dermatitis d. dermatitis herpetiformis This patient has the typical history history and PE indicative of scabies.

23. You should advise the patient that the etiologic agent a. is an insect 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

24. Upon physical examination, which of the following lesions would be characteristic of the disease? a. nodule b. burrow c. erosion d. plaque Burrows are the characteristic lesions of patients.

25. 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 the young, children and adults c. males are more commonly affected than females d. overcrowding has been assoc. with this condition The disease is sexually transmissible. Its occurrence is seen both in young children, adults and the elderly. Both females and males are equally affected. Overcrowding is associated with this condition.

26. A 30-year old male presents with pearly 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 the epidermis.

27. JB, 25 y/o male, married, with 2 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. HPV 16 and 18 are the common etiological agents. b. Imiquimod applied at night 3x/wk for 12-16 wks is effective in treating this condition c. once treated, he can be assured that he will not have the condition anymore d. all of the above is true HPV 6 and 11 account for the most cases of genital warts. Even after treatment, he can still have episodes of the infection.

28. CV, 35 y/o male, with previous history of genital herpes develops grouped vesicles on the glans penis. His condition a. is caused solely by human herpes virus 2 b. will be accompanied by fever, malaise, and dysuria c. is caused by a virus reactivated by stress, sexual activity, or local skin trauma d. will have vesicles replaced by crusts in 10 to 14 days HHV – 1 can also cause genital herpes. Recurrent episodes are often asymptomatic, and will have vesicles replaced by crusts in 4 to 8 days.

29. The newest theory in the pathogenesis of SLE: a. role of B lymphocytes b. Genetic predisposition c. MHC and HLA d. Roles of EBV infection A, B, C are already known. Exposure to EBV infection is a new theory being linked to the pathogenesis of SLE.

30. Maria, 24 y/o female was diagnosed to have SLE when she was 18. She has been on remission for about 18 mos. Already so she dared to go and joined her friends on a summer break in Boracay. After being exposed repetitively under the sun, she went home to Manila with rashes on her sun-exposed areas, fever and body malaise. Triggering events for SLE disease initiation or flare maybe: a. stress b. pregnancy c. sunlight d. all of the above A, B, C, are all known factors that can start or produce flares of SLE.

31. Female gender is permissive for SLE; females of many mammalian species make higher antibody responses than males. The reason for this is a. females have high progesterone levels b. Estrogens are important proteins in clearing apoptotic cells which play a role in genetic susceptibility c. Estradiol binds to receptors on T and B lymphocytes, increasing activation and survival of those cells, thus favouring prolonged immune responses D. Females bind immunoglobulin weakly, hence they are predisposed to SLE Estrogen hormone is one factor that makes young women more predisposed to developing SLE and this is the mechanism involved.

32. A patient shall be said to have SLE is he/she has satisfied: a. Any four or more of the 11 criteria b. Any four or more of the 12 criteria c. Any two of the criteria plus a positive ANA d. ANA must always be positive A patient must satisfy at least 4 out of 11, based on the American College of Rheumatology criteria for SLE diagnosis.

33. A patient with SLE came for follow up, her urinalysis showed ++++ protein, 30-40 RBC, and presence of numerous casts. The following can be used as indicators for lupus nephritis disease activity in SLE, EXCEPT: a. ESR b. ANA c. Anti-dsDNA d. C3 Generally speaking, ESR would be elvated when lupus is in flare, though this is very non-specific, this may also be used in disease monitoring and adjustment of dosaging of medications. Anti-dsDNA and C3 are more specific for nephritis. Hence, it is very useful in monitoring activity of lupus nephritis. ANA is only used as part of the criteria to document diagnosis of lupus. It is also used as a screening test but not to monitor disease activity. It is not even useful in guiding you in treatment of your patients. 34. A 25 y/o 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 three months duration. You ordered some laboratory work-ups, active presence of SLE is indicated by the presence of anemia and: a. thrombocytosis and ++ in the urinalysis b. High C3 and lymphocytosis c. 16000 WBC and +++ urine pus cells d. Low C3 and 4000 WBC In active lupus, we usually encounter decrease levels of blood elements such as anemia, leukopenia, lymphopenia and thrombocytopenia. C3 is usually low.

35. A 20 year old female with SLE comes to you with her urinalysis result showed: Sp gravity 1022, ++++ proteinuria, (-) sugar, RBC 5-10, WBC 10-15, (+) RBC casts. You are considering nephritis, what will be the next most valuable examination that you will perform to confirm your consideration? a. kidney biopsy b. renal ultrasound c. RBC morphology d. 24h urine collection to measure the patient’s total protein excretion Nephritis is already evident with the presence of +++ proteinuria and casts, we don’t need ultrasound, RBC morphology anymore, we do 24h urine for protein measurement if the proteinuria in the urinlaysisis 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.

36. You will usually be aggressive in the management of lupus nephritis in these classifications since they are usually not responsive to steroids alone and they tend to progress to end-stage renal disease: a. Class I and II b. Class III and IV c. Class IV and V D. Class VI Class I is normal, class II and III respond to steroids and prognosis may be good. We usually start cytotoxoc drugs or biological agents in class IV and V since the tend to progress fast and usually, steroids are not enough. Class VI is already sclerotic type, so this is end stage.

37. The most common manifestation at onset and at anytime during the course of SLE: a. nephritis b. alopecia c. constitutional symptoms d. anemia Constitutional symptoms still is the most common initial manifestation at onset and even at anytime during the disease course of SLE. It is present at onset in 53% of patients and 77% at anytime.

38. The “E” in the CREST syndrome: a. erythema marginatum b. erythema nodosom c. esophageal dysmotility d. esophageal reflux disease CREST syndrome is: C – Calcinosis, R – Raynaud’s phenomenon, E – Esophageal dysmotility, S – Sclerodactyly, T – Telangiectasia

39. Pathognomonic finding in dermatomyositis: a. Gottron’s rash b. Heliotrope rash c. V-sign d. Shawl sign Heliotrope, V and Shawl signs may be seen in other CTD’s such as SLE, because this is due to photosensitivity, Gottron’s sign however is seen only in dermatomyositis, hence this is characteristic of this disease.

40. A 72 y/o retired bank manager referred to a rheumatologist because of headaches and muscle pain. He was well until three months previously, when he was involved in a minor motor vehicle accident and hit his head on the windshield. Since this accident he has suffered from daily right-sided headaches, which are steady and boring, and last two to four hours at a time. Along with headaches, he has also experienced general malaise and a 5-pound weight loss. He has no history of seizures, confusion or blackout spells. He has no hypertension for which he takes hydrochlorothiazide 25 mg/day and aspirin daily. Which of the two of the following tests would most likely be abnormal? a. ESR and Hgb/Hct b. ESR and Urinalysis c. ESR and ANA d. ESR and spinal fluid analysis This is a case of giant cell arteritis or temporal arteritis, a large vessel vasculitis. Vasculitis is an inflammatory process, hence ESR is elevated and in giant cell arteritis anemia is one of the most common features. Renal involvement is not always a feature, hence urinalysis is seldom abnormal, we don’t require it for its diagnosis. ANA is not required, and not a reliable diagnostic feature.

41. Testicular pain or tenderness is one of the criteria in: a. Polyarteritis nodosa b. Hypersensitivity vasculitis c. Wegener’s granulomatosis d. Kawasaki arteritis PAN is a vasculitis that involves small and medium-sized vessels, one of its features which is part of the the criteria is testicular pain or tenderness.

42. Histopathological finding common in small vessel vasculitis: a. fibrinoid necrosis b. leucocytosis c. thrombosis d. aneurysm formation Leukocytosis is a feature of small vessel vasculitis and is not seen in medium and large vessel vasculitis. Fibrinoid necrosis is usually seen in medium-sized vasculitis and thrombosis and aneurysm formation are common in large vessel vasculitis.

43. We give prophylactic antibiotics, Pen G, 1.2M units every 21d in patients who had acute rheumatic fever to prevent the development of rheumatic heart disease. For how long should we give the prophylaxis? a. For life b. For 5 years c. Up to 40 y/o

d. For 10 years We give prophylaxis for 5 years since it was found out that the risk of recurrence is greatest w/in 5 years from the onset of initial infection.

44. It is the most powerful risk factor for osteoarthritis: a. weight b. sex c. age d. trauma OA is degenerative joint disease seen in older individuals, hence age is the common denominator. All of us will acquire this disease when we are old.

45. A 25 y/o female presents with a 10-day history of arthritis. She developed a fever of 39 C with chills, followed by pain and swelling in 2nd and 3rd MCP and PIP joints of her left hand and the 2 nd, 3rd, 4th MCP joints of her right hand, lasting 3 days. As the small-joint swelling disappeared, her left wrist became slightly red, warm, swollen, and very painful to flex or extend for two to three days. As the wrist became normal, her left knee became red, swollen, tender and warm, which remained for four days. She has a mild sore throat and noticed a few small skin lesions on her arms, which she said began as small, tender red bumps and then developed into pustules. She denies sexual activity. On PE, temperature in 39 C, posterior pharynx is slightly red. There are two red skin lesions