NMS Q&A Family Medicine

104 NMS Q&A Family MedicineExamination Answers1. The answer is B. When the pulse rate drops by about25%, or generally, 55–56 BPM, the therapeutic goal hasbeen reached for reduction of the chances of bleedingfrom esophageal varices in a case with cirrhosis. Thus,reduction of cardiac output appears to be the determiningfactor in such prevention. None of the other objectivescan be reached through the use of beta-adrenergicblocking agents, and, of course, elevation of blood pressurecarries no saving grace.2. The answer is A. Glucocorticoid toxicity is outrankedby the other choices as a cause of steatohepatosis. Themain causes are, in descending order, alcoholic liver diseaseand obesity roughly 28% each; diabetes and hypertriglyceridemia,about 14% each; the remaining 15% to16% are distributed among the treating drugs, glucocorticoids,amiodarone, diltiazem, tamoxifen, and others;Cushing syndrome, hypopituitarism, obstructive sleepapnea, and so on. Virtually all obese alcoholics have fattylivers. As the metabolic syndrome consists of prediabetes,diabetes, and dyslipidemia (in addition to hypertension),differentiation among those main causes must necessarilybe somewhat arbitrary. In any event, the top four sourcesof steatohepatosis are major health conditions and mustbe ruled out forthwith after the finding of fatty liver.3. The answer is C. 10 g (actually 9.8 g or 140 mg/kg) isdefined as the single toxic dose of acetaminophen. This isbased on the classic estimate of average human size 70 kgperson, which is likely outdated, so that the average toxicsingle dose may be higher. Be that it may, this is astoundingconsidering that the therapeutic dose (single dose asopposed to daily dosage ) range is 10 to 15 mg/kg, whichwith five doses or 75 mg/kg amounts to more than 5 g perday in a 70-kg person. Considering that patients withnonlethal illnesses such as chronic low back pain are notinfrequently prescribed hydrocodone 5 mg/acetaminophen500 mg (e.g., Vicodin 5/500) 2 pills 4 times per day,thus may reach the maximum safe dosage daily forextended periods. For smaller people, such as women, thetoxic dosage will be lower.4. The answer is E. HBsAg positive, anti-HBc positive,IgM anti HBc negative, anti-HBs negative denote the carrierwith chronic infection. Such a patient is probably acandidate interferon therapy. The other choices have thefollowing meanings: (A) HBsAg negative, anti-HBc negative,anti-HBs negative denotes the unexposed state, acandidate for vaccination; (B) HBsAg negative, anti-HBcpositive, anti-HBs negative yields multiple interpretations;(C) HBsAg negative, anti-HBc negative or positive,anti-HBs positive denotes immune status; (D) HBsAgpositive, anti-HBc positive, IgM anti-HBc positive, anti-HBs negative denotes the acutely infected state; HBsAgnegative, anti-HBc negative, anti-HBs negative signifiessusceptibility to hepatitis B because both types of antibodyare absent while surface antigen is absent as well.HBsAg negative, anti-HBc negative, anti-HBs positive signifiesimmunity through HB vaccination (the vaccinefunctions to produce antibodies to surface antigen but notto core antigen). HBsAg positive, anti-HBc positive, IgManti-HBc negative, anti-HBs negative signifies chronicinfection (core antibodies present, IgM antibodies absentbut surface antigen also present). HBsAg positive, anti-HBc positive, IgM anti-HBc negative, anti-HBs negativesignifies chronic HB infection.Finally, not among the choices, HBsAg negative, anti-HBc positive, anti-HBs negative may have four interpretations:(a) patient may be recovering from acute infection;(b) patient may be distantly immune (testing may missvery low levels of anti-HBs); (c) patient may be susceptiblebut exhibit a false-positive anti-HBs; and (d) theremay be undetectable levels of HBsAg and the patient acarrier.5. The answer is C. HBeAg correlates with a high degreeof viral replication. Conversely, HBe antibody correlateswith a low rate of replication. HBV DNA also correlateswith replication and is used to monitor response to therapyfor HPV infection, especially in cases where there hasoccurred an HBeAg mutant.6. The answer is D. The pattern test results given showno evidence of hepatocellular disease, absence of HBsAg,and positivity of HBc and HBs antibodies, indicatingimmunity from past infection. No precautions are indicatedregarding hepatitis B. Recombinant alpha-2b isemployed in chronic active hepatitis.7. The answer is B. Alpha-fetal protein is a marker forhepatoma (hepatocellular carcinoma). Carcinoembryonicantigen is best used for follow-up of progress for treatedcolorectal carcinoma; the BRCA1 gene is a marker forinherited tendency for breast cancer; human chorionicgonadotropin is a marker found in choriocarcinoma andtesticular cancer; prostate-specific antigen is a marker forfollow-up of prostate cancer. Not any of these markers areperfectly specific, and thus, they are best applied for followingthe progress of the cancer once diagnosed and treated.8. The answer is D. Ultrasound of the liver should not bedone until the factors included in the other choices have