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Spleen rupture
Evaluation and management of the comatose patient
Various Types of Headaches
Principles of Appropriate Antibiotic Use for Acute Respiratory Infections


Watch Pt's vital sign
If in offic
Do Peak flow <300 send Pt
2.100% O2
3.Peak flow [Low]
4.Nebulised Ventolin
5.CXR{exclude chest infection]
6.ABG-[If pulse O2<90%]
15 min after
peak flow+ Nebulizer
15 min after
peak flow+ nebulizer
if pt better
Prednisolone oral stat
2hrs pt better[stop O2]
2.Inhaled steroid-tid
3.Inhaled ventoline-prn
see after 7 days
Dx-Acute exasserbation of chronic asthma

You may also consider allergy skin test for environmantal control

a 44 y.o man comes for health maintainance. He has no sig. past medical HX. He drinks socially. He denies having any alcohol related problems.

What is the next step in screening for alcohol related got this patient.

a. Inquire about the type, frequency, and quantity of alcohol use
b. Administer a standardized questionaire to detect alcohol problem
c. Administer lab. tests to detect alcohol-related medical problems
d. Inquire about criteria that meet definitions of alcohol abuse, dependence, and alcoholism


I think answer is a.. screening for a scocial drinker per say should be focused on frequency and quantity,, If an Sx then it simportant to ask for standardize qs regarding abuse and dependenace.. What u think?

An 85-year-old white male nursing-home resident has a 18 days history of anorexia, malaise, and intermittent fever to 38.5° C (101.3° F). The fever has persisted despite empiric therapy with amoxicillin, followed by ciprofloxacin (Cipro). Her present weight is 49.5 kg , compared to 54.5 kg 3 weeks ago. Her mental status, characterized by a dementia pattern consistent with Alzheimer's disease, has not changed. A physical examination discloses no significant abnormalities. A CBC, urinalysis, erythrocyte sedimentation rate, and chest radiograph are also unremarkable.

Which one of the following is most likely to help make the diagnosis?

1.PPD skin testing
3.CT scan of the head
4.Serologic testing for syphilis
5.Liver biopsy


When vancomycin (Vancocin) should be used instead of cefazolin (Ancef, Defzol) for surgical prophylaxis against infection:

A) prosthetic valve replacement & prosthetic graft implantation

B) any cardiovascular procedure if the patient has (1) has received bra-spectrum antibacterial treatment and (2) is likely to be colonized with cephalosporin-resistant enterococci

C) cardiovascular surgical interventions at hospitals experiencing outbreaks or endemic rates of surgical infection with methicillin (Staphcillin)-resistant staphylococci


Vancomycin is the drug of choice for serious infections caused by methicillin-resistant Staphylococcus aureus and coagulase-negative staphylococci (including S. epidermidis). These infections include septicemia, endocarditis, osteomyelitis, pneumonia, lung abscesses, soft tissue infections, wound infections, and meningitis.

Diabetes Management Few Points Diabetes Management Few Points

Assess diabetes control by measuring HbA 1c Every 3-6 months for insulin treated patients.
Every 6-12 months for non-insulin treated patients

Ensure that a comprehensive ophthalmological examination is carried out At diagnosis and then every 1-2 years for patients whose diabetes onset was at age 30 years or more
Within 5 years of diagnosis and then every 1-2 years for patients whose diabetes onset was at age less than 30 years

Measure weight and height and calculate BMI On initial visit, then measure weight every 3 months
Measure weight more frequently if patient is on weight reduction program

Measure blood pressure Every visit

Examine feet Every 6 months or at every visit if ‘high risk foot’ or active foot problem
Ensure that patients with ‘high risk foot’ or an active foot problem receive appropriate care from specialists and podiatrists expert in the treatement of diabetic foot problems

Measure total cholesterol, triglycerides and HDL cholesterol Every 1-2 years (if normal)
Every 3-6 months (if abnormal or on treatment)

Test for microalbuminuria At diagnosis and then every 12 months for patients with NIDDM
5 years post diagnosis and then every 12 months for patients with IDDM

Encourage healthy lifestyle Healthy food choices
Appropriate activity
No smoking

Recommendations for Diabetes Screening of Asymptomatic Persons

Recommendations for Diabetes Screening of Asymptomatic Persons
Timing of first test and repeat tests

A:Test at age 45; repeat every three years:Patients 45 years of age or older

B:Test before age 45; repeat more frequently than every three years if patient has one or more of the following risk factors:

Obesity: >=120% of desirable body weight or BMI >=27 kg per m2

First-degree relative with diabetes mellitus

Member of high risk-ethnic group (black, Hispanic, Native American, Asian)

History of gestational diabetes mellitus or delivering a baby weighing more than 4,032 g (9 lb)

Hypertensive (>=140/90 mm Hg)

HDL cholesterol level ¾35 mg per dL (0.90 mmol per L) and/or triglyceride level >=250 mg per dL (2.83 mmol per L)

History of IGT or IFG on prior testing

(BMI=body mass index; HDL=high density lipoprotein; IGT=impaired glucose tolerance; IFG=impaired fasting glucose.)

A 22-year-old man seeks medical attention for perennial nasal congestion and postnasal discharge. He states he does not have asthma, eczema, conjunctivitis, or a family history of allergic disease. His nasal secretions are rich in eosinophils. The test most likely to yield a specific diagnosis in this setting is

A serum IgE level (competitive radioimmunosorbent technique)
B serum IgE level (radiodiffusion technique)
C elimination diet test
D skin testing
E sinus x-rays

The answer is D
Allergic rhinitis can be either seasonal as a result of pollen exposure or perennial as a result of exposure to dust or mold spores (or both). In these IgE-mediated reactions to inhaled foreign substances, nasal eosinophilia is common. Vasomotor rhinitis is a chronic, nonallergic condition in which vasomotor control in the nasal membranes is altered. Irritating stimuli, such as odors, fumes, and changes in humidity and barometric pressure, can cause nasal obstruction and discharge in affected persons, and nasal eosinophilia is not noted. Because the man described in the question has either perennial allergic rhinitis due to dust or mold-spore allergy or eosinophilic nonallergic rhinitis, skin testing for responses to suspected allergens should be diagnostic. Though total serum IgE may be elevated, demonstration of specificity is critical. Specificity can be demonstrated by binding to a solid-phase antigen and detected by uptake of radiolabeled anti-IgE (radioallergosorbent technique; RAST). RAST is more difficult than skin testing due to the requirement for defined antigens and standardization. Pollen skin tests are unlikely to be helpful because of the perennial nature of the condition described. An elimination diet can be used diagnostically or therapeutically in persons with suspected food allergy; however, food allergy rarely causes rhinitis. Sinus x-rays, whether positive or negative, would not reveal the underlying cause of the rhinitis.

The most common cause od complaint of breast pains is
a. fibrocyctic disease
b. costochondritis
c. trama
d. breast abscess
e. intraductal carcinoma


Breast pain is a very common complaint among women, but is rarely an indication of breast cancer.

There are two general categories of breast pain.

The more common type is cyclical(fibrocyctic breast changes or disease). The woman will often feel increasing fullness, heaviness, and tenderness in the two weeks before her period. In some women, the breast pain symptoms are much more severe, but will abate after her period.

A less common, but troublesome, type of breast pain is either constant or spasmodic. Some women describe sharp shooting pains, or severe pains that are occasionally mistaken for heart attack.


For pain associated with the disease, over-the-counter analgesics are usually taken. Prescription medications such as danazol or bromocriptine can be used, but are costly and have sometimes have unpleasant adverse affects. If they are very bothersome, lumps can be removed. Preventative measures can help too-- some women report a reduction in lumps after eliminating caffeine from their diet and quitting smoking. Vitamin E is also thought to provide some remedy, but there is no conclusive evidence of its effectiveness.

Each condition listed below is associated with an increased risk of cancer of the esophagus. Which one is most closely linked to adenocarcinoma of the esophagus?

A Achalasia
B Smoking
C Barrett's esophagus
D Tylosis
E Alcoholism

C esophageal ca.
upper 1/3-15%
middle 1/3- 50%
lower 1/3 -35%
squamous cell ca.>85%
adenoca. : distal 1/3 Barrett's esophagus relation

A 24-year-old man with a 12-year history of diabetes reports a fasting glucose level in the 250 to 300 range, a glucose level before lunch in the 110 to 120 range, and a glucose level before dinner and at bedtime in the 80 to 100 range. He also reports restless sleeping for the past several weeks associated with nightmares. He is presently taking 20 units of Neutral Protamine Hagedorn (NPH) and 10 units of regular insulin before breakfast and 10 units of NPH and 5 units of regular insulin before dinner.
Which of the following actions would be the best in the management of this patient?

a. Increase his NPH before dinner to 15 units.
b. Decrease the amount of food he is eating for a bedtime snack.
c. Instead of taking regular and NPH insulin before dinner, have him take both at bedtime.
d. Instead of taking both the regular and NPH insulin before dinner, instruct him to take only the 5 units of regular insulin before dinner and the 10 units of NPH at bedtime.
e. Instruct him to increase his regular insulin before breakfast to 14 units in order to lower his fasting glucose


  1. The high fasting glucose along with restless sleeping associated with nightmares are suggestive of unrecognized nocturnal hypoglycemia. This is referred to as the Somogyi effect in which nocturnal hypoglycemia is followed by a rebound hyperglycemia. Definite diagnosis can be determined by having the patient set his alarm for 2 A.M or 3 A.M. to check his glucose. This effect can be corrected by taking the NPH insulin at bedtime so its peak action occurs upon arising instead of in the middle of the night. The regular insulin still should be given before dinner. Increasing the NPH insulin before dinner would only increase the nocturnal hypoglycemia. Decreasing his bedtime snack would also increase the nocturnal hypoglycemia. Taking regular insulin with the NPH at bedtime would also cause nocturnal hypoglycemia, because regular insulin is short-acting and would peak during the early morning hours. Increasing the regular insulin before breakfast would not prevent the high fasting glucose because its major action occurs between breakfast and lunch.

A 75-year-old woman has been hospitalized for 4 weeks with multiple medical problems. Her appetite is poor. Her total T4 is 4.5 ìg/dL, T3 resin uptake is 38%, and thyroid-stimulating hormone (TSH) is slightly elevated. What could explain these findings about this patient?

a. She has secondary hypothyroidism
b. She has adrenal insufficiency
c. She has primary hypothyroidism
d. She has euthyroid sick syndrome
e. She has secondary hyperthyroidism

The correct answer is d.
d. This patient has euthyroid sick syndrome or nonthyroidal illness. Patients with euthyroid sick syndrome present with a wide variety of thyroid tests. These abnormalities can generally result in a low T3; the T4 generally is normal, decreased, or rarely elevated. The T3 resin uptake is generally elevated while the TSH is slightly decreased. The degree of decrease in the T4 correlates with the severity of the illness. It is believed that these changes represent adaptive forms of hypothyroidism. As the patient recovers from his illness, the thyroid function tests improve. Because this is felt to be an adaptive state, no thyroid hormone should be given.

A 26-year-old woman presents with progressive weakness, weight loss, decreased appetite, vague abdominal discomfort, and nausea and vomiting. Physical examination reveals volume loss, hypotension, and obvious weight loss. Laboratory data reveal hypoglycemia, hyponatremia, and hyperkalemia.
The best treatment for this patient would be

a. Prednisone
b. Methylprednisolone IV
c. Hydrocortisone IV
d. Hydrocortisone IV and isotonic saline
e. Isotonic saline


patinet Hx. is fit for adrenal failure.
but hyperpigmentation is only for primary adrenal failure(Addison's disease)
i am not sure this case is adrenal crisis or not
cause i didn't find any precipitating facotr Hx. such as illness, surgery, or injury
but adrenal failure with hypotension must be treated immediately.
hydrocortisone 100mg IV q8h and 0.9%saline with 5% dextrose should be infused until hypotension is corrected, steroid tapering and then change to oral
mineralocorticoid replacement is not needed until the dose of hydrocortisone is less than 100mg/day

Which diagnostic technique is used to identify a 24-year-old woman with an enlarged asymmetric thyroid?

a. Serum calcitonin
b. Fine-needle aspiration biopsy
c. Serum thyroglobulin
d. Serum thyroid-stimulating hormone (TSH)
e. Antithyroid microsomal antibody test


according to the Cecil,
the most sensitive index to evaluate thyroid status in patients with goiter is the TSH level
TSH can be elevated in the face of normal or low-normal T4 levels and mild normal T3 values, most such patients benefit from thyroxine replacement, with TSH decreasing into the normal range and removing the thyroid growth stimulus
the presence of pressure sx. - evaluation of substernal extension by CT, MRI

Which clinical description is associated with idiopathic hypoparathyroidism?

a. A 9-year-old obese boy with mental retardation and skeletal abnormalities and a serum calcium of 6.3 mg/dL, a phosphorus of 7.5 mg/dL, and a high parathyroid hormone (PTH)
b. A normal-appearing boy except for a short fourth metacarpal bone, with normal intelligence
c. An 8-year-old girl with paresis, especially around the perorate area, muscle spasm and cramps, and irritability. A serum calcium of 5.0 mg/dL, a phosphorus of 7.8 mg/dL, and a low PTH
d. A 32-year-old woman with hypercalcemia nephrolithiasis, depression, polyuria, and polydipsia. A serum calcium of 12.5 mg/dL, a phosphorus of 2.0 mg/dL, and a high PTH
e. A 24-year-old woman whose serum calcium remains high despite parathyroid surgery


The correct answer is c.
c. Idiopathic hypoparathyroidism is an autoimmune disorder and occurs as a sporadic or familial disorder. The average time between onset of symptoms and diagnosis is about 6 years. Onset is insidious. Patients experience paresthesia (particularly in the perioral area), muscle spasms, carpopedal spasm, facial grimacing, and, in extreme cases, laryngeal spasms and seizures. Other symptoms include irritability, depression, impaired memory, and psychosis. With longstanding hypocalcemia, patients can experience increased intracranial pressure with papilledema, dry skin, and lack of calcification. The serum calcium is low (generally in the range of 5 mg/dL), the serum phosphorus is increased to approximately 705 mg/dL, and the PTH level is low

idiopathic(autoimmune) hypoparathyroidism may be due to inherited mutations in the PTH gene that prevent synthesis and secretion of PTH
case c hx. is metlow Ca, high P, low PTH, hypocalcemic sx
and a is for pseudohypoparathyroidism(Albright's hereditary osteodystrophy)
rest of them shows hyperCa something,,,doesn't make sense

18 years old female with hiatory of HIV +ve came in office regular physical exam PAP is normal. what do you want to do next on her?
a)Annual breast exam
b)advice monthly Breast self exam
d)Repeat PAP on 6 month
e)Repeat PAP next year

Correct ans-C HIV +ve pt needs Colposcopy whatever the PAP Correct ans-C HIV +ve pt needs Colposcopy whatever the PAP

according to the blue print
there is synergic effect between HPV and HIV
HIV positive pap negative ->after 6mo.pap->if negative, do pap every1year

Ambulatory Medicine - Item 58

A 49-year-old woman presents for her annual examination. She has no signs or symptoms of illness. Her medical and family history are negative. She is still having regular menstrual periods, the last beginning 10 days ago. She is gravida 2 para 2, and her method of birth control is condoms.

On physical examination, there is a round, firm, nontender, and mobile mass approximately 1 cm in diameter in the upper outer quadrant of the patient’s left breast. Mammogram is negative, but the radiologist suggests that an ultrasound be performed to further evaluate the palpable mass. The ultrasound identifies no cysts.

Which of the following is the best approach to the management of this patient?

(A) Schedule an examination in 6 weeks to re-examine the breast during a different part of the patient’s menstrual cycle.

(B) Attempt needle aspiration of the mass.

(C) Reassure the patient and continue routine yearly examinations and mammograms.

(D) Schedule a mammogram in 3 months.

(E) Refer the patient to a surgeon for biopsy of the mass.

Answer: E
Evaluate and manage a discrete breast lump.

This patient illustrates the need for aggressive evaluation of her discrete solid breast mass. Any middle-aged woman with a discrete breast mass should be referred to a surgeon for biopsy regardless of the presence of benign characteristics on physical examination or a negative mammogram. The risk of malignancy increases with age, leading to the axiom that any discrete mass detected on physical breast examination in a woman aged 50 years or older should be considered to be malignant until proven otherwise. Although certain characteristics are associated with benign lesions (for example, masses that are round, mobile, and soft), a review of malignant masses found a significant portion to be regular (41%) and mobile (61%). Therefore, clinical characteristics cannot be relied upon to predict the pathologic nature of a discrete mass. If this were a younger woman with multiple, round, tender lumps or if cysts were identified on ultrasound, a return in 6 weeks for examination during a different part of the menstrual cycle or an attempt at aspiration would be appropriate. However, there is no evidence to support the presence of a cyst. Although a “negative triad” — benign characteristics on physical examination, negative cytology on fine-needle aspiration, and a negative mammogram — has been suggested as an adequate evaluation, studies have reported false-negative rates as high as 16% in the presence of a malignant mass. Risk factors for breast cancer are helpful in predicting the likelihood of a mass’s being malignant, but 75% of women with newly diagnosed breast cancer have no identifiable risk factors. Mammograms are the most sensitive method for detecting breast cancer, but large trials have reported that 3% to 45% of breast cancers are detected by palpation in women with negative mammograms.

screening mammography has been shown by a number of studies to decrease mortality from breast cancer , however, a normal mammogram in the setting of a palpable mass does not exclude a cancer.
mammogram suspicious for malignancy: densities with irregular margins, spiculated lesions, microcalcification,or rod-like or branching patterns
any changes from previous mammogram and any suspicious mass should be considered for Bx.
needle-directed Bx. is useful for nonpalpable mammographic abnormalities and palpable mass

cancer is unlikely if
1. the mass completely disappears after aspiration, does not return, the fluid is hemoccult netative
2. if any these criteria are not met, open excisional Bx.

Pl Correct CCS[18 y/o F with dysurea & lower abdominal discomfort]

Dx=Early pregnancy with UTI [OFFICE]
2.U/A microscopic
3 U Culture & sensitivity
Return visit 3 days
[Pregnancy +ve/urine org sensitive to Cipro/Bactrim/Amox]
P/E Ht/Lg/Ab/Genital
Wt & Ht
1 Amox [oral]
5.TORCH titre
6 Blood goup & cross match
9.Coombs test
Next visit 4wks after

Addition inv
Final Dx
UTI with Early pregnancy

I think on the initial visit, You should order Pregnancy test and CBC. Not after 3 days.

The case is in the real test, like this: a 30 yo AA woman was brought to your office by her husband and
presented with dysnuria and frequency for recent three days, she missed her mens for 6 weeks (didi not know that she is pregnant)

Need to do:

1. Complet prenatal work up
2. Antibiotics: Metro is contraindicated in the 1st trimester 2nd and 3d OK (select Nitroforantoin and amoxillin) I think on the initial visit, You should order Pregnancy test and CBC. Not after 3 days.

The case is in the real test, like this: a 30 yo AA woman was brought to your office by her husband and
presented with dysnuria and frequency for recent three days, she missed her mens for 6 weeks (didi not know that she is pregnant)

Need to do:

1. Complet prenatal work up
2. Antibiotics: Metro is contraindicated in the 1st trimester 2nd and 3d OK (select Nitroforantoin and amoxillin)


45 y/o h/o HTN& chest pain in morning walk also burning sensation on empty stomach[smoker/OFFICE]
HEENT/Ht/Lg/ abdomen/Extrimity
3.H. pylori Ab
4.Lipid profile
Office after 7 days
2.24 hrs esophageal ph minitoring

Visit 1 wk
P/E:- Ht/Lg/Abd
[Ph +ve for reflux/ETT +ve]
1.B blocker[pt was in thiazide & pr well controlled]
2.Nitro Oral Long acting.
1No smoking
2.No coffie
3.Frequent small diet

Which is the most common causative agent for viral pneumonia in an adult?
A. Influenza
B. Adenovirus
C. Parainfluenza Virus
D. Respiratory cyncytial Virus
E. Varicella


Influenza viruses are the most common causes of viral pneumonia in adults, while RSV is the most common etiology of viral pneumonia in infants and children. Influenza usually is seen in epidemics and pandemics in late winter and early spring. On the contrary, RSV infection is seasonal, with rates that increases in the fall, peaks in winter, and returns to baseline in the spring. Peak attack rates for RSV occur in the winter in infants younger than 6 months. Parainfluenza is seen most often in late fall or winter and is the second most common cause of viral illness in infants after RSV infection.

During a general physical examination of a hypertension male smoker, you palpate a pulstile abdominal mass in the mid supraumbilcal region. This mass can be felt laterally as well as anteriorly. Which of the following would put the patient at the greatest risk of a catastrophic complication from your suspected diagnosis

a. Diameter of the mass <4 cm
b. Age of the patient >65 yo
c. Presence of COPD
d. Presnece of chronic hepatitis
e. Presence of diabetes mellitus

Which is the major cause of intracerebral hemorrhage

a. Atrial fibrillation
b. Hypertension
c. Smoking
d. Cerebral aneurysm
e. Coagulopathy


hemorrhagic stroke-
intracerebral hemorrhage(hypertensive) -most common
subarachnoid hemorrhage9ruptured aneurysm
A-V malformation

All of the following are causes of increased serum prolactin levels except:
A - Chest wall lesions
B - Haloperidol therapy
C - Meperidine therapy
D - Pituitary tumors
E - Lymphocytic hypophysitis


All of the following are therapeutic options for certain kinds of pituitary adenomas except:

A - Surgical removal of the adenoma
B - Bromocriptine therapy
C - Radiation
D - Octreotide therapy
E - Somatostatin therapy


A 45-year-old male complains of occasional discharge from both nipples as well as erectile dysfunction. Which of the following tests is likely to give a correct diagnosis?

A - Serum prolactin level
B - Serum FSH level
C - Serum LH level
D - Serum ACTH level
E - Serum TSH level


Although pituitary tumors that secret prolactin may result in ED and experts recommend that a routine serum prolactin test be performed, prolactin levels are rarely elevated in ED without other symptoms. Hyperprolactinemia, most commonly secondary to a pituitary adenoma, can also result in hypogonadism and erectile dysfunction by interfering with the hypothalamic-pituitary axis.

All of the following statements about empty sella syndrome are true except:
A - Empty sella syndrome occurs when the subarachnoidal space extends into the sella turcica.
B - Congenital incompetence of the diaphragma sellae is the most common cause of enlarged sella turcica.
C - Empty sella syndrome may be a consequence of Sheehan’s syndrome.
D - Presence of empty sella syndrome excludes the possibility of a pituitary tumor.
E - Most patients are middle-aged obese women

B or C

A 32-year-old male presented with complaints of easy fatigue, feeling cold, constipation and muscle cramping. Physical examination revealed a cool, rough, dry skin; puffy face and hands; hoarse voice; and slow reflexes. Blood pressure was 116/72, pulse 54 min and respiration rate was 11 min. ECG revealed low voltage QRS. Routine urinalysis, complete blood cell count, electrolytes, glucose, BUN, and creatinine were in the normal range. The patient turns had low FT4 and TSH. Which of the following would be an appropriate management?

A - Levothyroxin supplementation
B - Thyroid ultrasound
C - Serum T3 level
D - Complete assessment of pituitary function
E - TSH supplementation


MEN–I syndrome is associated with all of these except:
A - Renal Stones
B - Diarrhea
C - Cushing’s syndrome
D - Galactorrhea
E - Hypertension

Match this clinical syndrome with its pancreatic endocrine tumor: Diarrhea, hypokalemia, dehydration, hypochlorhydria, flushing, hyperglycemia, hypercalcemia.

A - Gastrinoma
B - Glucagonoma
C - Insulinoma
D - VIP-oma
E – Somatostatinoma


Match this clinical syndrome with its pancreatic endocrine tumor: Abdominal pain, diarrhea, esophageal reflux.

A - Gastrinoma
B - Glucagonoma
C - Insulinoma
D - VIP-oma
E – Somatostatinoma


Match this clinical syndrome with its pancreatic endocrine tumor: Diabetes mellitus, gallbladder disease, diarrhea, steatorrhea, weight loss.
A - Gastrinoma
B - Glucagonoma
C - Insulinoma
D - VIP-oma
E – Somatostatinoma


Match this clinical syndrome with its pancreatic endocrine tumor: Necrolytic migratory erythema, diabetes mellitus, weight loss, anemia, hypoaminoacidemia, thromboembolism, diarrhea

A - Gastrinoma
B - Glucagonoma
C - Insulinoma
D - VIP-oma
E – Somatostatinoma


All of the following are risk factors for development of diabetic nephropathy except:
A - Decreased plasma prorenin
B - Race
C - Hypertension
D - Increased glomerular filtration rate
E - Poor glycemia control

Which of the following methods is the most reliable as a measure of microalbuminuria in patients with diabetes mellitus?

A - Measurement of the albumin in a random urine sample
B - Measurement of the albumin-to-creatinine ratio in a random urine sample
C - Measurement of the albumin in a timely (early morning) urine sample
D - Measurement of the albumin in a timely (before sleep) urine sample
E - Measurement of prealbumin in the serum sample


Screening for microalbuminuria can be performed by three methods: 1) measurement of the albumin-to-creatinine ratio in a random spot collection; 2) 24 hour collection with creatinine, allowing the simultaneous measurement of creatinine clearance; and 3) timed (e.g., 4 hour or overnight) collection. The first method is often found to be the easiest to carry out in an office setting and generally provides accurate information.

A 52-year-old woman develops watery diarrhea. She does not notice any blood in her stools but some fecal leukocytes are noted. She is afebrile. She was treated for a tooth abscess 2 weeks previously but is not sure of the name of the medication prescribed by her dentist. What is the most likely cause?

a. Toxigenic Escherichia coli
b. E. coli 0157:H7
c. Shigella
d. Giardia lamblia
e. Clostridium difficile


usually, 1 or 2 weeks after using antibiotics( clindamycin, ampicillin,etc..)
due to C.difficile enterotoxin
tx.)metronidazole 500mg po(preferred)or IV tid for 7-14days
refractory cases -vancomycin125mg po qh6
dx) c.difficile toxin positive stool

A 65-year-old male patient with cirrhosis would be unsuitable for liver transplantation in the presence of which one of the following factors?

A. Child class B cirrhosis.
B. Hepatocellular carcinoma smaller than 5 cm in greatest diameter.
C. Ascites.
D. Age 65 years or older.
E. Active alcohol abuse.


absolute CIx. systemic disease
2.uncontrolled extrahepatic bacterial/fungal infection
3.advanced cardiovascular/pulmonary disease
4.multiple uncorrectable life-threatening congenital
5.metastatic malignancy drug/alcohol abuse
7.HIV infection

advanced age(>60yo)is relative CIx.

he has to abstain from alcohol use for at least 6 month to be a candidate for liver transplantion

A 42-year-old female presented with pain in the left leg. Pain was mild, dull but constant. On examination there was a difference in the circumference of the calves, with the left leg being 2.5 cm (1.0 inch) bigger. There was also a 1.5 cm increased circumference in the left thigh area. Palpation of the left calf revealed tenderness in the popliteal fossa and half way down the posterior aspect of the calf. This was the first such episode in her life.
Her past medical history was significant only for multiple (3) spontaneous abortions. Impedance pletismography confirmed deep venous thrombosis. Which of the following findings is most likely in the laboratory results of this patient?

A - Polycythemia
B - Thrombocytopenia
C - Low white blood cell count
D - Hyponatremia
E – Hyperkalemia


Of the drugs approved by the U.S. Food and Drug Administration for treatment of intermittent claudication, which one of the following has been shown to be most effective in improving walking distance?

A. Warfarin (Coumadin).
B. Aspirin.
C. Dipyridamole (Persantine).
D. Cilostazol (Pletal).
E. Pentoxifylline (Trental).


Two prescription medications are approved by the U.S. Food and Drug Administration for treating intermittent claudication: pentoxifylline (Trental), an oral methylxanthine derivative, and cilostazol (Pletal), a phosphodiesterase III inhibitor. A recent randomized controlled trial comparing the two drugs found cilostazol to be significantly more effective in improving walking distance than pentoxifylline, which was equivalent to placebo. However, cilostazol is associated with a greater frequency of minor side effects, including headache and diarrhea, and is contraindicated in patients with congestive heart failure.

Gastrointestinal endoscopy is superior to contrast radiography in all of the following illnesses except:
A - Peptic ulcer disease
B - Colonic neoplasm
C - Esophagitis in AIDS
D - Intussusception
E - Crohn’s colitis


Which one of the following modalities is the most sensitive for diagnosis of renal calculi?

A - Abdominal plain film
B - Renal ultrasonography
C - Renal ultrasonography with color Doppler
D - Intravenous pyelography
E - CT scanning


CT 95 to 98% sensitine. non contrast CT

before it was IVP

All of the following are recognized risk factors for the development of renal stones containing calcium except:
A - Hypercalciuria
B - Hyperuricosuria
C - Hypercitraturia
D - High dietary protein intake
E - Low water intake


urine citrate is an inibitor of calcium oxalate precipitation

A 43 year-old female patient had successful removal of the struvite kidney stones by extracorporeal shock wave lithotripsy. Which of the following regimens is the best management for this patient?
A - No further treatment is necessary since kidney stones are successfully removed.
B - Two to four weeks of antibiotic therapy is necessary to sterilize urinary tract (Proteus and Klebsiella should be covered).
C - The acetohexamic acid (an urease inhibitor) should be used for long-term prevention of the recurrence.
D - Daily fluid intake that ensures 3 liters daily urine output should be maintained for at least 3 months to prevent recurrence.
E - Patient should be followed by biannual renal ultrasound examination since struvite stones recur in almost 75% of patients

Its B
Treat Infection, proteus and Klebs

A 43 year-old female patient with kidney stones underwent extracorporeal shock wave lithotripsy (ESWL). Stones are determined to be pure magnesium ammonium phosphate (struvite) stones. Patient has a history of several episodes of urinary tract infection. Which of the following microorganisms is most likely responsible for her urinary tract infections?

A - Klebsiella pneumoniae
B - Escherichia coli
C - Mycoplasma hominis
D - Pseudomonas aeruginosa
E - Chlamydia pneumoniae


Proteus, Klebsella

Which one of the following is the treatment of choice for most moderate to severe cases of obstructive sleep apnea?

A. Weight loss.
B. Position therapy.
C. Nasal continuous positive airway pressure.
D. Oral airway devices.
E. Uvulopalatopharyngoplasty.


Continuous Positive Airway Pressure (CPAP). During sleep, room air is continuously applied by a small, quiet air compressor that delivers positive pressure through a nasal mask. The CPAP system acts as a physical pressure splint to prevent partial or complete collapse of the upper airway during sleep. CPAP is the treatment of choice for patients with moderate to severe OSA, but it is also used to treat patients with mild OSA and those with loud and continuous snoring.

Nasal continuous positive airway pressure

Which one of the following is the gold standard for an accurate diagnosis of obstructive sleep apnea?

A. Otolaryngology evaluation.
B. Polysomnography study.
C. Electroencephalography.
D. Nighttime observation.


The gold standard for an accurate diagnosis of OSA is a polysomnography evaluation performed in a sleep disorders unit. During this overnight evaluation, the number of apneas and hypopneas can be quantified, their duration measured, their relationship to body position and sleep stages determined, the level of oxygen desaturation measured and the existence of arrhythmic episodes can be quantified. This information determines the severity of the disorder and helps determine the treatment choice. Other tests often performed to objectively evaluate daytime sleepiness include the Multiple Sleep Latency Test and the Maintainence of Wakefulness Test.

Urge incontinence may be caused by all of the following except:
A - Urinary tract infection
B - Bladder stones
C - Stroke
D - Idiopathic
E - Multiple pregnancies

E will cause Mechanical which is stress

A 43-year-old male patient with HIV infection presented with fever, cough, chest pain, and dyspnea. Physical examination reveals a thin male patient who is tachypneic. Lung auscultation revealed occasional crackle but otherwise was normal. To exclude Pneumocystis carinii pneumonia (PCP) which one of the following imaging methods should be used?

A - Conventional chest x-ray (AP an Lateral)
B - Gallium-67 scintigraphy of the chest
C - MRI of the chest
D - High resolution CT- scan of the chest
E - None of the above


All of the following statements about overflow incontinence are true except:

A - Overflow incontinence is caused by detrusor weakness or bladder outlet obstruction.
B - Leakage is typically small in volume, but when it starts it is continuous.
C - Outlet obstruction is the second most common cause of urinary incontinence in older men.
D - Almost all obstructed men develop urinary incontinence.
E - Detrussor overactivity occurs in a majority of men with obstruction resulting in urge symptoms.


usually in woman due to detrusor insufficiency(bladder hypotonia) or detrusor areflexia(bladder acontractility)- fecal impaction, medication(anticholinergics, alpha-adrenergic antagonist, epidural and spinal anesthesia), neurological disease (LMN disease, autonomic neuropathy such as diabetes, spinal cord disease, MS)

usually in man due to outflow obstruction due to surgical procedure

What is the most common type of urinary incontinence in women younger than 40 years?

A - Transient urinary incontinence (due to medications, urinary infections, etc.)
B - Stress incontinence
C - Urge incontinence
D - Overflow incontinence
E - UTI-induced incontinence


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