Gameboy Qs-1 PDF

0001. A 40 year old man with history of recurrent painful attacks affecting right big toe for that reason, he was diagnosed to have gout and started on allopurinol. He is also known case of psoriasis for several years. He presente...

0001. A 40 year old man with history of recurrent painful attacks affecting right big toe for that reason, he was diagnosed to have gout and started on allopurinol. He is also known case of psoriasis for several years. He presented to the clinic with recurrent joing pain affecting the right big toe, left ankle and bilateral knees. He is using allopurinol regularly as prescribed but no improvement in his joint pain. Examinations revealed he has active arthritis at left ankle and knee joints bilaterally (see lab results). ***Table*** Which of the following is the most likely cause for his joint pain? A. Active pseudogout arthritis. B. Active gout arthritis. *C. Psoriatic arthritis. D. Osteoarthritis. 0002. A 28-year-old woman with systemic lupus erythematosus for 2 years on hydroxychloroquine 200 mg/day, prednisone 5 mg/day and azathioprine 100 mg/day presented to the Emergency Room with sudden onset of lower limb weakness and urinary incontinence. Examination revealed she has paraplegia and hyperreflexia (see lab results). ***Table*** Which of the following is the most appropriate tests to be done immediate? A. Lumbar punture, MRI brain B. Lumbar puncture, CT brain *C. Lumbar puncture, MRI spinal cord D. Lumbar puncture, MRI, MRA and MRV of the brain 0003. A SO-year-old man is complaining of pain affecting wrist joints bilaterally, second and third proximal interphalangeal joints and right knee joint for the last 4 months. His examination revealed active arthritis at both wrists and second and third proximal interphalangeal joints (see lab results). ***Table*** Which of the following is the most appropriate treatment? A. Methotrexate B. Methotrexate and sulfasalazine c. Methotrexate and hydroxychloroquine -D. Methotrexate, hydroxychloroquine and prednisone 0004. A 30-year-old woman with systemic lupus erythematosus is evaluated for right hip pain that started 3 weeks ago and occurs at night and with walking. Her current medications are azathioprine, hydroxychloroquine, prednisolone and lisnopril for the last 5 years. Her examination was normal except for pain on internal rotation of the right hip. Laboratory tests including pelvic and left hip radiographs were normal. Which of the following is the most likely cause of hip pain? A. Active lupus arthritis A. Active lupus arthritis B. Septic arthritis affecting right hip -c. Avascular necrosis affecting right hip D. Degenerative changes affecting right hip 0005. A 60 year old man complaining of right knee pain for several years that is increased over the last few months. He also has noticed frequent knee clicks. A diagnosis of osteoarthritis is suspected. Which of the following is the most appropriate to confirm the diagnosis? A. Bilateral knee X-rays. B. MRI of the right knee. -c. No further investigation. D. Arthroscopy for the right knee. 0006. A 52-year-old man with rheumatoid arthritis, for 12 years. His Current treatment consists of methotrexate 15 mg weekly and adalimumab 40 mg/2 weeks. He presented to the clinic complaining Of fever and shortness of breath for 1 week. His chest examination reve~aled coarse crackles over lower part of right lung (see lab results). ***Table*** Which of the following is the most appropriate action to be taken m this visit? A. Hold adalimumab and start antibiotics B. Hold methotrexate and start antibiotics -c. Hold his current treatment and start antibiotics D. Continue his current treatment and start antibiotics 0007. A 30-year-old man presented to the Emergency Department with an acute monoarthritis where joint aspiration was perfumed. He is diagnosed as an acute gout based on the presence of crystals in the synovial fluid. Which of the following is the most likely type of the crystals seen? -A. Needle shaped negatively birefringent B. Needle shaped weekly positively birefringent c. Rhomboidal shaped negatively birefringent. D. Rhomboidal shaped weekly positively birefringent. 0008. A 30 year old woman with a diagnosis of systemic lupus erythematosus who was maintained on mycophenolate mofetil 1 gm/day, hydroxychloroquine 200 mg/day and prednisone 5 mg/day for the last 1 year. She has inactive disease for more than 6 months. She is planning to get pregnant (see lab results). ***Table*** Which of the following is the most appropriate action at this time? A. Discontinue prednisone and start cyclosporine. B. Discontinue hydroxychroquine and start quniactine. -c. Discontinue mycophenolate mofetil and start azathioprine. D. Discontinue mycophenolate mofetil and start methotrexate. 0009. A 61-year-old woman is evaluated for a left pulmonary nodule that was discovered incidentally 2 months ago. She is currently asym,ptomatic and has not had shortness of breath, fever, chills, weight loss, or night sweats. Medical history is otherwise unremarka,ble, and she takes no medications. She never smokes. Examination revealed no cervical or supraclavicular lymphadenopathy, the lun,gs are clear to auscultation (see report). ***Table*** CT scan chest: Showed 8 mm left lung nodule. Which of the following is the most appropriate next step in management? A. PET/CT scan B. Bronchoalveolar lavage c. Transthoracic lung biopsy -D. Observation and regular follow up 0010. A 63-year-old woman presented with exertional dyspnea for 8 months. She was diagnosed with COPD 3 years ago, and has had 4 exacer-* bations in the last year. She completed pulmonary rehabilitation and quit smoking 2 years ago. Medications are long-acting B2 ago-* nist, inhaled glucocorticoid, roflumilast, and albuterol as needed. Examination revealed there is no jugular venous distention; d - ecreased breath sounds, a loud pulmonary component of Si (see lab result and reports). ***Table*** ***Table*** Chest radiograph: Normal. Echocardiogram: Ejection fraction of 60%, no valvular or wall motion atonorrnaUfcies, and estimated mean pulmonary artery pressure is SS mrnHg. Which of the following is the most appropriate treatment? A. Daily prednisone -B. long term oxygen therapy c. Overnight pulse oximetry D. Repear pulmonary rehabilitation. 0011. A 58-year-old woman presented to the Medical clinic complaining of daily wheezing and breathlessness during allergy season. These episodes of wheezing have limited her activities several times a week. She has a long history of seasonal allergies in the form of itchy eyes and runny nose. No other medical history. Medications include loratadine as needed, and antihistamine eye drops. Examination revealed watery eyes with conjunctiva! irritation, expiratory wheezing, and normal cardiac examination (see reports). ***Table*** Chest radiograph: Unremarkable. Spirometry: FEVl of 74% of predicted, which improved by 18% with a bronchodilator. In addition to a short-acting p2-agonist. FEVl or /4~ or preaictea, wnicn improvea by witn a nroncnoailator. In aaaition to a snort-acting p~-agonist. Which of the following is the most appropriate treatment? A. Add a leukotriene antagonist B. Add a low-dose inhaled glucocorticoid c. Recommend daily oral antihistamine use -D. Add a low-dose inhaled glucocorticoid and long acting B2 agonist 0012. A 71-year-old man is evaluated after a recent hospitalization 10 days ago for pneumonia and was discharged with a 10-day course of appropriate antibiotics. For the 5 days, he has had low-grade fever, and increased shortness of breath. Pulmonary examination reveals decreased fremitus, dullness to percussion, and decreased breath sounds over the lower third of the right hemithorax (see lab results and report). ***Table*** ***Table*** Chest radiograph: Moderate right-sided pleural effusion. Which of the following is the most appropriate management? A. Ceftriaxone and azithromycin B. Chest tube and levofloxacin C. Repeat chest radiograph in 2 weeks -D. Small-bore pleural drain and piperacillin-tazobactam 0013. A 20-year-old man is evaluated for a 6-month history of chest and throat tightness, acute episodes of stridor and a prolonged wheeze that occur during his college basketball practice. He has a history of moderate persistent asthma, which is controlled. He takes as- needed short-acting B2 agonist inhaler, but this does not relieve his symptoms. In addition to low dose inhaled glucocorticoid and a long- acting inhaled B2 agonist. He otherwise feels well. Medical history is otherwise unremarkable. Examination reveales normal vital signs and unremarkable systemic examination (see reports). Chest radiograph: Normal. Spirometry: No evidence of obstruction. Which of the following is the most appropriate next step in management? A. Echocardiography B. Allergen immunotherapy -c. Otolaryngology evaluation D. Switch to a medium-dose inhaled glucocorticoid 0014. A 33-year-old man presented with shortness of breath, fatigue, and nighttime cough. He is working in car repairing shop for the past 1 year and notes that his symptoms began about 8 months ago. He believes his symptoms associated with his workdays, he is being evaluated after several days off from work and currently has no symptoms or medical concerns. He has unremarkable medical hist-> ory and takes no medications. He has never smoked. Physical examination is unremarkable. A chest radiograph and spirometry results are normal. takes no medications. He has never smoked. Physical examination is unremarkable. A chest radiograph and spirometry results are normal. Which of the following is the most appropriate next step in management? A. High-resolution chest CT B. Inhaled glucocorticoid daily C. Advise him to switch employment. -D. Repeat spirometry after workplace exposure. 0015. A 49-year-old woman is evaluated for a 4-month history, of dry cough which began 4 months ago when she noted paroxysmal onset of persistent coughing spells that make it difficult to carry on a conversation. She was initially diagnosed with allergic rhinitis and was started on a glucocorticoid nasal inhaler with no improvement. Medical history is otherwise unremarkable except for history of dust allergies: Examination reveales normal vital signs, slight nasal congestion and dry cough are noted during examination. Cardiovascular, pulmonary, and abdominal examination findings are unremarkable (see reports). Chest radiograph; Normal. Spirometry: Slightly reduced FEV/FVC ratio of 70% which increased after bronchodilator challenge by 20%. Which of the following is the most appropriate diagnostic test to perform next? A. Allergy skin testing B. High-resolution chest CT c. Measurement of serum lgE levels -D. Methacholine challenge testing 0016. A 57-year-old man is evaluated for chronic cough, occasional wheezing, and extertional dyspnea while walking. Medical history includes an episode of bronchitis, for which he underwent outpatient treatment 8 months ago. He has a 20-pack-year smoking history. Examination reveales normal vital signs, mildly decreased breath sound throughout both lung and scattered expiratory wheezes bilateral. Spirometry shows an FEVl of 75% of predicted and a postbronchodilator FEV/FVC ratio of 68%. His modified Medical Research Council (mMRC) symptom score is 2. In addition to smoking cessation, which of the following is the most appropriate long term management plan? A. Combination inhaled glucocorticoid and a long-acting bronchodilator B. phosphodiesterase-4 inhibitor and combination inhaled glucocorticoid and long-acting bronchodilator -c. Short-acting bronchodilator as needed, a long-acting bronchodilator, and pulmonary rehabilitation D. Short-acting bronchodilator as needed and an inhaled glucocorticoid 0017. A 42-year-old woman presented to the clinic for follow up of a 7-months history of chronic, nonproductive cough. She was recently diagnosed with cough-variant asthma after a methacholine challenge test. She was started on inhaled fluticasone and as-needed albuterol 2 months ago. Her cough initially improved; however, her symptoms have not fully resolved and are worsened at times, most notably when she lies down. She also noted that mild hoarseness occasionally accompanies her cough especially when she wake up i-. n the morning. Examination revealed dry cough with frequent throat clearing is noted. The chest was clear with no wheezing. ***Table*** Which of the following is the most appropriate management? A. Add a long-acting B2-agonist -B. Add a proton pump inhibitor c. Start nocturnal antitussive therapy D. Repeat methacholine challenge testing 0018. A 17-year-old man presented to the Emergency with severe asthma exacerbation began 12 hours ago. He is on albuterol inhaler and a long-acting glucocorticoid at home without improvement. He was hospitalized and intubated 2 years ago. Examination revealed resp-> iratory distress with diffuse expiratory wheezes. After 1 hour of systemic glucocorticoid and B2 agonist nebulizer he looked in r-> espiratory distress (see lab results and report)i ***Table*** ***Table*** ***Table*** ***Table*** Chest X-ray: Hyperinflated lungs. Which of the folflowing is the most appropriate next step in management? -A. Admit to the ICU. B. Reassure him and discharge home. c. Admit to the general medical floor. D. Discharge home i next dafollow up. 0019. A 63-year-old man was evaluated in the Emergency Room for 1 week progressive shortness of breath found to have right pleural effu~sion on chest X-ray. Aspiration yealeded a clear transudative fluid. ***table*** Which of the following is the most likely cause? A. Pancreatitis B. Pneumonia -c. Heart failure D. Malignancy 0020. A 24-year-old woman is reviewed in the Asthma Clinic. She currently uses salbutamol inhaler 100 meg prn combined with beclometasone dipropionate inhaler 400 meg bd. Despite this, she is having frequent exacerbations of her asthma that required frequent courses of prednisolone and hospitalization three times for the last 6 months. What is the most appropriate next step in management? A. Switch beclometasone to fluticasone B. Start to take the salbutamol regularly B. Start to take the salbutamol regularly -c. Add long acting B2 agoinst Salmeterol D. Add long acting anticholinergic bronchodilator Tiotropium 0021. A 63-year-old woman in the COPD clinic for frequent exacerbations in spite she was maintained on a salbutamol inhaler as required and a tiotropium inhaler regularly. She was diagnosed with COPD three years ago and she managed to quit smoking recently. Her latest FEVl was 39% of predicted. Which of the following is the most appropriate next step in her management? A. Salmeterol inhaler B. Betamethasone inhaler c. Long term oxygen therapy -D. Combined salmeterol + fluticasone inhaler 0022. A 69-year-old smoker presents with a 3-week history of worsening breathlessness. Examination revealed normal vital signs and decr~ease breathing sound over the lower left zone (see reports). Chest X-ray: Large left-sided pleural effusion. Pleural tapping: Pending result. Which of the following will most likely indicates that is is an exudative effusion? A. Pleural fluid LDH / Serum LDH