4th set (final)

Question 1

A 70-year-old white woman presents with LLQ abdominal pain, low-grade fever, and mild rectal bleeding. Examination shows LLQ tenderness.
Unprepped sigmoidoscopy reveals segmental inflammation beginning in the distal sigmoid colon through the mid-descending colon. The rest of the examination is negative. What is the most likely diagnosis?
A. Ulcerative colitis
B. Crohn disease
C. Ischemic colitis
D. Diverticulitis
E. Amebic colitis
F. Tuberculoma of the colon

Answer 1

C. Ischemic colitis

Question 2

A 68-year-old male was intubated in the emergency room because of pulmonary edema. Stat echocardiogram reveals an ejection fraction of 45% and severe mitral regurgitation. In spite of aggressive diuresis with furosemide, the patient continues to require mechanical ventilation secondary to pulmonary edema. What is the best next step in treating this patient?
A. Arrange for mitral valve replacement surgery.
B. Place an intra-aortic balloon pump.
C. Begin metoprolol.
D. Begin a second loop diuretic.
E. Begin intravenous enalapril.

Answer 2

E. Begin intravenous enalapril.

Question 3

Your patient is a 48-year-old Hispanic male with a 4-year history of diabetes mellitus type 2. He is currently utilizing NPH insulin/Regular insulin 40/20 units prior to breakfast and 20/10 units prior to supper. His supper time has become variable due to a new job and ranges from 5 to 8 PM. In reviewing his glucose diary you note some very low readings (40-60 mg/dL) during the past few weeks at 3 AM. When he awakens to urinate, he feels sweaty or jittery so has been checking a fingerstick blood glucose. Morning glucose levels following these episodes are always higher (200-250) than his average fasting glucose level (120-150). Which change in his insulin regimen is most likely to resolve this patient’s early AM hypoglycemic episodes?
A. Increase morning NPH and decrease evening NPH.
B. Decrease morning NPH and decrease evening regular insulin.
C. Change regimen to glargine at bedtime and continue morning and evening regular insulin.
D. Discontinue both NPH and regular insulin; implement sliding scale regular insulin with meals.
E. Change regimen to glargine at bedtime with lispro prior to each meal.

Answer 3

E. Change regimen to glargine at bedtime with lispro prior to each meal.

Question 4

A 70-year-old male with a history of coronary artery disease presents to the emergency department with 2 hours of substernal chest pressure, diaphoresis, and nausea. He reports difficulty “catching his breath.” An electrocardiogram shows septal T-wave inversion. The patient is given 325-mg aspirin and sublingual nitroglycerin while awaiting the results of his blood work. His troponin I is 0.65 ng/mL (normal < 0.04 ng/mL). The physician in the emergency department starts the patient on low-molecular-weight heparin. His pain is 3/10. Blood pressure is currently 154/78 and heart rate is 72. You are asked to assume care of this patient. What is the best next step in management?
A. Arrange for emergent cardiac catheterization.
B. Begin intravenous thrombolytic therapy.
C. Admit the patient to a monitored cardiac bed and repeat cardiac enzymes and ECG in 6 hours.
D. Begin intravenous beta-blocker therapy.
E. Begin clopidogrel 300 mg po each day.

Answer 4

D. Begin intravenous beta-blocker therapy.

Question 5

A 38-year-old woman presents with a 3-day history of fever and confusion. She was previously healthy and is taking no medications. She has
not had diarrhea or rectal bleeding. She has a temperature of 38°C (100.4°F) and a blood pressure of 145/85. Splenomegaly is absent. She has no petechiae but does have evidence of early digital gangrene of the right second finger. Except for confusion the neurological examination is normal. Her laboratory studies reveal the following:
* Hemoglobin: 8.7
* Platelet count: 25,000
* Peripheral smear: numerous fragmented RBCs, few platelets
* LDH 562 (normal <180)
* Creatinine: 2.7
* Liver enzymes: normal
* Prothrombin time/PTT/fibrinogen level: normal
What is the most likely pathogenesis of her condition?
A. Disseminated intravascular coagulation
B. Antiplatelet antibodies
C. Failure to cleave von Willebrand factor multimers
D. Verotoxin-induced endothelial damage
E. Cirrhosis with sequestration of erythrocytes and platelets in the spleen

Answer 5

C. Failure to cleave von Willebrand factor multimers

Question 6

A 48-year-old male is admitted to your service after an inhalational chemical exposure. He develops respiratory distress and requires endotracheal intubation and mechanical ventilation. Which of the following is most likely to decrease his risk of developing ventilator acquired pneumonia?
A. Daily interruption of sedation to assess respiratory status
B. Nasopharyngeal rather than oropharyngeal endotracheal intubation
C. Institution of protocol to keep bed flat during ventilation
D. Intermittent nasopharyngeal suctioning
E. Prophylactic narrow spectrum intravenous antibiotics

Answer 6

A. Daily interruption of sedation to assess respiratory status

Question 7

A 73-year-old female with arthritis presents with confusion. Neurologic examination is nonfocal, and CT of the head is normal. Laboratory data include
* Na: 140 mEq/L
* K: 3.0 mEq/L
* CI: 107 mEq/L
* HCO 3: 12 mEq/L
* Arterial blood gases: PO 2 62, PCO 2 24, pH 7.40
What is the acid-base disturbance?
A. Respiratory alkalosis with appropriate metabolic compensation
B. High anion-gap metabolic acidosis with appropriate respiratory compensation
C. Combined metabolic acidosis and respiratory alkalosis
D. No acid-base disorder
E. Hyperchloremic (normal anion gap) metabolic acidosis with appropriate respiratory compensation

Answer 7

C. Combined metabolic acidosis and respiratory alkalosis

Question 8

A 19-year-old man with insulin-dependent diabetes mellitus is taking 30 units of NPH insulin each morning and 15 units at night. Because of persistent morning glycosuria with some ketonuria, the evening dose is increased to 20 units. This worsens the morning glycosuria, and now moderate ketones are noted in urine. The patient complains of sweats and headaches at night. Which of the following is the most appropriate next step in management?
A. Measure blood glucose levels at bedtime.
B. Increase the evening dose of NPH insulin further.
C. Add regular insulin to NPH at a ratio of 2/3 NPH to 1/3 regular.
D. Obtain blood sugar levels between 2:00 and 5:00 AM
E. Add lispro via a calculated scale to each meal; continue NPH.

Answer 8

D. Obtain blood sugar levels between 2:00 and 5:00 AM

Question 9

A 30-year-old man is evaluated for a thyroid nodule. The patient reports that his father died from thyroid cancer and that a brother had a history of recurrent renal stones. Blood calcitonin concentration is 2000 pg/mL (normal is less than 100); serum calcium and phosphate levels are normal. The patient is referred to a thyroid surgeon. Which of the following studies should also be obtained?
A. Obtain a liver scan.
B. Measure parathormone level.
C. Measure urinary catecholamines.
D. Administer suppressive doses of thyroxine and measure levels of thyroid-stimulating hormone.
E. Treat the patient with radioactive iodine.

Answer 9

C. Measure urinary catecholamines.

Question 10

A 30-year-old male complains of unilateral headaches. He was diagnosed with migraine headaches at age 24. The headaches did not respond to triptan therapy at that time, but after 6 weeks the headaches resolved. He has had 3 or 4 spells of severe headaches since then. Currently his headaches have been present for the past 2 weeks. The headaches start with a stabbing pain just below the right eye. Usually the affected eye feels “irritated” (reddened with increased lacrimation). He saw an optometrist during one of the episodes and a miotic pupil was noted.Each pain lasts from 60 to 90 minutes, but he may have several discrete episodes each day. The neurological examination, including cranial nerve examination, is now normal. What is your best approach to treatment at this time?
A. Prescribe oral sumatriptan for use at the onset of headache.
B. Prednisone 60 mg daily for 2 to 4 weeks.
C. Obtain MRI scan of the head with gadolinium contrast.
D. Begin propranolol 20 mg bid.
E. Refer for neuropsychiatric testing.

Answer 10

B. Prednisone 60 mg daily for 2 to 4 weeks.

Question 11

A 64-year-old woman presents with diffuse hair loss. She says that her hair is “coming out by the handfuls” after shampooing. She was treated for severe community-acquired pneumonia 2 months ago but has regained her strength and is exercising regularly. She is taking no medications. Examination reveals diffuse hair loss. Several hairs can be removed by gentle tugging. The scalp is normal without scale or erythema. Her general examination is unremarkable; in particular, her vital signs are normal, she has no pallor or inflammatory synovitis, and her reflexes are normal with a normal relaxation phase. What is the best next step in her management?
A. Reassurance
B. Measurement of serum testosterone and DHEA-S levels
C. Topical minoxidil
D. Topical corticosteroids
E. CBC and antinuclear antibodies

Answer 11

Reassurance

Question 12

You have been asked to see a 58-year-old male admitted to the ICU after coronary artery bypass surgery yesterday. He has no history of
diabetes, but his blood sugars have ranged from 59 to 225 over the past 24 hours. His nurse reports that he has been nauseated and ate very little of his clear liquid diet this morning. His current medications include “sliding scale” insulin, a beta-blocker, and a thiazide diuretic. What is the best next step in managing this patient’s blood sugar?
A. Begin metformin 500-mg po bid.
B. Begin scheduled subcutaneous long-acting insulin and scheduled short-acting insulin with meals.
C. Begin intravenous insulin drip.
D. Continue sliding scale insulin and make patient NPO until blood sugars stabilize.
E. Continue sliding scale and stop the beta-blocker as this may mask signs of hypoglycemia.

Answer 12

C. Begin intravenous insulin drip.

Question 13

On routine physical examination, a 28-year-old woman is found to have a thyroid nodule. She denies pain, hoarseness, hemoptysis, or local symptoms. Serum TSH is normal. Which following is the best next step in evaluation?
A. Thyroid ultrasonography
B. Thyroid scan
C. Surgical resection
D. Fine needle aspiration of thyroid
E. No further evaluation

Answer 13

D. Fine needle aspiration of thyroid

Question 14

A 73-year-old male undergoes abdominal aortic aneurysm repair. Postoperatively, his blood pressure is 110/70, heart rate is 110, surgical wound is clean, and a Foley catheter is in place. His urine output drops to 40 cc/h, and creatinine rises from 1.5 to 2.2 mg/dL. Hemoglobin and hematocrit are stable, K 4.6, uric acid 8.2. Which initial diagnostic test is most useful for this patient?
A. Urine sodium/creatinine ratio
B. Urinalysis
C. Renal ultrasound
D. Urine uric acid/creatinine ratio
E. CT renal arteriogram

Answer 14

B. Urinalysis

Question 15

A 32-year-old white woman complains of abdominal pain off and on since the age of 17. She notices abdominal bloating relieved by defecation as well as alternating diarrhea and constipation. She has no weight loss, Gl bleeding, or nocturnal diarrhea. On examination, she has slight LLQ tenderness and gaseous abdominal distension. Laboratory studies, including CBC, are normal. Which of the following is the most appropriate initial approach?
A. Recommend increased dietary fiber, antispasmodics as needed, and follow-up examination in 2 months.
B. Refer to gastroenterologist for colonoscopy.
C. Obtain antiendomysial antibodies.
D. Order UGl series with small bowel follow-through.
E. Order small bowel biopsy.

Answer 15

A. Recommend increased dietary fiber, antispasmodics as needed, and follow-up examination in 2 months.

Question 16

A 40-year-old man with long-standing alcohol abuse complains of abdominal swelling, which has been progressive over several months. He has a history of gastrointestinal bleeding. On physical examination, there are spider angiomas and palmar erythema. Abdominal collateral vessels are seen around the umbilicus. There is shifting dullness, and bulging flanks are noted. Which of the following is the most important first step in the patient’s evaluation?
A. Diagnostic paracentesis
B. Upper Gl series
C. Ethanol level
D. CT scan of the abdomen
E. Examination of peripheral blood smear

Answer 16

A. Diagnostic paracentesis

Question 17

A 30-year-old male develops skin rash, pruritus, and mild wheezing about 20 minutes after an intravenous pyelogram performed for theevaluation of renal stone symptoms. Which of the following is the best approach to diagnosis of this patient?
A. Perform 24-hour urinary histamine measurement.
B. Measure immunoglobulin E to radiocontrast media.
C. Diagnose radiocontrast media sensitivity by history.
D. Recommend intradermal skin testing.
E. The patient cannot be exposed to iodinated contrast agents in the future.

Answer 17

C. Diagnose radiocontrast media sensitivity by history.

Question 18

A 47-year-old premenopausal woman of Mediterranean descent presents with a painless breast mass. Her mother underwent a mastectomy at age 74 because of breast cancer. Her sister has had ovarian cysts but no cancer. There is no other cancer in the family. Biopsy of the mass reveals infiltrating ductal carcinoma. The patient has two daughters and asks about genetic testing. What is the most likely cause of her malignancy?
A. A germline mutation in the p53 suppressor gene
B. A germline mutation in the BRA1 gene
C. A somatic mutation in the BRCA1 gene
D. Exposure to a carcinogen such as diethylstilbestrol in utero
E. Unknown

Answer 18

E. Unknown

Question 19

A 63-year-old retired farmer presents to the clinic complaining of red scaly spots on his head for the past 9 months. Physical examination is remarkable for numerous erythematous hyperkeratotic papules and plaques. The lesions are confined to the head and forehead and have poorly defined borders. Which of the following is the most appropriate next step in management of this patient?
A. Punch biopsy of one of the lesions
B. Application of hydrocortisone cream to affected areas and follow-up in 4 weeks
C. Reassurance that this is a benign finding and follow-up in 6 months
D. Application of fluocinide cream to affected areas and follow-up in 4 weeks
E. Application of 5-fluorouracil cream to affected areas and follow-up in 4 weeks

Answer 19

E. Application of 5-fluorouracil cream to affected areas and follow-up in 4 weeks

Question 20

A 50-year-old construction worker continues to have elevated blood pressure of 160/95 even after a third agent is added to his antihypertensive regimen. Physical examination is normal, electrolytes are normal, and the patient is taking no over-the-counter medications. Which of the following is the best next step for this patient?
A. Check pill count.
B. Evaluate for Cushing syndrome.
C. Check chest x-ray for coarctation of the aorta.
D. Obtain a renal angiogram.
E. Obtain an adrenal CT scan.

Answer 20

A. Check pill count.

Question 21

A 72-year-old man presents with progressive abdominal pain over the last 2 days. He has had several loose stools, subjective fever, and decreased appetite. Past medical history is significant for hypertension, diet-controlled diabetes mellitus, and one admission to the hospital for heart failure 2 years ago. He takes a beta-blocker and loop diuretic faithfully as prescribed by his physician. Vital signs include heart rate 92 and blood pressure 126/64. Physical examination reveals mucosal stranding of the oropharynx, no JVD, no lower extremity edema, and tenderness to palpation of the left lower quadrant of the abdomen. CT scan with contrast of the abdomen has been ordered. What is the best next step in the management of this patient?
A. Administer low-dose aspirin for prophylaxis of venous thromboembolism.
B. Administer low-dose low-molecular-weight heparin for prophylaxis of venous thromboembolism.
C. Administer treatment dose of low-molecular-weight heparin for presumed ischemic colitis.
D. Administer 600-mg N-acetylcysteine for prevention of contrast-induced nephropathy.
E. Administer 150-mEq sodium bicarbonate in 1-L D5 water for prevention of contrast-induced nephropathy.

Answer 21

E. Administer 150-mEq sodium bicarbonate in 1-L D5 water for prevention of contrast-induced nephropathy.

Question 22

A 32-year-old woman experiences a severe anaphylactic reaction following a sting from a hornet. Which of the following statements is correct?
A. She would not have a similar reaction to a sting from a yellow jacket.
B. She would have a prior history of an adverse reaction to an insect sting.
C. Adults are less likely to die as a result of an insect sting than children with the same history.
D. She should be skin-tested with venom antigens and, if positive, immunotherapy should be started.
E. She cannot use an epinephrine self-injector because of her age.

Answer 22

She should be skin-tested with venom antigens and, if positive, immunotherapy should be started.

Question 23

A 78-year-old man complains of increasing fatigue and bone pain, especially around the knees and ankles. He has been anemic for several years, with hemoglobin of 9 to 10 g/dL and MCV of 102. His leukocyte and platelet count have been normal; he has not had lymphadenopathy or splenomegaly. He had not responded to therapeutic trials of iron and vitamin B 12, but has been symptomatically stable until the past month. Examination reveals pallor and spleen tip at the left costal margin. CBC reveals hemoglobin of 8.2 g/dL, but for the first time his platelet count is low (15,000); the white blood cell count is 14,000. What is the likely cause of his worsening anemia?
A. Folic acid deficiency
B. Acute myeloid leukemia
C. Myelofibrosis
D. Tuberculosis
E. Viral infection

Answer 23

B. Acute myeloid leukemia

Question 24

A 60-year-old heavy smoker has severe chronic bronchitis, peripheral edema, and cyanosis. Which arterial blood gas and pH values are likely?
A. pH 7.50, PO2 75, PCO2 28
B. рН 7.14, РО2 78, PCO2 95
C. pH 7.06, PO2 36, PCO2 95
D. рН 7.06, РО2 108, PCO2 13
E. pH 7.37, P02 48, PCO2 54

Answer 24

E. pH 7.37, P02 48, PCO2 54

Question 25

A 22-year-old drug-addicted man is brought to the emergency room by friends who were unable to awaken him. Which arterial blood gas and pH values are likely? A. pH 7.50, PO2 75, PCO2 28 B. pH 7.14, PO2 78, PCO2 95 C. pH 7.06, РО2 36, РСО2 95 D. pH 7.06, PO2 108, PCO2 13 E. pH 7.37, PO2 48, PCO2 54

Answer 25

C. pH 7.06, РО2 36, РСО2 95

Question 26

A 75-year-old man with a prior history of adenocarcinoma of the prostate treated with radical prostatectomy presents with pain in the left hip. The pain awakens him at night and has become increasingly severe over the previous 3 weeks. Plain radiographs show numerous bilateral osteoblastic lesions in the hip and sacrum, and the prostate-specific antigen level is 83 mcg/mL (normal 0 to 4). Which of the following is the treatment of choice? A. Observation B. Radiation therapy C. Estrogen therapy D. Gonadotropin-releasing hormone (GnRH) analogue E. Chemotherapy

Answer 26

D. Gonadotropin-releasing hormone (GnRH) analogue

Question 27

A 19-year-old male has a history of athlete's foot but is otherwise healthy when he develops sudden onset of fever and pain in the right foot and leg. On physical examination, the foot and leg are fiery red with a well-defined indurated margin that appears to be rapidly advancing. There is tender inguinal lymphadenopathy. The most likely organism to cause this infection is which of the following? A. Staphylococcus epidermidis B. Tinea pedis C. Streptococcus pyogenes D. Mixed anaerobic infection E. Alpha-hemolytic streptococci

Answer 27

C. Streptococcus pyogenes

Question 28

An otherwise healthy 40-year-old woman sees you because of recurrent abdominal pain. In the past month she has had four episodes of colicky epigastric pain. Each of these episodes has lasted about 30 minutes and has occurred within an hour of eating. Two of the episodes have been associated with sweating and vomiting. None of the episodes have been associated with fever or shortness of breath. She has not lost weight. She does not drink alcohol or take any prescription or over-the-counter medications. Other than three previous uneventful vaginal deliveries, she has never been hospitalized. Her examination is negative except for mild obesity (BMI = 32). A complete blood count and multichannel chemistry profile that includes liver function test is normal. A gallbladder sonogram reveals multiple gallstones. What is the next best step in the treatment of this patient? A. Omeprazole, 20 mg daily for eight weeks. B. Ursodeoxycholic acid C. Observation without specific therapy D. Laparoscopic cholecystectomy E. Weight reduction

Answer 28

D. Laparoscopic cholecystectomy

Question 29

A 62-year-old man is diagnosed with neurosyphilis. Seven years ago he had an anaphylactic reaction to a penicillin shot which was administered for streptococcal pharyngitis. He required treatment with epinephrine and reports that he "almost died." What is the best approach to the management of his neurosyphilis? A. Oral doxycycline B. Intravenous ceftriaxone C. Oral erythromycin D. No treatment available E. Penicillin desensitization followed by parenteral penicillin G

Answer 29

E. Penicillin desensitization followed by parenteral penicillin G

Question 30

A 20-year-old male presents with obtundation. Past medical history is unobtainable. Blood pressure is 120/70 without orthostatic change, and he is well perfused peripherally. The neurological examination is nonfocal. His laboratory values are as follows: * Na: 138 mEq/L * K: 4.2 mEq/L * HCO 3: 5 mEq/L * CI: 104 mEq/L * Creatinine: 1.0 mg/dL * BUN: 14 mg/dL * Ca: 10 mg/dL * Arterial blood gas on room air: PO 296, PCO 2 15, pH 7.02 * Blood glucose: 90 mg/dL * Urinalysis: normal, without blood, protein, or crystals Which of the following is the most likely acid-base disorder? A. Pure normal anion-gap metabolic acidosis B. Respiratory acidosis C. Pure high anion-gap metabolic acidosis D. Combined high anion-gap metabolic acidosis and respiratory alkalosis E. Combined high anion-gap metabolic acidosis and respiratory

Answer 30

B. Respiratory acidosis

Question 31

A 65-year-old male with mild congestive heart failure is to receive total hip replacement. He has no other underlying diseases and no history of hypertension, recent surgery, or bleeding disorder. Which of the following is the best approach to prevention of pulmonary embolus in this patient? A. Aspirin 75 mg/d B. Aspirin 325 mg/d C. Warfarin with INR of 2 to 3 or low-molecular-weight heparin D. Early ambulation E. Heparin 5000 units subcutaneously every 12 hours

Answer 31

C. Warfarin with INR of 2 to 3 or low-molecular-weight heparin

Question 32

A 20-year-old male is found to have weight loss and generalized lymphadenopathy. He has hypogammaglobulinemia with a normal distribution of immunoglobulin isotypes. Histologic examination of lymphoid tissue shows germinal center hyperplasia. A diagnosis of common variable immuno-deficiency is made. Which of the following statements is correct? A. The patient likely had symptoms in childhood. B. At least one parent is also afflicted with the disease. C. The patient may develop recurrent bronchitis and chronic idiopathic diarrhea. D. The patient should receive the standard vaccine protocol. E. The patient should receive trimethoprim-sulfamethoxazole as prophylaxis against Pneumocystis infections.

Answer 32

C. The patient may develop recurrent bronchitis and chronic idiopathic diarrhea.

Question 33

An 88-year-old resident of a local nursing home is transferred to your facility with shortness of breath. She has been coughing for the past 2 to 3 days. The patient has a history of mild dementia, but has had no witnessed episodes of coughing or choking when eating. Vital signs include a heart rate of 103/minute, respiratory rate of 22/minute, blood pressure 158/68 mm Hg, temperature of 37.9°C (100.2°F) with a weight of 52 kg. Upon examination, she is pleasant but disoriented. Chest auscultation reveals crackles in the left lower lung field. WBC count is 11,000, BUN is 32, and creatinine is 1.3. Chest radiograph shows an infiltrate in the left lower lobe, and induced sputum sample has been sent for Gram stain and culture. What is the best initial course of therapy for this patient? A. Begin a third-generation cephalosporin and macrolide and admit her to the hospital. B. Begin a renal-dosed third-generation cephalosporin and macrolide and admit her to the hospital. C. Begin a respiratory fluoroquinolone and discharge her to the nursing home for follow-up. D. Begin an antipseudomonal carbapenem, antipseudomonal respiratory fluoroquinolone, and glycopeptide and admit her to the hospital. E. Begin a renal-dosed antipseudomonal carbapenem, antipseudomonal respiratory fluoroquinolone, and glycopeptide and admit her to the hospital.

Answer 33

E. Begin a renal-dosed antipseudomonal carbapenem, antipseudomonal respiratory fluoroquinolone, and glycopeptide and admit her to the hospital.

Question 34

A 32-year-old woman has a 3-year history of oligomenorrhea that has progressed to amenorrhea during the past year. She has observed loss of breast fullness, reduced hip measurements, acne, increased body hair, and deepening of her voice. Physical examination reveals frontal balding, clitoral hypertrophy, and a male escutcheon. Urinary free cortisol and dehydroepiandrosterone sulfate (DHEAS) are normal. Her plasma testosterone level is 6 ng/mL (normal is 0.2 to 0.8). Which of the following is the most likely diagnosis? A. Cushing syndrome B. Arrhenoblastoma C. Polycystic ovary syndrome D. Granulosa-theca cell tumor E. Ovarian teratoma

Answer 34

B. Arrhenoblastoma

Question 35

A 27-year-old alcoholic presents with the following electrolytes: calcium 6.9 mg/dL, albumin 3.5 g/dL, magnesium 0.7 mg/dL, phosphorus 2.0mg/dL. Which of the following is the most likely cause of the hypocalcemia? A. Poor dietary intake B. Hypoalbuminemia C. Decreased parathyroid hormone release because of hypomagnesemia D. Decreased end-organ response to parathyroid hormone because of hypomagnesemia E. Osteoporosis caused by hypogonadism

Answer 35

E. Osteoporosis caused by hypogonadism

Question 36

A 55-year-old white woman has had recurrent episodes of alcohol-induced pancreatitis. Despite abstinence, the patient develops postprandial abdominal pain, bloating, weight loss despite good appetite, and bulky, foul-smelling stools. KUB shows pancreatic calcifications. In this patient, you should expect to find which of the following? A. Diabetes mellitus B. Malabsorption of fat-soluble vitamins D and K C. Guaiac-positive stool D. Courvoisier sign E. Markedly elevated amylase

Answer 36

A. Diabetes mellitus

Question 37

A 42-year-old man sees you because of obesity. He played football in high school and at age 18 weighed 250 pounds. He has gradually gained weight since. Many previous attempts at dieting have resulted in transient weight loss of 10 to 15 pounds, which he then rapidly regains. He has been attending Weight Watchers for the last 3 months and has successfully lost 4 pounds. Recent attempts at exercise have been limited because of bilateral knee pain and swelling. On examination height is 6 ft 0 in, weight 340 pounds, BMI 46. Blood pressure with a large cuff is 150/95. Baseline laboratory studies including CBC, biochemical profile, thyroid stimulating hormone and lipids are normal with the exception of fasting serum glucose which is 145 mg/dL. What is the next best step? A. Discuss bariatric surgery with the patient. B. Refer to a commercial weight-loss program. C. Recommend a 1000 calorie per day diet. D. Prescribe sibutramine. E. Recommend a low-fat

Answer 37

A. Discuss bariatric surgery with the patient.

Question 38

A 34-year-old man presents with substernal discomfort. The symptoms are worse after meals, particularly a heavy evening meal, and are sometimes associated with hot/sour fluid in the back of the throat and nocturnal awakening. The patient denies difficulty swallowing, pain on swallowing, or weight loss. The symptoms have been present for 6 weeks; the patient has gained 20 lb in the past 2 years. Which of the following is the most appropriate initial approach? A. Therapeutic trial of ranitidine B. Exercise test with thallium imaging C. Esophagogastroduodenoscopy D. CT scan of the chest E. Coronary angiography

Answer 38

A. Therapeutic trial of ranitidine

Question 39

A 50-year-old woman is on high-dose corticosteroids and immunosuppressives because of renal transplant rejection. She presents with a 10-day history of fever, headache, and confusion. Lumbar puncture reveals 25 lymphocytes per microliter and a very high CSF protein. India ink stain is positive. What is the correct diagnosis? A. Pneumococcal meningitis B. Cryptococcal meningitis C. Coxsackievirus (aseptic) meningitis D. Pyogenic brain abscess E. Listeria monocytogenes meningitis F. Herpes simplex encephalitis G. Cerebral cysticercosis

Answer 39

C. Coxsackievirus (aseptic) meningitis

Question 40

A 37-year-old factory worker develops increasing weakness in the legs; coworkers have noted episodes of transient confusion. The patient has bilateral foot drop and atrophy; mild wrist weakness is also present. His CBC shows an anemia with hemoglobin of 9.6 g/dL; examination of the peripheral blood smear shows basophilic stippling. Which of the following is the most likely cause of this patient's symptoms? A. Amyotrophic lateral sclerosis B. Lead poisoning C. Overuse syndrome D. Myasthenia gravis E. Alcoholism

Answer 40

B. Lead poisoning

Question 41

The teacher of a 14-year-old child recounts episodes where the child stares into space and does not respond to verbal commands for a few seconds. These episodes occur several times per day. An EEG shows 3-per-second spike and slow wave discharges. What is the appropriate diagnosis? A. Absence (petit mal) seizure B. Complex partial seizure C. Simple partial seizure D. D Atonic seizure E. Myoclonic seizure F. Nonconvulsive seizure (pseudoseizure)

Answer 41

A. Absence (petit mal) seizure

Question 42

An 18-year-old male admitted to the hospital because of psychotic behavior is found to have a proximal "wing-beating" tremor, dystonia, and incoordination. Serum transaminases are moderately elevated; brownish corneal deposits are noted on slit-lamp examination. What is the most likely disease process? A. Parkinson disease B. Wilson disease C. Huntington disease D. Dystonia E. Essential tremor F. Tic G. Sydenham chorea

Answer 42

B. Wilson disease

Question 43

A 35-year-old male who had a fever, cough, and sore throat develops chest pain after several days, with diffuse ST-segment elevations on ECG. What is the most likely etiologic agent? A. Candida albicans B. Aspergillus flavus C. Coccidioides immitis D. Herpes simplex type 1 E. Herpes simplex type 2 F. Hantavirus G. Tropheryma whippelii H. Coxsackievirus B I. Histoplasma capsulatum J. Human parvovirus K. Cryptococcus neoformans  

Answer 43

H. Coxsackievirus B

Question 44

Mother of a 5-year-old with sore throat and slapped-cheek rash also develops rash and arthralgia of small joints of the hand. What is the likely infectious agent? A. Herpes simplex virus B. Epstein-Barr virus C. Parvovirus B19 D. Staphylococcus aureus E. Neisseria meningitidis F. Listeria monocytogenes G. Streptococcus viridans H. Haemophilus influenzae

Answer 44

C. Parvovirus B19

Question 45

A 25-year-old woman is admitted with fever and hypotension. She has a 3-day history of feeling feverish. She has no history of chronic disease, but she uses tampons for heavy menses. She is acutely ill and, on physical examination, found to have a diffuse erythematous rash extending to palms and soles. She is confused. Initial blood tests are as follows: White blood cell count: 22,000/uL Na + : 125 mEq/L K + : 3.0 mEq/L Ca ++ : 8.0 mEq/mL Activated partial thromboplastin time (PTT): 65 (normal 21 to 36) Prothrombin time (PT): 12s (normal < 15s) Aspartate aminotransferase: 240 U/L (normal <40) Creatinine: 3.0 mg/dL Antinuclear antibodies: negative Anti-DNA antibodies: negative Serologic tests for RMSF, leptospirosis, measles: negative Which of the following best describes the pathophysiology of the disease process? A. Acute bacteremia B. Toxin-mediated inflammatory response syndrome

Answer 45

B. Toxin-mediated inflammatory response syndrome

Question 46

A 56-year-old woman becomes the chief financial officer of a large company and, several months thereafter, develops upper abdominal pain that she ascribes to stress. She takes an over-the-counter antacid with temporary benefit. She uses no other medications. One night she awakens with nausea and vomits a large volume of coffee grounds-like material; she becomes weak and diaphoretic. Upon hospitalization, she is found to have an actively bleeding duodenal ulcer. Which of the following statements is true? A. The most likely etiology is adenocarcinoma of the duodenum. B. The etiology of duodenal ulcer is different in women than in men. C. The likelihood that she harbors Helicobacter pylori is greater than 50%. D. Lifetime residence in the United States makes H pylori unlikely as an etiologic agent. E. Organisms consistent with H pylori are rarely seen on biopsy in patients with duodenal ulcer

Answer 46

C. The likelihood that she harbors Helicobacter pylori is greater than 50%.

Question 47

What is the most appropriate screening test for a 22-year-old male nurse's aide who is beginning employment at a hospital? A. DNA or RNA amplification tests for chlamydia obtained from the cervix B. Intermediate strength tuberculin skin test C. Abdominal ultrasonography D. Chest x-ray E. Rapid plasma reagin (RPR)

Answer 47

B. Intermediate strength tuberculin skin test

Question 48

A 16-year-old has a sore throat and develops a diffuse rash after administration of ampicillin. What is the likely infectious agent? A. Herpes simplex virus B. Epstein-Barr virus C. Parvovirus B19 D. Staphylococcus aureus E. Neisseria meningitidis F. Listeria monocytogenes G. Streptococcus viridans H. Haemophilus influenzae

Answer 48

B. Epstein-Barr virus

Question 49

An obese 54-year-old white woman has a hemoglobin A1C of 9.5 and elevated urine microalbumin. 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 49

D. Angiotensin-converting enzyme inhibitor

Question 50

A Filipino patient develops a pulmonary nodule after travel through the American Southwest. What is the most likely etiologic agent? A. Candida albicans B. Aspergillus flavus C. Coccidioides immitis D. Herpes simplex type 1 E. Herpes simplex type 2 F. Hantavirus G. Tropheryma whippelii

Answer 50

C. Coccidioides immitis

Question 51

An obese 54-year-old white woman has a hemoglobin A1C of 9.5 and elevated urine microalbumin. 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 51

D. Angiotensin-converting enzyme inhibitor

Question 52

A Filipino patient develops a pulmonary nodule after travel through the American Southwest. What is the most likely etiologic agent? A. Candida albicans B. Aspergillus flavus C. Coccidioides immitis D. Herpes simplex type 1 E. Herpes simplex type 2 F. Hantavirus G. Tropheryma whippelii H. Coxsackievirus B I. Histoplasma capsulatum J. Human parvovirus K. Cryptococcus neoformans

Answer 52

C. Coccidioides immitis

Question 53

A 70-year-old man with unresectable carcinoma of the lung metastatic to liver and bone has developed progressive weight loss, anorexia, and shortness of breath. The patient has executed a valid living will that prohibits the use of feeding tube in the setting of terminal illness. The patient becomes lethargic and stops eating altogether. The patient's wife of 30 years now insists on enteral feeding for her husband. Which of the following is the most appropriate course of action? A. Respect the wife's wishes as a reliable surrogate decision maker. B. Resist the placement of a feeding tube in accordance with the living will. C. Ask the daughter to make the decision. D. Place a feeding tube until such time as the matter can be discussed with the patient. E. Request a court order to place a feeding tube.

Answer 53

B. Resist the placement of a feeding tube in accordance with the living will.

Question 54

A 63-year-old male alcoholic with a 50-pack-year history of smoking presents to the emergency room with fatigue and confusion. Physical examination reveals a blood pressure of 110/70 with no orthostatic change. Heart, lung, and abdominal examination are normal and there is no pedal edema. Laboratory data is as follows: Na: 110 mEq/L K: 3.7 mEq/L CI: 82 mEq/L CO 3: 20 mEq/L Glucose: 100 mg/dL BUN: 5 mg/dL Creatinine: 0.7 mg/dL Urinalysis: normal. Specific gravity: 1.016. Which of the following is the most likely diagnosis? A. Volume depletion B. Inappropriate secretion of antidiuretic hormone C. Psychogenic polydipsia D. Cirrhosis E. Congestive heart failure

Answer 54

B. Inappropriate secretion of antidiuretic hormone

Question 55

A 50-year-old presents with rapidly progressive change in mental status over 3 months. Numerous myoclonic jerks accompany the dementia; the EEG shows repetitive high-voltage polyphasic discharges. What is the most likely diagnosis? A. Senile dementia of the Alzheimer type B. Vascular (multi-infarct) dementia C. Vitamin B12 deficiency. D. Dementia with Lewy bodies E. Creutzfeldt-Jakob disease F. Normal pressure hydrocephalus

Answer 55

E. Creutzfeldt-Jakob disease

Question 56

A 40-year-old paraplegic with an indwelling urinary catheter has recurrent infections. The UA always shows leukocytes and the urine pH is 8. KUB shows the presence of staghorn calculi. What is the most likely type of stone that occurs in this clinical situation? A. Calcium phosphate B. Calcium oxalate C. Cystine D. Struvite E. Uric acid F. Xanthine G. Bilirubin

Answer 56

D. Struvite

Question 57

An 80-year-old male complains of a 3-day history of a painful rash extending over the left half of his forehead and down to his left eyelid. There are weeping vesicular lesions on physical examination. Which of the following is the most likely diagnosis? A. Impetigo B. Adult chickenpox C. Herpes zoster D. Coxsackie A virus E. Herpes simplex

Answer 57

C. Herpes zoster

Question 58

An 80-year-old develops steady, progressive memory and cognitive deficit over 2 years. He has normal blood pressure and no focal neurologic findings, and workup for "treatable" causes of dementia is negative. What is the most likely diagnosis? A. Senile dementia of the Alzheimer type B. Vascular (multi-infarct) dementia C. Vitamin B12 deficiency D. Dementia with Lewy bodies E. Creutzfeldt-Jakob disease F. Normal pressure hydrocephalus

Answer 58

A. Senile dementia of the Alzheimer type

Question 59

A 42-year-old male is persuaded by his wife to come to you for general checkup. She hints of concern about alcohol use.Therefore, you ask the CAGE questions as an initial screen. These include which of the following? A. Concern expressed by family B. Previous Alcoholics Anonymous contact C. Alcohol intake greater than two drinks per 24 hours D. Use of an eye-opener (early-morning alcoholic beverage) E. Presence of excess extremity shakiness

Answer 59

D. Use of an eye-opener (early-morning alcoholic beverage)

Question 60

A 17-year-old female presents with a pruritic rash localized to the wrist. Papules and vesicles are noted in a bandlike pattern, with slight oozing from some lesions. Which of the following is the most likely cause of the rash? A. Herpes simplex B. Shingles C. Atopic dermatitis D. Seborrheic dermatitis E. Contact dermatitis

Answer 60

E. Contact dermatitis

Question 61

An 18-year-old college student presents with fever, neck stiffness, and petechiae on his trunk. What is the likely infectious agent? A. Herpes simplex virus B. Epstein-Barr virus C. Parvovirus B19 D. Staphylococcus aureus E. Neisseria meningitidis F. Listeria monocytogenes G. Streptococcus viridans H. Haemophilus influenzae

Answer 61

E. Neisseria meningitidis

Question 62

A 20-year-old male has a cough and history of bronchitis with thick greenish sputum. There is no history of cigarette smoking. The patient has also been treated for abdominal cramping and malabsorption. What is the most likely diagnosis? A. Small cell carcinoma of the lung B. Bronchoalveolar carcinoma of the lung C. Silicosis D. Pneumonia E. Cystic fibrosis F. Hodgkin disease G. Asbestosis H. Hypersensitivity pneumonitis

Answer 62

E. Cystic fibrosis

Question 63

A 35-year-old female complains of slowly progressive dyspnea. Her past history is negative, and there is no cough, sputum production, pleuritic chest pain, or thrombophlebitis. She has taken appetite suppressants at different times. Physical examination reveals jugular venous distention, a palpable right ventricular lift, and a loud P 2 heart sound. Chest x-ray shows clear lung fields. Oxygen saturation is 94%. ECG shows right axis deviation. A perfusion lung scan is normal, with no segmental deficits. Which of the following is the most likely diagnosis? A. Primary pulmonary hypertension B. Recurrent pulmonary emboli C. Right-to-left cardiac shunt D. Interstitial lung disease E. Left ventricular diastolic dysfunction

Answer 63

A. Primary pulmonary hypertension

Question 64

A 35-year-old white man presents with diarrhea, weight loss, and RLQ pain. On examination, a tender mass is noted in the RLQ; the stool is guaiac-positive. Colonoscopy shows segmental areas of inflammation. Barium small bowel series shows nodular thickening of the terminal ileum. What is the most likely diagnosis? A. Ulcerative colitis B. Crohn disease C. Ischemic colitis. D. Diverticulitis E. Amebic colitis F. Tuberculoma of the colon

Answer 64

B. Crohn disease

Question 65

A 45-year-old diabetic woman presents with two days of severe upper abdominal pain that radiates into the back and has been associated with nausea and vomiting. She takes insulin but has been noncompliant for several weeks. She denies alcohol consumption. Her serum is lipemic. What is the most likely diagnosis? A. Acute diverticulitis B. Acute pancreatitis C. Acute cholecystitis D. Intestinal obstruction E. Irritable bowel syndrome F. Mesenteric ischemia

Answer 65

B. Acute pancreatitis

Question 66

A 42-year-old executive complains of a bandlike tightness across the temples and neck, worse in the afternoon, usually relieved by aspirin or acetaminophen. Neurological examination is normal. What is the appropriate diagnosis? A. Tension headache B. Cluster headache C. Migraine headache D. Temporal arteritis E. Brain tumor F. Sinusitis G. Temporomandibular joint dysfunction H. Tic douloureux

Answer 66

A. Tension headache

Question 67

A 35-year-old male with documented HIV disease has completed his initial evaluation. He feels well but has a CD4 count of 198 uL and a viral load of 200,000 copies per mL. His physical examination has shown no evidence of opportunistic infection. PPD skin test, RPR, routine chemistry, CBC, lipid profile, and fasting blood sugar are all within normal limits. Which of the following is best advice? A. The patient should begin treatment with either two nucleoside analogues and nonnucleoside reverse transcriptase inhibitor or two nucleoside analogues and a protease inhibitor. B. The patient should make his own decision on beginning therapy since time of initiation does not affect mortality in an asymptomatic patient. C. The patient should consider beginning new antiviral agents such as raltegravir or maraviroc. D. Any new regimen should avoid abacavir because of its high incidence of hypersensitivity reactions. E. Genotyping should not be obtained until the patient's first treatment failure.

Answer 67

A. The patient should begin treatment with either two nucleoside analogues and nonnucleoside reverse transcriptase inhibitor or two nucleoside analogues and a protease inhibitor.

Question 68

A 75-year-old patient presents to the ER after a syncopal episode. He is again alert and in retrospect describes occasional substernal chest pressure and shortness of breath on exertion. His blood pressure is 110/80 and lungs have a few bibasilar rales. Which auscultatory finding would best explain his findings? A. A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border B. A diastolic decrescendo murmur heard at the mid-left sternal border C. A holosystolic murmur heard best at the apex D. A midsystolic click E. A pericardial rub

Answer 68

A. A harsh systolic crescendo-decrescendo murmur heard best at the upper right sternal border

Question 69

You are seeing a 45-year-old female patient of your partner for the first time in your clinic. A quick review of the patient's medical record shows that her systolic blood pressure was greater than 140 mm Hg at both of her last clinic appointments. Her medical history is otherwise significant only for diabetes mellitus. Her blood pressure today is 164/92. What is the best next step in her blood pressure management? A. Ask the patient to keep a written record of her blood pressure and bring with her to a return appointment. B. Advise the patient to begin a heart healthy, low sodium diet and refer to a nutritionist. C. Prescribe an ACE inhibitor in addition to heart healthy diet. D. Prescribe a dihydropyridine calcium-channel blocker in addition to a heart healthy diet. E. Arrange for echocardiogram to assess for end-organ damage.

Answer 69

C. Prescribe an ACE inhibitor in addition to heart healthy diet.

Question 70

A 25-year-old male from East Tennessee had been ill for 5 days with fever, chills, and headache when he noted a rash that developed on his palms and soles. In addition to macular lesions, petechiae are noted on the wrists and ankles. The patient has spent the summer camping. Which of the following is the most important fact to be determined in the history? A. Exposure to contaminated springwater B. Exposure to raw pork C. Exposure to ticks. D. Exposure to prostitutes E. Exposure to mosquitos

Answer 70

C. Exposure to ticks.

Question 71

A 50-year-old woman complains of pain and swelling in her proximal interphalangeal joints, both wrists, and both knees. She complains of morning stiffness. She had a hysterectomy 10 years ago. Physical examination shows swelling and thickening of the PIP joints. Hemoglobin is 10.3 g/dL, MCV is 80 fL, serum iron is 28 ug/dL, iron-binding capacity is 200 ug/dL (normal is 250-370 ug/dL), and saturation is 14%. Which of the following is the most likely explanation for this woman's anemia? A. Occult blood loss B. Vitamin deficiency C. Anemia of chronic disease D. Sideroblastic anemia E. Occult renal disease

Answer 71

C. Anemia of chronic disease

Question 72

A 25-year-old female presents to your office with complaints of pain during intercourse for 2 months. She states the pain occurs with initial penetration and continues throughout the entire episode. She relates that she and her husband have been married for a year and previously had a pleasurable, pain free relationship. She tells you that she has been to several area doctors, and had a "full workup" without a diagnosis, including a pelvic examination, pap smear with cultures, and sonogram. When you examine her, she has a normal pelvic examination with no pain. You are unsure of the differential diagnosis, so you continue taking more history. She admits to vaginal dryness and low libido during this same timeframe. You ask if anything in her life changed 2 months ago. She suddenly begins to cry and states she found evidence of her husband's infidelity 2 months ago. What is the most appropriate recommendation for your patient? A. Marriage counseling B. Estrogen vaginal cream for vaginal dryness C. Vaginal dilators for treatment of vaginismus D. Antidepressant therapy E. Physical therapy for pelvic floor spasms

Answer 72

A. Marriage counseling

Question 73

A 20-year-old female presents with tachycardia, tremor, and heat intolerance. On physical examination, no thyromegaly is noted, but she does have RLQ fullness on pelvic examination. TSH is < 0.01, and radionuclide scan reveals low uptake in the thyroid gland. Which of the following is the most likely disease? A. Subacute thyroiditis B. Graves disease C. Factitious hyperthyroidism D. Struma ovarii
 E. Multinodular goiter
 F. Thyroid nodule G. 
lodide deficiency H. TSH-secreting pituitary adenoma

Answer 73

D. Struma ovarii


Question 74

A 30-year-old menstruating female has multisystem disease with hypotension, diffuse erythematous rash with desquamation of skin on hands and feet. What is the likely infectious agent? A. Herpes simplex virus B. Epstein-Barr virus C. Parvovirus B19 D. Staphylococcus aureus E. Neisseria meningitidis F. Listeria monocytogenes G. Streptococcus viridans H. Haemophilus influenzae

Answer 74

D. Staphylococcus aureus

Question 75

A 30-year-old male presents with right upper quadrant pain. He has been well except for an episode of diarrhea that occurred 4 months ago, just after he returned from a missionary trip to Mexico. He has lost 7 pounds. He is not having diarrhea. His blood pressure is 140/70, pulse 80, and temperature 37.5°C (99.5°F). On physical examination there is right upper-quadrant tenderness without rebound. There is some radiation of the pain to the shoulder. The liver is percussed at 14 cm. There is no lower-quadrant tenderness. Bowel sounds are normal and active. Which of the following is the most appropriate next step in evaluation of the patient? A. Serology and ultrasound B. Stool for ova and parasite C. Blood cultures D. Diagnostic aspirate E. Empiric broad-spectrum antibiotic therapy

Answer 75

A. Serology and ultrasound

Question 76

A 75-year-old woman is accompanied by her daughter to your clinic. The daughter reports that her mother fell in her yard last week while watering flowers. Her mother suffered scratches and bruises but no serious injury. The daughter is concerned that her mother might fall again with serious injury. The patient has hypertension and osteoarthritis of the knees. She takes HCTZ, lisinopril, naproxen, and occasional diphenhydramine for sleep. The daughter reports some mild forgetfulness over the past 2 years. The patient gets up frequently at night to urinate. Blood pressure is 142/78 lying and 136/74 standing. Pulse is 64 lying and standing. Except for some patellofemoral crepitance of the knees, her physical examination is normal. A Folstein mini-mental status testing is normal except that she only remembers two of three objects after 3 minutes (29/30). She takes 14 seconds to rise from sitting in a hard backed chair, walk 10 ft, turn, return to the chair, and sit down (timed up-and-go test, normal less than 10 seconds). A CBC, chemistry profile, and thyroid tests are normal. What is the next best step? A. CT scan of the brain. B. Holter monitor. C. Discontinue hydrochlorothiazide and prescribe donepezil. D. Discontinue diphenhydramine, assess her home for fall risks, and prescribe physical therapy. E. EEG. 

Answer 76

D. Discontinue diphenhydramine, assess her home for fall risks, and prescribe physical therapy.

Question 77

Two hours after ingesting potato salad at a picnic, a 50-year-old white woman develops severe nausea and vomiting. She has no diarrhea, fever, or chills. On examination, she appears hypovolemic, but the abdomen is benign. 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 77

A. Staphylococcus aureus

Question 78

A 30-year-old nursing student presents with confusion, sweating, hunger, and fatigue. Blood sugar is 40 mg/dL. The patient has no history of diabetes mellitus, although her sister is an insulin-dependent diabetic. The patient has had several similar episodes over the past year, all occurring just prior to reporting for work in the early morning. At the time of hypoglycemia, the patient is found to have a high insulin level and a low C peptide level. Which of the following is the most likely diagnosis? A. Reactive hypoglycemia B. Pheochromocytoma C. Factitious hypoglycemia D. Insulinoma E. Sulfonylurea use

Answer 78

C. Factitious hypoglycemia

Question 79

Evidence-based guidelines support which of the following cancer screening evaluations? A. Chest x-ray in a 50-year-old male cigarette smoker B. Mammography in a 35-year-old woman with a history of fibrocystic breast disease C. Prostate specific antigen in a 80-year-old man with a brother who has prostate cancer D. Colonoscopy in an asymptomatic 50-year-old man with no family history of colon cancer E. CA-125 in a 45-year-old woman with a sister who was just diagnosed with ovarian cancer

Answer 79

A. Chest x-ray in a 50-year-old male cigarette smoker

Question 80

A 26-year-old medical student plans a 3-week mission trip to Mexico. She will be staying with local villagers and working indoors in a rural area 30 minutes from Mexico City. She has previously been vaccinated for hepatitis B. Of the following choices, which vaccination is most important? A. Inactivated poliovirus vaccine (IPV) booster B. Hepatitis A vaccine C. Rabies vaccine D. Meningococcal vaccine E. Dengue vaccine

Answer 80

B. Hepatitis A vaccine

Question 81

A 45-year-old woman with long-standing, well-controlled rheumatoid arthritis develops severe pain and swelling in the left elbow over 2 days. She is not sexually active. Arthrocentesis reveals cloudy fluid. Synovial fluid analysis reveals >100,000 cells/mL; 98% of these are PMNs. What is the most likely organism to cause this scenario? A. Streptococcus pneumoniae B. Neisseria gonorrhoeae C. Escherichia coli D. Staphylococcus aureus E. Pseudomnonas aeruginosa

Answer 81

D. Staphylococcus aureus

Question 82

A 20-year-old woman complains of skin problems and is noted to have erythematous papules on her face with blackheads (open comedones) and whiteheads (closed comedones). She has also had cystic lesions. She is prescribed topical tretinoin, but without a totally acceptable result. You are considering oral antibiotics, but the patient requests oral isotretinoin, which several of her college classmates have used with benefit. Which of the following statements is correct? A. Intralesional triamcinolone should be avoided due to its systemic effects. B. Systemically administered isotretinoin therapy cannot be considered unless concomitant contraceptive therapy is provided. C. Antimicrobial therapy is of no value since bacteria are not part of the pathogenesis of the process. D. The teratogenic effects of isotretinoin are its only clinically important side effects. E. The patient will not benefit from topical antibiotics since she did not respond to topical retinoids.

Answer 82

B. Systemically administered isotretinoin therapy cannot be considered unless concomitant contraceptive therapy is provided.

Question 83

A young woman complains of one week of fatigue, change in skin color, and dark brown urine. She has right upper quadrant tenderness and ALT of 1035 U/L (normal <40). What is the most likely disease process? A. Hemolysis secondary to G6PD deficiency B. Pancreatic carcinoma C. Acute viral hepatitis D. Crigler-Najjar syndrome E. Gilbert syndrome F. Cirrhosis of liver

Answer 83

C. Acute viral hepatitis

Question 84

A 65-year-old male with diabetes mellitus, bronzed skin, and cirrhosis of the liver is being treated for hemochromatosis previously confirmed by liver biopsy. The patient experiences increasing right upper quadrant pain, and his serum alkaline phosphatase is now elevated. There is a 15-Ib weight loss. Which of the following is the best next step in management? A. Increase frequency of phlebotomy for worsening hemochromatosis. B. Obtain alpha-fetoprotein level and CT scan to rule out hepatoma. C. Obtain hepatitis B serology. D. Obtain antimitochondrial antibody to rule out primary biliary cirrhosis. E. Check a serum ferritin level.

Answer 84

B. Obtain alpha-fetoprotein level and CT scan to rule out hepatoma.

Question 85

A 16-year-old woman develops wheezing and shortness of breath minutes after receiving ceftriaxone for gonorrhea. Her blood pressure is 110/65, her pulse rate is 92, and her respiratory rate is 32. She is anxious, but she is well-perfused peripherally. Which of the following is the treatment of choice for this patient? A. Subcutaneous epinephrine for bronchospasm B. Intravenous fluids C. Prophylactic atropine D. Diazepam to prevent seizures
 E. Antihistamines

Answer 85

A. Subcutaneous epinephrine for bronchospasm

Question 86

A 36-year-old man presents for a well-patient examination. He gives a history that, over the past 20 years, he has had three episodes of abdominal pain and hematemesis, the most recent of which occurred several years ago. He was told that an ulcer was seen on a barium upper Gl radiograph. You obtain a serum assay for H pylori IgG, which is positive. What is the most effective regimen to eradicate this organism? A. Omeprazole 20 mg orally once daily for 6 weeks B. Ranitidine 300 mg orally once daily at bedtime for 6 weeks C. Omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days D. Pepto-Bismol and metronidazole twice daily for 7 days E. Benzathine penicillin, 1.2 million units intramuscularly weekly for three doses

Answer 86

C. Omeprazole 20 mg twice daily, amoxicillin 1000 mg twice daily, and clarithromycin 500 mg twice daily for 14 days

Question 87

65-year-old black female presents for an annual examination. Physical examination is unremarkable for her age. In completing the appropriate screening tests you order a dual x-ray absorptiometry (DXA) to evaluate whether the patient has osteoporosis. DXA results reveal a T-score of -3.0 at the total hip and-2.7 at the spine, consistent with a diagnosis of osteoporosis. Since her Z-score is -2.0, you proceed with an initial evaluation of secondary osteoporosis. Laboratory evaluation reveals N: 19mg/d T: 255,000/ μL OH Vitamin D: 12 ng/mL (optimal > 25) C: 7700/ μL T: 38g/dL Calcium: 9.7mg/dL Glucose: 98 mg/dL a. Normal iPTH, normal ionized calcium, elevated alkaline phosphatase b. Elevated iPTH (intact parathormone), low ionized calcium, normal alkaline phosphatase c. Elevated iPTH, nor

Answer 87

a. Normal iPTH, normal ionized calcium, elevated alkaline phosphatase

Question 88

A 73-year-old male undergoes abandoning aortic aneurysm repair. Postoperatively, his blood pressure is 110/80, heart rate is 110, surgical wound is clean, and a Foley catheter is in place. His urine output drops to 40cc, and creatinine rises from 1.5 to 2.2 mg/dL. Hemoglobin and hematocrit are stable, K uric acid 8.2. which initial diagnostic test most useful for this patient A. Urinalysis B. Urine sodium/creatinine ratio C. Renal ultrasound D. Urine uric acid/creatinine ratio

Answer 88

C. Renal ultrasound

Question 89

a 70 year old male with history of hypertension and diabetes presents with a stepwise loss of intellectual function. Prior episodes have been associated with unilateral weakness and difficulty swallowing. A unilateral Babinski sign is found on neurological examination what is the most likely diagnosis? a. Creutzfeldt-Jakob disease b. Vascular (multi-infarct) dementia c. Dementia with Lewy bodies d. Normal pressure hydrocephalus e. Vitamin B12 deficiency f. Senile dementia of the Alzheimer type

Answer 89

b. Vascular (multi-infarct) dementia

Question 90

37 year old man is brought to the doctor by his family because of intellectual decline over the past 2 months. Examination reveals slow writhing movements with dystonic posturing. His father died of a similar illness. What is the most likely disease process? a. Huntington disease b. Essential tremor c. Sydenham chorea d. Wilson disease e. Tic f. Parkinson disease g. Dystonia

Answer 90

a. Huntington disease

Question 91

An obese 50-year-old woman complains of insomnia, daytime sleepiness, and fatigue. During a sleep study she is found to have recurrent episodes of arterial desaturation - about 30 events per hour-with evidence of obstructive apnea. Which of the following is the treatment of choice for this patient? a. Nasal continuous positive airway pressure B. Uvulopalatopharyngoplasty C. Hypocaloric diet D. Tracheostomy E. Oxygen via nasal cannula

Answer 91

a. Nasal continuous positive airway pressure

Question 92

A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 37.8°C [100°F]), | sore throat, and coryza. On examination, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest examination shows a few basilar rales. Sputum Gram stain shows white blood cells without organisms. Laboratory findings are as follows: Hct: 31 WBC: 12,000/ML Lymphocytes: 50% Mean corpuscular volume (MCV): 94 nL Reticulocytes: 9% of red cells CXR: bilateral patchy lower lobe infiltrates Which of the following is the best method for confirmation of the diagnosis? A. High titers of antibody to adenovirus B. High titers of IgM cold agglutinins or complement fixation test C. Methenamine silver stain D. Blood culture E. Culture of sputum on chocolate media

Answer 92

B. High titers of IgM cold agglutinins or complement fixation test