Guangxi Medical University final examination of " Internal Medicine” for grade 2014 Major (class41) {Formal-examination) -{-11 pages enclosed) Date for examination: July 13, 2018 (8:30-1:00) Time: -150 minutes Name. Number. Please write down correctly Item Final Score Appraiser |- Ill Multiple Choice questions | Machine Scoring Macromedia AXC. dopoints) IV case analysis (50 points) Total Score AV items) calculaterNote: Please use the 82 pencil to fil the answer card in accordance with the requirements listed on the answer card, The student number isthe test number (left alignment). Be sure to fil the type of examination paper, otherwise no results! Please fill the name and student number on the examination paper. |. A1 and A2 type multipsingle choice questions ‘please choose the best answer and mark a black line on the answer paper 42 points) rheumatoid arthritis, radiographic changes of hands must include: A. surrounding soft tissue swelling 1. To diagnos. B. bone demineralization «2-rarrowing of the joint space and bone erosion D. bony and fibrous ankylosis E, Subluxation 2. The gost commonly used antirheumatic drug of dis Methotrexate ‘8. Cyclophosphamide modifying in rheumatoid arthritis is: C. Sulfasalazine D. hydroxychloroquine sulfate E, Leflunomide 3 We of the following isa specie antibody of systemic lupus erythematosus in ti-Sm antibodies B. Antinuclear antibodies C. Anti-Ro (SSA) D. Anti-RNP E, Antihi 4. Which disease is not belong to connective tue disease? Horas bilateral sacroiliitis 4 months ago because of his tenderness to percussion of the sacroiliac suntan pn on png tpi ap. He es seve na eno ton th tar vin Laken lag scnas eran andy sadam tr nd show the patient's human leukocyte antigen status is B27-positive. Which of the following is vr ey aon? 1 tne yatone _ponyonng apontyio C. Psoriatic arthritisD. Osteoarthritis E, Rheumatoid arthritis 6. Intype - Il respiratory failure, there is: A. Low PO: and low PCO: ohon PO2 and high PCO2 C. Normal PO2 and high PC D. Low PO: and normal PCO: E, Normal PO; and low PCO: 7. Which kind of pathological types of lung cancer has the worst prognosis? E, Exacerbation often occurs as a result of an upper respiratory tract infection 9. A 60-year-old man presents chronic productive cough and exertional dyspnea for 30 yaears duration, Presents worsening cough and purulent sputum combined with increasing dyspnea to the emergency department.-1. Which is the most likely diagnosis with this patient? A. pulmonary embolism B. heat failure C. bronchi asthma exacerbation D. pulmonary tuberculosis ECOPD 10, Which of the following signs is characteristic in patients with mitral stenosis? A. A holosystolic murmur at cardiae apex CA diastolic, rumbling murmur at cardiac apex C. Splitting of $2 D. A soft SI E. An $3 gallop 11, Which of the following medications should mot'Be initiated during an episode of acute B. Ace inhibitor C. Potassium supplementation D. Digoxin E. Furosemide12. A 65-year-old man with heart failure has pillow orthopnea and shortness of breath while walking around his house. He is comfortable only at rest. What NYHA heart failure class symptoms does he have? A. Class I Leto 13. A 78-year-old man presents with occasional syncope with exertion for the last 2 months. Physical exam demonstrates an III/VI late-peaking systolic murmur at the right upper sternal, border. The second hear sound is dampened, and the carotid upsteke is delayed. On the basa the ceamination wha isthe mos ily dgnoss? B. Mild to moderate aortic stenosis, C. Aortic dissection D. mitral stenosis, E, Hypertrophic obstructive cardiomyopathy 14, Which of the following describes about receptor disease is not true? A. Receptor deficiency, sensitivity of tissue to hormone decrease B. Type 2 diabetes mellitus is a kind of receptor disease C. The clinical manifestation of tor disease is hypofunction hormone J. target glands hormone? 15>“The main cause of death in type 2 diabetic patients is. A Biabetic macrovascular complications B. Diabetic microvascular complications C. Diabetic paraneuropathy D. Diabetic ketoacidosis E, Hyperosmolar hyperglycemic state 16. A 36-year-old male consults with you because of sore throat and fever (T38.6°C) for I days. He had Grave's disease for 2 months and now he takes tapazol 10mg, three times per day. Which of the following statements is not true? tive te pte oie an antial omey ony. of leukocytopenia or agranulocytosis should be considered. of hyperthyroidism accompanied by upper respiratory tract infection should be considered, D. Check white blood count immediately. E.None of the aboves 17. A 76-year-old female was admitted to our ward because of primary liver cancer. She had type 2 diabetes mellitus for 10 years and she constantly takes Gliclazide (oral glucose-lowering agent) 80mg, Bid. And now her fasting blood glucose is 9.7mmol/L and 2-hr PG 16.SmmolIL. The best choice of treatment is: A. Gliclazide 80mg, tid B. Metforminore + Metformin Insulin E, Diet control and exercise 18. A 58-year-old male, complained about polyuria, polydipsia,polyphagia and weight loss of 5 kilograms for three months. He checked fasting blood glucose twice, and the results were 1.0SmmoV/L and 8.12mmol/L. How to confirm the diagno {A Oral glucose tolerance tes OGTT) B.Intervenous glucose tolerance test(IVGTT) C. Cortsone glucose tolerance test D. pal glucose tolerance test after controlling det two months Frew any oe wt weds pl 19. Which is the range of GFR in CKD stage 5 patient? A 45:59mlimin 34a ml/min C. 30-59m/min D. 15.30mimin ,40.60mnin 20. Which one is the most common pathogenic bacteria of urinary tract infection A. Bacillus proteus 8. ppaclnes ~/eseherchin cl D. fecal streptococci E, staphylococcus 21. What is hematuria? Se red cells/HP B. 2S red cells/HP C. 240 red cells/HP D. 2S red cells/HP E, 220 red cells/HP 22. which is not the complication of Nephrotic Syndrome? A. Thrombosis and embolism B. Infection C. Acute renal failure D. Metabolic disorder of lipid and protein Significant anemia 23. which one is not the physiologic function of kidney? A. exerete metabolic substance fegulating immune function C. maintain fluid, electrolyte and acid-base balance D. Endocrine function , maintain appropriate fluid 24. Which examination is essential for the diagnosis of Paroxysmal Nocturnal Hemoglobinuria? Sao's est B. Bilirubineee igs zhane _slhon totter anemia ive menstrual bleeding for 3days. She has no how Hgb 98 g/L, MCV 71 AL, platelet count 8,500/microliter, and WBC count 6720/microliter. PAIgG is positive. hepatosplenomegaly and no lymphadenopathy. Laboratory studi Which of the following is true except? jone marrow shows a decreased in all cell lines 'B. Bone marrow shows an increased numbers of megakaryocytes C. Platelet transfusion is ineffective D. Glucocorticoid: the first line therapy E, Sometimes requires splenectomy 28. A 26 year old woman has had fever and malaise for several days. Her temperature is 39°C and purpura are noted over his legs. Her hematocrit is 28%, WBC 25,000/ul, and platelet count 9,000/ul. The peripheral blood WBC differential includes 75% blasts. Which of the following is the most necessary for her diagno A. Platelet antibody B. Ipmunophenotyping one marrow morphology and histochemical stain . Platelet function E. Chromosomal analysis 29. LWhat is the main symptom of peptic ulcer? A. nausea B. vomit CC. bpteh hythmic abdominal pain . Difficulty breathing 30. How to diagnose chronic gastitis? A.age B. Barium upper gastrointestinal series C. Testing for HpyloriD. Routine blood test endoscopy and Biopsy 31. A 25-year-female suffering with low-grade fever, abdominal pain and weight loss for 6 months. The past history of hepat sulosis is presence. Abdominal guarding, is and tul rsa II. A3 type case group best choice questions. The following questions, each question has a common title, and then put forward two or three questions related to the title, Please choose the best answer and mark a black line on the answer paper points). [Question33-34] A 17-year-old boy is brought to th after awakening roduclive cough and ‘The patie is found to have “Lung examination reveals difuse rhonchi and in addition to pulsus paradoxus. He is afebrile and has no recent history of fever. This is the patient's second visit to the ED with these symptoms; his first visit was 2 years ago. 33. What is the most likely diagnosis? A. Pneumor B. pulmonary tuberculosis C. lung cancer DéAsthma E. Acute heart failure 34, What tests could be used to confirm the diagnosis? ALA chest x-ray B. Arterial blood gas analysis CEKG D. color ultrasonic cardiogram 5 pulmonary function test 46-year-old graduate man presents to the clinic with sudden ‘yoare—On physical exam the pateint i clearly short of brealh-and tachyeardie, BP12070mmHs, AS HAG porlasssed denntrtten sie tachieanlia si postion abnormalities, 6[Question35-36] A 60-year-old man complains of increasing dyspnea on exertion and orthopnea for 3 days. The patient suffered from an anterior myocardial infarction 3 years ago. He has a 100- pack/ year history of cigarette smoking. His physical examination reveals an $3 gallop, pulmonary rales, jugular venous distension, and lower extremity edema. He is normotensive, and his extremities are warm to touch, An echocardiogram confirms an ejection fraction of 25% and a dilated left ventricle. What is the most likely diagnosis? A. Hypertension B. Cardiomyopathy ompensated heart failure D. Valvular disease itis E, Acute py ‘What is the most appropriate next step in management? A. Osal calcium channel blockers fatravenous furosemide C. Oral alpha blocker D. Sublingual nitroglycerin E, Intravenous sodium nitroprusside [Question37-38] Male, 28 years old, duodenal ball bulb ulcer history of the past 5 years, sudden epigastric pain for up to 5 hours, followed by abdominal pain, sweating. 7. Which signs is most support the diagnosis of ulcer perforation? 6A. abdominal tension B. abdominal percussion is drum sound SP Repatic dullness disappear . abdominal mobility dullness E, sounds disappear 8. Which part of duodenal perforation is more common? jodenal ampulla anterior wall of duodenal bulb C. posterior duodenal bulb D. descending part of duodenum E, horizontal part of duodenum IIL B1 type matched multiple choice questions ‘please choose the best answer and mark a black line on the answer paper 12 points) [Question3s-40] A. pulmonary tuberculosis B. lung cancer C. lung abscess fete teas ma one Benches 57 OF 539, presentation of loalifed wheezing sound-{8) 640. presentation of extensive wheezing sound-{D) [Question41-42] A. Sulfonylun B. Biguanide hypoglycemic drugs C. Alpha-glucosidase inhibitors. D. Thiazolidinedione drugs E, Insulin, Al. Type I diabetes should select fist: E S42. Type 2 diabetes mellitus combined with renal failure should select first! E [Question4s-44] A. Erythropoietin B, immunosuppressant . Indomethacin D. Penicillin E, Diuretic 243. Which drug is mainly for CKD 5 patients? {4} 40.44. Which drug is mainly for Nephrotie Syndrome 42}. [Question4s-46] A. Thiazide diureticsB. ACE inhibitors C. Alpha-blocking agents D. Beta-blocking agents E, Calcium channel blockers 445. Which of the blood pressure-lowering medication classes is a preferred agent in a hypertensive patient with diabetes mellitus? B 42.46. Which of the pressure-lowering medication classes is a preferred agent in a hypertensive patient with angina pectoris? D [Question47-48] A821) B.1(15:17) . inv16(13:422) D.1(9:22) E. 8:14) 13.47. Which cytogenetics can be found in chronic myelogenous leukemia? D LAS, Which cytogenetics can be found in acute promyelocytic leukemia? B A hepatitis B. liver cancer C. liver abscess D. fatty liver E. congestive hepatomegaly 4549. male, aged 42, right upper abdominal muscle tension, liver 2em, soft, the Fight 46.50. female, aged 37, were examined: liver dem , with blunt, tenderness, and hepatic venou: 1 GREET, The moet ely dingn is: C “reflux (4), The most likely diagnosis is: E IV. Case analysis (50 points) (10 points) A 65-year-old patient present to clinic with complaints of recurrent cough,sputum for 20 years, and syndrome always become severe after catch a -cold,and he had exertional dyspnea for 5 years ago, he didn’t received regular treatment for his illness. 4 days ago he fell his syndrome more severe than before. He had a long history smoking for 30 years. PE: T 370C, R 25, p 120 ; barrel chest, his breath sound diminished , both leg edema, His arterial blood gas revealed a pH of 7.45, pCO2 of 60 mm Hg, and a pO2 of 55 mm Hg. Question: (1) What the probable diagnosis of this patient? (2) which detection should be done for confirm the diagnosis?—f4}_a.CORD{acute-exacerbation} 353 b.Type ll Respiratory failure 34)- ¢-Cor pulmonale 25> ~2}_Lung functiontest 248 2. (7 points) Female, 26 years old. 10 years of type I diabetes, insulin treatment. ‘Hypoglycemia occurs often recently. In the past 3 months, the eyelid and lower ‘limbs were swollen, blood glucose was 10.2mmol/L, urinary protein excretion “rate was 180ug/min, WBC 0 ~ 3/HP, granule tube type a little, blood BUN and Cr _were normal. Question: (1) What is diagnosis of this patient? (2) Which is period of this patient? (3) What kind of substance should be reduced in dietary therapy? Diabetic nephropathy 34- ~4e:nicroalbuminuria (early nephropathy) 24 Protein 23 3. 6 points) An 18-year-old male patient presented with heavy edema for a week. Physical examination: vital sings all right. She had a frog belly with no tenderness or rebound tendemess. Shifting dullness was positive. There were worse edemas over both legs. pe eheey Laboratory examination: Routine exam of her uriné revealed protein +++, RBC 1~3/HP, WBC(-). Proteinuria 8.8g/24h. Serum albumin 14.6g/L. Serum creatinine S6ymol/L. BUN 7.3mmol/L. Total cholesterol 1.2mmol/L. Blood urine test showed that, HbI40.5g/L, WBC N65%, BPCIS6*109/L. ANAC), ds- DNA(-).HBsAg (-). B ultra sound showed the size of kidney is normal. Question: (1) What is the most properly diagnosis of the patient? (2) Please write down the diagnostic bases. (3) What is the complication of this patient? Could you write out some secondary renal diseases we need to identify? ()Primary Nephrotic syndrome/Nephrotic-syndrome—25)- Di i .(10 points) A 62-year-ol-d man arrives to the emergency department complaining of acute, severe precordial chest pain radiating to his arm and neck. He reports £ cling like“an elephant is standing on my chest” and states that his symptoms re a ccompanied by nausea . His chest pain began approximately 30 minutes go while he was watching television and it has not completely resolved since onset. His medical history includes hypertension, hyper of ci On examination the patient is diaphoretic and in moderate distress with the foll smia, and 50-pack/ year history arette smoking. owing vital signs: blood pressure 156/97 mmHg, pulse 113 bpm, respiratory rate 24 breaths/min, and oxygen saturation 98% on room air. He is tachycardic with normal $1 and $2 and without murmurs, rubs, or gallops. His jugular venous pressure is not elevated; he has left carotid bruit. Chest auscultation reveals faint crackles at the left base but is otherwise clear. His abdomen is protuberant but sof t and without masses. His lower extremities are without edema, He has 2+ pulses in his upper and lower extremities. An electrocardiogram (ECG) is performed and shown as following figure. Beran an esac Jn La (s Mian afl aE va, foun atone \ ALA Ve Lull Question: (1) What is the most likely diagnosis? (2) Which laboratory tests should been perform except ECG? (3) What management decision would you need to make at this time?(7 points) A 35-year-old man has had fatigue, fever, and episodes of epistaxis fo the past 3 months. On physical examination his temperature is 37.5 Laboratory studies show Hgb 6.5 g/dL, Het 27.6%,, platelet count 5,000/microliter, and WBC count 2,000/microliter. Question: (1) 4L4¢What is the likely diagnosis? List 3 diseases) (2) The peripheral blood WBC differential includes 75% promyelocytes, what is the most likely diagnosis? (3) what is the best treatment for h 6. (10 points) A male patient is 38 years old. The patient was admitted to hospital because recurrent upper abdominal pain 2 years and with hematemesis 2 day. The he had acid reflux. He had dizziness and weakness because of hematemesis . Physical examination: BP80/50mmHg, face was acute pale, Skin and sclera was not yellow. Heart rate was 110 beats / min, the rhythm was regular and without a murmur. Lung examination was normal. 6Abdomen examination was flat and soft, it was no tenderness and rebound tenderness, liver and spleen palpation was normal. Shifting dullness was negative. Questic (1) What is the most likely diagnosis in this disease 7543) (2) What needs to be done to confirm the diagnosis? (54) R11) Duodenal ulcer_and hemorrhage, hemorrhagic shock