Questions 1-5

1. A 55 year old man comes to the clinic because he thinks he has diabetes.  He is always thirsty and has to wake up multiple times to urinate at night.  Which of the following can be used to definitively diagnose him?

A. A fasting glucose of 135 mg/dL

B. microalbuminuria

C. HLADR3 genotype

D. non-fasting glucose of 210 mg/dL

2. A 13 year old boy is brought in by his mother because she thinks he has asthma.  He has "spells" where he can't catch his breath about 2 times per week.  She says has been getting worse since over the last week, and he has woken up coughing 3 times.  Upon examination, wheezes are heard bilaterally.   What is the most appropriate treatment?

A. Albuterol PRN

B. Low dose inhaled corticosteroid + Albuterol PRN

C. Medium dose inhaled corticosteroid + Albuterol PRN

D. Leukotriene modifiers + Albuterol PRN

E. Low dose inhaled corticosteroir + leukotriene modifiers

3. What is the next most appropriate step for the patient in question 2?

A. referral to a pulmonologist

B. allergy testing

C. admission

D. immediate nebulizer treatment with Albuterol

4.  What is the target LDL for a tobacco-free 48 year old male with BP of 125/90 controlled by HCTZ, BMI of 22, and a negative family history for CAD?  Recent lab values are as follows: LDL=150, HDL=39, glucose=114.

A. <160 mg/dL

B. <130

C. <100

D. <70

5. Observation without treatment for uncomplicated acute otitis media is appropriate in which age group?

A. >6 months old

B. >1 year old

C. > 2 years old

D. all of the above

E. none of the above

Answers 1-5

1. D  If a patient has symptoms, they can be diagnosed with a random plasma glucose level of ≥ 200mg/dL.  A fasting glucose of ≥ 126 mg/dL must be repeated to diagnose a patient.  HLADR3 and DR4 are associated with type I diabetes.  Microalbuminuria is commonly seen in diabetes and indicates the use of an ACE inhibitor to prevent diabetic nephropathy.

2. B  This boy has symptoms of Intermittent Asthma (2 episodes per week) and Mild Peristent Asthma (≥ 3 awakenings at night).  Therefore, he has Mild Persistent Asthma.  Answers A, B, and C are the treatments for Intermittent, Mild Persistent, and Moderate Persistent asthma, respectively.  Answer D is used to treat exercise induced asthma.

3. B  He is in no acute distress, so it is safe to send him home with his new medications.  Allergies account for the vast majority of asthma attacks, so allergy testing is the most appropriate next step.

4. C  This man has at least 3 risk factors: hypertension, age >45, and HDL<40.  Therefore, his LDL should be kept below 130mg/dL.  If he had known CAD, DM, TIA, stroke, AAA, or peripheral vascular disease, his LDL should be kept below 70.

5. C  Observation is appropriate if the child is 2 years old.  Observation can be appropriate in children 6 months to 2 years old if the diagnosis is uncertain.  In children under 6 months, always treat, even if the diagnosis is uncertain.  The first line treatment is amoxicillin.  If that fails, a third generation cephalosporin like cefdinir is appropriate.

Questions 6-10

6.  A 58 year old woman presents with jaundice and joint pain.  On physical examination, you notice mild ascites, edema, and splenomegaly.  She appears hyperpigmented.  A fasting blood sugar is 150.  mg/dL.  Which of the following explains the fundamental cause of this heritable condition?

A. the lack of transferrin within the hepatocyte

B. damage to mitochondria within the hepatocyte

C. Kupffer cell dysfunction

D. inadequate binding of transferrin to its receptor on intestinal cells

E. overproduction of ferritin by hepatocytes

7. A 5 year old boy comes to the clinic for recurrent epistaxis (nosebleeds).   He has a positive family history for Osler Weber Rendu disease.  What else would be expected in this patient?

A. cutaneous vascular malformations

B. arterovenous malformations (AVMs) in the brain

C. positive guiac test

D. all of the above

8. A 5 year old boy is seen by his pediatrician for a cold.  He has a history of multiple bacterial and viral respiratory tract infections and eczema. Non-palpable purpura are on his skin. Serum IgE is normal, IgM is decreased, and platelets are decreased.

Which of the following is the most likely diagnosis?

  A. SCID   

  B. Ataxia telangiectasia            

  C.  DiGeorge syndrome            

  D. Selective IgA deficiency     

  E. Wiskott-Aldrich syndrome  

9.  Over the course of 2 days, a 6 month old develops puffiness around the eyes, which then spreads over the entire body.  Her UA reveals 4+ proteinuria.  The most likely cause is

A. poststrep glomerulonephritis

B. minimal change disease

C. marasmus

D. kwashiokor

Answers 6-10

6. Answer D   This is the classic "bronze diabetes," or primary hemochromatosis, which is caused by a defect in HFE (or hereditary hemochromatosis gene) which helps plasma transferrin to bind with its receptor on intestinal cells, where it is endocytosed.  Defective HFE results in a buildup of iron in the liver, as well as other sites such as the pituitary, joints, heart, and skin.  In women, symptoms may not present until after they stop losing iron through menstuation.

7. Answer D  Osler Weber Rendu, or Hereditary Hemorrhagic Telangiectasia presents with recurrent nosebleeds, cutaneous vascular malformations, and AVMs in the brain and lungs.  It is an autosomal dominant disease.

9. Answer B  Since the baby has anasarca, or generalized edema, she likely has nephrotic syndrome.  This is most commonly from minimal change disease in children.  Post streptococcal glomerulonephritis is nephritic.  Both marasmus and kwashiokor would take more that 2 days to develop.

Abbreviations:

DM Diabetes Mellitus

CAD coronary artery disease

AAA abdominal aoric aneurism "triple A"

TIA transient ischemia attack