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A 71 year old man with recent diagnosis of adanocarcinoma of the left lung presents to the ED with acute onset of shortness of breath. When he woke up this morning he had no shortness of breath. It came on suddenly when he got up to walk to the bathroom. PMH: Adenocarcinoma of the left lung (receiving radiation therapy). Exam: BP 90/60 P 120 RR 36 T 37.8 O2 sat 80% Chest- clear cardiac- Nl S1S2 ABd soft, nontender. Ext- RLE edema. Lab: Hb 13 HCT 39 WBC 11,00 ABG 7.45/Po2 45/PCo2 34/Sat 80% Chest Xray- LUL mass, no infiltrates.Spiral CT shows a large clot in the left pulmonary artery. What is the most likely effect on the heart?

A) Pericarditis

B) Acute right ventricular dilation

C) Acute left ventricular dilation

D) Acute left atrial dilation

E) Ventricular arrythmia

What is the most common side effect of ACE inhibitors?

A) Rash

B) Cough

C) Angioedema

E) Neutropenia

F) Hypokalemia

In a study of 2271 patients with a history of colon cancer fecal occult blood testing (FOBT) is done to screen for recurrent colon cancer. One hundred and forty six patients have positive FOBT and 2125 patients have negative FOBT. Colonoscopy is done on all the patients, finding 46 cancers. Twelve patients with positive FOBT have colon cancer and 34 with negative tests have colon cancer. What is the sensitivity for FOBT?

A) 8.2%

B) 26.1%

C) 94%

D) 98.4%

interpretation of test results
Interpretation of Test Results

Disease Present Not Present

Present Absent




Cancer No Cancer




Sensitivity= 12/12+34=26.1%

A study is done to evaluate mammography as a screening tool for women between the ages of 40 and 45. 11,000 mammograms are obtained . Twenty five women have a positive mammogram and turn out to have breast cancer. One hundred and seventy five women have positive mammograms and do not have cancer. Eight hundred and ninety women have negative mammograms and do not have cancer and ten women with negative mammograms end up having breast cancer. What is the PPV for mammography?

A) 71.4%

B) 98.9%

C) 12.5%

D) 83.5%

E) 31.4%

positive predictive value
Positive Predictive Value
  • Positive predictive value is the proportion of positive tests who have the disease
  • TP/ TP+ FP
A 27 y.o. female whose brother died of cystic fibrosis is married to a 25 y.o. whose sister (age 16) has cystic fibrosis. What is the risk their first child will have CF?

a. 1/4

b. 1/9

c. 1/12

d. 1/16

e. 1/64

risk of child having cf in both parents sibs of cf patient
Risk of Child Having CF in Both Parents Sibs of CF patient
  • Each parent does not have CF, so their risk of carrying the gene is 2/3
  • 2/3 X 2/3 X 1/4 = 4/36= 1/9
A 20 yo man is concerned about his risk for developing Huntington’s disease. His father was diagnosed last year at the age of 43. What is the chance he will have inherited the disease from his father?

A) 1/4

B) 1/2

C) 1/9

D) 1/16

A 70 yo man is started on hydrochlorathiazide for hypertension. What set of side effects are most consistent for this medication?

A) Diarrhea, hypokalemia

B) Headache, hyperkalemia

C) Gout, hypokalemia

D) Hyperglycemia, diarrhea

E) Erectile dysfunction, headache

A 60 year old woman presents with hand stiffness. A picture of her hands is shown. What is her diagnosis?
  • Osteoarthritis
  • Rheumatoid arthritis
  • Gout
  • Psoriatic arthritis
A 22 y.o. woman comes to the Urgent Care Clinic for evaluation of dysuria and frequency which has been present for the past 3 days. She has also noticed hematuria. She denies fever or flank pain. Her physical exam in unremarkable.

What would you recommend?

a) Urinalysis

b) Urinalysis and urine culture

c) Urinalysis, urine culture and CBC

d) Urinalysis, urine culture and KUB

e) Urinalysis, urine culture and renal function

workup of simple cystitis
Workup of Simple Cystitis
  • Urinalysis
  • No urine culture
  • No such thing as simple cystitis in a man
A 67 year old woman presents with neck pain following a car accident. He has pain radiating down her right arm. On physical exam she has weakness of shoulder and wrist extension and a diminished triceps reflex. What is the most likely site of cervical disk herniation?

A) C3/C4

B) C5/C6

C) C6/C7

D) C7/C8

E) T1/T2

A 66 year old man is evaluated for fatigue. He is found to have a calcium level of 13 (NL 8.8-10.2). He has normal renal function. A serum PTH level is elevated (6X normal). What physiologically is causing his increased calcium?

A) Increased gut absorption of calcium

B) Increased calcium reabsorption in distal tubule, increased calcium release from bone

C) Decreased calcium resorption in distal tubule

D) Increased calcium release from bone and increased oral intake of calcium

E) Decreased calcium release from bone, increased gut absorption of calcium

All of the following factors contribute to an increased risk for development of CAD/MI except:

A) Diabetes

B) High level of high density lipoprotein

C) Hypertension

D) Family history

E) Cigarette smoking

F) High levels of C reactive protein

All of the following are directly from the celiac trunk except:

A) Left gastric artery

B) Common hepatic artery

C) Gastroduodenal artery

D) Splenic arterty

Where was William Osler Born?

A) England

B) Baltimore

C) Canada

D) Germany

A 67 yo man with shortness of breath and cough has trouble sleeping at night. He wakes up in the middle of the night short of breath. On exam he has crackles in his lung and a low pitched sound heard best with the bell at the apex. This sound follows S2. His xray shows pulmonary edema. What is the abnormal heart sound?

A) S3

B) S4

C) Split S2

D) Murmur

E) Click

A 33 year old man comes to clinic for evaluation of elevated blood pressure. He had a blood pressure of 160/100 measured at a health fair 2 months ago. He has since obtained 5 measurements at the fire station : 158/96, 166/100, 154/94, 170/98, and 168/98. He does not smoke. His physical exam is normal except for a BP of 166/104. What do you recommend?

A) Urinalysis, Renal artery duplex

B) Urinalysis, ECG, Basic metabolic panel

C) Renin/Aldosterone ratio, urine catecholamines

D) Urinalysis, Tox screen, ETT

E) No testing at this time

workup of the routine hypertensive patient
Workup of the “routine” hypertensive patient
  • Basic metabolic panel (renal/electrolyte /glucose/Ca panel)
  • UA
  • ECG
A 28 yo woman with type 1 diabetes presents with nausea and vomiting. She has felt poorly for the past four days and has not been able to eat much. She has cut her insulin dose to avoid hypoglycemia. Labs: Na 134, K-3.6, CL- 84, HCO3- 18. What is the most likely cause of her metabolic problems?

A) Anion gap metabolic acidosis

B) Respiratory alkalosis

C) Non anion gap metabolic acidosis

D) Anion gap metabolic acidosis, metabolic alkalosis

delta delta concept
Delta/Delta concept

Change anion gap

Change in bicarb

  • If ratio is > 2 then concurrent metabolic alkalosis is present
  • If ratio is < 1 then combined anion gap and non anion gap acidosis are present
A 46 year old man is evaluated for a one week history of fatigue and nausea. He had the onset of nausea, anorexia and fatigue a week ago. He also developed right upper quadrant pain. He reports no change from his usual diet of fast food (usually hamburgers and fried chicken) until the past week, when he stopped eating out because of profound anorexia. He had been partying with friends 10 days ago and had consumed a large amount of alcohol. He has not had any alcohol use for the past 5 days.

Substance use history-no history of IDU, smokes ½ pack of cigarettes/day stopped this week. Meds: Ranitidine, sertraline. Exam: BP 100/60 T-38.5 P-110 Eyes-icteric sclera Chest-clear cardiac Normal S1S2 no murmur Abd-soft, liver span 24 cm and tender, edge soft, palpable 6 cm below costal margin. Lab: HB 14 HCT 42 WBC 9,000 Bili-3.5 ALT 4300 AST 5400.

what is the most likely diagnosis
What is the most likely diagnosis?
  • Biliary obstruction due to gallstones
  • Viral hepatitis
  • Alcoholic hepatitis
  • Metastatic cancer
  • Drug induced hepatitis
differential diagnosis of very high alt
Differential Diagnosis of Very High ALT
  • Viral hepatitis

Hep A> Hep B > Hep C

  • Ischemia
  • Toxin

Acetominophen> mushroom

A 46 year old man is found to have an elevated ALT test during an insurance examination. Repeat testing of liver tests: ALT-76 AST-60 Bili-.8 Alb-3.8 PT(INR)-1.0. Hepatitis C testing is done and is positive. PMH-Hx MVA with ruptured spleen in 1995 requiring 10 unit blood transfusion. Acute renal failure after MVA requiring six weeks of dialysis. Hx testicular cancer. Hx injection drug use (cocaine) - none since 1987. Sexual history: history of multiple sexual partners (lifetime 15) all women.
what is his most likely exposure risk for hepatitis c
What is his most likely exposure risk for hepatitis C?
  • Blood transfusion
  • Hemodialysis
  • Injection drug use
  • Sexual exposure
  • Motor vehicle accident
risk for hepatitis c
Risk For Hepatitis C
  • Injection Drug history (highest risk)
  • Transfusion before 1989 (high risk)
  • Tattoo (unknown risk)
  • Sexual exposure (low risk)
A 59 yo man is evaluated for muscle pain. He has noticed discomfort in his lower extremities for the past 3 weeks. Labs: CPK 900. Medications:, Benazapril, Simvastatin, Omeprazole, Fluoxetine and Methotrexate.

Which medication is most likely responsible?

A) Benazapril

B) Simvastatin

C) Omeprazole

D) Fluoxetine

E) Methotrexate

side effects of statins
Side Effects of Statins
  • Rhabdomyolysis (rare)
  • Hepatotoxicity (rare)
  • Myalgias
A 29 yo man employed as a hospital custodial worker sustains a needlestick from a 20 gauge needle used for a successful blood draw. The patient the blood was drawn from has HIV (Viral load 60,000), Hepatitis C, and Hepatitis B (Sag +). The custodial worker has never had Hep B vaccine. What is the risk for acquiring infection?

A) HIV > Hep B > Hep C

B) HIV > Hep C > Hep B

C) Hep B > Hep C > HIV

D) Hep B > HIV > Hep C

E) Hep C > HIV > Hep B

F) Hep C > Hep B > HIV

A 33 yo woman comes to clinic for counseling on weight loss. Her height is 1.7 meters and her weight is 80 kg. What is her BMI?

A) 26

B) 28

C) 30

D) 32

E) 34

body mass index bmi
Body Mass Index (BMI)

BMI= Body weight in Kg

(Height in meters)2

A 72 y.o. male S/P AVR replacement two years ago for aortic stenosis presents with wide spread bruising on his back/legs and some bruising on the back of both hands. His last INR was three weeks ago and was 3.0. He states he saw an M.D. six days ago for a cough and was put on a medication described as a “white tablet.” His chronic medications include: Coumadin 5 mg qd, Albuterol inhaler 2 puffs 4 times a day and Nortryptiline 25 mg qhs.
What medication was he placed on?

a) Amoxicillin

b) Codeine

c) Cefixime

d) Azithromycin

e) TMP/Sulfa

warfarin interactions decrease metabolism increase pt
Warfarin InteractionsDecrease metabolism (increase PT)

Most Severe Possible*

TMP/Sulfa Ciprofloxacin

Erythromycin Omeprazole

Amiodarone Clarithromycin




Metronidazole * Especially in elderly

and polypharmacy