ILOCOS TRAINING AND REGIONAL MEDICAL CENTER

DEPARTMENT OF INTERNAL MEDICINE

JUNIOR INTERNS’ EXIT EXAMINATION

NAME: _____________________________________________________________ DATE: ________________________

SERVICE: ________________ SCORE: _______________________

A 53-year old man with diabetes presents to the emergency department for the evaluation of fever. He was in his usual state of health until 36 hours ago, when he
developed fever and fatigue; these symptoms were followed by productive cough. Over the past few hours, he has developed worsening shortness of breath, cough
and dizziness. He has had diabetes mellitus for many years, and he states that he has not seen a physician in 12 months. On physical examination, the patient is
tachycardic and tachypnic. His blood pressure is 90/40 mmHg, he is orthostatic, and his temperature is 39.3 oC. O2 saturation is 88% on room air. The patient has
rales and dullness to percussion at the right pulmonary base. Chest X-ray reveals a right lower lobe infiltrate. Laboratory data reveal a leukocytosis with a left shift, as
well as mild renal insufficiency.

_________1. Which of the following statements regarding CAP is true?

a. Bacterial pneumonia is principally spread from person to person
b. The inflammatory response to S. pneumonia or H. influenza often produces a lobar consolidation and significant tissue necrosis
c. For patients who do not require hospitalization, advanced macrolides, doxycycline, and respiratory fluoroquinolones are reasonable choices for therapy
d. For patients with HAP, advanced macrolides, vancomycin, or doxycycline will suffice as monotherapies

_________2. What is your Complete Diagnosis in this case?

_________3. Give an appropriate antibiotic for use in CAP-LR
_________4. Give an appropriate antibiotic for CAP-MR

A young woman presents to our clinic with concerns about HIV infection because of previous I.V. drug abuse. Results of ELISA and Western Blot are positive for HIV.

_________5. Which of the following statements is true regarding the classification of this patient’s infection?
a. If she is not treated for her HIV infection and gradually develops low CD4+ count with clinical manifestations of HIV, she has chronic infection
b. If she is not treated for her HIV infection and gradually develops low CD4+ count without clinical manifestations of HIV, she has latent infection
c. If she receives anti-retroviral therapy and maintains an elevated CD4+ count but maintains low but detectable plasma levels of HIV-1 RNA, she has
persistent infection
d. If she receives anti-retroviral therapy and achieves an undetectable level of HIV-1 RNA, she has latent infection
e. If she is also co-infected with HTLV-1 and develops manifestations of 40 years later, she can be said to have had chronic infection

_________6. What is the screening test for HIV infection?

_________7. Give a confirmatory test for HIV infection?
A 27-year old man presents to your clinic with what he describes as a cold. During the interview, the patient notes that he has had unprotected heterosexual
intercourse, and he is worried about contracting HIV. He asks you how the virus is transmitted.

_________8. Which of the following is not a mode of transmission of HIV?

a. Heterosexual intercourse; anal or oral-genital sexual intercourse
b. Transmission from mother to child during gestation or delivery or during breastfeeding
c. Sharing of needles when injecting drugs
d. Needle-stick injuries
e. Exposure of intact skin to contaminated blood products

_________9. What is the syndrome associated with full-blown symptomatic HIV infection?
________10. True or False: HIV is included in routine screening for blood donors prior to blood letting.

A 25-year old man presents to your office seeking to establish primary care. The patient has no complaints and denies any known medical history. His blood pressure
is noted to be 180/110; otherwise, his physical examination is normal. After measuring the patient’s blood pressure a total of four times during two office visits, you
diagnose hypertension.

_________11. Which of the following statements regarding the initial evaluation of hypertension in this patient is true?
a. A retinal exam should now be performed on this patient
b. Because this patient has been diagnosed with hypertension, obtaining a family history of hypertension of early CV is no longer useful
c. During the initial examination, only a single careful blood pressure measurement is needed
d. This patient has no findings consistent with secondary hypertension.

_________12. Give a diagnostic test used to evaluate patients with HPN as part of initial assessment.
_________13. Give a disease tested for as part of initial evaluation for in cases of HPN.

A 55-year old man presents to establish primary care. His medical history is significant only for 40 pack-years of smoking. He drinks four beers a night. He is
minimally physically active. On physical examination, the patient’s blood pressure is 150/90 mmHg and he is moderately obese (BMI, 27); the rest of his examination
is normal. His laboratory examination, including blood chemistry, CBC, TSH, and Urinalysis, is normal, as is his ECG. Repeated blood pressure measurements over the
next month are similar to the values first obtained.

_________14. With respect to this patient’s blood pressure, what therapeutic option should be offered to this patient now?
a. No treatment
b. Continued monitoring for 6 months
c. Lifestyle modifications, including decreased alcohol consumption, weight loss, smoking cessation, and moderate exercise for 6 months
d. Pharmacologic therapy
_________15. Given the above case, what sound advice will you give the patient regarding HPN and prevention of complications.

A 72-year old woman comes to see you to establish care, after her previous physician retired. Her medical history is significant for diet-controlled diabetes and a
myocardial infarction. She is taking Aspirin, Simvastatin, and Amlodipine. On examination, her blood pressure is 170/90 mmHg. She has an S4 gallop and a +1
pretibial edema.

_________16. What should be the target blood pressure in the long term for this patient?
a. <150/90 mmHg
b. <140/90 mmHg
c. <130/85 mmHg
d. <120/70 mmHg

_________17. What is the current guideline being used in the clinical setting for the diagnosis and evaluation of patients with HPN?
_________18. Give an example of medication used as initial treatment in cases of HPN.
_________19. What is the blood pressure cut-off used to diagnose HPN Urgency?
_________20. What is a necessary component required in order to diagnose HPN Emergency?

A 38-year old woman presents with symptoms of recurrent so-called yeast infection. Over the past 2 years, she has had repeated episodes of similar infections that
have only partially responded to OTC treatments. She has not seen a physician in over 10 years since her last pregnancy and denies knowledge of any major medical
illness. She has been moderately obese for the most of her adult life; her maximal weight was 234 lbs, although she recently lost 9 lbs. She reports that she has had
nocturia for the past several months. Physical examination is remarkable for blood pressure of 140/90, obesity, and findings consistent with vaginal candidiasis.

_________21. Which of the following would be the most useful test for diagnosing DM in this patient?
a. Immediate measure of blood glucose concentration
b. Determination of hemoglobin A1C level
c. A 50g oral glucose tolerance test
d. Measurement of glucose after an overnight fast
e. A 100g oral glucose tolerance test

_________22. Give a medication used as initial treatment in the management of newly diagnosed DM patients in the OPD setting.
_________23. Give one type of Hyperglycemic Crisis.
_________24. Give one treatment strategy used in the management of Hyperglycemic Crisis.

A 57-year old woman with hypertension, mitral valve prolapse with regurgitation, asthma and a history of alcoholism presents to your office for consult. Because the
patient has hypertension, you order a basic metabolic profile and urinalysis as part of your initial evaluation. The laboratory call you to notify you that the patient’s
serum creatinine level is 2.3 mg/dL.
_________25. Which of the following statements regarding CKD is true?
a. CKD is defined as a GFR of <30ml/min/1.73m2 for longer than 3 months
b. Persistently increased proteinuria in the setting of normal or increased GFR signifies the presence of stage 1 CKD
c. Measurement of 24-hour creatinine clearance to assess GFR is more accurate than estimating GFR from the Modified Diet in Renal Disease equation
d. Treatment of comorbid conditions, interventions to slow progression of kidney disease, and measures to reduce cardiovascular disease should begin
during stage 3 CKD

_________26. What is the gold standard of treatment in cases of ESRD?

_________27. Give an example of a medication used in managing the complications of ESRD in the outpatient setting.
_________28. Give a diagnostic usually requested during follow-up of ESRD patients.

A 21-year old man is admitted in the hospital. The patient reports that while jogging earlier that day, he developed acute right anterior chest pain that significantly
worsened by deep inspiration. His pain radiated to his left scapula. He also developed moderate shortness of breath. He denies having any fever or chills; he has not
experienced any recent immobility, and he has no personal or family history of clotting disorders. The patient has smoked one pack of cigarettes a day for the past 3
years. Chest X-ray is normal except for a large left pneumothorax.

_________29. Which of the following statements regarding idiopathic spontaneous pneumothorax is true?
a. The peak incidence occurs in persons between 30-50 years of age; there is a strong female preponderance
b. Patients are often tall and thin in stature and are often cigarette smokers
c. Most patients with idiopathic spontaneous pneumothorax have subpleural basilar blebs
d. Strenuous physical activity and airplane travel triggers for the development of idiopathic spontaneous pneumothorax

_________30. What type of Pneumothorax can lead to sudden lung collapse and shifting of mediastinal structures necessitating immediate emergency treatment?
_________31. Give a treatment modality used in the management of patients with pneumothorax.

A 55 year old man visits your clinic with a complaint of fatigue and increasing dyspnea on exertion. He has been experiencing these symptoms for 2 weeks. He denies
having fever, chills, cough, or weight loss, and he has no significant cardiac history. He denies having been in contact with anyone who was ill. He recently quit
smoking, after having smoked cigarettes for 35 years. He does have a history of alcoholism, and chronic pancreatitis; the pancreatitis has been well controlled with
analgesics and pancreatic enzyme replacement therapy. His serum blood chemistry and CBC are unremarkable. A chest x-ray reveals a large left pleural effusion. A
diagnostic Thoracentesis is performed.

_________32. Which of the following statement regarding laboratory studies of pleural effusion is true?
a. An elevated pleural fluid amylase level is uncommon in patients with malignant pleural effusion
b. Pleural fluid eosinophilia is diagnostic of pulmonary parasitic infection
c. A pleural fluid hematocrit that exceeds half the simultaneous peripheral blood hematocrit indicates frank bleeding into the pleural space and is diagnostic
of hemothorax
 d. A pleural effusion with a pH of 5.8 is suggestive of empyema

_________33. What criteria is used in differentiating exudative from transudative pleural effusion?
_________34. Give a treatment modality employed in the management of recurrent pleural effusion.
_________35. Give an etiologic agent or pathologic process that can lead to recurrent pleural effusion.

A 53-year old man presents to the emergency department with a complaint of chest pain of 2 hours duration. The pain woke him up from sleep. It is substernal and
radiates to the left shoulder. The patient has vomited twice and is diaphoretic. He has no history of coronary artery disease but has hypertension and
hypercholesterolemia,

_________36. Which of the following statements regarding AMI is false?

a. The presence of stenosis (i.e. > 70% of the diameter of the artery) , as seen on coronary angiography, correlates well with the most vulnerable sites for
plaque rupture and occlusion of the artery
b. Within 10 mins of arrival at the emergency department, a patient with symptoms suggestive of an MI should be evaluated; subsequently the patient
should be evaluated with a 12-lead ECG, and oxygen, Aspirin administered
c. Morphine Sulfate is acceptable for pain control in a patient with acute MI
d. In the 2nd International Study of Infarct Survival (ISIS-2) trial, Aspirin was found to be nearly as effective as Streptokinase in reducing 30-day mortality

_________37. What classification system is used to grade ACS-STEMI as to severity taking into account accompanying symptoms?
_________38. What is the treatment modality of choice for cases of ACS-STEMI brought to the emergency facility within a few minutes after the onset of chest pain?
_________39. What is the minimally invasive procedure used in cases of chest pain refractory to conventional therapies in lieu of CABG?
_________40. Give an example of low-molecular weight heparin used in the medical management of ACS.

A 27-year old student was recently brought to the emergency department complaining of severe myalgia, fever and decreased urine output. A few days prior to
admission, the patient had a history of swimming in the local creak after playing basketball. On examination, the patient had icterisia, jaundice, pronounced calf pain
and RUQ tenderness. Urine output was recorded at <5cc/hr.

_________41. What is your initial assessment of the case?

_________42. What treatment modality will you advise the patient to undergo given his symptomatology?

A 42 year old man with a history of wheezing and shortness of breath is referred to your pulmonary clinic for management of asthma. The diagnosis of asthma was
apparently based on pulmonary function testing.

_________43. During an episode of airflow obstruction, which of the following findingswould be specific for a diagnosis of asthma in this patient?
a. Depressed diffusing capacity of the lung for carbon monoxide (DLCO) on PFT
b. A normal alveolar-arterial difference in oxygen (A-aDO2) gradient
c. Improvement after administration of an inhaled bronchodilator
d. Improvement after administration of corticosteroid
 e. The episode is associated with ingestion of a non-steroidal anti-inflammatory drug

_________44. What class of drugs are considered controllers of bronchial asthma?

_________45. Give an example of trigger for asthma exacerbation.

A 57-year old patient who smokes cigarettes presents with chronic productive cough and persistent progressive exercise limitation that is a result of breathlessness.

_________46. For this patient, which of the following statements is true?

a. Significant airway obstruction occurs in only 10-15% of people who smoke
b. The best tool for assessing the severity of obstruction is the ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC)
c. Chronic bronchitis is a clinical diagnosis defined as the presence of cough and sputum production on most days for at least 3 consecutive months in a
year
d. Measurements of lung volumes in patients with chronic airway obstruction uniformly reveals an increased residual volume an a decreased functional
residual capacity

_________47. Give an example of inhaled medication used at the onset of diagnosis of COPD.
_________48. What supportive management has been proven to be effective and prolong survival in cases of COPD

A 26-year old female comes to your clinic complaining of recurrent epigastric pain, intermittent, burning in character for the past 2 years. She is a non-smoker, non-
alcoholic beverage drinker but enjoys eating spicy foods. She works as a nurse and admits to skipping meals during night shift duty. She seeks advice regarding
possible endoscopic procedure to diagnose the presence of peptic ulcer disease.

_________49. What is the most common bacterial etiologic agent identified in many cases of peptic ulcer disease?
_________50. What screening test is used to determine the presence of this bacterium?