A 46-year-old man, a high school teacher, consulted your office for his life style and health management. He has been healthy all his life without major medical problems. Both of his parents are at their late 70s. Father has mild hypertension and mother has mild diabetes. His body height was 168 cm, body weight 81 kg, waist 96 cm, and BMI 29. His blood pressure was 152/90 mmHg. Blood chemistry revealed fasting sugar of 140 mg/dL, 2-hour postprandial sugar 190 mg/dL, hemoglobin A1C (HbA1C) 7.2%, blood urea nitrogen (BUN) 18 mg/dL, creatinine 1.10 mg/dL, sodium 141 mEq/L, potassium 3.6 mEq/L, AST/GOT 30 U/L (N：0-34), ALT/GPT 32 U/L (N：0-36), cholesterol 202 mg/dL, triglyceride 295 mg/dL, LDL-cholesterol 109 mg/dL & HDL-cholesterol 34 mg/dL. His urinalysis & blood cell counts were normal. What is your advice to this gentleman? (20%)

 A 28-year-old lady visited your office with palpitation, excessive sweating and body weight loss for 7 kg in the last 6 months. She stated that her appetite was good, but she had experienced 2-3 bowel movements a day, and also suffered from oligomenorrhea. Her body height was 166 cm, body weight 46 kg, blood pressure 140/66 mmHg, respiratory rate 24/min, and pulse rate 106/min. She appeared nervous. Skin appeared velvety. Thyroid was mildly enlarged; vascular bruit was audible over neck. Third heart sound was audible over the apex and a grade 2/6 systolic murmur audible along the upper left sternal border. Mild hand tremor was also noted. The rest of the physical examination was normal. What is your tentative diagnosis? What will be your work-up to confirm the diagnosis and what will be your therapeutic plan when the diagnosis is confirmed? (20%)

 A 28-year-old lady complained of palpitation, fatigue and shortness of breath on climbing stairs for 6 months. She has been well without major medical problems previously. Review of history revealed that she started on vegetarian diet for weight reduction without following a special instruction 3 years ago. Her body weight had in fact not changed and the appetite remained the same. There had been no abdominal discomfort and the bowel movements appeared normal. However, she noted heavy menstrual flow in the last 6 months. On examination, she was pale looking especially over conjunctivae, nail beds and palms. Her body height was 160 cm, body weight 52 kg, blood pressure 136/70 mmHg, and pulse rate 96/min. A venous hum was audible above the clavicles. A grade 2/6 systolic murmur was audible along the left parasternal border and a third heart sound was audible at the cardiac apex. The rest of physical examination was normal. What is your working diagnosis and how are you going to work up and advise this lady? (20%)

An 18-year-old girl was admitted to the hospital because of chest pain, fever, and chills for a couple of days. On the day of admission, cough with blood-tinged sputum were also noted. She worked as a waitress in a night-club. She appeared acutely ill; body temperature was 39.4℃, respiratory rate 30/min, pulse rate 110/min, and blood pressure 112/70 mmHg. Chest auscultation revealed coarse rhonchi over lung fields bilaterally. A grade 2/6 systolic murmur was audible along the left sternal border. Liver & spleen were not palpable. Examination of the extremities showed tracks of needle injection marks along the antecubital veins on forearms. There was no leg edema. A chest-x-ray showed bilateral multiple patch infiltrations over lung fields. Blood cell counts showed white blood cell 22,000/mm3 , red blood cell 3,000,000/mm3 , hemoglobin 9 g/dL, hematocrit 31%, platelets 189,000/mm3 ; differential counts showed segment 80%, lymphocyte 16%, monocyte 2%, eosinophil 1%, and basophil 1%. Urinalysis showed 4+ protein, as well as red blood cell and white blood cell casts. Blood urea nitrogen (BUN) was 40 mg/dL, creatinine 2 mg/dL, sugar 112 mg/dL, sodium 143 mEq/L, and potassium 3.3 mEq/L. What is your diagnosis? What is your plan? (20%)

7. A 58-year-old man presented with 1 hour of chest and upper back pain. Blood pressure was 160/100 mmHg in the right arm and 106/50 mmHg in the left arm. There was a grade III/VI diastolic blowing murmur audible at left upper sternal border. Electrocardiography showed sinus rhythm with left ventricular hypertrophy. (10%) (A) What diagnostic procedures will you order for this patient? b. What is the most possible diagnosis? (C) What is your treatment plan?

6. A patient presents to the emergency room and has the following laboratory value: sodium 139 mEq/L, potassium 4.1 mEq/L, chloride 112 mEq/L, bicarbonate 15 mEq/L, blood urea nitrogen 24 mg/dL, creatinine 1.4 mg/dL and glucose 180 mg/dL. (10%) (A) What is the calculated anion gap and calculated osmolarity? b. Please list the possible etiologies that are responsible for the patient’s metabolic acidosis.

5. Please describe the management of hypernatremi(A) (10%)

4. Describe the diagnosis and management of adrenal insufficiency. (15%)

3. List the tumors associated with the following biomarkers. (20%) (A) α-fetoprotein b. Calcitonin (C) Human chorionic gonadotropin d. Carcinoembryonic antigen e. Neuron-specific enolase

2. Please describe the diagnosis and management of duodenal ulcer with gastrointestinal bleeding. (15%)

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