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INTERNAL MEDICINE

REVIEW
Class 2010

Dr. Raymond V. Oliva


Section of Hypertension
Department of Medicine
Correction#6, page 1.
e. none of the above
Just use one book for the Philippine Boards
◦ High Yield
◦ NMS
◦ First Aid
◦ Blue Book
◦ Blue Prints
◦ Harrison’s

Itis important to be familiar with the process of


examination

TIPS
Which of the following vaccines are
composed of inactivated bacterial or
viral components?

a. Tetanus – toxoid
b. Varicella – live attenuated
c. Influenza – inactivated virus
d. Measles – live attenuated
 

Question 1
Live Inactivated Toxoids Component
attenuated
MMR Inactivated Diphtheria Hib
polio
Oral polio Influenza tetanus Hep B
Varicella Hep A

Pneumococcal

Types of Vaccines
Which of the following vaccine/s is/are
contraindicated in a pregnant woman?

a. Varicella
b. Measles
c. Mumps
d. All of the above

Note: Only advisable vaccines for women are


Tetanus, reduced diphtheria toxoid, and
inactivated influenza vaccines.

Question 2
A 50 year old man with COPD was rushed to the ER for dyspnea. History
revealed a 1 week history of decreased sensorium associated with
high grade fever and decreased urine output. Initial PE: BP 80/60
becoming 90/60 after fluid challenge. HR: 100, RR: 40 T: 39C. Sputum
GS showed Gram negative bacilli. What is the most likely diagnosis?

a. Sepsis – SIRS with proven microbial etiology

b. Severe Sepsis - Sepsis with one or more signs of organ dysfunction


1. Cardiovascular: Arterial systolic blood pressure 90 mmHg or mean arterial
pressure 70 mmHg that responds to administration of intravenous fluid,
2. Renal: Urine output <0.5 mL/kg per hour for 1 h despite adequate fluid
resuscitation,
3. Respiratory: PaO2/FIO2 250 or, if the lung is the only dysfunctional organ, 200,
4. Hematologic: Platelet count <80,000/L or 50% decrease in platelet count
from highest value recorded over previous 3 days,
5. Unexplained metabolic acidosis: A pH 7.30 or a base deficit 5.0 mEq/L and a
plasma lactate level >1.5 times upper limit of normal for reporting lab,
6. Adequate fluid resuscitation: Pulmonary artery wedge pressure 12 mmHg or
central venous pressure 8 mmHg

Question 3
c. SIRS - Two or more of the following conditions:
(1) fever (oral temperature >38°C) or hypothermia
(<36°C);
(2) tachypnea (>24 breaths/min);
(3) tachycardia (heart rate >90 beats/min);
(4) leukocytosis (>12,000/L), leukopenia (<4,000/L), or
>10% bands; may have a noninfectious etiology

d. Septic Shock - Sepsis with hypotension (arterial blood


pressure <90 mmHg systolic, or 40 mmHg less than
patient's normal blood pressure) for at least 1 h despite
adequate fluid resuscitation; or Need for vasopressors to
maintain systolic blood pressure 90 mmHg or mean arterial
pressure 70 mmHg
 

Question 3
Which of the following organisms comprise are HACEK organisms ?

a. Haemophilus
b. Acinetobacter
c. Clostridium
d. Klebsiella
e. All of the above

Haemophilus species, Actinobacillus actinomycetemcomitans,


Cardiobacterium hominis, Eikenella corrodens, and Kingella
kingae

Question 4
What is the most common presenting
symptom of infective endocarditis?

a. fever – 80-90%
b. heart murmur – 80-85%
c. arthralgia – 15-30%
d. anorexia – 20-50%

Question 5
Definitive Endocarditis
• 2 major criteria (microbiologic,
endocardial involvement)
• 1 major + 3 minor
• 5 minor

Possible endocarditis
• 1 major + 1 minor
• 3 minor

Duke’s Criteria
Which of the following clinical scenario will
increase the risk of MDR-TB except?

a. A 30 year old female with pleural effusion secondary


to TB previously treated with 6 months quadruple
anti-Kochs, now has recurrent pleural effusion.
b. A 60 year old male with cavitary lesions on CXR.
c. A 35 year old female with cough, weight loss and
night sweats with bilateral infiltrates on CXR.
d. A 40 year old male with HIV infection acquiring
pulmonary TB.
e. None of the above
 
 

Question 6
Which of the following extrapulmonary TB will
benefit from oral steroids?

a. TB meningitis - adjunctive dexamethasone


b. pericardial TB - prednisone
c. Both A and B
d. Neither a and B
 
 

Question 7
Which of the following infections are
associated with Streptoccocus pyogenes?

a. Impetigo contagiosa
b. Bullous impetigo – Staph
c. Hot Tub Folliculitis – Pseudomonas
d. None of the above

Question 8
Which of the following viruses are
associated with the common cold
EXCEPT?

a. Rhinovirus
b. coronavirus
c. adenovirus
d. Influenza virus

Question 9
True statements regarding the diagnosis of typhoid
fever EXCEPT?

a. The WBC count is normal despite high fever.


b. Blood cultures are positive in 90% of cases during
the 2nd week of infection.
c. Bone marrow cultures are 90% positive despite
antibiotic treatment.
d. Stool cultures that are negative during the first
week can become positive during the 3rd week of
infection.
e. Culture of duodenal secretions can be positive
despite a negative bone marrow culture.

Question 10
Which of the following statements regarding Dengue
Fever is/are TRUE except?

a. All four types of dengue viruses have Aedes aegypti


as their principal vector and all cause a similar clinical
syndrome.
b. In Dengue fever, a macular rash is seen on the first
day accompanied by adenopathy, palatal vesicles and
scleral injection.
c. Near the time of defervescence, a maculopapular rash
is seen spreading centipetally. – from trunk to the
extremities and face
d. Macrophage- monocyte infection is central to the
pathogenesis of dengue fever.

Question 11
A 21 year old sexually active woman presents with
fever, pleuritic pain of the RUQ and lower abdominal
pain. Pelvic examination reveals mucopurulent
cervicitis and tenderness after production of cervical
motion. The RUQ, uterine fundus and adnexae are
slightly tender. Lab exam revealed a high WBC count
and elevated ESR, rest of the lab exams including
liver function tests are normal. Which of the following
agents are the most likely cause of this clinical
syndrome?

a. Herpes simplex – painful vesicles


b. Treponema pallidum – syphilis, ‘ painless ulcers’
c. Neisseria gonorrhea
d. Chlamydia trachomatis – mostly asymptomatic, or
with dysuria and change in vaginal discharge

Question 12
Which of the following regarding leptospirosis is/are TRUE?

a. Vasculitis is responsible for most of the manifestations of


the disease.
b. Severe hepatocellular necrosis is a feature of leptospirosis.
– centrilobular necrosis with Kuppfer cell proliferation
c. More than 90% of symptomatic patients have the anicteric
form of the disease without meningitis. - More than 90%
of symptomatic persons have the relatively mild and
usually anicteric form of leptospirosis, with or without
meningitis
d. In the immune leptospiremic phase, the most common
finding is fever with conjunctival suffusion. – 1st phase
(leptospiremic phase), 2nd phase (immune phase) –
development of antibodies

Question 13
Which of the following disease confer
protection against death in malaria?

a. Sickle cell disease


b. Alpha thalassemia
c. G6PD deficiency
d. All of the above
 

Question 14
A 20 year old female consults your clinic for chronic
cough for 1 month. She is 2 months pregnant. On
PE, there were no crackles. CXR showed apical
infiltrates on the R upper lung field, Sputum AFB
done thrice was +1. What is the most appropriate
treatment?

a. INH, Rifampicin and Ethambutol for 9 months


b. INH, Rifampicin, Ethambutol and Pyrazinamide for
9 months
c. INH, Rifampicin and Ethambutol for 6 months
d. INH, Rifampicin, Ethambutol and Pyrazinamide for
6 months

Question 15
Physical examination of a cardiac patient
reveals large, bounding peripheral pulses.
This finding is consistent with? – Hyperkinetic
pulse is usually associated with an increased
left ventricular stroke volume, a wide pulse
pressure, and a decrease in peripheral vascular
resistance

a. Mitral Regurgitation
b. Patent Ductus Arteriosus
c. Ventricular Septal Defect
d. All of the above

Question 16
Which of the following statements is/are true
regarding the a wave of the jugular venous pulse? -
positive presystolic a wave is produced by
venous distention due to right atrial contraction
and is the dominant wave in the JVP, particularly
during inspiration

a. It is produced by contraction of the right ventricle


b. It is prominent in patients with atrial fibrillation –
absent in AF
c. It becomes more prominent during expiration
d. It becomes more prominent in complete heart
block

Question 17
Jugular Venous Pulse
Which of the following heart murmur/s
decrease in length and intensity during
valsalva maneuver?

a. Mitral valve prolapsed


b. Systolic murmur of Hypertrophic
cardiomyopathy
c. Both A and B
d. Neither A nor B

Question 18
A 40 year old male suddenly collapsed on the golf
course is brought to the ER. At the ER, patient has no
spontaneous pulse or respiration. CPR was
performed, a line was inserted and the patient was
intubated. On the cardiac monitor, you see the strip
below, you order defibrillatory shocks: 200 joules, the
300 joules, then 360 joules. CPR is continued. Which
of the following is the most appropriate drug to
administer at this time?

a. Procainamide - Convert/prevent AF/VT


b. Bretylium tosylate – class III arrhythmic drug, but not
first line
c. Epinephrine – inotropic effect, for hypotension
d. Lidocaine – based on ACLS, 1st line for VT

Question 19
Vaughan Williams Classification
Factors accounting for bipedal edema
associated with congestive heart failure
include all of the following except?

a. increased secretion of aldosterone


b. increased effective arterial volume
c. increased level of plasma renin
d. sympathetic nervous system mediated renal
vasoconstriction

Question 20
Aspirin has been shown to reduce the risk of
myocardial infarction in all of the following
groups EXCEPT?

a. patients with chronic stable angina


b. patients who have survived myocardial
infarction
c. patients experiencing unstable angina
d. patients with ischemic cardiomyopathy

Question 21
A 63 year old woman with is brought to the ER by relatives
because she has become incoherent in the past 24 hours. At
the ER, PE revealed a disoriented woman with BP: 240/160
HR: 110, RR: 20, afebrile. The chest reveals bibasilar rales.
Rest of the findings was normal. Relatives revealed that the
patient has not been taking her antihypertives meds in the
past several weeks. Emergent CT scan showed no
hemorrhage or mass lesion. The most appropriate next step
would be to?

Dx: Hypertensive emergency

a. observe the patient in a quiet room for 1 hour before


administering therapy
b. wait for laboratory values to return before deciding on
specific therapy
c. administer Captopril 25 mg PO
d. administer IV nicardipine

Question 22
A 70 year old retired businessman with no past medical
history presents to the ER 4 hours after the onset of
severe substernal crushing chest pain with radiation to
the left arm and neck. ECG revealed ST elevation in
leads V1 to V6. The patient has no clear cut medical
contraindications to anticoagulation. Which of the
following would be the optimal management at this
time?

a. He should immediately be started on thrombolysis.


b. He should be given sublingual nitrates every 15
minutes to relieve the chest pain.
c. He can benefit from anticoagulation initially with
unfractionated heparin followed by warfarin
d. Immediate administration of metoprolol reduces the
risk of developing congestive heart failure by reducing
both preload and afterload.

Question 23
A 52 year old male with significant COPD presents
with dyspnea for 2 days and palpitations for the
past hour. On PE, there is diffuse expiratory
wheezing and an irregular heart rate. ECG
demonstrates rapid atrial fibrillation at HR of 170
and on specific ST- and T wave changes. All of the
following should be used to treat the patient’s AF
except?

a. Digoxin
b. Metoprolol
c. Verapamil
d. Cardioversion

Question 24
All of the following regarding the vascular biology of the
atherosclerotic process are true EXCEPT?

a. The fatty streak is the initial lesion of atherosclerosis


b. Adhesion molecules such as VCAM-1 are expressed by
endothelial cells and act as receptors for circulating
lymphocytes and monocytes.
c. Cellular hallmarks of the lesions that may lead to
myocardial infarction include large necrotic lipid cores, thin
fibrous caps, and large numbers of macrophages.
d. The clinical benefit of lipid lowering therapy with HMG
coreductase inhibitors appear to stem from a significant
decrease in the extent of coronary stenosis. - the benefit is
more on the stabilization of the atherosclerotic plaque

Question 25
A 72 year old male smoker with COPD was admitted 2 days
ago with a patchy right lower lobe pneumonia
accompanied by fever, cough and dyspnea. He was started
on IV Cefuroxime. On the 3rd hospital day, he is afebrile, has
good oral intake, no cough or sputum and is not short of
breath. O2 sat on room air is 92%. Repeat CXR shows a
slight decrease in his R lower lobe infiltrate compared to
his initial CXR. What is the next best clinical approach in
the management of this patient?

a. Order a chest CT scan


b. Continue IV Cefuroxime
c. Change the therapy to IV erythromycin and Imipenem
d. Switch to oral therapy

Question 26
A 65 year old man was hospitalized for an
exacerbation of newly diagnosed COPD. You
discharged him 4 weeks ago and now presents at
the OPD for follow up. He has never received any
adult vaccinations. Which of the following
preventive approach for pneumonia will you
recommend to your patient?

a. Pneumococcal vaccine
b. Pseudomonal vaccine
c. Haemophilus influenzae type B vaccine
d. Influenza vaccine

Question 27
A 25 year old woman presents at the ER with a 2 day history of fever,
chills, cough productive of greenish sputum and shortness of breath.
At the ER, she is in severe respiratory distress HR: 125, RR: 36, BP:
80/50, O2 sat at room air 82%. CXR shows bilateral diffuse infiltrates
with consolidation in the right middle lobe. Sputum GS shows
numerous neutrophils and scattered gram positive cocci and gram
negative bacilli. What is/are the appropriate antibiotic/s on which to
start this patient?

a. Erythromycin and Ampicillin-sulbactam


b. Trimethroprim-sulfamethoxazole and doxycycline
c. Erythromycin, gentamycin and ceftazidime
d. Doxycycline and cefuroxime

Inpatients, ICU    
 A beta-lactame [cefotaxime (1–2 g IV q8h), ceftriaxone (2 g IV od),
ampicillin-sulbactam (2 g IV q8h)] plus
 Azithromycin or a fluoroquinolone (as listed above for inpatients, non-
ICU)

Question 28
A 64 year old woman undergoes diuretic therapy for severe
CHF complicated by a right sided pleural effusion. Three
weeks later her symptoms are moderately improved and
her weight has decreased by 4.5 kg but the effusion
persists. She denies fever, chest pain, or leg swelling. PE
shows an S3 and a grade 3/6 holosystolic murmur. –
transudative

 Exudative pleural effusions meet at least one of the


following criteria, whereas transudative pleural effusions
meet none:
1. pleural fluid protein/serum protein >0.5
2. pleural fluid LDH/serum LDH >0.6
3. pleural fluid LDH more than two-thirds normal upper limit
for serum

Question 29
A 42 year old man presents with right upper
lobe cavitary infiltrate and also right sided
pleural effusion. Sputum and pleural fluid
acid fast smears are positive. – exudative

Question 30
Which of the following are TRUE regarding
measurements in lung volume?

a. Total lung capacity is the volume of gas


contained in the lungs after maximum expiration.
– maximal inspiration
b. Residual Volume is the volume of gas remaining
in the lungs at the end of maximal inspiration. –
maximal expiration
c. Vital capacity is TLC minus RV.
d. FEV1 is the volume of gas exhaled during the
first minute of expiration. – first second of
expiration

Question 31
Spirometry
Which of the following regarding features of asthma is TRUE?

a. Hypoxia is a universal finding during acute exacerbations


and frank ventilatory failure is common. - hypercarbia
b. The presence of a normal pCO2 is associated with quite
severe levels of obstruction.
c. Cyanosis is an early sign in patients with asthma. – late
asthma
d. The beginning of an asthmatic episode is frequently
marked by a cough that produces mucus with
Curschmann’s spirals. – airway lumen casts of exudates
(found in fatal asthma which can cause pathologic changes
in the segmental and subsegmental bronchi: Charcot-
Leyden crystals (eosinophil remnants), and Creola
bodies (clumps of sloughed epithelial cells)
e. The sine qua non for the symptoms of asthma is the triad
of fever, cough and wheezing. – wheezing; most common
symptoms include cough, wheezing and dyspnea

Question 32
Which of the following regarding treatment of asthma is
TRUE?

a. Saligenins produce airway dilation through stimulation of


B-adrenergic receptors and activation of G proteins with
resultant formation of cAMP. – increases CAMP
b. Resorcinols are highly selective for the respiratory tract
and are virtually devoid of significant cardiac effects
except at high doses. – use with caution because it may
cause tachyarrhythmias
c. Inhaled glucocorticoids control inflammation, facilitate long
term prevention of symptoms, minimize acute episodes
and prevent hospitalizations.
d. Leukotriene modifiers appear to be uniformly effective in
all patients with asthma. – may be more effective in
exercise induced asthma

Question 33
Which of the following statements regarding
pneumothorax is TRUE?

a. Primary spontaneous pneumothorax occurs


in the presence of underlying lung disease.
b. Primary spontaneous pneumothorax occurs
almost exclusively in smokers.
c. Secondary spontaneous pneumothorax
should be treated with simple aspiration.
d. Traumatic pneumothorax occurs exclusively
in patients with penetrating chest injuries.

Question 34
Primary vs Secondary Pneumothorax
Which of the following are proven risk
factors for COPD?

a. cigarette smoking
b. respiratory infections
c. All of the above
e. None of the above

Question 35
Which of the following interventions have
been demonstrated to influence the
natural course of COPD?

a. Smoking cessation
b. Ipatropium bromide
c. Theophylline
d. All of the above

Question 36
Which of the following statements regarding
the diagnosis of pneumonia is TRUE?

a. CXR which is 100% sensitive is a standard


for diagnosis of CAP
b. All patients with CAP require 2 sets of blood
culture before initiation of antibiotic therapy.
c. >25 WBCs and <10 squamous epithelial
cells per high power field makes a sputum
specimen suitable for culture. – low power
field
d. When Legionella spp is isolated in culture, it
is always considered a pathogen.

Question 37
A 65 yr old man with a long history of
constipation presents with cramping LLQ
pain. PE showed low grade fever,
midabdominal distention and LLQ
tenderness. CBC showed: leukocytosis with
shift to the left. The patient most likely has?

a. colon CA
b. Inflammatory Bowel Disease
c. Ulcerative Colitis
d. Acute diverticulitis

Question 38
Diverticulitis
Most common site of bleeding in porto-
systemic collaterals:

a. rectum (hemorrhoids)
b. left falciform ligament
c. esophagogastric varices
d. retroperitoneal space.

Question 39
A 60 year old man was brought to the ER for
diffusely painful abdomen. He has not had any
BM or flatus for the past 3 days. Plain abdominal
upright x-ray reveals marked distention of bowel
loops, air fluid levels and absence of rectal gas.
How will you manage this patient?

a. Pursue a surgical exploration.


b. A long intestinal tube should be inserted to
empty the colonic contents.
c. Fluid and electrolyte balance should be restored
after surgery.
d. Start broad spectrum antibiotics even if bowel
strangulation is unlikely.

Question 40
A 25 year old female comes to the ER for RLQ pain
associated with nausea and vomiting. Which of the
following is/are TRUE regarding making the diagnosis
of acute appendicitis in this patient?

a.The diagnosis can be established even when


tenderness could not be elicited. - The diagnosis
cannot be established unless tenderness can be
elicited
b. Flexing the right hip and abdominal guarding in
appendicitis is due to visceral peritoneal involvement.
- parietal peritoneal involvement
c. A (+) psoas sign is an early sign of great diagnostic
value. – late sign
d. Urinary frequency and dysuria may occur if the
appendix lies adjacent to the urinary bladder.

Question 41
Release of this hormone from the duodenum
and jejunum is largely triggered by long chain
fatty acids, essential amino acids and gastric
acid itself and evokes and enzyme rich
secretion from the pancreas?

a. secretin – S cells from the duodenum and


jejunum
b. gastrin – G cells from the gastric antrum,
regulator of gastric acid secretion
c. cholecystokinin – I cells from the small
intestines, gallbladder contraction
d. VIP – wide distribution in the body, neuronal
distribution

Question 42
A 45 year old businessman came to the ER for
vomiting of coffee ground material. PE was
normal except for poor skin turgor and
tachycardia. Which of the following is/are true
regarding the etiology of this patient’s upper GI
bleeding?

a. About half of cases are due to peptic ulcer


disease.
b. Majority of cases of obscure GI bleeding are from
the small intestines.
c. Hemorrhagic erosive gastropathy rarely present
as massive bleeding.
d. All of the above
 

Question 43
Correct statement/s regarding Hepatitis B
serology?

a. Persistence of HBeAg in the serum beyond the


first 3 months of acute infection may be
predictive of the development of chronic
infection. – reflects replicativity and infectivity
b. During the gap or window period, only anti-Hbe
is detectable in serum.
c. Anti-HBc of the IgG class predominates during
the first 6 months after acute infection.
d. All of the above

Question 44
Schematic diagram of Acute Hep B Infection
Which of the following statements is/are true
regarding transmission of Hepatitis B?

a. The likelihood of perinatal transmission of HBV


correlates with the presence of HBsAg.
b. The saliva of hepatitis B patients is infectious.
c. Most of the hepatitis transmitted by blood
transmission is caused by HBV.
d. Sexually promiscuous persons have high rates
of HBV infection.

Question 45
Which clinical and laboratory features
suggest progression of acute hepatitis to
chronic hepatitis?

a. Presence of bridging or multilobular


hepatic necrosis on liver biopsy.
b. Persistence of hepatomegaly
c. Lack of complete resolution of anorexia,
weight loss and fatigue.
d. All of the above
e. None of the above

Question 46
Which of the following causes of portal
circulatory obstruction is presinusoidal in
location?

a. Cirrhosis
b. Schistosomiasis
c. Budd-Chiari
d. Inferior Venal caval obstruction.

Question 47
Nos 48-49-. A 45 year old male with chronic alcoholism is
brought to the ER for agitation and bizarre behavior.
The patient is cachectic, jaundiced with ascites. ON PE,
you further note spider angiomas, palmar erythema
and flipping hand tremors and ankle clonus.
 
You know that this is most likely hepatic encephalopathy:
a. latent stage
b. stage I
c. stage II
d. stage III
e. stage IV

Question 48
Hepatic encephalopathy
The following are correct principles for management of
this patient?

a. Lactulose should be given for acute encephalopathy


30-80 ml every hour until diarrhea occurs.
b. Neomycin used to decrease ammonia production in
the gut may reach sufficient concentrations in the
bloodstream to cause renal toxicity.
c. Metronidazole and Neomycin have comparable
benefits.
d. All of the above
e. None of the above

Question 49
For nos 50-51. A 35 year old man complains of nausea
and vomiting and rapid onset of midepigastric pain
with radiation to the back after eating a large meal.
PE shows low grade fever, epigastric tenderness and
decreased bowel sounds. An abdominal film shows
localized dilatation of the upper duodenum. – infected
pancreatic necrosis

50. Which would be most useful for confirming your


diagnosis?

a. Upper GI barium study


b. Endoscopy
c. Serum lipase
d. Oral cholecystogram
e. HIDA radionuclide scan

Question 50
How will you manage this patient?

a. Surgical debridement (necrosectomy) should


be undertaken in the presence of infected
necrosis.
b. Anticholinergic drugs have no proven
benefit.
c. No benefit has been shown in the use of
antibiotics among all cases.
d. Only A and B
e. All of the above

Question 51
Which of the following medications for allergic
rhinitis is associated with rebound rhinitis?

a. Oximetazoline – alpha agonists after 7-14


days of treatment can cause rhinitis
medicamentosa
b. Fexofenadine
c. Cromolyn sodium
d. Fluticasone
e. Mometasone

Question 52

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