FUNDAMENTALS OF CLINICAL MEDICINE
PROBLEM BASED LEARNING
EXAMINATION V
VERSION B
Part A.
MULTIPLE CHOICE; SINGLE BEST ANSWER:
1. Which is most likely to retard the development of renal failure in a patient with diabetes mellitus and
microalbuminuria?
A. Treatment with trimethoprim/sulfamethoxazole
B. A high-protein (150 g protein daily) diet
C. Treatment with captopril
D. Treatment with ibuprofen
E. Treatment with furosemide.
2. Which is the earliest to occur in the pathogenic sequence of diabetic nephropathy, in an adult?
A. Serum urea nitrogen greater than 60 mg/dl (normal, less than 20 mg/dl)
B. Creatinine clearance less than 20 ml/min (normal, 90-130 ml/min)
C. Deposition of nodular hyaline masses in the periphery of most glomeruli
D. Creatinine clearance greater than 140 ml/min
E. Proteinuria greater than 5 g/day (normal, less than 0.15 g/day)
3. Which one of the following statements about the sulfonylurea drugs is LEAST correct?
A. If the patient skips meals, they may cause hypoglycemia
B. They should be given by continuous intravenous infusion, for treatment of diabetic
ketoacidosis
C. The risk of hypoglycemia is accentuated in patients with renal insufficiency
D. They do not benefit patients with long-standing Type I diabetes
E. Their efficacy is not diminished by obesity
4. Mr. M. is a 60-year-old man who complains of discomfort in his chest, related to exertion.
He has been obese since early adulthood, and has known of high blood pressure for about
5 years. He has no known past history of diabetes mellitus, but his mother had diabetes
mellitus toward the end of her life. Fasting serum glucose is 205 mg/dl (normal, 75 115 mg/dl). The pathogenesis of this patient's diabetes is least likely related to
A. Resistance to the action of insulin on the liver
B. Impaired pancreatic secretion of insulin
C. Resistance to the action of insulin on skeletal muscle
D. Obesity
E. Infiltration of pancreatic islets with lymphocytes
5. Which one of the following statements describes BEST a principle in the dietary management
of noninsulin-dependent diabetes mellitus (Type II diabetes)?
A. Alcohol should be prohibited
B. In the obese patient, at least 50 per cent of excess body fat must be lost, before there
is appreciable improvement of hyperglycemia
C. Calories should be restricted, if the patient is obese
D. Dietary carbohydrates do not contribute to obesity, owing to the resistance of
peripheral tissues to actions of insulin.
E. Treatment with metformin or other newer oral hypoglycemic agents obviates the need
for dietary restrictions
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6. Typical problems for a 3-month-old child with positive HIV ELISA, positive Western blot,
and 2 positive H1V-PCRs who has a CD4 count of 500/mm3 would include all of the
following EXCEPT:
A. Kaposi sarcoma
B. Growth failure
D. Sepsis with invasive bacterial pathogens
D. Failure to attain normal developmental milestones
E. Pneumocystis carinii pneumonia
7. Hepatosplenomegaly in a two-month-old infant might be due to all of the following except:
A. Glycogen storage disease
B. Treponema pallidum infection
C. Congenital cytomegalovirus infection
D. Congenital rubella infection
E. Infectious mononucleosis (EBV infection)
8. A 2-day-old infant develops low grade temperature elevation (101 F) and slight abdominal
distention. Although the examination is otherwise normal, an evaluation for possible sepsis
and meningitis is initiated. The blood count has a leukocytosis (25,000/mm3 and a left shift
(55% polys, 10% bands)). The CSF has 75 WBC/mm3 (85% polys) (normal for age < 30
WBC/mm3) a depressed glucose and an elevated protein value. The CSF culture grows S.
agalactiae. Benzathine penicillin would be inappropriate therapy for Group B streptococcal
(S. agalactiae) in this setting because:
A. Newborns usually have mixed infections that include penicillin susceptible and
resistant organisms.
B. An aminoglycoside (e.g gentamicin, tobramycin, amikacin) must be used as part of
therapy of bacterial meningitis..
C. Group B streptococcus is sensitive to penicillin but not to benzathine; this antagonism
causes treatment failures.
D. Benzathine penicillin fails to achieve adequate levels ofpenicillin in spinal fluid to treat
meningitis.
E. Newborns have too low a muscle mass to receive intramuscular injections.
9. Which one of the following statements about inflammation is MOST INCORRECT?
A. Medical management is often aimed at measures that control inflammation because
tissue damage often results from the host responses to the invading pathogens.
B. IL-6, a cytokine whose release is triggered by IL-1 beta and TNF-alpha, is an
endogenous pyrogen that causes fever.
C. Thl responses involve interferon gamma, IL-2 and IL-12; cytokines that are
important in development of delayed type hypersensitivity.
D. Th2 responses involve IL-4 IL-5, IL-6 d IL-10; cytokines that are important in
development of humoral (antibody-mediated) immunity.
E. Lipopolysaccharide endotoxin causes release of IL-1 beta but not TNF-alpha.
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10. A 15-month-old child is brought to you because of fever, irritability and vomiting. Your
physical examination finds no clear explanation for the illness but he appears to be quite ill
because his vital signs include a BP of 50/20 mmHg and pulse of 160/min.
Laboratory studies:
Study
peripheral blood
WBC
cerebrospinal fluid
WBC
protein
glucose
CSF gram stain
CSF culture
in vitro sensitivities
Patient's value
Normal for age
increased with a left shift
550/mm3
115 mg/dL
3mg/dL (blood glucose 80mg/dL)
lances shaped gram positive cocci
Streptococcus pneumoniae
Sensitive to:
Resistant to:
< 4 WBC/mm3
< 40 mg/dL
chloramphenicoi,
vancomycin
cefotaxime
penicillin.
Which one ofthe following statements regarding treatment options is MOST CORRECT?
A. Penicillin is inadequate therapy at the usual doses; however, it is adequate if used in
very high doses.
B. Chloramphenicol is not adequate therapy despite its in vitro susceptibility.
C. Cefotaxime administered alone intrathecally is adequate therapy.
D. Oral vancomycin is appropriate therapy late in the course after the patient has become
afebrile at point when it has become difficult to maintain iv access point.
E. Optimal therapy consists of high doses of vancomycin and cefotaxime given by mouth.
11. The osteoporosis associated with the menopause is the consequence of
A. The aging process.
B. The decline in the gonadotropin hormones.
C. The decline in circulating estrogens.
D. An increase in calcitonin production.
E. Hypoparathyroidism
12. In post-menopausal women there is:
A. An increased excretion of FSH but not of LH.
B. An increased secretion of LH but not of FSH.
C. An increased secretion of FSH and LH.
D. A reduced excretion of both LH and FSH.
E. An increased production of prolactin.
13. The changes in gonadotropin secretion in the menopause are caused by
A. The opening of a negative feedback loop.
B. An increased negative feedback inhibition by progesterone.
C. The positive feedback action of estrogen.
D. A cross talk between prolactin and LH.
E. A reduction of GnRH pulse generator activity.
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14. Hot flashes in the menopause
A. Are the result of LH pulses.
B. Are caused by GnRH pulses.
C. Are the result of hourly estrogenic oscillations.
D. Are the consequence of unopposed exposure to estrogens.
E. Have causes that are essentially unknown.
QUESTIONS 15 - 17 ARE BASED ON THE CASE OF MS. BETTER:
Ms. Hefter is a 55-year-old woman with hypertension and diabetes. She comes in for a pap smear.
Her last period was 4 years ago. After prodding, she admitted to "only a few spots" of vaginal
bleeding 3 weeks earlier.
15. Possible sites of Ms. Hetter's bleeding could include:
A. Hematuria
B. Vulvovaginal atrophy
C. Hemorrhoids
D. Endometrial
E. All of the Above
16. You explain to Ms. Hetter that the MOST IMPORTANT diagnostic test to do at this point is:
A. Endometrial Biopsy
B. Hemoglobin analysis of the peripheral blood
C. Urine Analysis
D. Pap Smear
17. Ms. Hetter's sister is a 49-year-old woman who comes to your office complaining of hot
hashes. She also reports difficulty sleeping and vaginal dryness. Her past medical history is
significant for a hysterectomy for fibroids. The most appropriate regimen for hormone
replacement for this patient would be:
A. Conjugated estrogens (Premarin) 0.625 orally once daily on days 1-25 of each month,
medoxyprogesterone acetate (Provera) 10 mg orally once daily on days 15-25 of the month.
B. Prempro® one orally daily (Premarin 0.625 mg plus Provera 2.5 mg).
C. Medoxyprogesterone acetate (Provera) 5 mg orally once daily.
D. Conjugated estrogens (Premarin) 0.625 mg orally once daily.
E. Prednisone 2.5 mg orally once daily.
18. The most common cancer of the female reproductive tract is:
A. Cervical
B. Fallopian tube
C. Ovarian
D. Endometrial
19. Which one ofthe following neoplasms of the female reproductive tract results in the highest mortality?
A. Cervical
B. Fallopian
C. Ovarian
D. Endometrial
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Part B
20. Which one of the following is an important mechanism whereby body temperature is lowered?
A Peripheral vascular vasodilatation
B. Shivering
C. Inefficiency of biochemical reactions
D. Additional clothing
E. Increased thyroid hormone release
21. Which one of the following about hyperthermia is MOST CORRECT?
A. The temperature may be normal
B. Exogenous pyrogens typically begin the process
C. The patient should be reassured that prognosis is invariably benign
D. The hypothalamic temperature set-point is normal
E. Intravascular volume depletion protects against the progression of hyperthermia to
heat exhaustion
22. Which one of the following statements about fever is LEAST CORRECT?
A. Fever results in an increase in serum iron.
B. While there .are reasons to think fever is beneficial to the host there is little direct
evidence that it is beneficial.
C. Patients with coronary artery disease and high fever should have their temperature
lowered artificially.
D. While a limited number of conditions show characteristic fever patterns, in most
febrile patients, the patterns of fever offer little diagnostic help to the clinician.
23. Which one of the following is the MOST commonly identified fever pattern in infectious
diseases?
A. Continuous or sustained
B. Remittent
C. Intermittent
D. Hectic
E. All patterns are of equivalent frequency
24. Which of the following is NOT a recognized principle of FUO workup and management?
A. Continued observation may be needed after the initial encounter
B. Both prescribed and social drugs may be causing the fever.
C. Some patients may be inducing the fever in themselves.
D. Abdominal laparotomy (surgical exploration) is performed in most patients who are
without diagnosis after a thorough but negative workup.
E. None of the options are principles of FUO workup.
25. Which one of the following organisms has intestinal colonization fimbriae which show host
species specific attachment to the intestine and which may be used in immunization against
the diarrhea caused by the organism?
A. Shigella
B. Campylobacter
C. Giardia
D. Enterotoxigenic E. Coli
E. Vibrio cholera
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26. Which one of the following statements about oral rehydration therapy as it is used in
developing regions of the world is LEAST CORRECT?
A. It is of no benefit when fluid and salt losses are the result of vomiting
B. It does not typically decrease the number of unformed stools passed.
C. It does not provide sufficient calories for some patients.
D. There is a potential for hypernatremia when it is used to treat milder forms of
diarrheal illness.
E. GI sodium absorption that restores volume is coupled to glucose absorption.
27. In a patient with three months of diarrhea following ingestion of unpasteurized milk, which
one of the following is the MOST LIKELY explanation?
A. Rotavirus gastroenteritis
B. Cholera
C. Enterotoxigenic E.coli diarrhea
D. Giardia
E. Brainerd diarrhea
28. A 51-year-old woman presents with fever two months after beginning chemotherapy for her
acute leukemia. She is found to have a temperature of 104° F and a severe neutropenia
(reduction in peripheral polymorphonuclear leukocytes). Which one of the following
organisms is MOST LIKELY the cause of fever and bacteremia (bacterial infection in the
blood stream) in this woman and similar patients?
A. Shigella sonnei
B. Coagulase-negative Staphylococcus
C. Streptococcus pneumoniae
D. Pseudomonas aeruginosa
E. Enterococcus
29. A 16-year-old high school athlete presents with fever and systemic toxicity. He has a
petechial skin rash and a leukocytosis (elevated white blood cell count). He does not abuse
drugs and does not have a history of recent unprotected sexual contact. Which one of the
following organisms should be considered the MOST LIKELY cause of septicemia in this
patient?
A. Escherichia coli
B. Neisseria menigitidis
C. Coagulase negative Staphylococcus
D. Treponema pallidum
E. Mycobacterium species
30. In a patient with high fever and systemic toxicity, which one of the following clinical findings
allows you to make the diagnosis of septic shock?
A. Important reductions of systolic blood pressure (hypotension) plus decreased renal function
B. Q waves on the EKG, compatible with an old myocardial infarction
C. Generalized seizures documented by EEG.
D. Ecthyma gangrenosa or skin lesions of indicative of pseudomonas infection.
E. Abdominal rebound plus positive blood culture for Bacteroides fragilis
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31. Which one of the following is a downstream (distal; phase II) event in the sepsis cascade?
A. Endotoxin release
B. Damaged vascular endothelium
C. Cytokine release
D. Complement activation
E. Compensatory vasoconstriction of the splanchnic blood vessels restoring blood flow
to vital organs
32. Which one of the following has been related MOST IMPORTANTLY to the pathogenesis
of noninsulin-dependent diabetes mellitus?
A. Inheritance of HLA genotype
B. Infiltration of pancreatic islets with activated T lymphocytes
C. Selective loss of beta cells of pancreatic islets
D. Obesity
E. Anti-islet cell antibodies
33. Which one of the following is E an important cause of illness among patients with diabetes
mellitus (type I and type II)?
A. Duodenal ulcers
B. Poorly healing ulcers of feet
C. Atherosclerosis of coronary arteries
D. Renal insufficiency
E. Retinal neovascularization
QUESTIONS 34 - 35 ARE BASED ON THE CASE OF Mr. J.
Case Rend
Mr. J. is a 32-year-old Caucasian man, born in Finland. He is not obese, and has no first-degree
relative with diabetes. Over a few days, he has developed extreme thirst, nausea and polyuria. He
is admitted to the hospital with severe volume depletion and metabolic acidosis.
Laboratory findings:
Serum ketones strongly positive (normal, negative)
Serum glucose = 1500 mg/dL (normal, 60 - 110 mg/dL)
Serum potassium = 4.9 mEq/L (normal, 3.5 - 5.0 mEq/L)
34. Which one of the following statements regarding the treatment for Mr. J in INCORRECT?
A. Intravenous saline solution should be given promptly
B. Insulin should be given promptly
C. The patient should be fed a hypocaloric diet; normal physiological mechanisms will
correct the ketoacidosis over the next 48 hours
D. Following correction of the ketoacidosis, the patient should be fed a diet low in simple
sugars
E. Mr. J. will eventually require treatment with insulin
35. Which one of the following is MOST appropriate in the long-term management of Mr. J?
A Avoidance of moderate or strenuous exercise
B. Periodic ophthalmologic examinations
C. A strict weight loss regimen
D. Treatment with sulfonylureas, alone
E. Complete elimination of alcoholic beverages
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QUESTIONS 36-37 ARE BASED ON THE CASE OF Mr. A.
Case Report
Mr. A. is a 32-year-old Mexican-American man, born in South Texas. His mother and two of his
sisters have diabetes. The patient is obese. He has no complaints. On admission to the hospital for
routine herniorrhaphy, he is found to have a fasting serum glucose of 265 mg/dL (normal, 55 to
100 mg/dL).
36. Which one of the following statements describes BEST an important feature of Mr. A's
diabetes mellitus?
A. By means of HLA typing, one can determine which of Mr. A's children will be at high
risk for development of diabetes.
B. This form of diabetes is rare among Mexican-Americans.
C. Unless Mr. A. is given insulin promptly, he will develop diabetic ketoacidosis.
D. A small dose of insulin will cause profound hypoglycemia.
E. The patient is likely to have a substantial level of circulating insulin.
37. Which one of the following is LEAST appropriate in the long-term management of Mr. A's
diabetes?
A Reduction of simple sugars in the diet
B. Treatment with insulin
C. Administration of immunosuppressive drus g
D. Treatment with sulfonylureas
E. Weight loss
38. A 10-year-old boy is brought by his parents, because of failure to grow. His height is 4
standard deviations below the mean, for his age. He is well-proportioned, and mentally
normal. Which would be the BEST test to confirm the clinical suspicion of growth hormone
deficiency?
A. Measurement of growth hormone, after administration of oral glucose
B. Measurement of circulating growth hormone, after induction of hypoglycemia
C. Radiologic determination of bone age
D. Magnetic resonance imaging of the sella turcica
E. Trans-sphenoidal biopsy of the pituitary
39. Which one of the following is LEAST CORRECT of pituitary tumors?
A After successful removal of a corticotrophic adenoma, the normal diurnal rhythm of
cortisol secretion is restored.
B. In Cushing's disease (corticotrophic adenoma), secretion of ACTH is subject to
feedback regulation.
C. The syndrome of acromegaly occurs only after a somatotrophic adenoma has
metastasized to the liver.
D. More than one hormone may be produced by a tumor that consist of only one
histological cell type.
E. In some patients with acromegaly, secretion of growth hormone is stimulated by
intravenous infusion of TRH.
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40. Which situation would not be expected to cause decreased secretion of LH and FSH?
A. Starvation
B. Granulomatous infiltration of the pituitary
C. Ischemic infarction of the pituitary
D. Treatment with bromocriptine
E. Vigorous gymnastics practice, for 6 hours daily
41. A 49-year-old man consulted his physician because of hypertension. Physical examination
showed broad hands and feet, prognathism, and widely spaced teeth. Which would be the
BEST test for confirmation of the clinical suspicion of acromegaly?
A Measurement of circulating growth hormone, after induction of hyperglycemia by
administration of oral glucose.
B. Measurement of growth hormone, after infusion of arginine.
C. Measurement of circulating somatostatin, after infusion of exogenous growth
hormone.
D. Measurement of circulating growth hormone, after induction of hypoglycemia.
E. Radiologic determination of bone age.
42. Which one of the following statements about the hypothalamic-pituitary axis MOST
CORRECT?
A Secretion of prolactin is stimulated by dopamine which reaches the pituitary via the
pituitary portal system
B. Pituitary hormones do not influence hypothalamic function.
C. Hypothalamic hormones promote secretion of pituitary hormones, but not their
synthesis.
D. Growth hormone is secreted once daily, from 6 to 7 a.m.
E. Thyrotropin (TSH), LH and FSH all share the same alpha subunit
43. Several years ago there was a sudden outbreak of thyrotoxicosis in several mid-western
states. After an epidemiologic investigation, it was found that one slaughterhouse of cattle
had included the thyroid into meat destined for hamburgers ("Hamburger Thyrotoxicosis").
On reviewing the medical records of the cases, you would expect the patients to all exhibit
which of the following findings;
A High 24 hour radioiodine uptakes
B. High antimicrosomal antibody levels
C. Nonpalpable thyroid glands
D. Low T3 Resin uptakes
E. Presence of exophthalmus
44. Severe acute and chronic Illness can sometimes affect thyroid fimction studies in patients that
are clinically euthyroid. The MOST common finding would be:
A. Elevated TBG
B. Decreased T3 Resin Uptake
C. Elevated free T4 level
D. Decreased Total T3 level
E. Elevated TSH level
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45. A 58-year-old man is found to be in atrial fibrillation with a ventricular rate of 110/min.
Thyroid function studies are obtained and demonstrate a decreased TSH. Which of the
following would confirm BEST the diagnosis of thyrotoxicosis?
A. Elevated Reverse T3 level
B. Elevated Total T3 Level
C. Decreased free T4level
D. Decreased T3 Resin Uptake
E. Elevated thyroglobulin
46. As a sexually transmitted disease, HIV is unique because:
A- It can be passed to newborns who are born of infected mothers.
B. It is sometimes passed by kissing.
C. There is often a decade between infection and symptoms.
D. Latex condoms are insufficient to prevent infection.
The groups at highest risk for infection know peers with symptoms of the disease.
47. A newly diagnosed patient with HIV presents to the clinic with fever, cough, weight loss and
interstitial infiltrates on chest x-ray. A recent CD4 count is 400. The most likely diagnosis
is:
A. Pneumocystis carinii pneumonia
B. Cryptococcus neoformans
C. Mycobacterium-avium complex
D. Mycobacterium tuberculosis.
48. Each of the following clinical circumstances should prompt a consideration for HIV testing
EXCEPT:
A. Any person with newly diagnosed syphilis.
B. Any person with newly diagnosed tuberculosis.
C. A young woman with an outbreak of herpes zoster.
D. A young man seeking employment as a medical clinic nurse.
E. A young man with slow healing (>1 month) oral herpes lesions.
QUESTIONS 49 -53, MATCHING
Match the antiviral medication with its most typical side-effect. Each letter choice may be used once,
more than once, or not at all
49. Zidovudine
A. Can cause nausea, insomnia
50. Didanesine
B Is associated with oral ulcers
51. Zalcitiibine
C. Causes decreased absorption of ketaconazole,
dapsone
52. Stavudine
D. Can cause anemia, leukopenia, myopathy
53. Lamivudine
E. Can cause neuropathy
END OF EXAMINATION
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ANSWERS:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
C
D
B
E
C
A
E
D
E
B
C
C
A
E
E
A
D
D
C
A
D
A
B
D
D
A
E
D
B
A
B
D
A
C
B
E
C
B
C
D
A
E
C
D
B
C
D
D
D
C
B
E
A
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