FUNDAMENTALS OF CLINICAL MEDICINE
FINAL EXAMINATION
Version A
TRUE / FALSE
1. Automatisms are involuntary automatic behaviors that occur when consciousness is impaired,
either during or after a seizure.
A. True
B. False
2. When treating a patient with an acute ischemic stroke blood pressure should not be lowered acutely.
A. True
B. False
MULTIPLE CHOICE; SLNGLE BEST ANSWER:
3. Among the reasons HIV infection is likely to be a major wealth problem for years to come is/are:
A. The long time between infection and symptoms of disease (median time 11.3 years).
B. Antigen stimulation of infected CD4 causes HTV production.
C. Age groups at risk for acquiring HIV have little experience with AIDS in their peer
group of friends.
D. All of the above.
4. All of the following are modifiable risk factors for stroke except:
A. Smoking
B. Diabetes
C. Hypertension
D. Coronary Heart Disease
E. Family history
5. Advers effects that may be associated with Tegretol include:
A. Diplopia
B. SIADH
C. Vertigo
D. All of the above
6. Indications for treatment of arrhythmias include all of the following except:
A. Relief of symptoms that interfere with a patients lifestyle.
B. Prevention of potentially life-threatening arrhythmias.
C. Prevention of asymptomatic frequent premature ventricular contractions.
D. Prevention of embolic events with atrial fibrillation.
7. You are assigned a consult on the Nephrology Consult Service. On your way to the bedside you
learn that the patient has an elevated plasma bicarbonate. Which one pair of acid-base disorders
listed below correctly lists two causes of an elevated bicarbonate?
A. Metabolic alkalosis and severe lactic acidosis.
B. Respiratory acidosis or metabolic alkalosis.
C. Respiratory acidosis or metabolic alkalosis.
D. Metabolic alkalosis or respiratory alkalosis.
8. You determine that a metabolic alkalosis is present in a patient on whom you are consulting.
From the following list, which answer below represents the most likely (common) scenario
leading to the development of a metabolic alkalosis in hospitalized patients.
A. N-G suction or the use of diuretics in a patient with effective volume depletion and
a low urine chloride concentration.
B. Hypertension in a volume expanded patient with a high urine chloride
concentration.
C. Congenital chlorhidorrhea.
D. Vomiting in a patient receiving large doses of cimetidine or omeprazole and an
acid urine pH.
9. A first year medical student presents to the clinic with a complaint of gnawing epigastric pain
relieved by eating. The remainder of the history and physical are unremarkable. Your
recommendation as his physician would be:
A. Buy more life insurance before any diagnostic testing is done.
B. Avoid fatty, greasy food
C. UGI endoscopy
D. A course of an H-2 blocker (e.g. Ranitidine)
E. UGI series
10. A retired physician presents to the clinic with a complaint of gnawing epigastric pain relieved by
eating. He has lost 20 pounds. The remainder of the history in unremarkable. Physical
examination is unremarkable except for heme + (guaiac +) stool. Your recommendation as his
physician would be:
A. Avoid fatty, greasy food
B. UGI endoscopy
C. A course of an H-2 blocker (e.g. Ranitidine)
D. UGI series
11. During the workup of a macrocytic anemia, a 62-year-old woman is determined to have an
intrinsic factor deficiency during a Schilling test. A serum gastrin is markedly elevated. Which
ONE of the following is a likely explanation'?
A. A gastrin-producing rumor
B. Achlorhydria
C. Cholera
D. Celiac sprue
E. Gallstones
12. To examine a program for educating health professionals in a sports injury clinic about the
importance of keeping detailed records, a researcher does a controlled trial in which the dependent variable is a range of motion of injured joints, which is classified as (a) worse, (b) same, or (c) better, and the independent variable is (a) program or (b) no program. What kinds of variables are they'?
A. Dependent is categorical (nominal); independent is ordinal.
B. Dependent is ordinal: independent is categorical
C. Dependent is continuous; independent is categorical.
D. Dependent is ordinal: independent is continuous.
E. None of the above.
13. Also referring to the above question (number 15), are these variables appropriate?
A. Both are appropriate.
B. Neither is appropriate.
C. The dependent variable should be measured continuously, rather than collapsing
data.
D. Choosing the type of variable is unimportant in medical research.
14. The Lipids Research Clinics Trial screened 300,000 men to find 3,000 with cholesterol in the top
1 percent, no heart disease, and compliance with their treatment regimen. They randomized the
population to active drug (cholesterol lowering) and placebo regimens and, after 10 years, found
38 cardiac deaths in the controls and 30 in the drug group (p < .05). A Margarine company then
proclaimed that everybody should switch from butter to low cholesterol margarine to prevent heart disease. You must decide what to recommend to your patients. What would be your
considerations with regards to a large clinical trial?
A. In large sample studies, statistical significance is very important.
B. In large sample studies, clinical significance is very important.
C. No matter how small a result, you should recommend dietary modifications to your
patients.
D. Even though few of your patients are similar to the study populations, it is a simple
task to extrapolate the results of the study to the general population.
15. A common omission in reports of studies is the "power" of the statistical tests to discover a
difference between the treatment and the placebo. The power of a test is related to the size of the
effect and the size of the sample. true or false'?
A. True
B. False
16. A 58-year-old male, with a history of hypertension and hypercholesterolemia, with no prior
history of dyspnea or exertional chest pain, presents with crushing retrosternal chest pain which
waxes and wanes, radiates down his left arm, and is associated with some diaphoresis. The most
likely diagnosis is:
A. Critical aortic stenosis with hypertensive crisis.
B. Hypertrophic cardiomyopathy.
C. Unstable angina or acute myocardial infarction.
D. Acute pericarditis.
17. The electrocardiogram is the single most useful tool for diagnosing acute myocardial infarction.
The single MOST specific pattern associated with acute myocardial infarction is:
A. ST depression across the pericardial leads.
B. A rapid and irregular rhythm.
C. Hyperacute ST elevation in at least two adjacent leads representing an anatomic
region (such as V1 and V2).
D. Hyperacute ST elevation in at least two leads representing an anatomic region,
such as leads 3 and AVF, with accompanying reciprocal ST depressions in a
anatomically opposite region such as leads VI and V2.
18. Your best friend has fallen in love with an exotic dancer. He is about to get married even though
you have tried to talk him out of such a rash decision since he has know her for only one week.
To make matters worse, she has informed your friend that she has chronic hepatitis B and her
doctor has told her it is actively replicating. Your advice to your friend would be the following:
A. HBIG (hepatitis B immune globulin) and hepatitis B vaccine
B. Hepatitis B vaccine only
C. HBIG (hepatitis B immune globulin) only
D. Check liver function tests and, if elevated, begin interferon treatments
MATCHING QUESTIONS 19 - 21
EACH CHOICE MAY BE USED ONLY ONCE
Match the following hepatitis B serology to the correct diagnosis:
HBsAg HBsAb HBcAB-IgM HBcAb(total) HBeAb HBeAg/HBV-DNA
A. + - - + - +
B. - + - + - -
C. + - + + - +
D. - + - - - -
E. + - - + + -
19. Acute hepatitis B.
20. Past infection with the appropriate antibody response.
21. Active (replicating) hepatitis B that is chronic (>6 months).
MULTIPLE CHOICE, SINGLE BEST AIN'SWER:
22. A 5 month old child is brought to your office because of fever (40° C), vomiting and irritability.
He has been febrile and irritable for one week. Examination shows positive Kernig and
Brudzinski signs. The initial CSF shows:
WBC 825/mm3 (99% mononuclear leukocytes)
RBC 10/mm'
protein 120 mgidL
glucose 35 mg- dL (blood glucose 85 mg/dL)
Gram stain - no organisms seen
Your interpretation of these data, and your treatment based on this interpretation, is:
A. probable viral meningitis; observe
B. probable tuberculous meningitis; give INH, Rifampin. Streptomycin.
pyrazinamide. and glucocorticosteroids
C. probable bacterial meningitis: give cefotaxime intravenously
D. probable non-infectious CSF pleocytosis; observe closely and repeat CSF later.
E. probable fungal meningitis; begin amphotericin B
23. An eight year old infant is brought to the hospital in respiratory distress. The emergency room physician notes that the child has large liver and spleen. Which of the following would not be in the differential diagnosis of neonatal hepatosplenomegaly and respiratory distress?
A. Congenital Treponema pallidus infection
B. Congenital cytomegalovirus infection
C. Congenital Toxoplasma gondii infection
D. Hepatitis B
E. Listeria monocytogenes sepsis
24. The natural history of AIDS differs in adults and children. Which of the following is a very
common problem in children but uncommon in adults?
A. Kaposi's sarcoma
B. Invasive bacterial infections (e.g. pneumococcal sepsis)
C. Mycobacterium avium-intracellulare blood stream infection
D. Pneumocystis carinii pneumonia
E. Cryptosporidiosis
QUESTION 25 - 26, CASE OF MR. KAPLAN:
Mr. Kaplan presents with a history of severe chest pain for 3 hours. The electrocardiogram shows
ST segment elevation with T wave inversion in leads I, II, AVL and V2 - V6. The most likely
pathological changes in the patient's heart are:
A. Atherosclerosis of the right coronary artery and subendocardial ischemia of the
posterior left ventricle.
B. Vasospasm of the left circumflex coronary artery and subendocardial ischemia of
the lateral left ventricle.
C. Acute thrombus of the left anterior coronary artery and evolving transmural
myocardial infarct of the anterior and lateral left ventricle.
D. Organizing thrombus of the left anterior descending artery and healing transmural
myocardial infarct of the anterior left ventricle.
E. Atherosclerosis of the left anterior descending coronary artery and
subendocardial infarct of the anterior left ventricle.
26. In the case of Mr. Kaplan, the most likely finding with serial measurements of serum levels of
creatine kinase (CK), CK-MB. and troponin - T (T) is:
(Normal values: CK. 12-191 V/L; CK-MB. 0 - 2.5 index; T. 0 - 0.5 MG/ml)
Admission 6 hours later 2 days later
A. CK 400 1000 300
CK-MB 10 20 4
T 25 50 10
B. CK 190 600 200
CK-MB 2 5 2
T 1 10 5
C. CK 200 700 2000
CK-MB 2 6 20
T 2 12 20
D. CK 150 180 140
CK-MG 0 1 0
T 1 2 1
E. CK 190 650 800
CK-MB 2 5 8
T 0 1 0
27. In the case of Mr. Kaplan the most appropriate therapy (excluding any major contraindications) is:
A. Sublingual nitroglycerin only.
B. Intravenous nitroglycerin and beta-adrenergic blocker only.
C. Aspirin by mouth.
D. Intravenous heparin.
E. All of the above, plus an intravenous thrombolytic agent such as tissue
plasminogen activating factor.
QUESTION 28 - 30, CASE OF MRS. SEARS:
28. Following recovery from a syncopal episode, Mrs. Sears was admitted to the Coronary Care Unit.
She was a 35-year-old woman previously in good health except for a flu-like illness over the
previous two weeks. Her blood pressure was 80 / 20 mm Hg. Hemodynamic monitoring
revealed: Right atrial pressure. 20 mm HG: pulmonary artery pressure, 60 / 36 mm HG;
pulmonary capillary wedge pressure, 34 mm HG: cardiac index, 1 9 L 'nun / m
The findings support a diagnosis of :
A. Cor pulmonale
B. Aortic Stenosis
C. Hyperdynamic left ventricle
D. Left ventricular failure
E. Neurogenic pulmonary edema
29. The most appropriate pharmacologic therapy for Mrs. Sears is:
A. Diuretics alone
B. Beta adrenergic blocker
C. Calcium channel blocker
D. Dobutamine and beta adrenergic blocker
E. Dobutamine, dopamine, with or without diuretic
30. Likely pathological findings in the case of Mrs. Sears INCLUDE:
A. Left ventricular dilation
B. Lymphocytic infiltrates in the myocardium
C. Centrilobular congestion of the liver
D. Congestion of the pulmonary capillaries
E. All of the above
QUESTION 31 - 33; CASE OF MIELVIN BELL
31. M. Bell, a 24-year-old Gym teacher, was hospitalized because of marked shortness of breath. His
temperature was 101 degree F, blood pressure was 100 / 60 mm Hg, and pulse was 130 bp and
irregularly irregular. He was given intravenous digoxin and a beta-adrenergic blocker. His heart
rate decreased to 100 bp with symptomatic improvement. Despite the symptomatic improvement.
on physical examination, he had persistent rales bilaterally, and on cardiac exam, an accentuated
P. right ventricular lift. loud opening snap and diastolic rumble at the apex. The most likely
pathogenesis of his signs and symptoms is:
A. Acute rheumatic fever with mitral regurgitation
B. Acute bacterial endocarditis with mitral regurgitation
C. Rheumatic mitral stenosis with fever of uncertain origin
D. Congestive cardiomyopathy with mitral stenosis
E. Ischemic heart disease with papillary muscle rupture
32. With regard to the treatment of Mr. Bell's arrhythmia the one most CORRECT statement is:
A. No attempt should have been made to control the heart rate
B. Lidocaine without digoxin should have been given
C. Beta-adrenergic blockers are contraindicated
D. Dopamine is the drug of choice
E. Intravenous administration of a beta-adrenergic blocker and digoxin is appropriate.
33. Mr. Bell is likely to have each one of the following pathological changes EXCEPT:
A. Chronic passive congestion of the lungs
B. Fibrotic mitral valve with marked commissinal fusion
C. Dilated left atrium
D. Hypertrophied right ventricle
E. Dilated left ventricle
QUESTIONS 34 - 36, CASE OF SIRS. GORDON:
34. Mrs. Gordon is a 72 y.o. woman who has been in good health. She was told on a physical
examination 2 years ago that her blood pressure was normal. Last week she was seen by Dr.
Rosenfelder for the first time and was told that she now had high blood pressure. Her blood
pressure in his office was recorded as 180 systolic / 65 diastolic.