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1

The following are bone manifestations of CKD:
A. Adynamic bone disease
B. Osteitis fibrosa cystica
C. Osteomalacia
D. Only A & B
E. All of the above

E. All of the above
(Adynamic bone disease, Osteitis fibrosa cystica, Osteomalacia)

Hyperparathyroidism in CKD stimulates bone turnover and leads to osteitis fibrosa cystica.

Low-turnover bone disease can be grouped into two categories--adynamic bone disease and osteomalacia.

2

A 35 year old presents with fever associated with headache and nuchal rigidity. CSF findings include: WBC 134, neutrophils 23%, lymphocytes 77%, sugar 81 mg/dl, protein 55 mg/dl. What is the MOST likely etiologic agent for this case?
A. Streptococcus pneumoniae
B. Enterovirus
C. Cryptococcus neoformans
D. Mycobacterium tuberculosis
E. Normal

B. Enterovirus

The typical profile for viral meningitis is a lymphocytic pleocytosis, a normal or slightly elevated protein concentration, a normal glucose concentration, and a norml or mildly elevated opening pressure.

Enteroviruses are the most common cause of viral meningitis, accounting for >85% of cases.

3

TRUE for the treatment of neurosyphilis:
A. Pen G benzathine, given in total dose of up to 7.2 million units is adequate
B. Tetracycline is alternative treatment for patients with confirmed penicillin allergy
C. Asymptomatic neurosyphilis may relapse into symptomatic disease following treatment with benzathine penicillin
D. Only symptomatic neurosyphilis should be treated with aqueous penicillin
E. There is poor response to penicillin therapy for meningeal syphilis

C. Asymptomatic neurosyphilis may relapse into symptomatic disease following treatment with benzathine penicillin

Both asymptomatic and symptomatic neurosyphilis should be treated with aqueous penicillin. Benzathine penicillin does not produce detectable concentrations of in CSF and should not be used for treatment. The clinical response to penicillin therapy for meningeal syphilis is dramatic, but treatment for neurosyphilis with existing parenchymal damage may only arrest disease progression.

In patients with penicillin allergy, desensitization and treatment with penicillin is recommended.

4

A 55 year old male suspected stroke patient comes to the ER because of sudden unilateral weakness. On neurologic examination, you found out that his left lower extremity is much weaker than his left upper extremity. He also has problem controlling his urination. The MOST likely affected blood vessel is the:
A. Anterior cerebral artery
B. Middle cerebral artery
C. Posterior cerebral artery
D. Internal carotid artery
E. Basilar artery

A. Anterior cerebral artery

The ACA stroke syndrome may present profound abulia, bilateral pyramidal signs with paresis which is greater in LE than in UE, and urinary incontinence.

MCA: contralateral hemiparesis (mainly face and hands); aphasia or contralateral visual neglect

PCA: diplopia, dysarthria, dysphagia, vertigo, gait imbalance

ICA: 3rd nerve palsy; mononuclear blindness

5

The currently preferred brain imaging modality for acute ishemic stroke to better appreciate hyperacute brain changes is:
A. MRI scan with DWI
B. CT scan with contrast
C. CT angiography
D. Transcranial doppler
E. 4-vessel cerebral angiogram

A. MRI scan with DWI

Diffusion-weighted imaging is more sensitive for early brain infarction than standard MR sequences or CT scan but is less sensitive than CT for detecting acute blood.

6

IV recombinant tissue plasminogen activator (r-tPA) is given within 3 hours of ischemic stroke. Absolute contraindications to thrombolytic therapy includes:
A. Myocardial infarction within the past 3 months
B. CABG within previous 14 days
C. UGIB within the past 3 months
D. Pregnancy
E. History of prior intracerebral hemorrhage

E. History of prior intracerebral hemorrhage

Relative contraindications include: major surgery or serious trauma within previous 14 days; GI or urinary tract hemorrhage within previous 21 days; MI within the past 3 months; only minor and rapidly improving neurologic signs; seizures at the time of onset of stroke symptoms with post-ictal neulogic impairment; pregnancy.

7

The following causes paradoxical splitting of the second heart sound (S2), EXCEPT:
A. Left bundle branch block
B. HOCM
C. Severe aortic stenosis
D. ASD
E. None of the above

D. ASD

ASD causes a fixed splitting of the second heart sound (S2).

Paradoxic splitting of S2 is caused by LBBB, RV apical pacing, severe AS, HOCM, MI.

8

Atrial rate of 220-350 beats/min with saw-tooth appearance of P wave is characteristic of which arrhythmia?
A. Atrial fibrillation
B. Atrial flutter
C. Atrial tachycardia
D. Wandering pacemaker
E. Ventricular tachycardia

B. Atrial flutter

Atrial flutter is a re-entrant circuit within the atria, with variable conduction of impulses through the AV node to the ventricles. Atrial rate is 250-350 bpm. Saw-thooth appearance of P waves is characteristic.

9

Prominent U wave is usually seen in what condition?
A. Hyperkalemia
B. Hypokalemia
C. Hypercalcemia
D. Hypocalcemia
E. Digitalis toxicity

B. Hypokalemia

Hypokalemia prolongs ventricular repolarization, often with prominent U waves.

10

A 65 year old male consulted at the OPD because of progressive dyspnea. Spirometry showed: FEV1/FVC: 0.56, FEV1: 45% predicted, FVC: 80% predicted. What is the classification of severity of airflow limitation?
A. Mild
B. Moderate
C. Severe
D. Very Severe
E. Normal

C. Severe

Classification based on severity of airflow limitation in COPD using spirometry (post-bronchodilator FEV1):

GOLD 1 (mild) - FEV1 ≥ 80%;
GOLD 2 (moderate) - 50 to < 80%;
GOLD 3 (severe) - 30 to < 50%;
GOLD 4 (very severe) - < 30%.

11

Mr. Tuhog came in for pre-employment check-up and presented the following hepatitis B serologic marker results: HBsAg (-); Anti-HBs (+); Anti-HBc (+) IgG; HBeAg (-); Anti-HBe (+). What is the MOST likely interpretation?
A. Chronic hepatitis, low infectivity
B. Immunization with HBsAg
C. Recovery from hepatitis B
D. Acute hepatitis B
E. None of the above

C. Recovery from hepatitis B

Recovery to hepatitis B would have the following serologic marker: HBsAg (-); Anti-HBs (+); Anti-HBc (+) IgG; HBeAg (-); Anti-HBe (+/-).

12

Which statement/s is/are TRUE for scleroderma?
A. The lower esophagus is frequently involved with sparing of upper third of the esophagus
B. Skin thickening is the hallmark that distinguishes systemic sclerosis from other connective tissue diseases.
C. Pulmonary involvement is the leading cause of death
D. Antinuclear autoantibodies are present in almost all patients with systemic sclerosis
E. All of the above

E. All of the above

Systemic sclerosis is a connective tissue disorder of unknown etiology, heterogenous clinical manifestations, and chronic and often progressive course. It is characterized by thickening of the skin and distinctive involvement of multiple internal organs, most notably the lungs, GI tract, heart, and kidneys. The presence of thickened skin distinguishes it from other connective tissue diseases. Antinuclear autoantibodies are present in almost all patients with systemic sclerosis. Autoantibodies against topoisomerase-I (Scl-70) and centromere are specific for systemic sclerosis.

13

The most frequently recognized cause of the common cold is:
A. Coronaviruses
B. Rhinoviruses
C. Adenoviruses
D. Parainfluenza viruses
E. Human respiratory syncytial virus

B. Rhinoviruses

Rhinoviruses are the most frequently recognized cause of the common cold and have been detected in up to 50% of common cold-like illnesses.

14

A 28 year old female consulted at your clinic due to joint pains affecting her both hands, wrist and feet accompanied with morning stiffness which lasted for 2 hours. Her symptoms started 2 years ago and self medicated with over the counter NSAIDs. PE showed ulnar deviation on left hand with swelling and tenderness at the MCP and PIPs. The MOST likely radiographic finding/s is/are the following:
A. Juxta-articular osteopenia
B. Symmetric joint space loss
C. Subchondral erosions
D. Soft tissue swelling
E. All of the above

E. All of the above

Classically in RA, the initial radiographic finding is juxtaarticular osteopenia.

Other findings include soft tissue swelling, symmetric joint space loss, and subchondral erosions.

15

Fulminant hepatitis is the most feared complication of viral hepatitis. Which of the following has the highest incidence of fulminant hepatitis?
A. Acute hepatitis B
B. Chronic hepatits B and C
C. Acute hepatitis B and D
D. Acute hepatitis E
E. None of the above

C. Acute hepatitis B and D

Fulminant hepatitis is primarily seen in hepatitis B and D, as well as hepatitis E.

Hepatitis B accounts for >50% of fulminant cases of viral hepatitis, a sizable proportion of which are associated with HDV infection

16

Which of the following is TRUE of beta-thalassemia?
A. Affected individual are symptomatic at birth
B. It is associated with formation of β4 tetramers or Hgb H
C. It carries a risk of spontaneous abortion
D. Hemogblobin A2 is elevated
E. Excess γ globin forms tetramers called Hb Barts

D. Hemogblobin A2 is elevated

Persons with alpha-thalassemia have normal levels of HbA2 and HbF in contrast to beta-thalassemia.

17

A 20 year old male developed chills, high grade fever, and sweating. Peripheral blood smear showed presence of P. vivax and he was started on chloroquine which provided relief of illness. He was then started on primaquine but developed pallor, malaise, weakness and abdominal pain. A day after he develops jaundice and passage of dark urine. The MOST likely diagnosis is:
A. Acute renal failure
B. Severe malaria
C. Post-streptococcal glomerulonephritis
D. Glucose-6-phosphate dehydrogenase deficiency
E. None of the above

D. Glucose-6-phosphate dehydrogenase deficiency

Antimalarials including primaquine and chloroquine carry risk of clinical hemolysis in persons with G6PD deficiency.

18

Which of the following findings forms part of the major criteria for the diagnosis of heart failure?
A. Weight loss > 4.5 kg after 5 days of diuretic use
B. Hepatomegaly
C. Exertional dyspnea
D. Night cough
E. Ankle edema

A. Weight loss > 4.5 kg after 5 days of diuretic use

Based on the Framingham Criteria for Heart Failure: weight loss > 4.5 kg in 5 days in response to treatment is considered a major or minor criteria.

19

The following statement/s is/are true for the diagnosis of leptospirosis:
A. Culture and isolation is the gold standard
B. A four-fold rise of the titer from acute to convalescent sera is confirmatory
C. Microagglutination test cross-reacts with syphilis
D. PCR can be used for early confirmation of diagnosis in the acute leptospiremic phase
E. All of the above

E. All of the above

Culture and isolation is the gold standard, but is time-consuming, labor intensive and has low diagnostic yield. PCR can be used for early confirmation of diagnosis especially during the acute leptospiremic phase. In MAT, a four-fold rise in the titer from acute to convalescent sera is confirmatory. MAT cross-reacts with syphilis, viral hepatitis, HIV, relapsing fever, Lyme disease, legionellosis, and autoimmune disease.

20

A 57 year old female, is brought to the ER due to sudden onset of left-sided weakness upon waking up. Her baseline BP at the ER is 160/100, HR is 98/min, irregularly irregular, RR is 20/min, CBG is 301 mg/dl. She is awake, oriented with slurred speech, 3/5 motor strength in the LUE and LLE, (+) right facial palsy and right facial numbness; (+) Babinski, left. Based on this patient's clinical profile, the MOST likely etiology of her stroke would be:
A. Atherothrombotic
B. Cardioembolic
C. Lacunar
D. Cryptogenic
E. Hemorrhagic

B. Cardioembolic

This patient has an irregularly irregular heart rhythm which suggests an underlying atrial fibrillation. Cardioembolism is responsible for ~20% of all ischemic strokes. The most significant causes of cardioembolic stroke in most of the world are nonrheumatic atrial fibrillation, MI, prosthetic valves, rheumatic heart disease, and ischemic cardiomyopathy.