3rd set

Question 1

A 53-year-old woman suffers from long-standing obesity complicated by DJD of the knees, making it difficult for her to exercise. Recently her fasting blood glucose values have been 148 mg/dL and 155 mg/dL; you tell her that she has developed type 2 diabetes. She wonders if diet will allow her to avoid medications. In addition, her daughter also suffers from obesity and has impaired fasting glucose, and the patient wonders about the management of her prediabetes. Which of the following is a correct statement based on the American Diabetes Association 2008 guidelines regarding nutrition recommendations and interventions for diabetes?
A. Low-carbohydrate diets such as “South Beach” and “Atkins” should be avoided.
B. Outcomes studies show that medical nutrition therapy (MNT) can produce a 1 to 2 point decrease in hemoglobin A1c in type 2 diabetics.
C. Prediabetic patients should be instructed to lose weight and exercise but a referral to a medical nutritionist is not necessary until full-blown diabetes is diagnosed.
D. Very low-calorie diets (< 800 cal/day) produce weight loss that is usually maintained after the diabetic patient returns to a self-selected diet.
E. Bariatric surgery may be considered for patients with type 2 diabetes and a BMI of > 30 kg/m2.

Answer 1

B. Outcomes studies show that medical nutrition therapy (MNT) can produce a 1 to 2 point decrease in hemoglobin A1c in type 2 diabetics.

Question 2

A 69-year-old African American man presents with weight loss and back pain. Over the past 2 months he has developed hyperglycemia with a fasting glucose of 153 mg/dL. He does not have nocturia. His appetite is decreased; he has noticed mild constipation. The back pain is constant and keeps him awake at night. On examination he appears cachectic and pale. He does not have scleral icterus. Laboratory studies reveal a mild normochromic anemia. Liver and kidney function studies are normal. What diagnostic study is most likely to reveal the cause of his symptoms?
A. CT scan of the abdomen with IV contrast
B. Glucose tolerance test
C. Colonoscopy.
D. Stool studies for malabsorption
E. Whole-body PET scan

Answer 2

A. CT scan of the abdomen with IV contrast

Question 3

A 35-year-old male complains of substernal chest pain aggravated by inspiration and relieved by sitting up. Lung fields are clear to auscultation, and heart sounds are somewhat distant. Chest X-ray shows an enlarged cardiac silhouette. Which of the following is the best next step in evaluation?
A. Right lateral decubitus chest x-ray
B. Cardiac catheterization
C. Echocardiogram
D. Serial ECGs
E. Thallium stress test

Answer 3

Echocardiogram

Question 4

You are caring for a 72-year-old male admitted to the hospital with an exacerbation of congestive heart failure. Two weeks prior to admission, he was able to ambulate two blocks before stopping because of dyspnea. He has now returned to baseline and is ready for discharge. His preadmission medications include aspirin, metoprolol, and furosemide. Systolic blood pressure has ranged from 110 mm Hg-128 mm Hg over the course of his hospitalization. Heart rate was in 120s at the time of presentation, but has been consistently around 70/minute over the past 24 hours. An echocardiogram performed during this hospitalization revealed global hypokinesis with an ejection fraction of 30%. Which of the following medications, when added to his preadmission regimen, would be most likely to decrease his risk of subsequent mortality?
A. Digoxin
B. Enalapril
C. Hydrochlorothiazide
D. Propranolol|
E. Spironolactone

Answer 4

B. Enalapril

Question 5

A 50-year-old white male presents with mild hypertension, nephrotic syndrome, microscopic hematuria, and venous thromboses (including renal vein
thrombosis). Renal biopsy reveals a thickened glomerular basement membrane with subepithelial immunoglobulin deposition. Which of the following is the correct primary glomerular disease?
A. Minimal change disease
B. IgA nephropathy
C. Focal and segmental glomerulosclerosis
D. Thin basement membrane disease
E. Membranous nephropathy
F. Membranoproliferative glomerulonephritis

Answer 5

E. Membranous nephropathy

Question 6

A 62-year-old man with chronic bronchitis develops chest pain and is given oxygen via mask in the ambulance en route to the hospital. He becomes lethargic in the emergency room. Which arterial blood gas and pH values are likely?
A. рН 7.50, РО2 75, PC02 28
B. рН 7.14, PO2 78, РО2 95
C. pH 7.06, PO2 36, PCO2 95
D. pH 7.06, PO2 108, PCO2 13
E. pH 7.37, PO2 48, PCO2 54

Answer 6

B. рН 7.14, PO2 78, РО2 95

Question 7

A 25-year-old who has been living in Washington, DC, presents with a diffuse vesicular rash over his face and trunk. He also has fever. He has no
history of chickenpox and has not received the varicella vaccine. Which of the following information obtained from history and physical examination suggests that the patient has chickenpox and not smallpox?
A. There are vesicular lesions on the palms and soles.
B. Vesicular lesions are concentrated on the trunk.
C. The rash is most prominent over the face.
D. All lesions are at the same stage of development.
E. The patient experienced high fever several days prior to the rash.

Answer 7

B. Vesicular lesions are concentrated on the trunk.

Question 8

A 76-year-old woman presents with weight loss, depression, and anemia of chronic disease. CT of the abdomen reveals a 4-cm pancreatic mass. What paraneoplastic syndrome would you associate with this scenario?
A. Humoral hypercalcemia of malignancy
B. Hyponatremia caused by inappropriate ADH secretion
C. Hypoglycemia due to IGF-2
D. Migratory thrombophlebitis associated with procoagulant cytokines
E. Skin infiltration with T lymphocytes
F. Erythrocytosis due to erythropoietin overproduction

Answer 8

D. Migratory thrombophlebitis associated with procoagulant cytokines

Question 9

• Bolus with 4 mg morphine and begin morphine patient controlled analgesia (PCA).
• Begin morphine patient controlled analgesia (PCA).
• Begin basal therapy with a transdermal fentanyl patch.
• Begin adjunct therapy with oral gabapentin.
• Change narcotic to meperidine at an equipotent

Answer 9

• Bolus with 4 mg morphine and begin morphine patient controlled analgesia (PCA).

Question 10

A young man develops a painless, fluctuant purplish lesion over the mandible. A cutaneous fistula is noted after several weeks. What is the most likely
organism?
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Viridans streptococci
D. Providencia stuartii
E. Actinomyces israelii
F. Haemophilus ducreyi
G. Neisseria meningitidis
H. Listeria monocytogenes

Answer 10

E. Actinomyces israelii

Question 11

A 43-year-old woman complains of fatigue and night sweats associated with itching for 2 months. On physical examination, there is diffuse nontender lymphadenopathy, including small supraclavicular, epitrochlear, and scalene nodes. CBC and chemistry studies (including liver enzymes) are normal. Chest x-ray shows hilar lymphadenopathy. Which of the following is the best next step in evaluation?
A. Excisional lymph node biopsy
B. Monospot test
C. Toxoplasmosis IgG serology
D. Serum angiotensin-converting enzyme level
E. Percutaneous aspiration biopsy of the largest lymph node

Answer 11

A. Excisional lymph node biopsy

Question 12

A 21-year-old male develops bloody diarrhea and fever. He owns and operates an exotic pet store, which specializes in reptile sales. What is the most
likely pathogen?
A. Staphylococcus aureus
B. Shigella dysenteriae
C. Entamoeba histolytica
D. Escherichia coli O157H7
E. Salmonella species
F. Giardia lamblia

Answer 12

E. Salmonella species

Question 13

A 42-year-old woman with hepatitis C develops fatigue, joint aches, and palpable purplish spots on her legs. Serum creatinine is 2.1 mg/dL and a 24-hour urine protein collection is 750 mg. Select the most probable diagnosis for this patient.
A. Churg Strauss syndrome
B. Cryoglobulinemic vasculitis
C. Temporal arteritis
D. Wegener granulomatosis
E. Takayasu arteritis
F. Polyarteritis nodosa
G. Henoch-Schönlein purpura

Answer 13

B. Cryoglobulinemic vasculitis

Question 14

A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea is deviated to the left. Which of the following is the most likely diagnosis?
A. Pneumothorax
B. Pleural effusion
C. Consolidated pneumonia
D. Atelectasis
E. Chronic obstructive lung disease

Answer 14

B. Pleural effusion

Question 15

A 72-year-old woman is admitted from the nursing home with fever and cough. Physical examination shows right basilar crackles and moderate dullness. CXR shows RLL pneumonia with moderate pleural effusion. She is treated with vancomycin and levofloxacin but remains febrile. Her shortness of breath worsens, and a follow-up chest x-ray shows enlarging pleural effusion. What is the likely type of pleural effusion?
A. Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending.
B. Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH 66 U/L (serum LDH 175), pH 7.42, glucose 100 mg/dL.
C. Bilateral effusions, slightly turbid, cell count 980 (10% polys, 30% lymphocytes, 60% mesothelial cells), protein 3.9 g/L (serum 3.8), LDH 225 U/L (serum
240), pH 7.52, glucose 5 mg/dL.
D. Bilateral effusions, straw colored, cell count 4200 (100% lymphocytes), protein 3 g/dL (serum 5.0), LDH 560 U/L (serum 450), pH 7.27, glucose 77 mg/dL.
E. Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% “reactive” mesothelial cells), RBC 130,000, protein 4.2 g/L (serum
4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL.
F. Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL.
G. Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum 220), pH 7.52, Gram stain negative, amylase 32,000.

Answer 15

A. Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending.

Question 16

A 68-year-old male complains of pain in his calves while walking. He notes bilateral foot pain, which awakens him at night. His blood pressure is 117/68.
Physical examination reveals diminished bilateral lower extremity pulses. An ankle:brachial index measures 0.6. The patient’s current medications include aspirin and hydrochlorothiazide. Which of the following is the best initial management plan for this patient’s complaint?
A. Smoking cessation therapy, warfarin
B. Smoking cessation therapy, graduated exercise regimen, cilostazol
C. Smoking cessation therapy, schedule an arteriogram
D. Smoking cessation therapy, warfarin, peripherally acting calcium-channel blocker
E. Smoking cessation therapy, consultation with a vascular surgeon

Answer 16

B. Smoking cessation therapy, graduated exercise regimen, cilostazol

Question 17

A 53-year-old woman presents with increasing weakness, most noticeable in the legs. She has noticed some cramping and weakness in the upper extremities as well. She has more difficulty removing the lids from jars than before. She has noticed some stiffness in the neck but denies back pain or injury. There is no bowel or bladder incontinence. She takes naproxen for osteoarthritis and is on alendronate for osteoporosis. She smokes one pack of cigarettes daily. The general physical examination reveals decreased range of motion in the cervical spine. On neurological examination, the patient has 4/5 strength in the hands with mild atrophy of the interosseous muscles. She also has 4/5 strength in the feet; the weakness is more prominent in the distal musculature. She has difficulty with both heel walking and toe walking. Reflexes are hyperactive in the lower extremities. Sustained clonus is demonstrated at the ankles. What is the best next step in her management?
A. Obtain MRI scan of the head.
B. Begin riluzole.
C. Obtain MRI scan of the cervical spine.
D. Check muscle enzymes including creatine kinase and aldolase.
E. Refer for physical therapy and gait training exercises.

Answer 17

C. Obtain MRI scan of the cervical spine.

Question 18

A 28-year-old nonsmoking woman presents to discuss birth control methods. She requests a contraceptive option that is not associated with
weight gain. She and her husband agree that they desire no children for the next few years. Her periods are regular, but heavy and painful. She frequently stays home from work on the first day due to severe lower abdominal cramping and back pain. She changes her pad every 4 hours. This pattern of bleeding has been present since she was 15 years old. For a week before her period begins, she is uncharacteristically tearful, irritable, and depressed. Her behavior change before her period is beginning to affect her work relationships. Her physical examination reveals blood pressure 110/75, BMI 22, and moderate acne on her face and neck. What recommendation will best address her mood, skin, and contraceptive needs?
A. Tubal ligation
B. Drosperinone and estrogen combination pill
C. Progesterone-infused intrauterine device
D. Progesterone shots every 3 months
E. Condoms

Answer 18

B. Drosperinone and estrogen combination pill

Question 19

A 24-year-old female develops bronchiectasis after recurrent episodes of severe bronchitis and pneumonia. She has prominent blood vessels on the ocular sclera and across the bridge of the nose. Her sister had a similar illness and died of lymphoma at age 29. What is the most likely immunologic deficiency?
A. Wiskott-Aldrich syndrome
B. Ataxia telangiectasia
C. DiGeorge syndrome
D. Immunoglobulin A deficiency
E. Severe combined immunodeficiency
F. C1 inhibitor deficiency
G. Adenosine deaminase deficiency

Answer 19

B. Ataxia telangiectasia

Question 20

A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10-Ib weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing.
Plain film is read as periosteal thickening, possible osteomyelitis. Which of the following is the most appropriate management of this patient?
A. Start ciprofloxacin.
B. Obtain chest x-ray.
C. Aspirate both wrists.
D. Begin methotrexate therapy.
E. Obtain erythrocyte sedimentation rate.

Answer 20

B. Obtain chest x-ray.

Question 21

of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard at the apex. What is the most likely cause of the murmur?
A. Rheumatic fever as a youth
B. Long-standing hypertension
C. A silent Ml within the past year
D. A congenital anomaly
E. Anemia from chronic blood loss

Answer 21

A. Rheumatic fever as a youth

Question 22

A 44-year-old Hispanic woman comes to clinic for a general checkup due to concern about a family history of diabetes and high blood
pressure. Her height is 62 in, weight 50 kg (110 lb), waist circumference 33 inches (85 cm), blood pressure 138/88. Laboratory evaluation reveals fasting glucose of 120 mg/dL. Lipid profile shows total cholesterol 240 mg/dL, HDL 38 mg/dL, and triglycerides 420 mg/dL; LDL cannot be calculated. She does not smoke, use alcohol, or take any medications. Which of the following is correct regarding the identification of the metabolic syndrome in this patient?
A. Metabolic syndrome is not present in this case due to the absence of abdominal obesity.
B. Metabolic syndrome is not present because the blood pressure is not sufficiently elevated to be a risk factor.
C. Metabolic syndrome is not present because the glucose is not sufficiently elevated to be a risk factor.
D. Metabolic syndrome is present based on the risk factors given.
E. Metabolic syndrome cannot be identified until the LDL is determined

Answer 22

D. Metabolic syndrome is present based on the risk factors given.

Question 23

A 68-year-old woman with a prior diagnosis of asthma presents to your clinic for a routine clinic visit. She complains of occasional palpitations and tremor. Her dyspnea is well controlled. Her past medical history is remarkable for hospitalization for mild congestive heart failure 2 months ago; she notes occasional postprandial acid reflux. Her medications include lisinopril, digoxin, furosemide, an intermittent short-acting inhaled beta agonist, and theophylline. She uses an over-the-counter pill (whose name she cannot remember) for the reflux symptoms. On examination her heart rate is 112 beats per minute. S1 and S 2 are normal; she has a mild tremor of the outstretched hands. What is the best next step in her management?
A. Chest x-ray to rule out congestive heart failure.
B. Theophylline level.
C. Spirometry before and after bronchodilator.
D. Intermittent lorazepam 0.5 mg po tid.
E. Discontinue beta agonist and substitute inhaled ipratropium.

Answer 23

A. Chest x-ray to rule out congestive heart failure.

Question 24

A 68-year-old retired construction worker has complained of right-sided chest pain and shortness of breath with dry cough. There is marked weight loss and anorexia. A chest x-ray shows right pleural effusion with pleural thickening. What is the likely type of pleural effusion?
A. Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending.
B. Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH
66 U/L (serum LDH 175), pH 7.42, glucose 100 mg/dL.
C. Bilateral effusions, slightly turbid, cell count 980 (10% polys, 30% lymphocytes, 60% mesothelial cells), protein 3.9 g/L (serum 3.8), LDH 225 U/L (serum 240), pH 7.52, glucose 5 mg/dL.
D. Bilateral effusions, straw colored, cell count 4200 (100% lymphocytes), protein 3 g/dL (serum 5.0), LDH 560 U/L (serum 450), pH 7.27, glucose 77 mg/dL.
E. Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% “reactive” mesothelial cells), RBC 130,000, protein 4.2 g/L (serum 4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL.
F. Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL.
G. Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum
220), pH 7.52, Gram stain negative, amylase 32,000.

Answer 24

E. Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% “reactive” mesothelial cells), RBC 130,000, protein 4.2 g/L (serum 4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL.

Question 25

A 37-year-old woman presents for evaluation of abnormal liver chemistries. She has long-standing obesity (current BMI 38) and has previously taken anorectic medications but not for the past several years. She takes no other medications and has not used parenteral drugs or had high-risk sexual exposure. On examination, her liver span is 13 cm; she has no spider angiomas or splenomegaly. Several sets of liver enzymes have shown transaminases two to three times normal. Bilirubin and alkaline phosphatase are normal. Hepatitis B surface antigen and hepatitis C antibody are normal, as are serum iron and total iron-binding capacity. Which of the following is the likely pathology on liver biopsy? A. Macrovesicular fatty liver B. Microvesicular fatty liver C. Portal triaditis with piecemeal necrosis D. Cirrhosis E. Copper deposition

Answer 25

A. Macrovesicular fatty liver

Question 26

A 78-year-old man presents with a 2-month history of fever and intermittent abdominal pain. He develops peritoneal signs and at laparotomy is found to have an area of infarcted bowel. Biopsy shows inflammation of small- to medium-sized muscular arteries. Select the most probable diagnosis for this patient. A. Churg Strauss syndrome B. Cryoglobulinemic vasculitis C. Temporal arteritis D. Wegener granulomatosis E. Takayasu arteritis F. Polyarteritis nodosa G. Henoch-Schönlein purpura

Answer 26

F. Polyarteritis nodosa

Question 27

A 68-year-old female presents to your office for follow-up. She has a history of paroxysmal atrial fibrillation and takes warfarin and digoxin for this problem. She has noted 5-Ib weight loss, daily fatigue, and loss of interest in her usual activities over the past 6 weeks. She states she doesn't feel like getting up in the morning. She has started taking some alternative therapies from the health food store in an attempt to boost her energy level and mood. On examination, the patient is less animated than usual, and her pulse is irregular at 120/minutes. She has clear lungs and no edema of the lower extremities. What supplement is most likely contributing to the patient's rapid heart rate? A. Ginkgo biloba B. Multivitamin with minerals C. St John's wort D. Vitamin D E. Ginseng

Answer 27

C. St John's wort

Question 28

A 54-year-old man who has had a Billroth Il procedure for peptic ulcer disease now presents with abdominal pain and is found to have recurrent ulcer disease. The physician is considering this patient's illness to be secondary either to retained antrum or to gastrinoma. Which of the following tests would best differentiate the two conditions? A. Random gastrin level B. Determination of 24-hour acid production C. Serum calcium level D. Secretin infusion E. Insulin-induced hypoglycemia

Answer 28

D. Secretin infusion

Question 29

A 60-year-old male patient is receiving aspirin, an angiotensin-converting enzyme inhibitor, nitrates, and a beta-blocker for chronic stable angina. He presents to the ER with an episode of more severe and long-lasting anginal chest pain each day over the past 3 days. His ECG and cardiac enzymes are normal. Which of the following is the best course of action? A. Admit the patient and add intravenous digoxin. B. Admit the patient and begin low-molecular-weight heparin. C. Admit the patient for thrombolytic therapy. D. Admit the patient for observation with no change in medication. E. Increase the doses of current medications and follow closely as an outpatient.

Answer 29

B. Admit the patient and begin low-molecular-weight heparin.

Question 30

A 25-year-old woman complains of dysuria, frequency, and suprapubic pain. She has not had previous symptoms of dysuria and is not on antibiotics. She is sexually active and on birth control pills. She has no fever, vaginal discharge or history of herpes infection. She denies back pain, nausea, or vomiting. On physical examination she appears well and has no costovertebral angle tenderness. A urinalysis shows 20 white blood cells per high power field. Which of the following statements is correct? A. A 3-day regimen of trimethoprim-sulfamethoxazole is adequate therapy. B. Quantitative urine culture with antimicrobial sensitivity testing is mandatory. C. Obstruction resulting from renal stone should be ruled out by ultrasound. D. Low-dose antibiotic therapy should be prescribed while the patient remains sexually active. E. The etiologic agent is more likely to be sensitive to trimethoprim-sulfamethoxazole than to fluoroquinolones.

Answer 30

A. A 3-day regimen of trimethoprim-sulfamethoxazole is adequate therapy.

Question 31

While on call in the hospital, you become involved in an emergent situation. A 58-year-old female smoker is admitted to the ICU with respiratory distress owing to pneumonia. Her course is complicated by an anterior myocardial infarction, with management including cautious use of beta-blockers. She now develops 10 to 12 PVCs per hour, occasional couplets, and a few short runs of ventricular tachycardia, although blood pressure and oxygen saturation remain stable. Choose the best next step in antiarrhythmic management. A. Amiodarone B. Atropine C. Digoxin D. Diltiazem E. Isoproterenol F. Lidocaine G. Metoprolol H. Quinidine I. Observation

Answer 31

A. Amiodarone

Question 32

A 17-year-old woman presents with peripheral and periorbital edema. She has previously been healthy and takes no medications. Her blood pressure is 146/92; she is afebrile. The patient has mild basilar dullness on lung examination; her cardiac examination is normal. She has periorbital edema and soft doughy 3+ edema in her legs. Her serum creatinine is 0.6 mg/dL and her serum albumin is 2.1 g/L. Urinalysis shows 3+ protein, no RBC or WBC, and some oval fat bodies. What is the most important initial diagnostic test? A. Serum and urine protein electrophoresis B. Serum cholesterol and triglyceride measurement C. Plasma aldosterone and renin activity D. Quantitation of urine albumin excretion E. Renal biopsy

Answer 32

D. Quantitation of urine albumin excretion

Question 33

A patient is admitted to the hospital with a nursing-home acquired pneumonia. His blood pressure is normal and the extremities well-perfused. Admission creatinine is 1.2 mg/dL. UA is clear. The patient is treated on the floor with piperacillin/tazobactam and improves clinically. On the fourth hospital day, the patient notes a nonpruritic rash over the abdomen. The creatinine has risen to 2.2 mg/dL. The urinalysis shows 2+ protein, 10 to 15 WBC/HPF, and no casts or RBCs. What is the likely cause of the patient's renal failure? A. Prerenal azotemia because of intravascular volume depletion B. Ischemia-induced acute tubular necrosis C. Nephrotoxin-induced acute tubular necrosis D. Acute interstitial nephritis E. Postrenal azotemia because of obstructive uropathy F. Postinfectious glomerulonephritis G. Acute cortical necrosis

Answer 33

D. Acute interstitial nephritis

Question 34

A 29-year-old male with HIV, on indinavir, zidovudine, and stavudine, presents with severe edema and a serum creatinine of 2.0 mg/dL. He has had bone pain for 5 years and takes large amounts of acetaminophen with codeine, aspirin, and ibuprofen. He is on prophylactic trimethoprim-sulfamethoxazole. Blood pressure is 170/110; urinalysis shows 4+ protein, 5 to 10 RBC, 0 WBC; 24-hour urine protein is 6.2 g. The serum albumin is 1.9 g/L (normal above 3.7).Which of the following is the most likely cause of his renal disease? A. Indinavir toxicity B. Analgesic nephropathy C. Trimethoprim-sulfamethoxazole-induced interstitial nephritis D. Focal glomerulosclerosis E. Renal artery stenosis

Answer 34

D. Focal glomerulosclerosis

Question 35

A 19-year-old white male presents with hypertension, nephrotic syndrome, mild renal insufficiency, RBC casts in urine, and depressed third component of complement (C3). Renal biopsy shows thickened basement membranes and increased cellular elements. Electron microscopy shows dense deposits within the basement membrane. Which of the following is the correct primary glomerular disease? A. Minimal change disease B. IgA nephropathy C. Focal and segmental glomerulosclerosis D. Thin basement membrane disease E. Membranous nephropathy F. Membranoproliferative glomerulonephritis

Answer 35

F. Membranoproliferative glomerulonephritis

Question 36

A 40-year-old man complains of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension. On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities. Which of the following is the best next step in management? A. Begin colchicine and broad-spectrum antibiotics. B. Perform arthrocentesis. C. Begin allopurinol if uric acid level is elevated. D. Obtain ankle x-ray to rule out fracture. E. Apply a splint or removable cast.

Answer 36

B. Perform arthrocentesis.

Question 37

A 45-year-old man has wheezing for several weeks and now presents with severe tingling of the hands and feet. There is wasting of the intrinsic muscles of the hands and loss of sensation in the feet. WBC is 13,000 with 28% eosinophils. Select the most probable diagnosis for this patient. A. Churg Strauss syndrome B. Cryoglobulinemic vasculitis C. Temporal arteritis D. Wegener granulomatosis E. Takayasu arteritis F. Polyarteritis nodosa G. Henoch-Schönlein purpura

Answer 37

A. Churg Strauss syndrome

Question 38

A 55-year-old patient presents to you after a 3-day hospital stay for gradually increasing shortness of breath and leg swelling while away on a business trip. He was told that he had congestive heart failure, but is asymptomatic now, with normal vital signs and physical examination. An echocardiogram shows an estimated ejection fraction of 38%. The patient likes to keep medications to a minimum. He is currently on aspirin and simvastatin. Which would be the most appropriate additional treatment? A. Begin an ACE inhibitor and then add a beta-blocker on a scheduled basis. B. Begin digoxin plus furosemide on a scheduled basis. C. Begin spironolactone on a scheduled basis. D. Begin furosemide plus nitroglycerin. E. Given his preferences, no other medication is needed unless shortness of breath and swelling recur.

Answer 38

A. Begin an ACE inhibitor and then add a beta-blocker on a scheduled basis.

Question 39

A 27-year-old female is found to have a positive hepatitis C antibody at the time of plasma donation. Physical examination is normal. Liver enzymes reveal ALT of 62 U/L (normal <40), AST 65 U/L (normal <40), bilirubin 1.2 mg/dL (normal), and alkaline phosphatase normal. Hepatitis C viral RNA is 100,000 copies/mL. Hepatitis B surface antigen and HIV antibody are negative. Which of the following statements is true? A. Liver biopsy is necessary to confirm the diagnosis of hepatitis C. B. Most patients with hepatitis C eventually resolve their infection without permanent sequelae. C. This patient should not receive vaccinations against other viral forms of hepatitis. D. Serum ALT levels are a good predictor of prognosis. E. Patients with hepatitis C genotype 2 or 3 are more likely to have a favorable response to treatment with interferon and ribavirin.

Answer 39

E. Patients with hepatitis C genotype 2 or 3 are more likely to have a favorable response to treatment with interferon and ribavirin.

Question 40

A 35-year-old previously healthy male develops cough with purulent sputum over several days. On presentation to the emergency room, he is lethargic. Temperature is 39°C, pulse 110, and blood pressure 100/70. He has rales and dullness to percussion at the left base. There is no rash. Flexion of the patient's neck when supine results in spontaneous flexion of hip and knee. Neurologic examination is otherwise normal. There is no papilledema. A lumbar puncture is performed in the emergency room. The cerebrospinal fluid (CSF) shows 8000 leukocytes/uL, 90% of which are polys. Glucose is 30 mg/dL with a peripheral glucose of 80 mg/dL. CSF protein is elevated to 200 mg/dL. A CSF Gram stain shows gram-positive diplococci. Which of the following is the correct treatment option? A. Begin acyclovir for herpes simplex encephalitis. B. Obtain emergency MRI scan before beginning treatment. C. Begin ceftriaxone and vancomycin for pneumococcal meningitis. D. Begin ceftriaxone, vancomycin, and ampicillin to cover both pneumococci and Listeria. E. Begin high-dose penicillin for meningococcal meningitis.

Answer 40

C. Begin ceftriaxone and vancomycin for pneumococcal meningitis.

Question 41

A 60-year-old male complains of low back pain, which has intensified over the past 3 months. He had experienced some fever at the onset of the pain. He was treated for acute pyelonephritis about 4 months ago. Physical examination shows tenderness over the L2-3 vertebra and paraspinal muscle spasm. Laboratory data show an erythrocyte sedimentation rate of 80 mm/h and elevated C-reactive protein. Which of the following statements is correct? A. Hematogenous osteomyelitis rarely involves the vertebra in adults. B. The most likely initial focus of infection was soft tissue. C. Blood cultures will be positive in most patients with this process. D. An MRI scan is both sensitive and specific in defining the process. E. Surgery will be necessary if the patient has osteomyelitis.

Answer 41

D. An MRI scan is both sensitive and specific in defining the process.

Question 42

A 25-year-old postal worker presents with a pruritic, nonpainful skin lesion on the dorsum of his hand. It began like an insect bite but expanded over several days. On examination, the lesion has a black, necrotic center associated with severe local swelling. The patient does not appear to be systemically ill, and vital signs are normal. Which of the following is correct? A. The lesion is ecthyma gangrenosum, and blood cultures will be positive for Pseudomonas aeruginosa. B. A skin biopsy should be performed and Gram stain examined for gram-positive rods. C. The patient has been bitten by Loxosceles reclusa, the brown recluse spider. D. The patient has the bubo of plague. E. The patient has necrotizing fasciitis and needs immediate surgical debridement.

Answer 42

B. A skin biopsy should be performed and Gram stain examined for gram-positive rods.

Question 43

A 39-year-old woman is admitted to the gynecology service for hysterectomy for symptomatic uterine fibroids. Postoperatively the patient develops an ileus accompanied by severe nausea and vomiting; ondansetron is piggybacked into an IV of D5 ½ normal saline running at 125 cc/hr. On the second postoperative day the patient becomes drowsy and displays a few myoclonic jerks. Stat labs reveal Na 118, K 3.2, Cl 88 HCO 3 22, BUN 3, creatinine 0.9. Urine studies for Na and osmolality are sent to the lab. What is the most appropriate next step? A. Change the IV fluid to 0.9% (normal) saline and restrict free-water intake to 600 cc/d B. Change the odansetron to promethazine, change the IV fluid to lactated Ringer solution and recheck the Na in 4 hours. C. Start 3% (hypertonic) saline, make the patient NPO and transfer to the ICU D. Change the IV fluid to normal saline and give furosemide 40mg IV stat. E. Make the patient NPO and send for stat CT scan of the head to look for cerebral edema.

Answer 43

C. Start 3% (hypertonic) saline, make the patient NPO and transfer to the ICU

Question 44

A college wrestler develops cellulitis after abrading his skin during a match. He is afebrile and appears well but his arm is red and swollen with several draining pustules. Gram stain of the pus shows gram-positive cocci in clusters. Which of the following statements is correct? A. The patient will require hospital admission and treatment with vancomycin. B. The organism will almost always be sensitive to oxacillin. C. The organism is likely to be sensitive to trimethoprim-sulfamethoxazole. D. Community-acquired methicillin-resistant staphylococci have the same sensitivity pattern as hospital-acquired methicillin-resistant staphylococci. E. The infection is likely caused by streptococci.

Answer 44

C. The organism is likely to be sensitive to trimethoprim-sulfamethoxazole.

Question 45

A 55-year-old man with psoriasis has been troubled by long-standing destructive arthritis involving the hands, wrists, shoulders, knees, and ankles. Hand films demonstrate pencil-in-cup deformities. He has been treated with naproxen 500 mg bid, sulfasalazine 1 g bid, prednisone 5 mg qd, and methotrexate 17.5 mg once a week without substantive improvement. Which of the following treatments is most likely to provide long-term benefit? A. Cyclophosphamide B. Addition of folic acid supplementation C. Oral cyclosporine D. Tumor necrosis factor alpha inhibitor E. Higher-dose steroids in the range of 20 mg of prednisone per day

Answer 45

D. Tumor necrosis factor alpha inhibitor

Question 46

A 62-year-old man has a history of a myocardial infarction and has chronic stable angina. The initial choice of an antihypertensive or the addition of further agents) to the regimen may depend on concomitant factors. Indicate the medication choice that would give the best additional benefit in addition to blood pressure control. A. Alpha-blocker B. Beta-blocker C. Calcium-channel blocker D. Angiotensin-converting enzyme inhibitor E. Centrally acting alpha agonist F. Diuretic

Answer 46

B. Beta-blocker

Question 47

A 63-year-old painter complains of severe right shoulder pain. The pain is located posteriorly over the scapula. These symptoms began after he fell from a ladder 2 weeks ago. The pain is especially bad at night and makes it difficult for him to sleep. In addition, he has had some pain in the right upper arm. Treatment with acetaminophen and ibuprofen has been unsuccessful in controlling his pain. On examination the patient appears uncomfortable. The right shoulder has full range of motion. Movement of the shoulder is not painful. There is no tenderness to palpation of the scapula. What is the most likely diagnosis? A. Subdeltoid bursitis B. Rotator cuff tendonitis C. Adhesive capsulitis D. Osteoarthritis E. Cervical radiculopathy

Answer 47

E. Cervical radiculopathy

Question 48

A 60-year-old male complains of shortness of breath 2 days after a cholecystectomy. He denies fever, chills, sputum production, and pleuritic chest pain. On physical examination, temperature is 37.2°C (99°F); pulse is 75; respiratory rate is 20; and blood pressure is 120/70. There are diminished breath sounds and dullness over the left base. Trachea is shifted to the left side. A chest x-ray shows a retrocardiac opacity that silhouettes the left diaphragm. Which of the following is the most likely anatomical problem in this patient? A. An acute process causing inflammation B. A left lower lobe mass C. Diminished lung volume in the left lower lobe, postoperative atelectasis D. Acute bronchospasm caused by surgery E. Acute pneumothorax

Answer 48

C. Diminished lung volume in the left lower lobe, postoperative atelectasis

Question 49

A 52-year-old woman is admitted with abdominal pain and hypertriglyceridemia. Amylase is elevated, and she is treated for pancreatitis with IV fluids and narcotics. Over the next several days she becomes more short of breath; left basilar dullness develops. What is the likely type of pleural effusion? A. Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending. B. Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH 66 U/L (serum LDH 175), pH 7.42, glucose 100 mg/dL. C. Bilateral effusions, slightly turbid, cell count 980 (10% polys, 30% lymphocytes, 60% mesothelial cells), protein 3.9 g/L (serum 3.8), LDH 225 U/L (serum 240), pH 7.52, glucose 5 mg/dL. D. Bilateral effusions, straw colored, cell count 4200 (100% lymphocytes), protein 3 g/dL (serum 5.0), LDH 560 U/L (serum 450), pH 7.27, glucose 77 mg/dL. E. Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% "reactive" mesothelial cells), RBC 130,000, protein 4.2 g/L (serum 4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL. F. Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL. G. Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum 220), pH 7.52, Gram stain negative, amylase 32,000.

Answer 49

G. Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum 220), pH 7.52, Gram stain negative, amylase 32,000.

Question 50

A 76-year-old man is admitted with pneumonia. He has a history of diabetes mellitus. Admission creatinine is 1.2 mg/dL. He responds to ceftriaxone and azithromycin. He develops occasional urinary incontinence treated with anticholinergics, but his overall status improves and he is ready for discharge by the fifth hospital day. On that morning, however, he develops urinary hesitancy and slight suprapubic tenderness. The creatinine is found to be 3.0 mg/dL; UA is clear with no RBCs, WBCs or protein. What is the likely cause of the patient's renal failure? A. Prerenal azotemia because of intravascular volume depletion B. Ischemia-induced acute tubular necrosis C. Nephrotoxin-induced acute tubular necrosis D. Acute interstitial nephritis E. Postrenal azotemia because of obstructive uropathy F. Postinfectious glomerulonephritis

Answer 50

E. Postrenal azotemia because of obstructive uropathy

Question 51

You are working in the university student health clinic, seeing adolescents and young adults for urgent care problems, but you remain attuned to the possibility of more serious underlying disease. A 23-year-old graduate student complains of extreme fatigue and a vague sense of feeling ill the past few weeks. He has been under a lot of stress recently and is slightly agitated. On examination, BP is 110/70, pulse is 100, and temperature is 100.5°F (38.0°C). The neck veins are distended with prominent v waves. A holosystolic murmur is heard at the left sternal border; the murmur intensifies on inspiration. What is the likely associated valvular or related heart disease? A. Tricuspid stenosis B. Tricuspid regurgitation C. Mitral stenosis D. Mitral regurgitation E. Aortic regurgitation (insufficiency) F. Aortic stenosis G. Hypertrophic cardiomyopathy H. Pulmonic stenosis I. Pulmonic regurgitation (insufficiency)

Answer 51

B. Tricuspid regurgitation

Question 52

A 70-year-old male complains of 2 months of low back pain and fatigue. He has developed fever with purulent sputum production. On physical examination, he has pain over several vertebrae and rales at the left base. Laboratory results are as follows: * Hemoglobin: 7 g/dL * MCV: 89 fL (normal 86 to 98) * WBC: 12,000/mL * BUN: 44 mg/dL * Creatinine: 3.2 mg/dL * Ca: 11.5 mg/dL * Chest x-ray: LLL infiltrate * Reticulocyte count: 1% The definitive diagnosis is best made by which of the following? A. 24-hour urine protein B. Bone scan C. Renal biopsy D. Rouleaux formation on blood smear E. Greater than 30% plasma cells in the bone marrow

Answer 52

E. Greater than 30% plasma cells in the bone marrow

Question 53

You respond to the cardiopulmonary arrest of a 72-year-old woman in the intensive care unit. She has no palpable pulse, but the cardiac monitor shows sinus tachycardia at 124/minute. Breath sounds are symmetric with bag-mask positive pressure ventilation. What is the best next step in evaluation or management of this patient? A. Immediate electrical cardioversion B. Immediate transthoracic cardiac pacing C. Immediate administration of high-volume normal saline D. Immediate large-bore pericardiocentesis E. Immediate administration of extended spectrum antibiotics

Answer 53

C. Immediate administration of high-volume normal saline

Question 54

A 65-year-old diabetic male with a creatinine of 1.6 was started on an angiotensin-converting enzyme inhibitor for hypertension and presents to the emergency room with weakness. His other medications include atorvastatin for hypercholesterolemia, metoprolol and spironolactone for congestive heart failure, insulin for diabetes, and aspirin. Laboratory studies include * K: 7.2 mEq/L * Creatinine: 1.8 mg/dL * Glucose: 250 mg/dL * CK: 400 IU/L Which of the following is the most likely cause of hyperkalemia in this patient? A. Worsening renal function B. Uncontrolled diabetes C. Statin-induced rhabdomyolysis D. Drug-induced effect on the renin-angiotensin-aldosterone system E. High potassium diet

Answer 54

D. Drug-induced effect on the renin-angiotensin-aldosterone system

Question 55

A 60-year-old woman comes to the emergency room in a coma. The patient's temperature is 32.2°C (90°F). She is bradycardic. Her thyroid gland is enlarged. There is diffuse hyporeflexia. BP is 100/60. Which of the following is the best next step in management? A. Await results of T4 and TSH. B. Obtain T4 and TSH; begin intravenous thyroid hormone and glucocorticoid. C. Begin rapid rewarming. D. Obtain CT scan of the head. E. Begin intravenous fluid resuscitation.

Answer 55

B. Obtain T4 and TSH; begin intravenous thyroid hormone and glucocorticoid.

Question 56

You evaluate a 48-year-old man for chronic renal insufficiency. He has a history of hypertension, osteoarthritis, and gout. He currently has no complaints. His medical regimen includes lisinopril 40 mg daily, hydrochlorothiazide 25 mg daily, allopurinol 300 mg daily, and acetaminophen for his joint pains. He does not smoke but drinks 8 oz of wine on a daily basis. Examination shows BP 146/86, pulse 76, a soft S 4 gallop and mild peripheral edema. There is no abdominal bruit. His UA reveals 1+ proteinuria and no cellular elements. Serum creatinine is 2.2 mg/dL and his estimated GFR from the MDRD formula is 42 ml/min. What is the most important element is preventing progression of his renal disease? A. Discontinuing all alcohol consumption B. Discontinuing acetaminophen C. Adding a calcium channel blocker to improve blood pressure control D. Obtaining a CT renal arteriogram to exclude renal artery stenosis E. Changing the lisinopril to losartan

Answer 56

C. Adding a calcium channel blocker to improve blood pressure control

Question 57

A 20-year-old black male presents to the emergency room complaining of diffuse bone pain and requesting narcotics for his sickle cell crisis. Which of the following physical examination features would suggest an alternative diagnosis to sickle cell anemia (hemoglobin SS)? A. Scleral icterus B. Systolic murmur C. Splenomegaly D. Ankle ulcers E. Leukocytosis

Answer 57

Splenomegaly

Question 58

A family brings their 82-year-old grandmother to the emergency room stating that they cannot care for her anymore. They tell you, "She has just been getting sicker and sicker." Now she stays in bed and won't eat because of stomach pain. She has diarrhea most of the time and can barely make it to the bathroom because of her weakness. Her symptoms have been worsening over the past year, but she has refused to see a doctor. The patient denies symptoms of depression. Blood pressure is 90/54 with the patient supine; it drops to 76/40 when she stands. Heart and lungs are normal. Skin examination reveals a bronze coloring to the elbows and palmar creases. What laboratory abnormality would you expect to find in this patient? A. Low serum Ca+ B. Low serum K+ C. Low serum Na+ D. Normal serum K+ E. Microcytic anemia

Answer 58

C. Low serum Na+

Question 59

A 40-year-old woman has had increasing fatigue and shortness of breath for years. Chest x-ray shows right ventricular hypertrophy and enlargement of the central pulmonary arteries. Pulmonary embolus is ruled out by spiral CT scan. Other causes of pulmonary hypertension have also been ruled out. Right heart catheterization reveals a pulmonary artery pressure of 75/30 mm Hg. Which of the following is the best next step in the management of the patient? A. Acute drug testing with short-acting pulmonary vasodilators B. High-dose nifedipine C. Intravenous prostacyclin D. Lung transplantation E. Empiric trial of sildenafil

Answer 59

A. Acute drug testing with short-acting pulmonary vasodilators

Question 60

Yesterday you admitted a 55-year-old white male to the hospital for an episode of chest pain, and you are seeking to rule out MI plus assess for any underlying coronary artery disease. The patient tends to be anxious about his health. On admission, his lungs were clear, but his heart revealed a grade 1/6 early systolic murmur at the upper left sternal border without radiation. Blood pressure readings have consistently been in the 140/90 to 150/100 range. Cardiac enzymes are normal. A resting ECG shows only left ventricular hypertrophy with secondary ST-T changes ("LVH with strain"). Why would a treadmill ECG stress test not be an appropriate test in this patient? A. Anticipated difficulty with the patient's anxiety (ie, he might falsely claim chest pain during the test) B. Increased risk associated with high blood pressure readings C. Concern about the heart murmur, a relative contraindication to stress testing D. The presence of LVH with ST-T changes on baseline ECG E. Concern that this represents the onset of unstable angina with unacceptable risk of Ml with stress testing

Answer 60

D. The presence of LVH with ST-T changes on baseline ECG

Question 61

A 53-year-old male with septic shock develops acute renal failure with a serum creatinine of 6.4 mg/dL. Which of the following is a specific indication to initiate dialysis? A. BUN rises to 75 mg/dL. B. Urine output falls to <10 mL/h. C. Pericardial friction rub develops. D. Hematocrit falls to <30%. E. Continued hypotension

Answer 61

C. Pericardial friction rub develops.

Question 62

A 30-year-old quadriplegic male presents to the emergency room with fever, dyspnea, and a cough. He has a chronic indwelling Foley catheter. Recurrent urinary tract infections have been a problem for a number of years. He has been on therapy to suppress the urinary tract infections. On examination, mild wheezing is audible over both lungs. A diffuse erythematous rash is noted. The chest x-ray shows a diffuse alveolar infiltrate. The CBC reveals a WBC of 13,500, with 50% segmented cells, 30% lymphocytes, and 20% eosinophils. Which of the following is the most likely diagnosis? A. Sepsis with ARDS secondary to urinary tract infection B. Healthcare-related pneumonia C. A drug reaction to one of his medications D. An acute exacerbation of COPD E. Lymphocytic interstitial pneumonitis

Answer 62

C. A drug reaction to one of his medications

Question 63

A 66-year-old male presents with severe hypertension and abdominal pain. He has low grade fever and livedo reticularis over the lower extremities. Neurological examination shows a right peroneal neuropathy and sensory loss in the left radial nerve distribution, consistent with mononeuritis multiplex. UA reveals 1+ proteinuria and 15 to 20 RBC/HPF. What is the most likely systemic disease? A. Macroscopic (classic) polyarteritis nodosa B. Microscopic polyangiitis C. Wegener granulomatosis D. Goodpasture syndrome E. Churg-Strauss syndrome F. Essential mixed cryoglobulinemia G. Systemic lupus erythematosus H. Behçet disease

Answer 63

A. Macroscopic (classic) polyarteritis nodosa

Question 64

A 20-year-old fireman comes to the emergency room complaining of headache and dizziness after helping to put out a garage fire. He does not complain of shortness of breath, and the arterial blood gas shows a normal partial pressure of oxygen. Which of the following is the best first step in the management of this patient? A. Begin oxygen therapy. B. Obtain chest x-ray. C. Obtain carboxyhemoglobin level. D. Obtain CT scan. E. Evaluate for anemia.

Answer 64

C. Obtain carboxyhemoglobin level.

Question 65

A 65-year-old woman was hospitalized for pulmonary embolus and eventually discharged on warfarin (Coumadin) with a therapeutic INR.During the next 2 weeks as an outpatient, she was started back on her previous ACE inhibitor antihypertensive, given temazepam for insomnia, treated with ciprofloxacin for a urinary tract infection, started on over-the-counter famotidine (Pepcid) for Gl symptoms, and told to stop the OTC naproxen she was taking. Follow-up INR was 5.0. Which of the following drugs most likely potentiated the effects of warfarin and led to the high INR? A. ACE inhibitor B. Temazepam C. Ciprofloxacin D. Famotidine (Pepcid) E. Naproxen discontinuation

Answer 65

C. Ciprofloxacin

Question 66

A 17-year-old male is brought to the emergency room with confusion and incoordination. He is uncooperative and refuses to provide further history. Physical examination reveals an RR of 30; the vital signs are otherwise normal as is the general physical examination. Laboratory values are as follows: * Na: 135 mEq/L * K: 2.7 mEq/L * HCO 3: 15 mEq/L * CI: 110 mEq/L * Arterial blood gases: PO 2 92, PCO 2 30, pH 7.28 * Urine: pH 7.5, glucose -negative * Ca: 9.7 mg/dL * PO 4: 4.0 mg/dL Which of the following is the most likely cause of the acid base disorder? A. Gl loss owing to diarrhea B. Proximal renal tubular acidosis C. Disorder of the renin-angiotensin system D. Distal renal tubular acidosis E. Respiratory acidosis

Answer 66

D. Distal renal tubular acidosis

Question 67

A 42-year-old pediatric nurse practitioner seeks your advice regarding his immunization needs. He is healthy and takes no regular medications. He had well-documented chickenpox as a child. He received a tetanus-diphtheria booster 5 years ago and influenza vaccine 4 months ago. Influenza A activity has been reported in your community in the last 2 weeks. Which of the following immunizations would you recommend for this patient at this time? A. An influenza booster B. Tetanus-diphtheria-acellular pertussis (Tdap) C. Pneumococcal vaccine D. Herpes zoster vaccine E. Meningococcal vaccine

Answer 67

B. Tetanus-diphtheria-acellular pertussis (Tdap)

Question 68

A 30-year-old male has developed fever, chills, and neck stiffness. Cerebrospinal fluid shows gram-negative diplococci. He has had a past episode of sepsis with meningococcemia. What is the most likely immunologic deficiency? A. Complement deficiency C5-C9 B. Selective IgA deficiency C. Postsplenectomy D. Neutropenia E. Interleukin-12 receptor deficit F. Microbicidal leukocyte defect G. Phagocyte immune deficit H. Congenital T-cell deficit

Answer 68

A. Complement deficiency C5-C9

Question 69

A 65-year-old man develops a severe headache and right-sided weakness. He has a history of osteoarthritis, gout, and hypertension. He regularly keeps his follow-up visits and is compliant with his medications, which include lisinopril 10 mg po q AM for hypertension, allopurinol 300 mg po q AM to prevent gout, and acetaminophen for his joint pains. Review of his recent office record shows that his mean blood pressure has been 124/78. On physical examination the patient is drowsy but arousable. His blood pressure is 164/90 and his pulse rate is 56. He has a right homonymous hemianopsia and a mild right hemiparesis. Sensory examination is difficult due to poor cooperation. Cardiac examination shows no S 3 or S 4 gallop and a regular rhythm. He has no ecchymoses or evidence of abnormal bruising. His ECG is normal without left ventricular hypertrophy. CT of the head without IV contrast shows an acute hemorrhage in the left parietal lobe; the basal ganglia and thalamus are uninvolved. What is the likely pathogenesis of the neurological problem? A. Small vessel vasculitis B. Intimal damage to penetrating cerebral vessels C. Trauma from domestic abuse D. Coagulopathy E. Amyloid deposition in the cerebral vasculature

Answer 69

E. Amyloid deposition in the cerebral vasculature

Question 70

An 18-year-old male presents to your office. His family has noted a blue discoloration of his nose, ears, and fingers. This finding has only been noticed for a few weeks. Which of the following is true? A. This patient has peripheral cyanosis. B. Total hemoglobin is important in determining whether or not a patient will have cyanosis. C. Central cyanosis with hypoxia suggests methemoglobinemia or sulfhemoglobinemia. D. The presence of clubbing in a cyanotic patient confirms an acute cause of the cyanosis. E. Large amounts of methemoglobin are required to produce cyanosis.

Answer 70

B. Total hemoglobin is important in determining whether or not a patient will have cyanosis.

Question 71

An 80-year-old male, hospitalized for hip fracture, has a Foley catheter in place when he develops shaking chills, fever, and hypotension. What is the most likely organism? A. Streptococcus pneumoniae B. Staphylococcus aureus C. Viridans streptococci D. Providencia stuartii E. Actinomyces israelii F. Haemophilus ducreyi G. Neisseria meningitidis H. Listeria monocytogenes

Answer 71

D. Providencia stuartii

Question 72

A patient comes to your office for a new-patient visit. He has moved recently to your city due to a job promotion. His last annual examination was 1 month prior to his move. He received a letter from his primary physician stating that laboratory workup had revealed an elevated alkaline phosphatase and that he needed to have this evaluated by a physician in his new location. On questioning, his only complaint is pain below the knee that has not improved with over-the-counter medications. The pain increases with standing. He denies trauma to the area. On examination you note slight warmth just below the knee, no deformity or effusion of the knee joint, and full ROM of the knee without pain. You order an x-ray, which shows cortical thickening of the superior fibula and sclerotic changes. Laboratory evaluation shows an elevated alkaline phosphatase of 297 mg/dL with an otherwise normal metabolic panel. Which of the following is the treatment of choice for this patient? A. Observation B. Nonsteroidal anti-inflammatory C. A bisphosphonate D. Melphalan and prednisone E. Ursodeoxycholic acid (UDCA)

Answer 72

C. A bisphosphonate

Question 73

A 46-year-old woman is transfused for upper gastrointestinal bleeding caused by peptic ulcer disease. Her past history is unremarkable except for 4 previous successful pregnancies and 3 previous spontaneous abortions. Immediately after the transfusion her hemoglobin rises to 10, the bleeding is controlled and she is dismissed from the hospital on omeprazole. One week later, however, she develops fatigue and dyspnea. Her hemoglobin has dropped to 7 g/dL. Her bilirubin, previously normal, has risen to 2.4 mg/dL (1.9 mg/dL indirect reacting), and the LDH value is 468. Stool is heme negative. What is the most likely pathogenesis? A. Congestive heart failure caused by volume overload B. Reaction of donor antibodies with antigens of the recipient C. Reaction of recipient antibodies to antigens of the donor D. IgE mediated reaction against donor IgA E. Bacterial contamination of the transfused product F. Activation of complement leading to intravascular hemolysis G. Infection with intraerythrocytic parasites from the donor

Answer 73

C. Reaction of recipient antibodies to antigens of the donor

Question 74

A 55-year-old African American female presents to the ER with lethargy and blood pressure of 250/150. Her family members indicate that she was complaining of severe headache and visual disturbance earlier in the day. They report a past history of asthma but no known kidney disease. On physical examination, retinal hemorrhages are present. Which of the following is the best approach? A. Intravenous labetalol therapy B. Continuous-infusion nitroprusside C. Clonidine by mouth to lower blood pressure D. Nifedipine sublingually to lower blood pressure E. Intravenous loop diuretic

Answer 74

B. Continuous-infusion nitroprusside

Question 75

An 18-year-old G1P1 presents to your office with the results of an abnormal pap smear dated 1 month ago. She tells you that she had one pap smear prior to this one and it was normal. She reports having had four sexual partners since beginning sexual activity at age 15. Upon reviewing the pap smear result you find it is reported as low-grade squamous intraepithelial lesion (LSIL). What is the most appropriate next step in the management of this patient with the abnormal pap smear? A. Recommend loop electrosurgical excision. B. Repeat pap at 12 months. C. Repeat pap smear if and when she changes sexual partners. D. Repeat pap smear every 3 years. E. Repeat the pap at this visit and perform HPV DNA testing.

Answer 75

B. Repeat pap at 12 months.

Question 76

A 76-year-old woman consults you because of leg discomfort. Her legs are comfortable during the day, but in the evening she develops an uncomfortable creepy-crawly sensation that keeps her awake for hours. The feeling is temporarily relieved by movement; she will awaken, pace around, and sometimes run water on her legs to achieve relief. Which of the following is the best initial treatment for her condition? A. Zolpidem 5 mg po at bedtime B. Trazodone 50 mg po at bedtime C. Stretching exercises of the legs D. Pramipexole 0.125 mg po in the evening E. Cyclobenzaprine 10 mg po at bedtime

Answer 76

D. Pramipexole 0.125 mg po in the evening

Question 77

A 20-year-old woman has developed low-grade fever, a malar rash, and arthralgias of the hands over several months. High titers of anti-DNA antibodies are noted, and complement levels are low. The patient's white blood cell count is 3000/uL, and platelet count is 90,000/uL. The patient is on no medications and has no signs of active infection. Which of the following statements is correct? A. If glomerulonephritis, severe thrombocytopenia, or hemolytic anemia develops, high-dose glucocorticoid therapy would be indicated. B. Central nervous system symptoms will occur within 10 years. C. The patient can be expected to develop Raynaud phenomenon when exposed to cold. D. Joint deformities will likely occur. E. The disease process described is an absolute contraindication to pregnancy

Answer 77

A. If glomerulonephritis, severe thrombocytopenia, or hemolytic anemia develops, high-dose glucocorticoid therapy would be indicated.

Question 78

A 20-year-old man complains of arthritis and eye irritation. He has a history of burning on urination. On examination, there is a joint effusion of the right knee and a rash of the glans penis. Which of the following is correct? A. Neisseria gonorrhoeae is likely to be cultured from the glans penis. B. The patient is likely to be rheumatoid factor-positive. C. An infectious process of the Gl tract may precipitate this disease. D. An ANA is very likely to be positive. E. CPK will be elevated.

Answer 78

C. An infectious process of the Gl tract may precipitate this disease.

Question 79

A 35-year-old female who is recovering from Mycoplasma pneumonia develops increasing weakness. Her Hgb is 9.0 g/dL and her MCV is 110. Which of the following is the best test to determine whether the patient has a hemolytic anemia? A. Serum bilirubin B. Reticulocyte count and blood smear C. Mycoplasma antigen D. Glucose phosphate dehydrogenase level E. Liver spleen scan

Answer 79

B. Reticulocyte count and blood smear

Question 80

A 52-year-old alcoholic man develops left chest pain after repeated bouts of vomiting. On presentation he is diaphoretic with fever of 101.5, heart rate 126, BP 84/52. There are crackles and moderate dullness at the left base. The right lung is clear. He has subcutaneous emphysema over the left supraclavicular area. What is the likely type of pleural effusion? A. Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending. B. Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH 66 U/L (serum LDH 175), pH 7.42, glucose 100 mg/dL. C. Bilateral effusions, slightly turbid, cell count 980 (10% polys, 30% lymphocytes, 60% mesothelial cells), protein 3.9 g/L (serum 3.8), LDH 225 U/L (serum 240), pH 7.52, glucose 5 mg/dL. D. Bilateral effusions, straw colored, cell count 4200 (100% lymphocytes), protein 3 g/dL (serum 5.0), LDH 560 U/L (serum 450), pH 7.27, glucose 77 mg/dL. E. Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% "reactive" mesothelial cells), RBC 130,000, protein 4.2 g/L (serum 4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL. F. Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL. G. Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum 220), pH 7.52, Gram stain negative, amylase 32,000.

Answer 80

F. Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL.

Question 81

A 65-year-old male complains of shortness of breath at night and nocturnal dyspnea. On physical examination there is neck vein distention and bilateral rales at the bases. A chest x-ray shows bilateral pleural effusions, right larger than left, with cardiomegaly. What is the likely type of pleural effusion? A. Unilateral effusion, turbid, cell count 90,000 (95% polymorphonuclear cells), protein 4.5 g/dL (serum protein 5.2), LDH 255 U/L (serum LDH 290), pH 6.84, glucose 20 mg/dL. Culture and Gram stain pending. B. Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH 66 U/L (serum LDH 175), pH 7.42, glucose 100 mg/dL. C. Bilateral effusions, slightly turbid, cell count 980 (10% polys, 30% lymphocytes, 60% mesothelial cells), protein 3.9 g/L (serum 3.8), LDH 225 U/L (serum 240), pH 7.52, glucose 5 mg/dL. D. Bilateral effusions, straw colored, cell count 4200 (100% lymphocytes), protein 3 g/dL (serum 5.0), LDH 560 U/L (serum 450), pH 7.27, glucose 77 mg/dL. E. Right-sided effusion, bloody, white cell count 1200 (15% polys, 5% lymphocytes, 80% "reactive" mesothelial cells), RBC 130,000, protein 4.2 g/L (serum 4.6), LDH 560 U/L (serum 226), pH 6.90, glucose 120 mg/dL. F. Left-sided effusion, turbid, cell count 54,000 (92% polys, 8% lymphocytes), protein 5.2 g/L (serum 5.2), LDH 400 U/L (serum 200), pH 3.02, glucose 40 mg/dL. G. Left-sided effusion, straw colored, cell count 2000 (80% polys, 10% lymphocytes, 10% mesothelial cells) protein 2.0 (serum 4.8), LDH 158 (serum 220), pH 7.52, Gram stain negative, amylase 32,000.

Answer 81

B. Right-sided effusion, straw colored, cell count 150 (20% polys, 35% lymphocytes, 45% mesothelial cells), protein 1.4 g/L (serum protein 5.4), LDH 66

Question 82

An anxious young woman who is taking birth control pills presents to the emergency room with shortness of breath. Which of the following physical findings would make the diagnosis of pulmonary embolus unlikely? A. Wheezing B. Pleuritic chest pain C. Right-sided S3 heart sound D. Hemoptysis E. Bibasilar rales

Answer 82

E. Bibasilar rales

Question 83

A 58-year-old male is referred to your office after evaluation in the emergency room for abdominal pain. The patient was diagnosed with gastritis but a CT scan with contrast performed during the workup of his pain revealed a 2-cm adrenal mass. The patient has no history of malignancy and denies erectile dysfunction. Physical examination reveals a BP of 122/78 with no gynecomastia or evidence of Cushing syndrome. His serum potassium is normal. What is the next step in determining whether this patient's adrenal mass should be resected? A. Plasma aldosterone/renin ratio. B. Estradiol level. C. Plasma metanephrines and dexamethasone-suppressed cortisol level. D. Testosterone level. E. Repeat CT scan in 6 months.

Answer 83

C. Plasma metanephrines and dexamethasone-suppressed cortisol level.

Question 84

You have been asked to perform preoperative consultation on a 66-year-old man who will be undergoing transurethral resection of the prostate for urinary retention. Of the following findings, which is of most concern in predicting a cardiac complication in this patient undergoing noncardiac surgery? A. Age over 65 B. Current cigarette use at one pack per day C. Serum creatinine 2.2 mg/dL D. History of three alcoholic drinks/day with ALT (SGOT) 60 mg/dL E. LDL cholesterol of 135 mg/dL

Answer 84

C. Serum creatinine 2.2 mg/dL

Question 85

You see a debilitated 80-year-old woman who requires nursing home placement in the early summer. She had had no immunizations for many years except for a pneumococcal vaccine 3 years ago when discharged from the hospital after a stay for pneumonia. Appropriate admission orders to the nursing home include which of the following? A. Influenza vaccine B. Haemophilus influenzae B immunization C. Hepatitis B immunization series D. Pneumococcal revaccination E. Tetanus-diphtheria toxoid booster

Answer 85

E. Tetanus-diphtheria toxoid booster

Question 86

You have been asked to evaluate a 42-year-old white male smoker who presented to the emergency department with sudden onset of crushing substernal chest pain, nausea, diaphoresis and shortness of breath. His initial ECG revealed ST segment elevation in the anterior-septal leads. Cardiac enzymes were normal. The patient underwent emergent cardiac catheterization, which revealed only a 25% stenosis of the left anterior descending (LAD) artery. No percutaneous intervention was performed. Which of the following interventions would most likely reduce his risk of similar episodes in the future? A. Placement of a percutaneous drug-eluting coronary artery stent. B. Placement of a percutaneous non-drug-eluting coronary artery stent. C. Beginning therapy with an ACE inhibitor. D. Beginning therapy with a beta-blocker. E. Beginning therapy with a calcium-channel blocker.

Answer 86

E. Beginning therapy with a calcium-channel blocker.

Question 87

A 64-year-old man presents with acute exacerbation of chronic obstructive pulmonary disease. The patient had a long smoking history before quitting 2 years ago. In spite of his poor baseline lung function, he has been able to maintain an independent lifestyle. The patient is in obvious respiratory distress and appears tired. He has difficulty greeting you secondary to shortness of breath. Respiratory rate is 32/minute. Auscultation of the lungs reveals minimal air movement. ABGs show pH = 7.28, PaCO 2 = 77, and PaO 2 = 54. One dose of IV methylprednisolone has already been administered. What is the best next step in the management of this patient's disease? A. Urgent institution of BiPAP (bilevel positive airway pressure) B. Urgent endotracheal intubation C. Administration of 100% FiO2 by face mask D. Arrangement for admission to monitored ICU bed E. IV levofloxacin

Answer 87

A. Urgent institution of BiPAP (bilevel positive airway pressure)

Question 88

A 56-year-old chronic alcoholic has a 1 year history of ascites. He is admitted with a 2-day history of diffuse abdominal pain and fever. Examination reveals scleral icterus, spider angiomas, a distended abdomen with shifting dullness, and diffuse abdominal tenderness. Paracentesis reveals slightly cloudy ascitic fluid with an ascitic fluid PMN cell count of 1000/uL. Which of the following statements about treatment is true? A. Antibiotic therapy is unnecessary if the ascitic fluid culture is negative for bacteria. B. The addition of albumin to antibiotic therapy improves survival. C. Repeated paracenteses are required to assess the response to antibiotic treatment. D. After treatment of this acute episode, a recurrent episode of spontaneous bacterial peritonitis would be unlikely. E. Treatment with multiple antibiotics is required because polymicrobial infection is common.

Answer 88

B. The addition of albumin to antibiotic therapy improves survival.

Question 89

A 68-year-old woman with stable coronary artery disease undergoes an aortogram with lower extremity run-off studies for symptomatic peripheral vascular disease. The patient is on warfarin (for recurrent deep vein thrombosis), aspirin, lisinopril, metoprolol, and atorvastatin. She received a course of dicloxacillin for cellulitis 1 week ago. Three weeks after angiography the patient is evaluated for general malaise. Physical examination reveals a petechial rash and livedo reticularis on both lower extremities. Laboratory evaluation reveals that her creatinine has risen from 1.5 to 3.7 mg/dL. Other laboratory abnormalities include an ESR of 96 mm/h, leukocytosis, eosinophilia, and a reduced third component of complement (C3). Urine sodium is 40 mEq/L. Urinalysis reveals 5 to 10 eosinophils/HPF, 10 to 20 WBC/HPF, 5 to 10 RBC/HPF, no casts, and 1+ dipstick proteinuria. Which of the following is the most likely diagnosis? A. Prerenal azotemia B. Radiocontrast-induced acute renal failure C. Drug-induced acute interstitial nephritis D. Acute glomerulonephritis E. Atheroembolic renal failure

Answer 89

E. Atheroembolic renal failure

Question 90

A 32-year-old male presents to your office with concern about progressive fatigue and lower extremity edema. He has experienced decreased exercise tolerance over the past few months, and occasionally awakens coughing at night. Past medical history is significant for sickle cell anemia and diabetes mellitus. He has had multiple admissions to the hospital secondary to vasoocclusive crises since the age of three. Physical examination reveals a displaced PMI, but is otherwise unremarkable. ECG shows a first degree AV block and low voltage. Chest X-ray shows an enlarged cardiac silhouette with clear lung fields. Which of the following would be the best initial diagnostic approach? A. Order serum iron, iron-binding capacity, and ferritin level. B. Order brain-natriuretic peptide (BNP) C. Order CT scan of the chest. D. Arrange for placement of a 24-hour ambulatory cardiac monitor. E. Arrange for cardiac catheterization.

Answer 90

A. Order serum iron, iron-binding capacity, and ferritin level.