End of Rotation Exam
September 2006
 

Each of the following items has only one correct answer. Read all statements and choices and select the correct answer by clearly marking the letter in front of your choice.

1. A 60-year-old man presented with several years history of severe diarrhea, flushing, abdominal pain, and wheezing. There is no history of smoking.
Which of the following tests would be helpful for confirming the presence of a carcinoid tumor?

1.-

 

a.Ca 125
b.5-hydroxy-indoleacetic acid excretion
c.FSH
d.TSH

2. A 34-year-old man in otherwise good health presents with coughing spasms followed by post-tussive emesis for three weeks. You suspect pertussis and collect a nasopharyngeal swab for a culture. According to the Centers for Disease Control and Prevention, which one of the following is the best next step?

2.-

a.Prescribe inhaled albuterol.
b.Do not prescribe antibiotics for the patient until culture results are available.
c.Administer whole-cell pertussis vaccine.
d.Treat close household contacts with antibiotics.

3. Which one of the following statements about exercise is correct?

3.

 

a.Most patients older than 65 years of age do report engaging in physical exercise routinely.
b.Persons must start an exercise routine early in life not when they get to 65 years of age.
c.Physical activity must be recommended in patients older than 65 years of age after appropriate screening because it is associated with a decrease in all-cause and cardiovascular mortality.
d.Exercise is contraindicated in most adults 65 years of age or older.

4. Interruption of treatment with an antidepressant medication is sometimes associated with an antidepressant discontinuation syndrome; in early reports it was referred to as a "withdrawal reaction." Symptoms of antidepressant discontinuation syndrome can include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances, and hyperarousal. Which of the following statements IS TRUE regarding this syndrome?

4.

a. Antidepressant discontinuation syndrome is less likely with a shorter half-life antidepressant drug. 
b. It occurs in approximately 20 percent of patients after abrupt discontinuation of an antidepressant medication that was taken for at least six weeks.
c. Symptoms associated with this syndrome are severe and are not rapidly extinguished with reinstitution of antidepressant medication.
d. Antidepressant discontinuation syndrome is less likely with a longer duration of treatment. 

 

5. Which of the following statements regarding iron deficiency anemia IS NOT TRUE?

5.

a.Iron deficiency anemia is associated with psychomotor and cognitive abnormalities in children.
b.Iron deficiency anemia during pregnancy has been associated with increased risk of low birth weight.
c.Iron deficiency anemia during pregnancy has been associated with preterm delivery, and perinatal mortality.
d.The prevalence of iron deficiency anemia has decreased appreciably in the last decade in the general U.S. population.

6. Which of the following statements regarding the current recommendations for vaccination against human papilloma virus (HPV) IS TRUE?

6.

a. Boys and girls must be vaccinated before they engage in sexual activity.
b.This vaccine is contraindicated in patients with HIV infection.
c.Girls 11 to 12 years of age should be routinely vaccinated against human papilloma virus (HPV).
 d.HPV vaccine cannot be given to children younger than 10 years of age
 

7. You have finally finished your training and have been licensed to serve the people of Florida. You begin working in a medical center in Central Florida. Your first patient is a 55-year-old woman who comes in looking a new doctor. She complains of weakness throughout the day even when she is not at work in the schools system of Orange County. She moved there from Chicago, Il where her husband worked in the airlines. Her last doctor placed her on nifedipine for blood pressure control. She has been on it for a couple of years. She denies chest pain, polyphagia, polyuria, labored sleep, of shortness of breath.  She has no serious illnesses in her medical history. She does not smoke. She drinks wine occasionally with dinner. She is married and has two children who are currently out to college. Since she arrived in Florida, she eats half a grapefruit every morning as part of a balanced breakfast. Her physical examination is essentially normal. Her BMI is 26 kg/m 2 . Her vital signs reveal a blood pressure of 105/60. Her electrocardiogram is essentially normal. Her serum chemistries are normal. Which of the following courses of action should be undertaken?

7.

a.Patient should be advised that she was incorrectly diagnosed with hypertension.
b.Patient should be asked to hold her antihypertensive medication and return to the clinic in 3-4 days.
c.Patient should be changed from nifedipine to nisoldipine.
d.Patient should be admitted to the hospital to treat shock..

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8. A 77-year-old woman who has been your patient for the past two years comes into the outpatient clinic and asks whether she should continue to receive annual mammograms. She has diabetes and chronic lung disease that somewhat limit her activities. She has difficulty walking several blocks and moving large objects such as the armchair in her living room. The patient no longer smokes and has a body mass index (BMI) of 21 kg per m 2 . Considering the data available fro the “Prognostic Index to Predict Four-Year Mortality Risk in Community-Dwelling Older Adults,” ( appears in the next page) which of the following statements is most appropriate?

table

Prognostic Index to Predict Four-Year Mortality Risk in Community-Dwelling Older Adults

 

Patient characteristic

Points

 

Age (years)

 

 

60 to 64

1

 

65 to 69

2

 

70 to 74

3

 

75 to 79

4

 

80 to 84

5

 

≥ 85

7

 

Male sex

2

 

Diabetes

1

 

Cancer (other than minor skin cancer)

2

 

Chronic lung disease (disease limits activities or patient requires oxygen)

2

 

Heart failure

2

 

Body mass index < 25 kg per m2

1

 

Current smoker

2

 

Functional difficulties caused by health or memory problems:

 

 

Bathing

2

 

Managing money or finances

2

 

Walking several blocks

2

 

Pulling or pushing large objects (e.g., living room chair)

1

 

Total:

 

 

Point total

Predicted four-year mortality risk (%)

 

0 to 5

< 4

 

6 to 9

15

 

10 to 13

42

 

≥ 14

64

 

Adapted with permission from Lee SJ, Lindquist K, Segal MR, Covinsky KE. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA 2006;295:805.

 

8.

 

 

a.Mammograms should be continued because the patient’s expected mortality is rather low and she may tolerate surgery for a tumor.
b.Mammograms should be discontinued because her expected mortality is relatively high.
c.Mammograms should be continued because she has not reached her 80th birthday.

 

9. All of the following symptoms are known to be associated with endometriosis. Which of them is THE MOST COMMON?

9.

 

 

a.Pelvic pain
b. Dysuria
c. Dyspareunia
d.Back pain
e.Loin pain

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10.Which one of the following is the recommended target range for serum digoxin concentration?

10.

 

 

a.0.5 to 1.0 ng/ml
b.1.0 to 1.5 ng/ml
c.1.0 to 2.1 ng/ml

11. A 74-year-old man was admitted to the psychiatric service because of agitation. In the course of his first 24 hours in the hospital, the nursing staff noted that he did not eat or drink and complained of abdominal pain. A medical consultation is requested and you see the patient. The patient is not combative at the time. His Mini-Mental Exam is 17/30 and the PIR is 2. The temperature is 99.0 deg F  ( deg C) 138/87, 80 regular, 16 unlabored. The HEENT exam reveals no inflammatory findings. The neck is supple with mildly decreased rotation range of motion bilaterally. Chest examination reveals shallow breath sounds that are clear. The heart sounds appear distant and there is a soft S4 sounds and no murmur or rub. The abdominal examination reveals normal abdominal wall temperature, no distension, no tenderness, and the bowel sounds are decreased but normal. A rectal exam is performed yielding a prostate gland 30 gm, 2+, with no nodules. The extremities are unremarkable except for the tobacco stains in the fingers of the right hand.  An EKG is immediately obtained and is available for your review. Which of the following courses of action is MOST appropriate?

11.

 

 

a.Obtain further laboratory work up including arterial blood gas and return in 8 hours to re-evaluate patient.
b.Advise the nursing staff that the patient has no medical problem and you defer the consult to neurology.
c.Make a preliminary diagnosis of dementia and begin treatment with an anticholinesterase inhibitor.
d.Transfer patient to a monitored bed and manage for myocardial infarction and/or ischemia.

12. 42 year old woman is seen in the outpatient clinic because of persistently worrisome bouts of palpitations and chest pain. These symptoms began about 6 months before and she has been seen in the clinic before where she was granted a number of consultations to various specialists. She has been started on methimazole at 10 mg daily. Her symptoms are somewhat unpredictable, worsened with physical exercise, and are associated with dyspnea. She otherwise complains of cold-heat intolerance, insomnia, headaches and fatigue. Eating chocolates and tomatoes do not exacerbate her condition. Her vital signs are as follows: Pulse 115 per minute, 150/80, 18 unlabored, Temperature 97.2 deg F (deg C).  The physical examination is otherwise essentially normal except for an enlarged thyroid gland in the anterior neck. An EKG is performed and is available for your review. Which of the following statements is MOST APPROPRIATE?

12.

 

 

a.Increase dose of methimazole to 10 mg q8h.
b.Begin treatment with propranolol 20 mg q8h
c.Admit patient to hospital for acute care management.
d.Administer alprazolam 1.0 mg twice daily.

13. A 73-year-old man with a history of COPD presented to the emergency room complaining of dyspnea and confusion. The vital signs are as follows: Pulse 100 per minute, resp rate 26 per minute, slightly labored, blood pressure 185/90 mm Hg.  Chest examination reveals fine wheezes. An arterial blood gas on room air reveals: pH 7.37, pCO2  57, pO2  59, calculated HCO3 . Which of the following statements is TRUE?

13.

 

 

a.The patient has no acid base disturbance since the pH is nearly normal.
b.There are findings of metabolic alkalosis because the bicarbonate is high.
c.There are findings of compensated respiratory acidosis.
d.There are findings of acute respiratory alkalosis.

14. A 40-year-old man is brought to the emergency room because of chest pain. He is not a smoker. The pain has lasted for about four hours and it seemed to decrease after sublingual nitroglycerine was administered. The pain is described as constant, pressure like, and radiating to the left arm. The vital signs were as follows: pulse 70 irregular, blood pressure 145/100, respirations 18 per minute. The chest is clear. The heart sounds reveal a soft systolic murmur in the apex and no rub or gallop. An EKG is obtained and is available for your review. Which of the following statements is MOST appropriate?.

14.

 

 

a.There are sings of acute inferior wall myocardial infarction.
b.There are frequent PVC’s.
c.There are frequent PAC’s.
d.There is poor R wave progression.
e.There are findings of left anterior fascicular block.

15. Filariasis is not an uncommon parasitosis in the Caribbean Basin. How is filariasis transmitted?

15.

 

 

a. Respiratory droplet
b. Food-borne
c. Water-borne
d. Mosquitoes

 

16.Which of the following statements regarding seminoma IS TRUE?

16.

 

 

a.Seminoma is usually metastatic outside the testis at the time of diagnosis.
b.Seminoma spreads first through lymphatics and then hematogenously.
c.The standard treatment for Stage I seminoma is chemotherapy.
d.It is common for seminoma to present with liver and pulmonary metastases.

 

17. A 32-year-old woman presents with pelvic pain and dyspareunia. Her mother and sister have endometriosis. A tender nodule is palpated in the vaginal fornix. Which one of the following is the most effective first-line therapy for endometriosis?

17.

 

 

a.Ibuprofen
b. An oral contraceptive
c.Danazol
d.Levonorgestrel-releasing intrauterine system

18. Digoxin therapy is LEAST appropriate for which one of the following groups of patients?

18.

 

 

a.Asymptomatic patients with chronic heart failure.
b.Patients with atrial fibrillation with a rapid ventricular response.
c.Symptomatic patients with stage C or D heart failure.

19. A recently adopted two-year-old black girl, who was born prematurely, is having difficulty walking. On physical examination, the child is below the fifth percentile for height and weight. Psychomotor and speech development are delayed. Skeletal inspection is significant for enlargement of the costal cartilages, thickened wrists bilaterally, and severe bowing (45 degrees) of the tibias bilaterally. Which one of the following would predispose this child to developing rickets?

19.

 

 

a.Formula fed since birth.
b.Daily treatment with phenytoin.
c.Excessive consumption of starch.
d.Childhood obesity.

20. Which one of the following laboratory test results would indicate nutritional rickets in a child?

20.

 

 

a.Decrease alkaline phosphatase
b.Decreased calcidiol.
c.Increased calcitriol.
d.Decrease PTH.

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