Professional Documents
Culture Documents
Remember !!
REMEMBER ! normal range
• Blood: AST,ALT, ALP,protein, albumin, globulin,
Reference range Amylase, Lipase, Ca,PO, T3, FT4, TSH, cholesterol, TG,
LDL, HDL, BUN, Cr, Na, K, Cl, HCO3, ABG, glucose,
serum osmole, uric
1
• 9. A patient being treated with clindamycin for aspiration
pneumonia develops diarrhea. The stool contains a toxin
that kills cultured epithelial cells. Stool culture grows an
anaerobic grampositive rod. The same organism is
cultured from his bedpan. Which of the following is most
likely to sterilize the bedpan?
Problem-based learning(PBL) !!!
(A) Boiling for 45 minutes
(B) Exposure to benzalkonium chloride for 1 hour
(C) Exposure to ethyl alcohol for 1 hour
(D) Exposure to saturated steam (121°C) for 15 minutes
(E) Heating in an oven at 150°C for 30 minutes
Clindamycin Vs Diarrhea
• side effect of long duration use = Antibiotic-associated
diarrhea & colitis, pseudomembranous colitis
(C.difficile)
• Clostridium difficile
– Anaerobic GPB
– toxins A & B diarrhea
– spores are resistant to heat, acid & ATB
– Saturated stream kills spores
– Rx: Metronidazole or Vancomycin pseudomembranous colitis
2
REMEMBER ! Acid-base disturbance
H+, • If ↑ CO2 (Repiratory acidosis) Lung RR ↑ & HCO-3 ↑(kidney)
Metabolic Acidosis/Alkalosis = HCO3- ↓ CO2 (Repiratory alkalosis) Lung RR ↓ & HCO-3 ↓ (kidney)
disturbances of PaCO2 • ABG: pH 7.4± 0.05, pCO2 = 40, HCO-3=24, pO2 = 80-100
Pure(compensate) / Mixed disorder from the normal value of 40 mmHg for PaCO2 or 24 mEq/L for HCO3-
3
• 13. An 18-year-old female athlete reports easy fatigability and weakness.
Physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 141 mEq/L
• 45. A 31-year-old man with a history of epilepsy has a major motor (grand Cl− 85 mEq/L
mal) seizure. Laboratory values obtained immediately after cessation of the K+ 2.1 mEq/L
seizure include: HCO3− 35 mEq/L
Arterial blood Urine
pH 7.14 Na+ 80 mEq/24 h
PCO2 35 mm Hg 1.pH:acidosis K+ 170 mEq/24 h
Plasma
2.HCO3− ↓ = Metabolic
Na+ 140 mEq/L Which of the following is the most likely diagnosis?
Cl− 98 mEq/L 3.Pure(compensate) PCO2↑ (A) Aldosterone deficiency
K+ 4.0 mEq/L (B) Anxiety reaction with hyperventilation
HCO3− 17 mEq/L (C) Diabetic ketoacidosis
Which of the following is the most likely acid base disturbance? (D) Ingestion of anabolic steroids
(A) High anion gap metabolic acidosis Calculated PaCO2 = 1.5(HCO3) + 8 ± 2 (E) Surreptitious use of diuretics
(B) High anion gap respiratory acidosis = 31.5 to 35.5
(C) Low anion gap metabolic acidosis
Anion gap = Na - Cl - HCO3 = 25
(D) Normal anion gap metabolic acidosis
(E) Normal anion gap respiratory acidosis
Hypokalemia • 13. An 18-year-old female athlete reports easy fatigability and weakness.
[acid-base, ECF volume, hypertension, urine K+] Physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 141 mEq/L
Metabolic acidosis Normal acid-base Metabolic alkalosis Cl− 85 mEq/L
K+ 2.1 mEq/L
HCO3− 35 mEq/L Serum K 3.5-5.0, HCO3 24
urine K+ low high urine K+ low high
Urine
Na+ 80 mEq/24 h Urine Na<20, K<20
K+ 170 mEq/24 h
Lower GI loss Renal loss Intracellular shift • loss gastric secretion (late)
• diarrhea • RTA • insulin (urine pH<5.5, low urine Cl-) Which of the following is the most likely diagnosis?
• laxative abuse • DKA • β-agonist • remote diuretic use
• villous adenoma • acetazolamide • ↑ extracellular pH (thiazide, loop diuretics) (A) Aldosterone deficiency Aldosterone Na reabsorp, K excretion
• thyrotoxicosis • laxative abuse (B) Anxiety reaction with hyperventilation Res.alkalosis pCO2↓, HCO3 ↓
• periodic paralysis
• ↑ cell production (C) Diabetic ketoacidosis Met.acidosis HCO3↓
• intoxication (D) Ingestion of anabolic steroids Testosterone inhibit Na reabsorp
• other drugs (see text)
normotension hypertension (E) Surreptitious use of diuretics
• loss gastric secretion (early) • mineralocorticoid
(urine pH>7, low urine Cl-) excess
• recent diuretic use
(thiazide, loop diuretics)
• Bartter’s syndrome
• Gitelman’s syndrome
• Mg2+ depletion
Hemoconcentration,
• 19. Hospital discharge of a 75-year-old man is delayed due to unavailability
Hypernatremia BUN & Cr mild ↑
of a bed in a nursing home. He is bedridden and unable to attend to his loss of free water
personal needs. During a 3-day period, his pulse increases from 82/min to
125/min, and blood pressure decreases from 124/72 mm Hg to 100/55
mm Hg. Laboratory values include:
Day 1 Day 3 Skin Renal GI Hypothalamus Administration
Hemoglobin 16.4 g/dL 18.4 g/dL
Serum Urea nitrogen 18 mg/dL 56 mg/dL
Glucose 100 mg/dL 89 mg/dL
Na+ 135 mEq/L 151 mEq/L -Sweating -DI -osmotic diarrhea -1 hypodipsia -IV.oral Nacl,
-Burn -glucose, mannitol lactulose -resat osmostat NaHCO3
Creatinine 1.1 mg/dL 1.2 mg/dL
4
• 19. Hospital discharge of a 75-year-old man is delayed due to unavailability
HypoNa of a bed in a nursing home. He is bedridden and unable to attend to his
personal needs. During a 3-day period, his pulse increases from 82/min to
125/min, and blood pressure decreases from 124/72 mm Hg to 100/55
True Hyponatremia mm Hg. Laboratory values include:
(exclude hyperglycemia, hyperlipidemia) Day 1 Day 3
Hemoglobin 16.4 g/dL 18.4 g/dL
Serum Urea nitrogen 18 mg/dL 56 mg/dL
Assess ECF volume status Glucose 100 mg/dL 89 mg/dL
Na+ 135 mEq/L 151 mEq/L
Creatinine 1.1 mg/dL 1.2 mg/dL
Hypovolemia Normovolemia Hypervolemia Which of the following is the most likely diagnosis?
TBW ↓ , TBNa↓↓ TBW ↑ , TBNa↔ TBW↑↑ , TBNa↑ (A) Acute renal failure Met.acidosis, Na ↓
(B) Dehydration
(C) Diabetic ketoacidosis Met.acidosis, BS>250-300 mg/dL
(D) Gastrointestinal hemorrhage Alkalosis/acidosis+ Hb↓
(E) Syndrome of inappropriate ADH (vasopressin)
UNa >20 <20 > 20 > 20 < 20 ADH↑--Na↓
BPH
• 5-Reductase Inhibitor = Finasteride • 29. A 30-year-old woman with a 1-week history of severe diarrhea feels
dizzy when she stands up. Blood pressure (while supine) is 112/76 mm Hg
block testosterone →Dihydrotestosterone with a pulse of 88/min; blood pressure (while standing) is 80/60 mmHg with
a pulse of 120/min. In addition to controlling her diarrhea, the most
appropriate initial therapy is intravenous administration of which of the
• α-1-adrenergic antagonist = terazosin, doxazosin, following?
tamsulosin,alfuzosin, & Prazosin block bladder outlet obstruction
(A) Desmopressin
(B) 5% Dextrose in water
(C) Fresh frozen plasma
(D) 0.9% Saline
(E) Methoxamine
(F) Verapamil
5
Blood pressure Shock
PCWP or CVP
Afterload PVR
Preload
BP
Stroke volume
Contractibility
CO
6
Rales = crackles = crepitations
7
8
Physical signs in Chest disorders
Physical signs in Chest disorders • 30. A 60-year-old man has a 5-day history of productive cough and
shortness of breath with exertion. In addition to a normal left lung base,
examination of the chest in the area of the right lung base shows:
Breath sounds bronchial
Condition Trachea percuss BS Fremitus Ad.sound Percussion note dull
Tactile fremitus increased
Adventitious sounds crackles
Pn.Tx. Shift to HyperReso. decrease decrease none
opposite Which of the following is the most likely diagnosis?
(A) Asthmatic bronchitis
Emphysema mid HyperReso. decrease decrease none (B) Bullous emphysema
(diffuse) (C) Chronic bronchitis
(D) Congestive heart failure
Asthma mid N or obscure decrease Wheezes (E) Lobar pneumonia
HyperReso. (F) Pleural effusion
(G) Pleuritis
(H) Pneumothorax
CHF mid N or dull N or N or Crakles
(I) Pulmonary embolism
decrease decrease ±Wheezes
(diffuse)
9
Warfarin & drug interaction
• 31. Warfarin is administered to a 56-year-old man following placement of a
prosthetic cardiac valve. The warfarin dosage is adjusted to maintain an • ↓ Warfarin: griseofulvin, macrolide ATB,
INR of 2.5. Subsequently, trimethoprim-sulfamethoxazole therapy is begun
for a recurring urinary tract infection. metronidazole, rifampicin, sulfasalazine, vit.K
In addition to monitoring prothrombin time, which of the following
actions should the physician take to maintain adequate anticoagulation?
• 31. Warfarin is administered to a 56-year-old man following placement of a • 37. Investigators are studying the use of a new laboratory test to identify
prosthetic cardiac valve. The warfarin dosage is adjusted to maintain an patients with a particular disease. The table below summarizes the results
INR of 2.5. Subsequently, trimethoprim-sulfamethoxazole therapy is begun
for a recurring urinary tract infection. of initial research involving 200 subjects
In addition to monitoring prothrombin time, which of the following
actions should the physician take to maintain adequate anticoagulation?
• Positive predictive value(PPV) = a/(a+b) Which of the following is the approximate sensitivity of a positive test result?
#&*+!*+"# &-)*% (A) 0.30
• Negative predictive value(NPV) = d/(c+d) (B) 0.33 Sensitivity= 60/(60+20)=0.75
#&*+!'&'
"# &-)*%
(C) 0.60 Specificity= 80/(80+40)=0.67
(D) 0.67
PPV= 60/(60+40)=0.60
• Prevalence= (a+c)/(a+b+c+d) (E) 0.75
• Accuracy =(a+d)/(a+b+c+d) NPV= 80/(80+20)=0.80
10
• 39. An inexpensive screening test for a disease is available through • 38. A cardiac catheterization is done in a healthy person. The blood sample
analysis of venous blood. The distributions of blood concentrations for withdrawn from the catheter shows 60% oxygen saturation, and the
persons with and without the disease are depicted in the graph. The pressure recording shows oscillations from a maximum of 26 mm Hg to a
disease is irreversible and fatal if not discovered minimum of 14 mm Hg.
A= false and treated
positive↑ ↑ ↑ early. Which of
the following letters represents the most appropriate cutoff point between The catheter tip was located in which of the following areas?
normal and abnormal? B= sensitivity↑ ↑ ↑, false positive ↑
C= sensitivity↑ , false negative ↑ (A) Ductus arteriosus
D= specificity ↑ ↑, false negative ↑ ↑ (B) Foramen ovale
(C) Left atrium
E= specificity ↑ ↑ ↑ , false negative ↑ ↑ ↑
(D) Pulmonary artery
(E) Right atrium
70%
O2 70%
95%
70%
Pressure 5 mmHg
LVEDP (=PCWP) 10 mmHg
11
Hyperthyroidism
• 43. A 66-year-old man has become increasingly short-tempered with his
wife. He has diarrhea, weight loss, and weakness in the proximal muscles. • high T3 &T4, low TSH = 1ºHyperthyroid
He has atrial fibrillation and tachycardia.
Which of the following is the most likely diagnosis? • high T3 &T4, high TSH = 2ºHyperthyroid
(A) Congestive heart failure
(B) Cushing syndrome
• S/S …Systemic organ symptoms & signs
(C) Hyperthyroidism
(D) Mitral valve prolapse
(E) Pheochromocytoma
Rx:Drug; PTU,methimazole
I131 ablation
Surgery
Normal
Enlarged gland
Hashimoto thyroiditis
• 43. A 66-year-old man has become increasingly short-tempered with his
• Chronic lymphocytic thyroiditis wife. He has diarrhea, weight loss, and weakness in the proximal muscles.
He has atrial fibrillation and tachycardia.
• Autoimmune disease Which of the following is the most likely diagnosis?
12
Valvular heart disease
& Congenital heart disease
• 53. A 28-year-old man who had rheumatic fever as a child comes to the
physician's office because of fatigue and dyspnea for the past 4 months. An • Mitral regurgitation: Pansystolic murmur
early diastolic sound followed by a low-pitched rumbling decrescendo
diastolic murmur is present 4 cm left of the sternal border in the fourth • Aortic stenosis: Systolic ejection m.
intercostal space and is heard best with the patient in the left lateral
decubitus position. • Aortic regurgitation: Diastolic blowing m.
Which of the following valve defects is most likely in this patient?
• Mitral stenosis: Diastolic rumbling m.
(A) Aortic regurgitation
‘M.R.-Pan, AS-Ject, AR-blow, MiSs-rum’
(B) Aortic stenosis
(C) Mitral regurgitation
(D) Mitral stenosis
(E) Pulmonic regurgitation
(F) Pulmonic stenosis
(G) Tricuspid regurgitation
• ASD: Fixed split S2
(H) Tricuspid stenos • PDA: continuous / machinery murmur
• VSD: Pansystolic m. MS
• 53. A 28-year-old man who had rheumatic fever as a child comes to the • 56. A 68-year-old man has had low back pain over the past 2 months.
physician's office because of fatigue and dyspnea for the past 4 months. An Laboratory studies show a normochromic, normocytic anemia and
early diastolic sound followed by a low-pitched rumbling decrescendo azotemia. Serum and urine calcium concentrations are abnormally
diastolic murmur is present 4 cm left of the sternal border in the fourth increased, and urinalysis shows excessive protein (4+) and proteinaceous
intercostal space and is heard best with the patient in the left lateral casts.
decubitus position. Bone marrow examination is most likely to show uncontrolled
Which of the following valve defects is most likely in this patient? proliferation of which of the following cells?
Plasma cells in BM
13
Common cancer with hypercalcemia
• 56. A 68-year-old man has had low back pain over the past 2 months.
• Breast Laboratory studies show a normochromic, normocytic anemia and
azotemia. Serum and urine calcium concentrations are abnormally
increased, and urinalysis shows excessive protein (4+) and proteinaceous
• Lung ( SCC, Large cell CA ) casts.
Bone marrow examination is most likely to show uncontrolled
• Kidney proliferation of which of the following cells?
Lipoprotein disorders
• 59. A 20-year-old man comes to the physician's office for a scheduled
health maintenance examination. His father died of a myocardial infarction
at age 55 years. Physical examination shows a tendon xanthoma on the
elbow. His serum total cholesterol concentration is 360 mg/dL.
A mutation is most likely to be found in which of the following genes?
(A) apoA2
(B) apoC2
(C) apoε4
(D) LDL receptor
(E) VLDL receptor
14
• 59. A 20-year-old man comes to the physician's office for a scheduled
health maintenance examination. His father died of a myocardial infarction
at age 55 years. Physical examination shows a tendon xanthoma on the
elbow. His serum total cholesterol concentration is 360 mg/dL.
A mutation is most likely to be found in which of the following genes?
HypoNa
• 60. A 74-year-old man has had confusion for 2 weeks. He has smoked two True Hyponatremia
packs of cigarettes daily for 50 years. An x-ray of the chest shows a 5-cm (exclude hyperglycemia, hyperlipidemia)
mass in the lung. Laboratory studies of serum show:
Na+ 110 mEq/L
Cl− 72 mEq/L Assess ECF volume status
K+ 4.5 mEq/L
HCO3− 30 mEq/L
Glucose 200 mg/dL Hypovolemia Normovolemia Hypervolemia
Creatinine 1.4 mg/dL
Which of the following is the most likely cause of these findings? TBW ↓ , TBNa↓↓ TBW ↑ , TBNa↔ TBW↑↑ , TBNa↑
15
• 60. A 74-year-old man has had confusion for 2 weeks. He has smoked two • 62. A previously healthy, tall, and slender 19-yearold woman has the
packs of cigarettes daily for 50 years. An x-ray of the chest shows a 5-cm sudden onset of right-sided chest pain followed by progressive dyspnea.
mass in the lung. Laboratory studies of serum show: Ten hours later, an x-ray of the chest shows a collapsed right lung and air in
Na+ 110 mEq/L the right pleural space.
Cl− 72 mEq/L Which of the following is the most likely underlying condition?
K+ 4.5 mEq/L
HCO3− 30 mEq/L
(A) Bronchiectasis
Glucose 200 mg/dL
Creatinine 1.4 mg/dL (B) Lung abscess
Which of the following is the most likely cause of these findings? (C) Panacinar emphysema
(D) Pulmonary sequestration
(A) Adenocarcinoma of the lung (E) Subpleural blebs
(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroid gland
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung
• 62. A previously healthy, tall, and slender 19-yearold woman has the
• Younger & tall sudden onset of right-sided chest pain followed by progressive dyspnea.
Ten hours later, an x-ray of the chest shows a collapsed right lung and air in
• ± smoking, family history, Marfan syndrome, the right pleural space.
homocystinuria, & thoracic endometriosis Which of the following is the most likely underlying condition?
Helicobacter pylori
• 64. A 46-year-old man has a 4-week history of epigastric pain; test of stool
is positive for occult blood. Examination of tissue obtained on biopsy of the
gastric antrum shows curved bacterial rods.
Which of the following additional findings is most likely?
Urease Test / CLO test®
(A) Achlorhydria
(B) Antiparietal cell antibodies
(C) Cholecystitis with antral seeding
(D) Immunodeficiency state
(E) Increased urease activity in the antrum urease
Novel Prize2005
16
• 64. A 46-year-old man has a 4-week history of epigastric pain; test of stool • 65. A 52-year-old man with recently diagnosed type 2 diabetes mellitus
is positive for occult blood. Examination of tissue obtained on biopsy of the comes to the physician for a follow-up examination. Physical examination
gastric antrum shows curved bacterial rods. shows no abnormalities. Laboratory studies show an increased hemoglobin
Which of the following additional findings is most likely? A1c despite patient compliance with diet and exercise recommendations.
Treatment with a sulfonylurea is started.
(A) Achlorhydria Which of the following is most likely to occur in this patient?
(B) Antiparietal cell antibodies
(C) Cholecystitis with antral seeding (A) Decreased entry of glucose into the muscle cells
(D) Immunodeficiency state (B) Decreased production of glucose from the liver
(E) Increased urease activity in the antrum (C) Decreased secretion of insulin from the pancreas
(D) Decreased speed of carbohydrate absorption from the intestines
(E) Increased entry of glucose into the muscle cells
(F) Increased production of glucose from the liver
(G) Increased secretion of insulin from the pancreas
(H) Increased speed of carbohydrate absorption from the intestines
• Thiazolidinediones (glitazones):
rosiglitazone, pioglitazone
17
Neutropenia
• 67. A 51-year-old woman with cancer is being treated with a hematopoietic
growth factor. Leukocyte differentials before and after treatment are shown: • post-chemotherapy for cancer
Before Treatment After Treatment • WBC↓: Neutrophil
Leukocyte count 1000/mm3 10,000/mm3
Eosinophils 1% 1% • Rx: G-CSF
Lymphocytes 90% 9%
Neutrophils 9% 90%
The growth factor is most likely to be which of the following?
• 67. A 51-year-old woman with cancer is being treated with a hematopoietic • 70. A 30-year-old man comes to the clinic because of a painful ulcer on his
growth factor. Leukocyte differentials before and after treatment are shown: penis for the past week. He has had multiple sexual partners, including
commercial sex workers. Physical examination shows lymphadenopathy in
Before Treatment After Treatment the inguinal region and a 1-cm tender ulcer with no induration located on the
frenulum. A culture of the ulcer grows colonies on supplemented chocolate
Leukocyte count 1000/mm3 10,000/mm3 agar. A Gram stain of the colonies shows gram negative coccobacilli. Which
Eosinophils 1% 1% of the following is the most likely causal organism?
Lymphocytes 90% 9%
Neutrophils 9% 90% (A) Haemophilus ducreyi
The growth factor is most likely to be which of the following? (B) Herpes simplex virus
(C) Neisseria gonorrhoeae
(A) Granulocyte colony-stimulating factor (D) Treponema pallidum
(B) Transforming growth factor-β (E) Trichomonas vaginalis
(C) Interleukin-6 (IL-6)
(D) IL-8
(E) Macrophage colony-stimulating factor
– chancroid(Haemophilus ducreyi)
– lymphogranuloma venereum(Chlamydia Primary syphilis
trachomatis)
• Chancroid: H. ducreyi
18
• 70. A 30-year-old man comes to the clinic because of a painful ulcer on his • 72. A 25-year-old woman has a 3-day history of vomiting and diarrhea. She
penis for the past week. He has had multiple sexual partners, including has postural hypotension and poor tissue turgor. Her serum sodium
commercial sex workers. Physical examination shows lymphadenopathy in concentration is 130 mEq/L.
the inguinal region and a 1-cm tender ulcer with no induration located on the
frenulum. A culture of the ulcer grows colonies on supplemented chocolate Which of the following findings is most likely?
agar. A Gram stain of the colonies shows gram negative coccobacilli. Which
of the following is the most likely causal organism? (A) Decreased serum aldosterone concentration
(B) Increased serum atrial natriuretic peptide concentration
(A) Haemophilus ducreyi
(B) Herpes simplex virus (C) Increased effective circulating volume
(C) Neisseria gonorrhoeae (D) Increased serum ADH (vasopressin) concentration
(D) Treponema pallidum (E) Urine osmolality less than serum osmolality
(E) Trichomonas vaginalis
Wernicke-Korsakoff syndrome
• 73. A 40-year-old man with a 20-year history of alcohol abuse is brought to
• chronic alcoholism, anorexia nervosa the hospital by his friends because he was difficult to rouse. He ate a large
meal several hours ago. He is emaciated and lethargic. Examination shows
severely restricted horizontal eye movements and ataxia of both upper
• thiamine (vitamin B1) deficiency extremities.
The most likely cause of these findings is a deficiency of which of the
• Tiad: ‘dementia, ophthalmoplegia, ataxia’ following nutrients?
Megaloblastic anemia
• Beri-beri: cardiac(CHF), nerve (A) Folic acid
(B) Vitamin A Visual impairement
(numbness) (C) Vitamin B1 (thiamine)
(D) Vitamin B6 (pyridoxine) Peripheral neuropathy
(E) Vitamin B12 (cobalamin)
Megaloblastic anemia &
peripheral neuropathy
19
Infection in Organ transplantation
• 74. Three weeks after a renal transplant, a patient develops fever and
leukopenia, followed by prostration and severe pulmonary and hepatic • Most common in neutropenia :
dysfunction.
CMV and TB
Which of the following is the most likely viral cause?
• 74. Three weeks after a renal transplant, a patient develops fever and • 85. An asymptomatic 50-year-old woman has hypertension. Her urinary
leukopenia, followed by prostration and severe pulmonary and hepatic excretion of catecholamines is increased. A CT scan shows a suprarenal
dysfunction. mass.
Which of the following is the most likely viral cause? Which of the following is the most likely cause?
(A) Adenovirus type 12
(B) Coxsackievirus (A) Benign neoplasm of the adrenal cortex
(C) Cytomegalovirus (B) Benign neoplasm of the adrenal medulla
(D) Influenza virus (C) Malignant neoplasm of the adrenal cortex
(E) Parvovirus B19 (D) Malignant neoplasm of the adrenal medulla
(E) Diffuse hyperplasia of the adrenal cortex
(F) Diffuse hypoplasia of the adrenal medulla
20
• 86. A 21-year-old man has weight loss and severe intermittent bloody • 95. The unlabeled solid curve in the graph shown represents the loading
diarrhea. A barium enema and colonoscopy show multiple ulcers and behavior of normal human hemoglobin at a pH of 7.35 as a function of
inflammatory changes extending from the rectum to the mid-transverse
colon. Biopsy specimens taken from multiple sites show acute and chronic oxygen concentration. Which of the following labeled curves best represents
inflammation restricted to the mucosa. Which of the following is the most the most likely change after addition of carbon dioxide?
likely diagnosis?
Alkalosis, temperature↓
• 96. A 45-year-old woman who is being treated for hypertension and
hypercholesterolemia develops diffuse muscle pain and weakness. Her
serum creatine kinase activity is increased. Which of the following drugs is
most likely to have caused this clinical picture?
(A) Captopril
Acidosis, CO2, H+, temperature↑, (B) Hydrochlorothiazide
2,3 DPG (C) Lovastatin
(D) Nicotinic acid
(E) Propranolol
Statin-induced rhabdomyolysis
• 96. A 45-year-old woman who is being treated for hypertension and
• HMG co-A reductase inhibitor = statin hypercholesterolemia develops diffuse muscle pain and weakness. Her
serum creatine kinase activity is increased. Which of the following drugs is
most likely to have caused this clinical picture?
21
SLE
Dx: 4 of 11
• 99. A 30-year-old woman being treated for hypertension has the sudden
onset of fever and malaise. Her temperature is 38.3°C (101°F), and blood
pressure is 120/80 mm Hg. Physical examination shows a malar rash,
swelling and tenderness of the wrists and knees, and a friction rub at the
lower left sternal border.
Which of the following drugs is the most likely cause of these findings?
(A) Captopril
(B) Hydralazine
(C) Minoxidil
(D) Nitroprusside
(E) Propranolol
• 99. A 30-year-old woman being treated for hypertension has the sudden • 111. A 55-year-old woman with breast cancer develops shortness of breath
onset of fever and malaise. Her temperature is 38.3°C (101°F), and blood and poor exercise tolerance while being treated with doxorubicin.
pressure is 120/80 mm Hg. Physical examination shows a malar rash,
swelling and tenderness of the wrists and knees, and a friction rub at the Which of the following is the most likely cause of these symptoms?
lower left sternal border.
Which of the following drugs is the most likely cause of these findings? (A) Dilated cardiomyopathy
(B) Obstructive pulmonary disease
(A) Captopril (C) Pulmonary hypertension
(B) Hydralazine (D) Restrictive cardiomyopathy
(C) Minoxidil
(E) Restrictive pulmonary disease
(D) Nitroprusside
(E) Propranolol
22
Doxorubicin induced cardiomyopathy
• 111. A 55-year-old woman with breast cancer develops shortness of breath
• Anthracycline: Doxorubicin(adriamycin®) , Idarubicin and poor exercise tolerance while being treated with doxorubicin.
• Chemotherapy for solid tumor & hematologic malignancy Which of the following is the most likely cause of these symptoms?
Pseudothrombocytopenia
Immune Thrombocytopenic Purpura
Must be Excluded
23
Immune thrombocytopenic purpura (ITP) Immune thrombocytopenic purpura (ITP)
24
Stress hormones
• 114. A 25-year-old woman with previously well controlled type 1 diabetes
mellitus develops ketoacidosis 2 days after onset of a urinary tract infection. • ↑Cortisol &
The most likely cause of the ketoacidosis is decreased efficacy of insulin on
muscle, adipose tissue, and liver resulting from antagonism by which of the • ↑Norepinephrine
following hormones?
(A) Androstenedione
(B) Cortisol
(C) Glucagon
(D) Leptin • ↓Anabolic hormone:
(E) Thyroxine (T)
Insulin, Glucagon,
GH, Thyroid hormone
Sex H.(Testosterone)
• 114. A 25-year-old woman with previously well controlled type 1 diabetes • 117. A 63-year-old man with a 5-year history of congestive heart failure
mellitus develops ketoacidosis 2 days after onset of a urinary tract infection. comes to the emergency department because of a 1-month history of
The most likely cause of the ketoacidosis is decreased efficacy of insulin on fatigue and labored breathing. Evaluation shows pulmonary edema.
muscle, adipose tissue, and liver resulting from antagonism by which of the Furosemide is administered. Which of the following sets of physiologic
following hormones?
changes is most likely following administration of the drug?
(A) Androstenedione
(B) Cortisol
(C) Glucagon
(D) Leptin
(E) Thyroxine (T)
Loop diuretic
Furosemide
Na+/K+/2Cl pump
25
• 117. A 63-year-old man with a 5-year history of congestive heart failure • 120. A 75-year-old woman has increasing shortness of breath on exertion.
comes to the emergency department because of a 1-month history of Findings on physical examination are unremarkable. X-rays of the chest
show no abnormalities of the heart or lungs. Pertinent laboratory findings
fatigue and labored breathing. Evaluation shows pulmonary edema. include:
Furosemide is administered. Which of the following sets of physiologic Hematocrit 28%
changes is most likely following administration of the drug? Hemoglobin 9 g/dL
Mean corpuscular volume 70 µm3
Which of the following is the most likely basis for these findings?
Hypersegmented PMN
Macro-ovalocyte
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Thalassemia
Causes of Microcytic anemia
• Iron deficiency anemia
• Thalassemia
• Anemia of chronic disease (late)
• Sideroblastic anemia
• Lead poisoning
Iron metabolism
Iron def. anemia
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COPD
(Chronic Obstructive Pulmonary Disease)
• 121. The incidence of chronic pulmonary disease in a community is 1.5
times greater than the national rate. If successful, which of the following • Chronic bronchitis
interventions would provide the greatest decrease in chronic pulmonary
disease in this community? • Emphysema
(A) Decrease the prevalence of cigarette smoking
(B) Decrease radon levels in homes
(C) Increase the number of people performing aerobic exercise
(D) Increase the rate of flu immunization
(E) Increase the rate of pneumococcal immunization
(F) Remove asbestos from all buildings
(G) Remove lead from all gasoline and other fuels
• 121. The incidence of chronic pulmonary disease in a community is 1.5 • 131. An otherwise healthy 55-year-old Asian American man is given
times greater than the national rate. If successful, which of the following isoniazid and vitamin B6(pyridoxine) after conversion of his PPD skin test.
interventions would provide the greatest decrease in chronic pulmonary An x-ray of the chest shows no abnormalities. Four weeks later, he
disease in this community? develops abdominal pain and jaundice. Which of the following is the most
likely explanation?
(A) Decrease the prevalence of cigarette smoking
(B) Decrease radon levels in homes
(A) Hepatic tuberculosis
(C) Increase the number of people performing aerobic exercise
(D) Increase the rate of flu immunization (B) Hepatitis B
(E) Increase the rate of pneumococcal immunization (C) Isoniazid-induced hepatitis
(F) Remove asbestos from all buildings (D) Pyridoxine-induced cholecystitis
(G) Remove lead from all gasoline and other fuels (E) Tuberculous pancreatitis
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Gouty arthritis
• 132. A 30-year-old man with peptic ulcer disease suddenly develops pain, • uric acid overproduction & ↓renal excretion
redness, and swelling of his right first metatarsophalangeal joint. There is no
history of injury. Serum uric acid concentration is 8 mg/dL. Examination of
joint aspirate shows birefringent crystals. Which of the following drugs is • common in males, postmenopausal women, & drink
most appropriate to treat the acute symptoms in this patient? alcohol, DM, Renal failure
(A) Allopurinol • Mono- or oligo- or poly-arthritis
(B) Colchicine • Synovial fluid: monosodium urate crystals
(C) Morphine
(D) Probenecid (needle shaped); negative birefringent
(E) Sulfinpyrazone
1st MTP joint Chronic tophaceous gout
Tophi
• 132. A 30-year-old man with peptic ulcer disease suddenly develops pain, • 133. The thrombolytic effect of tissue plasminogen activator depends on
redness, and swelling of his right first metatarsophalangeal joint. There is no which of the following?
history of injury. Serum uric acid concentration is 8 mg/dL. Examination of
joint aspirate shows birefringent crystals. Which of the following drugs is
most appropriate to treat the acute symptoms in this patient? (A) Circulating heparin
Inhibit xanthine oxidase purine↓ uric↓ (B) Concomitant therapy with high doses of aspirin
(A) Allopurinol
(B) Colchicine inhibit neutrophil motility & activity (C) Factor II (prothrombin) concentration
(C) Morphine (D) Fibrinogen concentration
(D) Probenecid uricosuric agent (E) Presence of fibrin at the site of the thrombus
(E) Sulfinpyrazone
uricosuric agent
Coagulation Pathway
29
• 133. The thrombolytic effect of tissue plasminogen activator depends on • 134. Which of the following figures (A–E) best illustrates the relationship
which of the following? between blood flow and mean arterial pressure (MAP) in a vascular bed that
demonstrates autoregulation of blood flow?
(A) Circulating heparin
(B) Concomitant therapy with high doses of aspirin
(C) Factor II (prothrombin) concentration
(D) Fibrinogen concentration
(E) Presence of fibrin at the site of the thrombus
Autoregulation
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ACS STEMI in Inferior wall
• Diagnosis
1.Clinical chest pain (angina)
2.EKG: Q,T wave, ST segment
3.Cardiac enzyme: CK-MB, Troponin-T or Trop-I
Complication of MI
• 136. A 72-year-old man collapses while playing golf. He has a 5-year history
• Mechanical: Heart failure of angina and type 2 diabetes mellitus. Paramedics arrive in 10 minutes.
Examination shows no respirations or blood pressure; an ECG shows
– Ruptured free wall, VSD asystole.Cardiopulmonary resuscitation is attempted for 10 minutes without
success. Which of the following is the most likely cause of death in this
– Ruptured papillary muscle patient?
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Sarcoidosis
• 137. A 34-year-old woman has had a nonproductive cough for 2 months.
She has never smoked. An x-ray of the chest shows bilateral interstitial • immune system disorder & non-caseating
markings and hilar adenopathy. Which of the following findings is most likely
on transbronchial biopsy?
granuloma (small inflammatory nodules)
• Involve lungs & LN, hypercalcemia
(A) Areas of hemorrhagic infiltrate
(B) Areas of liquefaction necrosis • D/Dx TB (must to be excluded)
(C) Dilation of respiratory bronchioles
(D) Microabscesses • Rx: corticosteroid
(E) Noncaseating granulomas
Hilar LN & bilat.
interstitial infiltration
• 137. A 34-year-old woman has had a nonproductive cough for 2 months. • 139. A 36-year-old woman dies from an acute adrenal crisis following a
She has never smoked. An x-ray of the chest shows bilateral interstitial surgical procedure. A pituitary tumor was diagnosed 3 weeks ago. At
markings and hilar adenopathy. Which of the following findings is most likely autopsy, the adrenal glands are small, and the cortex is composed primarily
on transbronchial biopsy? of cells from the zona glomerulosa. Which of the following best explains the
decreased size of the cortex?
(A) Areas of hemorrhagic infiltrate
(B) Areas of liquefaction necrosis (A) Autoimmune destruction
(C) Dilation of respiratory bronchioles (B) Decreased ACTH concentration
(D) Microabscesses (C) Decreased cortisol concentration
(E) Noncaseating granulomas (D) Denervation
(E) Granulomatous disease
• Cortex
-Z.glom: Mineralocorticoid
(Aldosterone)
-Z.fasciculata: Glucocorticoid
(Cortisol)
-Z.reticularis: Sex hormone
(Androgen)
• Medulla
Cathecolamine (NE,E)
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Adrenal insufficiency
• Cortisol ↓ & most decreased size of gland • 139. A 36-year-old woman dies from an acute adrenal crisis following a
surgical procedure. A pituitary tumor was diagnosed 3 weeks ago. At
autopsy, the adrenal glands are small, and the cortex is composed primarily
of cells from the zona glomerulosa. Which of the following best explains the
• Primary AI: exogenous steroid↑, disease of decreased size of the cortex?
adrenal gland (tumor, trauma, infection, (A) Autoimmune destruction
autoimmune) (B) Decreased ACTH concentration
(C) Decreased cortisol concentration
(D) Denervation
• Secondary AI (ACTH↓): Pituitary gland (E) Granulomatous disease
disease(tumor, trauma, infection,autoimmune)
Actinic keratoses
• 143. A 72-year-old man who is a retired construction worker comes to the
physician because he has had a lesion on his face for 3 months. Physical • not skin cancer, but precancerous
examination shows a 6-mm, red, ulcerated lesion with heaped borders. A
biopsy specimen of the lesion shows atypical, dysplastic keratinocytes
within the epidermis and dermis. • Senile lesion
Which of the following is the most likely diagnosis?
• indicates excess sun exposure
(A) Actinic keratoses
(B) Discoid lupus erythematosus • Red, rough, scaly spots, may itch or sting
(C) Melanoma
(D) Mycosis fungoides
(E) Squamous cell carcinoma
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SCC of face
• 143. A 72-year-old man who is a retired construction worker comes to the
physician because he has had a lesion on his face for 3 months. Physical
examination shows a 6-mm, red, ulcerated lesion with heaped borders. A
biopsy specimen of the lesion shows atypical, dysplastic keratinocytes
within the epidermis and dermis.
Which of the following is the most likely diagnosis?
Scurvy
• 147. A 70-year-old man has ecchymoses, perifollicular petechiae, and • Vit.C deficiency (collagen synthesis)
swelling of the gingiva. He has lived alone since the death of his wife 2
years ago. His diet consists primarily of cola and hot dogs. • skin spots, spongy gums
Which of the following is the most likely diagnosis?
• mucosal bleeding
(A) Beriberi
(B) Kwashiorkor
(C) Pellagra
(D) Rickets
(E) Scurvy corkscrew hair
periungual
hemorrhage
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