July MCQ

Question 1

A 61-year-old man with coronary artery disease complains of progressive
orthopnea and pedal edema. He is hospitalized with a blood pressure of
190/105 mm Hg. Cardiac enzyme levels and ECG are normal. Intravenous furosemide
has been administered. Which of the following is the best next step?
A. Prescribe a beta-blocker to decrease myocardial oxygen demands.
B. Start intravenous dopamine.
C. Observe.
D. Start an ACE inhibitor.

Answer 1

D. Elevated blood pressures may exacerbate congestive heart failure and must be treated. Generally, beta-blockers are avoided when patients are volume
overloaded because beta-blockers decrease myocardial contractility. ACE
inhibition reduces afterload, and oral nitrates or IV nitroglycerine reduce
preload, and are used to treat acute heart failure.

Question 2

A 58-year-old woman with aphasia and right-arm weakness of 8 hours’ duration
is seen in the ER. CT scan shows no intracranial hemorrhage. Her blood
pressure is 162/98 mm Hg. Which of the following is the best next step?
A. Normalize the blood pressure with beta-blockade.
B. Admit to ICU with sodium nitroprusside.
C. Normalize the blood pressure with an ACE inhibitor.
D. Observe the blood pressure.

Answer 2

D. In general, blood pressure should not be acutely decreased in an individual
suspected of having a stroke because of the concern for cerebral hypoperfusion
and worsening brain ischemia. If thrombolytic therapy is considered, blood
pressure should be controlled to <185/100 mm Hg, but this patient’s symptom
duration precludes that consideration.

Question 3

In a suicide attempt, an 18-year-old adolescent female took 4 g of acetaminophen,
approximately 8 hours previously. Her acetaminophen level is 30 μg/mL.
Which of the following is the best next step to be performed for this patient?
A. Immediately start N-acetylcysteine
B. Observation
C. Alkalinize the urine
D. Administer intravenous activated charcoal

Answer 3

B. The serum acetaminophen level of 30 μg/mL, with last ingestion 8 hours
previously, is plotted on the nomogram and falls below the “danger zone” of
possible hepatic injury. Thus, this patient should be observed. Sometimes,
patients will take more than one medication so that serum and/or urine drug
testing may be worthwhile. Gastrointestinal activated charcoal, not intravenous
charcoal, is used for other ingestions.

Question 4

A 42-year-old woman presents to your clinic for her annual physical examination.
On examination, you note neck fullness. When you palpate her thyroid,
it is enlarged, smooth, rubbery, and nontender. The patient is asymptomatic.
You send her for thyroid function testing: her T4, free T4, and T3 are normal,
but her TSH is slightly elevated. Which of the following is the most likely
diagnosis?
A. Iodine deficiency
B. Thyroid cancer
C. Hashimoto thyroiditis
D. Graves disease
E. Multinodular goiter

Answer 4

C. Hashimoto thyroiditis is the most common cause of hypothyroidism with
goiter in the United States. It is most commonly found in middle-aged women,
although it can be seen in all age groups. Patients can present with a rubbery,
nontender goiter that may have “scalloped” borders. Iodine defi ciency is
exceedingly uncommon in the United States because of iodized salt. Graves
disease is a hyperthyroid condition. Patients with multinodular goiter usually
are euthyroid. Patients with thyroid cancer usually are euthyroid and have a
history of head and neck irradiation.

Question 5

Which of the following laboratory tests could be performed to confirm your
diagnosis of the patient with Hashimoto thyroiditis?
A. Repeat thyroid function tests
B. Thyroid ultrasound
C. Nuclear thyroid scan
D. Antithyroid antibody tests
E. Complete blood count with differential

Answer 5

D. Hashimoto thyroiditis is an autoimmune disease of the thyroid. Several different autoantibodies directed toward components of the thyroid gland will be present in the patient’s serum; however, of these, antithyroperoxidase antibody
almost always is detectable (also called antimicrosomal antibody). These
antibodies are the markers, not the cause, of gland destruction. On thyroid
biopsy, lymphocytic infiltration and fi brosis of the gland are pathognomonic.
The presence of these autoantibodies predicts progressive gland failure and the need for hormone replacement. None of the other tests will be helpful.

Question 6

A 35-year-old woman who was diagnosed with hypothyroidism 4 weeks ago
presents to your clinic complaining of persistent feelings of fatigue and sluggishness.
After confi rming your diagnosis with a measurement of the TSH,
you started her on levothyroxine 50 μg daily. She has been reading about her
diagnosis on the Internet and wants to try desiccated thyroid extract instead of
the medicine you gave her. On examination, she weighs 175 lb, her heart rate
is 64 bpm at rest, and her blood pressure is normal. Which of the following is
the best next step?
A. Tell her that this delay in resolution of symptoms is normal and schedule
a follow-up visit with her in 2 months.
B. Change her medication, as requested, to thyroid extract and titrate.
C. Increase her dose of levothyroxine and have her come back in 4 weeks.
D. Tell her to start a multivitamin with iron to take with her levothyroxine.

Answer 6

C. Levothyroxine is the preferred replacement hormone for hypothyroidism.
The amount of hormone batch to batch and the patient dose response are
believed to be more predictable than with other forms of hormone replacement,
such as thyroid extract, which is made from desiccated beef or pork
thyroid glands. There is no evidence that the natural hormone replacement is
superior to the synthetic form. The dose of levothyroxine should be titrated to
relief of symptoms, as well as to normalization of the TSH. Other medications,
especially iron-containing vitamins, should be taken at different times than
levothyroxine because they may interfere with absorption.

Question 7

A 35-year-old man presents to your clinic with ulcerative colitis. Choose the
cause that is probably responsible for the patient’s presentation.
A. Wilson disease
B. Hematochromatosis
C. Primary biliary cirrhosis
D. Sclerosing cholangitis
E. Autoimmune hepatitis
F. Alcohol-induced hepatitis
G. Viral hepatitis

Answer 7

D. Sclerosing cholangitis is an autoimmune destruction of both the intrahepatic and extrahepatic bile ducts and often is associated with inflammatory bowel disease, most commonly ulcerative colitis. Patients present with jaundice or symptoms of biliary obstruction; cholangiography reveals the characteristic
beading of the bile ducts.

Question 8

A 56-year-old woman who presented with complaints of pruritus and fatigue
has elevated alkaline phosphatase. Select the cause that is probably responsible
for the patient’s presentation.
A. Wilson disease
B. Hematochromatosis
C. Primary biliary cirrhosis
D. Sclerosing cholangitis
E. Autoimmune hepatitis
F. Alcohol-induced hepatitis
G. Viral hepatitis

Answer 8

C. Primary biliary cirrhosis is thought to be an autoimmune disease leading to
destruction of small- to medium-size bile ducts. Most patients are women between
the ages of 35 and 60 years, who usually present with symptoms of pruritus and
fatigue. Alkaline phosphatase elevated two to five times above the baseline
should raise suspicion; diagnosis is confi rmed with antimitochondrial Ab.

Question 9

A 43-year-old man who is an alcoholic is admitted to the hospital with acute
pancreatitis. He is given intravenous hydration and is placed NPO. Which of
the following findings is a poor prognostic sign?
A. His age
B. Initial serum glucose level of 60 mg/dL
C. Blood urea nitrogen (BUN) level rises 7 mg/dL over 48 hours
D. Hematocrit drops 3%
E. Amylase level of 1000 IU/L

Answer 9

C. When the BUN rises by 5 mg/dL after 48 hours despite IV hydration, it is a
poor prognostic sign. Notably, the amylase level does not correlate to the severity
of the disease. An elevated serum glucose would be a poor prognostic factor.
A drop in hematocrit of at least 10% is a significant poor prognostic criterion.

Question 10

A 49-year-old man is admitted to the intensive care unit (ICU) with a diagnosis
of an inferior myocardial infarction. His heart rate is 35 bpm and blood
pressure 90/50 mm Hg. His ECG shows a Mobitz type I heart block. Which of
the following is the best next step?
A. Atropine
B. Transvenous pacer
C. Lidocaine
D. Observation

Answer 10

A. This patient’s bradycardia is severe, probably a result of the inferior myocardial
infarction. Atropine is the agent of choice in this situation. Mobitz type I
block has a good prognosis (vs complete heart block), so transvenous pacing is
not usually required.

Question 11

17.1 A 63-year-old woman with a history of cervical cancer treated with hysterectomy
and pelvic irradiation now presents with acute oliguric renal failure. On
physical examination, she has normal jugular venous pressure, is normotensive
without orthostasis, and has a benign abdominal examination. Her urinalysis
shows a specific gravity of 1.010, with no cells or casts on microscopy. Urinary
FENa is 2%, and the Na level is 35 mEq/L. Which of the following is the best
next step?
A. Bolus of intravenous fluids
B. Renal ultrasound
C. Computed tomographic (CT) scan of the abdomen with intravenous
contrast
D. Administration of furosemide to increase her urine output

Answer 11

B. Renal ultrasound is the next appropriate step to assess for hydronephrosis
and to evaluate for bilateral ureteral obstructions, which are common sites
of metastases of cervical cancer. Her physical examination and urine studies
(showing an FE > 1%) are inconsistent with hypovolemia, so intravenous
infusion is unlikely to improve her renal function. Use of loop diuretics may
increase her urine output somewhat but does not help to diagnose the cause of
her renal failure or to improve her outcome. Further imaging may be necessary
after the ultrasound, but use of intravenous contrast at this point may actually
worsen her renal failure.

Question 12

A 62-year-old diabetic man underwent an abdominal aortic aneurysm repair
2 days ago. He is being treated with gentamicin for a urinary tract infection.
His urine output has fallen to 300 mL over 24 hours, and his serum creatinine
has risen from 1.1 mg/dL on admission to 1.9 mg/dL. Which of the following
laboratory values would be most consistent with a prerenal etiology of his renal insufficiency?
A. FENa of 3%
B. Urinary sodium level of 10 mEq/L
C. Central venous pressure reading of 10 mm Hg
D. Gentamicin trough level of 4 μg/mL

Answer 12

B. Prerenal insuffi ciency connotes insuffi cient blood volume, typically with
FENa less than 1% and urinary sodium less than 20 mEq/L. Supporting information
would be a low central venous pressure reading (normal central venous
pressure is 4-8 mm Hg). The gentamicin level of 4 μg/mL is elevated (normal
<2 μg/mL) and may predispose to kidney damage.

Question 13

A 25-year-old woman complains of pain in her PIP and metacarpophalangeal
(MCP) joints and reports a recent positive ANA laboratory test. Which of the
following clinical features would not be consistent with a diagnosis of SLE?
A. Pleural effusion
B. Malar rash
C. Sclerodactyly
D. Urinary sediment with RBC casts

Answer 13

C. Sclerodactyly, which is thickened and tight skin of the fingers and toes, is
a classic feature of patients with scleroderma (who may also have a positive
ANA test), but is not seen in SLE. The other findings (malar rash, serositis,
glomerulonephritis) are typical of SLE, but not seen in scleroderma.

Question 14

Which of the following is the best screening test for early diabetic nephropathy?
A. Urine microalbuminuria
B. Dipstick urinalysis
C. Renal biopsy
D. Fasting blood glucose
E. Twenty-four-hour urine collection for creatinine clearance

Answer 14

A. Although a 24-hour urine collection for creatinine may be useful in assessing
declining GFR, it is not the best screening test for the diagnosis of early
diabetic nephropathy. In the outpatient setting, a dipstick urinalysis is readily
available but will detect only patients with overt nephropathy (proteinuria
>300 mg/d). Thus, a random urinary albumin/creatinine ratio of 30/300 is
the best test to screen for early diabetic nephropathy. A fasting blood glucose
may aid in the diagnosis of diabetes but not nephropathy. Finally, although
most patients with nephrotic syndrome require a renal biopsy for diagnosis,
a patient with worsening renal function who has had long-standing diabetes
is assumed to have renal disease secondary to diabetic nephropathy, and the
majority of these patients do not undergo a renal biopsy.

Question 15

Which of the following patients is most likely to be a candidate for bone
mineral density screening?
A. A 65-year-old, thin, white woman who smokes and is 15 years
postmenopausal
B. A 40-year-old white woman who exercises daily and still menstruates
C. A healthy 75-year-old white man who is sedentary
D. A 60-year-old overweight African American woman
E. A 35-year-old asthmatic woman who took prednisone 40 mg/d for a
2-week course 1 week ago

Answer 15

A. Of the choices, this woman is the only individual with risk factors. Risk factors
include white race, age, postmenopausal status, smoking, positive family
history, poor nutritional status, and chronic treatment with a drug known to
predispose to bone loss.

Question 16

During which of the following periods in a woman’s life is the most bone mass
accumulated?
A. Ages 15-25
B. Ages 25-35
C. Ages 35-45
D. Ages 45-55

Answer 16

A. The time of greatest accumulation of bone mass in women is during
adolescence.

Question 17

Which of the following agents most closely resembles the action of alcohol in
the brain?
A. Amphetamines
B. Marijuana
C. Cocaine
D. Benzodiazepine
E. Acetaminophen

Answer 17

D. Alcohol and benzodiazepines both interact with the γ-aminobutyric acid
(GABA) system; thus, benzodiazepines are the drugs of choice for treatment
of acute alcohol withdrawal.

Question 18

Compared with dementia, which of the following is a characteristic of delirium?
A. A fluctuating level of consciousness
B. Slow onset
C. Can be due to deficiencies of thiamine or cyanocobalamin
D. Decreased memory ability

Answer 18

A. Fluctuating levels of alertness and consciousness are typical of delirium.

Question 19

34-year-old man is brought to the emergency room for extreme tremors and
auditory hallucinations. Which of the following statements is most likely to
be correct?
A. Auditory hallucinations are unique to alcohol withdrawal and cannot be
caused by a brain tumor.
B. If the serum blood alcohol level is higher than the legal limits of intoxication,
these symptoms cannot be alcohol withdrawal.
C. This patient should receive glucose intravenously for possible hypoglycemia.
D. If the patient also has hypertension, fever, and tachycardia, he has a
5%-10% chance of mortality.

Answer 19

D. DT with autonomic instability and sympathetic overactivity is associated
with a 5%-10% mortality. Auditory hallucinations can occur from a number of
illicit agents or even brain tumors. The fall in serum blood alcohol level and
not the absolute level may induce symptoms of withdrawal. An individual who
abuses alcohol should fi rst be given thiamine, before glucose is administered,
to prevent acute Wernicke encephalopathy.

Question 20

Which of the following asymptomatic patients would most benefit from treatment of the finding of more than 105 CFU/mL of Escherichia coli on urine culture?
A. A 23-year-old asymptomatic sexually active woman
B. A 33-year-old asymptomatic pregnant woman
C. A 53-year-old asymptomatic diabetic woman
D. A 73-year-old asymptomatic woman in a nursing home

Answer 20

B. All of these patients are asymptomatic, and no benefi t from treatment in
terms of reduction in symptomatic UTIs or hospitalization has been shown
for any of the other cases mentioned, except for pregnancy. Treatment is
undertaken to prevent upper tract infection, preterm delivery, and possible
fetal loss.

Question 21

Which of the following is the best treatment for a 39-year-old woman with fever of 103°F, nausea, flank pain, and more than 105 CFU/mL of E coli in a urine culture?
A. Oral trimethoprim-sulfamethoxazole for 3 days
B. Single-dose ciprofloxacin
C. Intravenous and then oral gatifloxacin for 14 days
D. Oral ampicillin for 21-28 days

Answer 21

C. The patient in this scenario has symptoms of upper tract infection, for
example, pyelonephritis, and is moderately ill with nausea. She will need a
14-day course of treatment and may not be able to take oral antibiotics initially,
so hospitalization and treatment with intravenous antibiotics likely will
be necessary. Single-dose and 3-day regimens are useful only for acute uncomplicated
cystitis in women. E coli is frequently resistant to ampicillin.

Question 22

Which of the following features is not consistent with the diagnosis of irritable
bowel syndrome?
A. Abdominal pain relieved with defecation
B. Sensation of incomplete evacuation
C. Passage of mucus
D. Nocturnal awakening with pain or diarrhea
E. Normal bowel habits alternating with either diarrhea or constipation

Answer 22

D. Nocturnal diarrhea is not typically associated with IBS, and should prompt
further investigation, for example, with imaging or colonoscopy. The other
symptoms listed are included in commonly used diagnostic criteria for IBS. It
should be remembered that IBS is essentially a diagnosis of exclusion, and is
established when patients have typical symptoms, but other conditions with
similar clinical presentations have been excluded in a cost-effective manner.

Question 23

Which of the following findings is more consistent with an osmotic, rather
than a secretory, diarrhea?
A. The diarrhea persists despite a 48-hour fast.
B. Stool osmolality = 290 mOsm, stool Na = 95 mOsm, stool K = 15 mOsm.
C. Diarrhea is large volume and watery, and is accompanied by paroxysms of
flushing and wheezing.
D. Profuse, painless “rice-water” stool in a patient in a cholera-endemic area.

Answer 23

B. Normal stool osmolality is equal to plasma, about 290 mOsm. In secretory
diarrhea, most of the osmotically active particles are electrolytes, and can be
calculated as 2 × [Na + K]. The size of osmotic gap (the difference between calculated
and directly measured osmolality) is equivalent to the concentration
of the poorly absorbed unmeasured solute in the fecal water. This patient has a
stool osmotic gap of 70 (gap >50 is indicative of osmotic diarrhea). Answers C
and D are suggestive of carcinoid syndrome and cholera infection, respectively,
both causes of secretory diarrhea.

Question 24

Which of the following patients is not a good candidate for evaluation for
celiac disease, with either endoscopy or serologic testing?
A. A 26-year-old woman who experiences with intermittent abdominal
bloating but no diarrhea and is found to have osteopenia and vitamin D
deficiency.
B. A 19-year-old college freshman with bulky, foul-smelling, floating stools
and excessive flatulence, who has lost 20 lb unintentionally.
C. A thin, 39-year-old man with a family history of celiac disease, who has
been adhering to a gluten-free vegetarian diet for the last 3 years, and now
complains of gassiness and reflux.
D. A 42-year-old man who was found to have iron deficiency anemia, but has
no gastrointestinal symptoms, and recently had a negative colonoscopy.

Answer 24

C. While GI symptoms in a patient with a family history of celiac disease are
reasonable to investigate, the fact that he has been on a gluten-free diet for
a prolonged period greatly diminishes the sensitivity of both endoscopic and
serologic testing. Unexplained osteopenia and vitamin D defi ciency in a young
woman, unexplained iron defi ciency anemia in any patient, and the classic
presentation with steatorrhea and weight loss should all be investigated

Question 25

A 28-year-old woman complains of excessive bleeding from her gums and has
petechiae. Her CBC shows a platelet count of 22 000/mm3 with a hemoglobin
of 8.9 g/dL and a WBC count of 87,000/mm3. Which of the following is the
most likely etiology of her low platelet count?
A. Immune thrombocytopenia purpura
B. Systemic lupus erythematosus
C. Drug-induced thrombocytopenia
D. Acute leukemia

Answer 25

D. The thrombocytopenia is seen with other hematologic abnormalities, the
most abnormal of which is a markedly elevated WBC count, suggesting acute
leukemia.

Question 26

A 75-year-old woman, diagnosed with stage 0 CLL 1 year ago and being
monitored without treatment, now complains of fatigue and dyspnea. She
has no palpable adenopathy or splenomegaly, no rashes or arthritis, and her
CBC shows ALC 11 000/μL, with hemoglobin 6.8 mg/dL, and platelet count
127 000/μL. What is the most appropriate diagnostic test?
A. Direct antiglobulin (Coombs) test
B. Antinuclear antibody
C. Bone marrow biopsy
D. Test for Lewis alloantibody

Answer 26

A. The most likely diagnosis is autoimmune hemolytic anemia (AIHA),
which can be confirmed by detection of antibody and/or complement components
on the surface of the RBC, usually by the direct antiglobulin (Coombs)
test. AIHA is a common complication of CLL. ANA to screen for systemic
lupus erythematosus has a low probability in a woman of this age, without
other clinical features of SLE. Bone marrow biopsy to evaluate for bone marrow
failure due to CLL could be considered, but rapid progression to stage III/
IV would be unlikely. Lewis alloantibodies have no clinical significance.

Question 27

A 75-year-old man presents to the emergency room with the sudden onset of
nausea and vomiting. His medical history is notable for coronary artery disease
and well-controlled hypertension. On examination he refuses to open his eyes
or move his head, but when fi nally coaxed to sit up, he immediately starts to
retch and vomit. Rotational nystagmus is noted. He cannot walk because of
the dizziness and nausea that walking evokes. His noncontrast brain CT scan
is read as normal for age. Which of the following is the best next step?
A. MRI/magnetic resonance angiography (MRA).
B. Obtain a thorough psychosocial history.
C. Dix-Hallpike maneuver.
D. Prescribe meclizine.
E. Referral to neurology.

Answer 27

A. This patient has symptoms of central vertigo. The onset of symptoms was
abrupt and severe. His gait is affected. If he were able to cooperate with an
examination of his cerebellar functions, it would most likely be abnormal. His
age and history of hypertension and coronary artery disease place him at elevated
risk for cerebellar infarction or hemorrhage. CT is not the appropriate
test for examining the brainstem; MRI is much more accurate. MRA may be
useful for delineating the exact vascular cause of the symptoms.

Question 28

A 42-year-old woman from Pakistan is being treated with infl iximab for
rheumatoid arthritis. After 6 months of therapy, she develops persistent
fever, weight loss, and night sweats, and tuberculosis is suspected. Which of
the following is the most likely location of the tuberculosis?
A. Middle and lower lung zones
B. Pleural space
C. Apical segment of the upper lung lobes
D. Cervical or supraclavicular lymph nodes

Answer 28

C. Reactivation tuberculosis (in this case, likely triggered by infl iximab) usually
involves the apical aspects of the lungs. Primary TB infection most often
affects the middle and lower lung zones. Lymphadenitis and pleural infection
are the most common extrapulmonary sites of TB, but they are less common
than pulmonary TB.

Question 29

A 25-year-old woman is seen in the clinic because her father, who recently
immigrated from South America, was diagnosed with and has been treated for
tuberculosis. She denies a cough and her chest radiograph is normal. A PPD
test shows 10 mm of induration. Her only medication is an oral contraceptive.
Which of the following is the best next step?
A. Oral isoniazid and barrier contraception.
B. Combination therapy including isoniazid, rifampin, and pyrazinamide.
C. Observation.
D. Induce three sputum samples.

Answer 29

A. Because this woman is a household contact of a patient with active TB, she
is among the highest risk group: her skin test would be considered positive with
5 mm induration. She has latent TB infection and should be offered treatment
to prevent reactivation TB later in life. Oral contraceptives may reduce drug
levels, so barrier contraception might be a better option for her.

Question 30

A 35-year-old woman is noted to have a positive Kussmaul sign. Which of the
following conditions does she most likely have?
A. Constrictive pericarditis
B. Cardiac tamponade
C. Dilated cardiomyopathy
D. Diabetic ketoacidosis

Answer 30

A. Kussmaul sign, an increase in neck veins with inspiration, is seen with
constrictive pericarditis.

Question 31

Which of the following is the most sensitive fi nding in patients with cardiac
tamponade?
A. Disappearance of radial pulse during inspiration
B. Drop in systolic blood pressure more than 10 mm Hg during inspiration
C. Rise in heart rate more than 20 bpm during inspiration
D. Distant heart sounds

Answer 31

B. Pulsus paradoxus is a sensitive although nonspecifi c sign for cardiac
tamponade.

Question 32

While awaiting pericardiocentesis, immediate supportive care of a patient
with cardiac tamponade should include which of the following?
A. Diuresis with furosemide
B. Intravenous fluids
C. Nitrates to lower venous congestion
D. Morphine to relieve dyspnea

Answer 32

B. Patients with cardiac tamponade are preload dependent, and diuretics,
nitrates, or morphine may cause them to become hypotensive.

Question 33

Which of the following is most likely to cause restrictive cardiomyopathy?
A. Endomyocardial fibrosis
B. Viral myocarditis
C. Beriberi (thiamine deficiency)
D. Doxorubicin therapy

Answer 33

A. Endomyocardial fi brosis is an etiology of restrictive cardiomyopathy, common
in developing countries, that is associated with eosinophilia. The other
disease processes mentioned are causes of dilated cardiomyopathy.