DEPARTMENT OF MEDICINE Year End Long Examination corrected by. (coverage: 1* rite tea & Il; and part of 2% rite) signature: December 04, 2017 (monday) Name: ’ Choose the BEST Answer Level: ___— nosed to —— fa A.8? vear old male is admitted due to chest heaviness. He was diag of Dave myocaraial infarction. What is the term given to the constelaiot Ty ened) function fol (p.90) Pain and signs of sympathetic dys! Score: ___— b ComPlex regional pain syndrome quality ang wcPathic pain — has an unusual burning, ting! © hypnaybe triggered by very lighttouch Pests) Pain seneepePathia — a characteristic of neuropathic pain, a 9 Snsation to innuocous or mild nociceptive stimuli ao not now 2Odynia — lead to the triggering of a pain response from normally provoke pain. wikipedia CRPS type | — without obvious nerve injury CRPS type Il — occurs after identifiable nerve injury ling or electric-shock-like exaggerated 1i which do ; x)? Ty i , Which ofthe following compound does NOT inhibit cyclooxygenase (cox) P. 90) a. acetaminophen b. celecoxib ¢. ibuprofen d. ketorolac : ; others w/ COX inhibitor — acetylsalicylic acid, naproxen, indomethacin, valdecoxib, fenoprofen — 3. An abdominal pain that is characterized by steady, aching and localize directly over the inflamed area is a mechanism of: (p. 103) x a. inflammation of the parietal peritoneum - the pain of peritoneal inflammationDer ARTMENT OF MEDICINE (coveat End Long Examinati Se na mber 04, 2017 (monday) — N ete meu noose the BEST Answez— ONS RS BEST: mee have ra year old male = — have myocarsias ae admited due too as b, cemPlex regional pai Seniors ere age ered by very gh touch Innwocous or mild naciceptve stimu amertes allodyn Rot normally wid, (ead to the triggeri i y Provoke te tering of span response rom simul which do “CRI Care bre |—without obvious nerve inju ssh cen ero neve inary —— 2. Whiet {oo} Of the following compound does NOT inhibit eyclooxygenase (COX)? @. acetaminophen b. celecoxib ©. ibuprofen d. ketorolac others wi COX i 2 Pee of cox tater novtentcri a aveee rt ____3. An abdominal pain that is characterized by steady, aching and localize directly over the inflamed area is a mechanism of: (p. 103) a. inflammation of the parietal peritoneum - the pain of peritoneal inflammation is invariably accentuated by pressure or changes in tension of the peritoneum, whether produced by palpation or by movement such as with coughing or sneezing 'b. obstruction of hollow viscera - intermittent or colicky that is not as well localized as PP ‘¢. vascular disturbance — frequent misconception . is sudden and m or thrombosis of sup mesent A catastrophic in nature. such as emb« 4. abdominal wall ~ usually constant and aching. movement, prolonged ‘ccentuate the discomfort and associated muscle spasm standing, and pressure ai 4. Which of the following may present a. irritable bowel syndrome — others: I b. pleurisy -RUQ, LUQ ¢, mesenteric lymphadenitis - RLO d. typhilitis - RLQ js the most common type of primar ion headache — 6: a left lower quadrant pain? (p. 106-table) IBD, dveticuls, IH, salphingiis, nephrolth, EP ry headache? (p. 107-table) ry headache is systemic infection — 63% algia rheumatic, jaw female complained of headache, polymy: a ‘most likely diagnosis? (P. 108) 6. A70 year ol Sr joation, fever and weightloss, Whats ou eta ns Soyo and above, average 70 and 65% are women HA, stiff neck, wi fever -acute, severe hemorrhage —acute, ‘severe HA, stiff neck, wlo feveraut aching: a usually not descriptive — intermittent deePr jatumor— HA + casoree” by exertion OF change in position, may have N/V may 7. postiumbar puncture headache is due to persistent of low csF volume ee —— feak following LP. whet iB ‘the eee time of onset ? (p. 110) pal jghin 48 hours — maybe delayed up to 12 di Be yithin 72 hours eee a P wwithin 96 hours § within 5 days ; « to ane 9, What type of back pain that is typically sharp, radiates from the low B2°7 ng, —— Eg twithin the territory of a nerve root, and arp cit radiating Pain 5% cout tS Sezing or voluntary contraction of abdominal muscles such > rifting OP} ess OF sP'straining of stool? (p.112) ¢ radicular pain — means nerve root tr 2: local pain — caused by injury to pain-sensitive structures that com irritate sensory nerve endings ¢, referred back pain oo tend t0 ‘n of the spine origin — de. affecting the UPPER lumbar spine tone TOWER lumbar SP d. Pi refer pain to the lumbar region, groin or anterior thigh- buttocks, posterior thigh, calves or feet 9. What is a simple bedside test for nerve root dis ‘a. straight leg-raising (SLR) b. back pain on percussion of costovertebral angle c. forward bending — paraspinal muscle spasm d. heel percussion sign — hip disease; Hip pain cal .xternal rotation at the hip with the knee and hip in flexion oF examiner's paim while the leg Is extended chronic, OF 40. Lumbar disk disease is the most common cause of acute, aaa recurrent low back and leg pain. Itis most likely to occur at: (P- sease? (p- 11) internal and, ced by interne’ Ten the be reprodu sing the by compres? a.L4—L5- or L5-S1 b.L3-L4 c.L2-L3 d.L1-L2 44. Which of the following diseases cause neck pain? (p- 122) —— _ -raumatoid arthritis - saint eantains the first rib, the subcl: avian artery and naatural OFpo Pyrogenic Gpokinos NATE. INE ee FiGURE 23-1 fever. Chronology of Me nosine nts required for the induction of c ____13. Which of the f an followi pulse dissociation) ing cause a relative bradycardia? (p.126) (temperature- leptospirosis — factitious fever °°! ~ Others are TF, brucellosis, some drug induced fever, b. a ch ee = fever Q3rd day, Qath day - P. malariae d. hodgkin's aa, eerie eeiiowed by days of afebrile then ralapse to ee days then followed by afebrilo af tee ae | over ating eet coe tint ciersealt ava fever of ion oral (Fuo)? a, 35y.0. male w/ fever of > 38.3°C on two occasions for 23 days but diagnosis remain uncertain - > aweeks, no known immunocompromised st3¢0% uncertain dx after following obligatory investigations: determination of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level; platelet count; leukocyte count: and differential; measurement of levels of hemoglobin, electrolytes, creatinine, total protein, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, creatine kinase, ferritin, antinuclear antibodies, and rheumatoid factor; protein electrophoresis: urinalysis; blood cultures (n = 3); urine culture; chest x-ray; ‘abdominal ultrasonography; and tuberculin skin test (TST). b. 27 y.0. male, HIV suspect w/ fever of 38.3°C on two occasions for 20 days c. 25 y.0. female w! fever of 37.8°C on ingle occasion for 21 days 4. 23y.0. female w/ fever of 38.5 C on single occasion for 14 days 45. Which of the following diseases stimul cof dyspnea? (47e-2) a. cardiogenic pulmonary edema b. COPD lates vascular receptors as mechanismee aaasl ot «7, oes Contribute to air hunger. ore. muscles - metaborec pore" eletal -eptors, Pes tes of too Weve sctive por, ar bolleved tobe activated by changes in the rt. cercige and, when stimulated, contribute {° = [Drones ere FHGUREsTet Hypothetial model for integra een a ot sensory 1ed of dyspnea with @ systolic pressure drop 7 (47e-3) 47. A60 year old male complain of Fs 40mmHg during inspiration. What is/are the most likely cause’ COZ OpD tio acute athme, pericardial diease (cardiac RMPSTSS normally, du0ne .es a slight increase, iplood flow in the sent of re inspiration, there is 4 us Mgnt side of the heart (pressure transmitted to re right tamponade/hyperinfiation, during inspiration, there is increase right Ye tamPese preseure in the interventricular septur us decrease left ve decrease in stroke volume. -PULSUS PARADOXUS b. left ventricular dysfunction c. pulmonary edema d. all of the above causes g cause ssociated with > 8 weeks as chanism 48. A 40 year old female complained of cough for frequent throat clearing, sneezing and rhinorrhea. What is the met of the cough? (p. 244) — post nasal drip a, stimulation of sensory receptors of cough-reflex pathway in the hypopharynx — also aspiration of draining of secretions to the trachea b. sensitization of sensory nerve endings due to accumulation of bradyki ACE inhibitor fs ci c. airflow ‘obstruction upon exposure to a trigger — ‘cough-variant asthma”: NO est tightness, but cough resolve after d/c of exposure put Ger esophagus which trigger cough reflex ing, SOB & che 5 Reet? of gastric contents in t! d. reflux pathway is variably defined as hemoptysis of: (p.246) 20. What is NOT true alized vasoconstrictor property, particularly in the afferent peritubular capillaries vessels proximal tubulesEO —— water - inthe dineat eal caer e agin 0 10 etree hyponatremia MbULe ang on ceMtration we Occurs In reeset aon of free a “4 colggyaten thus inert rill caus in~ in Ng duct of the kidneys; this 4 ©. natriuretic pes, "*lease. 4d. all of tree PEPtideg Within istention ho above ae rine tal myoeyts uring aia ee ¥Y endothelial cells in severe he eG Year oom comyeat Old male edem co™Plained £72 in chron, emergency estan. (- 252) °F edema for n° Use of steroids came in to the ros Saar stoGENS, prayaestold Heron Week What isthe most Kel See etorolds auger rodeRting “ NOrMonee: wticoids, a” ; ; €.g. glucoco Fenal vasoa," 0% ody teriolar gig stiction "absorption Capilla a ge —__23. wy in hich Yaroxytryptamingr® ‘lowing 60) ine; rugs has a 5-HT antagonist? (P: 2 B Ohdansetron wemetic agent Metoclo, je 80 grat Pramige 8° 9Fanisetron inergic &: domperidene’“° ~ Prokinetic agent; SHTs agonist & antidopamine”e Meclizine ~ antieme,,../ antiemetic ; peripheral antidoPa ‘emetic agent; antihistaminergic its e ffect on the Pituitary region? (p. 261) " activity b. erythre . erythromycin — of fasting motor cS ocreotide, rokonetic; motiin agonist-> endogenous stimulant off d. amit - amitriptyline — antiemetic; tricyclic antidepressant 25. What is the most u as a st common cause of indigestion?he (p- 261) patients, functional dyspepsia ~ aiso GERO; the cause of symtoms Spa oro Yo orgarie cause ©. esophageal adenocarcinoma d. celiac disease ____ 26. During fasting period, the cyclical event called the migrating motor complex (MMC) serves to clear the nondigestible residue, is found in the: (p.265) a. small intestine b. stomach c. colon @. rectum rear old female experienced passage of abnormally liquid stools, Rae ae cating fried rice. What is the most likely organism? (p.266) BS rowtiius cereus - incubation period 4 to 8h; preformed toxin a. bac ium peringons ~I 8 to 26h; preformed toxin > eesria from uncooked food or soft cheese ti erhagis E-coll IP 12 t0 72h; from undercooked hamburger ey imonella (12h - 11d) - from mayonnaise or creams +s, aureus(1 ~ 8h) oF sal ¥ the following agents is enteroadherent? (p.266) ss wal ae others enetropath & enteroadhe E.coli, cyclosporidiosis, helminths. _ cytotoxic producers; also hemorrhagic E. coli b. ee invasive organisms, also norovirus & (cholera ~ enterotoxin; also enterotoxigenic E. coli, K. pneumoniae, aeromonas Species empirical foi eh shee ee 30. Which of the > 4weeks of diarrhea @. exogenous stimulant laxatives following has a secretory cause of chronic diarrhea? (p.268) b. MgSO« c. liver disease 4. IBD EEOTESSY heron chusts oF cunontc ouRRWEA ACCORDING TO \EDOMINANT PATHOPHYSIOLOGIC MECHANISM (Other tugs and tours Endogenous iaratves tyson leas Ictopatle secretory dates or bie acs rhe Certain bacterial fectons Bowel resection, disease of fstuia (1 stsortion) Pal bowel cbstucton oc fe! pion Nonabrorbable carbohydates arb, ituore, povethvene go) (Guten and FOOMAP intolerance ‘Steatortheal Causes Trustuminal maldgeston pancreatic exovine naFicency Bae ‘row. bait surgery verse: Mucor malbrorton lac sve, Whipp 3:56, oprotenemia, chemin Grugsnaucesenteopstny Posmucots obstruction ("or 2" yori Causes [Ilopaticiftsmatory Bowel dbease (Coho con Uses care) Lymphecytc and callsgenous cls Immune lated mucosa seas (1*0t 7 ireurccecencies, foo _alergy,eosnophilcgasvoeneert gaftwerus host o23:8) Infections (nase bacteria, vues, nd parasites, Bares oN) Radiation iury ‘fiber should be given in patientsSka over 89 defines weight oss? (P 27) pas 7 0 £9 Over 2 Period or 6.12 months -" opgowera period arta mar 5 Pounds C¥e" @ period of "6 months NOS over a Period of 6 = 12 months eS gh oNG is characterize by a classic history 20 nd Preceding nematemesie? (P. 277 a ars tie wath UI Setive in cena ny Urgent endoscopy win 12 hours In eltng fo 5 days: + Oc opie. ligation = perform, ress © erosi 18 bolus and Bo yg intuain) NEM gor ates 9. Reptic yess OPathy — may ae a te oe con ‘gmg/h infu 'C Ulcer diseast, nRCr, PPI omg bolus then vatients ——— 34, 2 mong pati aoe sogycommon Cause of small intestinal bleeding 4! LGIB in fa Years old? (p, 277) ommon >70yo; eg, 88eul (p27) also © jolasias — iced; P. Proximal caS@® ~ also NSAID indu b. smal colon c. mace bowel tumors - common in < 40 — 50 y.0- toulalY®rticulum — common in children diverticula econ > common in LGIB be manage by: (p. 278) 'erapy */- endoscopic therapy b. no IV PPI or endoscopic therapy ©. IVPPIth 'erapy + endoscopic therapy 4. ligation + Iv PP ‘Acute upper Gtbleedng Excohagea! varices |__| Mallory Weis tear = — at, Ligation + IV [es - oak sieison| |Centae| | astecie'dvg | [Mostra] | Bec Za) =|| ea |) & Lees 9rapy ‘therapy PPL for 1-2 days: fe=n No "Vendocon | |stonsesebe| [ormaanape || ornavcane| [aries eas] | roy | onan nee, therapy therapy therapy I Senoy_ z : Ward for Te 1, |[easiae] "oS™ | [om PEE] [re Bele with acute upper gastrointestinal (GI) bleeding. Recommendations on ls algorithm for patients: Suggested seat ic crahiivad without futher haan a thar enacts my Which ofthe following conditions does NOT increase the amount of gas me the intestine? (p.285) ei bacterial metabolism such as lactose c. excess d. none oe Sy results from gulping food; chewing gum; smoking; or as a response + others: Aerophagia (Peto repetitive belchingl lactose seed eae oligosaccharides, which can anxiety, which cans nydropen, carbon dioxide, or methanal irritable bowel syndrome and fo productowntive sense of abdominal pressure fa to impaired intestinal transit oe ine than increased gas volumel/ abdominal distention an _of gas rather ‘objective ir in girth—is Aiaphragmatic contraction and anterior stoning in patients with cirrhosis?c. a 2Sed j increase’ eve, 9. all of S° level’ °f vase, tor te not the apvSl OF aS Ula endothelial gro fact wet in ci * Necrosis growth factor ate Seen a actuator of erate Porcine tation ents cone (dev. of hepatic cirhosil Wyo. veGr & TNE 2 cree ere agit in conan neat NO velmudiuretic ean emu ena in cont to aeceane ia ‘sn Meron) Se rant, Sn 2 Compensatory vanceonsticton aio crater retention and activation © ne system, which lead in tur 38.4, 4 (SAgG) 48 Year og radient of mak bumin gI sis? (©. 205) ozo. and ae th ascites, nas a serum-asc tear most likely dieGno a = protein of 1.5g/dL. What is -eehesta SCI also te os era b purthosig level - sor ar faire Merete @ tubereuioes, [cer tatrotonaciwe —] [iy lak Petcasee apron Fein omic || espera tpcaby >. 000m IMC bsructon Pertoneal earcromatosi Susi ebstrcton Tbeceiois come b. amiloride 5 — 40mg/d ©. furosemide, spironolactone ratio of 40:100 -F: loop diuretics, S: aldactone antagonist that inhibits Na resorption in the distal Convoluted tubule of the kidney = fentriction> oral diuretics(Spiron sie: hyponat, hyperk & painful Synecomastia, substitute by sntagontet or samax dose 160mg and 400mg respectively add never at-adrenergic antagonist or clonidine — a2-adrenergic antagonist both ncte oo vasoconstrictors, counteracting splanchnic vasodilatation) Others: Beta-blocker, repeated large volume Paracentesis (LVP) or transjugular intrahepatic ertonea! shunt TIPS) -TIPS}—2 radiological placed pertayetomic ec decompresse: the hepatic sinusoids. 40. What will you give to prevent “post-paracentesis Circulatory dysfunction” after LVP? (p. 288) a. intravenous infusion of albumin ~ 6 to 8g/L of asc: b. volume replacement with isotonic solution c. gradual drainage of ascitic fluid 4, start dopamine drip oa rinse cataract ote eestor cae eet LVP,ranactaneous ‘should receive " ne (SBP Zegy Matic antibiotic fluid removed4. all of the above + Hepatic hydr: ydrothorax - Chest tube should be avoided on ayo ___42. What we level of GiomeruarFitration Rate (GFF) develop? a< Temi”) b. <20mimin ©. < 25mi/min 4. < 30min Sein onal “Ronwed ausrepulton (araNts tea plan OO acer ala Reap cceton of sue GBM, glomesoler Dasemnecs ‘ave laboratory findings of ___43. A 50y.o. female with acute renal failure hi ality >500mosmol/L H20.. Urinena < 20meq/L, FeNa <1% and urine osmo! What is the most likely cause of ARF? (P- 291) a. diarrhea b. urinary tract obstruction c. total renal vein occlusion d. total renal artery occlusion (FEEITEZIEN tssorarony rnoincsim ACUTE RENAL FAILURE Prevenal ‘Otiguic Acute ode Ae BUN/?,, ratio: 201 10-15 Urine sodium U,, meq/t <20 340 Urine osmolality, mosmoVLH,O >500 2350 Fractional excretion of ‘sodium® <1% 2% Urine/plasma creatinine U./P,, 40 <0 Urinalysis (casts) None or hyaline? Muddy b granular Upp xP, x 100 “Few paths