REVIEW EXAM PRIMARY, ACUTE CARE MEDICINE. September 2005.Albarran School of Medicine

End of Rotation Exam
September 2005

Each of the following items has only one correct answer. Read all statements and choices and the select the correct answer by clearly select the letter in the answer box to the left of the choices. Click on “submit” to register your answer. Click on “Discussion” to review some of the teaching issues covered by this answer.

1.-A 42-year-old married woman presents to the office with history of dysuria for the past 48 hours. She took some over-the-counter drug that made her urine colored orange and her symptoms improved somewhat but did not abate completely. She has no fever and denies nausea or vomiting. She has a history of several urinary tract infections that manifested clinically in similar manner over the past 20 years. She is afebrile and on physical exam is negative except for mild suprapubic tenderness. Her urine analysis reveals cloudy appearance, leukocyte esterase positive and nitrite trace.
Which of the following courses of therapy would be most advantageous?

2.-The most common cause of death in children aged 10-14 years of age is:

a. Vehicular injury.
b. Congenital disorders
c. Dysentery
d. HIV/AIDS

3.-An 18-year-old adolescent presents for evaluation after sustaining a syncopal episode during a football practice. He has no history of syncope, chest pain, heart murmur or palpitations in the past. A urine toxicology screen is negative for illicit drugs. His total, non-fasted cholesterol is 185 mg/dl. His serum iron is 95 mcg/dl. There is a family history of heart disease manifested by syncope in an uncle and his maternal grandfather. His sister died at age 22 from a syncopal attach related to ventricular arrhythmia. The patient’s (F3) family pedigree is diagramed here:

The EKG for the proband is available for review. Which of the following statements IS UNTRUE?

a.The patient has signs of Long QT Interval Syndrome
b.The 22 year sister probably died of torsade de pointes
c.The pattern of inheritance is probably recessive.
d.The pattern of inheritance is dominant.

4.-Health literacy may be defined as "a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment." Inadequate health literacy contributes to poor compliance on therapeutic and preventive measures, uncontrolled chronic disease, and rising health care costs. Health literacy should not be assumed in any patient population or individual patient. A recent report by the Agency for Healthcare Research and Quality on health literacy concluded that "low reading skills and poor health are clearly related to poor health outcomes.” At what level are usually health literature materials written?

3^rd grade
6^th grade
10^th grade
Junior College level

6.-An 85-year-old woman is brought to the emergency department because of abdominal pain, nausea and vomiting. The symptoms began about 48 hours prior to entry. She has a history of hypothyroidism that is controlled with 0.10 mg of levothyroxine daily. The patient has no history of diarrhea, weight loss, chronic abdominal pain. She denies history of fatty food intolerance. On arrival at the ER she is in acute distress. Her blood pressure is 90/60, the pulse rate is 115 reg and the respirations are 22 unlabored. The chest and heart exam are unremarkable except for the tachycardia. The abdomen is minimally distended and there is mild right upper quadrant tenderness and left costovertebral angle tenderness. The urine analysis reveals a urine specific gravity of 1.025 and negative leukocyte esterase and nitrite. The serum lipase is 38,000 U/L and the amylase is 3,300 U/L. A gall bladder ultrasound reveals small gall stones and a common bile duct with a diameter of 0.5 mm. Assuming her cardiopulmonary function allows for surgical clearance,which of the following seems most appropriate?

Schedule surgery immediately
Schedule surgery in the next 72 hours
Postpone surgery until other symptoms of gall bladder disease arise.
Schedule surgery when pancreatitis has resolved

7.-Which of the following is the most common blood-borne disease in the United States?

8.-A 35-year-old woman comes into the outpatient clinic with complaints of lesions arising in her1 feet. A photograph of the sole of the right foot is available.

Which of the following treatments is least appropriate?

a.Cryotherapy for each lesion
b.Rocephin 250 mg IM
c.Aldara (Imiquimod) 5% three times per week.
d.Salicylic acid 20% daily

9.- A 67-year-old man is admitted to the hospital with moderate to massive bleeding per rectum. The patient has a history of coronary artery disease and a previous CVA. He is being treated with clopidogrel orally. On the morning of admission the patient woke up with a pool of blood in his bed. He denies epigastric pain. Complained of constipation. He has no history of anal pain, itching or hematochezia. He has no history of screening lower GI endoscopy in the past. On examination, he is in no acute distress but rather concerned. His temperature is 98.6 deg F (37.0 deg C), 84 reg, 18 unlabored, and 126/70.

The physical exam reveals mild vasoconstriction, no heart murmur and minimal left lower quadrant and suprapubic discomfort on deep palpation. His hemoglobin is 14.7 gm/dl. Which of the following is the most likely diagnosis?

a.Hemorrhoids
b.Vascular ectasias including arteriovenous fistula.
c.Colonic ulcers
d.Carcinoma of the colon
e.Colonic diverticulosis

10.-A 59-year-old woman comes into the emergency department with sudden onset of chest pain. She denies history of angina, myocardial infarction, diabetes mellitus, or high blood pressure. She does not smoke tobacco or use illicit drugs. The chest pain is described as 10/10 and it radiates to the left arm and the left shoulder and the left side of the neck. She tried to drink some herbal tea in the hopes of improving her condition but the pain did not abate and she became more scared than she was before. On examination she has a temperature of 98.9 deg F (37.2 deg C), 64 reg, 16 unlabored, and 151/89. The neck veins are normal there is a negative Kussmaul sign. Her chest is clear. The heart reveals an S4. An EKG is obtained for your review. Which of the following courses of action is most appropriate?

a.Start Protonix (pentoprazole) drip at 80 mg intravenous per 24 hours.
b.Administer ibuprofen 600 mg twice daily and apply Lidoderm 5% patch to chest wall.
c.Administer intravenous nitroglycerin starting at 5 mcg/min and clopidogrel 300 mg orally and 75 mg daily and admit to coronary care unit.
d.Consult cardiovascular surgery for evaluation of acute pericardiocentesis.

11.- A 16-year-old adolescent is brought to the clinic in South Florida with a skin lesion in her right arm. According to the history, the lesion began as a raised, slightly erythematous area that evolved to a larger area with a raised border. There is no history of travel, injections, trauma, or anything like this occurring before. She is otherwise healthy attending a local school. She denies sexual contacts with her mother in the exam room. On exam, she appears in no acute distressed. Her vital signs are 98.6 deg F (37 deg C), 68 reg, 13 unlabored, and 110/72. The general physical examination is normal. Examination of the skin lesion in the right arm reveals a 2.0 x 1.5 cm lesion with rough, scaly and slightly raised border and a clearing center. The palms and soles are free from any pathology.
Which of the following treatments seems most appropriate?

a.Referral to neurology for lumbar puncture.
b.Ceftriaxone (Rocephin) 250 mg IM
c.Penicillin G 4.8 million units IM
d. Vibramycin 100 mg po bid x one month
e.Ketoconozole cream bid.

12.- A 70-year-old woman is brought to the emergency department from a local ALF because of shortness of breath. She has a well-documented history of hypertension, hypertensive heart disease and congestive heart failure, and chronic obstructive lung disease. Her PIR (Patient Interactive Rating) is 2 (0-4). On examination she appears confused. Her vital signs are as follows: 97.0 deg F (36.1 deg C) 119 irregular, 28 slightly labored and 137/88. Her neck veins reveal mild distension at 45 degrees of truncal elevation. The chest is shallow and clear. The heart is tachycardic with a soft systolic murmur at the base. The abdominal exam reveals strong abdominal wall muscles. Her EKG is available for review. Which of the following statements is TRUE?

a.The rhythm is atrial fibrillation
b.There are signs of left anterior fascicular block.
c.There is no sign of anterior wall infarction in the past
d.The R wave progression appears normal.

13.- A 54-year-old man presents to the emergency department with a history of chest pain since a few hours prior to entry. The pain is continuous and located in the mid and left side of the chest. At its peak, the pain was 10/10. Nothing the patient has tried including taking acetaminophen orally has helped. He has no history of chest pain, hypertension, diabetes mellitus, and his total serum cholesterol several years when he donated blood was 210 mg/dl. On examination he appears to uncomfortable. His vital signs are as follows: 98.4 deg F (36.9), 76 reg, 16 unlabored, 120/60. His neck veins are not distended. The chest is clear and the chest wall is not tender. The heart sounds are normal. There is mild tenderness in the epigastrium. His EKG is available for review. His WBC is 6,900/ cubic mm and the liver functions are normal.
Which of the following treatments options seems most appropriate?

a.Start Protonix (pantoprazole) drip at 80 mg intravenous per 24 hours.
b.Administer ibuprofen 600 mg twice daily and apply Lidoderm (lidocaine) 5% patch to chest wall.
c.Administer intravenous nitroglycerin starting at 5 mcg/min and clopidogrel 300 mg orally and 75 mg daily and admit to coronary care unit.
d.Consult cardiovascular surgery for evaluation of acute pericardiocentesis.
e.Consult general surgery for laparoscopic cholecystectomy

15.- You are caring for a patient with HIV whose Mantoux TB skin test shows 7 mm induration. The patient has a normal chest x-ray and she denies fever, cough, or night sweats. Which of the following is the most appropriate recommendation for this patient?

a.Initiate INH treatment
b.Sputum culture for AFB
c.Reassure patient and repeat the Mantoux test in one year
d.Repeat the TB skin test with an anergy panel.

16. .A 24-year-old female in seen for an annual examination.
Her menstrual history is normal and all of her previous Pap results have been normal. Her physical examination is normal but her Pap result returns with low-grade squamous intraepithelial lesion (LSIL). Which of the following is the most appropriate management option for this patient?

a.Repeat Pap in 6 months
b.HPV DNA typing
c.Endometrial biopsy
d.Colposcopy
e.Repeat Pap utilizing thin prep methodology

17. Which of the following statements is TRUE regarding ASCUS?

a.should always be managed by endometrial biopsy
b.should always be managed by endocervical curettage
c.should always be managed by colposcopic directed biopsy
d.the majority of patients with ASCUS will develop high grade cervical abnormalities within 3 years
e.immediate colposcopy, HPV DNA testing, or repeat pap in 6 months are all acceptable management options.

19. A 2-year-old African American male presents with a 10-day history of fever ranging from 100.8-102°F (37.9 – 38.2) that is unresponsive to acetaminophen and ibuprofen. On exam he has a diffuse maculopapular erythematous rash and dry cracked lips. He also has a “strawberry tongue”, bilateral conjunctival injection, and bilateral pedal edema. Which of the following is the most appropriate treatment?

20.- A mother brings in her 12-month-old for evaluation of diarrhea. He is having 10 to 12 stools per day. Physical exam reveals a lethargic child who is whining softly and clinging to his Mom. He has a 1 lb. weight loss since a well-child visit 1 week ago. His pulse is 90, respirations 24, and temperature 99.6°F. Mucous membranes are dry.

What is the most likely cause of this child’s diarrhea?

a.Vibrio cholerae
b.Clostridium difficile
c.rotavirus
d.poor diet
e.cytomegalovirus

21. Of the following, which vaccines contain live organism?

22. A 13-year-old male is evaluated for scrotal pain of 4 hours duration. He denies dysuria sexual activity. His urinalysis normal. Physical exam shows unilateral scrotal swelling and tenderness without erythema. The cremasteric reflex is absent. Which of the following is the most appropriate next step for this patient?

23. A 22-year-old female is evaluated for an annual health appraisal. She is sexually active, consistently utilizes oral contraceptives. Her vaccination at age 13 months, and that she had chicken pox at age 6 but has not received Varicella vaccine. Which of the following combination of preventive services is most appropriate for this patient:

a.Pap and MMR
b.Pap and varicella vaccine
c.Pap, MMR, varicella titer
d.Pap, MMR, and varicella vaccine
e.Pap, MMR, and Chlamydia screening

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