~~

@@

1.Which statement regarding dyspnea is INCORRECT?

(A) Dyspnea is associated with a wide variety of disease
(B) In most forms of chronic heart failure, dypnea progresses slowly over
weeks or months
(C) Inspiratory dyspnea suggests obstruction of lower airways
(D) Paroxysmal nocturnal dyspnea is most commonly secondary to left
ventricular heart failure.

: (C) upper airways

(D) PND -> Awakening from sleep with shortness of breath

-> left ventricular heart failure or mitral stenosis

2.Which statement regarding S2 splitting in normal subjects is correct?

(A) Increased splitting during inspiration, decreased splitting during
expiration
(B) Decreased splitting during inspiration, increased splitting during
expiration
(D) The duration of splitting is usually longer than 0.08 sec.

: (A)

Normal splitting is accentuated by inspiration and usually disappears

on expiration.

3.Which of the following physical finding is LESS LIKELY in a patient with

chronic moderately severe hypertension and normal ventricular function?
(A)Sustained apical pulse
(B)S4 audible
(C)bounding pulse
(D)Hyperdynamic apical impulse and S3

: (D)

4.Which statement regarding jugular venous waves is INCORRECT?

(A) The amplitude of A wave increased in case of right ventricular
hypertrophy.
(B) The amplitude of V wave increased in case of tricuspid regurgitation.
(C) Deep Y descent in case of constrictive pericarditis
(D) A wave represents atrial relaxation

: (D)

a wave -> occurs before S1, reflects the slight rise in atrial pressure that
accompanies atrial contraction.
x decent -> starts with atrial relaxation
v wave -> During ventricular systole, blood continues to flow into the right
atrium from the vena cavae. The tricuspid valve is closed, the chamber begins
to fill, and right atrial pressure begins to rise again, creating the second
elevation, the v wave.
y descent -> When the tricuspid valve opens early in diastole, blood in the
right atrium flows passively into the right ventricle, and right atrial
pressure falls again, creating the second trough or y descent.

**Prominent a waves occur in increased resistance to right atrial

contraction, as in tricuspid stenosis; also in first-degree atrioventricular
block, supraventricular tachycardia, junctional rhythms, pulmonary
hypertension, and pulmonic stenosis. Absent a waves occur in atrial
fibrillation.
Large v waves occur in tricuspid regurgitation, and constrictive pericarditis

5.A bounding carotid pulse is LESS LIKELY to be noted in:

(A) Severe shock
(B) Anemia
(C) Hypermetabolic status
(D) Aortic regurgitation

: (A) BATES 393

The pulse pressure is increased, and the pulse feels strong and bounding.
The rise and fall may feel rapid, the peak brief. Causes include
(1)increased stroke volume, decreased peripheral resistance, or both, as in
fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous
fistulas, and patent ductus arteriosus;
(2) increased stroke volume because of slow heart rates, as in bradycardia
and complete heart block; and
(3) decreased compliance (increased stiffness) of the aortic walls, as
in aging or atherosclerosis.

6. Opening snap is usually audible in

(A) Aortic stenosis
(B) Mitral stenosis
(C) Mitral regurgitation
(D) Aortic regurgitation

: (B)

When an atrioventricular valve is narrowed, or stenotic, the opening of

the valve may be heard and is termed an opening snap.

7.A 18-year old female complained of excertional dyspnea. Physical

examination revealed diffuse apical impulse palpable over 6th intercostal
space, left anterior axillary line. Ausculatation showed S3 and Gr 4/6
pansystolic murmur over apex with radiating toward left axillary area. The
most likely diagnosis in thsi patient is:
(A) Severe mitral regurgitation
(B) Mild mitral regurgitation
(C) Severe aortic regurgitation
(D) Severe aortic stenosis

: (A) (A)

(C) -> murmur location: 2nd to 4th interspace; grade 1/6-3/6; radiation to
the apex
(D) -> murmur location: right 2nd interspace

8.A 20 year-old female was referred due to cardiac murmur since childhood.
Physical examination revealed pulsation over left 2nd intercostal space with
Gr 3/6 continuous murmur. The most likely diagnosis in this patient is:
(A) Ventricular septal defect
(B) Patent ductus arteriosus
(C) Pulmonary stenosis
(D) Aortic stenosis and regurgitation

: (B)

murmur location

murmur grade Gr 3/6 -> moderately loud

(A)3rd, 4th, and 5th left interspaces; often very loud, with a thrill (

Gr 4/6)
(B)left 2nd interspace
(C)2nd and 3rd left interspace; soft to loud intensity, if loud, associated
with a thrill
(D)aortic stenosis -> right 2nd interspace; sometimes soft butoften loud,
with a thrill
aortic regurgitation -> 2nd to 4th left interspaces

9. Which statement regarding cyanosis is INCORRECT?

(A) Clubbing of the digits is characteristic of peripheral cyanosis.
(B) Cyanosis resulted from an increased quantity of reduced hemoglobin or of
abnormal hemoglobin pigments in the blood perfusion these areas.
(C) Central cyanosis is characterized by decreased arterial oxygen saturation.
(D) Peripheral cyanosis is most commonly secondary to cutaneous
vasoconstriction.

: (A)

Clubbing of the fingers

-> Mechanism still unknown but involve vasodilation with increases blood
flow to the distal portion of the digits.
-> Clubbing of the nails is seen in association with central cyanosis and
significant cardiopulmonary disorders.
-> Central cyanosis occurs only after the oxygen saturation has fallen
below 80%.

10.The cardiac murmur usually become fainter on valsalva maneuver,except:

(A)Aortic stenosis
(B)rheumatic mitral regurgitation
(C)pulmonary stenosis
(D)idiopathic hypertrophy cardiomyopathy

: (D)

(1)The murmur of hypertrophic cardiomyopathy is the only systolic

murmur that increases during the strain phase of the Valsalva
maneuver due to increased outflow tract obstruction
(2)standing or strain phase of Valsalva
-> Arterial blood pressure, stroke volume, and the volume of blood in the
left ventricle all decline

-> Aortic stenosis intensity of murmur

hypertrophy cardiomyopathy intensity of murmur

(3)squatting or release of Valsalva

-> (2)

-> increased left ventricular volume, increased arterial blood pressure

-> Aortic stenosis intensity of murmur

hypertrophy cardiomyopathy intensity of murmur

11.A 50-year-old man was referred because of chest discomfort for 6

months. The chest discomfort was oppressive sensation in character, provoked
while exercise, relieved 5 minutes later by rest. Mild throat tightness was
noted while chest discomfort. The chest discomfort in this patient is most
likely due to:
(A) Neuromuscular chest pain
(B) Pleuritis
(C) Angina pectoris
(D) Reflux esophagitis

:(C)

chest pain

(C) -> Substernal pressure, worsen with exercise

(A) ->

(B) -> sharp pain

(D) -> , burning sensation

12. A 80-year-old femalewas referred because of exertional dyspnea. Physical

examination revealed weak and retarded carotid pulse, sustained PMI with S4,
Gr3/6 systolic ejection murmur over right upper sternal border with radiation
toward apex and both sides of neck. The etiology of dyspnea in this patient
is most likely due to
(A)mitral regurgitation
(B)aortic stenosis
(C)aortic regurgitation
(D)mitral stenosis

: (B)

(1)weak carotid pulse

a. decreased stroke volume, as in heart failure, hypovolemia, and severe
aortic stenosis;
b. increased peripheral resistance, as in exposure to cold and severe heart
failure.
(2)radiation
(A)to the left axilla, less often to the left sterna border
(B)often to the carotids, down the sterna border, even to the apex.
(C)if loud to the apex, perhaps to the right sterna angle
(D)little or no radiation

radiation (B)(C) carotid pulse (B)

Aortic regurgiation bounding pulse

lubay ()

Year4

[]

Sun Apr 13 12:12:27 2014

13. Cheyne-Stokes Respiration ?

(A)

(B)

(C)

(D)

: (A)

: 1. pattern
 2.?

3.normal adult , tachypnea & bradypnea

14.Which of the following will show Dullness when percussion of the chest?
(A)Emphysema
(B)Pneumothorax
(C)Pleural Effusion
(D)Bronchitis

: (C)

Hyperresonance -> emphysema, pneumothorax

Dull -> pneumonia, pleural effusion, atelectasis, tumor

15. Bronchial sound trachea 1/3

(A)asthma
(B)pneumonia
(C)pleural effusion
(D)Atelectasis

: (B)

-> If bronchovesticular or bronchial breath sounds are heard in locations

distant from those listed, suspect that air-filled lung has been replaced by
fluid-filled or solid lung tissue.

16.clubbing figers

(A) diffuse lung fibrosis

(B) mycoplasmal pneumonia
(C) lung cancer
(D) bronchiectasis
: (B)

Clubbing finger -> 1. (!!!)

2. Diffuse interstitial fibrosis

3. Suppurative lung disease (lung abscess, bronchiectasis,
empyema )

17. intercostal indrawing retraction of intercostal

muscle?

(A)

(B)

(C) COPD

(D)

: (A)-> Larger negative pressure during inspiration suck soft tissue

inwards.

18. barrel chest ?

(A)Emphysema
(B)Congestive heart failure
(C)Pulmonary embolism
(D)Pneumoia

: (A)

Barrel chest chronic emphysema !!!

 Pectus Excavatum & Pectus Carinatum ~

19. diaphragm movement, ?

(A) Marked atelectasis

(B) Pneumonia
(C) Emphysema
(D) Pneumothorax

: (A)(C) (B)(D) (B)@@

20. diaphragm movement

(A) 1~2 cm
(B) 3~5 cm
(C) 7~9 cm

(D)

: (B) =V=

: chest expansion 3.5 cm

21. Wheezing

(A) COPD
(B) asthma
(C) pneumonia
(D) heart failure

: (C)

Wheezing -> High-pitched, musical sounds, predominately in expiratory

asthma, COPD, chronic bronchitis, congestive heart failure

(cardiac asthma)

-> wheezing, crackles, stridor ?

22. stridor ?

(A)

(B)

(C)

(D)

: (A)

ppt Inspiratory

srtidor () ~(C)

23. Stridor

(A) vocal cord swelling

(B) asthma
(C) tracheomalacia
(D) tracheal tumor

: (B)

Stridor -> high pitched,

: foreign body, epiglottis, croup, tumor

(C)

(B) wheezing
24. Pneumonia ?

(A) Cyanosis
(B) Crackles
(C) Hyper-resonance percussion

(D) tactile fremitus

: (C)

Percussion 14 dull

Pneumonis percussion & tactile fremitus !!!

Tactile fremitus -> pneumonia, consolidation, atlectasis

Tactile fremitus -> pneumothorax, emphysema, pleural effusion/thickling,

COPD &

Atlectasis () tactile fremitus (absent)

()

1. Cheyne-Stokes Respiration?

(A) Severe heart failure

(B) Asthma
(C) Renal failure
(D) Meningitis

: (B)

: pattern !!

Cheyne-Stokes Respiration ->



1.Severe heart failure

2.Renal failure
3.Increased intracranial pressure
4.Meningitis
5.Drug overdose

2.Chronic cough

(A) 1

(B) 3

(C) 1

(D) 6

: (B) acute or chronic cough

3.Chronic cough

(A) postnasal drip

(B) gastrointestinal acid reflux
(C) asthma
(D) lung cancer

: (D)

1. (4 ) 2.(1/4) 3.(2 )

PS. allergic rhinitis, asthma, & COPD

Allergic rhinitis -> cobblestone, ,

Asthma ->

4. 30 1.5

(A) smoking 30 year

(B) smoking 45 pack-year
(C) smoking 1.5 pack per day
(D) smoking 30 year and 1.5 pack every day

: pack-year

x -> 30 x 1.5 = (B)

5. tactile fremitus

(A)

(B)

(C) COPD

(D)

: (D) 24

6. Which statement regarding dyspnea is INCORRECT?

(A) Dyspnea is associated with a wide variety of disease
(B) In most forms of chronic heart failure, dyspnea progresses slowly over
weeks or months
(C) Inspiratory dyspnea suggests obstruction of the lower airways
(D) Paroxysmal nocturnal dyspnea is most commonly secondary to left
ventricular heart failure.

: (C) upper airways

(D) PND -> Awakening from sleep with shortness of breath

 -> left ventricular heart failure or mitral stenosis

lubay ()

Year4

[]

Sun Apr 13 03:44:04 2014

44. abdominal PE in the patient with abdominal pain.

A. InspectionPalpationPercussionAuscltation

B. InspectionPalpationAuscultationPercussion

C.InspectionAuscultationPalpationPercussion

D.AuscultationInspectionPalpationPercussion

: (C) !!!!

45.

A. Sensitivity.
B. Speficity.
C. Positive likeihood ratio.
D. Positive predictive value.

: @@ (D)

46. PE liver cirrhosis

A. Superficial vein engorgement on abdominal wall indicates portal
hypertension.
B. Spider naevi on forechest indicates portal hypertension.
C. Shifting dullness indicates portal hypertension.
D. Spenomegaly indicates portal hypertension.

: (B)

Liver cirrhosis
(1)portal hypertension
a. superficial vein engorgement
b. ascites -> shifting dullness, fluid wave
c. splenomegaly
(2)sign of hyper-estrogenemia
a. spider angioma or naevi
b. palmar erythema
c. gynecomastia
d. testicle atrophy

47. The function of abdominal physical examination is below, which of the

following is incorrect?
A. To diagnosis the disease
B. To ensure the severity of disease
C. To screen the disease of high prevalence
D. None the the above

: (D) PE

48.Which is true about Grey Turner's sign ?

A.Echymosis around periumbilical area.
B.Blood from retroperitonium to the abdominal musculature and subcutaneous
tissue.
C.Its sensitivity is high for acute pancreatitis.
D.It is specic for acute pancreatitis.

: (B)

(A)-> Ecchymosis of the flanks

(C)(D) -> Poor sensitivity & specificity in patients with acute pancreatitis.

PS. Cullen's sign !!!

-> Peri-umbilical ecchymosis!!!

49. Which statement below is correct about McBurneys point?

(A)It is located at the right upper quadrant region.
(B)It is at the mid-point of an imaginary line connecting umbilicus and ASIS.
(C)Presence of tenderness indicates acute cholecystitis.
(D)It is not useful in diagnosing retrocecal appendicitis.

: (D)

McBurney's point
-> acute appendicitis
-> right lower region
-> one-third of the distance from the anterior superior iliac spine to the
umbilicus (navel).

( ASIS 1/3)

(C)acute cholecystitis -> Murphy sign

50. How do you calculate positive predictive value?

(A)a/a+b (C)b/b+d
(B)a/a+c (D)d/b+d
D(+) D(-)
Positive a c
Negative b d

: Positive Predictive Value (PPV)

= True positives/All patients with positive test = a/a+c -> (B)

lubay ()

Year4

[]
 Sun Apr 13 20:20:50 2014

PPT fever pattern

PPT (ex.Collagen vascular disorders)

:edema , E4V5M6, breath sound

37.Which of the following statements for chief complain is better?

(A) upper respiratory tract infection for three days
(B) periumbilical dull pain since yesterday
(C) renal tumor for three years
(D) all of the above

: (B)

-> + !!!

38.The followling picture demonstrate different heart sound in respiration,

which of the following statement is correct?

( wide/fixed/paradoxial splitting, expiration/inspiration,

S1/S2 )

( History taking ppt 91 )

(A)wide splitting of S2 usually occur in complete right branch bundle block

(B)fixed splitting of S2 is happened in atrial septum defect
(C)paradoxial splitting of S2 occur in complete left branch bundle block
(D)all of the above

: (D)

(A)-(C) !!!

39. present illness

(A)clear, complete, chronologic account of the problem

(B)problems LQQ-OPERA(location, quantity......)
(C)differicial diagnosis
(D)all above

: (D)

40. Which of following guide line of history taking is wrong?

(A)maintain privacy
(B)do not overtire the patient
(C)accept a previous diagnosis
(D)avoid using a manuver that suggest you only a yes or no answer

: (C)

41. personal and social history,?

(A)

(B)

(C)
(D)

: (D)

Personal & social history

43. Which of the following is the respiratory pattern of Cheyne-Stokes

A~D pattern cheyne-stokes(

apnea )

: !!!! ppt.85 !!!!

1. Which of the following statements for history taking is correct?

(A) The written history should embody all the facts of medical significance
in the life of the
patient.
(B) An informative history is more than an orderly listing of symptoms
(C) Recent events should be given the most attention
(D) All of the above

: (D)

2. Which of the following factor is important in history taking?

(A) allergies or drug reaction in the past medical history
(B) cause of death in family history
(C) recent travel abroad in personal & social history
(D) All of the above

: (D)
3. Regarding the diagnostic process, which of the following sequence is
correct?
(1) develop hypothesis (2) modify your differential diagnosis (3) take a
history (4) generate a differential diagnosis (5) perform a physical
examination (6) test your hypothesis

(A) 1 3 4 2 5 6

(B) 3 1 5 4 6 2

(C) 3 5 4 2 1 6

(D) 3 4 5 2 1 6

: (B)

4. Which of the following statements regarding inspection and palpation of

the precordium is true?
(A) The point of maximal impulse and the cardiac apex impulse are synonymous.
(B) High frequency movements, such as ejection sounds and valve closure
sounds, are best assessed by palpation with the finger pads.
(C) A systolic thrill over the left chest usually means Grade 4~6 murmur.
(D) A sustained apex impulse indicates left ventricular dilation.

: (C)

(A) right ventriclar hypertrophy

PMI xiphoid or epigastric area apex

(B)High frequency movements, such as ejection sounds, valve closure sounds,

and mitral opening snaps are detected more easily with the hand held firmly
against the chest wall; whereas lower frequency movement such as ventricular
diastolic filling events are best recognized with light pressure with the
fingertips.
(D) A sustained, high-amplitude impulse that is normally located suggests
left ventricular hypertrophy from pressure overload (as in hypertension)
A sustained low-amplitude (hypokinetic) impulse is seen in dilated
cardiomyopathy.

: dilatation hypertrophy!!!!!

5. A 52-year-old man presents to the emergency department complaining of

chest pain that started 30 minutes ago. What would be most important initial
step for this patient?
(A) Asking what happened before chest pain
(B) Checking vital signs first
(C) Chest X-ray and ECG right away
(D) On critical

: (B) vital sign

6. A 23-year-old male college student is found passed out in the door if his
dormitory. On
physical examination, the blood pressure is 120/80 mmHg, the pulse rate is
80/min. Which of
the following is the most important history for this patients condition?
(A) Seizure history
(B) Diabetes mellitus history
(C) Alcohol consumption history
(D) All of the above

: (D) !!!!

7. A 62-year-old woman comes to your office complaining of fatigue and

tiredness for the past
months. Her hair is dry and coarse. Her lateral eyebrows become thin. She has
a puffy dull face
with dry skin. What is your tentative diagnosis for this patient?
(A) Parkinsonism
(B) Acromegaly
(C) Hypothyroidism
(D) Nephrotic syndrome

: (C) ~~

(1)Myxedema: The patient with severe hypothyroidism (myxedema) has a dull,

puffy facies. The edema, often pronounced around the eyes, does not pit with p\
ressure. The hair
and eyebrows are dry, coarse, and thinned. The skin is dry.
(2)Cushing's Syndrome: The increased adrenal cortisol production of
Cushing's syndrome produces a round or moon face with red cheeks.
Excessive hair growth may be present in the mustache and sideburn areas and
on the chin.
(3)Acromegaly: The increased growth hormone of acromegaly produces
enlargement of both bone and soft tissues. The head is elongated, with bony
prominence of the forehead, nose, and lower jaw. Soft tissues of the nose,
lips, and ears also enlarge. The facial features appear generally coarsened.
(4)Nephrotic Syndrome: The face is edematous and often pale. Swelling
usually appears first around the eyes and in the morning. The eyes may become
slitlike when edema is severe.