Top 10 most difficult questions from Elixir Daily Tests

- June 1st Week

1) A 65-year-old woman presents to her physician for check up. She has a history of high
blood pressure and gout. She takes lisinopril, amlodipine, and allopurinol and has been
stable on them. The patient's diet mostly consists of fruits and vegetables. She has
smoked 1 pack of cigarettes daily for the past 35 years and has been trying to reduce it.
She is to undergo colonoscopy today as part of her colon cancer screening and she
wanted to get tested for baldder cancer as well. What is the most appropriate response to
this query? [Surgery]

A. Screening for bladder cancer is not advisable

B. Screening should be done now because of her smoking history
C. Screening should be done now because of her age
D. Screening for bladder cancer is initiated at the age of 70 years

Explanation:
• Screening for bladder cancer is not recommended, even in patients who are at risk of developing
the disease.
• The majority of bladder cancers are due to environmental causes. In the United States, smoking
is the most common risk factor for developing bladder cancer.
• Bladder cancer also is associated with industrial exposure to paints, solvents, rubbers, and
various dyes.

2) Which of the following dietary treatments are recommended in children with

inflammatory bowel disease? [Surgery]

A. High-residue diet
B. High-protein diet
C. High fiber diet
D. Diet of elemental formula

Explanation:
• The elemental formula is known to cause remission in patients with Crohn disease.
• The difficulty in this treatment is that the formulas have poor palatability and require a
nasogastric tube for infusion.
• Other recommendations include a low-residue diet in patients with colitis.
3) A 56-year-old renal transplant patient was hospitalized following an abrupt onset of high
fever (39.6°C), confusion, headache, diarrhea, a cough productive of scant sputum, and
shortness of breath. His chemistry profile revealed hyponatremia. A chest radiograph
showed lobar infiltrates. Gram stain of sputum showed numerous neu- trophils but failed to
show any organisms. A urine antigen test was positive for the causative agent. What is the
major virulence factor of the causative agent? [Medicine-Microbiology]

A. Antiphagocytic capsule
B. Cord factor
C. Exotoxin production
D. Intracellular growth

Explanation
• The case describes an infection with Legionella pneumophila, an organism that grows within
amoeba outside of the body and within alveolar macrophages following infection.
• Hallmarks of the infection include non- productive cough, negative sputum Gram stain, and
extrapulmonary signs (confusion, headache, and GI symptoms). The patient is immune
compromised, an important risk factor for Legionella infection

4) The maximal absorption of calcium takes place in which part of the nephron?
[Physiology]

A. Loop of Henle
B. Distal tubules
C. Collecting duct
D. None

Explanation
Calcium reabsorption:

• Both ionized and complexed calcium are filtered at the glomerulus and >95% (up to 99%) of the
filtered calcium is reabsorbed
• The maximal absorption of calcium takes place in the proximal convoluted tubules and about
60% of reabsorption occurs here
• Around 20% of the filtered calcium is reabsorbed in the cortical segments of the loop of Henle
and the remainder in the distal tubules (10%) and collecting ducts
5) A 66-year-old man, who had been diagnosed to have a 4 mm aneurysm involving the
anterior communicating artery, presents with a sudden onset weakness involving the left
side of the body for the past one hour. His vital signs are stable, and he is conscious and
oriented. His National Institutes of Health Stroke Scale (NIHSS) is 8, and computed
tomogram (CT) of the brain is normal. Which of the following is the next step in
management? [Medicine]

A. Administer alteplase
B. Administer aspirin
C. Observation
D. Emergency clipping of the aneurysm followed by administration of alteplase

Explanation

• The patient is having a probable ischemic stroke involving the right middle cerebral artery
territory.
• In ischemic stroke in the presence of unruptured aneurysms sized less than 10 mm,
administration of intravenous (IV) alteplase is reasonable and recommended.
• In patients with giant unruptured and unsecured intracranial aneurysms, the usefulness of
alteplase is not well established.
• In patients with an unruptured and untreated intracranial vascular malformation, the usefulness
of IV alteplase is not well established.

6) A 65-year-old female is being discharged from the hospital after an admission for new-
onset stroke. The patient was treated with intravenous alteplase one week ago. She has a
past medical history of COPD, hypertension, diabetes, and atrial fibrillation. The patient's
weight is 86 kg, her creatinine clearance is 56 mL/min, ALT 19 U/L, AST 29 U/L, and albumin
is 4 gm/dL. What is the patient’s CHA2DS2-VASc risk stratification score? [Medicine]

A. CHA2DS2-VASc score of 2
B. CHA2DS2-VASc score of 3
C. CHA2DS2-VASc score of 4
D. CHA2DS2-VASc score of 6

Explanation
• The risk versus benefit for assessment of initiating anticoagulation can be calculated by using
validated calculations, such as CHA2DS2-VASc for stroke risk, and HAS-BLED for bleeding risk.
• The recommendation is to initiate oral anticoagulation if CHA2DS2-VASc stratification score of 2
or greater.
• CHA2DS2-VASc score stands for: congestive heart failure, hypertension, age greater than 75 (2
points), diabetes mellitus, stroke history, vascular disease, age 65-74 (1 point), and female gender.
One point is given if any of these categories are present, except for age over 75, where two points
are given.
• CHA2DS2-VASc evaluates ischemic stroke risk in patients with atrial fibrillation. This patient has
a history of hypertension, diabetes mellitus, stroke history, age of 65, and is female, giving her a
total score of 6.

7) A 63-year-old male presents with complaints of severe fatigue. He reports worsening

exercise tolerance and anorexia. He denies any history of blood loss. Physical exam shows
enlarged cervical, inguinal, and supraclavicular lymph nodes. The abdomen is soft and
non-tender with a mildly enlarged spleen. Imaging was consistent with bilaterally enlarged
kidneys, measuring 13.5 cm and 12.9 cm each. His hemoglobin level is 6.8 mg/dl, MCV 87 fl/
cell, BUN 56 mg/dl, and creatinine 1.5 mg/dl. Which of the following is the most likely cause
of this patient's anemia? [Surgery]

A. Iron deficiency anemia

B. Intravascular hemolysis
C. Bone marrow infiltration
D. Erythropoietin deficiency

Explanation
• The patient in this question has several signs and symptoms suggestive of a lymphoproliferative
disorder, most likely lymphoma.
• The anemia of lymphoproliferative disorders, such as leukemia and lymphoma, is due to the
replacement of RBC progenitor cells with cancer cells in the bone marrow.
• When renal lymphoma is suspected, biopsy is the most appropriate next step.

8) A 65-year-old man presents to the emergency department due to intermittent moderate

right flank pain over the past few days. The flank pain is intermittent, moderate in intensity,
and pressure like in nature. The pain is not aggravated or relieved by medications. The
patient has a history of epilepsy and was switched from valproic acid to lamotrigine 4
months ago due to thrombocytopenia and increased hair loss. His primary care provider
also switched his thiazide medication to amlodipine 6 months ago for high blood pressure.
Laboratory results include potassium levels of 4.3 mEq/L and creatinine of 0.8mg/dl.
Urinalysis reveals trace proteins, white blood casts, urinary eosinophilia, and red blood cell
6/hpf. His urinalysis 6 months ago was normal. Which of the following is the most likely
cause of this patient's urinalysis results? [Medicine]

A. Hypertensive nephropathy
B. Amlodipine
C. Valproic acid
D. Lamotrigine

Explanation
• Eosinophilia and white blood cast with renal failure are highly suggestive of allergic interstitial
nephritis.
• Allergic interstitial nephritis is most commonly associated with medication exposure. Non-
steroidal anti-inflammatory drugs (NSAIDs) are the most common medications associated with
allergic interstitial nephritis. Other drugs include anti-epileptics like phenytoin and lamotrigine,
hypertensive drugs like lisinopril, and thiazides.
• Drug-induced allergic interstitial nephritis (AIN) should be suspected when the onset of
characteristic laboratory findings is related to the initiation of a new drug, particularly one that
has been previously reported to cause AIN. A definitive diagnosis of AIN is made by renal
biopsy.
• The classic triad of fever, rash, and eosinophilia is present in 10% of cases of allergic interstitial
nephritis.

9) Which of the following is true with respect to renal lymphoma? [Surgery]

A. Primary lymphoma isolated to the kidney is the most common presentation

B. Found at autopsy in 25 percent of those with lymphoma
C. Found on CT in 20 percent of those with lymphoma
D. There are multiple CT appearances of lymphoma

Explanation
Primary renal lymphoma is rare, but the kidney is often involved in systemic lymphoma.
It is seen in 30-60 percent of lymphoma patients at autopsy.
It is seen in 3-8 percent of lymphoma patients on CT.
Lymphomas shows multiple patterns at CT, multiple masses, a single homogeneous mass, spread
from retroperitoneum to kidney, diffuse infiltration, and perinephric encasement.

10) A 16-year-old woman presents to the emergency department with a generalized

convulsion consisting of asynchronous thrusting of the limbs, side-to-side head-turning,
while keeping her eyes tightly closed. Airway, breathing, and circulation assessments
conclude that the patient is stable. After 10 minutes of the continuing event, the patient
abruptly awakens and starts screaming. Her mother reports that there was a fight between
them after which this event occured. What is the preferred term for such events? [Medicine]

A. Psychogenic non-epileptic spell

B. Pseudoseizure
C. Hysterical seizure
D. Psychogenic seizure

Explanation
• Several features suggest that this event is a non-epileptic spell. Generalized epileptic seizures
typically have in-phase movements of the extremities. The eyes are typically open, not closed.
After a generalized epileptic seizure, there is often a period of confusion.
• The preferred terminology currently for these events is a psychogenic non-epileptic spell. The
use of the word spell rather than seizure may help communicate with the family and caregivers
that these are non-neurologic events.
• Hysterical seizure and pseudoseizures have pejorative connotations and are ideally avoided.
Psychogenic non-epileptic spell is the preferred term.
• Most often, deliberate deception of caregivers is not the motivating force of these events. A
respectful approach and the reassurance that supportive therapy will most likely decrease or
even eliminate the frequency of spells should be outlined.