MEDICINE I 9.

Test of lower extremity strength

6TH LONG EXAMINATIONS a. Stand up, walk 2 m, turn 360 deg  up-and-go test
SY 2012-2013 b. Maintaining balance for 30 sec
c. Resistance to a nudge
1. In assessing the functional status of senior elderly, we have to determine the d. All of the above
ability to perform basic activities of daily living
a. The ability to make food choices and prepare meals 10. Assessment of patient with urinary incontinence should include the following:
b. Taking appropriate medications and correct dosage on time a. Daily water intake
c. Choosing appropriate garments and dress and undress b. Cognitive function
d. All of the above c. Mobility
d. All of the above
2. All are instrumental activities of daily livings, except:
a. Prepares adequate meals if supplied with ingredients  should be plans, 11. Medications associated with increased risk of falls in the elderly
prepares and serves adequate meals independently  Antiarrhythmics  Diuretics
b. Does personal laundry completely  Antihistamines  Laxatives
c. Travels independently on public transportation or drives on car  Antihypertensives  Muscle relaxants
d. Operates telephone on own initiative, looks up and dials numbers  Antipsychotics;  Narcotics
 Benzodiazepines and other  Tricyclic antidepressants
3. True about prognosis: sedative-hypnotics and selective serotonin
a. In all races, males have better prognosis  Digoxin (Lanoxin) reuptake inhibitors
b. Black African Americans females have better prognosis (for >85y.o.)
c. Both 12. Recommended adult immunization schedules: tetanus toxoid vaccination every 10
d. Neither years (others: annual influenza vaccination, one-time vaccination for pneumonia,
& herpes zoster and pneumococcal vaccine)
4. 80 years old female sought for consult due to ... of 3 days duration. History and
PE were insignificant. This may be due to 13. Frailty is thought to be a wasting syndrome usually presenting with weakness,
a. Stroke/CVA poor exercise tolerance, slowed motor performance, low physical activity and
b. Pneumonia  nonspecific changes in mentation as primary presenting Sx weight loss.
c. MI  change in mental status, dizziness or weakness rather than the
typical chest pain 14. A healthy 45 year old is different from a healthy 7 year old mainly because of:
d. Any of the above a. Multimorbidity
b. Frailty
5. Most common visual acuity pathology in the elderly is due to in the c. Both are correct
a. Cataract d. Neither A nor B is correct
b. Diabetic retinopathy
c. Glaucoma 15. Given: weight loss from 75 kg to 67 kg in __ months. No other complaints. Mini-
d. Presbyopia cognitive test result more than 5. Normal for his age?

6. Physical Disability is defined as having difficulty or being dependent on others for 16. To solve for estimated REE:
the conduct of essential or personally meaningful activities of life from: (1) Basic For males = 900 + (10 x weight in kg)
self-care such as bathing and toileting; to (2) tasks required to live independently For females = 700 + (7 x weight in kg)
such as shopping, paying bills or preparing meals. Adjust for physical activity level: final REE = (estimated REE x PAL)
Sedentary: 1.2
7. The #1 determinant of population growth is the economic condition of the country. Moderately active: 1.4
Very active: 1.8
8. 77 y/o went for a consult because she is less alert, always sleepy, has difficulty in
feeding and sometimes disoriented. 17. Given: 60 years old, 60 kg, moderately active lifestyle. What is his REE?
a. Dementia a. 1,500
b. CVA or brain stroke b. 1,800
c. Neither c. 2,100  {1.4 x [900 + (10 x 60)]}
d. Both d. 2,400
18. 44 y/o diagnosed with chronic kidney failure disease secondary to diabetic d. Edema  in Kwashiorkor
nephropathy. You reduced his protein intake. In what other condition, would you
reduce protein intake? 27. Given: BMI of 24.5 kg/m2  Normal
a. Rehabilitation after therapy 28. Calculated BMI: ~32 kg/m2  Obese
b. Liver cirrhosis
c. Acute myocardial infarction
d. Bronchial asthma

19. 44y/o female came in to ask for dietary intervention. She is diagnosed with CAD
and her latest lipid profile shows elevated total cholesterol and LDL but low HDL.
You advise her to increase intake of Salmon which contains a certain fat which will
help her correct her cholesterol problem. This fat is:
a. Saturated fats  assoc. with high levels of total cholesterol and LDL
b. Monounsaturated fats  lower total cholesterol and LDL, increase HDL
c. Polyunsaturated fat  N-6: lowers both LDL and HDL, N-3: reduce TAG
d. Trans fat  elevates LDL but not HDL

20. Old lady seeks advice from you on how much water intake is appropriate, what
reference will you use 29. A 31-year-old female is referred for nutritional counseling which of the following
a. Estimated average requirement  50% risk of inadequate intake physical findings will point to a protein deficiency
b. RDA  overly generous, less risk for inadequate intake a. Corkscrew hair
c. Upper tolerable limit  highest level that is unlikely to pose a risk of b. Swollen, retracted bleeding gums
adverse health effects c. Scaling
d. Adequate intake  also for Ca, chromium, Na, Cl, K (for all ages) d. Easily pluckable hair with positive flag sign

21. Surrogate for visceral adipose tissue: 30. 49 y/o male diabetic comes in for dietary counseling. Which tool gathers food
a. Triceps skin fold  estimates body fat stores habits for the past 3 days and serves as an intervention as well?
b. Waist circumference a. 24 hr food recall
c. Mid-arm muscle circumference  estimates skeletal muscle mass b. Food Frequency Questionnaire
c. Food Diary
22. Serum creatinine: reflects muscle mass d. FFQ with recall of last night’s meal

23. A 42 y/o female came in for check-up. You plan to give her a dietary prescription. 31. Intake of vitamins A,D,E, K can lead to overdose because:
Which of the following reference intake will you use to come up with your a. They are stored in the liver and fat tissues
prescription that will ensure she will get sufficient amounts of protein, b. They are transported in water in the blood
Carbohydrates and fats? Recommended Dietary Allowance (RDA) c. They pass through the kidneys
d. They pass through the lymphatic system
24. For Asian females: waist circumference > 80 cm (31.5 in)
32. Which of the following is not recommended for the elderly as source of vitamin D?
a. Cod liver oil
25. A 28 year old male Filipino has a 94 cm waist circumference on physical
b. Salmon
examination. What is the cut off value?
c. Sunlight
a. 80 cm
d. Milk
b. 85 cm
c. 90 cm (35 in)
33. Deficiency of this vitamin causes nose bleeding and internal bleeding: Vitamin K
d. 94 cm
34. Excessive intake of these vitamins produce no adverse effects, except:
26. A patient was referred to you for findings for possible protein energy malnutrition.
All are excreted through the urine immediately.
What will indicate that it is marasmus?
a. Thiamin
a. A normal appearance  starved appearance
b. Vitamin C  large doses can cause diarrhea and nausea
b. Triceps skin fold of less than 3mm (& mid-arm MC < 15 cm)
c. Riboflavin
c. Moon facie ????
d. Cobalamin
35. Anti-oxidant that when in larger amount produces heart failure 47. Which of the following causes non-osmotic release of AVP?
a. Vit. A a. Pain
b. Vit. C b. Nausea
c. Vit. E c. Pregnancy
d. Manganese d. All of the above

36. The mineral that improves the immune system is: 48. If lab results show, 298mosm, which of the following results is inconsistent?
a. Copper AVP secretion is stimulated as systemic osmolality increases above a threshold
b. Zinc level of ~285 (but human body osmolality is maintained at 280-295 mosmol/kg).
c. Phosphorus Beyond the threshold value, thirst and water ingestion are also activated.
d. Chromium
49. True about renal NaCl renal absorption:
37. An alcoholic patient was admitted because of weakness, unsteady gait and a. ¾ NaCl ultrafiltrate from plasma is reabsorbed in the proximal collecting
confusion. What will be the likely vitamin deficiency? tubule  only 2/3 is reabsorbed in the PCT
a. Vitamin B12 b. 30-40 % NaCl is absorbed in the distal collecting duct  only 5-10%
b. Vitamin B1 c. NaCl is reabsorbed in the intercallated cells in the collecting duct via ENaC
c. Vitamin B6 d. Vasopressin mainly acts in the distal nephron by absorbing Na and Cl and
d. Vitamin B3 secreting K  Vasopressin acts on the collecting duct, increasing the water
permeability of the CD (i.e. aquaporin channels are inserted to luminal
38. An 81-year-old had a history of a fall in her bathroom, breaking her hip bone in the membrane)
process. Which of the following is probably not related?
a. Hypocalcemia 50. The following are renal causes of hypovolemia, except:
b. Manganese deficiency a. Mannitol infusion  causes osmotic diuresis (renal water & Na loss)
c. Hypovitaminosis D b. Ketonuria  in starvation or in diabetic or alcoholic ketoacidosis (volume
d. Iron deficiency depletion and hyponatremia d/t increased excretion of an osmotically active
nonreabsorbable or poorly reabsorbable solute)
39. Frozen vegetables contain more vitamins than vegetables stored in room temp. c. Diabetes insipidus  ADH deficiency or insensitivity to ADH by the kidney
(renal water loss)
40. Chromium: Helps body use sugar properly, breakdown of proteins and fats d. Sepsis  increased venous capacitance (ECF volume normal or expanded)

41. Signs of vitamin B12 (cobalamin) deficiency: tiredness and fatigue, tingling and 51. The most common cause of euvolemic hyponatremia:
numbness in hands/feet, memory problems, macrocytic anemia a. Severe hypothyroidism
b. Pituitary Adenoma
42. Folic acid (folate): This is essential in the first 3 months of pregnancy to prevent c. SIADH
birth defects such as spina bifida, cleft palate or cleft lip. d. SSRI

43. These are all oxidants, except: 52. Osmotic demyelination syndrome (ODS): Overly rapid correction of hyponatremia
a. Manganese is associated with a disruption in integrity of the blood-brain-barrier, allowing the
b. Vitamin A entry of immune mediators that may contribute to demyelination.
c. Vitamin E
d. Vitamin K 53. 60 year old 60 kg male patient came in with decreased sensorium. Na = 110meqs/L
(low), K= 4 meqs/L (normal), Crea = 1, Hgb = 10. Muscle strength 2/5 (decreased)
44. Good source of calcium but with low levels of phosphorus? Corn? Milk? on all extremities, urinalysis normal; BP = 130/80, HR= 78, RR=18; Chest xray
Fruits, vegetables and soy products? showing a 3.5 mass/opacity at right midlung (probably small cell CA of the lung that
can produce an ADH-like peptide). Which of the following is not consistent with the
45. Sources of calcium would be, EXCEPT: condition management of this patient?
a. Yogurt a. Give hypertonic NaCl solution; Na deficient of 1000 meqs  SIADH is d/t
b. Milk ADH-induced water and NaCl retention and hypertonic sol’n further causes
c. Dark green leafy vegetables ECF expansion
d. Diet cola b. Limit water intake to 1 to 1.5 L
c. Give furosemide  can aggravate hyponatremia if taken without saline sol’n
46. Most effective and reliable treatment of hyperkalemia: Hemodialysis d. Random urine Na = 15; Urine specific gravity 1.005  UNa must be >20
54. What do you use as a resuscitating fluid with the same osmolality as plasma? 66. Case similar to this: A 2nd year resident missed acute necrotizing pancreatitis in a
Isotonic solution used for the treatment of hypovolemic hyponatremia? patient presenting with abdominal pain. She got so traumatized from that incident
a. LRS  130 meq/dL Na and from then on, she will order for serum amylase for all her patients in the ER.
b. DW5 with two vials of 54 meq/dL NaCl a. Representative heuristic
c. NSS  154 meq/dL Na b. Availability heuristic
d. DW5 with half a vial of 3% NaCl (513 meq/dL) c. Anchoring heuristic
d. None of the above
55. Serum K+ drops by ~0.27 mM for every 100-mmol reduction in total body stores. 67. A clinician examined a 25-year-old female patient who complained of epigastric
Normal serum K+ = 4.0 mmol. If serum K+ is 2.0 mmol, then: 4 mmol – 2 mmol = 2. comfort after eating a fatty meal. The clinician asked the patient if the pain
Total loss: (2 mmol / 0.27 mmol) x 100mmol = 7.4 x 100 mmol = 740 mmol. radiates to the back at the right tip of the scapula and if it is relieved by the intake
of anti spasmodic. What type of cognitive shortcut is used here?
56. Question on Na deficit, corrected plasma Na concentration a. Representativeness heuristics
57. Question on water deficit (marathoner with serum electrolytes reflecting hypernatremia) b. Availability heuristics
58. Question on exclusion of pseudohyponatremia c. Anchoring heuristics
d. None of the above
59. Best treatment for case above (#58)
a. D5NSS (if hypovolemic hyponatremia this is the answer) 68. Gold standard should have:
b. D5W a. 100% sensitivity
c. Not sure if D5LR b. At least 98% specificity
d. Free water c. 100% positive predictive value
d. At least 95% negative predictive value
60. Hypokalemia due to Na+/K+-ATPase-mediated cell uptake of K+ is caused by
a. Insulin 69. Specificity: Ability of the test to label as negative those who don’t have the disease
b. Calcium gluconate 10%, slow push Sensitivity: Ability of the test to label as positive those who have the disease
c. Hypothyroidism
d. - 70. Among those who tested positive to a test, the probability of having a disease is
called?
61. 23 y.o., female, office clerk, came in complaining of recurrent hypokalemic a. Sensitivity
episodes for the past 6 months. She has been experiencing progressive muscle b. Specificity
weakness and difficulty of breathing. Serum K+ is 1.7 meq/L and thyroid function c. Positive Predictive Value
is normal. Diagnostic work-up for this patient should include all of the following d. Negative Predictive Value
EXCEPT:
a. 24 hour Urine K+ excretion 71. Pre-test probability: probability of the disease in the clinical scenario
b. Blood pressure monitoring Possible sources: surveys, literature (case series, epidemiologic studies)
c. Arterial Blood Gas measurement
d. Water restriction 72. The probability of a disease above which the physician should stop testing and
start instituting treatment maneuver and below which the physician should
62. Shifting of K from ICF to ECF (hyperkalemia), occurs which of the following: continue conducting further testing is called?
a. IV administration of calcium gluconate 10% a. Testing threshold
b. Radiocontrast administration especially the high osmolar type b. Treatment threshold
c. Metabolic alkalosis  should be acidosis c. Pretest probability
d. All of the above d. Post test probability

63. – 73. If the testing threshold for diagnosing pancreatic cancer is usually set at 2%, what
64. – should be the testing threshold for diagnosing chronic pancreatitis?
65. -- a. The same at 2% since they are both pancreatic conditions
b. Above 2% since this can be treated with medications
c. Below 2 % since this is a more aggressive condition
d. Needs for more assessment
If the disease to be diagnosed is more (less) severe than the disease with the
known testing threshold  then the testing threshold of the disease to be
diagnosed must be lower (higher).
74. If the treatment is life-threatening or involves a very expensive operation to treat 80. If a pretest probability value of a disease is 50% and the first diagnostic test has a
an aggressive condition, then the treatment threshold should be set higher. positive likelihood ratio of 5 and a negative likelihood ratio of 0.2, and the second
a. The same at 95% since these are the same procedures diagnostic test has a positive likelihood value of 10 and the negative likelihood
b. Higher than 95% because cancer surgery has a higher surgical risk value of 0.1, what are the odds that the first diagnostic test is positive and the
c. Lower than 95% because cancer surgery is more expensive second diagnostic test is negative?
d. Cannot be determined unless pre-test probability is known. a. 0.5:2
b. 1:2
75. If the sensitivity of the test is 90% and the specificity is 10%, what is the positive c. 2:1
likelihood ratio? d. 2:0.5
a. 1  PLR = Sensitivity / (1-Specificity) = 0.9 / (1 - 0.1) = 0.9 / 0.9 = 1 Given: p = 0.5, 1st test PLR = 5, 2nd NLR = 0.1
b. 9 Convert first to odds: p = 0.5  p / (1-p) = 0.5 / (1- 0.5) = 1:1
c. 0.11 Odds if first test is positive (1x5):1 = 5:1  then if second test is negative (5x0.1):1 = 0.5:1 = 1:2
d. 0 81. If the above conditions are followed (referring to number 80), what are the odds
that the 1st test is negative and the 2nd test is positive?
76. If the sensitivity of the test is 10% and the specificity is 90%, what is the negative a. 1:3
likelihood ratio? b. 1:2
a. 1  PLR = (1-Sensitivity) / Specificity = (1-0.1) / 0.9 = 0.9 / 0.9 = 1 c. 2:1
b. 9 d. 3:1
Given: p = 0.5, 1st test NLR = 0.2, 2nd PLR = 10
c. 0.11
Convert first to odds: p = 0.5  p / (1-p) = 0.5 / (1- 0.5) = 1:1
d. 0 Probability to Odds Odds if first test is negative (1x0.2):1 = 0.2:1  then if second test is positive (0.2x10):1 = 2:1
Conversion: Odds = p / (1-p) = A / B = A : B
77. -- Wherein “p” = probability, “A” = successful outcome, 82. Post-test odds of 4:1. What is its probability?
a. – “B” = unsuccessful outcome. Convert until A or B is 1. a. 20%
b. 1.2 Odds to Probability b. 40%
c. 2.1 This conversion is needed to obtain the post-test probability. c. 60%
d. 3.1 d. 80%  4 / 4+1 = 4/5 = 0.8
Conversion: If Odds = A : B, Probability = A / (A+B).
83. Interpretation of post-test probability:
78. If pretest probability is 25% and diagnostic test positive likelihood ratio is 30, what  Above the treatment threshold, we stop testing and start treating.
would be the odds if the diagnostic test is positive?  Below the testing threshold, we stop testing and start observing.
a. 30:1  Between the two values, we continue with testing.
b. 10:1
c. 1:30 84. How would you interpret the data if the p-value is 4%?
d. 1:10 a. The null hypothesis is rejected if the set alpha error is 5%.
p = 0.25, PLR=30, Probability to odds: p / (1-p) = 0.25 / (1 - 0.25) = 0.25 / 0.75 = 1 / 3 or 1:3 b. --
Odds if diagnostic test is positive = (1 x 30):3 = 30:3 = 10:1
c. --
79. If the pretest probability of the test is 66.7% and a diagnostic test has a negative d. --
likelihood ratio of 0.5, what would be the odds of the disease if the diagnostic test Rule: Reject the null hypothesis when the p-value is less than the set alpha error.
is positive (this should be negative)?
a. 3:1 85. In a randomized controlled trial of a new drug, the results show that the 95%
b. 2:1 confidence interval of the relative risk is -10 to 50 with a set alpha error of 5%.
c. 1:1 What would be your interpretation?
a. The new drug is definitely harmful.
d. 1:2
p = 0.67, PLR=0.5, Probability to odds: p / (1-p) = 0.67/ (1 - 0.67) = 0.67 / 0.33 = 2 / 1 or 2:1 b. The new drug is definitely beneficial.
Odds if diagnostic test is positive = (2 x 0.5):1 = 1:1 c. The new drug is slightly beneficial.
d. The new drug is neither beneficial nor harmful.
If the 95% CI doesn’t include unity (or doesn’t cross 1), then the p-value must be <5%.
In the case above, it crosses 1 and so the p-value is >5%. Since the set α error is 5%,
we accept the null hypothesis that the new drug is harmful. We only reject the null
hypothesis if the p-value is less than the set α error.
86. Patient presenting with GI bleeding should be admitted to ICU if he has:
a. Episodes of syncope
b. Age is 50 yrs old
c. Hypertensive
d. All of the above
Syncope attacks or dizzy spells are signs of significant blood loss that could be about
30% of the total blood volume. ICU bed is usually indicated for patients who have
severe manifestations of bleeding such as shock or hemodynamic instability.
enough for melena to develop. When hematochezia is the presenting symptom of
UGIB, it is associated with hemodynamic instability and dropping hemoglobin.
 Significant bleeding leads to postural changes in heart rate and blood pressure.
 Stigmata of cirrhosis (that will most likely cause severe variceal bleeding):
gynecomastia, spider angiomatas, caput medusa, jaundice, splenomegaly, and
sparse, thin, dry pubic hair

87. Which of the following favors UGIB over LGIB?  No therapeutic intervention needed for a patient with a history of NSAID or aspirin
a. Three times the normal BUN and creatinine intake and found to have ulcers during endoscopy.
b. Normoactive bowel sounds
c. Blood stained finger after rectal exam  Recommended treatment for active GI bleeding? Variceal bleeding?
d. Splenomegaly Endoloop? Elastic band?

88. Which of the following is true?

a. NGT insertion is done to determine if the bleeding is from the upper or lower
GIT especially in patients presenting with hematochezia.
b. NGT is not removed for subsequent diagnostic procedures.
For example, it is necessary to clean the patient first (by flashing NGT with
water and then suction) before doing endoscopy
c. Preventing encephalopathy among patients with encephalitis (???).
NGT insertion is done because we don’t want the blood to go down in
cirrhotic patients with elevated BUN and creatinine as it can lead to hepatic
encephalopathy (according to Dr. Basco’s lecture).
d. All of the above

89. Use to predict recurrent bleeding of non variceal lesion.

a. Patient’s predisposition to bleeding
b. Patient’s vital signs upon admission
c. Forrest Classification
d. Rockall Scoring

90. Which of the following is the most appropriate diagnostic test for an occult blood
exam?
a. Enteroscopy
b. Capsule endoscopy
c. CT scan
d. Mesenteric angiography

 Refer the patient for mesenteric angiography if nothing is seen during endoscopy.

 Hematochezia is 80%-90% LGIB from colon but patient with bleeding in the
duodenum may also present with hematochezia.
 Among patients with hematochezia, it is very important that vital signs are
monitored since it can help in differentiating whether the bleeding comes from the
upper GI or the lower GI. If a patient presents with hematochezia but is still
roaming around, the bleeding is most probably from the lower GI particularly in the
colon. However if the hematochezia is associated with very low BP or postural
hypotension, the bleeding is most probably from the upper GI.
 Hematochezia usually represents a lower GI source of bleeding, although an
upper GI lesion may bleed so briskly that blood does not remain in the bowel long