1. A 48 year old female came into your office for a routine checkup. Her BP is 180/100.

During her previous checkups, her BP has been 110-120/80. Her BMI is 27. She is a nonsmoker and drinks 2 glasses of wine a few times a week. Her father died of a heart attack at 68 years old. What should be your recommendations to her during this initial visit? a. She should limit her alcohol intake to 2 glasses of alcohol per day. b. She should start anti-hypertensive medications immediately. c. She should be encouraged to lose weight with a target BMI of less than 25. d. She should start engaging in resistance training on most days of the week. Health-promoting lifestyle modifications are recommended for individuals with pre-hypertension (120-139 / 80-89) and as an adjunct to drug therapy in hypertensive individuals. weight loss and reduction of dietary NaCl have been shown to prevent the development of hypertension. Drug therapy is recommended for individuals with blood pressures 140/90 mmHg. HPIM, 17th ed. Chapter 241 Hypertensive Vascular Disease > Treatment: Hypertension 2. At what blood pressure levels is maximum protection against combined cardiovascular endpoints achieved? a. <120-125 systolic and <75-80 diastolic b. <135-140 systolic and <80-85 diastolic c. <140-145 systolic and <90-95 diastolic d. <100-115 systolic and <75-80 diastolic Maximum protection against combined cardiovascular endpoints is achieved with pressures <135 140 mmHg for SBP and <80 85 mmHg for DBP.... More aggressive blood pressure targets for blood pressure control (< 130/80 mmHg) may be appropriate for patients with diabetes, CHD, chronic kidney disease, or with additional cardiovascular disease risk factors HPIM, 17th ed. Chapter 241 Hypertensive Vascular Disease > Treatment: Hypertension 3. Which of the following lipid profile abnormalities are most commonly seen in type 2 DM patients? a. high LDL, low HDL b. High triglycerides, low HDL c. Low LDL, low HDL d. Low triglyceride, high HDL Low levels of HDL cholesterol, often associated with elevated triglyceride levels, are the most prevalent pattern of dyslipidemia in people with type 2 diabetes. ADA Standards of Medical Care in Diabetes 2010 Part VI. Prevention and Management of Diabetes Complications 4. What is the target BP of hypertensive patients with type 2 DM and macroalbuminuria? a. < 120/80 mm Hg b. < 125/75 mm Hg c. < 130/75 mm Hg d. < 140/90 mm Hg Many individuals with type 1 or type 2 DM develop hypertension. Numerous studies in both type 1 and type 2 DM demonstrate the effectiveness of strict blood pressure control in reducing albumin excretion and slowing the decline in renal function. Blood pressure should be maintained at <130/80 mmHg in diabetic individuals without proteinuria. A slightly lower blood pressure (125/75) should be considered for individuals with microalbuminuria or macroalbuminuria HPIM, 17th ed. Chapter 338 Diabetes Mellitus

5. A 42 year old female from the Cordilleras consults at the OPD for an anterior neck mass that has enlarged slowly over the past 10 years. History reveals that she has a daughter with developmental abnormalities. What is the expected thyroid function test of this patient? a. Elevated FT4, elevated TSH b. Low FT4, low TSH c. Elevated FT4, low TSH d. Low FT4, elevated TSH In areas of relative iodine deficiency, there is an increased prevalence of goiter and, when deficiency is severe, hypothyroidism and cretinism. Cretinism is characterized by mental and growth retardation and occurs when children who live in iodine-deficient regions are not treated with iodine or thyroid hormone to restore normal thyroid hormone levels during early life. These children are often born to mothers with iodine deficiency, and it is likely that maternal thyroid hormone deficiency worsens the condition. HPIM, 17th ed. Chapter 335. Disorders of the Thyroid Gland > Hypothyroidism 6. Which of the following is the preferred treatment for Graves disease in pregnant women? a. Methimazole b. Propylthiouracil c. SSKI (Saturated solution Potassium Iodide) d. Radioiodine D is an absolute contraindication to pregnancy and breastfeeding moms. - HPIM 17th ed. Chapter 335. Some clinicians prefer propylthiouracil (PTU) because it crosses the placenta less readily than methimazole. Although not definitely proven, methimazole in early pregnancy rare methimazole embryopathy (esophageal or choanal atresia, aplasia cutis). PTU still is the preferred thionamide in the United States Williams Obstetrics, 23rd ed. Chapter 53. Thyroid and Other Endocrine Disorders. (wala sa Harrison s eh, except for the one about RAI contraindications) 7. A patient you are treating with methimazole comes to your clinic complaining of oral ulcers, fever, and sore throat 1 week after you prescribed the medication. What would you do? a. Observe closely and reassure patient b. Continue methimazole at a lower dose c. Shift her to another anti-thyroid drug d. Stop medication and do CBC Common side effects of antithyroid drugs: rash, urticaria, fever, and arthralgia (1 5% of patients) which may resolve spontaneously or after substituting an alternative drug. Rare but major side effects: hepatitis, SLE-like syndrome, and, most importantly, agranulocytosis (<1%). It is essential that antithyroid drugs are stopped and not restarted if a patient develops major side effects. Written instructions should be provided regarding the symptoms of possible agranulocytosis (e.g., sore throat, fever, mouth ulcers) and the need to stop treatment pending a CBC to confirm that agranulocytosis. But it s not useful to monitor blood counts prospectively, as the onset of agranulocytosis is idiosyncratic and abrupt. - HPIM 17th ed. Chapter 335 Chapter 335 Disorders of the Thyroid Gland 8. According to the Philippine Guideline on Periodic Health Examination, screening of all individuals for type 2 Diabetes Mellitus should begin at what age? a. 35 b. 40 c. 45 d. 50 9. In what phase of pneumonia do we see predominance of neutrophils, fibrin deposition, disappearance of bacteria, and improvement of gas exchange?

a. b. c. d. Classic 1)

Edema Red hepatization Gray hepatization Resolution Pneumonia phases: edema- proteinaceous exudates + bacteria in alveoli. This phase is rarely evident in clinical or autopsy specimens because it is so rapidly followed by 2) red hepatization phase: erythrocytes in the intraalveolar exudates + neutrophils (important from the standpoint of host defense). Bacteria occasionally seen in cultures 3) gray hepatization, no new erythrocytes are extravasatingold ones have been lysed and degraded + pinakasikat ang NEUTROPHILS + abundant fibrin deposition + bacteria disappeared This phase = successful containment of infection and improvement in gas exchange. 4) resolution, macrophage is dominant cell type in the alveolar space+ debris of neutrophils, bacteria, and fibrin has been cleared HPIM 17th d. Chapter 251 Pneumonia

10. What is the major risk factor for asthma? a. Atopy b. Family history of asthma c. Age d. Environmental setting Atopy is the major risk factor for asthma. whether or not the genes predisposing to asthma are similar or in addition to those predisposing of atopy is not yet clear. It is likely that environmental factors in early life determine which atopic individuals become asthmatic. HPIM 17th ed., Chapter 248 Asthma 11. Which finding, if found in a COPD patient, should make you suspect a lung malignancy? a. Cyanosis b. Clubbing c. Hemoptysis d. Muscle wasting Clubbing of the digits is not a sign of COPD the development of lung cancer is the most likely explanation for newly developed clubbing. - HPIM 17th ed, Ch. 254, Physical Findings 12. What is the main preventive measure for community-acquired pneumonia? a. Avoidance of self-medication with antibiotics b. Healthy diet and smoking cessation c. multivitamins with zinc d. Vaccination The main preventive measure is vaccination. HPIM 17th ed. Chapter 251 Pneumonia The mainstays of CAP prevention are pneumococcal and influenza vaccination. PSMID CAP 2010 13. What is the most common etiology of secondary hypertension? a. Medications b. Vigorous coughing c. Primary renal disease d. Phaeochromocytoma Primary renal disease is the most common etiology of secondary hypertension. - HPIM 17th ed, Ch. 241 Hypertensive Vascular Disease

14. What is the most widely used test for both the diagnosis of ischemic heart disease and estimating the prognosis? a. Treadmill Stress test b. 2D echocardiography with Doppler studies c. Thallium perfusion scan d. Coronary angiography The most widely used test for both the diagnosis of IHD and estimating the prognosis involves recording the 12-lead ECG before, during, and after exercise, usually on a treadmill - HPIM 17th ed, Ch. 237, under Stress Testing 15. A 50 year old female comes to your clinic wanting to know about her risk of having a heart attack. She is a smoker. Her last menstrual period was about 8 years ago. Her BP is 120/80 and her BMI is 21. Physical Examination is unremarkable. The following factors increase her risk for ischemic heart disease EXCEPT: a. postmenopausal b. cigarette smoking c. family history d. Age Risk factor: Age (men 45 years; women 55 years) HPIM 17th ed, Ch. 235, Table 235-1 Major Risk Factors 16. What is the LDL goal for patients with acute coronary syndrome or coronary heart disease with diabetes or multiple coronary risk factors? a. < 70 b. < 100 c. < 130 d. < 160 In individuals with overt CVD, a lower LDL cholesterol goal of <70 mg/dL (1.8 mmol/L), using a high dose of statin, is an option. ADA 2010 Less than 70 mg/dL for those with heart or blood vessel disease and for other patients at very high risk of heart disease (those with metabolic syndrome) National Cholesterol Education Program's (NCEP's) Expert Panel Guidelines 17. A 54 year old male consults for dyspnea on exertion that started 6 months ago. Physical examination shows the apex beat displaced to the 6th intercostal space, left anterior axillary line; Gr. 3/6 systolic murmur at the midaxillary line; and fine crackles, both lung bases. What should be your primary therapeutic goal for this patient at this point? a. Alleviate fluid retention b. Prevent cardiac remodeling with medications c. Control blood pressure d. Reduce risk of further disease progression For patients who have developed symptoms (class II IV NYHA Classification), the primary goal should be to alleviate fluid retention, lessen disability, and reduce the risk of further disease progression and death. These goals generally require a strategy that combines diuretics (to control salt and water retention) with neurohormonal interventions (to minimize cardiac remodeling). - HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale 18. Which of the following drugs used for patients with heart failure is NOT correctly matched with the special population for which it is indicated? a. Digoxin heart failure with atrial fibrillation

b. Warfarin dilated LV with depressed LV function c. Angiotensin Receptor Blocker ACE intolerant d. Spironolactone renal insufficiency (Creatinine clearance <30 ml) A. Digoxin: symptomatic LV systolic dysfunction + concomitant atrial fibrillation; should be considered for those with Sx and symptoms of HF while receiving standard therapy, including ACEI and B-blockers. B. Warfarin [goal NR: 2.0 3.0]: HF + chronic or paroxysmal a. fib, or with history of systemic or pulmonary emboli (stroke or TIA). Patients with symptomatic or asymptomatic ischemic cardiomyopathy and documented recent large anterior MI or recent MI with documented LV thrombus should be treated with warfarin. C. ARBs are well tolerated in patients who are intolerant of ACE inhibitors because of cough, skin rash, and angioedema. D. Aldosterone antagonists are not recommended when serum Cr is >2.5 mg/dL (Cr clearance is <30 mL/min) or when the serum K is >5.0 mmol/L. - HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale 19. What is the most common cause of Cor Pulmonale? a. Chronic Bronchitis b. Recurrent pulmonary embolism c. RV failure d. Pulmonary Hypertension Cor pulmonale develops in response to acute or chronic changes in the pulmonary vasculature and/or the lung parenchyma that are sufficient to cause pulmonary hypertension. COPD and chronic bronchitis are responsible for approximately 50% percent of the cases of cor pulmonale in North America. According to Dr. Palileo, the root cause is COPD which leads to pulmonary hypertension (the pathologic mechanism) which then results to cor pulmonale. The question is pertaining to the root cause. b. - HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale 20. Which of the following is NOT an effect of B adrenergic agonists on airways: a. Relaxation of airway smooth muscle b. Inhibition of mast cell mediator release c. Increased mucociliary clearance d. Decrease of chronic inflammation when used over time Table 248-3 Effects of B2-Adrenergic Agonists on Airways Relaxation of airway smooth muscle (proximal and distal airways) Inhibition of mast cell mediator release Inhibition of plasma exudation and airway edema Increased mucociliary clearance Increased mucus secretion Decreased cough No effect on chronic inflammation - HPIM 17th ed. Chapter 248 Asthma 21. Which of the following is a cardinal symptom of heart failure? a. Shortness of breath b. Palpitation c. Chest pain d. Bipedal edema The cardinal symptoms of HF are fatigue and shortness of breath. - HPIM 17th ed., Chapter 227 Heart Failure and Cor Pulmonale

22. Which of the following has been shown to reduce mortality in patients with COPD? a. Oral glucocorticoids b. Inhaled glucocorticoids c. Supplemental oxygen d. Long-acting Beta agonists Supplemental O2 is the only pharmacologic therapy demonstrated to decrease mortality in patients with COPD. For patients with resting hypoxemia (O2 saturation <88% or <90% with signs of pulmonary HTN or RHF), O2 has been demonstrated to have a significant impact on mortality. - HPIM 17th ed., Chapter 254 Chronic Obstructive Pulmonary Disease 23. The major features of Metabolic Syndrome are the following EXCEPT: a. peripheral obesity b. hypertension c. hyperglycemia d. dyslipidemia Features of Metabolic Syndrome: 1) Central obesity: Waist circumference >102 cm (M), >88 cm (F) 2) Hypertriglyceridemia: Triglycerides >150 mg/dL or specific medication Low HDL cholesterol: <40 mg/dL and <50 mg/dL, respectively, or specific medication 3) Hypertension: Blood pressure >130 mm systolic or >85 mm diastolic or specific medication 4) Fasting plasma glucose >100 mg/dL or specific medication or previously diagnosed type 2 diabetes - HPIM 17th ed., Chapter 236. The Metabolic Syndrome 24. A previously healthy 19-year-old consults you for productive cough and fever of 3 weeks duration. You diagnose him with community-acquired pneumonia. Based on the 2010 Philippine Guidelines, which antibiotic would you prescribe? a. Amoxicillin b. Levofloxacin c. Cefuroxime d. Cotrimoxazole For low-risk CAP without comorbid illness, amoxicillin remains the standard drug of choice (Grade A) PSMID CAP 2010 25. A 65 year old male comes to your clinic complaining of persistent productive cough with whitish sputum but no fever. For the last 2 months he has noted increasing dyspnea on exertion. He has been smoking 1-2 packs of cigarettes a day for the last 40 years. Physical examination is normal. You would expect to find the following on the chest x-ray EXCEPT: a. Cardiomegaly b. flattening of the diaphragm c. Hyperlucency d. bullae In COPD: Obvious bullae, paucity of parenchymal markings, or hyperlucency suggest the presence of emphysema. Increased lung volumes and flattening of the diaphragm suggest hyperinflation but do not provide information about chronicity of the changes. - HPIM 17th ed., Chapter 254 Chronic Obstructive Pulmonary Disease 26. What is the drug of choice for Prinzmetal s Variant Angina? a. ACE-inhibitor b. Beta Blocker c. Diuretics d. Calcium Channel Blocker

EXPLANATION: Nitrates and CCBs are the main treatments for patients with variant angina. SL or IV nitroglycerin often abolishes episodes of variant angina promptly, and long-acting nitrates are useful in preventing recurrences. Calcium antagonists are extremely effective in preventing the coronary artery spasm of variant angina, and they should be prescribed in maximally tolerated doses. HPIM 17th ed., Chapter 238. Unstable Angina and Non-ST-Elevation Myocardial Infarction

27. Resistant hypertension refers to patients with BP persistently _______ despite taking 3 or more antihypertensive agents, including diuretics, in combination and at full doses. a. > 140/90 mm Hg b. > 160/90 mm Hg c. > 180/100 mm Hg d. > 200/100 mm Hg EXPLANATION: Verbatim from Chapter 241. Hypertensive Vascular Disease > Blood Pressure Goals for Hypertensive Therapy

28. What test differentiates obstructive lung disease from restrictive lung disease? a. Chest X-ray b. Spirometry c. Chest CT scan with Contrast d. History and Physical Examination EXPLANATION: The two major patterns of abnormal ventilatory function, as measured by static lung volumes and spirometry, are restrictive and obstructive patterns . . . . In the obstructive pattern, the hallmark is a decrease in expiratory flow rates. The hallmark of a restrictive pattern is a decrease in lung volumes, primarily TLC and VC. - HPIM 17th ed., Chapter 246. Disturbances of Respiratory Function

29. In which of the following patients would you consider treatment for Hepatitis B infection? a. 28 year old seaman who is HBsAg reactive, HBeAg negative, with normal ALT (3rd row) b. 35 year old laboratory technician who is HBs reactive, HBe reactive, with elevated ALT (2.5x the upper limit of normal) (Acute or Chronic) c. 45 year old executive who is HBsAg reactive, anti-HBe reactive, with ALT 1.5x the normal value (3rd row) d. 43 year old nurse who is anti-HBS reactive, anti-HBe reactive, with elevated ALT (2x the upper limit of normal)4th row, or recovery from Hep B EXPLANATION: A. Late acute or chronic hepatitis, low infectivity B. Acute or Chronic Hepatitis B, high infectivity C. Late acute or chronic hepatitis, low infectivity D. Recovery from Hep B/ HBsAg of one subtype and heterotypic anti-HBs (common)

- HPIM 17th ed., Chapter 298 Acute Viral Hepatitis, Table 298.3 30. The following are considered first line anti-TB drugs EXCEPT: a. Rifampicin b. Isoniazid c. Pyrazinamide d. Streptomycin EXPLANATION: Four major drugs are considered the first-line agents for the treatment of TB: isoniazid, rifampin, pyrazinamide, and ethambutol HPIM 17th ed., Chapter 158 Tuberculosis 31. Which of the following is the most potent anti-TB drug? a. Rifampicin b. Isoniazid c. Pyrazinamide d. Streptomycin Rifampin, a semisynthetic derivative of Streptomyces mediterranei, is considered the most important and potent antituberculous agent. It is also active against a wide spectrum of other organisms, including some gram-positive and gram-negative bacteria, Legionella spp., M. kansasii, and M. marinum.- (HPIM 17th ed) 32. Which is the most common extrapulmonary site for tuberculosis? a. Liver b. Larynx c. Lymph node d. Spine In order of frequency, most common extrapulmonary sites of TB: lymph nodes (40%) > pleura > GUT > bones and joints > meninges > peritoneum > pericardium

HPIM 17th ed., Chapter 158 Tuberculosis 33. The following adverse drug reactions are correctly matched to the known anti-TB meds EXCEPT: a. Isoniazid - Seizures b. Rifampicin - Hyperuricemia c. Pyrazinamide Hepatotoxicity d. Streptomycin - Ototoxicity A. Isoniazid: The two most important adverse effects of isoniazid therapy are hepatotoxicity and peripheral neuropathy. Other adverse reactions are either rare or less significant and include rash (2%), fever (1.2%), anemia, acne, arthritic symptoms, a systemic lupus erythematosus like syndrome, optic atrophy, seizures, and psychiatric symptoms. B. Rifampin: rashes, thrombocytopenia, nephritis, cholestatic jaundice, occasionally, hepatitis, light-chain proteinuria. If administeres less often than 2x weekly, it causes a flu-like syndrome (fever, chills, myalgia, anemia, thrombocytopenia, sometimes associated with acute tubuar necrosis) C. Pyrazinamide: hepatotoxicity, nausea, vomiting, drug fever, hyperuricemia. Optic neuritis is an adverse effect of Ethambuto/Streptomycin. D. Streptomycin: ototoxic, nephrotoxic, vertigo, hearing loss. Pyrazinamide is the one that usually causes hyperuricemia. - Katzung Basic and Clinical Pharmacology 11th ed.. Chapter 47 Antimycobacterial Drugs (Wala sa Harrison s, or at least, hindi in depth ang discussion) 34. A 67 year old male patient is brought to your clinic by his relatives for sudden onset of weakness of the right lower extremity. Which of the following signs will point to an upper motor neuron problem? a. Decreased muscle tone b. Presence of fasciculations c. Proximal muscle atrophy

d. Hyperactive tendon reflexes

HPIM 17th ed. Chapter 23 Weakness

35. The following medications may be used for prophylaxis against NSAID-related mucosal injury EXCEPT: a. Misoprostol b. Bismuth c. Proton pump inhibitor d. Selective COX-2 inhibitor -HPIM 17th ed. Chapter 287 Peptic Ulcer Disease, Table 5 contains Prophylactic therapy (w/c include the 3 above)

36. Chest pain that presents as a severe ripping and tearing pain or a sudden severe sharp pain in the front of the chest that extends into the back, between the shoulder blades is characteristic of what condition? a. Acute pericarditis b. Pulmonary embolism c. Aortic dissection d. Acute myocardial infarction Unlike the pain of IHD, symptoms of AD tend to reach peak severity immediately, often causing patient to collapse from intensity. The classic teaching is that the adjectives used to describe the pain reflect the process occurring within the wall of the aorta "ripping" and "tearing" but more recent data suggest that the most common presenting complaint is sudden onset of severe, sharp pain. HPIM 17th ed. Chapter 13. Chest Discomfort 37. A 65 year old male consults your clinic for loss of consciousness. His son found him seated on the bathroom floor this morning, looking confused. When asked what happened, all he could remember was that he was turning his head to the side while shaving. There were no prior episodes reported. He takes hydrochlorothiazide daily for hypertension. There were no deficits on neurologic exam. Which of the following would you LEAST consider in this patient? a. Cardiac arrhythmia b. Ischemic stroke c. Orthostatic hypotension d. carotid sinus hypersensitivity "A stroke, or cerebrovascular accident: abrupt onset of neurologic deficit attributable to focal vascular cause..." "call emergency medical services immediately if they experience or witness the sudden onset of any of the following: loss of sensory and/or motor function on one side of the body (~85% of ischemic stroke patients have hemiparesis); change in vision, gait, or ability to speak or understand; or if they experience a sudden, severe headache. HPIM 17th edition, Ch. 364 Cerebrovascular disease 38. A 40 year old female comes to your clinic for right leg edema, gradually worsening over the past few months. There was initially no limitation in her daily activities, but recently, she has started to have difficulty walking long distances because of heaviness of the right leg. There were no other symptoms. You note erythema, warmth and tenderness on examination of the right leg with hyperpigmentation of the skin and ulceration near the malleoli. What is your primary impression? a. lymphedema tarda b. chronic venous insufficiency c. cellulitis d. peripheral arterial occlusive disease Patients with venous insufficiency often complain of a dull ache in the leg that worsens with prolonged standing and resolves with leg elevation. Examination demonstrates increased leg circumference, edema, and superficial varicose veins. Erythema, dermatitis, and hyperpigmentation develop along the distal aspect of the leg, and skin ulceration may occur near the medial and lateral malleoli. - HPIM 17th ed. Chapter 243 Vascular Diseases of the Extremities 39. Chest pain that presents as a sharp retrosternal chest pain that sometimes radiates to the left shoulder and is relieved by sitting up and leaning forward is characteristic of which of the following conditions? a. Pulmonary embolism b. Esophageal reflux c. Acute pericarditis d. Acute myocardial infarction

Perdicarditis: most typically, pain is retrosternal, aggravated by coughing, deep breaths, or changes in position (movement of pleural surfaces). Pain often worse while supine, and relieved by sitting upright and leaning forward - HPIM 17th ed. Chapter 13. Chest Discomfort 40. Which of the following laboratory findings may distinguish a cardiac from a renal cause of edema? a. Hyponatremia b. Azotemia c. Pulmonary congestion on chest x-ray d. Elevated liver transaminases AST is also elevated in cardiac conditions, unaffected in renal diseases. 41. What is the initial analgesic of choice for patients with osteoarthritis? a. tramadol b. celecoxib c. ibuprofen d. acetaminophen answer: D 42. A 57 year old male patient consults you for yellow discoloration of his skin. He does not complain of abdominal pain, nausea or vomiting but reports that he has lost about 5 kg in the past month. On physical exam, you note a vague epigastric mass on deep palpation and excoriation on his skin. There is no Murphy's sign. Which of the following abnormalities do you expect to be on blood chemistry? a. prolonged protime b. decreased serum albumin c. elevated alkaline phosphatase d. normal total bilirubin Answer: C. The patient has cholangiocarcinoma 43. A 67 year old man comes to your clinic for burning epigastric pain that radiates to the retrosternal area, exacerbated by means and sometimes wakens him from sleep, leaving a sour taste in his mouth. Which of the following signs would warrant further evaluation prior to empiric treatment? a. occasional vomiting b. pallor c. early satiety d. bloatedness answer: B. Pallor is a danger sign 44. In which of the following conditions would emesis relieve abdominal pain? a. renal colic b. acute pancreatitis c. esophageal reflux d. small bowel obstruction answer: D 45. A 75 year old male consults your clinic for vomiting of previoiusly ingested food associated with bloatedness, flatulence, and weight loss. He also complains of nocturia, dizziness upon getting up from bed, and tingling of the fingers and toes. Physical examination reveals anhidrosis and areas of hyperpigmentation over both lower extremities. Which of the following medication would you prescribe to relieve his symptoms? a. ondansetron b. lorazepam c. meclizine

d. metoclopromide Answer: D Ondansetron is used to relieve chemotherapy induced vomiting Lorazepam is used to relieve anticipatory vomiting in chemotherapy Meclizine is used for motion sickness Metoclopromide is used as a prokinetic drug. Patient has gastroparesia from Diabetes Mellitus type 2 46. What is the leading cause of mortality and morbidity in patients with CKD? a. Cerebrovascular disease b. Significant uremia c. Cardiovascular disease d. Infectious disease Since diabetes mellitus and hypertension are the two most frequent causes of advanced CKD, it is not surprising that cardiovascular disease is the most frequent cause of death in dialysis patients. HPIM 17th ed. Chapter 274 Chronic Kidney DIsease

47. The following conditions may produce vomiting within 1 hour of eating EXCEPT: a. Diabetic gastropathy b. Food poisoning c. Gastric carcinoma d. Chemotherapy Pyloric obstruction and gastroparesis produce vomiting within 1 h of eating Chemotherapy causes vomiting that is acute (within hours of administration), delayed (after 1 or more days), or anticipatory. HPIM 17th ed. Chapter 39 Nausea, Vomiting and Indigestion 48. The reason for the secondary anemia in patients with CKD is a. Intermittent GI blood loss b. Iron deficiency c. Loss of bone marrow stimulation d. Vitamin deficiency A normocytic, normochromic anemia is observed as early as stage 3 CKD and is almost universal by stage 4. The primary cause in patients with CKD is insufficient production of erythropoietin (EPO) by the diseased kidneys. Additional factors include iron deficiency, acute and chronic inflammation with impaired iron utilization, severe hyperparathyroidism with consequent bone marrow fibrosis, and shortened red cell survival in the uremic environment. Less common causes include folate and vitamin B12 deficiency and aluminum toxicity. HPIM 17th ed. Chapter 274 Chronic Kidney Disease 47. What is the cornerstone of diagnosis in patients suspected to have acute severe infectious diarrhea? a. proctosigmoidoscopy b. abdominal CT scan c. stool microbiologic studies d. serology The cornerstone of diagnosis in suspected severe acute infectious diarrhea is microbiologic analysis of the stool. Workup includes cultures for bacterial and viral pathogens, direct inspection for ova and parasites,

and immunoassays for certain bacterial toxins (C. difficile), viral antigens (rotavirus), and protozoal antigens (Giardia, E. histolytica). HPIM 17th ed., Chapter 40. Diarrhea and Constipation 50. Which of the following nephrolithiasis is associated with Proteus infection? a. Calcium b. Uric Acid c. Struvite d. Cysteine Struvite stones are common and potentially dangerous. These stones occur mainly in women or patients who require chronic bladder catheterization and result from urinary tract infection with urease-producing bacteria, usually Proteus species. The stones can grow to a large size and fill the renal pelvis and calyces to produce a "staghorn" appearance. HPIM 17th ed. Chapter 281 Nephrolithiasis 51. The following conditions are common causes of involuntary weight loss among elderly patients EXCEPT: a. Hyperthyroidism b. Depression c. Malignancy d. Acid peptic disease In the elderly, the most common causes of weight loss are depression, cancer, and benign gastrointestinal disease. HPIM 17th ed. Chapter 41. Weight Loss 52. Majority of urolithiasis will pass out from urine spontaneously without any intervention when the stone size is a. < 0.5 cm b. < 1.0 cm c. < 1.5 cm d. < 2.0 cm The vast majority of ureteral stones <0.5 cm in diameter will pass spontaneously. HPIM 17th ed, Chapter 281 Nephrolithiasis 53. Pregnant women with cystitis should be treated with any of the following antibiotics EXCEPT: a. Amoxicillin b. Cefuroxime c. Ofloxacin d. Nitrofurantoin In pregnancy, acute cystitis can be managed with 7 days of treatment with amoxicillin, nitrofurantoin, or a cephalosporin. HPIM 17th ed. Chapter 282 Urinary Tract Infections, Pyelonephritis, and Prostatitis. Of the fluoroquinolones, ofloxacin (300 mg by mouth bid for 7 days) and levofloxacin (500 mg/d by mouth for 7 days) are as effective as doxycycline for the treatment of chlamydial infection and appear to be safe and well tolerated. These drugs cannot be used in pregnancy. HPIM 17th ed. Chapter 169 Chlamydial Infections Ofloxacin should be avoided during pregnancy in the absence of specific data documenting their (fluoroquinolones ) safety. Katzung 11th ed. 54. A 21-year-old male medical student consults your clinic for fever of 1-week duration associated with chills and sweating. Fever would resolve spontaneously but would return again after 36 hours. Medical student just came from a mission in Cagayan Valley where they slept in the community with locals for several days. Temperature is 37.3oC. What is your primary impression?

a. Malaria b. Typhoid fever c. Leptospirosis d. Dengue Some infections have characteristic patterns in which febrile episodes are separated by intervals of normal temperature. For example, Plasmodium vivax causes fever every third day HPIM 17th ed. Chapter 17 Fever and Hyperthermia 55. A 65-year-old female patient consults your clinic for fever which began 3 weeks ago. She reports that her temperature was usually between 38-38.3C. She claims that she would often feel tired and sometimes experience muscle aches, but no cough, dysuria, diarrhea or abdominal pain. All laboratory tests done in the past week were negative (CBC, urinalysis, septic work-up, blood chemistry). Which of the following would you LEAST consider as the probable cause of fever in this patient? a. Factitious fever b. Colon cancer c. Giant cell arteritis d. Tuberculosis In the elderly, multisystem disease is the most frequent cause of FUO, giant-cell arteritis being the leading etiologic entity in this category. In patients >50 years of age, this disease accounts for 15 20% of FUO cases. Tuberculosis is the most common infection causing FUO in the elderly, and colon cancer is an important cause of FUO with malignancy in this age group. A significant proportion (9%) had factitious fevers i.e., fevers due either to false elevations of temperature or to self-induced disease. A substantial number of these factitious cases were in young women in the health professions. HPIM 17th ed. Chapter 19 Fever of Unknown Origin 56. A 65-year-old female patient consults your clinic for fever which began 3 weeks ago. She reports that her temperature was usually between 38-38.3C. She claims that she would often feel tired and sometimes experience muscle aches, but no cough, dysuria, diarrhea or abdominal pain. All laboratory tests done in the past week were negative (CBC, urinalysis, septic work-up, blood chemistry). Which of the following would you LEAST consider as the probable cause of fever in this patient? a. Factitious fever b. Colon cancer c. Giant cell arteritis d. Tuberculosis In the elderly, multisystem disease is the most frequent cause of FUO, giant-cell arteritis being the leading etiologic entity in this category. In patients >50 years of age, this disease accounts for 15 20% of FUO cases. Tuberculosis is the most common infection causing FUO in the elderly, and colon cancer is an important cause of FUO with malignancy in this age group. HPIM 17th ed. Chapter 19 Fever of Unknown Origin 57. The emphasis in patients with classic fever of unknown origin is on continued observation and examination, with the avoidance of shotgun empirical therapy. In which of the following patients is empiric therapy indicated? a. 75 year old male with leukocyte count of 15,000 cells/ L b. 20 year old female with hemoglobin level of 90 g/L c. 35 year old male with absolute neutrophil count of 300 cells/ L d. 55 year old female with platelet count of 20,000 cells/ L Vital-sign instability or neutropenia is an indication for empirical therapy with a fluoroquinolone + piperacillin.

- HPIM 17th ed. Chapter 19. Fever of Unknown Origin Neutropenia: Susceptibility to infectious diseases increases sharply when neutrophil counts fall below 1000 cells/ L. When the absolute neutrophil count (ANC- band forms and mature neutrophils combined) falls to <500 cells/ L, control of endogenous microbial flora (e.g., mouth, gut) is impaired; when the ANC is <200/ L, the inflammatory process is absent. - HPIM 17th ed. Chapter 61 Disorders of Granulocytes and Monocytes 57. Which of the following features can distinguish central from peripheral vertigo? a. Presence of nystagmus b. Character of dizziness c. Tendency to fall after a spin d. Response to visual fixation HPIM 17th ed. Chapter 22 Dizziness and Vertigo

58. According to the Philippine Guidelines for Periodic Health Examination, which of the following is recommended to screen for large bowel cancer in asymptomatic patients beginning age 50? a. Fecal occult blood test b. Colonoscopy c. Barium enema d. Analysis of fecal DNA PHEX 59. Which of the following laboratory findings would distinguish a renal from a hepatic cause of edema? a. Hyponatremia b. Hypoalbuminemia c. Albuminuria d. Azotemia 60. A 24 year-old female consulted at the OPD for vaginal itchiness. On examination, you noted a strawberry cervix. What would be your treatment of choice? a. Metronidazole b. Ciprofloxacin c. Amoxicillin d. Cefuroxime Symptomatic trichomoniasis characteristically produces a profuse, yellow, purulent, homogeneous vaginal discharge and vulvar irritation, often with visible inflammation of the vaginal and vulvar epithelium and petechial lesions on cervix (strawberry cervix, usually evident only by colposcopy). Only nitroimidazoles (e.g., metronidazole and tinidazole) consistently cure trichomoniasis. A single 2-g oral dose of metronidazole is effective and much less expensive than the alternatives. HPIM 17th ed. Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach

61. A 30 year old male came in for a painless penile ulcer which had a distinct edge without purulent discharge. What is the likely diagnosis? a. Chancroid b. Lymphogranuloma venereum c. Herpes b. Primary Syphilis Painless, nontender, indurated ulcers with firm, nontender inguinal adenopathy suggest primary syphilis.

HPIM 17th ed. Chapter 124. Sexually Transmitted Infections: Overview and Clinical Approach 62. In a patient who has been on a strict vegan diet for more than 20 years, what findings would you expect on peripheral blood smear? a. Normocytic, normochromic anemia b. Macrocytic, hypochromic anemia c. Microcytic, normochromic anemia d. Microcytic, hypochromic anemia Severe IDA: microcytic and hypochromic RBCs smaller than nucleus of a lymphocyte associated with marked variation in size and shape. HPIM 17th ed. Chapter 58 Anemia and Polycythemia 63. All of the following clotting factors are produced exclusively by the liver EXCEPT: a. Factor 7 b. Factor 8 c. Factor 9 d. Factor 5 With the exception of factor VIII, the blood clotting factors are made exclusively in hepatocytes. - HPIM 17th ed. Chapter 296 Evaluation of Liver Function 64. The following are used as a standard therapy for H. pylori infection EXCEPT: a. Proton pump inhibitors b. Ceftriaxone c. Amoxicillin d. Clarithromycin Multiple drugs have been evaluated in the therapy of H. pylori. No single agent is effective in eradicating the organism. Combination therapy for 14 days provides the greatest efficacy. The agents used with the greatest frequency include amoxicillin, metronidazole, tetracycline, clarithromycin, and bismuth compounds. HPIM 17th ed. Chapter 286 Diseases of the Esophagus 65. What is the most common complication observed in patients with peptic ulcer disease? a. Anemia b. Gastric outlet obstruction c. Bleeding d. Perforation Bleeding (15%, more often in individuals >60 years old) > Perforation (6-7%) > Gastric Outlet Obstruction (1-2%) HPIM 17th ed. Chapter 287 Peptic Ulcer Disease and Related Disorders 66. What is the most consistent clinical feature in irritable bowel syndrome? a. Abdominal pain b. Alteration in bowel habits c. Gas, bloatedness, and flatulence d. Vomiting According to current IBS diagnostic criteria, abdominal pain or discomfort is a prerequisite clinical feature of IBS. Highly variable in intensity and location, pain in IBS is hypogastric in 25% > right side 20% > left side in 20% > epigastric 10% - HPIM 17th ed. Chapter 290 Irritable Bowel Syndrome 67. What is the hallmark of all forms of intestinal obstruction? a. Abdominal distention b. Abdominal tenderness

c. Hyperactive bowel sound d. Abdominal mass Abdominal distention is the hallmark of all forms of IO. It is least marked in cases of obstruction high in the small intestine and most marked in colonic obstruction. HPIM 17th ed. Chapter 293 Acute Intestinal Obstruction 68. Which of the following etiologic agents causes acute onset watery diarrhea, abdominal cramping and high-grade fever within a few hours of ingestion? a. Bacillus cereus b. Escherichia coli c. Giardia sp. d. Vibrio parahaemolyticus See Table 40.2 Pathobiology of Causative Agents and Clinical Features in Acute Infectious Diarrhea in HPIM 17th ed. Chapter 40 Diarrhea(sorry, too big to Print Screen) Essentially the deciding factor was the high-grade fever. Incubati Vomiti Ab. Fev Diarrhea on ng Pai er Period n Bacillus Cereus 1-8h 3-4+ 103-4+, 2+ 1+ water E. Coli 8 72 h 2 4+ 1 0 3 4+, 2+ 1+ watery Giardia sp. 1 8d 0 1+ 1 0 1 2+, 3+ 2+ watery, mushy V. parahaemolyticus 12 h 11 0 3+ 2 3 1 4+, d 4+ 4+ watery or bloody 69. Interpret the following Hepatitis profile: HBsAg (-); Anti-HBs (+), AntiHBc total (-): a. Past Hepatits B infection b. Previous immunization c. Chronic Hepatitis B infection d. Acute Hepatitis B infection Please see Chart in # 29. Thanks. 70. Cornerstone in the treatment of alcoholic liver disease a. Silymarin b. No treatment available c. Alcohol abstinence d. Vitamin B complex Complete abstinence from alcohol is the cornerstone in the treatment of ALD. HPIM 17th ed. Chapter 301 Alcoholic Liver Disease 71. Which hepatitis virus is the major cause of liver cirrhosis worldwide? a. Hepatitis A b. Hepatitis B c. Hepatitis C d. Hepatitis D In the 2013 samplices, the answer is Hep C, however according to Dr. Palileo and Dr. Lo, the question emphasized liver cirrhosis WOLDWIDE and not just in the US, and worldwide there are more Hep B

cases. According to harrison s (excerpts found below), about 170M have hepatitis C and 20-30% of them will develop cirrhosis, thus 51M cases (170Mx0.3) of liver cirrhosis will be/is caused by the Hep C virus. Meanwhile 300-400M worldwide have Hepatitis B and 25% may ultimately develop cirrhosis, meaning 100M cases (400 x 0.25) of liver cirrhosis will be/ is caused by the HepB virus. HPIM excerpts Of patients exposed to the Hep C virus (HCV), approx. 80% develop chronic Hep C, and of those, about 20 30% will develop cirrhosis over 20 30 years. In the United States, approximately 5 million people have been exposed to the hepatitis C virus, with about 3 4 million who are chronically viremic. Worldwide, about 170 million individuals have hepatitis C, with some areas of the world (e.g., Egypt) having up to 15% of the population infected. Of patients exposed to hepatitis B, about 5% develop chronic hepatitis B, and about 20% of those patients will go on to develop cirrhosis. In the United States, there are about 1.25 million carriers of hepatitis B, whereas in other parts of the world where hepatitis B virus (HBV) is endemic (i.e., Southeast Asia, sub-Saharan Africa), up to 15% of the population may be infected having acquired the infection vertically at the time of birth. Thus, over 300 400 million individuals are thought to have hepatitis B worldwide. Approximately 25% of these individuals may ultimately develop cirrhosis. HPIM 17th ed. Chapter 302 Cirrhosis and its Complications 72. A 50 year-old male came in for consult of a 3 month history of painless jaundice associated with weight loss. Labs showed elevated CA 19-9. What would be the expected liver function test of this patient? a. Low ALT, High AST, Low Alk phos b. Normal ALT, Normal AST, Normal Alk phos c. High ALT, Low AST, Low Alk phos d. High ALT, High AST, High Alk phos During the feedback, it was emphasized that the liver function test of someone with elevated CA 19-9 (with cholangiocarcinoma) may have normal or minimally elevated Aminotransferases (AST, ALT), however ALP is always elevated since it rises with bilirubin, thus the best answer is D. Cholangiocarcinoma- most typically presents as painless jaundice, often with pruritus or weight loss, and acholic stools. Serologic tumor markers appear to be nonspecific, but CEA, CA 19-9, and CA-125 are often elevated in CCC patients and are useful for following response to therapy. HPIM 17th ed. Chapter 88. Tumors of the Liver and Biliary Tree 73. A 35 year old female patient consulted you for jaundice 3 days ago. She is back at your clinic with the following test results: AST 1232 mmol/L, ALT 1889 mmol/L. You expect to find these results in the following conditions EXCEPT: a. Drugs b. Acute Viral hepatitis c. Hypotension d. Choledocholithiasis Striking elevations i.e., aminotransferases > 1000 U/L occur almost exclusively in disorders associated with extensive hepatocellular injury such as (1) viral hepatitis, (2) ischemic liver injury (prolonged hypotension or acute heart failure), or (3) toxin- or drug-induced liver injury. HPIM 17th ed. Chapter 296 Evaluation of Liver Function 74. A 26 year old female came in at the OPD for her complaint of an anterior neck mass not associated with any symptoms. You decided to do an FNAB which showed papillary thyroid cancer. Several work ups done showed multiple lung masses. What would be her stage?

a. Stage I b. Stage II c. Stage III d. Stage IV Stage II for those <45 is any T, any N, basta may mets (M1).

HPIM 17th ed. Chapter 335. Disorders of the Thyroid Gland

75. What is the hallmark of proliferative diabetic retinopathy? a. Blot hemorrhage b. Macular edema c. Neovascularization d. Retinal microaneurysms The appearance of neovascularization in response to retinal hypoxia is the hallmark of proliferative diabetic retinopathy. These newly formed vessels appear near the optic nerve and/or macula and rupture easily, leading to vitreous hemorrhage, fibrosis, and ultimately retinal detachment. HPIM 17th ed. Chapter 338 Diabetes Mellitus 76. A 33-year-old female consults you for dysuria of 1 week duration associated with frequency occasionally with vaginal discharge. She has already been treated with antibiotics for urinary tract infection thrice in the past 2 months for the same symptoms. Which of the following conditions should you consider in this patient? a. Acute bacterial cystitis b. Acute urethritis c. Acute pyelonephritis d. Acute urinary tract infection Cystitis: Patients with cystitis usually report dysuria, frequency, urgency, and suprapubic pain . If a genital lesion or a vaginal discharge is evident, especially in conjunction with <105 bacteria per mL on urine culture, then pathogens that may cause urethritis, vaginitis, or cervicitis (e.g., C. trachomatis, N. gonorrhoeae, Trichomonas, Candida, and HSV) should be considered. Urethritis: Of women with acute dysuria, frequency, and pyuria, ~30% have midstream urine cultures with either no growth or insignificant bacterial growth. Clinically, these women cannot always be readily distinguished from those with cystitis Chlamydial or gonococcal infection should be suspected in women with a gradual onset of illness, no hematuria, no suprapubic pain, and >7 days of symptoms. The additional history of a recent sex-partner change, especially if the partner has recently had chlamydial or gonococcal urethritis, should heighten the suspicion of a sexually transmitted infection, as should the finding of mucopurulent cervicitis

HPIM 17th ed. Chapter 282 Urinary Tract Infections, Pyelonephritis, and Prostatitis. 77. A 45 y.o. patient came to the OPD with symptom of weight loss. He also presented with tachyarrhythmia and easy fatigability. What would you request to confirm your most likely impression? a. Fasting blood glucose b. Thyroid stimulating hormone c. Complete blood count d. 2D-echocardiogram Thyrotoxicosis may cause unexplained weight loss, despite enhanced appetite, due to the increased metabolic rate. Other prominent features include hyperactivity, nervousness, and irritability, ultimately leading to a sense of easy fatigability in some. The most common cardiovascular manifestation is sinus tachycardia, often associated with palpitations, occasionally caused by supraventricular tachycardia. - HPIM 17th ed. Chapter 335. Disorders of the Thyroid Gland 78. Hepatitis B virus can be acquired through the following mode of transmission EXCEPT: a. Sexual intercourse b. Blood contamination c. Oro-fecal contamination d. Maternal transmission via vaginal delivery Transmission HBV Fecal-oral Percutaneous +++ Perinatal +++ Sexual ++ - HPIM 17th ed, Chapter 298 Acute Viral Hepatitis > Table 298.2 Clinical and Epidemiologic Features of Viral Hepatitis 79. Estrogen replacement therapy has been found to be beneficial for: a. Cognitive function b. Sexual desires c. Osteoporosis d. Cardiovascular disease A large body of clinical trial data indicates that various types of estrogens reduce bone turnover, prevent bone loss, and induce small increases in bone mass of the spine, hip, and total body. HPIM 17th ed. Chapter 348 Osteoporosis 80. Your classmate tells you that he was absent for the past 3 days because he had a high grade fever. You notice that he has generalized rashes so you do a Tourniquet test, which turned out positive. He says he is worried because he had episodes of epistaxis this morning. What would you do next? a. Reassure your classmate b. Advise CBC monitoring every 12 hours on OPD basis c. Tell him to proceed to the ER immediately. d. Request for further tests to confirm diagnosis. Dengue HF is identified by the detection of bleeding tendencies (tourniquet test, petechiae) or overt bleeding in the absence of underlying causes such as preexisting gastrointestinal lesions. We want to prevent Dengue shock syndrome, which is usually accompanied by hemorrhagic signs, is much more serious and results from increased vascular permeability leading to shock. HPIM 17th ed. Chapter 189 Infections Caused by Arthropod- and Rodent-Borne Viruses

81. What is the most effective means of controlling allergic rhinitis? a. Allergen avoidance b. Oral anti-histamines c. Intranasal steroids d. Mast cell stabilizer Nasal corticosteroid sprays are the most effective treatment for allergic rhinitis. Although allergen avoidance helps, the question was about control. 82. What is the most dreaded complication of warfarin therapy? a. Allergic reaction b. Bleeding c. Hepatotoxicity d. GI disturbances Warfarin may cause severe bleeding that can be life-threatening and even cause death. 83. A 19 year old male student was brought to your clinic for sudden onset abdominal pain which started on the epigastric area and is now localized in the right lower quadrant in the abdomen. Your physical examination revealed direct epigastric tenderness with guarding and generalized rebound tenderness. What is the next step in managing this patient? a. Start the patient on acid suppressive agents. b. Refer the patient for emergency surgery c. Advise the patient to increase dietary fiber d. Observe and reassure Patient probably has appendicitis. The goal is to remove an infected appendix before it breaks open (ruptures). 84. A 55 year old male came to your clinic complaining of recurrent retrosternal chest pain usually occurring in the early morning, does not radiate to either arm and is worse on lying down. He denies any chest pain or dyspnea on exertion but notes similar pain after drinking a few beers or sodas and after eating spicy food. What is the most likely diagnosis? a. Stable angina b. Esophageal reflux c. Aortic dissection d. Acute pericarditis Because of burning pain in the chest which was increased by bending, stooping, lying down, or eating. 85. A 43 year old obese woman consults you for on and off abdominal pain of 1 month duration, described as crampy, usually occurring after meals. She has no other associated symptoms. Which of the following diagnostic tests would you order? a. hepatobiliary ultrasound b. abdominal CT scan c. serum lipase d. serum bilirubin Patient likely has biliary tree pathology. Ultrasound is better at visualizing the hepatobiliary tree (if there are stones) than CT scan (according to Dr. Palileo) 86. A 23 year old female arrives at your clinic with severe right lower quadrant abdominal pain, sudden onset. Her last menstrual period was 5 weeks ago. On physical examination, she is tachycardic, tachypneic, and pale, with generalized direct and rebound tenderness over her abdomen. Which of the following conditions should you primarily consider? a. Acute Calculous Cholecystitis b. Ruptured ectopic pregnancy c. Acute Gastroenteritis

d. Renal colic from nephrolithiasis Symptoms and Signs of ectopic pregnancy 1. Pain. Pelvic and abdominal pain are reported by 95 percent of women with tubal pregnancy. 2. Abnormal bleeding. Amenorrhea with some degree of vaginal spotting or bleeding is reported by 60 to 80 percent of women with tubal pregnancy. 3. Abdominal and pelvic tenderness. With rupture, exquisite tenderness during abdominal and vaginal examination is demonstrable. 4. Uterine changes. Although minimal early, later the uterus may be pushed to one side by an ectopic mass. 5. Vital signs. Birkhahn and colleagues (2003) noted that in 25 women with ruptured ectopic pregnancy, the majority on presentation had a heart rate of less than 100 beats per minute and a systolic blood pressure greater than 100 mm Hg. - Williams Obstetrics, 23rd ed. Chapter 10. Ectopic Pregnancy

87. Your 30-year-old cousin asks your advice regarding an executive check up because she is getting married and plans to get pregnant soon after. She is generally healthy, has never been hospitalized, and has no known drug or food allergies. Her father is diabetic, and her mother has hypertension. She has been smoking 3-5 cigarettes daily for the past 10 years and drinks wine on occasion. Based on the Philippine Guidelines on Periodic Health Examinations, you would recommend the following examinations EXCEPT a. Fasting blood glucose b. Total cholesterol c. Chest radiography d. Mammography PHEX 88. She also asks your advice regarding what vaccinations she needs prior to getting pregnant. What would you advise her? a. A complete course of HPV vaccination is recommended for all women who are sexually active. b. Hepatitis A vaccination is recommended prior to pregnancy for all women of childbearing age. c. Tetanus toxoid vaccine should be administered to pregnant women during the first trimester. d. Vaccination against Varicella should not be given to women who might get pregnant within 4 weeks of receiving the vaccine. Before Pregnancy Of particular importance are: y Tdap (tetanus, diphtheria, pertussis) this is important for preventing pertussis (whooping cough). It should be given in place of Td vaccine, when tetanus protection is indicated y MMR y Varicella y Influenza- especially important if your patient might be pregnant during flu season, but recommended for all adults y Hep B, if indicated Live vaccines (including MMR and varicella) should be given a month or more before pregnancy. Inactivated vaccines can be given before or during pregnancy, as needed. * HPV recommended for F from 11-26 years of age. More research is needed about HPV vaccine and pregnancy. For now, pregnant women should wait until their pregnancy is over before getting the vaccine.

- www.cdc.gov/vaccines/pubs/downloads/f_preg_chart.pdf 89. A 20 year-old female came to your clinic for a check-up prior to starting classes the following semester. She is apparently healthy with no known comorbidities. Past medical history and family medical history are unremarkable. She denies smoking or alcohol use but admits to unprotected sexual intercourse with 3 promiscuous partners in the last 3 years. She is a nursing student and will be starting to work in the hospital the following month. You would recommend the following EXCEPT: a. Pap smear b. HIV screening c. Hepatitis B vaccine d. Pneumonococcal vaccine 90. The treatment goals for adults with diabetes include which of the following? a. Preprandial capillary glucose 140-160 mg/dl b. A1C < 7 c. Peak postprandial capillary plasma glucose < 200 mg/dl d. Blood pressure < 120/80 - ADA 2010 91. A 52-year old woman consults at the outpatient clinic for progressive weakness. She noticed that symptoms began about3 months ago, described as a feeling of being tired easily. She also complained of blurring of vision, gradual loss of weight, thirst, and frequent urination. She has three children, the last of whom was delivered via Caesarean section because of cephalopelvic disproportion. What laboratory test will help you confirm your initial impression? a. Chest radiograph b. Fasting blood glucose c. Thyroid stimulating hormone d. Electrocardiography CS due to CPD may have be a history of GDM or delivery of baby >4 kg (>9 lb), which is a risk factor for T2DM. Symptoms of hyperglycemia: polyuria, polydipsia, weight loss, fatigue, weakness, blurry vision, frequent superficial infections, and slow healing of skin lesions after minor trauma. Metabolic derangements relate mostly to hyperglycemia (osmotic diuresis, reduced glucose entry into muscle) and to the catabolic state of the patient (urinary loss of glucose and calories, muscle breakdown due to protein degradation and decreased protein synthesis). Blurred vision results from changes in the water content of the lens and resolves as the hyperglycemia is controlled. (HPIM 17th ed. Chapter 338 Diabetes Mellitus) 92. A 25 year old female consults at the OPD for a 1-month history of non-productive cough usualy occurring early in the morning. She denies any episode of fever, and claims that several chest x-rays done in the past 4 weeks have all been normal. She does not smoke. Chest examination is normal. What is the next step in the management of this patient? a. Treat with an anti-histamine-decongestant combination b. Treat with a proton-pump inhibitor c. Refer for bronchoscopy d. Request for chest CT scan Hallmarks of allergic rhinitis: Episodic rhinorrhea, sneezing, obstruction of the nasal passages with lacrimation, and pruritus of the conjunctiva, nasal mucosa, and oropharynx All occurring in temporal relationship to allergen exposure. Although commonly seasonal due to elicitation by airborne pollens, it can be perennial in an environment of chronic exposure (HPIM 17th ed. Chapter 311 Allergies, Anaphylaxis, and Systemic Mastocytosis)

93. A 55 year old female consults you for gradual abdominal enlargement. She reports that she limits her daily activities because she easily tires even with light chores and has lost her appetite. There was no orthopnea or PND, but her duaghter noted that seemed to have gained weight in the past few weeks. On physical examination, you note that she is lethargic with heart rate of 55/min. There is no fluid wave on abdominal examination, but there was bilateral non-pitting edema on both legs. What test would you order to confirm your diagnosis? a. Holoabdominal ultrasound b. Thyroid stimulating hormone c. Colonoscopy d. Fasting blood glucose Table 335-5 Signs and Symptoms of Hypothyroidism (Descending Order of Frequency) Symptoms Signs Tiredness, weakness Dry coarse skin; cool peripheral extremities Dry skin Puffy face, hands, and feet (myxedema) Feeling cold Diffuse alopecia Hair loss Bradycardia Difficulty concentrating and poor memory Peripheral edema Constipation Delayed tendon reflex relaxation Weight gain with poor appetite Carpal tunnel syndrome Dyspnea Serous cavity effusions Hoarse voice Menorrhagia (later oligomenorrhea or amenorrhea) Paresthesia Impaired hearing (HPIM 17th ed. Chapter 335. Disorders of the Thyroid Gland) 94. Which of the following conditions wil present with red blood cell casts on urinalysis? a. Poststreptococcal glomerulonephritis b. Acute pyelonephritis c. Renal tubular acidosis d. Nephrolithiasis In general, RBC casts indicate glomerular injury or, less often, acute tubulointerstitial nephritis. (HPIM 17th ed. Chapter 273 Acute Renal Failure). 95. Which of the following examinations is not recommended for initial testing in patients presenting with involuntary weight loss? a. Chest radiograph b. Abdominal ultrasound c. Fasting blood glucose d. Complete blood count Table 41-2 Screening for Evaluation of Involuntary Weight Loss Initial testing CBC Electrolytes, calcium, glucose Renal and liver function tests Additional testing HIV test Upper and/or lower GI endoscopy Abdominal CT scan or MRI Chest CT scan

Urinalysis TSH Chest x-ray Recommended cancer screening (HPIM 17th ed. Chapter 41 Weight Loss) 96. A 28 year old female consults your clinic for shortness of breath. She said symptoms started about a month ago, associated with frequent productive cough, anorexia, low-grade fever and weight loss. Physical examination revealed a respiratory rate of 22/min, weight of 40 kg, and height of 5 ft. The rest of the PE was unremarkable. Chest x-ray showed infiltrates and areas of lucency surrounded by reticular densities on the R upper lobe. A pre-employment chest X-ray taken 6 months prior was normal. What is your primary diagnosis? a. Community-acquired pneumonia b. Atypical pneumonia c. Pulmonary tuberculosis d. Bronchogenic carcinoma Early in the course of disease, symptoms and signs are often nonspecific and insidious, consisting mainly of fever and night sweats, weight loss, anorexia, general malaise, and weakness. However, in the majority of cases, cough eventually develops often initially nonproductive and subsequently accompanied by the production of purulent sputum, sometimes with blood streaking. Essentially normal PE further strengthens diagnosis, and rules out CAP (no crackles/fever, even if Pt is tachypneic). Radiographically speaking, Although the "classic" picture is that of upper-lobe disease with infiltrates and cavities, virtually any radiographic pattern from a normal film or a solitary pulmonary nodule to diffuse alveolar infiltrates in a patient with ARDS may be seen. HPIM 17th ed. Chapter 158 Tuberculosis 97. A 26 year old female consults at the OPD for recurrent productive cough. The cough is more common in the early morning hours and is associated with chest tightness but no fever. She is comfortable, not in distress with no retractions. Chest auscultation reveals inspiratory and expiratory rhonchi at the bases but good air entry. What test will you order to confirm your diagnosis? a. Chest x-ray b. Skin prick test c. Methacholine challenge d. Spirometry The diagnosis of asthma is usually apparent from the symptoms of variable and intermittent airways obstruction, but is usually confirmed by objective measurements of lung function Simple spirometry confirms airflow limitation with a reduced FEV1, FEV1/FVC ratio, and PEF. HPIM 17th ed. Chapter 248 Asthma 98. A 78 year old female was brought to your clinic by her daughter for a check-up. She was almost hit by a bicycle this morning while crossing the street. She has no known comorbidities and walks to the church 4 blocks away from her home without difficulty. She has no vices and no previous hospitalizations. BP is 110/70, BMI is 24 and the physical examination was normal. You would recommend the following for this patient except a. VA testing b. Audiometry c. Functional Reach d. Bone densitometry PHEX 99. A 24 year old female came to the OPD complaining of chest pain. The pain is on the right side but sometimes on the left, described as sharp, lasting only few minutes. However, the pain sometimes

persists as a dull ache lasting several hours. She has no other illnesses, is a non-smoker and has no family history of heart disease. Physical examination is normal except for mild tenderness on palpation of the right anterior chest. What is the most likely diagnosis? a. Costochondritis b. Chronic stable angina c. Herpes zoster d. Unstable angina Costochondral and chondrosternal syndromes are the most common causes of anterior chest musculoskeletal pain. ... The pain of such syndromes is usually fleeting and sharp, but some patients experience a dull ache that lasts for hours. Direct pressure on the chondrosternal and costochondral junctions may reproduce the pain from these and other musculoskeletal syndromes. - HPIM 17th ed. Chapter 13 Chest Discomfort 100. A 40 year-old female came to your clinic for a routine check-up. She has not seen a doctor in several years and denies any symptoms or co-morbidities. She is a non-smoker and denies alcohol intake. Her family history is unremarkable. BP is 120/80 and BMI is 24. The rest of the physical exam is unremarkable. What would you recommend for this patient? a. Fecal occult blood b. Bone densitometry c. Pap smear d. Chest x-ray PHEX