1

Thailand Medical Licensing
Examination 2008
Narongkorn Saiphoklang, M.D.
Department of internal medicine
Faculty of medicine, Thammasat university
Thailand
Why we exam the medical license ??
• The medical council of Thailand au«a«.· want to
make the international standard.
• Thai National test (beginning in 2006)
– Basic medical sciences Preclinic
– Clinical sciences (& clinical skill) Clinic
• Copy from US Medical Licensing Examination
– 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 !!
Reference range
REMEMBER ! normal range
• Blood: AST,ALT, ALP,protein, albumin, globulin,
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
2
Problem-based learning(PBL) !!!
• 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?
(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
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
blood gas analysis is most likely to show which of the
following sets of values?
PCO2 HCO3−
pH (mm Hg) (mEq/L)
(A) 7.30 28 15
(B) 7.30 55 27
(C) 7.40 40 24
(D) 7.50 30 22
(E) 7.50 47 35
Acid-base mechanism
• pH(H+), pCO
2
, HCO
-
3
• Buffer system: HCO
-
3
, protein, bone
• Respiratory abnormality :CO
2
Lung(1
st
)
• Metabolic abnormality: HCO
-
3
kidney
3
REMEMBER !
Metabolic Acidosis/Alkalosis =
disturbances of HCO
3
Respiratory Acidosis/Alkalosis=
disturbances of PaCO
2
PCO
2
H
+
,
HCO
3
-
Acid-base disturbance
• If ↑ CO
2
(Repiratory acidosis) Lung RR↑ & HCO
-
3
↑(kidney)
↓ CO
2
(Repiratory alkalosis) Lung RR ↓ & HCO
-
3
↓ (kidney)
• If ↓ HCO
-
3
(Metabolic acidosis) ↓CO
2
by Lung RR↑ & HCO
-
3
↑ (kidney)
↑ HCO
-
3
(Metabolic alkalosis) ↑ CO
2
by Lung RR↓ & HCO
-
3
↓ (kidney)
• 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
• Hyperventilation = Respiratory alkalosis
• Anion gap= Na - Cl - HCO
-
3
(normal 8 - 14)
• ABG: pH 7.4± 0.05, pCO
2
= 40, HCO
-
3
=24, pO
2
= 80-100
Interpretation of ABG
• 1
st
: pH acidosis/alkalosis
• 2
nd
: PCOz HCOs− ↑.↓
• 3
rd
: Pure(compensate) /Mixed disorder
pH
Acidosis Alkalosis
↑CO: ↓HCO− ↓CO: ↑HCO−
Res.acid Met.acid Res.Alkalo Met.Alkalo
Pure(compensate) / Mixed disorder
Compensation Formulas for Compensation Formulas for
Simple Acid Simple Acid- -Base Disorders Base Disorders
- - Metabolic acidosis Metabolic acidosis PaCO PaCO
2 2
= 1.5 (HCO = 1.5 (HCO
3 3
) + 8 ) + 8 + + 2 2
- - Metabolic alkalosis Metabolic alkalosis PaCO PaCO
2 2
= 0.9 (HCO = 0.9 (HCO
3 3
) + 9 ) + 9+ + 20 20
or or ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ PaCO PaCO
2 2
= 0.6 = 0.6 ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ (HCO (HCO
3 3
) )
- - Ac. respiratory acidosis Ac. respiratory acidosis ∆ ∆∆ ∆ ∆ ∆∆ ∆ HCO HCO
3 3
= 0.1 ( = 0.1 (∆ ∆∆ ∆ ∆ ∆∆ ∆ PaCO PaCO
2 2
) )
- - Chr Chr. respiratory acidosis . respiratory acidosis ∆ ∆∆ ∆ ∆ ∆∆ ∆ HCO HCO
3 3
= 0.35 ( = 0.35 (∆ ∆∆ ∆ ∆ ∆∆ ∆ PaCO PaCO
2 2
) )
- - Ac. respiratory alkalosis Ac. respiratory alkalosis ∆ ∆∆ ∆ ∆ ∆∆ ∆ HCO HCO
3 3
= 0.2 ( = 0.2 (∆ ∆∆ ∆ ∆ ∆∆ ∆ PaCO PaCO
2 2
) )
- - Chr Chr. respiratory alkalosis . respiratory alkalosis ∆ ∆∆ ∆ ∆ ∆∆ ∆ HCO HCO
3 3
= 0.5 ( = 0.5 (∆ ∆∆ ∆ ∆ ∆∆ ∆ PaCO PaCO
2 2
) )
from the normal value of 40 mmHg for PaCO from the normal value of 40 mmHg for PaCO
2 2
or 24 mEq/L for HCO or 24 mEq/L for HCO
3 3
- -
• 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-
headedness, especially when sitting or standing. Arterial
blood gas analysis is most likely to show which of the
following sets of values?
PCO2 HCO3−
pH (mm Hg) (mEq/L)
(A) 7.30 28 15
(B) 7.30 55 27
(C) 7.40 40 24
(D) 7.50 30 22
(E) 7.50 47 35
1.pH: alkalosis
2.HCO
3
↑- Metabolic
3.Pure(compensate)
↑ PCOz =(0.9 x 35) + 9 ±20 = 20.5 to 60.5
Or ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ ∆↑ PaCO2 PaCO2 = 0.6 = 0.6 ∆↑ ∆↑ (10)=6 (+40)=46 (10)=6 (+40)=46
• 45. A 31-year-old man with a history of epilepsy has a major motor (grand
mal) seizure. Laboratory values obtained immediately after cessation of the
seizure include:
Arterial blood
pH 7.14
PCO2 35 mm Hg
Plasma
Na+ 140 mEq/L
Cl− 98 mEq/L
K+ 4.0 mEq/L
HCO3− 17 mEq/L
Which of the following is the most likely acid base disturbance?
(A) High anion gap metabolic acidosis
(B) High anion gap respiratory acidosis
(C) Low anion gap metabolic acidosis
(D) Normal anion gap metabolic acidosis
(E) Normal anion gap respiratory acidosis
4
• 45. A 31-year-old man with a history of epilepsy has a major motor (grand
mal) seizure. Laboratory values obtained immediately after cessation of the
seizure include:
Arterial blood
pH 7.14
PCO2 35 mm Hg
Plasma
Na+ 140 mEq/L
Cl− 98 mEq/L
K+ 4.0 mEq/L
HCO3− 17 mEq/L
Which of the following is the most likely acid base disturbance?
(A) High anion gap metabolic acidosis
(B) High anion gap respiratory acidosis
(C) Low anion gap metabolic acidosis
(D) Normal anion gap metabolic acidosis
(E) Normal anion gap respiratory acidosis
1.pH:acidosis
2.HCO3− ↓ - Metabolic
3.Pure(compensate) PCOz↑
Calculated PaCO2 = 1.5(HCO3) + 8 ± 2
= 31.5 to 35.5
Anion gap = Na - Cl - HCO
3
= 25
• 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
Cl− 85 mEq/L
K+ 2.1 mEq/L
HCO3− 35 mEq/L
Urine
Na+ 80 mEq/24 h
K+ 170 mEq/24 h
Which of the following is the most likely diagnosis?
(A) Aldosterone deficiency
(B) Anxiety reaction with hyperventilation
(C) Diabetic ketoacidosis
(D) Ingestion of anabolic steroids
(E) Surreptitious use of diuretics
Hypokalemia
[acid-base, ECF volume, hypertension, urine K
+
]
Metabolic acidosis
urine K
+
low high
Lower GI loss
• diarrhea
• laxative abuse
• villous adenoma
Renal loss
• RTA
• DKA
• acetazolamide
Metabolic alkalosis
urine K
+
low high
• loss gastric secretion (late)
(urine pH<5.5, low urine Cl
-
)
• remote diuretic use
(thiazide, loop diuretics)
• laxative abuse
• loss gastric secretion (early)
(urine pH>7, low urine Cl
-
)
• recent diuretic use
(thiazide, loop diuretics)
• Bartter’s syndrome
• Gitelman’s syndrome
• Mg
2+
depletion
normotension hypertension
• mineralocorticoid
excess
Normal acid-base
Intracellular shift
• insulin
• β-agonist
• ↑ extracellular pH
• thyrotoxicosis
• periodic paralysis
• ↑ cell production
• intoxication
• other drugs (see text)
• 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
Cl− 85 mEq/L
K+ 2.1 mEq/L
HCO3− 35 mEq/L
Urine
Na+ 80 mEq/24 h
K+ 170 mEq/24 h
Which of the following is the most likely diagnosis?
(A) Aldosterone deficiency
(B) Anxiety reaction with hyperventilation
(C) Diabetic ketoacidosis
(D) Ingestion of anabolic steroids
(E) Surreptitious use of diuretics
Serum K 3.5-5.0, HCO
3
24
Urine Na<20, K<20
AldosteroneNa reabsorp, K excretion
Res.alkalosispCO2↓, HCO
3

Met.acidosisHCO
3

Testosteroneinhibit Na reabsorp
• 19. Hospital discharge of a 75-year-old man is delayed due to unavailability
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
mm Hg. Laboratory values include:
Day 1 Day 3
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
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)
Hypernatremia
Skin
-Sweating
-Burn
-DI
-glucose, mannitol
Administration GI
loss of free water
Renal
-osmotic diarrhea
lactulose
Hypothalamus
-1 hypodipsia
-resat osmostat
-IV.oral Nacl,
NaHCO3
Hemoconcentration,
BUN & Cr mild ↑
5
HypoNa
True Hyponatremia
(exclude hyperglycemia, hyperlipidemia)
Assess ECF volume status
TBW ↓ , TBNa↓↓
Hypovolemia
TBW↑↑ , TBNa↑
Hypervolemia
TBW ↑ , TBNa↔
Normovolemia
Renal
loss
Extrarenal
loss
Renal
failure
Edematous
State
( nephrotic synd,
cirrhosis, CHF)
SIADH
Endocrinopathy
(thyroid↓, cortisol↓)
UNa >20 <20 > 20 > 20 < 20
• 19. Hospital discharge of a 75-year-old man is delayed due to unavailability
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
mm Hg. Laboratory values include:
Day 1 Day 3
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
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)
Met.acidosis, Na ↓
Met.acidosis, BS>250-300 mg/dL
Alkalosis/acidosis+ Hb↓
ADH↑--Na↓
• 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
atherosclerosis. To prevent further heart damage, which of the following is
the most appropriate recommendation?
(A) Aerobic exercise program
(B) Avoidance of alcohol
(C) Ingestion of more vegetables and decrease in red meat intake
(D) Isometric/weight-training exercise program
(E) Weight loss
• 27. A 74-year-old man with urinary frequency and urgency has benign
prostatic hyperplasia. He refuses operative intervention but agrees to a trial
of finasteride therapy. During the trial, synthesis of which of the following
substances is most likely to be inhibited?
(A) Androstenedione
(B) Dihydrotestosterone
(C) Estradiol
(D) Estrone
(E) Testosterone
BPH
• 5-Reductase Inhibitor = Finasteride
block testosterone →Dihydrotestosterone
• α-1-adrenergic antagonist = terazosin, doxazosin,
tamsulosin,alfuzosin, & Prazosin block bladder outlet obstruction
• 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
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
following?
(A) Desmopressin
(B) 5% Dextrose in water
(C) Fresh frozen plasma
(D) 0.9% Saline
(E) Methoxamine
(F) Verapamil
6
Blood pressure
PVR
CO
BP
Preload
Stroke volume
HR
Contractibility
Afterload
PCWP or CVP
Ejection fraction (EF)
Shock
• Hypovolemic: blood loss, N/V, diarrhea
• Cardiogenic: myocardial infarction, cardiac tamponade, arrhythmia
• Distributive: septic, anaphylaxis, adrenal insufficiency,myxedema coma
neurogenic
• Rx: Hypovolemia crystalloid1
st
=Isotonic saline, Ringer lactate sol.
colloid 2
nd
= 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,
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?
(A) Asthmatic bronchitis
(B) Bullous emphysema
(C) Chronic bronchitis
(D) Congestive heart failure
(E) Lobar pneumonia
(F) Pleural effusion
(G) Pleuritis
(H) Pneumothorax
(I) Pulmonary embolism
Stethoscope
Bell -Low pitch sound
Diaphragm- High pitch
7
Rales = crackles = crepitations
8
9
Physical signs in Chest disorders
none decrease decrease dull shift to
opposite
Pl.effusion
none absent absent dull shift to
involved
Atelectasis
crakles increased Bron. dull mid Lobar
none N Ves. resonance mid Normal
Ad.sound Fremitus BS percuss Trachea Condition
Physical signs in Chest disorders
Crakles
±Wheezes
(diffuse)
N or
decrease
N or
decrease
N or dull mid CHF
Wheezes decrease obscure N or
HyperReso.
mid Asthma
none decrease decrease HyperReso.
(diffuse)
mid Emphysema
none decrease decrease HyperReso. Shift to
opposite
Pn.Tx.
Ad.sound Fremitus BS percuss Trachea Condition
• 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
Percussion note dull
Tactile fremitus increased
Adventitious sounds crackles
Which of the following is the most likely diagnosis?
(A) Asthmatic bronchitis
(B) Bullous emphysema
(C) Chronic bronchitis
(D) Congestive heart failure
(E) Lobar pneumonia
(F) Pleural effusion
(G) Pleuritis
(H) Pneumothorax
(I) Pulmonary embolism
10
• 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
INR of 2.5. Subsequently, trimethoprim-sulfamethoxazole therapy is begun
for a recurring urinary tract infection.
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
(D) Decrease the dosage of warfarin
(E) Stop the warfarin and change to low dose aspirin
Warfarin & drug interaction
• ↓ Warfarin: griseofulvin, macrolide ATB,
metronidazole, rifampicin, sulfasalazine, vit.K
• ↑ Warfarin : allopurinol, amiodarone ,Azole
antifungal, antiplatelet, NSAID, cephalosporins,
statin, phenytoin, proton pump inhibitor,
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
prosthetic cardiac valve. The warfarin dosage is adjusted to maintain an
INR of 2.5. Subsequently, trimethoprim-sulfamethoxazole therapy is begun
for a recurring urinary tract infection.
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
(D) Decrease the dosage of warfarin
(E) Stop the warfarin and change to low dose aspirin
• 37. Investigators are studying the use of a new laboratory test to identify
patients with a particular disease. The table below summarizes the results
of initial research involving 200 subjects
Which of the following is the approximate sensitivity of a positive test result?
(A) 0.30
(B) 0.33
(C) 0.60
(D) 0.67
(E) 0.75
Sensitivity x Specificity of the test
• Sensitivity = a/(a+c)
«a«.··».++..«a«»:«.vˈ·:..!·+vˁ.a«.vˈ·¹.+«.·.a
• Specificity = d/(b+d)
«a«.··».++..«a«»:«.vˈ·+:!·+vˁ.a« ¹..vˈ·¹.+«.·.a
a+vˁ.a«!·++.....·.vˈ·:... ¹».««·..vˈ·¹.+·..«.
b= false positive
c= false negative
• Positive predictive value(PPV) = a/(a+b)
+..··..vˈ·«+vˁ.a·..vˈ·¹.+ ..».....·!·++:..
• Negative predictive value(NPV) = d/(c+d)
+..··..vˈ·«+vˁ.a¹.¹a.vˈ·¹.+ ..».....·!·++.vˈ·+:
• Prevalence= (a+c)/(a+b+c+d)
• Accuracy =(a+d)/(a+b+c+d)
d c Test
negative
b a Test
positive
Normal Disease
• 37. Investigators are studying the use of a new laboratory test to identify
patients with a particular disease. The table below summarizes the results
of initial research involving 200 subjects
Which of the following is the approximate sensitivity of a positive test result?
(A) 0.30
(B) 0.33
(C) 0.60
(D) 0.67
(E) 0.75
Sensitivity= 60/(60+20)=0.75
Specificity= 80/(80+40)=0.67
PPV= 60/(60+40)=0.60
NPV= 80/(80+20)=0.80
11
• 39. An inexpensive screening test for a disease is available through
analysis of venous blood. The distributions of blood concentrations for
persons with and without the disease are depicted in the graph. The
disease is irreversible and fatal if not discovered and treated early. Which of
the following letters represents the most appropriate cutoff point between
normal and abnormal?
A= false positive↑ ↑ ↑
B= sensitivity↑ ↑ ↑, false positive ↑
C= sensitivity↑ , false negative ↑
D= specificity ↑ ↑, false negative ↑ ↑
E= specificity ↑ ↑ ↑ , false negative ↑ ↑ ↑
• 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
minimum of 14 mm Hg.
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
Normal heart blood flow
O
2
70%
70%
95%
95%
95%
70%
Pressure 5 mmHg
Pressure 25/5 mm/Hg
Pressure 30/15 mmHg
LVEDP (=PCWP) 10 mmHg
Pressure 10 mmHg
Swan Ganz catheter
Pulm.capillary wedge pressure
(PCWP) = LVEDP
• 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
minimum of 14 mm Hg.
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
12
• 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.
He has atrial fibrillation and tachycardia.
Which of the following is the most likely diagnosis?
(A) Congestive heart failure
(B) Cushing syndrome
(C) Hyperthyroidism
(D) Mitral valve prolapse
(E) Pheochromocytoma
Hyperthyroidism
• high T3 &T4, low TSH = 1ºHyperthyroid
• high T3 &T4, high TSH = 2ºHyperthyroid
• S/S …Systemic organ symptoms & signs
Clinical manifestation of Hyperthyroidism
Graves’ disease
• Autoantibody to TSH-Receptor
• Clinical S/S of hyperthyroidism
• Lab: TFT, anti-MPO(antimicrosomal) . anti-thyroglobulin
• Exophthalmos, goiter, pretibial myxedema
Normal
Enlarged gland
Rx:Drug; PTU,methimazole
I
131
ablation
Surgery
Hashimoto thyroiditis
• Chronic lymphocytic thyroiditis
• Autoimmune disease
• Clinical: hyperthyroid Euthyroidhypothyroid
• Lab: TFT, High titer Antibody
anti-MPO(antimicrosomal)
anti-thyroglobulin
• 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.
He has atrial fibrillation and tachycardia.
Which of the following is the most likely diagnosis?
(A) Congestive heart failure
(B) Cushing syndrome
(C) Hyperthyroidism
(D) Mitral valve prolapse
(E) Pheochromocytoma
↑cortisol: obesity, prox.muscle weaknes
↑ cathecolamine(E, NE): triad ‘’headache+
tachycardia+ sweating’’ + HT
13
• 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
early diastolic sound followed by a low-pitched rumbling decrescendo
diastolic murmur is present 4 cm left of the sternal border in the fourth
intercostal space and is heard best with the patient in the left lateral
decubitus position.
Which of the following valve defects is most likely in this patient?
(A) Aortic regurgitation
(B) Aortic stenosis
(C) Mitral regurgitation
(D) Mitral stenosis
(E) Pulmonic regurgitation
(F) Pulmonic stenosis
(G) Tricuspid regurgitation
(H) Tricuspid stenos
Valvular heart disease
& Congenital heart disease
• Mitral regurgitation: Pansystolic murmur
• Aortic stenosis: Systolic ejection m.
• Aortic regurgitation: Diastolic blowing m.
• Mitral stenosis: Diastolic rumbling m.
aa·»· ‘M.R.-Pan, AS-Ject, AR-blow, MiSs-rum’
• ASD: Fixed split S2
• PDA: continuous / machinery murmur
• VSD: Pansystolic m.
MS
• 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
early diastolic sound followed by a low-pitched rumbling decrescendo
diastolic murmur is present 4 cm left of the sternal border in the fourth
intercostal space and is heard best with the patient in the left lateral
decubitus position.
Which of the following valve defects is most likely in this patient?
(A) Aortic regurgitation
(B) Aortic stenosis
(C) Mitral regurgitation
(D) Mitral stenosis
(E) Pulmonic regurgitation
(F) Pulmonic stenosis
(G) Tricuspid regurgitation
(H) Tricuspid stenos
Rheumatic heart disease = MS is most common
• 56. A 68-year-old man has had low back pain over the past 2 months.
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
casts.
Bone marrow examination is most likely to show uncontrolled
proliferation of which of the following cells?
(A) Basophils
(B) Lymphocytes
(C) Macrophages
(D) Plasma cells
(E) Reticulocytes
Multiple myeloma (MM)
• clonal proliferation of plasma cells in BM
producing monoclonal Immunoglobulin
• monoclonal gammopathy (serum protein: immunoglobulin↑,
Bence Jones proteinuria)
• hypercalcemia, renal failure, anemia,& bone
pain (osteolytic lesion)
aa·»· ‘CRAB: Ca,Renal,Anemia,Bone’
MM
Rouleaux formation in PBS
Plasma cells in BM
Osteolytic lesion on skull film
14
Common cancer with hypercalcemia
• Breast
• Lung ( SCC, Large cell CA )
• Kidney
• Ovary
• Multiple Myeloma
• T-cell Lymphoma
• 56. A 68-year-old man has had low back pain over the past 2 months.
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
casts.
Bone marrow examination is most likely to show uncontrolled
proliferation of which of the following cells?
(A) Basophils
(B) Lymphocytes
(C) Macrophages
(D) Plasma cells
(E) Reticulocytes
• 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
Lipoprotein disorders
Familial hypercholesterolemia
• autosomal disorder
• apo B/E (LDL) receptor mutation
• LDL-C oxizided LDLfatty streak/fibrous
plaque in vessel Atheroscleosis
• CAD(MI),CVD(ischemic stroke),PVD
• tendon xanthoma
Lipoproteins metabolism
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
15
• 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
Total cholesterol <200 mgdL
LDL-C <100 mgdL in MI
• 60. A 74-year-old man has had confusion for 2 weeks. He has smoked two
packs of cigarettes daily for 50 years. An x-ray of the chest shows a 5-cm
mass in the lung. Laboratory studies of serum show:
Na+ 110 mEq/L
Cl− 72 mEq/L
K+ 4.5 mEq/L
HCO3− 30 mEq/L
Glucose 200 mg/dL
Creatinine 1.4 mg/dL
Which of the following is the most likely cause of these findings?
(A) Adenocarcinoma of the lung
(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroid gland
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung
HypoNa
True Hyponatremia
(exclude hyperglycemia, hyperlipidemia)
Assess ECF volume status
TBW ↓ , TBNa↓↓
Hypovolemia
TBW↑↑ , TBNa↑
Hypervolemia
TBW ↑ , TBNa↔
Normovolemia
Renal
loss
Extrarenal
loss
Renal
failure
Edematous
State
( nephrotic synd,
cirrhosis)
SIADH
Endocrinopathy
(thyroid, cortisol)
UNa >20 <20 > 20 > 20 < 20
Syndrome of inappropriate ADH
(SIADH)
• ↑ADHwater retention & [Na]↓, [uric]↓, serum osmole ↓,
urine osmole↑
• Causes:
1.Brain:tumor,infection
2.Lung: tumor (small cell;SCLC), Infection
3.Cancer(paraneoplastic syndrome): bronchus,
duodenum, pancreas, thymus
4.Drug: antipsychotic, carbamazepine, chlorpropamide,
cyclophosphamide
• Rx: restrict free water
Paraneoplastic Syndrome associated SCLC
• SIADH most common
• Hypercoagulable state common
• Ectopic ACTH uncommon
(50% Ectopic Cushing’s syndrome)
• Neuro
Eaton-Lambert (Myasthenic) Syndrome ***
16
• 60. A 74-year-old man has had confusion for 2 weeks. He has smoked two
packs of cigarettes daily for 50 years. An x-ray of the chest shows a 5-cm
mass in the lung. Laboratory studies of serum show:
Na+ 110 mEq/L
Cl− 72 mEq/L
K+ 4.5 mEq/L
HCO3− 30 mEq/L
Glucose 200 mg/dL
Creatinine 1.4 mg/dL
Which of the following is the most likely cause of these findings?
(A) Adenocarcinoma of the lung
(B) Craniopharyngioma
(C) Medullary carcinoma of the thyroid gland
(D) Renal cell carcinoma
(E) Small cell carcinoma of the lung
• 62. A previously healthy, tall, and slender 19-yearold woman has the
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
the right pleural space.
Which of the following is the most likely underlying condition?
(A) Bronchiectasis
(B) Lung abscess
(C) Panacinar emphysema
(D) Pulmonary sequestration
(E) Subpleural blebs
Primary spontaneous pneumothorax
• Younger & tall
• ± smoking, family history, Marfan syndrome,
homocystinuria, & thoracic endometriosis
• rupture of subpleural bleb
• Rx: tube thoracostomy (ICD)
• 62. A previously healthy, tall, and slender 19-yearold woman has the
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
the right pleural space.
Which of the following is the most likely underlying condition?
(A) Bronchiectasis
(B) Lung abscess
(C) Panacinar emphysema
(D) Pulmonary sequestration
(E) Subpleural blebs
chronic productive cough
productive cough + subacute fever
chronic dyspnea+ Hx of heavy smoking
chronicrecurrent cough
• 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?
(A) Achlorhydria
(B) Antiparietal cell antibodies
(C) Cholecystitis with antral seeding
(D) Immunodeficiency state
(E) Increased urease activity in the antrum
Helicobacter pylori
Novel Prize2005
Urease Test / CLO test®
Peptic ulcer & Gastric cancer
urease
17
• 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?
(A) Achlorhydria
(B) Antiparietal cell antibodies
(C) Cholecystitis with antral seeding
(D) Immunodeficiency state
(E) Increased urease activity in the antrum
• 65. A 52-year-old man with recently diagnosed type 2 diabetes mellitus
comes to the physician for a follow-up examination. Physical examination
shows no abnormalities. Laboratory studies show an increased hemoglobin
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
(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
(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
• +pancreatic ß-cells
• Sulfonylurea. glibenclamide, glipizide,
gliclazide, glimepiride
• Glinide: repaglinide,& nateglinide
Insulin sensitizer
• ↓hepatic glucose output
• ↑glucose utilization in peripheral tissues
(muscle & liver) & antilipolysis
• Biguanides: metformin
• Thiazolidinediones (glitazones):
rosiglitazone, pioglitazone
Other antidiabetic drugs
• Glucosidase inhibitors: acarbose,
voglibose
• Insulin
• New novel: Incretin
(+pancreatic ß-cells & inhibit glucagon)
• 65. A 52-year-old man with recently diagnosed type 2 diabetes mellitus
comes to the physician for a follow-up examination. Physical examination
shows no abnormalities. Laboratory studies show an increased hemoglobin
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
(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
(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
18
• 67. A 51-year-old woman with cancer is being treated with a hematopoietic
growth factor. Leukocyte differentials before and after treatment are shown:
Before Treatment After Treatment
Leukocyte count 1000/mm3 10,000/mm3
Eosinophils 1% 1%
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
Neutropenia
• post-chemotherapy for cancer
• WBC↓: Neutrophil
• Rx: G-CSF
• 67. A 51-year-old woman with cancer is being treated with a hematopoietic
growth factor. Leukocyte differentials before and after treatment are shown:
Before Treatment After Treatment
Leukocyte count 1000/mm3 10,000/mm3
Eosinophils 1% 1%
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
• 70. A 30-year-old man comes to the clinic because of a painful ulcer on his
penis for the past week. He has had multiple sexual partners, including
commercial sex workers. Physical examination shows lymphadenopathy in
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
agar. A Gram stain of the colonies shows gram negative coccobacilli. Which
of the following is the most likely causal organism?
(A) Haemophilus ducreyi
(B) Herpes simplex virus
(C) Neisseria gonorrhoeae
(D) Treponema pallidum
(E) Trichomonas vaginalis
Sexual transmitted disease
• Genital ulcer syndrome:
– HSV1&2
– primary syphilisTreponema pallidum)
– chancroidHaemophilus ducreyi)
– lymphogranuloma venereum(Chlamydia
trachomatis)
• Chancroid: H ducreyi
Chancroid HSV: group of vesicles
Primary syphilis
Genital ulcer syndrome
Lymphogranuloma venereum
19
• 70. A 30-year-old man comes to the clinic because of a painful ulcer on his
penis for the past week. He has had multiple sexual partners, including
commercial sex workers. Physical examination shows lymphadenopathy in
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
agar. A Gram stain of the colonies shows gram negative coccobacilli. Which
of the following is the most likely causal organism?
(A) Haemophilus ducreyi
(B) Herpes simplex virus
(C) Neisseria gonorrhoeae
(D) Treponema pallidum
(E) Trichomonas vaginalis
• 72. A 25-year-old woman has a 3-day history of vomiting and diarrhea. She
has postural hypotension and poor tissue turgor. Her serum sodium
concentration is 130 mEq/L.
Which of the following findings is most likely?
(A) Decreased serum aldosterone concentration
(B) Increased serum atrial natriuretic peptide concentration
(C) Increased effective circulating volume
(D) Increased serum ADH (vasopressin) concentration
(E) Urine osmolality less than serum osmolality
Hypovolemic hypoNa ↑Aldosterone & ↑ADH
Break !!!
• 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
following nutrients?
(A) Folic acid
(B) Vitamin A
(C) Vitamin B1 (thiamine)
(D) Vitamin B6 (pyridoxine)
(E) Vitamin B12 (cobalamin)
Wernicke-Korsakoff syndrome
• chronic alcoholism, anorexia nervosa
• thiamine (vitamin B1) deficiency
• Tiad: ‘dementia, ophthalmoplegia, ataxia’
• Beri-beri: cardiac(CHF), nerve
(numbness)
• 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
following nutrients?
(A) Folic acid
(B) Vitamin A
(C) Vitamin B1 (thiamine)
(D) Vitamin B6 (pyridoxine)
(E) Vitamin B12 (cobalamin)
Megaloblastic anemia
Visual impairement
Peripheral neuropathy
Megaloblastic anemia &
peripheral neuropathy
20
• 74. Three weeks after a renal transplant, a patient develops fever and
leukopenia, followed by prostration and severe pulmonary and hepatic
dysfunction.
Which of the following is the most likely viral cause?
(A) Adenovirus type 12
(B) Coxsackievirus
(C) Cytomegalovirus
(D) Influenza virus
(E) Parvovirus B19
Infection in Organ transplantation
• Most common in neutropenia :
CMV and TB
• 74. Three weeks after a renal transplant, a patient develops fever and
leukopenia, followed by prostration and severe pulmonary and hepatic
dysfunction.
Which of the following is the most likely viral cause?
(A) Adenovirus type 12
(B) Coxsackievirus
(C) Cytomegalovirus
(D) Influenza virus
(E) Parvovirus B19
• 85. An asymptomatic 50-year-old woman has hypertension. Her urinary
excretion of catecholamines is increased. A CT scan shows a suprarenal
mass.
Which of the following is the most likely cause?
(A) Benign neoplasm of the adrenal cortex
(B) Benign neoplasm of the adrenal medulla
(C) Malignant neoplasm of the adrenal cortex
(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
• 86. A 21-year-old man has weight loss and severe intermittent bloody
diarrhea. A barium enema and colonoscopy show multiple ulcers and
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
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
Inflammatory bowel disease
• Ulcerative colitis: continuous lesion
• Crohn disease: skip lesionsmall bowel
21
• 86. A 21-year-old man has weight loss and severe intermittent bloody
diarrhea. A barium enema and colonoscopy show multiple ulcers and
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
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
• 95. The unlabeled solid curve in the graph shown represents the loading
behavior of normal human hemoglobin at a pH of 7.35 as a function of
oxygen concentration. Which of the following labeled curves best represents
the most likely change after addition of carbon dioxide?
Acidosis, CO2, H+, temperature↑,
2,3 DPG
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
(B) Hydrochlorothiazide
(C) Lovastatin
(D) Nicotinic acid
(E) Propranolol
Statin-induced rhabdomyolysis
• HMG co-A reductase inhibitor = statin
• Side effect: hepatitis, myositis(CK↑),
rhabdomyolysis
• Rhabdomyolysis: myalgia, weakness,
renal failure, CPK↑
• 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
(B) Hydrochlorothiazide
(C) Lovastatin
(D) Nicotinic acid
(E) Propranolol
22
• 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
SLE
Dx: 4 of 11
Systemic lupus erythematosus (SLE)
• Autoimmune disease
• «..· ‘DOPAMIN RASH’
Discoid, Oral ulcer, Photosensitivity, Arthritis, Malar,
Immuno, Neuro, Renal, ANA, Serositis, Hemato
Malar/Butterfly rash Discoid rash
Drug-induced lupus
• hydralazine
• procainamide, minocycline, diltiazem,
penicillamine
• isoniazid (INH)
• methyldopa, chlorpromazine
• anti-TNF: infliximab,etanercept,& IFN
• 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
• 111. A 55-year-old woman with breast cancer develops shortness of breath
and poor exercise tolerance while being treated with doxorubicin.
Which of the following is the most likely cause of these symptoms?
(A) Dilated cardiomyopathy
(B) Obstructive pulmonary disease
(C) Pulmonary hypertension
(D) Restrictive cardiomyopathy
(E) Restrictive pulmonary disease
23
Doxorubicin induced cardiomyopathy
• Anthracycline: Doxorubicin(adriamycin®) . Idarubicin
• Chemotherapy for solid tumor & hematologic malignancy
e.g. MM
• Long term side effect: Cardiomyopathy; irreversible
• Cumulative dose toxicity: 550 mg/m
2
BSA
Endocardial biopsy showed
loss of myofibrils and
vacuolization of
cytoplasm
Chest X-ray showed
cardiomegaly (dilated CM)
• 111. A 55-year-old woman with breast cancer develops shortness of breath
and poor exercise tolerance while being treated with doxorubicin.
Which of the following is the most likely cause of these symptoms?
(A) Dilated cardiomyopathy
(B) Obstructive pulmonary disease
(C) Pulmonary hypertension
(D) Restrictive cardiomyopathy
(E) Restrictive pulmonary disease
• 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
Hematocrit 39.7%
Leukocyte count 8500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 µm3
Platelet count 20,000/mm3
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
Thrombocytopenia
Immune
-Autoimmune
-ITP
-SLE
-Evan’syndrome
-Alloimmune
-Multiple Blood transfusion
Increased destruction
Non-immune
-DIC
-Hypersplenism
-TTP, HUS
Decreased production
Stem cell defects
-Aplastic anemia
-Amegakaryocytic
Thrombocytopenia
Infiltrative marrow
disease
-Myelophthisis
-Acute leukemia
Ineffective thrombopoiesis
-Megaloblastic anemia
-Alcohol
Pseudothrombocytopenia
Must be Excluded
Immune Thrombocytopenic Purpura
24
Immune thrombocytopenic purpura (ITP)
• Autoantibody to GPIIb/IIIa or GPIb/IX
• Acute vs Chronic
• Mucocutaneous bleeding
• Bone marrow examination required in
– The presence of other cytopenias
– Age > 60 years
– Failure of corticosteroid therapy
• Screen for HIV infection: anti-HIV
Treatment
• Platelet > 30,000 /mL
• Initial treatment
– Prednisolone
– IVIG
– Platelet transfusion
• Long term treatment
– Splenectomy: pneumococcal vaccine
– Cyclophosphamide, cyclosporin
– Danazol, rituximab, interferon, vitaminC
Immune thrombocytopenic purpura (ITP)
Thrombotic Thrombocytopenic Purpura (TTP)
MAHA: fragmented RBC(schistocyte)
Thrombocytopenia
TTP
Criteria
1.Microangiopathic
hemolytic anemia
2.Thrombocytopenia
3.Neurologic :seizure,
confusion
4.Fever
5.Renal disease(RF)
• Idiopathic
• Toxin-associated
• Familial
• Drugs:Quinine,
Cyclosporin A
• Transplantation
• Malignancy/ treatment
• HIV
• Pregnancy
Emergency Treatment
• Plasma exchange (FFP)
• Plasma infusion
• 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
Hematocrit 39.7%
Leukocyte count 8500/mm3
Neutrophils 65%
Lymphocytes 30%
Monocytes 5%
Mean corpuscular volume 82.2 µm3
Platelet count 20,000/mm3
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
25
• 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.
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
following hormones?
(A) Androstenedione
(B) Cortisol
(C) Glucagon
(D) Leptin
(E) Thyroxine (T)
Stress hormones
• ↑Cortisol &
• ↑Norepinephrine
• ↓Anabolic hormone:
Insulin, Glucagon,
GH, Thyroid hormone
Sex H.(Testosterone)
• 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.
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
following hormones?
(A) Androstenedione
(B) Cortisol
(C) Glucagon
(D) Leptin
(E) Thyroxine (T)
• 117. A 63-year-old man with a 5-year history of congestive heart failure
comes to the emergency department because of a 1-month history of
fatigue and labored breathing. Evaluation shows pulmonary edema.
Furosemide is administered. Which of the following sets of physiologic
changes is most likely following administration of the drug?
Loop diuretic
Furosemide
Na+/K+/2Cl pump
26
• 117. A 63-year-old man with a 5-year history of congestive heart failure
comes to the emergency department because of a 1-month history of
fatigue and labored breathing. Evaluation shows pulmonary edema.
Furosemide is administered. Which of the following sets of physiologic
changes is most likely following administration of the drug?
• 120. A 75-year-old woman has increasing shortness of breath on exertion.
Findings on physical examination are unremarkable. X-rays of the chest
show no abnormalities of the heart or lungs. Pertinent laboratory findings
include:
Hematocrit 28%
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
• Hb < 13 g/dL in male
• Hb < 12 g/dL in female
• Hb < 11 g/dL in pregnant female
CAUSES OF ANEMIA
k|»c:|e aee:eae»
a.++uae ( aoc e:eeee:|e»:
n+a+en+n ( aoc ec.::ee:|e»:
:ae:a aø aoc |e..
ue:e»e|ee|e aee:eae»
u|e:ee,:|e a»c¬|a (ru+ø:an:
ue:¬ee,:|e a»c¬|a
uae:ee,:|e a»c¬|a (ru+øìna :
ANEMIA
MACROCYTIC
ANEMIA
MCV > 100 fL
NORMOCYTIC
ANEMIA
MCV 80-100
MICROCYTIC
ANEMIA
MCV < 80 fL
Megaloblastic anemia
Hypersegmented PMN
Macro-ovalocyte
27
Causes of Microcytic anemia
• Iron deficiency anemia
• Thalassemia
• Anemia of chronic disease (late)
• Sideroblastic anemia
• Lead poisoning
Thalassemia
Iron def. anemia
Iron metabolism
Causes of Iron Deficiency anemia
• Overt blood loss: traumatic hemorrhage,
hematemesis, menorrhagia, gross hematuria
• Occult blood loss: GI-Peptic ulcer, cancer
• Repeated blood donations
• Diet deficiency in iron
• Reduced iron absorption:bypass surgery
• EPO administration
• 120. A 75-year-old woman has increasing shortness of breath on exertion.
Findings on physical examination are unremarkable. X-rays of the chest
show no abnormalities of the heart or lungs. Pertinent laboratory findings
include:
Hematocrit 28%
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
28
• 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
interventions would provide the greatest decrease in chronic pulmonary
disease in this community?
(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
COPD
(Chronic Obstructive Pulmonary Disease)
• Chronic bronchitis
• Emphysema
• 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
interventions would provide the greatest decrease in chronic pulmonary
disease in this community?
(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
• 131. An otherwise healthy 55-year-old Asian American man is given
isoniazid and vitamin B6(pyridoxine) after conversion of his PPD skin test.
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
likely explanation?
(A) Hepatic tuberculosis
(B) Hepatitis B
(C) Isoniazid-induced hepatitis
(D) Pyridoxine-induced cholecystitis
(E) Tuberculous pancreatitis
Drug induced hepatitis
• Paracetamol overdose
• NSAIDs: ibuprofen & naproxen
• Anti-TB: isoniazid(I), rifampicin(R), pyrazinamide(Z)
• Amiodarone
• Anabolic steroids
• Alcohol
• Birth control pills
• Chlorpromazine
• Erythromycin
• Halothane
• Methyldopa
• Methotrexate
• Statins
• 131. An otherwise healthy 55-year-old Asian American man is given
isoniazid and vitamin B6(pyridoxine) after conversion of his PPD skin test.
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
likely explanation?
(A) Hepatic tuberculosis
(B) Hepatitis B
(C) Isoniazid-induced hepatitis
(D) Pyridoxine-induced cholecystitis
(E) Tuberculous pancreatitis
29
• 132. A 30-year-old man with peptic ulcer disease suddenly develops pain,
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
most appropriate to treat the acute symptoms in this patient?
(A) Allopurinol
(B) Colchicine
(C) Morphine
(D) Probenecid
(E) Sulfinpyrazone
Gouty arthritis
• uric acid overproduction & ↓renal excretion
• common in males, postmenopausal women, & drink
alcohol, DM, Renal failure
• Mono- or oligo- or poly-arthritis
• Synovial fluid: monosodium urate crystals
(needle shaped); negative birefringent
1
st
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,
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
most appropriate to treat the acute symptoms in this patient?
(A) Allopurinol
(B) Colchicine
(C) Morphine
(D) Probenecid
(E) Sulfinpyrazone
uricosuric agent
Inhibit xanthine oxidase purine↓ uric↓
inhibit neutrophil motility & activity
uricosuric agent
• 133. The thrombolytic effect of tissue plasminogen activator depends on
which of the following?
(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
Coagulation Pathway Coagulation Pathway
Stimulate= black or blue arrow
Inhibit= red arrow
Fibrinolytic system & tPA
30
• 133. The thrombolytic effect of tissue plasminogen activator depends on
which of the following?
(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
• 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 of cerebral blood flow
Systemic BP
Autoregulation
Similar to Renal BF
CBF = mABP - ICP
• 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?
• 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
Acute coronary syndrome
31
ACS
• Diagnosis
1.Clinical chest pain (angina)
2.EKG: Q,T wave, ST segment
3.Cardiac enzyme: CK-MB, Troponin-T or Trop-I
STEMI in Inferior wall
Ventricular fibrillation Ventricular fibrillation
Complication of MI
• Mechanical: Heart failure
– Ruptured free wall, VSD
– Ruptured papillary muscle
• Electrical: Arrhythmia
– Heart block
– Ventricular tachycardia (VT)
– Ventricular fibrillation (VF)
– Asytole
• 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
32
• 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
markings and hilar adenopathy. Which of the following findings is most likely
on transbronchial biopsy?
(A) Areas of hemorrhagic infiltrate
(B) Areas of liquefaction necrosis
(C) Dilation of respiratory bronchioles
(D) Microabscesses
(E) Noncaseating granulomas
Sarcoidosis
• immune system disorder & non-caseating
granuloma (small inflammatory nodules)
• Involve lungs & LN, hypercalcemia
• D/Dx TB (must to be excluded)
• Rx: corticosteroid
Hilar LN & bilat.
interstitial infiltration
• 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
markings and hilar adenopathy. Which of the following findings is most likely
on transbronchial biopsy?
(A) Areas of hemorrhagic infiltrate
(B) Areas of liquefaction necrosis
(C) Dilation of respiratory bronchioles
(D) Microabscesses
(E) Noncaseating granulomas
• 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
decreased size of the cortex?
(A) Autoimmune destruction
(B) Decreased ACTH concentration
(C) Decreased cortisol concentration
(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)
33
Adrenal insufficiency
• Cortisol ↓ & most decreased size of gland
• Primary AI: exogenous steroid↑, disease of
adrenal gland (tumor, trauma, infection,
autoimmune)
• Secondary AI (ACTH↓): Pituitary gland
disease(tumor, trauma, infection,autoimmune)
• Rx: corticosteroid replacement
• 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
decreased size of the cortex?
(A) Autoimmune destruction
(B) Decreased ACTH concentration
(C) Decreased cortisol concentration
(D) Denervation
(E) Granulomatous disease
• 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
Actinic keratoses
• not skin cancer. but precancerous
• Senile lesion
• indicates excess sun exposure
• Red. rough. scaly spots. may itch or sting
Melanoma
• Malignant of melanocyte
Mycosis fungoides
• cutaneous T-cell lymphoma
34
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
• 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
years ago. His diet consists primarily of cola and hot dogs.
Which of the following is the most likely diagnosis?
(A) Beriberi
(B) Kwashiorkor
(C) Pellagra
(D) Rickets
(E) Scurvy
Scurvy
• Vit.C deficiency (collagen synthesis)
• skin spots, spongy gums
• mucosal bleeding
corkscrew hair
periungual
hemorrhage
• 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
years ago. His diet consists primarily of cola and hot dogs.
Which of the following is the most likely diagnosis?
(A) Beriberi
(B) Kwashiorkor
(C) Pellagra
(D) Rickets
(E) Scurvy
Vit.B1(thiamine) def.: cardiac, nerve
Protein energy malnutrition (PEM): only protein
Vit.D def.:Ca↓, osteomalacia in adult
Vit.B3(Niacin) def.: 3D ‘Dermatitis,Diarrhea,Demetia’
Thank you & Good luck
• .vʽaa.a+..»aa..·»«»:·..·». USMLE step1
examination ¹a«
• www.usmle.org
• Click .+».« examination step 1
• .+».« step 1 content description
• .+».« learn more
• .+».« PDF step 1 sample test

Sign up to vote on this title
UsefulNot useful