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Why we exam the medical license ??

• The medical council of Thailand () want to


make the international standard.
Thailand Medical Licensing
• Thai National test
Examination 2008 – Basic medical sciences
(beginning in 2006)
Preclinic
– Clinical sciences (& clinical skill) Clinic
Narongkorn Saiphoklang, M.D.
Department of internal medicine
Faculty of medicine, Thammasat university • Copy from US Medical Licensing Examination
Thailand – USMLE step1
– USMLE step2 (& step2 CS)

Topics of preclinic Topic highlight of Preclinic


• General principles + 10 systems
– Normal processes basic sciences
– Abnormal processes clinical knowledge

• Suggestion for National test of Preclinic:

– Read USMLE step1:knowledge& sample questions


– Prepare for national test of clinic: USMLE step2

Remember !!
REMEMBER ! normal range
• Blood: AST,ALT, ALP,protein, albumin, globulin,
Reference range Amylase, Lipase, Ca,PO, T3, FT4, TSH, cholesterol, TG,
LDL, HDL, BUN, Cr, Na, K, Cl, HCO3, ABG, glucose,
serum osmole, uric

• Hemato: BT,PT,aPTT, ESR


CBC(Hb,Hct, wbc & diff., plt, MCV)

• CSF: pressure, cell, glucose, protein

• Urine: Spec.gravity, osmole, blood, ketone, cell, cast,


• Urine electrolytes: Na, K, Cl

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• 9. A patient being treated with clindamycin for aspiration
pneumonia develops diarrhea. The stool contains a toxin
that kills cultured epithelial cells. Stool culture grows an
anaerobic grampositive rod. The same organism is
cultured from his bedpan. Which of the following is most
likely to sterilize the bedpan?
Problem-based learning(PBL) !!!
(A) Boiling for 45 minutes
(B) Exposure to benzalkonium chloride for 1 hour
(C) Exposure to ethyl alcohol for 1 hour
(D) Exposure to saturated steam (121°C) for 15 minutes
(E) Heating in an oven at 150°C for 30 minutes

Clindamycin Vs Diarrhea
• side effect of long duration use = Antibiotic-associated
diarrhea & colitis, pseudomembranous colitis
(C.difficile)

• Clostridium difficile
– Anaerobic GPB
– toxins A & B  diarrhea
– spores are resistant to heat, acid & ATB
– Saturated stream kills spores
– Rx: Metronidazole or Vancomycin pseudomembranous colitis

• 10. An 18-year-old woman has gastroenteritis with Acid-base mechanism


nausea and vomiting and is able to ingest only small
amounts of water. After 3 days, she develops light-
headedness, especially when sitting or standing. Arterial • pH(H+), pCO2 , HCO-3
blood gas analysis is most likely to show which of the
following sets of values?
• Buffer system: HCO-3 , protein, bone
PCO2 HCO3−
pH (mm Hg) (mEq/L) • Respiratory abnormality :CO2  Lung(1st)
(A) 7.30 28 15
• Metabolic abnormality: HCO-3  kidney
(B) 7.30 55 27
(C) 7.40 40 24
(D) 7.50 30 22
(E) 7.50 47 35

2
REMEMBER ! Acid-base disturbance
H+, • If ↑ CO2 (Repiratory acidosis)  Lung RR ↑ & HCO-3 ↑(kidney)

Metabolic Acidosis/Alkalosis = HCO3- ↓ CO2 (Repiratory alkalosis)  Lung RR ↓ & HCO-3 ↓ (kidney)

• If ↓ HCO-3 (Metabolic acidosis)  ↓CO2 by Lung RR ↑ & HCO-3 ↑ (kidney)


↑ HCO-3 (Metabolic alkalosis) ↑ CO2 by Lung RR↓ & HCO-3 ↓ (kidney)
disturbances of HCO3 • Vomiting, dehydration = Metabolic alkalosis
• Diarrhea= Metabolic acidosis, normal anion gap
• Sepsis, infection, RF= Metabolic acidosis, wide anion gap
• DKA = Metabolic acidosis, wide anion gap
• COPD= Respiratory acidosis

Respiratory Acidosis/Alkalosis= PCO2 • Hyperventilation = Respiratory alkalosis

• Anion gap= Na - Cl - HCO-3 (normal 8 - 14)

disturbances of PaCO2 • ABG: pH 7.4± 0.05, pCO2 = 40, HCO-3=24, pO2 = 80-100

Compensation Formulas for


Interpretation of ABG
Simple Acid-
Acid-Base Disorders
• 1st: pH
 acidosis/alkalosis - Metabolic acidosis PaCO2 = 1.5 (HCO3) + 8 + 2
• 2nd: PCO2 / HCO3− ↑,↓ - Metabolic alkalosis PaCO2 = 0.9 (HCO3) + 9+
9+ 20
or ∆↑ PaCO2 = 0.6 ∆↑ (HCO3)
• 3rd: Pure(compensate) /Mixed disorder
- Ac. respiratory acidosis ∆ HCO3 = 0.1 (∆
(∆ PaCO2)
pH
- Chr.
Chr. respiratory acidosis ∆ HCO3 = 0.35 (∆
(∆ PaCO2)
Acidosis Alkalosis - Ac. respiratory alkalosis ∆ HCO3 = 0.2 (∆
(∆ PaCO2)
↑CO2 ↓HCO3− ↓CO2 ↑HCO3− - Chr.
Chr. respiratory alkalosis ∆ HCO3 = 0.5 (∆
(∆ PaCO2)

Res.acid Met.acid Res.Alkalo Met.Alkalo

Pure(compensate) / Mixed disorder from the normal value of 40 mmHg for PaCO2 or 24 mEq/L for HCO3-

• 10. An 18-year-old woman has gastroenteritis with


nausea and vomiting and is able to ingest only small
amounts of water. After 3 days, she develops light- • 45. A 31-year-old man with a history of epilepsy has a major motor (grand
headedness, especially when sitting or standing. Arterial mal) seizure. Laboratory values obtained immediately after cessation of the
seizure include:
blood gas analysis is most likely to show which of the Arterial blood
following sets of values? pH 7.14
PCO2 35 mm Hg
Plasma
PCO2 HCO3− Na+ 140 mEq/L
1.pH:
pHalkalosis (mm Hg) (mEq/L) Cl− 98 mEq/L
K+ 4.0 mEq/L
(A) 2.HCO 3↑= Metabolic
7.30 28 15 HCO3− 17 mEq/L
(B) 3.Pure(compensate)
7.30 55 27 Which of the following is the most likely acid base disturbance?
↑ PCO2 =(0.9 x 35) + 940
±20 = 20.5 to 60.5 (A) High anion gap metabolic acidosis
(C) 7.40 24 (B) High anion gap respiratory acidosis
(D) Or ∆↑ PaCO2 = 0.6 ∆↑
7.50 30(10)=6 (+40)=4622 (C) Low anion gap metabolic acidosis
(D) Normal anion gap metabolic acidosis
(E) 7.50 47 35 (E) Normal anion gap respiratory acidosis

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• 13. An 18-year-old female athlete reports easy fatigability and weakness.
Physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 141 mEq/L
• 45. A 31-year-old man with a history of epilepsy has a major motor (grand Cl− 85 mEq/L
mal) seizure. Laboratory values obtained immediately after cessation of the K+ 2.1 mEq/L
seizure include: HCO3− 35 mEq/L
Arterial blood Urine
pH 7.14 Na+ 80 mEq/24 h
PCO2 35 mm Hg 1.pH:acidosis K+ 170 mEq/24 h
Plasma
2.HCO3− ↓ = Metabolic
Na+ 140 mEq/L Which of the following is the most likely diagnosis?
Cl− 98 mEq/L 3.Pure(compensate)  PCO2↑ (A) Aldosterone deficiency
K+ 4.0 mEq/L (B) Anxiety reaction with hyperventilation
HCO3− 17 mEq/L (C) Diabetic ketoacidosis
Which of the following is the most likely acid base disturbance? (D) Ingestion of anabolic steroids
(A) High anion gap metabolic acidosis Calculated PaCO2 = 1.5(HCO3) + 8 ± 2 (E) Surreptitious use of diuretics
(B) High anion gap respiratory acidosis = 31.5 to 35.5
(C) Low anion gap metabolic acidosis
Anion gap = Na - Cl - HCO3 = 25
(D) Normal anion gap metabolic acidosis
(E) Normal anion gap respiratory acidosis

Hypokalemia • 13. An 18-year-old female athlete reports easy fatigability and weakness.
[acid-base, ECF volume, hypertension, urine K+] Physical examination shows no abnormalities. Laboratory studies show:
Serum
Na+ 141 mEq/L
Metabolic acidosis Normal acid-base Metabolic alkalosis Cl− 85 mEq/L
K+ 2.1 mEq/L
HCO3− 35 mEq/L Serum K 3.5-5.0, HCO3 24
urine K+ low high urine K+ low high
Urine
Na+ 80 mEq/24 h Urine Na<20, K<20
K+ 170 mEq/24 h
Lower GI loss Renal loss Intracellular shift • loss gastric secretion (late)
• diarrhea • RTA • insulin (urine pH<5.5, low urine Cl-) Which of the following is the most likely diagnosis?
• laxative abuse • DKA • β-agonist • remote diuretic use
• villous adenoma • acetazolamide • ↑ extracellular pH (thiazide, loop diuretics) (A) Aldosterone deficiency Aldosterone Na reabsorp, K excretion
• thyrotoxicosis • laxative abuse (B) Anxiety reaction with hyperventilation Res.alkalosis pCO2↓, HCO3 ↓
• periodic paralysis
• ↑ cell production (C) Diabetic ketoacidosis Met.acidosis HCO3↓
• intoxication (D) Ingestion of anabolic steroids Testosterone inhibit Na reabsorp
• other drugs (see text)
normotension hypertension (E) Surreptitious use of diuretics
• loss gastric secretion (early) • mineralocorticoid
(urine pH>7, low urine Cl-) excess
• recent diuretic use
(thiazide, loop diuretics)
• Bartter’s syndrome
• Gitelman’s syndrome
• Mg2+ depletion

Hemoconcentration,
• 19. Hospital discharge of a 75-year-old man is delayed due to unavailability
Hypernatremia BUN & Cr mild ↑
of a bed in a nursing home. He is bedridden and unable to attend to his loss of free water
personal needs. During a 3-day period, his pulse increases from 82/min to
125/min, and blood pressure decreases from 124/72 mm Hg to 100/55
mm Hg. Laboratory values include:
Day 1 Day 3 Skin Renal GI Hypothalamus Administration
Hemoglobin 16.4 g/dL 18.4 g/dL
Serum Urea nitrogen 18 mg/dL 56 mg/dL
Glucose 100 mg/dL 89 mg/dL
Na+ 135 mEq/L 151 mEq/L -Sweating -DI -osmotic diarrhea -1 hypodipsia -IV.oral Nacl,
-Burn -glucose, mannitol lactulose -resat osmostat NaHCO3
Creatinine 1.1 mg/dL 1.2 mg/dL

Which of the following is the most likely diagnosis?


(A) Acute renal failure
(B) Dehydration
(C) Diabetic ketoacidosis
(D) Gastrointestinal hemorrhage
(E) Syndrome of inappropriate ADH (vasopressin)

4
• 19. Hospital discharge of a 75-year-old man is delayed due to unavailability
HypoNa of a bed in a nursing home. He is bedridden and unable to attend to his
personal needs. During a 3-day period, his pulse increases from 82/min to
125/min, and blood pressure decreases from 124/72 mm Hg to 100/55
True Hyponatremia mm Hg. Laboratory values include:
(exclude hyperglycemia, hyperlipidemia) Day 1 Day 3
Hemoglobin 16.4 g/dL 18.4 g/dL
Serum Urea nitrogen 18 mg/dL 56 mg/dL
Assess ECF volume status Glucose 100 mg/dL 89 mg/dL
Na+ 135 mEq/L 151 mEq/L
Creatinine 1.1 mg/dL 1.2 mg/dL
Hypovolemia Normovolemia Hypervolemia Which of the following is the most likely diagnosis?
TBW ↓ , TBNa↓↓ TBW ↑ , TBNa↔ TBW↑↑ , TBNa↑ (A) Acute renal failure Met.acidosis, Na ↓
(B) Dehydration
(C) Diabetic ketoacidosis Met.acidosis, BS>250-300 mg/dL
(D) Gastrointestinal hemorrhage Alkalosis/acidosis+ Hb↓
(E) Syndrome of inappropriate ADH (vasopressin)
UNa >20 <20 > 20 > 20 < 20 ADH↑--Na↓

Renal Extrarenal SIADH Renal Edematous


loss loss Endocrinopathy failure State
(thyroid↓, cortisol↓) ( nephrotic synd,
cirrhosis, CHF)

• 25. A 45-year-old man has a left ventricular ejection fraction of 25%


(N>55%) with diffuse hypokinesis. He has a sedentary life-style. He eats red
meat up to 6 times weekly and drinks 4 alcoholic beverages daily. He is 185
cm (6 ft 1 in) tall and weighs 86 kg (190 lb); BMI is 25 kg/m2. His blood
pressure is 90/60 mm Hg. Coronary arteriography shows no evidence of • 27. A 74-year-old man with urinary frequency and urgency has benign
atherosclerosis. To prevent further heart damage, which of the following is prostatic hyperplasia. He refuses operative intervention but agrees to a trial
the most appropriate recommendation? of finasteride therapy. During the trial, synthesis of which of the following
substances is most likely to be inhibited?

(A) Aerobic exercise program (A) Androstenedione


(B) Avoidance of alcohol (B) Dihydrotestosterone
(C) Ingestion of more vegetables and decrease in red meat intake (C) Estradiol
(D) Isometric/weight-training exercise program (D) Estrone
(E) Weight loss (E) Testosterone

BPH
• 5-Reductase Inhibitor = Finasteride • 29. A 30-year-old woman with a 1-week history of severe diarrhea feels
dizzy when she stands up. Blood pressure (while supine) is 112/76 mm Hg
block testosterone →Dihydrotestosterone with a pulse of 88/min; blood pressure (while standing) is 80/60 mmHg with
a pulse of 120/min. In addition to controlling her diarrhea, the most
appropriate initial therapy is intravenous administration of which of the
• α-1-adrenergic antagonist = terazosin, doxazosin, following?
tamsulosin,alfuzosin, & Prazosin  block bladder outlet obstruction
(A) Desmopressin
(B) 5% Dextrose in water
(C) Fresh frozen plasma
(D) 0.9% Saline
(E) Methoxamine
(F) Verapamil

5
Blood pressure Shock
PCWP or CVP

Afterload PVR
Preload
BP
Stroke volume

Contractibility
CO

HR • Hypovolemic: blood loss, N/V, diarrhea


Ejection fraction (EF) • Cardiogenic: myocardial infarction, cardiac tamponade, arrhythmia
• Distributive: septic, anaphylaxis, adrenal insufficiency,myxedema coma
neurogenic

• Rx: Hypovolemia crystalloid1st =Isotonic saline, Ringer lactate sol.


colloid 2nd = blood, albumin, starch, acetar sol.

• 30. A 60-year-old man has a 5-day history of productive cough and


shortness of breath with exertion. In addition to a normal left lung base,
Stethoscope
examination of the chest in the area of the right lung base shows:
Breath sounds bronchial
Percussion note dull
Tactile fremitus increased
Adventitious sounds crackles

Which of the following is the most likely diagnosis?


Bell -Low pitch sound
(A) Asthmatic bronchitis
(B) Bullous emphysema Diaphragm- High pitch
(C) Chronic bronchitis
(D) Congestive heart failure
(E) Lobar pneumonia
(F) Pleural effusion
(G) Pleuritis
(H) Pneumothorax
(I) Pulmonary embolism

6
Rales = crackles = crepitations

7
8
Physical signs in Chest disorders

Condition Trachea percuss BS Fremitus Ad.sound

Normal mid resonance Ves. N none

Lobar mid dull Bron. increased crakles

Atelectasis shift to dull absent absent none


involved

Pl.effusion shift to dull decrease decrease none


opposite

Physical signs in Chest disorders • 30. A 60-year-old man has a 5-day history of productive cough and
shortness of breath with exertion. In addition to a normal left lung base,
examination of the chest in the area of the right lung base shows:
Breath sounds bronchial
Condition Trachea percuss BS Fremitus Ad.sound Percussion note dull
Tactile fremitus increased
Adventitious sounds crackles
Pn.Tx. Shift to HyperReso. decrease decrease none
opposite Which of the following is the most likely diagnosis?
(A) Asthmatic bronchitis
Emphysema mid HyperReso. decrease decrease none (B) Bullous emphysema
(diffuse) (C) Chronic bronchitis
(D) Congestive heart failure
Asthma mid N or obscure decrease Wheezes (E) Lobar pneumonia
HyperReso. (F) Pleural effusion
(G) Pleuritis
(H) Pneumothorax
CHF mid N or dull N or N or Crakles
(I) Pulmonary embolism
decrease decrease ±Wheezes
(diffuse)

9
Warfarin & drug interaction
• 31. Warfarin is administered to a 56-year-old man following placement of a
prosthetic cardiac valve. The warfarin dosage is adjusted to maintain an • ↓ Warfarin: griseofulvin, macrolide ATB,
INR of 2.5. Subsequently, trimethoprim-sulfamethoxazole therapy is begun
for a recurring urinary tract infection. metronidazole, rifampicin, sulfasalazine, vit.K
In addition to monitoring prothrombin time, which of the following
actions should the physician take to maintain adequate anticoagulation?

(A) Begin therapy with vitamin K


• ↑ Warfarin : allopurinol, amiodarone ,Azole
(B) Increase the dosage of warfarin antifungal, antiplatelet, NSAID, cephalosporins,
(C) Make no alterations in the dosage of warfarin
(D) Decrease the dosage of warfarin statin, phenytoin, proton pump inhibitor,
(E) Stop the warfarin and change to low dose aspirin sulfonamide e.g. Co-trimoxazole

• Monitor: PT, INR 2.0-3.0

• 31. Warfarin is administered to a 56-year-old man following placement of a • 37. Investigators are studying the use of a new laboratory test to identify
prosthetic cardiac valve. The warfarin dosage is adjusted to maintain an patients with a particular disease. The table below summarizes the results
INR of 2.5. Subsequently, trimethoprim-sulfamethoxazole therapy is begun
for a recurring urinary tract infection. of initial research involving 200 subjects
In addition to monitoring prothrombin time, which of the following
actions should the physician take to maintain adequate anticoagulation?

(A) Begin therapy with vitamin K


(B) Increase the dosage of warfarin
(C) Make no alterations in the dosage of warfarin Which of the following is the approximate sensitivity of a positive test result?
(D) Decrease the dosage of warfarin (A) 0.30
(E) Stop the warfarin and change to low dose aspirin (B) 0.33
(C) 0.60
(D) 0.67
(E) 0.75

Sensitivity & Specificity of the test


• Sensitivity = a/(a+c) Disease Normal • 37. Investigators are studying the use of a new laboratory test to identify
  !"# $%& patients with a particular disease. The table below summarizes the results
• Specificity = d/(b+d) Test a b of initial research involving 200 subjects
  !'&"# $%& positive
(!%)*&"*+"#*,
b= false positive
Test c d
c= false negative negative

• Positive predictive value(PPV) = a/(a+b) Which of the following is the approximate sensitivity of a positive test result?
#&*+!*+"# &-)*% (A) 0.30
• Negative predictive value(NPV) = d/(c+d) (B) 0.33 Sensitivity= 60/(60+20)=0.75
#&*+!'&' "# &-)*%
(C) 0.60 Specificity= 80/(80+40)=0.67
(D) 0.67
PPV= 60/(60+40)=0.60
• Prevalence= (a+c)/(a+b+c+d) (E) 0.75
• Accuracy =(a+d)/(a+b+c+d) NPV= 80/(80+20)=0.80

10
• 39. An inexpensive screening test for a disease is available through • 38. A cardiac catheterization is done in a healthy person. The blood sample
analysis of venous blood. The distributions of blood concentrations for withdrawn from the catheter shows 60% oxygen saturation, and the
persons with and without the disease are depicted in the graph. The pressure recording shows oscillations from a maximum of 26 mm Hg to a
disease is irreversible and fatal if not discovered minimum of 14 mm Hg.
A= false and treated
positive↑ ↑ ↑ early. Which of
the following letters represents the most appropriate cutoff point between The catheter tip was located in which of the following areas?
normal and abnormal? B= sensitivity↑ ↑ ↑, false positive ↑
C= sensitivity↑ , false negative ↑ (A) Ductus arteriosus
D= specificity ↑ ↑, false negative ↑ ↑ (B) Foramen ovale
(C) Left atrium
E= specificity ↑ ↑ ↑ , false negative ↑ ↑ ↑
(D) Pulmonary artery
(E) Right atrium

Normal heart blood flow

95% Pressure 30/15 mmHg

70%

95% Pressure 10 mmHg

O2 70%
95%
70%
Pressure 5 mmHg
LVEDP (=PCWP) 10 mmHg

Pressure 25/5 mm/Hg

Swan Ganz catheter


• 38. A cardiac catheterization is done in a healthy person. The blood sample
withdrawn from the catheter shows 60% oxygen saturation, and the
pressure recording shows oscillations from a maximum of 26 mm Hg to a
Pulm.capillary wedge pressure minimum of 14 mm Hg.
(PCWP) = LVEDP The catheter tip was located in which of the following areas?

(A) Ductus arteriosus


(B) Foramen ovale
(C) Left atrium
(D) Pulmonary artery
(E) Right atrium

11
Hyperthyroidism
• 43. A 66-year-old man has become increasingly short-tempered with his
wife. He has diarrhea, weight loss, and weakness in the proximal muscles. • high T3 &T4, low TSH = 1ºHyperthyroid
He has atrial fibrillation and tachycardia.
Which of the following is the most likely diagnosis? • high T3 &T4, high TSH = 2ºHyperthyroid
(A) Congestive heart failure
(B) Cushing syndrome
• S/S …Systemic organ symptoms & signs
(C) Hyperthyroidism
(D) Mitral valve prolapse
(E) Pheochromocytoma

Clinical manifestation of Hyperthyroidism Graves’ disease


• Autoantibody to TSH-Receptor
• Clinical S/S of hyperthyroidism
• Lab: TFT, anti-MPO(anti-microsomal) , anti-thyroglobulin
• Exophthalmos, goiter, pretibial myxedema

Rx:Drug; PTU,methimazole
I131 ablation
Surgery

Normal
Enlarged gland

Hashimoto thyroiditis
• 43. A 66-year-old man has become increasingly short-tempered with his
• Chronic lymphocytic thyroiditis wife. He has diarrhea, weight loss, and weakness in the proximal muscles.
He has atrial fibrillation and tachycardia.
• Autoimmune disease Which of the following is the most likely diagnosis?

• Clinical: hyperthyroid  Euthyroid hypothyroid (A) Congestive heart failure


↑cortisol: obesity, prox.muscle weaknes
(B) Cushing syndrome
• Lab: TFT, High titer Antibody (C) Hyperthyroidism
(D) Mitral valve prolapse
anti-MPO(anti-microsomal) (E) Pheochromocytoma ↑ cathecolamine(E, NE): triad ‘’headache+

anti-thyroglobulin tachycardia+ sweating’’ + HT

12
Valvular heart disease
& Congenital heart disease
• 53. A 28-year-old man who had rheumatic fever as a child comes to the
physician's office because of fatigue and dyspnea for the past 4 months. An • Mitral regurgitation: Pansystolic murmur
early diastolic sound followed by a low-pitched rumbling decrescendo
diastolic murmur is present 4 cm left of the sternal border in the fourth • Aortic stenosis: Systolic ejection m.
intercostal space and is heard best with the patient in the left lateral
decubitus position. • Aortic regurgitation: Diastolic blowing m.
Which of the following valve defects is most likely in this patient?
• Mitral stenosis: Diastolic rumbling m.
(A) Aortic regurgitation 
‘M.R.-Pan, AS-Ject, AR-blow, MiSs-rum’
(B) Aortic stenosis
(C) Mitral regurgitation
(D) Mitral stenosis
(E) Pulmonic regurgitation
(F) Pulmonic stenosis
(G) Tricuspid regurgitation
• ASD: Fixed split S2
(H) Tricuspid stenos • PDA: continuous / machinery murmur
• VSD: Pansystolic m. MS

• 53. A 28-year-old man who had rheumatic fever as a child comes to the • 56. A 68-year-old man has had low back pain over the past 2 months.
physician's office because of fatigue and dyspnea for the past 4 months. An Laboratory studies show a normochromic, normocytic anemia and
early diastolic sound followed by a low-pitched rumbling decrescendo azotemia. Serum and urine calcium concentrations are abnormally
diastolic murmur is present 4 cm left of the sternal border in the fourth increased, and urinalysis shows excessive protein (4+) and proteinaceous
intercostal space and is heard best with the patient in the left lateral casts.
decubitus position. Bone marrow examination is most likely to show uncontrolled
Which of the following valve defects is most likely in this patient? proliferation of which of the following cells?

(A) Aortic regurgitation (A) Basophils


(B) Aortic stenosis (B) Lymphocytes
(C) Mitral regurgitation (C) Macrophages
(D) Mitral stenosis
Rheumatic heart disease = MS is most common (D) Plasma cells
(E) Pulmonic regurgitation (E) Reticulocytes
(F) Pulmonic stenosis
(G) Tricuspid regurgitation
(H) Tricuspid stenos

Multiple myeloma (MM) MM


Osteolytic lesion on skull film
• clonal proliferation of plasma cells in BM
producing monoclonal Immunoglobulin

• monoclonal gammopathy (serum protein: immunoglobulin↑,


Bence Jones proteinuria)
Rouleaux formation in PBS

• hypercalcemia, renal failure, anemia,& bone


pain (osteolytic lesion)

‘CRAB: Ca,Renal,Anemia,Bone’

Plasma cells in BM

13
Common cancer with hypercalcemia
• 56. A 68-year-old man has had low back pain over the past 2 months.
• Breast Laboratory studies show a normochromic, normocytic anemia and
azotemia. Serum and urine calcium concentrations are abnormally
increased, and urinalysis shows excessive protein (4+) and proteinaceous
• Lung ( SCC, Large cell CA ) casts.
Bone marrow examination is most likely to show uncontrolled
• Kidney proliferation of which of the following cells?

• Ovary (A) Basophils


(B) Lymphocytes
• Multiple Myeloma (C) Macrophages
(D) Plasma cells
• T-cell Lymphoma (E) Reticulocytes

Lipoprotein disorders
• 59. A 20-year-old man comes to the physician's office for a scheduled
health maintenance examination. His father died of a myocardial infarction
at age 55 years. Physical examination shows a tendon xanthoma on the
elbow. His serum total cholesterol concentration is 360 mg/dL.
A mutation is most likely to be found in which of the following genes?

(A) apoA2
(B) apoC2
(C) apoε4
(D) LDL receptor
(E) VLDL receptor

Familial hypercholesterolemia Lipoproteins metabolism


• autosomal disorder
• apo B/E (LDL) receptor mutation
• LDL-C  oxizided LDL fatty streak/fibrous
plaque in vessel  Atheroscleosis
• CAD(MI),CVD(ischemic stroke),PVD
• tendon xanthoma

TG=triglycerides; chol=cholesterol; B-48, B-100, C-II & E =specific apolipoproteins;


LPL=lipoprotein lipase; HL=hepatic lipase; LDLR=LDL receptor; LRP=LDLR-related
protein

14
• 59. A 20-year-old man comes to the physician's office for a scheduled
health maintenance examination. His father died of a myocardial infarction
at age 55 years. Physical examination shows a tendon xanthoma on the
elbow. His serum total cholesterol concentration is 360 mg/dL.
A mutation is most likely to be found in which of the following genes?

(A) apoA2 Total cholesterol <200 mg/dL


(B) apoC2
(C) apoε4 LDL-C <100 mg/dL in MI
(D) LDL receptor
(E) VLDL receptor

HypoNa
• 60. A 74-year-old man has had confusion for 2 weeks. He has smoked two True Hyponatremia
packs of cigarettes daily for 50 years. An x-ray of the chest shows a 5-cm (exclude hyperglycemia, hyperlipidemia)
mass in the lung. Laboratory studies of serum show:
Na+ 110 mEq/L
Cl− 72 mEq/L Assess ECF volume status
K+ 4.5 mEq/L
HCO3− 30 mEq/L
Glucose 200 mg/dL Hypovolemia Normovolemia Hypervolemia
Creatinine 1.4 mg/dL
Which of the following is the most likely cause of these findings? TBW ↓ , TBNa↓↓ TBW ↑ , TBNa↔ TBW↑↑ , TBNa↑

(A) Adenocarcinoma of the lung


(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroid gland UNa >20 <20 > 20 > 20 < 20
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung Renal Extrarenal SIADH Renal Edematous
loss loss Endocrinopathy failure State
(thyroid, cortisol) ( nephrotic synd,
cirrhosis)

Syndrome of inappropriate ADH


Paraneoplastic Syndrome associated SCLC
(SIADH)
• ↑ADH water retention & [Na]↓, [uric]↓, serum osmole ↓,
urine osmole↑ • SIADH most common
• Hypercoagulable state common
• Causes:
1.Brain:tumor,infection • Ectopic ACTH uncommon
2.Lung: tumor (small cell;SCLC), Infection
(50% Ectopic Cushing’s syndrome)
3.Cancer(paraneoplastic syndrome): bronchus,
duodenum, pancreas, thymus • Neuro
4.Drug: antipsychotic, carbamazepine, chlorpropamide,
cyclophosphamide Eaton-Lambert (Myasthenic) Syndrome ***
• Rx: restrict free water

15
• 60. A 74-year-old man has had confusion for 2 weeks. He has smoked two • 62. A previously healthy, tall, and slender 19-yearold woman has the
packs of cigarettes daily for 50 years. An x-ray of the chest shows a 5-cm sudden onset of right-sided chest pain followed by progressive dyspnea.
mass in the lung. Laboratory studies of serum show: Ten hours later, an x-ray of the chest shows a collapsed right lung and air in
Na+ 110 mEq/L the right pleural space.
Cl− 72 mEq/L Which of the following is the most likely underlying condition?
K+ 4.5 mEq/L
HCO3− 30 mEq/L
(A) Bronchiectasis
Glucose 200 mg/dL
Creatinine 1.4 mg/dL (B) Lung abscess
Which of the following is the most likely cause of these findings? (C) Panacinar emphysema
(D) Pulmonary sequestration
(A) Adenocarcinoma of the lung (E) Subpleural blebs
(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroid gland
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung

Primary spontaneous pneumothorax

• 62. A previously healthy, tall, and slender 19-yearold woman has the
• Younger & tall sudden onset of right-sided chest pain followed by progressive dyspnea.
Ten hours later, an x-ray of the chest shows a collapsed right lung and air in
• ± smoking, family history, Marfan syndrome, the right pleural space.
homocystinuria, & thoracic endometriosis Which of the following is the most likely underlying condition?

(A) Bronchiectasis chronic productive cough


(B) Lung abscess productive cough + subacute fever
• rupture of subpleural bleb (C) Panacinar emphysema chronic dyspnea+ Hx of heavy smoking
(D) Pulmonary sequestration
chronic/recurrent cough
(E) Subpleural blebs
• Rx: tube thoracostomy (ICD)

Helicobacter pylori
• 64. A 46-year-old man has a 4-week history of epigastric pain; test of stool
is positive for occult blood. Examination of tissue obtained on biopsy of the
gastric antrum shows curved bacterial rods.
Which of the following additional findings is most likely?
Urease Test / CLO test®
(A) Achlorhydria
(B) Antiparietal cell antibodies
(C) Cholecystitis with antral seeding
(D) Immunodeficiency state
(E) Increased urease activity in the antrum urease

Novel Prize2005

Peptic ulcer & Gastric cancer

16
• 64. A 46-year-old man has a 4-week history of epigastric pain; test of stool • 65. A 52-year-old man with recently diagnosed type 2 diabetes mellitus
is positive for occult blood. Examination of tissue obtained on biopsy of the comes to the physician for a follow-up examination. Physical examination
gastric antrum shows curved bacterial rods. shows no abnormalities. Laboratory studies show an increased hemoglobin
Which of the following additional findings is most likely? A1c despite patient compliance with diet and exercise recommendations.
Treatment with a sulfonylurea is started.
(A) Achlorhydria Which of the following is most likely to occur in this patient?
(B) Antiparietal cell antibodies
(C) Cholecystitis with antral seeding (A) Decreased entry of glucose into the muscle cells
(D) Immunodeficiency state (B) Decreased production of glucose from the liver
(E) Increased urease activity in the antrum (C) Decreased secretion of insulin from the pancreas
(D) Decreased speed of carbohydrate absorption from the intestines
(E) Increased entry of glucose into the muscle cells
(F) Increased production of glucose from the liver
(G) Increased secretion of insulin from the pancreas
(H) Increased speed of carbohydrate absorption from the intestines

Insulin secretagogue Insulin sensitizer


• +pancreatic ß-cells • ↓hepatic glucose output
• Sulfonylurea: glibenclamide, glipizide, • ↑glucose utilization in peripheral tissues
gliclazide, glimepiride (muscle & liver) & antilipolysis

• Glinide: repaglinide,& nateglinide • Biguanides: metformin

• Thiazolidinediones (glitazones):
rosiglitazone, pioglitazone

Other antidiabetic drugs


• 65. A 52-year-old man with recently diagnosed type 2 diabetes mellitus
• Glucosidase inhibitors: acarbose, comes to the physician for a follow-up examination. Physical examination
shows no abnormalities. Laboratory studies show an increased hemoglobin
voglibose A1c despite patient compliance with diet and exercise recommendations.
Treatment with a sulfonylurea is started.
Which of the following is most likely to occur in this patient?

(A) Decreased entry of glucose into the muscle cells


• Insulin (B) Decreased production of glucose from the liver
(C) Decreased secretion of insulin from the pancreas
(D) Decreased speed of carbohydrate absorption from the intestines
(E) Increased entry of glucose into the muscle cells
• New novel: Incretin (F) Increased production of glucose from the liver
(G) Increased secretion of insulin from the pancreas
(+pancreatic ß-cells & inhibit glucagon) (H) Increased speed of carbohydrate absorption from the intestines

17
Neutropenia
• 67. A 51-year-old woman with cancer is being treated with a hematopoietic
growth factor. Leukocyte differentials before and after treatment are shown: • post-chemotherapy for cancer
Before Treatment After Treatment • WBC↓: Neutrophil
Leukocyte count 1000/mm3 10,000/mm3
Eosinophils 1% 1% • Rx: G-CSF
Lymphocytes 90% 9%
Neutrophils 9% 90%
The growth factor is most likely to be which of the following?

(A) Granulocyte colony-stimulating factor


(B) Transforming growth factor-β
(C) Interleukin-6 (IL-6)
(D) IL-8
(E) Macrophage colony-stimulating factor

• 67. A 51-year-old woman with cancer is being treated with a hematopoietic • 70. A 30-year-old man comes to the clinic because of a painful ulcer on his
growth factor. Leukocyte differentials before and after treatment are shown: penis for the past week. He has had multiple sexual partners, including
commercial sex workers. Physical examination shows lymphadenopathy in
Before Treatment After Treatment the inguinal region and a 1-cm tender ulcer with no induration located on the
frenulum. A culture of the ulcer grows colonies on supplemented chocolate
Leukocyte count 1000/mm3 10,000/mm3 agar. A Gram stain of the colonies shows gram negative coccobacilli. Which
Eosinophils 1% 1% of the following is the most likely causal organism?
Lymphocytes 90% 9%
Neutrophils 9% 90% (A) Haemophilus ducreyi
The growth factor is most likely to be which of the following? (B) Herpes simplex virus
(C) Neisseria gonorrhoeae
(A) Granulocyte colony-stimulating factor (D) Treponema pallidum
(B) Transforming growth factor-β (E) Trichomonas vaginalis
(C) Interleukin-6 (IL-6)
(D) IL-8
(E) Macrophage colony-stimulating factor

Genital ulcer syndrome


Sexual transmitted disease Lymphogranuloma venereum

• Genital ulcer syndrome:


– HSV1&2
– primary syphilis(Treponema pallidum) Chancroid HSV: group of vesicles

– chancroid(Haemophilus ducreyi)
– lymphogranuloma venereum(Chlamydia Primary syphilis
trachomatis)
• Chancroid: H. ducreyi

18
• 70. A 30-year-old man comes to the clinic because of a painful ulcer on his • 72. A 25-year-old woman has a 3-day history of vomiting and diarrhea. She
penis for the past week. He has had multiple sexual partners, including has postural hypotension and poor tissue turgor. Her serum sodium
commercial sex workers. Physical examination shows lymphadenopathy in concentration is 130 mEq/L.
the inguinal region and a 1-cm tender ulcer with no induration located on the
frenulum. A culture of the ulcer grows colonies on supplemented chocolate Which of the following findings is most likely?
agar. A Gram stain of the colonies shows gram negative coccobacilli. Which
of the following is the most likely causal organism? (A) Decreased serum aldosterone concentration
(B) Increased serum atrial natriuretic peptide concentration
(A) Haemophilus ducreyi
(B) Herpes simplex virus (C) Increased effective circulating volume
(C) Neisseria gonorrhoeae (D) Increased serum ADH (vasopressin) concentration
(D) Treponema pallidum (E) Urine osmolality less than serum osmolality
(E) Trichomonas vaginalis

Hypovolemic hypoNa  ↑Aldosterone & ↑ADH

• 73. A 40-year-old man with a 20-year history of alcohol abuse is brought to


the hospital by his friends because he was difficult to rouse. He ate a large
meal several hours ago. He is emaciated and lethargic. Examination shows
severely restricted horizontal eye movements and ataxia of both upper
extremities.
The most likely cause of these findings is a deficiency of which of the
Break !!! following nutrients?

(A) Folic acid


(B) Vitamin A
(C) Vitamin B1 (thiamine)
(D) Vitamin B6 (pyridoxine)
(E) Vitamin B12 (cobalamin)

Wernicke-Korsakoff syndrome
• 73. A 40-year-old man with a 20-year history of alcohol abuse is brought to
• chronic alcoholism, anorexia nervosa the hospital by his friends because he was difficult to rouse. He ate a large
meal several hours ago. He is emaciated and lethargic. Examination shows
severely restricted horizontal eye movements and ataxia of both upper
• thiamine (vitamin B1) deficiency extremities.
The most likely cause of these findings is a deficiency of which of the
• Tiad: ‘dementia, ophthalmoplegia, ataxia’ following nutrients?
Megaloblastic anemia
• Beri-beri: cardiac(CHF), nerve (A) Folic acid
(B) Vitamin A Visual impairement
(numbness) (C) Vitamin B1 (thiamine)
(D) Vitamin B6 (pyridoxine) Peripheral neuropathy
(E) Vitamin B12 (cobalamin)
Megaloblastic anemia &
peripheral neuropathy

19
Infection in Organ transplantation

• 74. Three weeks after a renal transplant, a patient develops fever and
leukopenia, followed by prostration and severe pulmonary and hepatic • Most common in neutropenia :
dysfunction.
CMV and TB
Which of the following is the most likely viral cause?

(A) Adenovirus type 12


(B) Coxsackievirus
(C) Cytomegalovirus
(D) Influenza virus
(E) Parvovirus B19

• 74. Three weeks after a renal transplant, a patient develops fever and • 85. An asymptomatic 50-year-old woman has hypertension. Her urinary
leukopenia, followed by prostration and severe pulmonary and hepatic excretion of catecholamines is increased. A CT scan shows a suprarenal
dysfunction. mass.
Which of the following is the most likely viral cause? Which of the following is the most likely cause?
(A) Adenovirus type 12
(B) Coxsackievirus (A) Benign neoplasm of the adrenal cortex
(C) Cytomegalovirus (B) Benign neoplasm of the adrenal medulla
(D) Influenza virus (C) Malignant neoplasm of the adrenal cortex
(E) Parvovirus B19 (D) Malignant neoplasm of the adrenal medulla
(E) Diffuse hyperplasia of the adrenal cortex
(F) Diffuse hypoplasia of the adrenal medulla

Pheochromocytoma: ‘’headache+ tachycardia+ sweating’’ + HT

Inflammatory bowel disease


• 86. A 21-year-old man has weight loss and severe intermittent bloody
diarrhea. A barium enema and colonoscopy show multiple ulcers and • Ulcerative colitis: continuous lesion
inflammatory changes extending from the rectum to the mid-transverse
colon. Biopsy specimens taken from multiple sites show acute and chronic
inflammation restricted to the mucosa. Which of the following is the most • Crohn disease: skip lesion small bowel
likely diagnosis?

(A) AIDS-associated gastroenteritis


(B) Amebiasis
(C) Crohn disease
(D) Clostridium difficile-associated colitis
(E) Escherichia coli-associated colitis
(F) Ischemic colitis
(G) Salmonella gastroenteritis
(H) Ulcerative colitis

20
• 86. A 21-year-old man has weight loss and severe intermittent bloody • 95. The unlabeled solid curve in the graph shown represents the loading
diarrhea. A barium enema and colonoscopy show multiple ulcers and behavior of normal human hemoglobin at a pH of 7.35 as a function of
inflammatory changes extending from the rectum to the mid-transverse
colon. Biopsy specimens taken from multiple sites show acute and chronic oxygen concentration. Which of the following labeled curves best represents
inflammation restricted to the mucosa. Which of the following is the most the most likely change after addition of carbon dioxide?
likely diagnosis?

(A) AIDS-associated gastroenteritis


(B) Amebiasis
(C) Crohn disease
(D) Clostridium difficile-associated colitis
(E) Escherichia coli-associated colitis
(F) Ischemic colitis
(G) Salmonella gastroenteritis
(H) Ulcerative colitis

Alkalosis, temperature↓
• 96. A 45-year-old woman who is being treated for hypertension and
hypercholesterolemia develops diffuse muscle pain and weakness. Her
serum creatine kinase activity is increased. Which of the following drugs is
most likely to have caused this clinical picture?

(A) Captopril
Acidosis, CO2, H+, temperature↑, (B) Hydrochlorothiazide
2,3 DPG (C) Lovastatin
(D) Nicotinic acid
(E) Propranolol

Statin-induced rhabdomyolysis
• 96. A 45-year-old woman who is being treated for hypertension and
• HMG co-A reductase inhibitor = statin hypercholesterolemia develops diffuse muscle pain and weakness. Her
serum creatine kinase activity is increased. Which of the following drugs is
most likely to have caused this clinical picture?

• Side effect: hepatitis, myositis(CK↑), (A) Captopril


(B) Hydrochlorothiazide
rhabdomyolysis (C) Lovastatin
(D) Nicotinic acid
(E) Propranolol

• Rhabdomyolysis: myalgia, weakness,


renal failure, CPK↑

21
SLE
Dx: 4 of 11
• 99. A 30-year-old woman being treated for hypertension has the sudden
onset of fever and malaise. Her temperature is 38.3°C (101°F), and blood
pressure is 120/80 mm Hg. Physical examination shows a malar rash,
swelling and tenderness of the wrists and knees, and a friction rub at the
lower left sternal border.
Which of the following drugs is the most likely cause of these findings?

(A) Captopril
(B) Hydralazine
(C) Minoxidil
(D) Nitroprusside
(E) Propranolol

Systemic lupus erythematosus (SLE) Drug-induced lupus


• Autoimmune disease • hydralazine
Discoid rash Malar/Butterfly rash
• procainamide, minocycline, diltiazem,
penicillamine
• isoniazid (INH)
• methyldopa, chlorpromazine
• anti-TNF: infliximab,etanercept,& IFN
• )*2 ‘DOPAMIN RASH’
Discoid, Oral ulcer, Photosensitivity, Arthritis, Malar,
Immuno, Neuro, Renal, ANA, Serositis, Hemato

• 99. A 30-year-old woman being treated for hypertension has the sudden • 111. A 55-year-old woman with breast cancer develops shortness of breath
onset of fever and malaise. Her temperature is 38.3°C (101°F), and blood and poor exercise tolerance while being treated with doxorubicin.
pressure is 120/80 mm Hg. Physical examination shows a malar rash,
swelling and tenderness of the wrists and knees, and a friction rub at the Which of the following is the most likely cause of these symptoms?
lower left sternal border.
Which of the following drugs is the most likely cause of these findings? (A) Dilated cardiomyopathy
(B) Obstructive pulmonary disease
(A) Captopril (C) Pulmonary hypertension
(B) Hydralazine (D) Restrictive cardiomyopathy
(C) Minoxidil
(E) Restrictive pulmonary disease
(D) Nitroprusside
(E) Propranolol

22
Doxorubicin induced cardiomyopathy
• 111. A 55-year-old woman with breast cancer develops shortness of breath
• Anthracycline: Doxorubicin(adriamycin®) , Idarubicin and poor exercise tolerance while being treated with doxorubicin.
• Chemotherapy for solid tumor & hematologic malignancy Which of the following is the most likely cause of these symptoms?

e.g. MM (A) Dilated cardiomyopathy


• Long term side effect: Cardiomyopathy; irreversible (B) Obstructive pulmonary disease
(C) Pulmonary hypertension
• Cumulative dose toxicity: 550 mg/m2 BSA
(D) Restrictive cardiomyopathy
(E) Restrictive pulmonary disease
Endocardial biopsy showed
loss of myofibrils and
vacuolization of
cytoplasm

Chest X-ray showed


cardiomegaly (dilated CM)

• 113. An otherwise healthy 26-year-old woman has had petechiae on her


legs during the last 24 hours. Laboratory studies show:
Hemoglobin 13.1 g/dL Thrombocytopenia
Hematocrit 39.7%
Leukocyte count 8500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5% Increased destruction Decreased production
Mean corpuscular volume 82.2 µm3
Platelet count 20,000/mm3
A peripheral blood smear shows normal red cell morphology; a bone Immune Non-immune
marrow smear shows mature megakaryocytic hyperplasia. Which of the -Autoimmune -DIC Stem cell defects Infiltrative marrow
following is the most likely diagnosis?
-ITP -Hypersplenism -Aplastic anemia disease
(A) Acute megakaryocytic leukemia -SLE -TTP, HUS -Amegakaryocytic -Myelophthisis
(B) Acute myelogenous leukemia -Evan’syndrome Thrombocytopenia -Acute leukemia
(C) Aplastic anemia -Alloimmune
(D) Immune thrombocytopenic purpura -Multiple Blood transfusion
(E) Epstein-Barr viral infection
Ineffective thrombopoiesis
(F) Papovavirus infection
(G) Thrombotic thrombocytopenic purpura
-Megaloblastic anemia
-Alcohol

Pseudothrombocytopenia
Immune Thrombocytopenic Purpura
Must be Excluded

23
Immune thrombocytopenic purpura (ITP) Immune thrombocytopenic purpura (ITP)

• Autoantibody to GPIIb/IIIa or GPIb/IX Treatment


• Acute vs Chronic • Platelet > 30,000 /mL
• Mucocutaneous bleeding • Initial treatment
• Bone marrow examination required in – Prednisolone
– The presence of other cytopenias – IVIG
– Age > 60 years – Platelet transfusion
– Failure of corticosteroid therapy • Long term treatment
• Screen for HIV infection: anti-HIV – Splenectomy: pneumococcal vaccine
– Cyclophosphamide, cyclosporin
– Danazol, rituximab, interferon, vitaminC

Thrombotic Thrombocytopenic Purpura (TTP) TTP


Criteria • Idiopathic
1.Microangiopathic • Toxin-associated
hemolytic anemia • Familial
2.Thrombocytopenia • Drugs:Quinine,
3.Neurologic :seizure, Cyclosporin A
confusion • Transplantation
4.Fever • Malignancy/ treatment
5.Renal disease(RF) • HIV
MAHA: fragmented RBC(schistocyte) • Pregnancy
Thrombocytopenia

• 113. An otherwise healthy 26-year-old woman has had petechiae on her


legs during the last 24 hours. Laboratory studies show:
Emergency Treatment Hemoglobin
Hematocrit
13.1 g/dL
39.7%
Leukocyte count 8500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
• Plasma exchange (FFP) Mean corpuscular volume 82.2 µm3
Platelet count 20,000/mm3
• Plasma infusion A peripheral blood smear shows normal red cell morphology; a bone
marrow smear shows mature megakaryocytic hyperplasia. Which of the
following is the most likely diagnosis?

(A) Acute megakaryocytic leukemia


(B) Acute myelogenous leukemia
(C) Aplastic anemia
(D) Immune thrombocytopenic purpura
(E) Epstein-Barr viral infection
(F) Papovavirus infection
(G) Thrombotic thrombocytopenic purpura

24
Stress hormones
• 114. A 25-year-old woman with previously well controlled type 1 diabetes
mellitus develops ketoacidosis 2 days after onset of a urinary tract infection. • ↑Cortisol &
The most likely cause of the ketoacidosis is decreased efficacy of insulin on
muscle, adipose tissue, and liver resulting from antagonism by which of the • ↑Norepinephrine
following hormones?

(A) Androstenedione
(B) Cortisol
(C) Glucagon
(D) Leptin • ↓Anabolic hormone:
(E) Thyroxine (T)
Insulin, Glucagon,
GH, Thyroid hormone
Sex H.(Testosterone)

• 114. A 25-year-old woman with previously well controlled type 1 diabetes • 117. A 63-year-old man with a 5-year history of congestive heart failure
mellitus develops ketoacidosis 2 days after onset of a urinary tract infection. comes to the emergency department because of a 1-month history of
The most likely cause of the ketoacidosis is decreased efficacy of insulin on fatigue and labored breathing. Evaluation shows pulmonary edema.
muscle, adipose tissue, and liver resulting from antagonism by which of the Furosemide is administered. Which of the following sets of physiologic
following hormones?
changes is most likely following administration of the drug?

(A) Androstenedione
(B) Cortisol
(C) Glucagon
(D) Leptin
(E) Thyroxine (T)

Loop diuretic

Furosemide
Na+/K+/2Cl pump

25
• 117. A 63-year-old man with a 5-year history of congestive heart failure • 120. A 75-year-old woman has increasing shortness of breath on exertion.
comes to the emergency department because of a 1-month history of Findings on physical examination are unremarkable. X-rays of the chest
show no abnormalities of the heart or lungs. Pertinent laboratory findings
fatigue and labored breathing. Evaluation shows pulmonary edema. include:
Furosemide is administered. Which of the following sets of physiologic Hematocrit 28%
changes is most likely following administration of the drug? Hemoglobin 9 g/dL
Mean corpuscular volume 70 µm3
Which of the following is the most likely basis for these findings?

(A) Acquired hemolytic anemia


(B) Chronic blood loss
(C) Folic acid deficiency
(D) β-Thalassemia minor
(E) Pernicious anemia

Criteria for anemia CAUSES OF ANEMIA


• Hb < 13 g/dL in male  Kinetic approach
• Hb < 12 g/dL in female   (
 RBC production)
• Hb < 11 g/dL in pregnant female   (  RBC destruction)
 " #"$% RBC loss
 Morphologic approach
 Microcytic anemia (+%", )
 Normocytic anemia
 Macrocytic anemia (+%./01)

ANEMIA Megaloblastic anemia

MICROCYTIC NORMOCYTIC MACROCYTIC


ANEMIA ANEMIA ANEMIA
MCV < 80 fL MCV 80-100 MCV > 100 fL

Hypersegmented PMN
Macro-ovalocyte

26
Thalassemia
Causes of Microcytic anemia
• Iron deficiency anemia
• Thalassemia
• Anemia of chronic disease (late)
• Sideroblastic anemia
• Lead poisoning

Iron metabolism
Iron def. anemia

Causes of Iron Deficiency anemia


• 120. A 75-year-old woman has increasing shortness of breath on exertion.
• Overt blood loss: traumatic hemorrhage, Findings on physical examination are unremarkable. X-rays of the chest
show no abnormalities of the heart or lungs. Pertinent laboratory findings
hematemesis, menorrhagia, gross hematuria include:
Hematocrit 28%
• Occult blood loss: GI-Peptic ulcer, cancer Hemoglobin 9 g/dL
Mean corpuscular volume 70 µm3
• Repeated blood donations Which of the following is the most likely basis for these findings?

• Diet deficiency in iron (A) Acquired hemolytic anemia


(B) Chronic blood loss
• Reduced iron absorption:bypass surgery (C) Folic acid deficiency
(D) β-Thalassemia minor
(E) Pernicious anemia
• EPO administration

27
COPD
(Chronic Obstructive Pulmonary Disease)
• 121. The incidence of chronic pulmonary disease in a community is 1.5
times greater than the national rate. If successful, which of the following • Chronic bronchitis
interventions would provide the greatest decrease in chronic pulmonary
disease in this community? • Emphysema
(A) Decrease the prevalence of cigarette smoking
(B) Decrease radon levels in homes
(C) Increase the number of people performing aerobic exercise
(D) Increase the rate of flu immunization
(E) Increase the rate of pneumococcal immunization
(F) Remove asbestos from all buildings
(G) Remove lead from all gasoline and other fuels

• 121. The incidence of chronic pulmonary disease in a community is 1.5 • 131. An otherwise healthy 55-year-old Asian American man is given
times greater than the national rate. If successful, which of the following isoniazid and vitamin B6(pyridoxine) after conversion of his PPD skin test.
interventions would provide the greatest decrease in chronic pulmonary An x-ray of the chest shows no abnormalities. Four weeks later, he
disease in this community? develops abdominal pain and jaundice. Which of the following is the most
likely explanation?
(A) Decrease the prevalence of cigarette smoking
(B) Decrease radon levels in homes
(A) Hepatic tuberculosis
(C) Increase the number of people performing aerobic exercise
(D) Increase the rate of flu immunization (B) Hepatitis B
(E) Increase the rate of pneumococcal immunization (C) Isoniazid-induced hepatitis
(F) Remove asbestos from all buildings (D) Pyridoxine-induced cholecystitis
(G) Remove lead from all gasoline and other fuels (E) Tuberculous pancreatitis

Drug induced hepatitis


• Paracetamol overdose • 131. An otherwise healthy 55-year-old Asian American man is given
• NSAIDs: ibuprofen & naproxen isoniazid and vitamin B6(pyridoxine) after conversion of his PPD skin test.
• Anti-TB: isoniazid(I), rifampicin(R), pyrazinamide(Z) An x-ray of the chest shows no abnormalities. Four weeks later, he
develops abdominal pain and jaundice. Which of the following is the most
• Amiodarone likely explanation?
• Anabolic steroids
• Alcohol (A) Hepatic tuberculosis
• Birth control pills (B) Hepatitis B
• Chlorpromazine (C) Isoniazid-induced hepatitis
• Erythromycin (D) Pyridoxine-induced cholecystitis
• Halothane (E) Tuberculous pancreatitis
• Methyldopa
• Methotrexate
• Statins

28
Gouty arthritis
• 132. A 30-year-old man with peptic ulcer disease suddenly develops pain, • uric acid overproduction & ↓renal excretion
redness, and swelling of his right first metatarsophalangeal joint. There is no
history of injury. Serum uric acid concentration is 8 mg/dL. Examination of
joint aspirate shows birefringent crystals. Which of the following drugs is • common in males, postmenopausal women, & drink
most appropriate to treat the acute symptoms in this patient? alcohol, DM, Renal failure
(A) Allopurinol • Mono- or oligo- or poly-arthritis
(B) Colchicine • Synovial fluid: monosodium urate crystals
(C) Morphine
(D) Probenecid (needle shaped); negative birefringent
(E) Sulfinpyrazone
1st MTP joint Chronic tophaceous gout

Tophi

Rx: Acute  Colchicine,


Chronic tophi  Allopurinol

• 132. A 30-year-old man with peptic ulcer disease suddenly develops pain, • 133. The thrombolytic effect of tissue plasminogen activator depends on
redness, and swelling of his right first metatarsophalangeal joint. There is no which of the following?
history of injury. Serum uric acid concentration is 8 mg/dL. Examination of
joint aspirate shows birefringent crystals. Which of the following drugs is
most appropriate to treat the acute symptoms in this patient? (A) Circulating heparin
Inhibit xanthine oxidase purine↓  uric↓ (B) Concomitant therapy with high doses of aspirin
(A) Allopurinol
(B) Colchicine inhibit neutrophil motility & activity (C) Factor II (prothrombin) concentration
(C) Morphine (D) Fibrinogen concentration
(D) Probenecid uricosuric agent (E) Presence of fibrin at the site of the thrombus
(E) Sulfinpyrazone
uricosuric agent

Coagulation Pathway

Fibrinolytic system & tPA

Stimulate= black or blue arrow


Inhibit= red arrow

29
• 133. The thrombolytic effect of tissue plasminogen activator depends on • 134. Which of the following figures (A–E) best illustrates the relationship
which of the following? between blood flow and mean arterial pressure (MAP) in a vascular bed that
demonstrates autoregulation of blood flow?
(A) Circulating heparin
(B) Concomitant therapy with high doses of aspirin
(C) Factor II (prothrombin) concentration
(D) Fibrinogen concentration
(E) Presence of fibrin at the site of the thrombus

Autoregulation of cerebral blood flow


• 134. Which of the following figures (A–E) best illustrates the relationship
between blood flow and mean arterial pressure (MAP) in a vascular bed that
demonstrates autoregulation of blood flow?

Autoregulation

CBF = mABP - ICP

Systemic BP Similar to Renal BF

Acute coronary syndrome


• 136. A 72-year-old man collapses while playing golf. He has a 5-year history
of angina and type 2 diabetes mellitus. Paramedics arrive in 10 minutes.
Examination shows no respirations or blood pressure; an ECG shows
asystole.Cardiopulmonary resuscitation is attempted for 10 minutes without
success. Which of the following is the most likely cause of death in this
patient?

(A) Cardiac tamponade


(B) Embolus to the right middle cerebral artery
(C) Necrosis of the myocardium
(D) Rupture of the papillary muscle
(E) Ventricular fibrillation

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ACS STEMI in Inferior wall
• Diagnosis
1.Clinical chest pain (angina)
2.EKG: Q,T wave, ST segment
3.Cardiac enzyme: CK-MB, Troponin-T or Trop-I

Ventricular fibrillation Ventricular fibrillation

Complication of MI
• 136. A 72-year-old man collapses while playing golf. He has a 5-year history
• Mechanical: Heart failure of angina and type 2 diabetes mellitus. Paramedics arrive in 10 minutes.
Examination shows no respirations or blood pressure; an ECG shows
– Ruptured free wall, VSD asystole.Cardiopulmonary resuscitation is attempted for 10 minutes without
success. Which of the following is the most likely cause of death in this
– Ruptured papillary muscle patient?

• Electrical: Arrhythmia (A) Cardiac tamponade


(B) Embolus to the right middle cerebral artery
– Heart block (C) Necrosis of the myocardium
(D) Rupture of the papillary muscle
– Ventricular tachycardia (VT) (E) Ventricular fibrillation
– Ventricular fibrillation (VF)
– Asytole

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Sarcoidosis
• 137. A 34-year-old woman has had a nonproductive cough for 2 months.
She has never smoked. An x-ray of the chest shows bilateral interstitial • immune system disorder & non-caseating
markings and hilar adenopathy. Which of the following findings is most likely
on transbronchial biopsy?
granuloma (small inflammatory nodules)
• Involve lungs & LN, hypercalcemia
(A) Areas of hemorrhagic infiltrate
(B) Areas of liquefaction necrosis • D/Dx TB (must to be excluded)
(C) Dilation of respiratory bronchioles
(D) Microabscesses • Rx: corticosteroid
(E) Noncaseating granulomas
Hilar LN & bilat.
interstitial infiltration

• 137. A 34-year-old woman has had a nonproductive cough for 2 months. • 139. A 36-year-old woman dies from an acute adrenal crisis following a
She has never smoked. An x-ray of the chest shows bilateral interstitial surgical procedure. A pituitary tumor was diagnosed 3 weeks ago. At
markings and hilar adenopathy. Which of the following findings is most likely autopsy, the adrenal glands are small, and the cortex is composed primarily
on transbronchial biopsy? of cells from the zona glomerulosa. Which of the following best explains the
decreased size of the cortex?
(A) Areas of hemorrhagic infiltrate
(B) Areas of liquefaction necrosis (A) Autoimmune destruction
(C) Dilation of respiratory bronchioles (B) Decreased ACTH concentration
(D) Microabscesses (C) Decreased cortisol concentration
(E) Noncaseating granulomas (D) Denervation
(E) Granulomatous disease

HPA axis Adrenal gland functions

• Cortex
-Z.glom: Mineralocorticoid
(Aldosterone)
-Z.fasciculata: Glucocorticoid
(Cortisol)
-Z.reticularis: Sex hormone
(Androgen)

• Medulla
Cathecolamine (NE,E)

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Adrenal insufficiency
• Cortisol ↓ & most decreased size of gland • 139. A 36-year-old woman dies from an acute adrenal crisis following a
surgical procedure. A pituitary tumor was diagnosed 3 weeks ago. At
autopsy, the adrenal glands are small, and the cortex is composed primarily
of cells from the zona glomerulosa. Which of the following best explains the
• Primary AI: exogenous steroid↑, disease of decreased size of the cortex?
adrenal gland (tumor, trauma, infection, (A) Autoimmune destruction
autoimmune) (B) Decreased ACTH concentration
(C) Decreased cortisol concentration
(D) Denervation
• Secondary AI (ACTH↓): Pituitary gland (E) Granulomatous disease
disease(tumor, trauma, infection,autoimmune)

• Rx: corticosteroid replacement

Actinic keratoses
• 143. A 72-year-old man who is a retired construction worker comes to the
physician because he has had a lesion on his face for 3 months. Physical • not skin cancer, but precancerous
examination shows a 6-mm, red, ulcerated lesion with heaped borders. A
biopsy specimen of the lesion shows atypical, dysplastic keratinocytes
within the epidermis and dermis. • Senile lesion
Which of the following is the most likely diagnosis?
• indicates excess sun exposure
(A) Actinic keratoses
(B) Discoid lupus erythematosus • Red, rough, scaly spots, may itch or sting
(C) Melanoma
(D) Mycosis fungoides
(E) Squamous cell carcinoma

Melanoma Mycosis fungoides


• Malignant of melanocyte • cutaneous T-cell lymphoma

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SCC of face
• 143. A 72-year-old man who is a retired construction worker comes to the
physician because he has had a lesion on his face for 3 months. Physical
examination shows a 6-mm, red, ulcerated lesion with heaped borders. A
biopsy specimen of the lesion shows atypical, dysplastic keratinocytes
within the epidermis and dermis.
Which of the following is the most likely diagnosis?

(A) Actinic keratoses


(B) Discoid lupus erythematosus
(C) Melanoma
(D) Mycosis fungoides
(E) Squamous cell carcinoma

Scurvy
• 147. A 70-year-old man has ecchymoses, perifollicular petechiae, and • Vit.C deficiency (collagen synthesis)
swelling of the gingiva. He has lived alone since the death of his wife 2
years ago. His diet consists primarily of cola and hot dogs. • skin spots, spongy gums
Which of the following is the most likely diagnosis?
• mucosal bleeding
(A) Beriberi
(B) Kwashiorkor
(C) Pellagra
(D) Rickets
(E) Scurvy corkscrew hair

periungual
hemorrhage

Thank you & Good luck


• 147. A 70-year-old man has ecchymoses, perifollicular petechiae, and
swelling of the gingiva. He has lived alone since the death of his wife 2 • 3 + ) *, USMLE step1
years ago. His diet consists primarily of cola and hot dogs.
Which of the following is the most likely diagnosis?
examination ' 
(A) Beriberi
Vit.B1(thiamine) def.: cardiac, nerve • www.usmle.org
(B) Kwashiorkor Protein energy malnutrition (PEM): only protein
• Click - examination step 1
(C) Pellagra Vit.B3(Niacin) def.: 3D ‘Dermatitis,Diarrhea,Demetia’
(D) Rickets
Vit.D def.:Ca↓, osteomalacia in adult • - step 1 content description
(E) Scurvy
• - learn more
• - PDF step 1 sample test

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