UJIAN TULIS IPD GRUP C
A 47 year old man came with the complaint of cough. The cough began approximately 3 months prior to this appointment and it has become more annoying to the patient. The cough is non-productive, 2-3 times/day, worse at night, 3 times at night/week. He recently restarted an aexercise program after approximately 2 years of a more sedentary lifestyle and says he is having a much harder time with the exertion. He just run out of breath earlier than he used to and cough a great deal. He has not had any blood-tinged sputum or weight loss. He does not smoke and has no significant medical history. His examination is notable for a blood pressure 130/70 mmHg and lungs that are clear to auscultation bilaterally, except for an occasional expiratory wheeze on forced expiration. A chest radiograph is read as normal. 1. What is the most likely diagnosis? a. RBC b. Asthma c. Pneumonia d. Bronchiectasis e. Chronic obstructive pulmonary disease 2. What is the classification? a. Acute asthma b. Mild intermittent c. Mild persistent d. Moderate persistent e. Severe persistent 3. What is the best daily medication for this patient? a. No daily medication b. Leukotriene modifier c. Low dose inhaled steroids d. Medium dose inhaled steroids and long acting B2 agonist e. High dose inhaled steroids, long acting B2 agonist and oral steroids A female, 18 years old, came to the clinic with hair fallen. She had pain at all joints, reddish at her cheeks, with painless oral ulcer. She also felt fatigue. In physical examination, there was pale at her conjunctivas. 4. What a. b. c. d. e. 5. What a. b. c. d. e. 6. What
is the most possible diagnosis of this case? Tuberculosis Rheumatoid arthritis SLE Sepsis Osteoarthritis is the confirmation test for the case? CD4 HIV elisa Anti dsDNA Mantoux test Viral load is the main principle to manage this case?
a. b. c. d. e.See AlsoFree and Bound T4 | OSF HealthCareThyroid Blood Tests: Diagnostics for Thyroid HealthA rare case of bilateral frontal lobe lesions due to thyroid stormHigh free cortisol with low serum Cortisol issue - Thyroid UK
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A 48-year-old man with a long history of tobacco use presents to Emergency department 4 hours after the onset of severe substernal crushing chest pain with radiating to the left arm. He has body weight of 90 kg and body height of 179 cm. Physical examination reveals blood pressure 140/90 mmHg, heart rate of 90 bpm, respiratory rate of 20 breaths per minute and temperature of 37°C. Heart sounds are normal, there are no extra heart sounds. Electrocardiography displays:
7. Which of the following is most consistent with this clinical picture? a. Inferior NSTEMI, Stage I hypertension, obesity b. Extensive Anterior NSTEMI, stage I hypertension, obesity c. Anterior segment STEMI, stage I hypertension, obesity d. Inferior NSTEMI, and anterior STEMI, stage I hypertension, obesity e. Extensive anterior STEMI, stage I hypertension, obesity 8. If the patient has no clear-cur medical contraindications to anticoagulation, which of the following would be the optimal management strategy at that time? a. Intravenous tissue plasminogen activator alone b. Intravenous tissue plasminogen activator and aspirin c. Intravenous tissue plasminogen activator and heparin d. Intravenous tissue plasminogen activator, heparin and aspirin e. Intravenous tissue plasminogen activator is contraindicated in this clinical setting 9. Absolute contraindications to the use of thrombolytic agents in the setting of emergency department include: a. Left carotid artery occlusion with hemiparesis 1 month ago b. Diabetic retinopathy c. Cardiopulmonary rescucitation for 1 to 2 mins d. Patient age > 70 y.o. e. Patient on warfarin for atrial fibrillation, with an INR of 1.8 10.The patient was given Atorvastatin 40 mg. Which of the following statements regarding cholesterol reduction is true? a. Pharmacologic cholesterol reduction does not significantly decrease the risk of cardiovascular mortality in patients with known cardiovascular disease b. Pharmacologic cholesterol reduction can decrease cardiovascular mortality in patients with and without coronary artery disease c. In patients without diabetes mellitus but with cardiovascular disease, the pharmacologic intervention should be initiated when the LDL cholesterol level is >160 mg/dl d. Cholesterol reduction does not alter the restenosis rate in patients after cutaneous cardiac intervention
e. Cardiovascular morbidity has only been shown to be reduced in the use of HMG-CoA reductase inhibitor A 37 year old executive returns to your office for follow up of recurrent upper abdominal pain. He initially presented 6 weeks ago, complaining of an increase in frequency and severity of burning epigastric pain, which he has experienced occasionally for more than 1 year. Now the pain occurs three or four times per week, usually when he has an empty stomach, and it often awakens him at night. The pain usually relieved within 2-3 hours. He admitted that stress at work had recently increased and that because of long working hours, he was drinking more caffeine and eating a lot of “take out” foods. His physical examination was normal, including stool was negative for occult blood. You advised a change in diet and started him on a n H2 blocker. His symptoms resolved completely with the diet changes and daily use of the medication. Result of the laboratory tests performed at his first visit showed no anemia. 11.What is the diagnosis? a. Gastritis b. Cholelithiasis c. Acute hepatitis d. Peptic ulcer disease e. Gastroesophageal reflux disease 12.Which of the following is not true of H. pylori infection? a. It is more common in developing countries b. The rout of transmission is believed to be fecal-oral c. It is believed to be the cause of non-ulcer dyspepsia d. It is associated with the development of gastric lymphoma e. It is believe to be the cause of most duodenal and gastric ulcers 13.6 months later, the patient as brought to the emergency room after vomiting bright red blood. He has a blood pressure of 85/40 mmHg and heart rate 120 bpm. Which of the following is the best next step? a. Guaiac test for a stool b. Referred to endoscopy c. Treatment for H. Pylori d. Administration of proton-pump inhibitor e. Intravenous fluid resuscitation and preparation for a transfusion 14.Which one of the following patients should be promptly reffered for endoscopy? a. A 21 year old man with severity of burning epigastric pain b. A 29 year old H. pylori positive patient with dyspeptic symptoms c. A 32 year old patient whose symptoms are not relieved with ranitidine d. A 65 year old man with new onset of epigastric pain and weight loss e. A 49 year old woman with intermittent right upper quadrant pain following meals A 42-year old female with chief complaint heavy menorrhagia for the past eight month. She felt fatigue, light headache, and palpitation. Physical examination showed BP 120/80 mmHg, HR 110 bpm, RR 20 breaths per minute, and
conjunctiva was pale. Hb 7.8 g/dl with MCV 75 (low), leukocytes count 6800/mm 3 and platelet 168,000/μL. 15.What is the hematologic problem in this patient? a. Macrocytic anemia b. Normocytic anemia c. Microcytic anemia d. Anemia of chronic disorder e. Sideroblastic anemia 16.What do you need to perform to establish the diagnosis? a. Serum Iron b. Ferritin c. Total iron binding capacity d. Reticulocytes e. Coomb’s test 17.What is the most likely diagnosis in this patient? a. Iron deficiency anemia b. Anemia of Chronic disorder c. Thallasemia d. Aplastic anemia e. Hypoplastic anemia A 49-year-old woman presents to emergency room complaining of a 4-week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms, and she has normal appetite and normal bowel habits. Her medical history was three pregnancies, one of which was complicated by excessive blood loss, requiring blood transfusion. She is happily married for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, however, she does admit that she was “wild” in her youth, and she had snorted cocaine once or twice at parties many years ago. She does not use drugs now. She was HIV negative at the time of the birth of her last child. On examination, her temperature is 37.9C, heart rate 88 bpm, and blood pressure 94/60 mmHg. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. She has no peripheral edema. Laboratory studies are normal except for Na 129 mEq/L, albumin 2.8 mg/dL, total bilirubin 4 mg/dL, prothrombin time 15 seconds, haemoglobin 12 g/dL with MCV 102 fL, and platelet count 78,000/mm3. 18.What is the most likely diagnosis? a. Ascites caused by hepatic cirrhosis b. Ascites caused by hypoalbumin c. Ascites caused by malignancy d. Ascites caused by alcoholic hepatitis e. Ascites caused by acute viral hepatitis 19.What is your next step? a. Diuretics b. USG work up c. Albumin transfusion d. Perform a paracentesis e. Serologic examination
20.What are the other possible physical examination findings in this patient? a. Palmar erythema, spider nevi, epigastric pain b. Gynecomastia, palmar erythema, epigastric pain c. Gynecomastia, palmar erythema, spider nevi d. Gynecomastia, spider naevi, hyperemic conjunctiva e. Palmar erythema, epigastric pain, hyperemic conjunctiva 21.What are the tests for Hepatitis C? a. Low serum ceruloplasmin b. Anti-HCV Ab, presence of HCV RNA c. Persistent HbsAg, presence of HbeAg d. ANA, anti-LKM (liver kidney microsome) e. High transferrin saturation (>50%), high ferritin A 46 year old woman presents for her yearly physical examination. She has been fine and has no complain today. With her full-time job and three children, she finds it difficult to exercise, and she admits that her family eat out frequently. Today her blood pressure was 140/95 mmHg. Body weight 65 kg, height 155 cm. The patient has not eaten yet today, so on your preceptor recommendation, a fasting plasma glucose test is performed, and the result is 140 mg/dL. 22.Which of the following is the most appropriate next step? a. Reassurance that these are normal blood sugars b. Diagnose diabetes mellitus and start a biguanide agent c. Recommend cardiac stress testing d. Obtain start arterial blood gas and serum ketone levels e. Recommend repeated fasting or random blood glucose 23.Her last HbA1c was 7.9%. She states that she conscientiously follows her diet and walk 30 minutes to 1 hour daily. What is the best next step in her care? a. Add insulin pump b. Add metformin c. Add NPH insulin d. Hospitalize her urgently e. Recommend weight loss 24.30 years later, she is brought into the hospital by her daughter for follow up and her creatinine level is 2.2 mg/dL. She currently takes glimepiride for her diabetes and captopril. Her daughter reports that, in the past 2 weeks, her mother became sweaty, shaky, and confused. Her random blood glucose is 90 mg/dL. Which of the following conditions is most likely to be contributing to these episodes? a. Excess caloric oral intake b. Interaction between the ACE inhibitory and the sulfonylurea agents c. Worsening renal function d. Hyperglycemic amnesia e. Prolonged hypoglycemia 25.A 45 year old asymptomatic woman has a random serum glucose level of 165 mg/dL on routine examination. Which of the following studies should be used next to evaluate this finding? a. Urine glucose b. Oral glucose tolerance test c. Fasting serum glucose d. 2 hour postprandial serum glucose
e. Haemoglobin A1C measurement An 37 year old previously healthy woman presents to your clinic for unintentional weight loss. Over the past 3 months, she has lost approximately 15 kg without changing her diet or activity level. Otherwise, she feels great. She has an excellent appetite, no gastrointestinal complaints except for her occasional loose stools, a good energy level, and no complaints except of fatigue. She denies heat or cold intolerance. On examination, her heart rate is 110 bpm, blood pressure 160/70 mmHg, and she is afebrile. Her eyes are somewhat protuberant. You note a diffusely large, smooth, nontender thyroid gland. A 2/6 systolic ejection murmur on cardiac examination, and her skin is warm and dry. There is no tremor. 26.What is the most likely diagnosis? a. Hashimoto thyroiditis b. Graves’ disease c. Multinodular toxic goiter d. Plummer disease e. Lymphocytic thyroiditis 27.How could you confirm this? a. A low TSH level and low free T4 level b. A low TSH level and increase free T 4 level c. An increase TSH and increase free T 4 level d. An increase TSH and low free T4 level e. Normal both TSH and free T4 level 28.If the woman became pregnant, which of the following is the first choice therapy? a. Propylthiouracil b. Long term propranolol c. Radioactive iodine ablation d. Surgical thyroidectomy e. Fine needle aspiration 29.A 42 year old woman has recently experienced fatigue, sleepiness, dry skin, constipation, and 10 pound weight gain. Her thyroid is firm and twice the normal size. Which one of the following laboratory tests is most likely to confirm the suspected diagnosis of hypothyroidism? a. Serum thyroxin b. Serum triiodothyronine T3 c. T3 resin uptake d. Antithyroid antibodies e. Serum thyroid stimulating hormone (TSH) 30.A 30-year old woman is noted to have blood pressure in the 160/100 mmHg range. She also has increased obesity, especially around her abdomen with striate. She has been bruising very easily and has hirsutism. Which of the following is the most likely diagnosis? a. Essential hypertension b. Hyperthyroidism c. Coarctation of the aorta d. Cushing syndrome e. Pheochromocytoma 31.A 45 year old man is diagnosed with essential hypertension based on two blood pressure of 130/100 mmHg and 156/102 mmHg. Which of the
following would most likely provide prognostic information regarding the patient? a. Vascular biopsy b. Left ventricular hypertrophy c. Patient’s enrolment in a clinical trial d. Measurement of serum homocysteine levels e. Patient’s antihypertensive agents 32.A 34 year old woman is noted to be diagnosed with stage 1 hypertension and after an evaluation is noted to have no complications. Which of the following antihypertensive agents are generally considered first line agents for this individual? a. Thiazide diuretics b. Angiotensin-receptor blockers c. Alpha-blocking agents d. Nitrates e. Vasodilators such as hydralazine 33.A 45 year-old man with type II diabetes is noted to have blood pressures of 145/90 and 150/96 mmHg on two separate occasions. Which of the following is the best initial therapy for this patient? a. Thiazide diuretics b. ACE inhibitor c. Beta-blocker d. Nitrates e. Alpha-blocking agents 34.A 30 year old man with chronic hypertension presents at the clinic having run out of his medication, clonidine. He has no complaints and has a blood pressure of 200/104 mmHg. Which of the following is the best management? a. Admit in the hospital and initiate intravenous antihypertensive agents b. Restart the clonidine and recheck the blood pressure in 24 to 48 hours c. Change to an angiotensin-converting enzyme (ACE) inhibitor d. Refer to a social worker and do not prescribe antihypertensive agents e. Change to beta blocker A 45 year old woman returns today to your outpatient clinic for follow up. You have seen her frequently over the last 3 months for various complaints. Over past 2-3 weeks, however, she says that she just felt terrible. Her symptoms include intermittent headaches, bilateral shoulder and neck pain, overwhelming fatigue, and difficulty sleeping. She cries easily, and she is irritable with her children. She feels unable to keep up with the demands of her work and family, she feels her life is meaningless, and she has trouble concentrating. The patient smokes half a pack of cigarettes per day and drinks alcohol per weekends. The patient states that she has regular menses. She works as a waitress and doesn’t work at least for 2 weeks. Physical examination reveals blood pressure 110/70 mmHg, heart rate 80 bpm, and temperature 37°C. Her thyroid is normal to palpation. Her heart has normal rate and rhythm without murmur. Another physical examination is normal.
35.What is the best next step? a. Assess thyroid stimulating hormone (TSH), electrolytes, complete blood count b. Prescribe a serotonine selective reuptake inhibitor c. Referral to a psychiatrist d. Prescribe a tricyclic antidepressant e. Recommend a bone scan 36. 37. 38. 39. 40. 41. A woman, 57 years old, came to the out-patient clinic, with the chief complaint of tenderness of her hand fingers since three months ago. She also complains tenderness of her left knee, especially when she was squatted or goes down the stairs. Based on clinical examination, she looked mildly ill, with body weight 68 kg and height 157 cm. There was tenderness of 3rd and 4th proximal and distal interphalanx joint, in both hands, with restricted range of motion. There was also Heberden nodal in the 2nd distal interphalanx joint. The whole vertebrate was within normal limit. There was evidence of crepitation without any swelling in her left knee. The ESR examination was 15 mm/h. There was slightly narrowing of left knee joint space in X-Ray examination. 42.What is the appropriate diagnosis for this patient? a. Ankylosing spondylitis b. Rheumatoid arthritis c. Osteoarthritis d. Gout arthritis e. Osteoporosis 43.If we found joint effusion and tenderness of the knee, what is the most appropriate management for this patient? a. Glucosamine sulphate and chondroitin sulphate b. Intraarticular hyaluronic acid injection c. Systemic corticosteroid (oral or IM) d. Calcium supplement e. Knee arthrocentesis A woman, 34 years old, came to the outpatient clinic, with the chief complaint of tender and swallowing of her wrist hand and fingers in both hands, since eight months ago, with morning stiffness more than 2 hours. Since two months ago, she also felt tender and swallowing of her knee and ankle. The arthritis manifestation was very clear in her both 2nd-4th proximal interphalanx, 1st-5th metacarpophalanx, carpometacarpo, knee and ankle joint. The ESR examination was 98 mm/h, with positive rheumatoid factor, ANA (-), and anti dsDNA (-). 44.The most appropriate diagnosis was:
a. Systemic lupus erythematosus b. Rheumatoid arthritis c. Psoriatic arthritis d. Osteoarthritis e. Gout arthritis 45.This patient took place more than four years without any adequate treatment, what is the most possible permanent complication in this patient? a. Muscle weakness b. Joint deformity c. Bamboo spine d. Digital ulcers e. Joint effusion Mr. C is a 35 year-old man who comes to your outpatient office complaining of 3 days of diarrhea. 46.What is the most possible diagnosis? a. Antibiotics associated diarrhea b. Chronic diarrhea c. Acute diarrhea d. Traveller associated diarrhea 47.He was in good health until the morning before he comes to visit you. He noticed of poor appetite, nausea, diaphoresis. He described the stool being watery and brown without any blood. What is the most possible cause? a. Lactose intolerance b. Nutritional supplements c. Any infections (virus or bacterial) d. Pancreatitis 48.On physical examination his temperature 38.2°C, BP 110/80 mmHg, pulse 100 bpm, RR 12 breaths per minute. The abdomen is soft and diffusely tender with hyperactive bowel sounds. What is your plan? a. Treat him directly because the clinical information is sufficient b. Need more information before start treatment c. Need a laboratory test before starting any treatment d. He needs to be hospitalized Mrs. W, 78 years old, carried by her son, come to hospital with chief complaint of sleepless and disoriented since 1 day ago. Seven days before admission, she slipped and fell out in bathroom while walking in. she felt pain in her left leg, so that she had difficulty in walking. She only did her activity on her bed. Four days before admission, she could not hold her urination. She lost appetite and her meal intake was less than before. She had diabetes mellitus and hypertension since 20 years. Before sick, she could manage her daily activities by herself. Physical examination: blood pressure 160/100 mmHg, heart rate 70x/mins, respiratory rate 20x/mins, temperature 37°C, dry tongue, reddish wound in her buttock. Heart, lung and abdominal were within normal limit. Laboratory examination: Hb 12, Ht 41, Leukocyte 7000, thrombocyte 200.000. Segment 68. Blood glucose level 101. Urinalysis within normal limit. 49.Geriatric syndrome in this patient are: a. Delirium, inanition, immobilization
b. Inanition, infection, independency c. Incontinence, immobilization, infection d. Immobilization, impecunity, incontinence e. Acute confusional stage, impecunity, instability 50.Comprehensive Geriatric Assessment must be assessed for Mrs. W: a. Functional status can be assessed by using Mini Mental State Examination b. Nutritional Status must be assessed by using the timed up and go test c. Psychoaffective status was assessed by using AMT (Abbreviated Mental Test) d. Activity of Daily Living (ADL) Barthel must be assessed, before and during illness e. Systemic anamnesis will be done, if history of present illness is done b alloanamnesis