Family medicine FOR BOARD REVSISON MCQs

Family medicine MCQs &EMQs: 

Family medicine MCQs &EMQs Saeed Salah Abduljalil Assist. Lecturer of family medicine Kasr Elaini school of medicine ,Cairo University

Introducing EMQs: 

Introducing EMQs 1/30/2012 MCQs by Saeed Salah

A 54-year-old man with a long history of heartburn is proven to have Barrett's oesophagus on biopsy (histology report states non-dysplastic columnar-lined oesophagus). What is the most suitable management? : 

A 54-year-old man with a long history of heartburn is proven to have Barrett's oesophagus on biopsy (histology report states non-dysplastic columnar-lined oesophagus ). What is the most suitable management? 1/30/2012 MCQs by Saeed Salah Reassure and discharge Fundoplication Laser ablation Ivor -Lewis oesophagectomy High-dose proton pump inhibitor

PowerPoint Presentation: 

1/30/2012 MCQs by Saeed Salah The 2005 British Society of Gastroenterology guidelines state that high-dose proton pump inhibitor therapy is first-line treatment in such patients. There is yet insufficient evidence to support the use of endoscopic ablation. Barrett's refers to the metaplasia of the lower oesophageal mucosa, with the usual squamous epithelium being replaced by columnar epithelium. There is an increased risk of oesophageal adenocarcinoma , estimated at 50-100 folds. Histological features The columnar epithelium may resemble that of either the cardiac region of the stomach or that of the small intestine (e.g. with goblet cells, brush border) Management endoscopic surveillance with biopsies high-dose PPI

EMQ :Dysphagia:For each clinical scenario below, give the most likely cause for the dysphagia. Each option may be used only once (ANS :G I L K A): 

EMQ : Dysphagia:For each clinical scenario below, give the most likely cause for the dysphagia. Each option may be used only once (ANS :G I L K A) 1/30/2012 MCQs by Saeed Salah A bulbar palsy B pharyngeal pouch C Plummer–Vinson syndrome D obstructing foreign body E seventh nerve palsy F Sturge –Weber syndrome G oesophageal achalasia H retrosternal goitre I oesophageal carcinoma J caustic stricture K diffuse oesophageal spasm L globus hystericus A 35-year-old woman presents with dysphagia for solid and liquids associated with regurgitation and weight loss. Barium swallow shows a dilated tapering oesophagus . A 65-year-old smoker presents with a history of severe oesophagitis and gradually worsening dysphagia. A 28-year-old woman presents with a feeling of a lump in her throat that causes some discomfort on swallowing. Examination and imaging of the pharynx and oesophagus reveal no abnormality. A 40-year-old man complains of intermittent dysphagia associated with chest pain . Barium swallow reveals a corkscrew oesophagus . A 55-year-old man presents coughing when he tries to swallow. On examination he has a flaccid fasciculating tongue.

EMQs Abdominal pain Answers: B K F E J: 

EMQs Abdominal pain Answers: B K F E J 1/30/2012 MCQs by aeed Salah A large bowel obstruction B acute pancreatitis C perforated viscus D appendicitis E small bowel obstruction F acute cholecystitis G ulcerative colitis H aortic dissection I diverticulosis J duodenal ulcer K renal colic L colorectal carcinoma M mesenteric adenitis 1 A 45-year-old man with a history of gallstones presents in A&E with severe epigastric pain radiating to the back and vomiting. 2 A 28-year-old man presents with sharp left loin and left upper quadrant pain radiating to the groin. He is not jaundiced. 3 A 44-year-old woman presents with continuous right upper quadrant pain, vomiting and fever. Murphy’s sign is positive. 4 A 26-year-old man with a previous history of abdominal surgery presents with colicky central abdominal pain, rapidly followed by production of copious bile- stained vomitus. 5 A 50-year-old man presents with epigastric pain worse at night and relieved by eating or drinking milk.

Headache :Answers: F A L J B: 

Headache :Answers: F A L J B 1/30/2012 MCQs by Saeed Salah A tension headache B migraine C amaurosis fugax D epilepsy E subdural haematoma F subarachnoid haemorrhage G encephalitis H meningitis I sinusitis J cluster headache K analgesic headache L giant cell arteritis M episcleritis 1 A 40-year-old man complains of severe headache of sudden onset 4 h ago, likened to being kicked in the back of the head. He has vomited twice and is now feeling stiff in his neck. 2 A 40-year-old businesswoman complains of a headache that feels like a tight band around her head. 3 A 55-year-old woman presents with a headache that has lasted a few weeks. She gets pain in her jaw during meals and her scalp is tender on palpation. 4 A 30-year-old man complains of rapid-onset pain around his left eye every night for the last 2 weeks, ssociated with lid swelling, watery eye and flushing. He suffers from these bouts every 3 months. 5 A 24-year-old woman complains of a unilateral throbbing headache lasting 6 hours associated with vomiting nd photophobia. She has had several episodes in the past.

A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea. After discussing treatment options he elects not to be cardioverted. If the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer? : 

A 54-year-old male with no past medical history is found to be in atrial fibrillation during a consultation regarding a sprained ankle. He reports no history of palpitations or dyspnoea . After discussing treatment options he elects not to be cardioverted . If the patient remains in chronic atrial fibrillation what is the most suitable treatment to offer? 1/30/2012 MCQs by Saeed Salah Aspirin Warfarin , target INR 2-3 No anticoagulation Warfarin , target INR 3-4 Warfarin , target INR 2-3 for six months then aspirin

Young AF, no TIA, or risk factors, just give aspirin: 

Young AF, no TIA, or risk factors, just give aspirin 1/30/2012 MCQs by Saeed Salah Atrial fibrillation: anticoagulation The Royal College of Physicians and NICE published guidelines on the management of atrial fibrillation (AF) in 2006 The guidelines suggest a stroke risk stratification approach when determining how to anticoagulate a patient, as detailed below: Low risk - annual risk of stroke = 1 % age < 65 years with no moderate or high risk factors use aspirin Moderate risk - annual risk of stroke = 4 % age > 65 years with no high risk factors, or : age < 75 years with diabetes, hypertension or vascular disease ( ischaemic heart disease or peripheral arterial disease ) use aspirin or warfarin depending on individual circumstances High risk - annual risk of stroke = 8-12 % age > 75 years with diabetes, hypertension or vascular disease ( ischaemic heart disease or peripheral arterial disease ) previous TIA, ischaemic stroke or thromboembolic event valve disease, heart failure or impaired left ventricular function use warfarin

Which one of the following treatments have not been shown to improve mortality in patients with chronic heart failure?: 

Which one of the following treatments have not been shown to improve mortality in patients with chronic heart failure? 1/30/2012 MCQs by Saeed Salah Beta-blockers Spironolactone Frusemide Nitrates and hydralazine Enalapril

Whilst useful in managing the symptoms of acute and chronic heart failure frusemide offers no prognostic benefits. : 

Whilst useful in managing the symptoms of acute and chronic heart failure frusemide offers no prognostic benefits . 1/30/2012 MCQs by Saeed Salah NICE produced guidelines on management in 2003, key points include : All patients should be given an ACE inhibitor unless contradictions exist Once an ACE inhibitor has been introduced a beta-blocker should be started regardless of whether the patient is still symptomatic Offer annual influenza vaccine , offer pneumococcal vaccine Digoxin has also not been proven to reduce mortality in patients with heart failure. Digoxin is strongly indicated if there is coexistent atrial fibrillation

A 35-year-old man who is usually fit and well presents with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is unremarkable. Of the following options, what is the most suitable initial management? : 

A 35-year-old man who is usually fit and well presents with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia . Examination of the abdomen is unremarkable. Of the following options, what is the most suitable initial management? 1/30/2012 MCQs by Saeed Salah Urea breathe testing and non-urgent referral for endoscopy H pylori eradication therapy and full-dose proton pump inhibitor for three months Full-dose Proton pump inhibitor and immediate referral for endoscopy Three month course of a standard-dose proton pump inhibitor One month course of a full-dose proton pump inhibitor

NICE guidelines for the management of dyspepsia: 

NICE guidelines for the management of dyspepsia 1/30/2012 MCQs by Saeed Salah Managing patients who do not meet referral criteria ('undiagnosed dyspepsia') This can be summarized at a step-wise approach Review medications for possible causes of dyspepsia Lifestyle advice Trial of full-dose PPI for one month* Test and treat' using carbon-13 urea breath test

A 23-year-old British man develops watery diarrhoea whilst travelling in Egypt.Which one of the following is the most likely responsible organism? : 

A 23-year-old British man develops watery diarrhoea whilst travelling in Egypt.Which one of the following is the most likely responsible organism? 1/30/2012 MCQs by Saeed Salah Salmonella Shigella Campylobacter Escherichia coli Bacillus cereus

E. coli is the most common cause of traveller's diarrhoea: 

E. coli is the most common cause of traveller's diarrhoea 1/30/2012 MCQs by Saeed Salah Gastroenteritis Which organism - clues Most common cause of traveller's diarrhoea is E coli Incubation period 1-6 hrs : Staph aureus, Bacillus cereus 12-48 hrs: Salmonella, E. coli 48-72 hrs: Shigella , Campylobacter > 7 days: Giardiasis , Amoebiasis Stereotypical histories profuse, watery diarrhoea : cholera prolonged, non-bloody diarrhoea : Giardia bloody diarrhoea :, vomiting, abdo pain: Shigella severe vomiting: Staphylococcus aureus

A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A diagnostic aspiration is performed and sent to microbiology. Which of the following organisms is most likely to be? responsible?: 

A 50-year-old female with a history of rheumatoid presents with a suspected septic knee joint. A diagnostic aspiration is performed and sent to microbiology. Which of the following organisms is most likely to be? responsible ? 1/30/2012 MCQs by Saeed Salah Staphylococcus aureusia Staphylococcus epidermidisia Escherichia coliia Neisseria gonorrhoeaeia Streptococcus pneumoniaeia

Septic arthritis - most common organism: Staphylococcus aureus: 

Septic arthritis - most common organism: Staphylococcus aureus 1/30/2012 MCQs by Saeed Salah Septic arthritis overview Most common organism overall is Staphylococcus aureus in young adults who are sexually active Neisseria gonorrhoeae should also be consider Management Synovial fluid should be obtained before starting treatment intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxacillin + fusidic acid or clindamycin if penicillin allergic antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks ( needle aspiration should be used to decompress the joint surgical drainage may be needed if frequent needle aspiration is required

A 45-year-old female develops pleuritic chest pain following a hysterectomy 10 days ago. Low-molecular weight heparin is given initially and CTPA confirms a pulmonary embolism. There is no previous history of venous thromboembolism. How long should the patient be warfarinised for?? : 

A 45-year-old female develops pleuritic chest pain following a hysterectomy 10 days ago. Low-molecular weight heparin is given initially and CTPA confirms a pulmonary embolism. There is no previous history of venous thromboembolism . How long should the patient be warfarinised for?? 1/30/2012 MCQs by Saeed Salah Not suitable for anticoagulationia 6 weeks 6 months 12 months Life-long

In temporary risk factor for a thromboembolic event the recommended period of anticoagulation is 4-6 weeks: 

In temporary risk factor for a thromboembolic event the recommended period of anticoagulation is 4-6 weeks 1/30/2012 MCQs by Saeed Salah

A 29-year-old woman who is 28 weeks pregnant is reviewed. She has developed pre-eclampsia with her current blood pressure being 156/104 mmHg and the urine dipstick reported as follows: Protein + Leucocytes negative Blood negativeThere is no oedema and the patient is otherwise asymptomatic. Of the following drugs, which one is least suitable to use? : 

A 29-year-old woman who is 28 weeks pregnant is reviewed. She has developed pre- eclampsia with her current blood pressure being 156/104 mmHg and the urine dipstick reported as follows: Protein + Leucocytes negative Blood negativeThere is no oedema and the patient is otherwise asymptomatic. Of the following drugs, which one is least suitable to use? 1/30/2012 MCQs by Saeed Salah Labetalol Nifedipine Losartan Methyldopa Hydralazine

ACE inhibitors and angiotensin-2 receptor blockers should be avoided as they are teratogenic.: 

ACE inhibitors and angiotensin-2 receptor blockers should be avoided as they are teratogenic . 1/30/2012 MCQs by Saeed Salah Most clinicians would either use methyldopa or labetalol first-line in this situation Pre- eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific Management consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral methyldopa is often used first-line with oral labetalol , nifedipine and hydralazine also being used for severe hypertension IV labetalol and IV hydralazine are used in addition to the above

Risk factors: 

Risk factors 1/30/2012 MCQs by Saeed Salah > 40 years old nulliparity (or new partner) multiple pregnancy body mass index > 30 kg/m^2 diabetes mellitus pregnancy interval of more than 10 years family history of pre- eclampsia previous history of pre- eclampsia pre-existing vascular disease such as hypertension or renal disease

Features of severe pre-eclampsia: 

Features of severe pre- eclampsia 1/30/2012 MCQs by Saeed Salah Hypertension: typically > 170/110 mmHg and proteinuria as above Proteinuria : dipstick ++/+++ Headache Visual disturbance Papilloedema RUQ/ epigastric pain Hyperreflexia Platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

A 76-year-old man is admitted with a right hemiparesis. CT scan shows an ischaemic stroke and aspirin 300mg is commenced. In terms of further management in the acute phase, which one of the following values should not be corrected? : 

A 76-year-old man is admitted with a right hemiparesis. CT scan shows an ischaemic stroke and aspirin 300mg is commenced. In terms of further management in the acute phase, which one of the following values should not be corrected? 1/30/2012 MCQs by Saeed Salah BP 210/110 Blood glucose 200 mg dl Oxygen saturation 94% Temp 38.3ºC Blood glucose 3.5 mmol /l

Hypertension should not be treated in the initial period following a stroke: 

Hypertension should not be treated in the initial period following a stroke 1/30/2012 MCQs by Saeed Salah Selected points relating to the management of acute stroke include: blood glucose, hydration, oxygen saturation and temperature should be maintained within normal limits blood pressure should not be lowered in the acute phase unless there are complications e.g. hypertensive encephalopathy aspirin 300mg orally or rectally should be given as soon as possible if a haemorrhagic stroke has been excluded with regards to atrial fibrillation, the RCP state: 'anticoagulants should not be started until brain imaging has excluded haemorrhage , and usually not until 14 days have passed from the onset of an ischaemic stroke‘ if the cholesterol is > 3.5 mmol /l patients should be commence on a statin Thrombolysis it is administered within 3 hours of onset of stroke symptoms (unless as part of a clinical trial) haemorrhage has been definitively excluded (i.e. imaging has been performed) Alteplase is currently recommended by NICE

11.A 55-year-old male with osteoarthritis of the knees asks for advice on improving the function of his knees and controlling arthritis pain. Which one of the following would be appropriate advice?: 

11.A 55-year-old male with osteoarthritis of the knees asks for advice on improving the function of his knees and controlling arthritis pain. Which one of the following would be appropriate advice? 1/30/2012 MCQs by Saeed Salah Topical capsaicin ( Zostrix ) applied twice daily will improve both pain and function Glucosamine will improve both pain and function A therapeutic exercise program will improve both pain and function An intra- articular corticosteroid injection will provide at least 6 months of pain relief NSAIDs will slow the progression of the disease

A therapeutic exercise program will reduce both pain and disability in patients with osteoarthritis of the knee (SOR A).: 

A therapeutic exercise program will reduce both pain and disability in patients with osteoarthritis of the knee (SOR A). 1/30/2012 MCQs by Saeed Salah There is no evidence to support the use of capsaicin cream, but NSAIDs will reduce pain and there are proven therapies that will improve function of the patient’s knee. While intra- articular corticosteroids are effective in relieving pain in the short term (up to 4 weeks), there is no evidence for long-term efficacy. There is not good evidence to support the use of glucosamine for treating osteoarthritis of the knee. One systematic review found it no more effective than placebo.

12.One day after a nurse performs CPR on an emergency-department patient, she learns that the patient had meningococcal meningitis. Which one of the following is the most appropriate chemoprophylaxis for this condition?: 

12.One day after a nurse performs CPR on an emergency-department patient, she learns that the patient had meningococcal meningitis. Which one of the following is the most appropriate chemoprophylaxis for this condition? 1/30/2012 MCQs by Saeed Salah Penicillin G benzathine ( Bicillin ), 1.2 million units intramuscularly Rifampin ( Rifadin ), 600 mg every 12 hours for 2 days Oral prednisone, 40 mg daily for 5 days Quadrivalent meningococcal vaccine No prophylaxis

Rifampin has been shown to be 90% effective in eliminating meningococcus from the nasopharynx: 

Rifampin has been shown to be 90% effective in eliminating meningococcus from the nasopharynx 1/30/2012 MCQs by Saeed Salah Even high doses of penicillin may not eradicate nasopharyngeal meningococci . Prednisone has no place in chemoprophylaxis. Meningococcal vaccine appears to have clinical efficacy, but it usually takes more than5 days to become effective.

13.A 36-year-old male presents with pain over the lumbar paraspinal muscles. He says the pain began suddenly while he was shoveling snow. Which one of the following is true regarding this patient’s injury? : 

13.A 36-year-old male presents with pain over the lumbar paraspinal muscles. He says the pain began suddenly while he was shoveling snow. Which one of the following is true regarding this patient’s injury? 1/30/2012 MCQs by Saeed Salah Systemic corticosteroids speed recovery Exercises specific to low back injuries speed recovery Opioids have significant advantages for symptom relief when compared with NSAID or acetaminophen Continued activity rather than bed rest helps speed recovery Trigger-point injections are superior to placebo in relieving acute back pain

Patients should be encouraged to remain as active as possible.: 

Patients should be encouraged to remain as active as possible. 1/30/2012 MCQs by Saeed Salah Exercises designed specifically for the treatment of low back pain have not been shown to be helpful. Neither opioids nor trigger-point injections have shown superiority over placebo, NSAIDs, or acetaminophen in relieving acute back pain. There is no good evidence to suggest that systemic corticosteroids are effective for low back pain with or without sciatica.

PowerPoint Presentation: 

1/30/2012 MCQs by Saeed Salah A 40-year-old female comes to your office with a 1-month history of right heel pain that she describes as sharp, searing, and severe. The pain is worst when she first bears weight on the foot after prolonged sitting and when she gets out of bed in the morning. It gets better with continued walking , but worsens at the end of the day. She does not exercise except for being on her feet all day in the hospital where she works as a floor nurse. She denies any history of trauma. An examination reveals point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity.

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1/30/2012 MCQs by Saeed Salah Which one of the following should you recommend as first-line treatment ? A) Taping/strapping B) Over-the-counter heel inserts C) Extracorporeal shock wave therapy D) A corticosteroid injection E) A fiberglass walking cast

ANSWER: B: 

ANSWER: B 1/30/2012 MCQs by Saeed Salah Plantar fasciitis is a common cause of heel pain. It may be unilateral or bilateral, and the etiology is unknown , although it is thought to be due to cumulative overload stress. While it may be associated with obesity or overuse, it may also occur in active or inactive patients of all ages. Typically the pain is located in the plantar surface of the heel and is worst when the patient first stands up when getting out of bed in the morning (first step phenomenon) or after prolonged sitting. The pain may then improve after the patient walks around, only to worsen after prolonged walking. The diagnosis is made by history and physical examination . Typical findings include point tenderness to palpation on the plantar surface of the heel at the medial calcaneal tuberosity where the calcaneal aponeurosis inserts. Radiographs are not necessary unless there is a history of trauma or if the diagnosis is unclear. The condition may last for months or years, and resolves in most patients over time with or without specific therapy. One long-term follow-up study showed that 80% of patients had complete resolution of their pain after 4 years . Treatments with limited (level 2) evidence of effectiveness include off-the-shelf insoles , custom-made insoles, stretching of the plantar fascia, corticosteroid iontophoresis , custom-made night splints, and surgery (for those who have failed conservative therapy). NSAIDs and ice, although not independently studied for plantar fasciitis, are inclu ded in most studies of other treatments, and are reasonable adjuncts to first-line therapy. Magnetic insoles and extracorporeal shockwave therapy are ineffective in treating plantar fasciitis. Due to their expense, custom-made insoles, custom-made night splints, and corticosteroid iontophoresis should be reserved as second-line treatments for patients who fail first-line treatment. Surgery may be offered if more conservative therapies fail. Corticosteroid injection may have a short-term benefit at 1 month , but is no better than other treatments at 6 months and carries a risk of plantar fascia rupture

CHEST PAIN : ANSWERS :HANBD: 

CHEST PAIN : ANSWERS :HANBD 1/30/2012 MCQs by Saeed Salah Pulmonary embolus H Aortic dissection B Pneumothorax K Cardiac tamponade C Lobar pneumonia L Herpes zoster D Costochondritis M Pericarditis E Esophageal spasm N Angina F Atrial fibrillation G Infective endocarditis A 63 years old man with history of hypertension , in ER with sudden tearing pain radiating to the neck A 40 years old woman develops sudden onset dyspnea at rest following hip replacement , on examination she is tachycardic and ECG shows right axis deviation. A 60 years old businessman complains of central crushing chest pain radiating to both arms after running to catch a bus , pain relieved upon rest and ECG recording 1 h later was unremarkable . A 21 years old high jumper represents with acute onset dyspnea and right side stitching pain that increase with inspiration , examination reveal increased resonance on the right side and reduced lung expansion on that side A 23 years old woman presents with localized left sided chest pain that is exacerbated by coughing and is particularly painful to light pressure to that area , pain is relieved by aspirin , ECG is unremarkable .

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1/30/2012 MCQs by Saeed Salah A 30-year-old female asks you whether she should have a colonoscopy, as her father was diagnosed with colon cancer at the age of 58. There are no other family members with a history of colon polyps or cancer You recommend that she have her first screening colonoscop A) now and every 5 years if normal B) now and every 10 years if normal C) at age 40 and then every 5 years if normal D) at age 40 and then every 10 years if normal E) at age 50 and then every 5 years if normal

ANSWER: C: 

ANSWER: C 1/30/2012 MCQs by Saeed Salah Patients should be risk-stratified according to their family history. Patients who have one first degree relative diagnosed with colorectal cancer or adenomatous polyps before age 60, or at least two second degree relatives with colorectal cancer, are in the highest risk group. They should start colon cancer screening at age 40, or 10 years before the earliest age at which an affected relative was diagnosed (whichever comes first) and be rescreened every 5 years. Colonoscopy is the preferred screening method for this highest-risk group, as high-risk patients are more likely to have right-sided colon lesions that would not be detected with sigmoidoscopy

Rakel 2011: 

Rakel 2011 1/30/2012 MCQs by Saeed Salah Preferred Screening Tests Cancer prevention tests should be offered first. The preferred CRC prevention test is colonoscopy every 10 years, beginning at age 50. Screening should begin at age 45 years in African Americans.Cancer detection test should be offered to patients who decline colonoscopy or another cancer prevention test. The preferred cancer detection test is annual FIT for blood

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1/30/2012 MCQs by Saeed Salah You have just diagnosed mild persistent asthma in a 13-year-old African-American female. Along with patient education, your initial medical management should be A) a short-acting inhaled B2-agonist to be used only as needed B) a long-acting inhaled B2-agonist daily C) a low-dose inhaled corticosteroid daily, along with a short-acting inhaled B2 -agonist as needed D) a low-dose inhaled corticosteroid daily, along with a long-acting inhaled B2-agonist daily E) montelukast ( Singulair ) daily

ANSWER: C: 

ANSWER: C 1/30/2012 MCQs by Saeed Salah nhaled corticosteroids improve asthma control in adults and children more effectively than any other single long-term controller medication, and all patients should also receive a prescription for a short-acting B2-agonist (SOR A)

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1/30/2012 MCQs by Saeed Salah Patients with rheumatoid arthritis should be screened for tuberculosis before starting which one of the following medications ? A) Gold B) Hydroxychloroquine ( Plaquenil C) Infliximab ( Remicade ) D) Methotrexate ( Rheumatrex ) E) Sulfasalazine ( Azulfidine )

ANSWER: C: 

ANSWER: C 1/30/2012 MCQs by Saeed Salah

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1/30/2012 MCQs by Saeed Salah A 42-year-old male with a history of intravenous drug use asks to be tested for hepatitis C. The hepatitis C virus (HCV) antibody enzyme immunoassay and recombinant immunoblot assay are both reported as positive. The quantitative HCV RNA polymerase chain reaction test is negative . These test results are most consistent with A) very early HCV infection B) current active HCV infection C) a false-positive antibody test D) past infection with HCV that is now resolved

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1/30/2012 MCQs by Saeed Salah Which one of the following patients should be advised to take aspirin, 81 mg daily, for the primary prevention of stroke ? A) A 42-year-old male with a history of hypertension B) A 72-year-old female with no chronic medical conditions C) An 80-year-old male with a history of depression D) An 87-year-old female with a history of peptic ulcer disease

ANSWER: B: 

ANSWER: B 1/30/2012 MCQs by Saeed Salah The U.S. Preventive Services Task Force (USPSTF) has summarized the evidence for the use of aspirin in the primary prevention of cardiovascular disease as follows: • The USPSTF recommends the use of aspirin for men 45–79 years of age when the potential benefit from a reduction in myocardial infarctions outweighs the potential harm from an increase in gastrointestinal hemorrhage (Grade A recommendation) • The USPSTF recommends the use of aspirin for women 55–79 years of age when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage (Grade A recommendation) • The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years of age or older (Grade I statement) • The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 and for myocardial infarction prevention in men younger than 45 (Grade D recommendation

SUMMARY: 

SUMMARY 1/30/2012 MCQs by Saeed Salah In summary, consistent evidence from randomized clinical trials indicates that aspirin use reduces the risk for cardiovascular disease events in adults without a history of cardiovascular disease. It reduces the risk for myocardial infarction in men, and ischemic stroke in women. Consistent evidence shows that aspirin use increases the risk for gastrointestinal bleeding, and limited evidence shows that aspirin use increases the risk for hemorrhagic strokes. The overall benefit in the reduction of cardiovascular disease events with aspirin use depends on baseline risk and the risk for gastrointestinal bleeding.

Q: 

Q A 15-month-old male is brought to your office 3 hours after the onset of an increased respiratory rate and wheezing. He has an occasional cough and no rhinorrhea. His immunizations are up to date and he attends day care regularly. His temperature is 38.2°C (100.8°F), respiratory rate 42/min, and pulse rate 118 beats/min. The child is sitting quietly on his mother’s lap. His oxygen saturation is 94% on room air. On examination you note inspiratory crackles in the left lower lung field. The child appears to be well hydrated and the remainder of the examination, including an HEENT examination, is normal. Nebulized albuterol ( AccuNeb ) is administered and no improvement is noted.

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Which one of the following would be most appropriate in the management of this patient? A) Laboratory evaluation B) Inpatient monitoring, with no antibiotics at this time C) Hospitalization and intravenous ceftriaxone D) Close outpatient follow-up, with no antibiotics at this time E) Oral high-dose amoxicillin (90 mg/kg/day), with close outpatient follow-up

ANSWER: E : 

ANSWER: E The diagnosis of community-acquired pneumonia is mostly based on the history and physical examination. Pneumonia should be suspected in any child with fever, cyanosis, and any abnormal. Laboratory tests are rarely helpful in differentiating viral versus bacterial etiologies and should not be routinely performed. Outpatient antibiotics are appropriate if the child does not have a toxic appearance, hypoxemia, signs of respiratory distress, or dehydration.

ASTHMA AND COPD :Answers: K C E F G: 

ASTHMA AND COPD :Answers: K C E F G 1/30/2012 MCQs by Saeed Salah A low-dose oral aminophylline B oral prednisolone C inhaled beclomethasone D inhaled ipratropium bromide E nebulized ipratropium bromide F inhaled sodium cromoglycate G nebulized salbutamol H inhaled salmeterol I home 100 per cent oxygen J inhaled aminophylline K inhaled salbutamol M oral sodium cromoglycate N inhaled salbutamol with spacer 1 A 7-year-old girl with slight wheeze and shortness of breath despite inhaled salbutamol. 2 A 22-year-old student with mild asthma that needs treatment for occasional early morning wheeze. 3 A 17-year-old student complains that he has to use his salbutamol inhaler regularly to control wheezing. 4 A 32-year-old patient taking maximum dose-inhaled therapy and slow-release theophylline shows persistently inadequate control of symptoms. 5 A 25-year-old woman requires add-on therapy because inhaled beclomethasone and salbutamol do not adequately combat her symptoms.

ENDOCRINOLOGY : 

ENDOCRINOLOGY 1/30/2012 MCQs by Saeed Salah

Q.1.: 

Q.1. A 61-year-old woman is seen in cardiology clinic for evaluation of a new-onset cardiomyopathy . She has had diabetes since 1986 and has been managed with glipizide 5 mg twice daily and metformin 1000 mg twice daily. At her initial visit, she was noted to have fasting triglycerides of 565 mg/ dL , HbA1c of 8.8, and creatinine of 2.8. Her heart failure was stable, and she had returned to her normal level of functioning. What should be done with her therapy? A. Continue glipizide and metformin and add an injection of insulin at bedtime B. Discontinue metformin and substitute pioglitazone C. Discontinue metformin and substitute rosiglitazone D. Discontinue metformin and add an injection of insulin at bedtime E. B or D

Ans.1Answer: E.: 

Ans.1Answer: E. This case illustrates the importance of considering underlying comorbidities in selecting therapy. The patient’s renal insufficiency necessitates discontinuation of the metformin . Given her HbA1c, however, she clearly needs to substitute another agent. Because her heart failure is stable and her triglycerides are so high, pioglitazone is a good choice. Pioglitazone lowers triglycerides and raises HDL, whereas rosiglitazone raises LDL and HDL. Discontinuing metformin and adding insulin at bedtime would also be a correct option.

Q2 :: 

Q2 : A 36-year-old woman with type 2 diabetes presents reporting that she has missed her most recent menstrual cycle. Urine human chorionic gonadotropin testing in the office confirms that she is pregnant. Her diabetes has been treated with glyburide 10 mg once a day. Her most recent hemoglobin A1c has been 8.2. At this point, she should A. Continue with her current regimen B. Increase the dosage of her sulfonylurea C. Add metformin to her regimen D. Discontinue glyburide and start insulin E. Switch glyburide to metformin

Q3 :Answer: D.: 

Q3 :Answer: D. Insulin is the drug of choice for control of blood sugar during pregnancy. The patient should be educated about the importance of as near normal blood glucose levels as possible during the pregnancy. She should also be referred to a maternal-fetal medicine specialist and/or an endocrinologist for management.

Q4 :: 

Q4 : A 42-year-old woman presents with concerns regarding diabetes. She reports that her father and mother and two siblings have diabetes. She denies any polyuria or polydipsia , blurry vision, or recent weight change. On examination, she has a BMI of 28 and a blood pressure of 128/80. Which of the following regarding testing for diabetes is false? A. Fasting plasma glucose of greater than or equal to 126 mg/ dL is diagnostic B. Two-hour post glucose challenge of greater than or equal to 200 mg/ dL is diagnostic C. Random plasma glucose of greater than or equal to 200 mg/ dL is diagnostic D. A positive test should be repeated

Q5 :: 

Q5 : A 26-year-old woman develops typical symptoms of hyperthyroidism and is diagnosed with Graves’ disease. She has mild ophthalmopathy and a large goiterwith a bruit. Which is true about possible treatment options? A :Radioactive iodine therapy should be used, but may worsen her mild ophthalmopathy B. Propranolol is preferable to atenolol for symptomatic relief C. Surgery is indicated to debulk the thyroid first before pursing radioactive iodine therapy D. Given the large size of the goiter, radioactive iodine may be inadequate and antithyroid drugs alone are the best option to achieve remission E. Radioactive iodine should be avoided in this patient of child-bearing age due to the long-term association with infertility

5 :Answer: A.: 

5 :Answer: A. Radioactive iodine therapy is a reasonable first-line choice of therapy, but may worsen her underlying eye disease. Beta-blocker therapy is appropriate for symptom relief. Longer acting agents ( atenolol as opposed to propranolol ) are preferable to avoid frequent symptom recurrence. Surgery is usually not indicated for Graves’ disease unless there is evidence of tracheal compression or the patient refuses other options. Antithyroid drugs are less likely to achieve remission in patients with large goiters. Finally, radioactive iodine has not been associated with infertility or birth defects and is fine to use in women of child-bearing age.

Q 6:: 

Q 6: A 55-year-old woman is seen in your office for a routine annual physical. On examination, you find a small, firm, nontender nodule in the left thyroid lobe that is approximately 1 cm in diameter. She has no symptoms, although she does recall that her mother also had a thyroid nodule. You order a TSH, which is normal. What do you recommend? A. You recommend watchful waiting with close observation, given her lack of symptoms, no evidence of rapid growth, and lack of cervical adenopathy B. You recommend a fine needle biopsy to rule out malignancy C. You recommend an ultrasound to help determine if the nodule is benig or malignant, and thus whether biopsy is recommended D. You recommend a calcitonin level, given her family history of thyroid disease

Q 6:Answer: B.: 

Q 6: Answer: B. This patient has an asymptomatic thyroid nodule. It is nearl impossible to discern malignancy by physical exam alone, and watchful waiting would be inappropriate. A biopsy is required to determine if the nodule if benign or malignant. An ultrasound is not helpful in this determination, unless it shows a small, simple cyst. A calcitonin level is useful in screening for medullary thyroid cancer in patients with family history of medullary cancer or MEN II (not present in her family history). It is not useful in the routine workup of thyroid nodules.

Q 7 :: 

Q 7 : A 23-year-old woman presents with a two-month history of nervousness, heat intolerance, and a 10-pound weight loss. Her physical examination reveals a pulse of 85 beats per minute and a slightly enlarged nontender thyroid. There is no proptosis . Thyroid function tests are as follows: Free T4 2.5 ng / dL (0.8–1.8), T3 200 ng / dL (70–180), TSH <0.05 mU /L (0.5–5). What would be the next most appropriate step? A. Start an antithyroid drug at a low dose (e.g., PTU 50 mg tid or methimazole 10 mg daily) B. Refer for radioiodine therapy C. Order a 24-hour radioiodine uptake D. Neasure antithyroid antibodies E. Check thyroid stimulating antibodies ( TSAb )

Q 7: Answer: C.: 

Q 7: Answer: C. It is unclear whether this patient has mild Graves’ disease or silent thyroiditis . The 24-hour radioiodine uptake would establish the diagnosis. It is inappropriate to begin antithyroid drug therapy until the diagnosis is clear. Measuring antithyroid antibodies would not be of use because they can be positive in silent thyroiditis , as well as in Graves’ disease. Because her disease is mild, TSAb would likely be normal even if Graves’ disease were present.

Q .8: 

Q .8 A 25-year-old woman has been taking thyroxine replacement therapy for hypothyroidism for 10 years. Thyroid function tests have generally been normal. She is seen for a routine follow-up exam and aside from mild fatigue, she reports feeling well. Her physical examination is normal, and her thyroid is not palpable. Thyroid function tests are as follows: Free T4 1.0 ng / dL , TSH 25 m U/L. Which of the following is not an explanation for these results? A. Iron therapy B. Calcium supplementation C. Over-the-counter cimetidine D. Oral contraceptives

8. Answer: C.: 

8. Answer: C. Iron supplements, calcium, and oral contraceptives can increase thyroxine requirements. Iron and calcium block thyroxine absorption. Oral contraceptives increase thyroid-binding globulin levels which, in turn, transiently decrease free T4, which results in an increased thyroid hormone output in normal individuals. H2-blockers and proton pump inhibitors have no effect on thyroxine absorption.

Q 9:: 

Q 9: A 40-year-old woman presents with a two-week history of a fever, malaise, and anterior neck pain. Her physical examination is remarkable for a pulse of 100 beats per minute, and an exquisitely tender thyroid that is firm, irregular, and three-fold enlarged. There is a mild tremor. Thyroid function tests are as follows: Free T4 2.0 ng / dL , TSH less than 0.05 m U/L. The erythrocyte sedimentation rate is 100 mm/hour. Which of the following statements is true about this patient’s condition? A. Following the hyperthyroid phase, the patient will likely become permanently hypothyroid B. The best treatment for this condition is broad-spectrum antibiotics C. The radioiodine uptake will be markedly elevated D. Antithyroid drugs should be given until thyroid function is normal E. Nonsteroidal anti-inflammatory drugs are often helpful in alleviating pain

Q 9 : Answer: E: 

Q 9 : Answer: E This patient has subacute thyroiditis . Following the hyperthyroid phase, most patients ultimately recover normal thyroid function. The best treatment is nonsteroidals , although prednisone may be needed in severe cases. The radioiodine uptake is low and antithyroid drugs are not indicated.

Q 10:: 

Q 10: You are the only physician in a rural community. A 13-year-old boy presents to you with complaints of breast enlargement. His growth and development to date have been normal. His school performance is above average. He is on no medications. Physical examination reveals a young man in the 60th percentile for height with age-appropriate genital development and secondary sex characteristics. What should be your recommendation? A. Bromocriptine once daily B. Testosterone injections twice weekly C. Referral for pituitary surgery D. Reassurance

10: Answer: D.: 

10: Answer: D. Most likely this boy has physiologic pubertal gynecomastia . This resolves in most cases within several months

Q 11:: 

Q 11: A 54-year-old female takes levothyroxine ( Synthroid ), 0.125 mg/day, for central hypothyroidism secondary to a pituitary adenoma. The nurse practitioner in your office orders a TSH level, which is found to be 0.1 mIU / mL (N 0.5–5.0). Which one of the following would you recommend? A) Decrease the dosage of levothyroxine B) Increase the dosage of levothyroxine C) Order a free T4 level D) Order a TRH stimulation test E) Repeat the TSH level in 3 months

11 :answer :c: 

11 :answer :c Although uncommon, pituitary disease can cause secondary hypothyroidism. The characteristic laboratory 4 4 findings are a low serum free T and a low TSH. A free T level is needed to evaluate the proper dosage of replacement therapy in secondary hypothyroidism. The TSH level is not useful for determining the adequacy of thyroid replacement in this case, and the low level would prevent the physician from determining whether the dosage of levothyroxine is appropriate. In the initial evaluation of secondary hypothyroidism, a TRH stimulation test would be useful if TSH failed to rise in response to stimulation. It is not necessary in this case, since the diagnosis has already been made.

Q 12:: 

Q 12: A 34-year-old female who delivered a healthy infant 18 months ago complains of a milky discharge from both nipples. She reports that normal periods have resumed since cessation of breastfeeding 6 months ago. She takes ethinyl estradiol / norgestimate (Ortho Tri- Cyclen ) for birth control. A complete review of systems is otherwise negative. The most likely cause of the discharge is A) a medication side effect B) breast cancer C) a hypothalamic tumor D) hypothyroidism

12: ANSWER: A: 

12: ANSWER: A This patient has galactorrhea , which is defined as a milk-like discharge from the breast in the absence of pregnancy in a non-breastfeeding patient who is more than 6 months post partum. It is more common in women ages 20–35 and in women who are previously parous . It also can occur in men. Medication side effect is the most common etiology.

Q 13:: 

Q 13: A 20-year-old female long-distance runner presents with a 3-month history of amenorrhea. A pregnancy test is negative, and other blood work is normal. She has no other medical problems and takes no medications. With respect to her amenorrhea, you advise her A) to increase her caloric intake B) that this is a normal response to training C) to begin an estrogen-containing oral contraceptive D) to stop running

13:ANSWER: A: 

13: ANSWER: A Amenorrhea is an indicator of inadequate calorie intake, which may be related to either reduced food consumption or increased energy use. This is not a normal response to training, and may be the first indication of a potential developing problem. Young athletes may develop a combination of conditions, including eating disorders, amenorrhea, and osteoporosis (the female athlete triad). Amenorrhea usually responds to increased calorie intake or a decrease in exercise intensity. It is not necessary for patients such as this one to stop running entirely, however.

Q 14 .: 

Q 14 . A 26-year-old female presents with a 2-month history of amenorrhea, nausea, and fluttering in her chest. The fluttering feels similar to what she experienced 3 years ago when diagnosed with Graves’ disease. At that time, she was successfully treated with medication, which she discontinued after 18 months. Current laboratory tests reveal a positive hCG , a TSH of 0.03 4 U/ mL (N 0.4–5.0), and a free T of 4.0 g/ dL (N 0.8–2.0). Which one of the following would be the most appropriate treatment in this situation? A) I ablation 131 B) Propylthiouracil C) Subtotal thyroidectomy D) Methimazole ( Tapazole )

Q 14 :ANSWER: B: 

Q 14 : ANSWER: B Overt hyperthyroidism causes an increase in neonatal morbidity from preterm birth and low birth weight. Propylthiouracil should be considered the treatment of choice because methimazole may be associated with congenital anomalies. I is contraindicated in pregnancy because of radiation dangers to the fetus, as well as thyroid destruction. Although subtotal thyroidectomy is a viable treatment option, it is recommended only if medical therapy is unsuccessful.

Q 15: 

Q 15 A 55-year-old white male sees you for a routine annual visit. His fasting blood glucose level is 187 mg/ dL . Repeat testing 1 week later reveals a fasting glucose level of 155 mg/ dL and an 1c HbA of 9.4%. His BMI is 30 kg/m . He does not seem to have any symptoms of diabetes 2 mellitus. In addition to lifestyle changes, which one of the following would you prescribe initially? A) Metformin ( Glucophage ) B) Glyburide ( DiaBeta , Micronase ) C) Rosiglitazone ( Avandia ) D) Bedtime long-acting insulin ( Lantus ) E) Bedtime long-acting insulin and rapid-acting insulin ( Novolog ) with each meal

Q 15 ANSWER: A: 

Q 15 ANSWER: A Metformin is widely accepted as the first-line drug for type 2 diabetes mellitus. It is relatively effective, safe, and inexpensive, and has been used widely for many years. Unlike other oral hypoglycemics and insulin, it does not cause weight gain. It should be started at the same time as lifestyle modifications, rather than waiting to see if a diet and exercise regimen alone will work. If metformin is not effective, a sulfonylurea, a thiazolidinedione , or insulin can be added, with the choice based on the severity of the hyperglycemia.

Q 16 :: 

Q 16 : A 43-year-old male complains of difficulty washing his face and combing his hair with his right hand. On examination a nodule, band, and slight contracture are noted in the palm proximal to the fourth finger. This patient’s symptoms are associated with which one of the following? A) Hyperparathyroidism B) Diabetes mellitus C) Hyperthyroidism D) Hypothyroidism E) Adrenal insufficiency

Q 16 :ANSWER: B: 

Q 16 :ANSWER: B The patient has Dupuytren’s disease, which is most common in men over 40 years of age. It is a progressive condition that causes the fibrous fascia of the palmar surface to shorten and thicken. It initially can be managed with observation, but corticosteroid injection and surgery may be needed. The condition will regress in 10% of patients. There is a 3%–33% prevalence of Dupuytren’s contracture in patients with diabetes mellitus; however, these patients tend to have a mild form of the disease with slow progression

Q 17 :: 

Q 17 : A frail 83-year-old male with a 10-year history of diabetes mellitus is admitted to a nursing home. His blood glucose level, which he rarely checks, is typically over 200 mg/ dL . His serum creatinine level is 1.9 mg/ dL . He also has had several episodes of heart failure. His current medications include glipizide ( Glucotrol ), lisinopril ( Prinivil , Zestril ), and furosemide ( Lasix ). Which one of the following would be most appropriate to add to this patient’s regimen to treat his diabetes mellitus? A) The American Diabetes Association 1800-calorie/day diet B) Metformin ( Glucophage ) C) Pioglitazone ( Actos ) D) Exenatide ( Byetta ) E) Insulin glargine ( Lantus )

Q 17 :ANSWER: E: 

Q 17 :ANSWER: E For geriatric patients in long-term care facilities, the predictable glucose control of glargine is the best approach to consider initially. The American Diabetes Association does not recommend a strict diet for frail diabetic patients in nursing homes. Exenatide is not recommended for the frail elderly because of concerns about weight loss and nausea. Heart failure precludes the use of pioglitazone , and renal failure precludes the use of metformin .

Q 18: 

Q 18 A 27-year-old female presents for her annual examination. Her BMI is 31 and she has hirsutism and reports difficulty with conception. Her periods are irregular. Based on her likely diagnosis, which of the following malignancies is she most at increased risk for? A) Ovarian carcinoma B) Colon cancer C) Pancreatic cancer D) Endometrial carcinoma E) Breast cancer

Q 18:The answer is D.: 

Q 18:The answer is D . Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality in women of reproductive age. The syndrome is associated with chronic anovulation , abnormal menstrual bleeding, and infertility. Macrovascular diseases such as type 2 diabetes mellitus, hypertension, and atherosclerotic heart disease are more likely in women with PCOS. In addition, chronic anovulation predisposes women to endometrial hyperplasia and carcinoma. Symptoms that prompt females to seek attention include irregular menses, hirsutism , or infertility. The earliest manifestations of PCOS are noted around the time of puberty. Adolescent girls affected with PCOS often have early puberty and show hyperandrogenism and insulin resistance. In the early reproductive period, chronic anovulation results in difficulty with fertility. If pregnancy is achieved, it frequently terminates in spontaneous, first-trimester loss or is associated with gestational diabetes. More than 50% of those affected are obese. Abnormal androgen production declines as menopause approaches (as it does in women without PCOS), and menstrual patterns may normalize. However perimenopausal and postmenopausal women with a history of PCOS have increased rates of type 2 diabetes, hypertension, and coronary artery disease compared with control patients. PCOS appears to follow a familial distribution. LH and FSH levels are often elevated in PCOS, with the LH:FSH ratio greater than 3:1. Individualized therapy should incorporate steroid hormones, antiandrogens , and insulin-sensitizing agents ( metformin ). Weight loss by way of reduced carbohydrate intake and exercise is the most important intervention; this step alone can restore menstrual regularity and fertility, and provide long-term prevention against diabetes and heart disease.

Q 19: 

Q 19 Which of the following laboratory results best support the diagnosis of subclinical hypothyroidism? A) Normal T4, low TSH B) Normal T4, high TSH C) Low T4, high TSH D) Normal T4, normal TSH E) Low T4, borderline low TSH

19 The answer is B: 

19 The answer is B Diagnosis Laboratory Findings Overt hypothyroidism Low T4, high sTSH Subclinical hypothyroidism Normal T4, high sTSH Hypothyroidism secondary to hypopituitarism Low T4, normal or borderline low sTSH Euthyroid Normal T4, normal sTSH Subclinical hyperthyroidism Normal T4, low sTSH

20: 

20 18-year-old insulin-dependant diabetic wishes to work. He can pursue the following occupation: A. Taxi driver B. Heavy goods vehicle driver C. Commercial pilot D. Nurse E. Police constable

21: 

21 A 68-year-old African-American female with primary hypothyroidism is taking levothyroxine 125 g/day. Her TSH level is 0.2 IU/mL (N 0.5–5.0). She has no symptoms of either hypothyroidism or hyperthyroidism. Which one of the following would be most appropriate at this point? A) Continuing levothyroxine at the same dosage B) Increasing the levothyroxine dosage C) Decreasing the levothyroxine dosage D) Discontinuing levothyroxine E ) Ordering a free T4

ANSWER: C: 

ANSWER: C Because of the precise relationship between circulating thyroid hormone and pituitary TSH secretion, measurement of serum TSH is essential in the management of patients receiving levothyroxine therapy. Immunoassays can reliably distinguish between normal and suppressed concentrations of TSH. In a patient receiving levothyroxine, a low TSH level usually indicates overreplacement . If this occurs, the dosage should be reduced slightly and the TSH level repeated in 2–3 months’ time. There is no need to discontinue therapy in this situation, and repeating the TSH level in 2 weeks would not be helpful. A free T4 level would also be unnecessary, since it is not as sensitive as a TSH level for detecting mild states ofexcess thyroid hormone

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