4. A 45-yesr-old male vehicular accident patient was admitted at the ICU for ventilator support after he was brought to the ER unconscious. Prior to the accident, he was previously well. He was stable until the 4th ICU day when he had fever and yellowish secretions. Chest x-ray showed new infiltrates on the left mid-lung field. Recommended initial antibiotic treatment (HPIM p. 2139):a. IV ampicillin-sulbactamb. IV linezoidc. Vancomycind. Ceftazimide + IV levofloxacin

5. A 57-year-old male was admitted because of hemoptysis amounting to 1 ½ cups. He had a history of recurrent hemoptysis over the last 10 years. Chest x-ray showed bilateral basal cystic lucencies. Chest CT scan showed bilateral dilated airways at the bases. Fiberoptic bronchoscopy showed bleeding coming from both basal air passages. Appropriate management for this patient (HPIM p. 2144)e. Bronchial arterial embolizationf. Surgical resection g. Forgarty catheter insertionh. Pulmonary physiotherapy

6. A 67-year-old male, non-smoker consulted at the OPD because of occasional shortness of breath and chest wheezing 1-2x a month. On PE, patient had clear breath sounds . Chest x-ray was unremarkable and pulmonary function test showed more than 15% improvement post-bronchodilator in FEV₁ and FEV₁ %. Management for this patient is (HPIM p. 2113):a. ICS low-dose + β₂ agonist prnb. LABA + ICS low-dose + β₂ agonist prnc. Inhaled β₂ agonistd. Oral β₂ agonist

7. A 55-year-old male was admitted because of low-grade fever of 3 weeks associated with cough productive of greenish foul-smelling phlegm. PE showed rales at the right lung base and clubbing. Chest x-ray showed cavity with an air fluid level at the right base . The patient was given 6 weeks of clindamycin but symptoms persisted and x-ray findings remained the same. Management of this patient is (HPIM p. 2146):e. 4-6 weeks of another antibioticf. TB treatment g. Surgery on lesionh. Anti-fungal treatment

Gynecology consultant plan was to do surgery for the myoma, but only after the medical problem was managed appropriately. Your management of the patient prior to surgery is (HPIM p. 2176):a. Low molecular weight heparinb. Fibrinolysis with rTPA (tissue plasminogen activator)c. IVC filter insertiond. Fresh frozen plasma transfusion

1. The following condition/s can result to hypokinetic pulses:T a. Left ventricular failureT b. Shock from massive blood lossT c. Large perincardial effusionF d. Mitral regurgitationF e. Aortic regurgitation

2. Proposed mechanism/s of cardiac arrhythmias:a. Alterations in impulse initiationb. Automacityc. Early after depolarizations and triggered automaticityd. Abnormal impulse conductione. Phase 4 depolarization

3. Causes of heart failureT a. Myocardial infarctionF b. PericarditisT c. ThyrotoxicosisF d. Dissecting aortic aneurysmT e. Chronic anemia

4. Which of the following statement/s is/are true regarding diagnostic examinations in heart failure?T a. New-onset heart failure warrants a complete blood count, urinalysis, BUN, creatinine, liver enzymes and electrolytes. F b. The most useful index of LV function is the EF calculated by the end-diastolic volume divided by stroke volume.T c. the gold standard for assessing LV mass and volume is the cardiac MRIT d. Both B-type natriuretic peptide (BNP) and N-terminal pro-BNP are sensitive markers for heart failure even in those with preserved EFF e. A normal ECG virtually excludes LV systolic dysfunction.

5. Features of peripartum cardiomyopathyT a. Prognosis depends on whether the heart size returns to normal after the first episode of CHFT b. May develop during the last trimester of pregnancy or within 6 months of delivery F c. Typical patients are nulliparous and >30 yearsF d. clinical outcome is dependent on whether the delivered via caesarian section or spontaneous normal vaginal deliveryT e. the cause is unknown

6. Cardinal manifestations of acute pericarditis:T a. PainT b. Pericardial friction rubT c. Pericardial effusion and tamponadeT d. Paradoxical pulseF e. Shortness of breath

8. Which of the following is/are risk of factor/s for stroke in a patient with atrial fibrillation?F a. ObesityF b. Mitral RegurgitationT c. Diabetes Mellitus T d. Spontaneous echo contrastF e. Market right atrial enlargement

9. Unstable angina is defined as defined as angina pectoris or equavalent chest discomfort with the following features:T a. it occurs at rest (or with )usually fasting >10 minT b. it is severe and of T c. it occurs with a crescendo pattern (i.e. distinctly more severe prolonged or frequent than previously)F d. positive cardiac F e. BP <90/ 60mmhg requiring inotropic support

10. Which of the following is/are ECG clue/s supporting the diagnosis of ventricular tachycardia?T a. Concordance of QRS complex in all precordial leadsF b. Frontal plane axis + 90 to 110 degreesT c. QRS duration >140ms for RBBB type V1 morphologyT d. AV dissociation (atrial capture, fusion beats)T e. RS dominant S in V6 for RBBB VT

11. Patients with the following congenital heart disease/s should be advised to avoid pregnancy:T a. VSD with EisenmengerizationT b. Congenital aortic stenosisT c. Coarctation of the aortaF d. Large patent ductus arteriosusT e. Marfan syndrome

12. Features of cardiogenic shock:T a. Prompt reperfusion, efforts to reduce infarct size, ad treatment of ongoing ischemia and other complications of MI appear to have reduced its incidence from 20% to about 7%F b. Inferior location of the myocardial infarction increases the riskT c. typically , at least 40% of the myocardium is damaged by old scars and new infarctsF d. Plans for percutaneous transcoronary intervention should be delayed until patient is stabilized via inotropicsT e. typically, patients who develop cardiogenic shock have severe multivessel coronary artery disease with evidence of “placemeal” necrosis extending outward from the original infarct zone

13. Which of the following is/are true about the patterns and causes of hypertension?T a. Blunting of the day-night BP pattern is seen in sleep apnea and autonomic dysfunctionT b. white coat hypertension is associated with sustained hypertension and target organ damageF c. BP tends to be higher at noontime until late in the afternoonT d. thyrotoxicosis leads to systolic hypertension while hypothyroidism causes diastolic hypertensionF e. Night time “dips” in BP has been shown to increased cardiovascular disease risk

14. Cause/s of systolic hypertension with widened pulse pressure:T a. Hyperkinetic heart syndromeF b. HypothermiaF c. Hypothyroidism T d. Aortic regurgitationF e. Mitral regurgitation

15. Features of resistant hypertension:F a. Abrupt increase of BP in a patient with underlying hypertensionF b. More common in young patientsT c. May be related to nonadherence to therapy, obesity and excessive alcohol intake, and use of any number of nonprescription and prescription drugsT d. refers to patients with BPs persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic, in reasonable combination and at full doses.T e. Evaluation of patients include home BP monitoring to determine if office Bpare representative of the usual BP.

16. Features of aortic aneurysms:T a. Many patients with aortic aneurysms have co-existing risk factors for atherosclerosisF b. Cystic medial necrosis characteristically affects the distal aortaT c. Familial clustering of aortic aneurysms occur in 20% of patients, suggesting a hereditary basis for the diseaseT d. the infectious causes of aortic aneurysms include syphilis, tuberculosis, and other bacterial infections. F e. vasculitides associated with aortic aneurysm include Takayasu’ s arteritis and giant cell arteritis, which may cause proximal ascending aorta and descending thoracic aorta

17. Major manifestations of Rheumatic Fever based on Revised Jones Criteria:T a. CarditisF b. MonoarthritisF c. MyagliaT d. Subcutaneous nodulesT e. Chorea

18. Clinical variables that increase the likehood of deep venous thrombosis:T a. Active cancerF b. Bilateral calf swellingT c. Pitting edemaT d. Surgery within 4 weeksF e. Non-healing wound at the toes

19. Organisms commonly involved in infective endocarditis:T a. StaphylococcusF b. Pseudomonas aeruginosaT c. EnterococciF d. CorynebacteriumT e. Streptococcus

20. Clinical presentation of STEMI:T a. In up to ½ of cases, a precipitating factor is presentF b. Pain is the most common presenting complaint and is uniformly presentT c. The precordium is usually quietT d. Paradoxic spitting of 52T e. Fever

21. Clinical manifestations of acute rheumatic fever:T a. There is a latent period of -3 weeks (1-5 weeks) between the precipitating group A streptococcal infection and the appearance of the clinical featuresF b. Chorea and indolent carditis may follow prolonged latent periods lasting up to 12 monthsT c. A streptococcal infection is commonly subclinical, in these cases it can only be confirmed using streptococcal antibody testingF d. Carditis is more commonly present than polyarthritisT e. Erythema marginatum and subcutaneous nodules are now rare, being found in <5% of cases

22. Clinical features of systemic arterial hypertension:F a. cardiac compensation is by eccentric left ventricular hypertrophyF b. the ECG is more sensitive than 2D echocardiography for detecting left ventricular hypertrophyF c. it is an independent predisposing factor for coronary artery disease, stroke, renal disease and peripheral vascular disease but not heart failureT d. Opthalmoscopic examination provides the opportunity to observe the progress of vascular effects of hypertensionT e. systolic blood pressure has a greater effect on morbidity and mortality than diastolic blood pressure

23. Features of mitral valve prolapse:F a. In most patients, the cause is unknown, but in some it appears to be genetically determined elastin disorderT b. A frequent finding in patients with heritable disorders of connective tissueF c. the anterior leaflet is usually more affected than the posterior leafletT d. may occur as a sequel to acute rheumatic feverT e. More common in females and occurs most commonly between the ages of 15 and 30 years

2.What is cause of falsely negative treadmill exercise test?a. Abnormal serumpotassiumb. Use of cardioactive drugs (e.g. digitalis, anti-arrhythmic agents)c. Obstruction limited to the circumflex coronary arteryd. Asymptomatic men under the age of 40

3. Most common site of focal spasm in Prinzmetal’s variant anginae. Proximal left anterior descending coronary arteryf. Distal left anterior descending coronary arteryg. Left circumflex arteryh. Right coronary artery

4. Gold standard in the assessment of myocardial viabilityi. SPECTj. Cardiac MRIk. PET Scanl. Stress Echocardiography

6. Not a feature of atrial septal defects (ASD):a. Occurs more frequently in femalesb. Ostium primum defects type are common in Down’s syndromec. Surgical closure should be carried out in patients small defects and trivial left to

right shunts and in those with severe pulmonary vascular disease wihtout a significant left-to-right shunt

d. ASD of the sinus venosis or ostium secundum types rarely die before the fifth decade.

7. Not a feature of ventricular septal defect (VSD):a. Patients with large VSD and pulmonary hypertension are those at greatest risk for developing pulmonary vascular obstructionb. Large defects should be corrected surgically early in life when pulmonary vascular disease is still reversible or not yet developedc. In patients with severe pulmonary vascular obstruction (Eisenmenger syndrome), symptoms in adult life consist of exertional dyspnea, chest pain, syncope, and hemoptysisd. Spontaneous closure is common even in moderate-sized defects early in adulthood

8. NOT a pharmacologic property of amiodarone:a. Class III agent delays repolarization due to inhibition of potassium current or

activation of depolarizing currentb. Useful in atrial fibrilliation, ventricular tachycardia and sinus bradycardiac. Potential toxic effects include both hypothyroidism, chronic lung disease, and liver

function test abnormalitiesd. Non-inferior to automatic implantable cardioverter defibrillator indecreasing

arrhythmetic recurrence and deaths

9. In patients with hypertrophic cardiomyopathy, this type of drug amellorates angina pectoris and syncope in 1/3 to ½ of patients:e. Nondihydropyridine calcium channel blockersf. Ace inhibitorsg. Beta blockers h. Diuretics

10. A major feature of metabolic syndrome:a. FBS ≥ 110mg/dLb. HDL in men < 50mg/dLc. Blood pressure > 130/90d. Triglycerides > 200mg/dL

11. Hallmark of the restrictive cardionyopathies a. Systolic dysfunctionb. Myocardial fibrosisc. Abnormal diastolic functiond. Concomittant endocardial involvment

12. Not a treatment of Prinzmetal’s angina:e. ASAf. Nitratesg. Calcium channel blockers h. Alpha-adrenoceptor blockers

13. Not an absolute contraindication to the use of fibrinolytics in STEMI:a. History of cerebrovascular hemorrhage at any timeb. Nonhemorrhagic stroke 5 years agoc. BP > 180/110mmHgd. Active bleeding excluding menstruation

14. Most frequent arrythmia seen in alcoholic cardiotoxicity or “holiday heart syndrome”e. Ventricular Tachycardiaf. Frequent PVCsg. Atrial flutterh. Atrial fibrillation

15.Not cardinal manifestation of severe aortic stenosisi. Chest painj. Syncopek. Edemal. Congestive heart failure

16. Most common congenital cardiovascular cause of hypertension:a. Bicuspid aortic Valveb. Coarctication of the Aortac. Patent Ductus Arteriosusd. Coronary Arteriovenous Fistula

17. Best diagnostic modality in pericardial effusion:e. Chest x-rayf. Myocardial perfusion imagingg. 2D echocardiogramh. Cardiac catherization

20. Hormone found to be helpful in differentiating dyspnea caused by cardiac vs other etiologiesa. BUNb. BNPc. ANPd. D-Dimer

20. Pharmacologic agent found to reduce mortality in heart failure patients:a. Digoxinb. ACE inhibitorsc. Salt restrictiond. Isosorbide mononitrate

21. Management of acute myocardial infarction:e. Aspirin is effective across the entire spectrum of acute coronary syndromesf. Nitrates increase preload, thus decreasing myocardial oxygen demandg. Morphine causes venous pooling leading to increased cardiac output h. Supplemental oxygen is helpful in decreasing the size of the infarcted myocardium

even in patients with normal arterial O2 saturation

22. What is the EKG diagnosis?i. First degree atrioventricular blockj. 2nd degree atrioventricular block Type 1k. 2nd degree atrioventricular block Type 2l. 3rd degree atrioventricular block

23. A feature of mitral stenosis:a. VT is most common cause of deathb. Atherosclerosis remains the leading cause of mitral stenosisc. The normal mitral valve orifice is 2-4cm2d. Percutaneous valvuloplasty is treatment of choice for symptomatic patients, unless

technically not amenable

25. Not present in significant right ventricular infarction:e. Jugular venous distentionf. Kussmaul’s signg. Bilateral mid to basal ralesh. Hepatomegaly

26. Drug of choice for medical management of aortic aneurysmsi. Beta blocker j. Ace inhibitors k. Calcium channel blockerl. nitrates

27. Mechanisms of action of thienopyridines:a. Inhibition of thromboxane synthesisb. Inhibition of the clotting factor Xac. Inhibition of the P2Y12 ADP receptord. Inhibition of the IIIB/IIIA receptor

28. A principle of treadmill exercise testing:e. Sensitivity for coronary disease is the same as coronary angiogramf. Specificity for coronary disease is unaffected by the presence of LVH, digoxin use,

or resting ST-T abnormalityg. Contraindications include active myocarditis , symptomatic severe aortic stenosis

and early acute myocardial infarctionh. Routine screening is recommended for all adults over 30 years of age

29. Not a clinical manifestation of orthostatic hypotension:a. Polypharmacy with antihypertensive or antidepressant drugs is often non-

contributory b. After physical deconditioning such as after prolonged illness with recumbency,

especially in elderly individuals with reduced muscle tonec. Occurs in hypovolemic states from diuretics, excessive sweating, diarrhea,

vomiting, hemorrhage or adrenal insufficiencyd. Falls in 10 mmHg systolic or 29 mmHg diastolic blood pressure on standing is

diagnostic when due to autonomic dysfunction from various neurologic causes

30. Feature of Atrial Flutter:e. Atrial flutter does not require anticoagulation because of low thromboembolic risk.f. Cardioversion is not effective in terminating hemodynamically tolerated

tachyarrhythmias, and amiodarone is therefore preffered g. Atrial flutter will not cause tachycardia-induced severe left ventricular dysfnctionh. Rate control with calcium antagonist, betablockers or lanoxin maybe difficult

31. Pathophysiology of hypertension:a. Both hypertropic (increased cell number increased cell size and increased deposition

of intercellular matrix) and eutrophic (no change in the amount of material in the vessel wall) vascular remodelling result in decreased lumen size and contribute to increased peripheral resistance

b. The renin-angiotensin-aldosterone system contributes to arterial pressure regulation via angiotensin II which causes vasoconstriction, and aldosterone which causes natriuresis.

c. Stiffer arteries in hypertension, particularly in arteriosclerotic patients results in high systolic blood pressures and narrow pulse pressures.

d. Pheochromocytoma is an example of hypertension related to increased salt retention.

32. A characteristics of secondaryhypertension:e. Hyperthyroidism causes systolic hypertension with a narrow pulse pressuref. Beta blockers are contraindicated in bilateral renal artery stenosis, or unilateral

stenosis in s solitary kidneyg. Surgical excision is the definitive treatment of pheochromcytoma and results in cure

in-90% of patientsh. Pheochromocytoma is the most common cause

33. A feature of hypertension in pregnancy:a. For women with severe preeclamsia , BP >160/110 must be aggressively treated;

and delaying the delivery of the fetus and placenta as much as possible improves maternal outcomes.

b. During pregnancy, a blood pressure of 140/90mmHg is considered to be abnormally elevated and is associated with an increase in perinatal morbidity and mortality

c. Magnesium sulfate is no longer used for the prevention and treatment of eclamptic seizures

d. Methyldopa, ARBs and hydralazine are used most often because they have no known adverse effect on the fetus.

34. A feature of aortic aneurysms:e. If asymptomatic, surgery is indicated if the diameter is > 6 cm in thoracic aneurysms

and > 5.5 abdominal aneurysms.f. Cystic medial necrosis is the most common cause of all aortic aneurysms.g. Atherosclerosis is the condition not frequently associated with aneurysms of the

aortic archand descending thoracic aorta.h. Abdominal aortic aneurysms occur more frequently in females.

35. Management of aortic dissections:a. MPI with sestamibi is the most sensitive test.b. Ct and MRI are accurate tests in this condition, while transesophangeal

echocardiography is generally unreliable for this coondition.c. Systemic hypertension, cystic medial necrosis, Marfan’s syndrome are rare

predisposing factors.d. Medical management is the preferred initial therapy for proximal Type A aortic

dissection.

36.A feature of neurogenic syncope:e. beta-blockers are popular for the condition because trials have shown it to be

clearly effective f. ICD implantation are indicated in these casesg. Tilt table testing has a poorer sensitivity (20-75%) compared to its specificity

(nearly 90%), but specificity decreases with pharmacologic provocationh. Usually accompanied by tonic clonic episodes

37. An indication for infective endocarditis prophylaxis:a. Atrial septal defects deemed uncomplicatedb. s/p prosthetic mitral valve replacement c. LV aneurysmsd. Patients with permanent pacemakers

38. Pulsus paradoxicus consist of a greater than normal inspiratory decline in systolic arterial pressure by:e. 10mmHgf. 15mmHgg. 20mmHgh. 25mmHg

39. The significant ankle bachial index to suspect PAD:i. <1j. <1.5k. <2l. <2.5

40. Not a cause of aortic regurgitation:a. Congenital b. Marfan’s syndromec. Syphilisd. Carcinoid

41. Cornerstones of modern therapy for heart failure with a depressed ejection fraction to prevent disease progressione. Diuretics and Beta-blockersf. Beta blockers and ACE-inhibitorsg. Ace-inhibitors or Angiotensin receptor blockersh. Diuretics and ACE-inhibitors

42. A late sign in cor pulmonale resulting from low cardiac output with systemic vasoconstriction and ventilation-perfusion mismatches in the lung:i. carvallo’s signj. Dyspneak. Clubbingl. cyanosis

43. Most common maalignant cardiac tumor:a. Sarcomab. Myxomac. Hemangiomad. Lymphoma

44. Not a failure of cardiovascular syndrome caused by thiamine deficiency:e. Characterized by high-output heart failure, tachycardia, and often elevated left and

right ventricular filling pressuresf. Major cause of the high-output state is vasomotor depression leading to reduced

response to thiamin and may take 1-2 weeks before effects are clinically apparent g. Reduced systemic vascular resistanceh. Cardiac examination reveal a wide pulse pressure, tachycardia, a third heart sound,

and frequently, an apical systolic murmur.

45. Marks a turning point in the course of a patient with a mitral stenosis, associated with acceleration of the rate at which symptoms progress:a. Infective Endocarditisb. LV dilatationc. Permanent Atrial Fibrillationd. MV orifice of <1.5 cm2

46. Not an indication for coronary angiography in chronic stable angina:e. Patients with chronic stable angina pectoris who are severely symptomatic despite

medical therapy and who are being considered for revascularization, i.e., a percutaneous coronary artery bypass grafting (CABG)

f. Patients with troublesome symptoms that present diagnostic difficulties in whom there is a need to confirm or rule out the diagnosis of IHD

g. Patients with no evidence of ischemia on noninvasive testing and no-clinical or laboratory evidence of ventricular dysfunction

h. Patients with known or possible angina pectoris who have survived cardiac arrest

47. Advantageof bioprosthetic and mechanical valve replacement:a. Bioprosthetic valves are superior to mechanical prosthetic valves in durability

andthrombogenicityb. Lifetime anicoagulation is warranted for mechanical prosthetic valvesc. Valve replacement is indicated for asymptomatic moderate mitral or aortic

regurgitation with well-preserved left ventricular systolic functiond. Prosthetic valves pose a low risk for infective endocarditis and antibiotic

prophylaxis is not indicated prior to dental procedures that may cause transient bacteremia

1. A 55 year old female was admitted due to shortness of breath with associated bipedal edema. Your resident saw the patient earlier and told you that the present working impression is cor pulmonale. Which of the following point in the history and PE does not contribute to the diagnosis?

a. Chronic productive cough for 3 months in each of two consecutive yearsb. 30 pack year smoker up to presentc. Normal JVPd. She has been on warfarin regimen for the past year with irregular intake for history

of deep venous thrombosis

2. The cardiology fellow was called to do a pericardiocentesis procedure on one of the patients at the emergency room. As he was doing the procedure, he asks you, which of the ff is not a feature of cardiac tamponade?a. Hypotensionb. Soft or absent heart soundsc. Fixed wide Split S2d. Jugular venous distention with a prominent x descent and absent y descent

3. You were making rounds at the wards when the nurse referred a patient to you. Apparently, the patient lost consciousness. What should you NOT do?e. Patient should be placed supine with the head turned to the sidef. Clothing that fits tightly around the neck or waist should be loosenedg. Sprinkling cold water on the face may be helpfulh. Have the patient drink cold water

4. While on your duty, you were referred a patient with infective endocarditis. He has been admitted for 5 weeks already but today, he became unstable complaining of shortness of breath. There was a new murmur according to the intern. Your resident is thinking the patient might need urgent heart surgery. Which of the following is not an indication for cardiac surgical intervention in patients with endocarditis?a. Moderate to severe congestive heart failure due to valve dysfunctionb. Persistent bacteremia despite multiple anti microbial therapyc. Presence of effective but expensive microbicidal therapy (e.g. fungal or brucella

endocarditis) d. S.aureus prosthetic valve endocarditis with intracardiac complication

5. 69/F with dizziness, on Imipramine for depression for a few years now. BP of 140/90, RR 22/min, HR variable rhythm. Cardiac monitor shows: what will you do?e. Immediately start IV lidocaine bolus and dripf. Cardiovert the patient with 200 Jg. Administer IV amiodaroneh. Give IV magnesium sulfate bolus and drip

6. You are making rounds with your OB consultant. In front of you is a 35 week AOG pregnant patient that has been having elevated blood pressure since 2 days ago. Right in front of you, the patient had a seizure. Blood pressure was taken and BP = 200/110mmHg. What do you do?a. Give captepril25mg tab SL stat q15 minutesb. Send the patient to the ICU for further monitoring and start her on Duvadilan dripc. Give magnesium sulfate to the patientd. Start oral ACE inhibitors

7. 60 year old male suddenly had dizziness and diaphoresis. BP is 80/50mmHg with cold clammy extremities. ECG shows the following. What to do?e. IV streptokinasef. Give verapamil 5mg IV statg. Send to cathlab immediatelyh. Provide electrical cardioversion

8. 45/M, hypotesive , cold and clammy with EKG below:True about this patient’s condition:a. If right-sided V3 and V4 leads show 1mm ST depression, it indicates RV infarction

from proximal occlusion of the night coronary arteryb. Elevated JVP with kussmaul’s sign and clear lungs are consistent with RV infarction.

IV fluids dobutamine and reperfusion therapy are appropriatec. ST-elevation or right-sided V3 and V4 leads, elevated JVP and pulmonary ,

congestion should be treated with IV fluids, dobutamine and reperfusion therapyd. Intraaortic ballon counterpulsation is contraindicated

9. 1. administer CPR2. check for responsiveness3. call for help,activate EMS4. survey the scene5. check pulse and breathing

a. 3-4-5-2-1 Fb. 4-2-1-3-5 Fc. 4-2-3-5-1 Td. 1-2-3-4-5 Fe. 2-4-3-1-5 F

10. A 58/M, smoker, hypertensive , diabetic patient with dyslipidemia consulted at your clinic. Based on the NCEP guidelines, the LDL target for this patient should be:a. <200mg/dL Fb. <150mg/dL Fc. <100mg/dL Fd. <70mg/dL Te. <50mg/dL F

11. 60/F w sudden dyspnea 2 hrs after BK amputation for diabetic foot ulcer. BP 150/100, HR 96/min, RR 22/min soft S1, cold, clammy extremities. ECG shows:Best treatment option is:f. IV r-tPA thrombolysisg. IV streptokinase thrombolysish. Cardiac catherization and angioplasty/stentingi. IV streptokinase followed by cardiac catherization

7. Which of the following statements is/are TRUE of connective tissue diseases?F a. Systemic lupus erythematosis and dermatomyocitis can be differentiated through skin biopsy and direct immunofluorescence findingsT b. red plaques on the knuckles of the hands are characteristic of dermatomyocitisF c. Presence of malar rash distinguishes lesions of SLE from dermatomyocytisF d. perifungual erythema are common in sclerodermaF e. Scleroi…is

7. Which of the following is NOT characteristic of rosacea?a. Flushingb. Comedonesc. Red papulesd. Telangiectasia

9. Which of the following xanthomas is the LEAST specific cutaneous sign of hyperlipidemia?e. Xanthelasmaf. Planar xanthomag. Eruptive xanthomah. Tuberous xanthoma

Oral antihyperglycemic agents that reduce postprandial hyperglycemiaa. Alpha glucocidase inhibitorb. Arrythin agonistc. Bile and sequestrantd. Megitnidee. Thiazolidne

Antidiabetic agents contraindicated in patients with elevated plasma triglyceridesf. Alpha gluccosidase inhibitorg. Bile acid sequestrantsh. i. GLP-1 receptor agonistj. Thiamidinadione

Differentiates HHS from DKAk. Presence of nausea and vomitingl. Anion gapm. Serum potassiumn. More pronounced volume o. Higher mortality rate

Microvascular complications of diabetesa. Cataractsb. Diabetic skin spotsc. Macular edemad. e. Sexual dysfunction

Mechanism for the development of chronic DM complications f. Epignhetic charges in the affected cellsg. Non erythmatic formation of advanced glycosylation and productsh. Increased glucose metabolism in the sorbital pathwayi. Increased j. Formation of diacylglycerol leading to activation of protein phase C

True of diabetic nephropathya. Diabetic patients with nephropathy usually have concomittant neuropathy b. Only c.

True of diabetic neuropathya. Smoking is a risk factorb. Is a diagnosis of exclusion c. Most common form is distal symmetric polyneuropathyd. For polyneuropathy pain is usually present at most and worse at nighte. is a FDA-approved treatment

True according hypoglycemiaf. Most common cause are drugsg. During

Associated with low radioiodine updatea. grave’s diseaseb. Plummer’s diseasec. d. e. hypothyroidism True of myeoderma comaa. Still has highmortality rate despite treatmentb. Almost always occurs in the elderlyc. Hyperventilation plays a major d. External e.

Characteristics of thyroiditisf. Acute thyroiditis is rare and due to g. Diagnosis ofh. Silent thyroiditis occurs in patients with underlying autoimmune thyroid diseasei. Cytoxine induced thyroiditis is more common in women with TPD antibodiesj. Thyroid dysfunction is

Presentation of amodarone-induced a.b.c.d.e.

Characteristics of goitersa.b.c.d.e.

Increases risk for osteoporosisa. Dementiab. Alcoholismc. Anorexia-nervosad. Type 1 DMe. Rheumatoid arthritis

Causes of hypocalcemia in the critically ill patientsa. Acidosisb. Blood transfusionc. Heparind. Hypoalbuminuriae. Pan

Patients with assymptomatic hyperparathyroidism whoare candidates for surgeryf. 55 year old maleg. BMD T score of -2.0h. Creatinine i. 24H urinary calcium 3 g/dayj. Serum calcium 16 mg/dl

Finding consistent with phaeochromocytomasa. Highly vascular and tumorsb. Most all c. Palpitations, headaches and produce sweating d. Documentation of e. Liberal salt intake and hydration are necessary treatments

Features of adrenal insufficiencyf. Most common cause is autoimmune adrenaltiesg. Secondary adrenal insufficiency presents with loss of glucoccorticoid and androgen

secretionh. Distinguishing feature of primary adrenal insufficiency is hyperpigmentation in

areas of frictioni. Hypercalcemia is found at presentation in 80% of patients with primary adrenal

insufficiencyj. Random serum cortisol measurements are limited diagnostic value

Features of acromegalya. Due to GH and AOF -1 hypersecretion the after epiphysis has cloasedb. Calorie c. Prolcatin is elevated in 21%d. Screening is done by getting random iOF-1 hormone levelse.

Differentiates ectopic ACTH secretion from ACTH-secreting pituitary tumora. Gender of patientb. Rapidly of onsetc. Levels of 24H urine free cortisold. Marked hypokalemiae. High dose dexamethasone test

Characteristics of diabetes insipidusf. Due to a decreased secretion of action of AVPg. Overt dehydration on physical examh. “Bright spot” noted on T1-weighted midsagital MRI imagesi. Weight loss occurs with water deprivationj. Desmopresssin is appropriate for D1

Treatment of SIADHa. Fluid intake that is 500 cc less than the urine output increases serum sodium by 1-

2% per dayb. IV infusion of 3% hypertonic saline connects the sodium deficiency and removes

excess water by solute diuresesc. Demeclocycline produces a reversible form of nephrogenic diabetes insipidusd. Blocks the antidiuretic effect of AVP on V2 and V1s receptorse. Too rapid correction can be complicated by cerebral ionizing

Definite benefits of HRTf. Cognitive dysfunctiong. Diabetes mellitush. sypmtomsi. Osteoporosisj.

Insulin biosynthesis secretion and actiona. C peptide is cleared more slowly than insulin and is a useful in differentiating

endogenous from ecogenous insulin occursb.

Diagnosis and screening for diabetesc. Diabetes is defined as the level at which diabetic specific complications occurd. FPG is the most reliable and convenient test for identifying assymptomatic

individuals HPG or HBsAge. Diagnosis of diabetes can be withdrawn when the glucose incidence reverts back

to normalf. Screening is recommended for both type 2 DM

Factors that confer a very high risk of progression from prediabetes to diabetesg. Age < 60 yearsh. Family history of DM in any relativei. Hypertensionj. Elevated total cholesterol

Pathogenesis of type 1 DMa. Patients will have evidence of islet directed autoimmunity b. In the majority, immunologic markers appear the triggering event and before diabetes

appearsc. Major susceptibility gene for type 1 DM is located in the HLA region of chromosome d. Most individuals with diabetes will not have a relative with this disorder

Treatment goals for adults with type 2 DMe. HBA 1c < 6.9% in most patientsf. Postgrandial capillary glucose < 110mg/dlg. Triglyceride < 160 mg/dlh. BP < 120/80 mmHg

Nutrition and physical activity in patients with diabetesi. The components of optimal medical nutrition therapy are generally similar for T1 DM,

T2 DM and the general population j. Nonnutrient sweeteners are allowed k. Insulin and SUg patients are very prone to hypoglycemia during exercisel. Proliferative diabetic retinopathy is a contraindication to vigorous exercise

Rapid acting insulina. Aspartb. Detemirc. Glargined. NPH

Explains the absence of ketosis in HHSe. Insulin deficiencyf. Lower levels of

Differentiates DKA from single hyperglycemiag. Glucose levelsh. Ketonemiai. Ketonuriaj. Plasma osmolarity

Features of DKAa. Insulin deficiency is necessary for diabetic

Laboratory abnormalities of DKAa. total body stores of sodium, potassium, chloride and phosphorus are total body by their serum levelsb. Elevated serum creatinine c. Elevated serum amylase is indicative of salivary in originMetabolic acidosis is from ketone bodies and lactic acid

Possible unifying mechanism in the theories regarding the development of chronic diabetica. Epignetic charges in affected cellsb. Formation of advanced glycosylationc. Increased production of growth factors d. Increased production of reactive oxygen appear in the melochondria

Correct conclusions from trials on glycemic control and development of chronic complicationsa. In the Diabetes Control and Complications Trial (DCCT) reduction in chronic

hyperglycemia can prevent microvicular complications in patients with type 2 DMb. Benefits from improved glycemic control during the trials persisted even after the

study concluded and glycemic control worsened in both the DCCT and in the United Kingdom Prospective Diabetes Study (UKPDS)

c. Benefits of an improved glycemic control occurred only in the tighter ranges of A1c values

d. In UKPDS strict blood pressure control significantly reduced microvascular complications but had no effect on microvascular complications

Features of opthalmologic complications of diabetese. Blindness is primarily the result of progressive diabetic retinopathy and the

development of cataractsf. Proliferative diabetic retinopathy is characterized by retinal vascular microaneurysm,

biot hemorrhages and cotton-wool spotsg. Hypertension is also a risk for the development rethropathyh. Genetic susceptibility

Management of diabetic retinopathya. There is in established diabetic nephropathy in the first 6 – 12 months of improved

glycemic control transient worseningb. Toutine nondilated eye examination by the primary care provider or diabetes

specialist is detect diabetic eye disease opthalmologist neededc. Exercise has not been conclusively shown to worsen proliferative diabetic

nephropathyd. Aspirin therapy 650 mg/day

Differentiates nephropathy in T1 DM from nephropathy of T2 DMe. Microalbuminuria may be present on diagnosisf. More commonly with accompanying hypertensiong. Presence of microalbuminuria is predictive of progression of microalbiminuriah. Albuminuria may be secondary to factors unrelated to the

Cardiovascular morbidity and mortality in patients with diabetesa. Screening for coronary heart disease in assypmtomatic individuals with diabetes

controversial have not yet shown clinical benefit b. In both DCCT and UKPDS, cardiovascular events were reduced during the trial and

remained low at follow up 10-17 years later trend for benefit in the first part of the trial

c. Current recommendations target A1 c levels near to reduce cardiovascular events d. Aspirin therapy (75-162 mg/day) is primarily recommended for secondary

prevention

Characterisitc of diabetic dyslipidemae. Most common pattern is high triglyceride, low HDL c, small dose LDLf. DM does not increase levels of LDLg. Beneficial effects of LDL reduction are similar in diabetic and nondiabetic

populationsh. High dose niacin may worsen glycemic control and insulin resistance

Antihypertensive agents which can increase insulin resistance a. Ace inhibitorb. Calcium channel blockers c. Central adrenergic antagonistsd. Thiazide

Features of infectious & dermatologic complications in patients with diabetese. Organisms that cause pulmonary infections are similar from that found in the

general populationf. Infections seen almost exclusively in the diabetic population include malignant

otitis externag. “diabetic skin spots” result from minor trauma in the pretibial region and are

more common in elderly h. Necrobiosis tipodice diabeticorum predominantly affects young females with type

1 DM

Which of the following emerging therapies is an important therapeutic option for patients with T1DMa. Whole pancreas transplantationb. Panccreatic islet cell transplantationc. SGLT-2 inhibitorsd. Banatric surgery

True regarding DM management in special situationse. Target blood glucose levels in critically ill patients is 140-180 mg/dlf. Total parenteral nutrition increases insulin requirementsg. Oral antihyperglycemia agents be will not efficacious for patients on

glucoccorticoids with FPG > 200 mg/dlh. The most crucial period of glycemic control during pregnancy is during the second

term

Primary phyysiologic defense of the body against hypoglycemiaa. Decrease in insulinb. Increase in glucagonc. Increase in epinephrined. Decrease in cortisol

Treatment of hypoglycemiae. Reasonable initial dose of glucose is 20gf. Glucagon is effective for of hyoglycemia ineffective for glycogen-depleted individuals

also less useful for t2dmg. Medical therapy with diazonide orr octreotinide is useful for endogenous

hyperinsulinemia from beta-cell tumors also for nontumor beta cell disordersh. Administrations of uncooked cornstarch at bedtime may be necessary in some patients

Laboratory test for thyroid dysfunctiona. Exception, TSH alone is sufficient to exclude a primary abnormality of thyroid fxb. Thyroxine-binding globulin are increased by estrogen androgens decrease TBGc. TSI antibodies are mainly used to predict thyrotoxicosis fetald. Salicylates can transiently increase free thyroid hormone levels

Features of thyroid hormone resistance syndromea. Autosomal disorder due to a mutation in the TRB gene dominantb. Usuallyasypmtomaticc. Can present with tachycardiad. Most patients not require levothyroxine replacement

Management of hypothyroidism e. FT3 determination in diagnosis & management 25% with normal FT3 reflecting adaption

deiodenase responsesf. Liothyronine has no place for long term replacement g. Patients who develop hypothyroidism after treatment of Grave’s disease require

replacement doses of LT4h. Full relief from symptoms may take 3-6 months after normalization of TSH

Special treatment considerations of hypothyroidism i. Levothyroxine treatment of clinically euthyroid patients with thyroid autoantibodies can

reduce the risk of preterm deliveryj. Levothyroxine dose requirements even in pregnancy increased by ≥ 50%k. Elderly patients require 20% less levothyroxine than younger patientsl. Emergency surgery until euthyroidism is achieved generally safe

Features of Autoimmune hypothyroidisma. More common in populations with chronic exposure to a low iodine dietb. TPO and thyroiglobulin antibodies have a primary pathogenetic role and are

clinically useful markers of thyroid autoimmunityc. Pericardial effusions occur in up to 30% and commonly leads to cardiac

compromised. Thyroid-associated opthalmopathy occurs in 5% of patients

Causes of secondary hyperthyroidism e. Gestational thyrotoxicosisf. Silent thyroiditisg. Struma ovanih. Iodine excess

Features of Graves diseasea. Minor for grave’s disease, major for the opthalmopathy smoking is a risk factor for

Grave’s diseaseb. Worsens in 3-6 mos., plateaus in 6-12 mos. Climical course of the opthalmopathy

that of the thyroid diseasec. TSI antibodies do not correlate directly with thyroid hormone levelsd. May present with pretibial myxedema

Treatment of Graves diseasee. All antithyroid drugs inhibit the function of TPO reduce thyroid antibody levels, and

enhance remission ratesf. FT4 is used as a basis to the titrate doses of the antithyroid drugsg. PTU has a prolonged radioprotective effect and must be stopped several weeks

before radioactive treatmenth. It is often possible antithyroid drugs during the first term of pregnancy

Characteristic of sick euthyroid syndromea. Most common pattern is low T3 syndromeb. Major causes is cytokinesc. Progressive HIV disease is associated with a decrease in T3d. Magnitude of fall in T3 levels correlates with the severity of the illness

Factors altering thyroid function in pregnancy e. Rise of circulating hCG in the first term is accompanied by a reciprocal fall in TSHf. Estrogen induced rise in TBG during the first trimesterg. Increased thyroid hormone metabolism by the placentah. Increases urinary iodide excretion

Characteristics of thyroid canceri. Papillary thyroid cancer has a propensity for spreadj. Follicular thyroid cancer be diagnosed by thyroid FNABk. Medullary thyroid cancer is sensitive to RAIl. Anaplastic thyroid cancer is always stage IV

Most common cause of drug-induced osteoporosisa. Alcoholb. Glucoccorticoidsc. Heparind. levethyroxine

Management of Osteoporosise. Primary use of biochemical markers is to predict fracture risk independently of bone

density monitoring to reaponsef. Preferred source of calcium is dietary sourcesg. Weight-bearing exercises in postmenopausal women prevents bone loss but does not

appear to result in substantial gain of bone massh. Supplementation with vitamin K are helpful

Pharmacologic therapy for osteoporosis that promotes bone formationi. Bisphosphonatesj. Calcitonink. Denosumabl. Teriparitide

Causes hypercalcemia and low serum PTH levelsa. granulomulous diseaseb. Lithium toxicityc. Parathyroid hyperplasia d. Tertiary hyperparathyroidism

Features of hyperparathyroidisma. Hereditary hyperparathyroidism may be found in MEN-2A and MEN-1b. Most common cause is parathyroid adenomac. More than half are asymptomaticd. Incidence peaks between the 3rd and 4th decade

Approach to a patient with an adrenal incidentalomae. Diagnostic evaluation should be done for > 1 cm adrenal massesf. For the diferentation of benign from malignant adrenal masses, imaging is relatively

sensitive though specificity is suboptimalg. FNA to rule out malignancy, to establish malignancy need to demonstrate mets may

cause needle canal metastase of ACCh. Adrenal masses with confirmed hormone excess and usually treated surgically

Features of adrenocortical cancera. 60-70% overproduce hormones and produce clinically syndromes, usually inapparent

due to defective synthesisb. Metastasis most commonly occurs to the liverc. Tumor size > 8 cm is associated with a high risk of recurrenced. Five years survival rates are 30-40%

Principles of estrogen therapy in menopausee. Oral estrogen is better than transdermal estrogen in managing hot flushesf. It is useful in the management of hypertriglyceridemiag. It is useful in patients with thromboembolic diseaseh. It increases the risk of endometrial cancer

Characteristics of infertilityi. Defined as inability to conceive after 12 months of unprotected sexual intercoursej. Female factors account for 58% of infertilityk. Modifiable risk factors include alcohol caffeine, obesity, and smokingl. Time for evaluation, correction and expectant movement can be longer in women > 35

years.

Who has diabetes?a. 40F with fasting blood sugar of 126 mg/dL taken onceb. 35M with prebreakfast cbg 130 mg/dLc. 28F with 50 g OGCT 150 mg/dLd. 18M with a standardized HBA 1c of 6.8%

29F was admitted for decrease

30F is for fertility work up. She is assymptomatic and PE is unremarkable. Her TSH is 7 uU/L, (NV 0.4 – 4 uU/L) and FT4 is 13 uU/L (NV 12 – 20 uU/L) TPO antibodies are positive. What should you do next?a. Request for a total T3b. Request for thyroid scanc. Repeat TSH, FT4 after 3 monthsd. Start levothyroxine

26M with weakness of both thighs was noted to have a TSH 0.01 uU/L (NV 0.4 – 4 uU/L) and FT4 20 uU/L (NV 12 – 22 uU/L). Physical examination is unremarkable. What should you do next?e. Request for total T4f. Request for free T3g. Start PTU 50 mg TID POh. Reassure the patient and ask him to follow up after 6 – 12 months

45M has 2 cm firm nodule on the right thyroid lobe on palpation THS is uU/L (NV 0.4-4 uU/L) FNAB shows follicular tumor. What should you do next?a. Do a thyroid scanb. Do an ultrasound guided FNABc. Monitor by ultrasound d. Send the patient for surgery

Who should be given medical therapy for osteoporosis?e. Z score -2.0f. 30F with bronchial asthma who was given Prednisone 30 mg OD PO x 7 daysg. 60F with BMI 16 and T score -1h. 62M with family history of leg fracture

25F with BP 160/100 consulted for work up. She is on losartan 50 mg OD PO and amlodipine 5 mg OD PO. Serum creatinine is 90 ug/dL. Na 140 meq/L, K 3.2 meq/L. what should you do need?i. Request for plasma aldosterone-renin ratioj. Get on abdominal CT scank. Correct serum potassium firstl. Start spirinolactone 50 mg OD PO

28F complains ofamenorrhea in 6 months. Work up showed a fasting serum orolactin 150 ug/L. She has a history of thyroid surgery 2 years ago. Currently she is not taking any medications. Physical examination is unremarkable except for dry thick skin. What should you do advice the patient? (HPIM 18th and chapter 139)a. Repeat prolactin levels using sample dilutionb. Request for THS and FT4c. Request for a sellar FT4d. Start bromocriptiine 2.5 mg/tab ½ tab OD PO

MTF 1. Features of ErythropoiesisF a. the first morphologically recognizable erythroid precursor in the bone marrow is themyeloblastF b. In the absence of Granulocyte Colony Stimulating Factor (GCSF), erythroid precursors willnundergo programmed cell death (apoptosis)T c. EPO governs day-to-day production of red cellsT d. Average life span of red cells is 100-120 daysT e. The fundamental stimulus for EPO production is the availability of O₂ for tissue metabolic needs

MTF 2. Oxygen affinity og hemoglobin in different situationsT a. Hemoglobin has a lower oxygen affinity among acidotic septic patientsF b. Hemoglobin has a lower oxygen affinity at higher pH (Bohr effect)T c. Immediately after transfusion of PRBC, there may be decrease in O2 release by the hemoglobinF d. Increase in 2,3 BPG increases hemoglobin oxygen affinityF e. Better oxygen delivery is noted ay higher attitudes

MTF 3. Differential diagnosis of microcytic hypochromic anemiaT a. ThalassemiaT b. Lead PoisoningT c. Iron deficiency AnemiaF d. Diphyllobotrium latum infestationT e. Anemia of chronic disease

MTF 4. Compatible with Iron deficiency anemiaF a. Microcytic hypochromic red cells low serum iron, normal ferritin levelT b. Microcytic hypochromic red cells, low serum iron, low ferritin level F c. Microcytic hypochromic red cells, normal serum iron, increased ferritin F d. Microcytic hypochromic red cells, normal serum iron and TIBCT e. Microcytic hypochromic red cells, low serum iron, high

MTF 5. Microcytic hypochromic cells with low serum iron and normal or increased bone marrow iron stores may be found in the following:F a. 32 y/o female with alpha thalassemia traitF b. 19 year old heavily menstruating woman with iron deficiency anemiaT c. 55 year old male with rheumatoid arthritisF d. 28 y/o male with chronic lead positioningT e. 49 year old female with systemic lupus erythematosus

MTF 6. Features of hypoproliferative anemiasT a. Acute and chronic inflammation is the most common of theseF b. Anemia of inflammation, like iron deficiency, is related in part to abnormal erythropoietin responseT c. Renal disease, cancer and hypometabolic states are characterized by an abnormal erythropoietin response to the anemiaT d. These abenia are assocciated with normocytic and normochromic red calls and an inapppropriately low reticulocyte responseF e. Most commonly associated with exposure to benzene derva

MTF 7. Diseases associated with intravascular hemolysisT a. Paroxysmal nocturnal hemoglobinuriaF b. Hemolytic uremic syndromeT c. HemoglobinupathiesF d. HypersplenismF e. Microangiopathic hemolytic anemias

MTF 8. Characteristic of Unsatable Hemoglobin VariantsT a. Should be suspected in patients with nonimmune hemolytic anemia, jaundice, splenomegaly, or premature billiary tract disease. Or leg ulcersF b.Severe hemolysis usually presents in adults F c. Spontaneous mutation ucommonT d. The peripheral blood smear often show anisocytosis, abundant cells with punctate inclusions, and irregular shapes (i.e., poikilocytosis).T e. Best test for diagnosing unstable hemoglobins are the Heinz body preparation and the isopropanol or heart stability test.

MTF 9. Guidelines on splenectomy in patients with hemolytic diseasesT a. Avoid splenectomy in mild casesF b. delay splenectomy until at least 10 years of ageT c. Antipneumococcal vaccination before splenectomy is imperativeF d. Anticoagulation may be required.T e. Hereditary Spherocytosis patients often may require cholescystectomy

MTF 10. Characteristic of Vitamin B12 and associated deficiency resulting to Megaloblastic AnemiaT a. Cobalamin (Vitamin B12) is synthesized solely by microorganisms.T b. Only source for humans is food of animal origin, e.g. meat, fish, and dairy products. F c. Body stores are of the order of 2-3 mg, sufficient for 3-4 months if supplies are completely cut offF d. Vegetables, fruits and other foods of non-animal origin also contain cobalaminT e. Most common among individuals of Hindu religion

MTF 11. The M Component noted in Serum Protein Electrophoresis may be seen in ff condition/sT a. multiple MyelomaT b. Chronic lymphocytic leukemiaF c. ThalassemiaF d. Chronic renal diseaseT e. Breast Cancer

MTF 12. Characteristics of Multiple myelomaT a. Malignant proliferation of plasma cells derived from a single cloneT b. Overexpression of myc or ras genes hass been noted in some casesF c. Inversion of chromosome 16 was also observed in certain varietiesT d. Management with Thalidomide and Dexamethasone have shown better survivalF e. Translocation of chromosome 9:22 is associated with worst prognosis

MTF 13. The following conditions predispose a patient to development of Acute Myelogenous LeukemiaT a. Myelodysplastic SyndromeT b. Polycythemia VeraF c. ThalassemiaT d. Paroxysmal Nocturnal HemoglobinuriaF e. Iron Deficiency Anemia

MTF 14. The following are part of the initial laboratory evaluation of adult patients with acute myeloid leukemiaT a. CBC with manual differential cell countF b. Ultrasound of whole abdomenT c. Bone marrow aspirate and biopsy (morphology cytogenetics, flow cytometry, molecular studies)T d. HLA typing of patient, siblings, and parents for potential allogeneic SCTF e. Urinalysis

MTF 15. Ccharacteristic of myelophthisic anemiaT a. A common finding in the peripheral blood smear is a shift to the left of the granulocytic series and presence of nucleated red cells, these findings are suggestive of the diagnosisT b. Usually the infectious or malignant underlying processes are obvious in secondary causesF c. Leukopenia F d.F e.

MTF 16. Conditions with pancytopenia and cellular bone marrow:F a. Aplastic anemiaT b. Paroxysmal nocturnal hemoglobinuriaT c. MyelodysplasiaF d. Dyskeratosis congenitaT e. Hairy cell leukemia

MTF 17. Drugs definitely reported to cause isolated thrombocytopeniaF a. Acetyl salicylic acidT b. Trimethoprim/sulfamethoxazoleT c. DanazolT d. ParacetamolF e. Phenylpropanolamine

MTF 18. Consequences of Neutropenia

MTF 19. treatment of Immune Thrombocytopenic Purpura (ITP)F a. Patients with platelet counts greater than 30,000/L should be started on oral steroidsT b. Traditional OPD management of ITP this has been prednisone at 1 mg/kgT c. Rh₀(D) immune globulin must be used only in Rh-positive patientsT d. Refractory ITP may benefit from anti-CD 20 agentsT e. Oral eltrombopag shows potential benefits for acute ITP

MTF 20. The following principles should be applied in the management of bleeding disordersF a. RestT b. Ice or cold compress over affected areasF c. Warm compress over affected areasT d. Elevation of affected extremityF e. Aspiration of bleeding joints

MTF 21. Features of venous thrombosisF a. Majority of cases are secondary to hereditary causesF b. Females are at greater risk for venous thrombosis than are malesT c. High prevalence of Factor V Leiden was reported in ArabsF d. factors 8 and vWF are decreased during pregnancy thus predisposing to venous thrombosisT e. LMWH is recommended for acute thrombotic events

MTF 22. Conditions associated with both arterial and venous thrombosisT a. HyperhocystenemiaT b. Paroxysmal nocturnal hemoglobinuriaF c. ImmobilizationF d. Activated protein CT e. Polycythemia vera

MTF 23. In the setting of acute thrombosis or anticoagulation, working up for a hypercoagulable state should take into consideration:T a. Coumadin reduces protein C and S levelsT b. Heparin can reduce antithrombin levelsF c. Heparin and Coumadin have no effect on testing for lupus anticoagulant and APCT d. Sepsis is associated with reduction in levels of protein C, Protein S,, antithrombinF e. Work ups may be done anytime

MTF 24. Indications forHematopoietic Stem cell transplantation (HSCT)T a. Acute Myelogenous LeukemiaT b. Breast CaT c. Severe combined immunodeficiencyT d. Very Severe Aplastic AnemiaF e. Diffuse B Cell Lymphoma, newly diagnosed

1. The world Health Organization (WHO) defines anemia asa. Hemoglobin level <130g/L (13 g/dL) in menb. Hemoglobin level <120g/L (12 g/dL) in menc. Hemoglobin level <130g/L (13 g/dL) in womend. Hemoglobin level < 120g/L (13 g/dL) in pregnant women

3. The main iron transport proteina. Transferrin b. Apoferritinc. Albumind. globulin

4. The “gold standard” for iron stores determinatione. Bone marrow iron stainf. Serum ferriting. Serum ironh. Total Iron Binding Capacity (TIBC)

5. Definitive management may be achieved through splenectomyi. Hereditary spherocytosisj. G6PD deficiencyk. Thalassemial. Sickle cell hemoglobinopathy

6. History of pallor and tea colored urine after being given anti malarials and eating legumes or beans best fits this disease:a. Pyruvate kinase deficiencyb. GCPD deficiencyc. Spherocytosisd. Fancom’s anemia

7. Most effective management of G6PDe. Splenectomyf. Gene therapy g. Blood transfusionh. Avoidance of drugs which may induce hemolysis

8. Disease almost always associated with positive direct Coomb’s test:i. PNHj. G6PD deficiencyk. Acute hemolytic reaction sec to ABO incompatibilityl. Idiopathic autoimmune hemolysis

9. Hallmark of the common forms of alpha thalassemia:a. Elevated Hgb Ab. Elevated Hgb A2c. Elevated HgbFd. Low HgbA2

11. Hemoglobin levels in the elderly populatione. Almost all the elderly population have normal hemoglobin levelf. The female gender is more prone to nutritional type of anemiag. About 25% of the elderly without underlying disease will have below normal hemoglobin

levelsh. About 30% of the male gender with anemia would be diagnosed with underlying

malignancy

12. Vegetarians are prone to anemia secondary to which of the following deficiencyi. Folic acidj. Cyanocobalamink. Niacinl. Zinc

13. Fundamental abnormality in pernicious anemiaa. Short bowel syndromeb. Atrophic gastritisc. Lack of Vitamin B12 in dietd. malabsorption

14. Chronic renal diseases where erythropoietin production is sparede. Chronic glomerulonephritisf. Polycystic kidney diseaseg. Chronic pyelonephritish. Diabetic nephropathy

15. Compatible with Anemia of Chronic diseasei. Microcytic hypochromic red cells, low serum iron, increased ferritin levelj. Microcytic hypochromic red cells, normal serum iron, low ferritink. Microcytic hypochromic red cells, normal serum iron and TIBCl. Microcytic hypochromic red cells, low serum iron, high TIBC

16. Agent

17. Mechanisms of action of cyclosporine in aplastic anemiaa. Reduce cytotoxic T cellsb. Inhibits IL 2 production by T lyhmphocytesc. Modulates adverse reactions to ATGd. Stimulate production of erythropoietin18. Specific treatment of marrow aplasia in severe aplastic anemiae. Allogeneic stem cell transplantationf. Autologous bone marrow transplantationg. Cyclosporineh. Blood transfusion

19. Hallmark clinical feature PNHi. Ineffective eryhtropoiesisj. Chronic intravascular hemolysisk. Bone marrow failurel. Bleeding diathesis

20. Clinical featured of idiopathic Thrombocytopenic Purpura in adults:a. More common in men than womenb. Onset is acutec. Spontaneous remission in 2%d. A and C

21. Treatment for assymptomatic patients newly diagnosed with ITP with platelet count of 50,000:e. Oral prednisone 1 to 2 mg/kg/dayf. IVIgg. IV hydrocortisoneh. Observation

22. Mild Von Willebrand’s disease type 2 patient for surgery is best managed with i. DDAVPj. Cryoprecipitatek. Factor VIII/VWF concentratesl. Factor VIIa

23. 19 year old male with 3% Factor 8 assay activity is compatible witha. glanzmann’s thrombastheniab. Hemophilia A, mildc. Hemophilia A, moderated. Hemophilia B, mild

24. What is the probability that a hemophilia A male married to a carrier will have a carrier female offspring (Chapter 116)?e. 25%f. 50%g. 75%h. 100%

25. Treatments of choice for hemophilia A patients with inhibitors (Chapter 116)i. Factor Vllaj. Factor VIII, recombinantk. Cryoprecipitatel. Tranexamic acid

26. Central mechanism of disseminated intravascular coagulation (Chapter 116):a. Massive platelet activationb. Uncontrolled plasmin generationc. Excessive thrombin generationd. hyperfibrinolysis

27. Most sensitive test for disseminated intravascular coagulation e. Platelet countf. Fibrinogen levelg. D-dimerh. Fibrinogen degradation products

28. Post partum hemorrhage is a major cause of maternal mortality with disseminated intravascular coagulation. With consumption of fibrinogen as sequelae resulting to bleeding, this may be replaced with (Chapter 113)i. Whole Bloodj. Cryoprecipitatek. Cryosupernatel. Tranexamic acid

29. The following have been observed among patients who inherited thrombophilias a. Often present with unusual sites of thrombosisb. In majority of cases, thrombosis is provoked by surgery, pregnancy, immobilization OCP,

HRT or old agec. Those heterozygous for factor V Leiden and prothrombin gene mutation have been shown

to have a higher rate of recurrent venous thrombosis verses the general populationd. B and C

30. The following situation does not predispose to venous thrombosis (Chapter 117)e. Increasing agef. Varicose veinsg. Intake of melphalan in multiple myelomah. Trauma

31. trousseau’s syndrome may be noted in which of the following (Chapter 117): a. Gastric Ca b. Prolonged best rest c. Trauma to blood vessels d. Intake of Coumadin

32. Recommended anticoagulant prophylaxis for high risk activities like prolonged air travels etc., for patients with thrombophilia (Chapter 118):a. Aspirinb. Warfarinc. UFHd. LMWH

34. Standard initial treatment for deep vein thrombosis (Chapter 118):e. UFHf. LMWHg. Argatrobanh. Fondaparinux

35. Pharmacologic characteristics of warfarin (Chapter 110):i. The onset of action is immediatej. The antithrombotic effect depends on the reduction of the functional levels of the

clotting factors with longest half lives which are Factors II and X.k. It is rapidly and almost completely absorbed from the kidneyl. Anticoagulation effect best for acute DVT

36. Treatment of choice for thrombotic thrombocytopenic Purpura (Chapter 175)a. TpEb. Cryosupernatec. Steroids d. Aspirin

37. Associated with ADAMTS 13 deficiencye. Hemolytic uremic syndromef. Thrombotic thrombocytopenic purpurag. Essential thrombocythemiah. Heparin induced thrombocytopenia

39. The following is not a major indication for splenectomy in primary myelofibrosis (Chapter 108)i. Massively enlarged spleenj. Excessive transfusion requirementsk. Portal hypertensionl. Severe thrombocytopenia

40. Molecular pathology of CML (Chapter 104)

41. Characteristics of CML compared with the other Chronic Myeloproliferative disorder (P.vera, Idiopathic Myelofibrosis, Essential Thrombocythemia) (Chapter 108, 109)a. Total WBC count > 30,000/ul in >90%b. Platelet count > 750,000/ul in >50%c. Increased red cell mass and plethorad. JAK 2 mutation

42. The tyrosine kinase inhibitor Imatinib Mesylate (Chapter 109)e. Initial therapy in almost all CML, chronic phase f. Improved survival outcomes among CML patients in accelerated phaseg. Patients treated with imatinib after IFN failure had better survival than those who

continued receiving IFNh. May be given as an alterative to autologous hematopoietic stem cell

transplantation

43. Best treatment option for accelerated and blast crisis CML (chapter 109)a. Chemotherapyb. Allogeneic stem cell transplantc. Autologous stem cell transplantd. Imatinib mesylate, higher dose

44. Most common site of relapse in ALLe. CNSf. Ovaryg. Bone marrowh. Testes in males

45. Classic triad of multiple myelomai. Marrow plasmacytosis (>10%), lytic bone lesions, and serum and/or urine M

componentj. Anemia, lytic bone lesions and serum and. Urine M componentk. Marrow plasmacytosis (>10%), reverse albumin/globulin ratio, and serum and/or urine

M componentl. Anemia, marrow plasmacytosis (>20%), reverse albumin/globulin ratio

46. Major specific pathophysiologic mechanism in MDS (Chapter 107)a. Defective maturation and death of marrow precursor cellsb. Fibrosis associated with PDGFRc. Bone marrow suppression which may be associated with increased cytokine productiond. Bone marrow infiltration

47. Treatment of choice for elderly patients with MDS, RAEB (Chapter 107)e. Lenolidamidef. Intensive chemotherapyg. Azacytidineh. Arsenic trioxide

48. Management of platelet refractoriness in alloimmunized bleeding patient with severe thrombocytopenia,with sepsis (Chap 113)i. Random donor platelets at 1 unit/10 kg body weight, treat sepsisj. Apheresed Platelets, steroids, treat sepsisk. HLA matched Apheresed Platelets treat sepsisl. Apheresed platelets and IV IG

A 1. A 26 year old female was stabbed with an ice pick several times over the right anterior chest wall and was brought to the Emergency Room by her boyfriend. Vital signs: BP=80 palpatory, HR=128/min, weak thready pulse RR=28/min. patient appeared paper white with blood oozing over puncture wounds. For blood transfusion requirements, whole blood (WB) was requested however only blood components were available at the blood bank. What components can be combined in place of whole blood?a. Packed red blood cells (PRBC) + fresh frozen plasma (FFP) + plateletsb. PRBC + FFPc. PRBC + Cryosupernated. PRBC + Cryosupernate + platelets

A 2. the above patient’s laboratory CBC hemoglobin-42 g/L, wbc-12.3, platelet count-142,000; PT = 13.2 secs control 12.9, PTT = 40 secs control=36, Blood type was A Rh positive. The patient is best managed with:e. Crystalloids/colloids + A Rh positive PRBCf. Crystalloids/colloids + A Rh positive PRBC and platelet countg. Crystalloids/colloids + A Rh positive FWBh. Crystalloids/colloids + O Rh positive FWB

A 3. A 38 year old male presents with hgb 76 g/L, MCV of 105fl, platelet count 80,000/ul, low level of serum folate ands a normal serum level of vitamin B12. this is most compatible with:a. Pregnancyb. Alcoholismc. Pernicious anemiad. Resection of ileum

A 4. A 56 year old male, diabetic, was admitted with peripheral arterial occlusive disease affecting his toes on both lower extremities. A few days after starting Enoxaparine subcutaneously, his platelet count was noted to be 20 x 109/L. what would be the best management for this patient?e. Continue Enoxaparine and observe patientf. Discontinue Enoxaparine and observe patient g. Discontinue enoxaparine and start Unfrationated Heparin IV with monitoring of

INRh. Discontinue Enoxaparine and start heparinoids

A 5.An Assymtomatic 72 y/o Multiple Myeloma patient with renal insufficiency with hemoglobin at 94 g/dl, platelet count =102,000 is best managed witha. PRBC transfusionb. Leukocyte depleted PRBC transfusionc. Whole Bloodd. Erythropoietin

A 6. An assymptomatic 22 year old woman was seen at the OPD requesting clearance for work, history revealed regular monthly cycles, wherein she utilizes 12-14 maternity napkins, most fully soaked. Physical examination (except forpallor)was unremarkable. Labs: CBC-Hgb=72 g/L, hct ==0.22, wbc=7.5 (seg 68%, lympho=30%), plt ct = 450, MCV=65, mch=18, RDW=21Serum ferritin =6.7What is best management for the anemia?e. Oral iron supplementf. Intravenous irong. Blood transfusionh. Improve diet

A 7. A 36 year old male, asymptomatic consulted because of incidental finding of platelet count at 850,000 on CBC (Hgb=138, wbc=18.5)during annual medical. Pas medical history, other labs and PE unremarkable. If the patient was further worked up and showed still elevated plt count at 600,000 mild leukocytosis, positive JAK 2 mutation assay and negative bcr-abl, what would be best management for the patient?a. Observation and monitoringb. Start anagrelide and hydroxyureac. Start imatinibd. allogeneic bone marrow transplant

A 8. A 62/M, previous total gastrectomy for NHL 7 years ago, came in because of easy fatigability of 4 months duration. CBC: Hb 5.2 HCT 25 MCV 125 WBC 3.5 Seg 54 Ly 46 Platelets 78; Retic count 1.2% PBS: Macricytosis, aisopoikilocytosisWHAT CLINICAL SITUATION COULD EXPLAIN THE FINDINGS?A. Iron deficiency anemiaB. Vitamin B12 deficiencyC. Sideroblastic anemiaD. Myelopthisic anemia

2. In a patient with metabolic alkalosis from vomiting, this urine parameter serves as an accurate indicator of volume status:a. Sodiumb. Chloridec. Potassiumd. Specific gravity

6. This chinese herb present in slimming tea preparations is also believed to be the cause of Balkan nephropathye. Aristolochic acidf. Ochratoxin Ag. Melamineh. cadmium

8. Components involved in providing gastroduodenal defense against peptic ulcers• T A. Unstirred layer of mucus and bicarbonate• T B. Surface epithelial cells that generate heart shock proteins• T C. Cell renewal from mucosal progenitor cells• T D. Submucosal vascular system that generates alkaline tide• T E.Prostaglandins that promote epithelial cell restitution

42. Primary prophylaxis of esophageal variceal hemorrhage• T A. Propanolol • T B. Nadolol• T C. Variceal band ligation• F D.Transjugular intrahepatic portosystemic shunt (TIPS)• F E. Surgical esophageal transection

43. Radiographic findings present in acute intestinal obstruction• T A. Stepladder pattern in small intestine• T B. Absence of colonic gas• T C. Coffee bean-shaped mass• F D. Free air in the peritoneum• F E. “Thumbprinting”

44. Diagnosis of diverticulitisis best made on CT with these findings• T A. Sigmoid diverticula• T B. Thickened thickened colonic wall >4mm• T C. Inflammation within pericolic fat• F D. String of beads sign• F E. Bird’s beak sign

45. Treatment for stage II hemorrhoids, which are protrusions with spontaneous reduction• T A. Fiber supplementation• T B. Cortisone suppository• F C. Sclerotherapy• F D. Banding• F E. Operative hemorrhoidectomy

46. Colorectal cancer screening strategies for asymptomatic individuals ≥ 50 years of age• T A. Colonscopy every 10 years• T B. Fecal DNA testing every 3 years• T C. CT colonography every 5 years• T D. Flexible sigmoidoscopy every 5 years• T E. Double-contrast barium enema every 5 years

47. Epidemiologic characteristics of ulcerative colitis• T A. Smoking is preventive• F B. Oral contraceptive pills increase risk• T C. Appendectomy is protective• T D. More common in African Americans than asians• T E. Has two peak ages of onset

48. Pathologic feature of Crohn’s disease• T A. Can affect the mouth and anus• T B. Cobblestone appearance• T C. Perirectal fistulas and anal stenosis• F D. Almost always involves the rectum• F E. Disease process is limited to the submucosa

49. Pathologic features of ulcerative colitis• F A. “Skip areas” or areas of histologically normal mucosa are common• T B. Pseudopolyps may be present• F C. Disease process is transmural• F D. “Creeping fat” or thickened mesentry encasing bowel is a common feature• F E. Granulomas are a pathognomonic feature

50. Extraintestinal manifestations of inflammatory bowel disease more commonly seen in Crohn’s disease than in ulcerative colitis• F A. Pyoderma gangrenosum• T B. Ankylosing sspondylatis• F C. Primary sclerosing cholangitis• T D. Nephrolithiasis• T E. Reactive amyloidosis

51. Indications for surgery of ulcerative colitis• T A. Toxic megacolon• F B. Refractory fistula• T C. Colon cancer prophylaxis• T D. Colon dysplasia• F E. Perianal disease unresponsive to medical therapy

1. Most important indication for urgent gastrointestinal endoscopy in the list below• A. Age>60 Years• B. Decrease in hemoglobin• C.Decrease in hematocrit• D. Orthostatic hypotension

2. What is the most sensitive and specific approach to testing for peptic ulcer disease?• A. Double-contrast barium study• B. Urea breath test• Serum gastrin level• D. Endoscopy

3. Which type of chronic atrophic gastritis is associated with pernicious anemia?• A. Isolated granulomatous gastritis• B. Antral predominant or type B gastritis• C. Multifocal atrophic gastritis• D. Autoimmune or type A gastritis

4. Risk of rebleed is lowest with this type of peptic ulcer• A. ulcer with spurting• B. ulcer with visible vessel• C. ulcer with pigmented spot• D. clean-based ulcer

5. Preferred endoscopic therapy for control of active esophageal variceal bleeding• A. Band ligation• B. Sclerotherapy • C. Balloon tamponade• D. Transjugular intrapatic portosystemic shunt (TIPS)

6. Large-caliber arteriole that runs immediately beneath the gastrointestinal mucosa and bleeds through pinpoint mucosal erosion• A. Gastroesophageal varix type I (GOV1)• B. Mallory-Weiss tear• C. Gastric antral vascular ectasis (GAVE)• D. Dieulafoy’s lesion

7. Sight, smell and taste of food are components of this phase of stimulated gastric and secretion• A. cephalic• B. Gastric • C. Pancreatic• D. Intestinal

8. This cell is responsible for gastric acid secretion• A. Chief cell• B. G cell• C. Parietal cell• D. ECL cell

9. Ulcers within 3cm of the pylorus, commonly accompanied by high gastric acid production and duodenal ulcers• A. Type I gastric ulcers• B. Type II gastric ulcers• C. Type III gastric ulcers• D. Type IV gastric ulcers

10. This type of gastritis produced by chronic H. pylori infection may lead to development of MALT lymphoma• A. Antral-predominant gastritis• B. Nonatrophic pangastritis• C. corpus-predominant atrophic gastritis• D. Fundal gastritis

11. Dose of aspirin deemed safe, as it does not cause peptic ulceration• A. 75mg/day• B. 81mg/day• C. 325mg/day• D. no dose is completely safe

12. Most commonly encountered diagnosis among patient’s seen for upper abdominal discomfort• A. Nonulcer dyspepsia (NUD)• B. Gastroesophaegeal reflux disease (GERD)• C. peptic ulcer disease (PUD)• D. Nonerosive reflux disease (NERD)

13. Cyto preotective agent used in peptic ulcer disease that may lead to aluminum-induced neurotoxicity in patients with chronic renal insufficiency• A. Bismuth subsalicylate• B. Misoprostol• C. Rebamipide• Sucralfate

14. Cytoprotective agent used in peptic ulcer disease contraindicated in women who may be pregnant• A. Sucralfate• B. Colloidal bismuth subcitrate• C. Misoprostol• D. Amitriptyline

15. Proven benefit of H. pylori eradication in patients with peptic ulcer disease• A. Decreases in ulcer recurrence• B. Elimination of risk of ulcer perforation• C. Prevention of gastric cancer• D. Prevention of gastric lymphoma

16. Most feared complication with amoxicillin use in triple therapy of peptic ulcer disease• A. Black tongue• B. Pseudomembranous colitis• C. Allergic reaction• D. Hepatotoxicity

17. Most common cause of treatment failure in compliant patients on triple therapy for peptic ulcer disease• A. underdosing• B. Antibiotic-resistant strains• Drug side effects leading to discontinuation• Lower bioavailability of generic drugs

18. Test of choice for documenting H. pylori eradication• A. Stool antigen test• B. Urea breath test• C. Serologic testing• D. Histopathologic exam

19.Definition of a refractory peptic ulcer• A. Gastric ulcer that fails to heal after 12 weeks• B. gastric ulcer that fails to heal after 6 weeks• C. Duodenal ulcer that fails to heal after 4 weeks• D. Duodenal ulcer that fails to heal after 2 weeks

20. Surgical treatment of choice for a gastric antral ulcer• A. Antrectomy, intraoperative ulcer biopsy, vagotomy• B. Subtotal gastrectomy with Roux-en-Y• C. Antrectomy with a Billroth I anastomosis• D. Ulcer excision with vagotomy and drainage

21. Cornerstone of therapy for patients with dumping syndrome after surgery for peptic ulcer disease• A. Antidiarrheal medications• B. Octreotide• C. Anticholinergic agents• Dietary modification

22. Physical exam finding which indicates the presence of a severe necrotizing pancreatitisa. Abdominal distenstionb. Jaundicec. Pleural effusiond. Blue discoloration around umbilicus

23. Lab value consistent with acute pancreatitisa. Threefold elevated serum lipaseb. Fourfold elevated salivary-type amytasec. Hypoglycemiad. hypercalcemia

24. Type of viral hepatitis for which no vaccine existse. HAVf. HCVg. HDVh. HEV

25. Endovascular stenting is a management option for this type of acute intestinal ischemia• A. Aterial embolus• B. Arterial thrombosis• C. Venous thrombosis• D. Non-occlusive mesenteric ischemia

26. This is the gold standard for the diagnosis and management of acute intestinal arterial occlusive ischemia• A. mesenteric duplex scan• B. CT angiography• C. Lapatoramy• D. Ablation of renin-angiotensin axis

27. This is the most common extrauterine condition requiring abdominal operation during pregnancy• A. neprolithiasis• B. Small-bowel obstruction• C. perinephric abscesses• D. Appendicitis

28. Most common cause of hematocheza in patients >60 years• A. inflammatory bowel disease• B. Colon Cancer• C. Colonic diverticulitis• D. hemorrhoids

29. Which laboratory test is a highly sensitive and specific marker for detecting intestinal inflammation in inflammatory bowel disease?• A. Fecal lactoferin• B. C-reactive protein• C. Erythrocyte sedimentation rate• D. Platelet count• E. Fecalysis

30. In which variant of inflammatory bowel disease does total parenteral nutrition play a major role in inducing remission?• A. Distal ulcerative colitis• B. Extensive ulcerative colitis• C. Inflammatory Crohn’s disease• D. Crohn’s disease with TB ileitis• E. Fistulizing Crohn’s disease

1. A 40-year-old male with melena is found to have a gastric ulcer with a visible vessel on endoscopy. Which treatment strategy is recommended?

• A. Discharge home with oral PPI therapy• B. ward admission, no IV PPI therapy, no endoscopic therapy• C. ICU admission, IV PPI therapy, endoscopic therapy• D. Ward admission, IV PPI therapy, endoscopic therapy

2. A 22-year-oldman had hepatitis B serologies done as part of his seafarer’s pre-employment workup. Which serologic pattern assures that his childhood vaccination series remain effective?a. HBsAg(+), anti-HBc(+), anti-HBs(-)b. HBsAg(+), anti-HBc(+), anti-HBs(+)c. HBsAG(-), anti-HBc(-), anti-HBs(-)d. HBsAG(-), anti-HBc(-),anti-HBs(+)

3. Your 50-year old uncle is in the hospital for hepatitis. His serologies are (+)HBsAG, (+)IgM anti-HAV, (+)IgM anti-HBc, (-) anti-HCV. What is your interpretation?e. Acute hepatitis Bf. Acute hepatitis A and Bg. Acute hepatitis A superimposed on chronic hepatitis Bh. Acute hepatitis C

4. A 48-year-old man with HBeAg-negative chronic hepatitis B asks to be treated. His viral load is 1,500 IU/mL and his ALT is normal. This would be a reasonable recommendation:• A. Treatment with pegylated interferon• B. treatment with entecavir• C. referral for liver transplantation• D. No treatment

5. A 40-year-old man was admitted from the ER with the following test results, prothrombin time 18 (N=12), serum bilirubin 12mg?dL. Which is the best treatment for his alcoholic hepatitis?• A. High dose thiamine• B. Silymarin• C. IV multivitamins• D. Prednisolone

6. A 50-year-old first degree relative of patient diagnosed with colon cancer at age 65 should undergo colonoscopy this often.• A. every 10 years• B. every 5 years• C. every 3 years• D. every year

6. Deficiencies of the Adaptive Immune System:T a. Severe combined immune deficiency (SCID)T b. Hyper-IgE syndrome (autosomal dominant)T c. Hyper IgM syndromeT d. Common variable immunodeficiency (CVID)F e. Chronic granulomatous disease (CGD)

7. Pathogenesis of Drug ReactionsT a. Untoward cutaneous responses can arise as a result of immunologic mechanisms.T b. Immunologic reactions require toward activation of host immunologic pathways and are designated as drug allergy. T c. Drug reactions occurring through nonimmunologic mechanisms may be due to activation of effector pathways, ovedosage, cumulative toxicity, side effects, drug interactions, metabolic alterations, exacerbation of preexisting dermatologic conditions or inherited protein or enzyme deficiencies. T d. Increase in molecular size is associated with increased immunogenicity.F e. Anaphylaxis is more common among oral medications than IV medications.

15. Extent of epidermal detachment in Stevens-Johnson Dyndrome:a. <5% body surface areab. <10% body surface areac. <15% body surface aread. <20% body surface area

1. A 60 year old male with a 50 pack year smoking history consults for chronic cough, hemophylis, weight loss and exertional dysnea. You consider lung cancer. Which of the following would be consistent with his case?

T a. A chest x-ray would likely reveal a lung lesion that is central in location.T b. The most likely histologic subtype is going to be squamouss cell carcinoma.F c. The histologic subtype plays in the most important prognostic factor in non-small cell lung cancer.F d. This patient will most likely benefit from anti-angiogenic agents added to systemic therapy.T e. The main etiology factor associated with every histologic subtype of lung cancer is cigarette smoking.

2. Clinical manifestations of lung cancer.T a. Hemoptysis is a manifestations of endobronchial tumor growth.F b. Symptoms of cough, hemoptysis, and stridor are examples of symptoms caused by peripherally growing lesions.T c. Shoulder pain, destruction of the 1st snd 2nd ribs, and involvement odf the 8th cervical and 1st and 2nd thoracic nerves are features of a Pancoast’s syndromes.F d. A Cushing-like sundrome is an uncommon paraneoplastic syndrome associated with adenocarcinomasT e. Non-small cell lung cancers have a predilection for causing metastatis but these don’t cause adrenal insufficiency.

3. A 66 year old female with adenocarcinoma of the lung is found to have a 6 x 5 cm tumor a the lower lobe of the right lung on the CT scan. Mediastinal adenopathy is detected as well as an enlarged right supraclavicular node. Liver and adrenals are free of tumor. Bone scan reveals multiple enhancing lesions at the thoracic and lumbar vertebrae.T a. The tumor may be labelled as T2F b. Mediastenal adenopathy makes this an N1 lesion.T c. The presence of palpable supraclavicular nodes makes this a N3 staged disease.F d. Because the liver and adrenals are free of tumor this can be labelled as MO.F e. A 5-year survival rate of > 40% is expected with systemic therapy even in the presence of abnormal bone scan.

4. Critical dates in a woman’s life that have a major impact on the incidence of breast cancer:T a. Age of menarcheF b. Age of marriageT c. Age of first full-term pregnancyF d. Age of first lactationT e. Age of menopause

5. In the evaluation of breast masses in women, which of the following is applicable?T a. In the absence of certain risk factors cannot be used to avoid the need for biopsy in women with palpable breast masses.F b. In a woman with palpable breast mass, MRI features are diagnostic and may avoid the need for biopsy.T c. Diagnostic mammography defines the procedure done after the discovery of a palpable breast mass in order to evaluate the rest of the breast prior to a biopsy.F d. In pregnant women, the occurrence of a dominant breast mass is most likely due to hormonal changes, thus avoiding the need for a biopsy.T e. Women whose biopsies reveal benign lesions without atypia have little risk of developing cancer.

6. Prognostic factors in breast cancer.T a. Tumor stageT b. ER and PR statusT c. Her 2 statusT d. S phase functionT e. Histologic grade

7. Risk factors in colorectal cancers.T a. Diet high in animal fatF b. Low fiber dietT c. Inflammatory bowel diseaseF d. Female sexT e. Lynch syndrome

8. Recommended screening procedures for colorectal cancer.F a. Digital rectal examT b. Feccal occult blood testT c. Flexible sigmoidoscopyF d. Abdominal CT scanF e. Whole body PET scan

9. Predictors of prognosis in patients with colorectal cancer.F a. AgeT b. Grade of the tumorT c. Depth of tumor invasionF d. EGFR mutation statusT e. Lymph node involvement

10. Clinical features of Gastric cancer.T a. Elderly patients have a history of chronic ulceration with the histopathology most likely an intestinal type of adenocarcinoma.F b. H. pylori increases the risk for gastric cancer by causing mutations in a critical set of tumour suppressor genes.F c. Dysphagia and early satiety are symptoms due to intestinal types of lesions that may involve the entire stomach.T d. Intestinal type lesions occur most frequently in the antrum and lesser curvative of the stomach.F e. The lung is the most common site of hematogenous spread.

11. Etiologic factors believed to be associated with esophageal cancer.T a. Chronic alcohol intakeT b. Radiation induced stricturesF c. Vitamin C deficiencyF d. Chronic intake of cold beveragesT e. Fungal toxins in pickled vegetables

12. Risk factors associated with Hepatocellular cancer.T a. Poor hepatitic cirrhosisT b. Ingestion of poorly stored grainsF c. Cigarette smokingF d. History of Hepatitis AF e. Juvenile diabetes mellitus

13. A 60 year oldmale alcoholic with a 2 week history of jaundice is noted to have a hard nodular mass on liver palpation. Serum AFP is 500 IU/L. with regards to his management , which of the following isapplicable?T a. The best procedure for evaluating tumor vascularity and size is a triphasis CT scan of the abdomen.T b. Pain is the most common presenting symptom in high risk areas of liver cancer.F c. an alpha feto protein level of > 1000 IU/L is diagnostic for HCC.F d. Radiofrequency ablation or ethanol injection can be very useful for tumor near the main portal areas.F e. The multikinase inhibitor Erlotinib has been found to improve median survival by 3 months in patients with advanced diseas.

14. The clinical presentation of pancreatic cancer.F a. Courvorsier’s sign involves a dilated portal vein in a patient with carcinoma of the pancreatic headT b. Pain is the most frequent symptom in patient’s with tumors of the pancreatic bodyF c. Elevated CA 19-9 levels are diagnostic of pancreatic cancer but carry no prognostic implications.F d. A detailed clinical staging evaluation provides important therapeutic and prognostic information in patients with advanced disease.F e. 5-fluorouracil + Folinic acid remain the initial combination of choice in patients with metastatic disease.

15. Clinical characteristics of renal cell carcinoma.T a. the proximal tubules are the most common sites of origin of clear cell carcinomas.F b. the strongest risk factor associated with tumor development remains a positive family history.F c. the classic triad of hematuria, flank pain, and flank mass can be seen in more than half of patients.F d. clear cell carcinoma is associated with the inhibition of the epidermal growth factor receptor gene resulting in tumor angiogenesis.T e. agents that inhibit angiogenesis may be useful in the management of metastatic disease.

16. Clinical characteristics of transitional cell cancers of the genito-urinary tract.T a. Polychromatropism, the ability to recur in new sites along the urothelial tract, is a common clinical manifestationT b. Smoking increases risk for developing urothelial carcinomas.T c. Once node positive disease is detected, the patientis labelled as having stage IV disease.F d. The bladder should be suspected as the most common site of microscopic hematuria.F e. In stage IV disease, cure may still be possible in the presence of visceral metastase.

17. Clinical manifestations of prostate cancer.F a. PSA screening is the main reason behind the marked decline in mortality rates.F b. Bicalumatide has been shown to improve survival in the chemo-prevention of prostate cancer.T c. PSA screening has resulted in treatment of many low-grade tumors that would otherwise not have been clinically significant.F d. Elevated PSA is diagnostic for the presence of prostatic carcinoma.T e. the main function of trans-rectal ultrasound is directing prostate biopsies rather than staging.

18. Risk factors for head and neck cancers.T a. Cigarette smokingF b. Age > 60 yearsT c. Low consumption of fruits and vegetablesT d. Human papilloma virusF e. Eat Asian race

19. Management of head and neck cancers.T a. Localized (T1 and T2) squamous cell cancer can be treated with surgery of RT with curative intentT b. Despite toxicity, concomitant chemo-RT has a better survival rate compared to sequential therapy in advanced disease.T c. Concomitant chemo-RT produces better survival rates and allows for organ preservation in advanced head and neck cancers compared to RT alone.F d. Concomitant chemo RT can produce similar benefits in patients with metastatic disease compared to chemotherapy alone squamous cell cancers.F e. Cis-retinoic acid can result in regression of leukoplakia and prevents occurrence of second primary sites.

20. Clinical features of ovarian cancer.T a. the use of oral contraceptives has been associated with a decreased risk of epithelial ovarian cancers.T b. pelvic pain is a common symptom of ovarian cancer and may help identify early stage disease.F c. screening with annual CA-125 determination is expected to improve survival and to identify early stage disease.T d. the most common type of epithelial ovarian tumors is the serous type.T e. prognostic factors for ovarian cancer include tumor stage, tumor grade and extent of residual disease after surgery

21. Clinical features of cervical cancer.T a. the most important etiologic agent is the venereal transmission of the human papilloma virusT b. PAP smear is capable of detecting up to 95% of early cervical lesionsF c. the presence of a mass in the cervix is the most common sign of cervical cancerF d. the presence of hydronephrosis immediately classifies a patient as having stage IV diseaseT e. Tumors that extend beyond the area of the true pelvis are labelled as stage IV disease

22. Paraneoplastic metabolic syndromes and their associated malignancies.F a. Hypercalcemia - OsteosarcomasT b. Cushing’s syndrome – Carcinoid tumorsT c. SIADH – Squamous cell CA, lungF d. Hypoglycemia –Adrenal medulla tumorsT e. Diarrhea – Pancreatic cancer

23. Paraneoplastic hemotologic syndromes and their associated malignancies.T a. Erythrocytosis – Renal cell cancerT b. Thrombocytosis – Lung cancerT c. Granulocytosis – Hodgkin’s lymphomaF d. Eosinophilia – Neuroendocrine tumorsT e. Thrombophlebitis – Breast cancer

24. Clinical features of malignant melanoma.T a. Adults have a higher risk for development compared to children.F b. well-defined boarders are more characteristic of melanoma than benign nevi. F c. The most important prognostic factor for melanoma is tumor size.T d. of the characteristics that can differentiate melanoma from other pigmented lesions, the weakest is diameter of the lesionF e. uniformly dark pigmentation is associated more than benign nevi.

2. What procedure would you advise to a 50 year old female who would want to undergo screening for breast cancer?a. Breast MRIb. Mammographyc. Self-breast examinationd. Self-breast + annual clinical breast exam

3. A 65 year old woman with breast cancer post-MRM was discovered on pathologic analysis to have a 4 x 3 cm tumor in her left breast. 7 of the 14 isolated axillary nodes are positive for malignancy. Liver US, chest x-ray and bone scan are all normal. What would her stage be?a. Ib. IIc. IIId. IV

4. In which of the following conditions would a biologic immune therapy be indicated as part of the adjuvant treatment of early stage breast cancer?e. Estrogen receptor positivef. Progesterone receptor positiveg. Her2/neu receptor positiveh. Triple negative

5. Which of the following signs or symptoms is the result of a peripherally located tumor in lung cancer?a. Clubbingb. Pleuritis chest painc. Hemoptysisd. Facial edema

6. Which situation would argue strongly for proceeding with the resection of a asymptomatic pulmonary nodule?e. Male sexf. Presence of calcification on chest x-rayg. Stable findings on serial chest x-rayh. Presence of atelectasis

7. In which of the following situations is curative surgery or radiotherapy no longer possible in a patient with non-small cell lung cancer?i. A 5 cm tumor 4 cm from the carinaj. N1 nodal involvementk. Ipsilateral mediastinal node involvementl. Paralysis of the vocal cords

8. Which of the following is an acceptable strategy for chemotherapy in advanced non-small cell lung cancer?a. Patients with good performance status should be treated with single agentsb. Non-platinum doublets are the new standard of care in these situationsc. Cisplatin or carboplatin remains a standard component of doublet chemotherapyd. The concomittant administration of tyrosine kinase inhibitors with standard

chemotherapy is superior to either used alone

9. Which of the following is a recognized risk factor of carcinogen for salivary gland cancer?e. Cigarette smokingf. Alcohol intakeg. Human papilloma virush. None identified

10. Which of the following is recognized as an acute toxicity of RT in head and neck cancers?i. Mucositisj. Immobilization of the tonguek. Loss of tastel. xerostomia

11. Which of the following subtypes is the most aggressive in melanoma?a. Desmoplasticb. Acral lentiginousc. Nodulard. Lentigo maligna

12. Which of the following is considered a standard form of therapy in metastatic melanoma?e. Dacarbazinef. Interferong. Cisplatinumh. Interleukein-2

13. Which of the following is consistent with a more aggressive type of basal cell cancer?i. Superficial subtypej. Small lesionsk. Located on the scalpl. Pigmented lesions

14. What is an expected response of tumor blood vessels to treatment with bevacizumab, a potenta anti-VEGF monoclonal antibody?a. Inhibition of dendritic cell actionb. Inhibition of vascular permeabilityc. Growth of dilated and leaky vesselsd. Sprouting of endothelial cells from host vessels

15. Which of the following is important in enhancing the efficacy of radiation against cancer cells?e. Coldf. Heatg. Oxygenh. Iron

16. In which of the following tumors is cure still possible with chemotherapy even in an advanced stage of the disease?i. Endometrial cancerj. Testicular cancerk. Breast cancerl. Follicular lymphomas

17. Which of the following is an example of a biologic form of therapy?a. Aromastase inhibitorsb. Interferonc. Anti-tumor antibioticsd. gefitinib

18. In which of the following conditions would routine G-CSF prophylaxis against febrile neutropenia be required during the first cylce of chemotherapy?e. Conventional dose regimenf. Performance status of 3g. Age of 50 years h. Adjuvant chemotherapy for breast cancer

19. Hyponatremia as a paraneoplastic syndrome may be seen in which of the following?i. Renal cell cancerj. Rhabdomyosacomak. Small cell lung cancerl. Non-Hodgkin’s lymphoma

20. Eosinophilia is a paraneoplastic syndrome usually associated with which of the following?a. Gastric cancerb. Breast cancerc. Lymphomasd. Paancreatic cancer

21. Which of the following sarcomas arises from the interstitial cells of Cajal and are dependent on the c-kit oncogene for malignant transformation?e. Leiomyorsarcomef. Primitive neuroectodermal tumorg. Gastrointestinal stromal tumorh. Ewing’s sarcoma

22. Which of the following is a known characteristic of metastatic bone lesions?i. Osteolytic lesions have a higher incidence of hypercalcemiaj. Osteolytic lesions produce higher levels of serum alkaline phosphatasek. Osteoblastic lesions are best diagnosed by plain radiographsl. Osteoblastic lesions are associated with the elaboration of parathyroid hormone related

peptides

23. An 80 year old female is diagnosed to have peritoneal carcinomatosis from an epithelial ovarian cancer. Which of the following is the best treatment option?a. Paclitaxel-platinum combinationb. Intraperitoneal chemotherapyc. Pelvic exanteration followed by chemo-RTd. Targeted agents

24. Which of the following is a known risk factor for endometrial cancer?e. Multiple partnersf. Multiparityg. Obesityh. Late menarche

25. Which of the following is the molecular target of the E& protein of HPV 16 which may results in the development of cervical cancer?i. P53j. Rbk. Bcl-2l. K-ras

26. According to the American Cancer Society guidelines, when should PAP smear screening begin?a. Menarcheb. After the 1st pregnancyc. After the 1st live birthd. Start of sexual activity

27. In which situation should SVC syndrome be considered a true medical emergency?e. Facial edemaf. Jugular vein engorgement g. Dyspneah. dysphagia

28. What is the most common location of esophageal adenocarcinomas?i. Oropharyngeal portionj. Upper thirdk. Middle thirdl. Lower third

29. A 75 year old male, chronic smoker, is diagnosed to have an unresectable esophageal cancer and complains of severe dysphagia and anorexia. What is the most promising management approach?a. Radiotherapyb. Chemotherapy + RTc. Endoscopic laser therapyd. Repeated endoscopic dilatation

30. Which of the following is consistent with the intestinal type of gastric adenocarcinomas?e. Found mostly in the cardiaf. Presents as linitis plasticag. Ulcerative in presentationh. Usually seen in younger patients

31. Which of the following represents a pre-malignant lesion of colorectal cancer?i. Hamartomaj. Hyperplastic polypk. Adenomatous polypl. Juvenile polyp

32. Which of the following is a characteristic of tumors of the right side of the colon?a. Obstructive symptoms are prominentb. Lesions tend to ulcerative and largec. Hematochezia is often presentd. Changes in stool character are very common

33. Which of the following predicts a poor outcome for patients with colorectal cancers?e. Tumor extends to the muscularis mucosaf. Well-differentiated histologyg. Regional lymph node involvement h. EGFR gene amplication

34. What is the most common symptom of hepatocellular cancer?i. Jaundicej. Abdominal enlargementk. Abdominal painl. Weight loss

35. A 57 year old male is diagnosed to have an unresectable hepatocellular carcinoma. Which therapy can achieved the best quality of life?a. Systemic chemotherapyb. Transanterial chemo-embolizationc. Sorafenibd. Regional hyperthermia

36. Compared to cholanciocarcinomas of the biliary tract, which feature is more consistent with tumors of the Ampulla of Vater?e. Jaundice is more common in ampullary tumorsf. Adenocarcinomas are more common in cholangiocarcinomas.g. Cholangiocarcinomas produce higher elevations in CA 19-9 levels.h. Tumors of the ampulla tend to be resectable on initial diagnosis.

37. Which of the following is a clinical characteristic of advanced pancreatic cancer?i. Obstructive jaundice is a common manifestation of tumors of the bodyj. Pain is the most common presenting symptom, regardless of tumor sitek. Tumors of the head tend to be diagnosed later than those of the bodyl. Neuroendocrine tumors are the most common pathologic type

38. Which of the following treatments would give the best survival advantage in the management of advanced, unresectable pancreatic cancer?a. Endoscopic biliary stentingb. Complete or partial tumor debulkingc. External beam radiotherapyd. Gemcitabine-based chemotherapy

39. What is the characteristic of urothelial tumors associated with their tendency to recur over time and in new places in the urothelial track?e. Phenotypic heterogeneityf. Predeterminationg. Peri-epithelial migrationh. polychronotropism

40. Inactivation of which gene can result in the overexpression of factors that promote both tumor growth and angiogenesis in renal cell cancers?i. Von Hippel-Landau j. P53k. Epidermal growth factor receptorl. Vascular endothelial growth factor receptor

41. Which among the following has led to an improved 5 year survival for patients with early stage renal cell carcinoma?a. Widespread use of urinalysis as work up for hematuriab. Incidental detection on imaging during work up for other conditionsc. Improved screening procedures for renal cell carcinomad. Development of molecularly targeted therapies

42. Which of the following would be the best reason for performing a nephrectomy in patients with metastatic renal cell cancer?e. Obtain tissue for molecular analysisf. Control of pain and hematuriag. Improve survival when followed by systemic therapyh. Patient is unable to tolerate external beam RT

43. Which strategy can improve the diagnostic accuracy for prostate cancer in men with PSA values between 4 and 10 ng/mL?a. PSA densityb. Free PSAc. PSA velocityd. PSA ratios

44. Which procedure can be best diagnose the presence of prostatic cancer?e. Digital rectal examf. Serial PSA determinationg. TRUS guided core needle biopsyh. CT scan or MRI combined with “free” PSA

45. What is the management of prostate cancer patients with non-castrate metastatic disease who refuse orchiectomy?i. Gonadrophin-releasing hormone analoguesj. Diethystilbesterolk. Non-steroidal anti-androgensl. Taxane-based chemoptherapy

46. Which tumor marker can differentiate a pure seminoma from a non-seminomatous germ cell tumor?a. Lactic dehydrogenaseb. Human chorionic gonadotrophinc. Alpha-feto proteind. CA 125

47. For non-seminomatous germ cell tumors, in which situation would prognosis be the worst?e. Mediastinal primary sitef. AFP level of 1000 ng/mLg. LDH of 3x upper limit of normalh. Presence of pulmonary metastasis

1. A 45 old premenopausal woman consults because of a palpable, non tender mass in her left breast. Which procedure will definitely reveal a malignancy?i. Mammographyj. Ultrasonographyk. Breast MRIl. Breast biopsy

2. A 55 year old male, chronic smoker, is diagnosed to have small cell cancer and undergoes routine staging exams. Which of the following results would label his disease as extensive-stage?a. 5 cm primary tumor in the right hilar areab. Contralateral hilar lypmh nodec. Palpable right supra clavicular noded. Pericardial tamponade

3. In a 70 year male diagnosed with a squamous cell carcinoma of the head and neck, which condition would be consistent with an early stage tumor?e. A 3.5 cm cprimary in the oropharynxf. Tumor involvement of the thyroid cartilage in primaries of the hypopharynxg. Bilateral cervical lypmh node metastases in eitherh. Supraclavical node inlvolvement in either

4. Which of the following represents a therapeutic application of the concept of oncogene addiction?a. Interferon in the treatment of metastatic melanomab. The use of imatinib in the treatment of Ph+ chronic myeologenous leukemiac. Sorafenib in the treatment of metastatic renal cell cancerd. Bortezonib in the treatment of multiple myeoloma

5. A 65 year old female with adenocarcinoma of the lung is prescribed Gefitinib. She asks you what type of side effects to expect. Which of the following would you mention? e. Skin rashf. Nausea and vomitingg. Protenuriah. Hand-foot syndrome

6. A 19 year old male with a 10 cm mass at the right distal tibia is diagnosed to have osteosarcoma. His metastatic work-up reveals a 1 cm mass in the lower lobe of the left lung on chest CT. he receives 3 cycles of doxurubicin-based chemotherapy followed by a successful limb-sparring operation. Post-op histopathologic analysis reveals a tumor necrosis of 95%. Which features of his case would be the strongest determinant of his overall prognosis?a. 10 cm right distal tibia massb. 1 cm mass in lower lobe of the lungc. Successful limb-salvage procedured. Tumor necrosis of 95% after chemotherapy

7. A 55 year old male with a mediastinal mass is diagnosed to have small cell lung cancer. He complains of cough, facial edema, anorexia, and weight loss but denies dyspnea or orthopnea. What is your treatment of choice?e. Corticosteroidsf. Diureticsg. Radiotherapyh. chemotherapy

8. A 60 year old male diagnosed with gastric cancer and with an ECOG of 1 is discovered to have three solid liver masses on CT of the abdomen, largest measuring 3cm. His main problem is his inability to eat. What would you recommend?a. Surgical debulking of the primaryb. Radiation therapyc. Systemic chemotherapyd. Combined chemotherapy and RT

9. A 75 year old male with transitional cell cancer of the urinary bladder consults for treatment. Abdominal CT shows a 9cm bladder mass with enlargement of multiple regional nodes. Chest scan is clear but bone scan is positive for metastasis to pelvic and L1-4 vertebrae. Although complaining of low back pain, he is still able to perform activities of daily living without assistance. Which of his clinical presentations would negatively impact on survival?e. Perfromance statusf. Ageg. Metastasis to adjacent nodal regionsh. Multiple bone metastais