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Question 1

An 18-year-old male has been seen in the clinic for urethral discharge. He is treated with ceftriaxone, but the discharge has not resolved and the culture has returned as no growth. Which of the following is the most likely etiologic agent to cause this infection?
A. Ceftriaxone-resistant gonococci
B. Chlamydia psittaci
C. Chlamydia trachomatis
D. Herpes simplex
E. Chlamydia pneumoniae

Answer 1

C. Chlamydia trachomatis

Question 2

A 21-year-old female presents for her annual examination. She enjoys drinking to excess on the weekends with her friends and smokes cigarettes to “keep her weight down.” She avoids dairy products because they cause bloating and diarrhea.
Her medications include birth control pills and OTC antihistamine. She runs 3 miles per day at least 5 days per week. She is 5 ft 2 in and 105 Ib. In addition to counseling her on using a barrier method for avoidance of sexually transmitted diseases, what other advice should you give?
A. Binge drinking has no adverse health repercussions
B. She shouldn’t start vitamin D or calcium until after menopause.
C. She should change her current exercise routine to water aerobics.
D. She has several significant factors contributing to a low peak bone mass.
E. Smoking is an acceptable form of weight control.

Answer 2

D. She has several significant factors contributing to a low peak bone mass.

Question 3

A 26-year-old man complains of heaviness in the left testicle. There has been no recent trauma. Physical examination reveals a 3-cm painless firm mass that clearly arises from the testicle. The physical examination is otherwise unremarkable. Abdominal CT scan shows matted periaortic lymphadenopathy, with the largest node approximately 3.5 cm in size. CT of the chest shows no abnormalities. In addition to urological referral, what should be the next diagnostic study?
A. Needle aspiration biopsy of the retroperitoneal mass
B. Needle aspiration of the testicular mass
C. Measurement of alpha fetoprotein, beta HCG and lactate dehydrogenase (LDH)
D. Positron emission tomography (PET) scan
E. Measurement of carcinoembryonic antigen (CEA) and a-fetoprotein

Answer 3

C. Measurement of alpha fetoprotein, beta HCG and lactate dehydrogenase (LDH)

Question 4

A 78-year-old woman comes to your office with symptoms of insomnia nearly every day, fatigue, weight loss of over 5% of body weight over the past month, loss of interest in most activities, and diminished ability to concentrate. Physical examination is normal. Which treatment is most likely to improve her symptomatology?
A. Antidepressant
B. Donepezil
C. Iron supplement.
D. Prednisone
E. Thyroid supplement

Answer 4

A. Antidepressant

Question 5

A 63-year-old woman with cirrhosis caused by chronic hepatitis C is hospitalized because of confusion. She has guaiac-positive stools and a low-grade fever. She has received lorazepam for sleep disturbance. On physical examination, the patient is confused. She has no meningeal signs and no focal neurologic findings. There is hyperreflexia and a nonrhythmic flapping tremor of the wrists. Which of the following is the most likely explanation for this patient’s mental status change?
A. Tuberculous meningitis
B. Subdural hematoma
C. Alcohol withdrawal seizure
D. Hepatic encephalopathy
E. Central nervous system vasculitis from cryoglobulinemia

Answer 5

D. Hepatic encephalopathy

Question 6

A 48-year-old woman complains of joint pain and morning stiffness for 4 months. Examination reveals swelling of the wrists and MCPs as well as tenderness and joint effusion in both knees. The rheumatoid factor is positive, antibodies to cyclic citrullinated protein are present, and subcutaneous nodules are noted on the extensor surfaces of the forearm. Which of the following statements is correct?
A. Prednisone 60 mg per day should be started.
B. The patient has RA and should be evaluated for disease-modifying antirheumatic therapy.
C. A nonsteroidal antiinflammatory drug should be added to aspirin.
D. The patient’s prognosis is highly favorable

Answer 6

B. The patient has RA and should be evaluated for disease-modifying antirheumatic therapy.

Question 7

A 64-year-old man complains of cough, increasing shortness of breath, and headache for the past 3 weeks. He has mild hypertension for which he takes hydrochlorothiazide; he has smoked one pack of cigarettes a day for 40 years. On examination you notice facial plethora and jugular venous distension to the angle of the jaw. He has prominent veins over the anterior chest and a firm to hard right supraclavicular lymph node. Cardiac examination is normal and lungs are without rales. Peripheral edema is absent. What is the most likely cause of his condition?
A. Long-standing hypertension
B. Gastric carcinoma
C. Emphysema
D. Lung cancer
E. Nephrotic syndrome

Answer 7

D. Lung cancer

Question 8

You are helping with school sports physicals and see a 16-year-old boy who has had trouble keeping up with his peers. Which of the following auscultatory findings suggests a previously undiagnosed ventricular septal defect?
A. A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with radiation to the carotids; the murmur is augmented with exercise.
B. A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border.
C. A holosystolic murmur at the mid-left sternal border.
D. A diastolic decrescendo murmur at the mid-left sternal border.
E. A continuous murmur through systole and diastole at the upper left sternal border.

Answer 8

C. A holosystolic murmur at the mid-left sternal border.

Question 9

A 35-year-old male complains of inability to close his right eye. Examination shows facial nerve weakness of the upper and lower halves of the face. There are no other cranial nerve abnormalities, and the rest of the neurological examination is normal. Examination of the heart, chest, abdomen, and skin show no additional abnormalities. There is no lymphadenopathy. About one month ago the patient was seen by a dermatologist for a bull’s-eye skin rash. The patient lives in upstate New York and returned from a camping trip a few weeks before noting the rash. Which of the following is the most likely diagnosis?
A. Sarcoidosis
B. Idiopathic Bell palsy
C. Lyme disease
D. Syphilis
E. Lacunar infarct

Answer 9

C. Lyme disease

Question 10

A 37-year-old smoker who takes birth control pills presents with sudden weakness and numbness of the right side of her body. She has a severe expressive aphasia and tends to neglect the deficit on her right side. For this symptom of cerebrovascular disease, select the site of the lesion. Each lettered option may be used once, more than once, or not at all.
A. Vertebral artery
B. Middle cerebral artery
C. Midbasilar artery
D. Anterior cerebral artery
E. Penetrating branch, middle cerebral artery
F. Superior cerebellar artery

Answer 10

B. Middle cerebral artery

Question 11

A 28-year-old laborer sees you because of low back pain. Ten days ago he strained his back while moving a refrigerator. Despite taking acetaminophen, his pain has worsened. He has difficulty sleeping because of the pain and for the past 3 days he has spent most of the day in bed. He has not had fever, leg numbness or weakness, or bladder or bowel problems. He takes no regular prescription medications. On examination he has difficulty getting on and off the examination table because of back pain. He has normal vital signs including a normal temperature. There is evidence of bilateral paraspinous muscle spasm. The patient is able to walk on his heels and toes and has negative straight leg raising test bilaterally. What is the next best step in the treatment of this patient?
A. Two view lumbar spine
B. MRI scan of the lumbar spine
C. Continued bed rest
D. Massage and nonsteroidal anti-inflammatories
E. Epidural corticosteroids

Answer 11

D. Massage and nonsteroidal anti-inflammatories

Question 12

A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?
A. The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor should be obtained.
B. The prodrome of lethargy suggests chronic fatigue syndrome.
C. Lack of systemic symptoms suggests osteoarthritis.
D. X-rays of the hand are likely to show joint space narrowing and erosion.
E. An aggressive search for occult malignancy is indicated.

Answer 12

A. The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor should be obtained.

Question 13

A 25-year-old white female presents to your office for an annual examination. She is a G2P2 and had a bilateral tubal ligation after her last child was born (3 years ago). Her menstrual periods are regular; her LMP was 2 weeks before her visit. On review of systems she describes two to three headaches per month for the past year, usually unilateral and occasionally associated with nausea. The headaches last for several hours. She denies visual changes or other neurological changes when the headaches occur. She had migraine headaches in high school, but they stopped when she was about 20. She has not noted that foods, alcohol, stress, or fatigue trigger the headaches. Her headaches usually happen within the same several-day period and are not spread out over the month. Her last bout with the headaches occurred about 2½ weeks ago. What is the most likely diagnosis?
A. Tension headache
B. Cluster headache
C. Sinus headache
D. Classic migraine
E. Menstrual migraine

Answer 13

E. Menstrual migraine

Question 14

What is the most appropriate screening test for a 23-year-old asymptomatic unmarried woman who is in a monogamous relationship?
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 14

A. DNA or RNA amplification tests for chlamydia obtained from the cervix

Question 15

A 35-year-old woman complains of aching all over. She says she sleeps poorly and all her muscles and joints hurt. Her symptoms have progressed over several years. She reports she is desperate because pain and weakness often cause her to drop things. Physical examination shows multiple points of tenderness over the neck, shoulders, elbows, and wrists. There is no joint swelling or deformity. A complete blood count and erythrocyte sedimentation rate are normal. Rheumatoid factor is negative. Which of the following is the best therapeutic option in this patient?
A. Graded aerobic exercise
B. Prednisone
C. Weekly methotrexate
D. Hydroxychloroquine
E. A nonsteroidal anti-inflammatory drug

Answer 15

A. Graded aerobic exercise

Question 16

A 70-year-old man presents with a complaint of fatigue. There is no history of alcohol abuse or liver disease; the patient is taking no medications. Scleral icterus is noted on physical examination; the liver and spleen are nonpalpable. The patient has a normocytic, normochromic anemia. Urinalysis shows bilirubinuria with absent urine urobilinogen. Serum bilirubin is 12 mg/dL, AST and ALT are normal, and alkaline phosphatase is 300 U/L (three times normal). Which of the following is the best next step in evaluation?
A. Ultrasound or CT scan of the abdomen
B. Viral hepatitis profile
C. Reticulocyte count
D. Serum ferritin
E. Antimitochondrial antibodies

Answer 16

A. Ultrasound or CT scan of the abdomen

Question 17

A 58-year-old male complains of the sudden onset of syncope. It occurs without warning and with no sweating, dizziness, or light headedness. He believes episodes tend to occur when he turns his head too quickly or sometimes when he is shaving. Physical examination is unremarkable. He has no carotid bruits, and cardiac examination is normal. Which of the following is the best way to make a definitive diagnosis in this patient?
A. ECG
B. Carotid massage with ECG monitoring
C. Holter monitor
D. Electrophysiologic study to evaluate the AV node
E. Carotid duplex ultrasonogram

Answer 17

B. Carotid massage with ECG monitoring

Question 18

A 45-year-old G2P2 female presents for annual examination. She reports regular menstrual cycles lasting 3 to 5 days. She exercises 5 times per week and reports no difficulty sleeping. Her weight is stable 140 lbs and she is 5 ft 8 in tall. Physical examination is unremarkable. Laboratory studies are normal with the exception of a TSH value of 6.6 mU/L (normal 0.4-4.0 mU/L). Which of the following represents the best option for management of this patient’s elevated TSH?
A. Repeat TSH in 3 months and reassess for signs of hypothyroidism.
B. Begin low dose levothyroxine (25-50 g/d).
C. Recommend dietary iodide supplementation.
D. Order thyroid uptake scan.

Answer 18

A. Repeat TSH in 3 months and reassess for signs of hypothyroidism.

Question 19

A 75-year-old male presents with a 6 month history of nasal congestion, mild epistaxis and sinus tenderness. He develops a cough and peripheral edema. CT scan of the sinuses shows evidence of chronic sinusitis, and the chest x-ray reveals several nodular densities, one with early cavitation. His serum creatinine has risen from 1.1 mg/dL to 2.7 mg/dL over the past 3 weeks. The UA shows 2+ protein and moderate hematuria. 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 19

C. Wegener granulomatosis

Question 20

A 40-year-old white female complains of pruritus. Physical examination reveals xanthelasma and mild splenomegaly. She has an elevated alkaline phosphatase, but her transaminases are normal. The antimitochondrial antibody test is positive.
What is the most likely disease process?
A. Primary biliary cirrhosis
B. Sclerosing cholangitis
C. Anaerobic liver abscess
D. Hepatocellular carcinoma
E. Hepatitis C
F. Hepatitis D
G. Hemochromatosis

Answer 20

A. Primary biliary cirrhosis

Question 21

20-year-old man with diabetes mellitus comes to the emergency room with diffuse abdominal pain, tachypnea, and fever. 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, PO2 36, PCO2 95
D. pH 7.06, PO2 108, PCO2 13
E. pH 7.37, PO2 48, PCO2 54

Answer 21

D. pH 7.06, PO2 108, PCO2 13

Question 22

A 28-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical examination would predict a benign course?
A. Silent chest
B. Hypercapnia
C. Thoracoabdominal paradox (paradoxical respiration)
D. Pulsus paradoxus of 5 mm Hg
E. Altered mental status

Answer 22

D. Pulsus paradoxus of 5 mm Hg

Question 23

A 79-year-old diabetic presents with right-sided weakness. The weakness is equal in the right face, arm, and leg. Sensation, speech, and comprehension are intact. For this symptom of cerebrovascular disease, select the site of the lesion. Each lettered option may be used once, more than once, or not at all.
A. Vertebral artery
B. Middle cerebral artery
C. Midbasilar artery
D. Anterior cerebral artery
E. Penetrating branch, middle cerebral artery
F. Superior cerebellar artery

Answer 23

E. Penetrating branch, middle cerebral artery

Question 24

A male nursing assistant presents with weakness and tremor. Examination shows no ophthalmopathy or pretibial myxedema. No thyroid tissue is palpable. T 4 is elevated; radioactive iodine uptake is reduced. 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 24

C. Factitious hyperthyroidism

Question 25

A 30-year-old female with Graves disease has been started on propylthiouracil. She complains of low-grade fever, chills, and sore throat. Which of the following is the most important initial step in evaluating this patient's fever? A. Serum TSH B. Serum T3 by RIA C. СВС D. Chest x-ray E. Blood cultures

Answer 25

C. СВС

Question 26

A 40-year-old woman cut her finger while cooking in her kitchen. Two days later she became rapidly ill with fever and shaking chills. Her hand became painful and mildly erythematous. Later that evening her condition deteriorated as the erythema progressed and the hand became a dusky red. Bullae and decreased sensation to touch developed over the involved hand. What is the most important next step in the management of this patient? A. Surgical consultation and exploration of the wound B. Treatment with clindamycin for mixed aerobic-anaerobic infection C. Treatment with penicillin for clostridia infection D. Vancomycin to cover community-acquired methicillin-resistant Staphylococcus E. Evaluation for acute osteomyelitis

Answer 26

A. Surgical consultation and exploration of the wound

Question 27

An 83-year-old woman presents for follow-up of hypertension, type 2 diabetes mellitus, and depression. She complains of fatigue and mild dependent edema. Her medications include hydrochlorothiazide 25 mg/d, atenolol 50 mg/d, glyburide 5 mg bid., and paroxetine 20 mg/d. Physical examination shows BP 152/88, weight 42 kg, clear lung fields, normal liver and spleen, and 1+ peripheral edema. She appears mildly pale. CBC shows Hb 9.6 with an MCV of 87 and normal WBC and platelets. Chem profile shows Na 136, K 4.9, CO 2 18, Cl 108, creat 1.5, and glucose 178 mg/dL. Liver enzymes are normal. What is the most likely cause of her anemia? A. Anemia of chronic kidney disease (CKD) B. Anemia of chronic disease caused by diabetes C. Depression with nutritional folate deficiency D. Occult colon cancer E. Medication-induced bone marrow suppression

Answer 27

A. Anemia of chronic kidney disease (CKD)

Question 28

You recently evaluated a 28-year-old woman who presented with complaints of **shakiness** and heat intolerance. The patient plans to have children and is currently using no contraception. On examination you noted tachycardia with an HR of 102, a fine tremor, a diffuse goiter, and proptosis. You now have the laboratory results and note a TSH < 0.001, elevated total T 4 of 17.8, and increased T 3 uptake. Radionuclide uptake by the thyroid gland is elevated. You tell her that she has Graves disease. What is the best treatment plan for this patient? A. Propylthiouracil B. Radioactive iodine C. Propranolol D. Thyroid surgery E. Oral corticosteroids

Answer 28

A. Propylthiouracil

Question 29

A 70-year-old nursing home resident was admitted to the hospital for pneumonia and treated for 10 days with levofloxacin. On discharge she was improved but developed diarrhea one week later. She had low-grade fever and mild abdominal pain with 2 to 3 watery, nonbloody stools per day. A cell culture cytotoxicity test for Clostridium difficile-associated disease was positive. The patient was treated with oral metronidazole, but did not improve, even after 10 days. Diarrhea has increased and fever and abdominal pain continue. What is the best next step in the management of this patient? A. Obtain C difficile enzyme immunoassay. B. Continue metronidazole for at least two more weeks. C. Switch treatment to oral vancomycin. D. Hospitalize patient for fulminant C difficile-associated disease. E. Use synthetic fecal bacterial enema.

Answer 29

C. Switch treatment to oral vancomycin.

Question 30

A 76-year-old woman presents with numbness and mild weakness in the legs. She has noticed mild numbness in thenfingertips bilaterally. The symptoms have been slowly progressive over the past year. She rarely goes to the doctor and takes no medications. Neurological examination shows sensory loss to light touch distal to the knees and wrists in a symmetric pattern. Joint position and vibratory sensation are normal. Ankle reflexes are absent, and she has mild distal weakness. Which of the following is the most likely abnormality on laboratory testing? A. Hyperglycemia B. Macrocytic anemia with a low vitamin B12 level C. Oligoclonal bands on CSF analysis D. Low T4, elevated TSH E. Positive antiacetylcholine receptor antibody titers

Answer 30

A. Hyperglycemia

Question 31

An 80-year-old nursing home patient has become increasingly confused and unstable on her feet. On one occasion she has wandered outside the nursing home. In considering the issue of restraints for this individual, which of the following is correct? A. A geri-chair would provide the best approach to safety and restraint. B. Physical restraints are the best method to prevent falls. C. Restraints cause many complications and increase the risk of falls. D. Sedative medication should be used instead of restraints. E. Wrist restraints are more effective than ankle restraints.

Answer 31

C. Restraints cause many complications and increase the risk of falls.

Question 32

An 80-year-old male has been admitted to a nursing home after a stroke. He has a hemiparesis and expressive aphasia. After 2 weeks he is still unable to make it to the bathroom. Urodynamic testing shows no abnormalities. What is the most likely type of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Functional incontinence E. Mixed incontinence F. Normal physiologic functioning of old age

Answer 32

D. Functional incontinence

Question 33

You are asked to see a 78-year-old woman prior to surgical repair of a femoral neck fracture. Her medical problems include hypertension, osteoporosis, and hypothyroidism. Morphine is the only medication ordered so far. She is comfortable at rest. Her BP is 136/82, HR 88, RR 16. Her cardiac examination is normal, and her lungs are clear. What is the best recommendation to prevent postoperative venous thrombosis? A. Postoperative low-dose ASA B. Postoperative SCDs (sequential compression devices) C. Early mobilization and ambulation D. Postoperative subcutaneous low-molecular-weight heparin
 E. 
Postoperative intravenous unfractionated heparin

Answer 33

D. Postoperative subcutaneous low-molecular-weight heparin


Question 34

An 80-year-old woman was admitted to your service for dizziness. Cardiac monitoring initially revealed atrial fibrillation with rapid ventricular response. Her ventricular rate was controlled with beta-blocker. An echocardiogram revealed an enlarged left atrium and an ejection fraction of 50%. No evidence of diastolic heart dysfunction was noted. She is now asymptomatic, with blood pressure 130/80, heart rhythm irregularly irregular, and heart rate around 80/minute. Which of the following is the best management strategy of this patient's arrhythmia? A. Electrical cardioversion plus prolonged anticoagulation B. Electrical cardioversion without anticoagulation C. Chemical cardioversion plus prolonged anticoagulation D. Chemical cardioversion without anticoagulation E. Continued rate control plus prolonged anticoagulation

Answer 34

E. Continued rate control plus prolonged anticoagulation

Question 35

A 78-year-old male presents to the emergency department with acute onset of bright red blood per rectum. Symptoms started 2 hours earlier, and he has had **3 bowel movements** since then with copious amounts of blood. He denies prior episodes of rectal bleeding. He notes dizziness with standing but denies abdominal pain. He has had no vomiting or nausea. A nasogastric lavage is performed and shows no coffee ground emesis or blood. Lab evaluation reveals hemoglobin of 10.5 g/dL. What is the most likely source of the bleeding? A. Internal hemorrhoids B. Dreulofoy lesion C. Diverticulosis D. Mallory-Weiss tear E. Sessile polyp

Answer 35

C. Diverticulosis

Question 36

A 24-year-old single woman with hypertension has delayed seeing a doctor over the past 3 months due to lack of insurance; she has experienced amenorrhea and nausea. The choice of an antihypertensive agent may involve trying to avoid an adverse effect on a comorbid condition. Indicate the medication choice that needs to be avoided above all others. A. Angiotensin-converting enzyme inhibitor B. Beta-blocker, noncardioselective C. Calcium-channel blocker D. Diuretic E. Hydralazine

Answer 36

A. Angiotensin-converting enzyme inhibitor

Question 37

A 47-year-old diabetic female presents to the emergency room with a 45-minute history of chest pain with radiation to the arms and jaw. The pain is relieved with nitroglycerin and morphine. She has ECG changes of ischemia; her second serum troponin level (obtained 6 hours after onset of pain) is elevated. Compared to a similar male patient, which of the following is more likely to occur in this female patient? A. Death during this hospitalization B. Percutaneous transluminal coronary angioplasty C. Hypertension during initial presentation D. High triglycerides contributing to cardiac risk E. Less depression after Ml than her male counterparts

Answer 37

A. Death during this hospitalization

Question 38

A patient with small cell carcinoma of the lung develops increasing fatigue but is otherwise alert and oriented. Serum electrolytes show a serum sodium of 118 mg/L. There is no evidence of edema, orthostatic hypotension, or dehydration. Urine is concentrated with an osmolality of 550 mmol/L. Serum BUN, creatinine, and glucose are within normal range. Which of the following is the next appropriate step? A. Normal saline infusion B. Diuresis C. Fluid restriction D. Demeclocycline E. Hypertonic saline infusion

Answer 38

C. Fluid restriction

Question 39

A 37-year-old woman presents for evaluation of a self-discovered breast mass. There is no family history of breast cancer; she is otherwise healthy. Examination reveals a 1.5-cm area of firmness in the right upper outer quadrant. No skin changes are noted. You attempt to aspirate the mass, but no fluid is obtained; a mammogram is ordered and is normal. Which of the following is the most appropriate next step in management? A. Refer the patient for further evaluation to a surgeon or comprehensive breast radiologist. B. Reevaluate the patient in 6 months. C. Give oral contraceptives to decrease ovulation and help shrink the lesion. D. Recommend tamoxifen to decrease her chance of developing cancer. E. Reassure the patient

Answer 39

A. Refer the patient for further evaluation to a surgeon or comprehensive breast radiologist.

Question 40

A 30-year-old male is brought to the emergency room from prison, where he works in the paint shop. He is barely arousable but has no focal abnormalities. He has no past medical history. CT scan of the head is normal. Urine toxicology screen is negative. Ethanol and acetaminophen are not detectable. Laboratory data is as follows: * Na: 140 mEq/L * K: 5.1 mEq/L * CI: 100 mEq/L * HCO 3 10 mEq/L * Creatinine 1.2 mg/dL * Blood ethanol: nondetectable * Blood glucose: 110 mg/dL * Arterial blood gases: PO 288, PCO 2 23, pH 7.21 Which of the following tests will provide the key to correct diagnosis? A. Serum ketones B. Serum lactate C. Serum creatine kinase D. Measured plasma osmolality E. Magnetic resonance scan of the head

Answer 40

D. Measured plasma osmolality

Question 41

A 37-year-old woman receives four units of packed red blood cells after a motor vehicle accident with splenic rupture. She is otherwise healthy, without cardiac or pulmonary disease. She takes no medications. The patient does well initially, but the next day she develops shortness of breath, hypoxemia, and has diffuse crackles on her lung examination. Her neck veins are not distended and her weight is unchanged from admission. An ECG is normal, but CXR shows pulmonary edema. 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 41

B. Reaction of donor antibodies with antigens of the recipient

Question 42

A 30-year-old black female has a 2-month history of nonproductive cough and a painful skin eruption in the lower extremities. She denies fever or weight loss. Physical examination shows several nontender raised plaques around the nares and scattered similar plaques around the base of the neck. In the lower extremities she has several erythematous tender nonulcerated nodules, measuring up to 4 cm in diameter. Chest x-ray reveals bilateral hilar adenopathy and a streaky interstitial density in the right upper lobe. What is the best way to establish a histological diagnosis? A. Punch biopsy of one of the plaques on the neck B. Incisional biopsy of one of the lower extremity nodules C. Sputum studies for AFB and fungi D. Mediastinoscopy and biopsy of one of the hilar or mediastinal nodes E. Serum angiotensin-converting enzyme assay

Answer 42

A. Punch biopsy of one of the plaques on the neck

Question 43

Last week a 30-year-old woman received treatment with trimethoprim-sulfamethoxazole for bloody diarrhea. She now presents with a creatinine of 6.0 mg/dL (normal 0.5-1.0) and a hemoglobin of 7.2 g/dL (normal 12.5-14.0). 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 43

E. Salmonella species

Question 44

A 50-year-old female complains of vague abdominal pain, constipation, and a sense of fullness in the lower abdomen. The abdomen is nontender, but there is shifting dullness to percussion. Which of the following is the best next step in evaluation? A. Abdominal ultrasound B. Therapeutic trial of diuretics C. CA-125 cancer antigen D. Sigmoidoscopy E. Pelvic examination

Answer 44

E. Pelvic examination

Question 45

An obese hypertensive woman has chronic headaches, normal visual fields, and normal pituitary function. What is the most likely disease process for this clinical syndrome? A. Acromegaly B. Essential hypertension C. Empty sella syndrome D. Cushing disease E. TSH-secreting adenoma F. Diabetes insipidus G. Chronic oral glucocorticoid use H. Prolactin-secreting adenoma

Answer 45

C. Empty sella syndrome

Question 46

A 22-year-old man being treated for acute lymphoblastic leukemia receives 6 units of platelets because of treatment associated thrombocytopenia. Near the end of the transfusion, the patient develops chills and fever to 39.6°C (103.3°F). His blood pressure drops to 74/46. There is no hemoglobinemia, and a direct antiglobulin (direct Coombs) test is 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 46

E. Bacterial contamination of the transfused product

Question 47

A 39-year-old male with a prior history of myocardial infarction complains of yellow bumps on his elbows and buttocks. **Yellow-colored cutaneous plaques are noted in those areas.** The lesions occur in crops and have a surrounding reddish halo. Which of the following is the best next step in evaluation of this patient? A. Biopsy of skin lesions B. Lipid profile C. Uric acid level D. Chest x-ray E. Liver enzymes

Answer 47

B. Lipid profile

Question 48

A 55-year-old male is being evaluated for **constipation**. There is no history of prior gastrectomy or of upper GI symptoms. Hemoglobin is 10 g/dL, mean corpuscular volume (MCV) is 72 fL, serum iron is 4 ug/dL (normal is 50-150 ug/dL), iron-binding capacity is 450 ug/dL (normal is 250-370 ug/dL), saturation is 1% (normal is 20%-45%), and ferritin is 10 ug/L (normal is 15-400 ug/L). Which of the following is the best next step in the evaluation of this patient's anemia? A. Red blood cell folate B. Serum lead level C. Colonoscopy D. Bone marrow examination E. Hemoglobin electrophoresis with A2 and F levels

Answer 48

C. Colonoscopy

Question 49

A diabetic male presents with hypertension. His blood pressure is 146/92. He has no peripheral edema but does note sensory loss to the midcalves bilaterally. A spot urine specimen shows 150 micrograms of albumin per mg creatinine (microalbuminuria present if this value is 30-300 mcg/mg). Which of the following is the most appropriate antihypertensive drug to prevent progression of renal failure? A. Clonidine B. Beta-blocker C. Thiazide diuretic D. Angiotensin-converting enzyme inhibitor E. Short-acting dihydropyridine calcium channel blocker (nifedipine)

Answer 49

D. Angiotensin-converting enzyme inhibitor

Question 50

A 54-year-old man sees you for follow-up of hypertension and a seizure disorder that is well-controlled. He established as a new patient 2 months ago and is back for his second office visit with you. At the time of his initial visit he admitted to a 35-year history of smoking 2 packages of cigarettes per day. At that time he indicated that he was not interested in stopping smoking, and seemed irritated when you suggested that he quit. Today his blood pressure is well controlled and there are no new medical issues. With regard to discussing cessation of cigarette smoking during today's visit, what is the next best step? A. Do not discuss cessation of cigarette smoking because it will likely upset him again. B. Do not discuss cessation of cigarette smoking, because there is no real benefit to cessation of cigarette smoking after smoking this long. C. Ask him if he is still smoking, and if so advise him to quit and assess his willingness to do so. D. Recommend bupropion. E. Recommend that he switch to smokeless tobacco.

Answer 50

C. Ask him if he is still smoking, and if so advise him to quit and assess his willingness to do so.

Question 51

A 28-year-old female presents to her internist with a 2-day history of low-grade fever and lower abdominal pain. She denies nausea, vomiting, or diarrhea. On physical examination, there is temperature of 38.3°C (100.9°F) and bilateral lower quadrant tenderness, without point or rebound tenderness. Bowel sounds are normal. On pelvic examination, an exudate is present and there is tenderness on motion of the cervix. Her white blood cell count is 15,000/uL and urinalysis shows no red or white blood cells. Serum B-hCG is undetectable. Which of the following is the best next step in management? A. Treatment with ceftriaxone and doxycycline B. Endometrial biopsy C. Surgical exploration. D. Dilation and curettage E. Aztreonam

Answer 51

A. Treatment with ceftriaxone and doxycycline

Question 52

A 70-year-old man complains of fever and pain in his left knee. Several days previously, he suffered an abrasion of his knee while working in his garage. The knee is red, warm, and swollen. An arthocentesis is performed, which shows 200,000 leukocytes/uL and a glucose of 20 mg/dL. No crystals are noted. Which of the following is the most important next step? A. Gram stain and culture of joint fluid B. Urethral culture C. Uric acid level D. Antinuclear antibody
 E. Antineutrophil cytoplasmic antibody

Answer 52

A. Gram stain and culture of joint fluid

Question 53

A 20-year-old woman complains of weakness that is worse in the afternoon, worse during prolonged activity, and improved by rest. When fatigued, the patient is unable to hold her head up or chew her food. On physical examination, she has no loss of reflexes, sensation, or coordination. Which of the following is the likely pathogenesis of this disease? A. Antiacetylcholine receptor antibodies causing neuromuscular transmission failure B. Destruction of anterior horn cells by virus C. Progressive muscular atrophy caused by spinal degeneration D. Demyelinating disease E. Defect in muscle glycogen breakdown

Answer 53

A. Antiacetylcholine receptor antibodies causing neuromuscular transmission failure

Question 54

A 70-year-old woman complains of leakage of urine in small amounts. This occurs when laughing or coughing. It has also occurred while bending or exercising. The patient has five children who are concerned about her urinary problems. What is the most likely type of urinary incontinence? A. Stress incontinence B. Urge incontinence C. Overflow incontinence D. Functional incontinence E. Mixed incontinence F. Normal physiologic functioning of old age

Answer 54

A. Stress incontinence

Question 55

A 23-year-old GO smoker wonders if she is a candidate for the quadrivalent HPV vaccine. She has been sexually active for 5 years with three partners. Her recent first pap smear was normal, but her examination revealed two nontender vaginal lesions which resemble flesh-colored cauliflower. You first educate her that quitting smoking will help her immune system fight the strain of HPV that she already has acquired. What advice should you give her? A. She is already infected with one strain, but the vaccine will still be effective against acquiring the other three strains. B. The vaccine will protect her from every HPV strain. C. If she receives the vaccine, she will never have to have another pap smear. D. She is already infected with one strain, and there is no benefit in vaccination against the others. E. The vaccine will help cure her vaginal warts.

Answer 55

A. She is already infected with one strain, but the vaccine will still be effective against acquiring the other three strains.

Question 56

A 30-year-old male is admitted to the hospital after a motorcycle accident that resulted in a fracture of the right femur. The fracture is managed with traction. Three days later the patient becomes confused and tachypneic. A petechial rash is noted over the chest. Lungs are clear to auscultation. Arterial blood gases show PO 2 of 50, PCO 2 of 28, and pH of 7.49. Which of the following is the most likely diagnosis? A. Unilateral pulmonary edema B. Hematoma of the chest C. Fat embolism D. Pulmonary embolism E. Early Staphylococcus aureus pneumonia

Answer 56

C. Fat embolism

Question 57

A 32-year-old male has cough with yellow, blood-tinged sputum. He also has a history of night sweats and a 10-Ib weight loss. The patient was born in India. On physical examination there is dullness to percussion above both clavicles. Chest x-ray shows bilateral upper lobe infiltrates with cavity formation. What is the most likely diagnosis? A. Tuberculosis B. Primary lung tumor C. Pulmonary embolus. D. Metastatic lung cancer E. Asbestosis F. Histoplasmosis G. Idiopathic pulmonary fibrosis

Answer 57

A. Tuberculosis

Question 58

A 22-year-old male, recently incarcerated and now homeless, has received one week of clarithromycin for low-grade fever and left upper-lobe pneumonia. He has not improved on antibiotics, with persistent cough productive of purulent sputum and flecks of blood. Repeat chest x-ray suggests a small cavity in the left upper lobe. Which of the following statements is correct? A. The patient has anaerobic infection and needs outpatient clindamycin therapy. B. The patient requires sputum smear and culture for acid fast bacilli. C. The patient requires glove and gown contact precautions. D. Isoniazid prophylaxis should be started if PPD is positive. E. Drug resistant pneumococci may be causing this infection.

Answer 58

B. The patient requires sputum smear and culture for acid fast bacilli.

Question 59

A 70-year-old female has been healthy except for hypertension treated with a thiazide diuretic. She presents with sudden onset of a severe, tearing chest pain, which radiates to the back and is associated with dyspnea and diaphoresis. Blood pressure is 210/94. Lung auscultation reveals bilateral basilar rales. A faint murmur of aortic insufficiency is heard. The BNP level is elevated at 550 pg/mL (Normal <100). ECG shows nonspecific ST-T changes. Chest x-ray suggests a widened mediastinum. Which of the following choices represents the best initial management? A. IV furosemide plus IV loading dose of digoxin B. Percutaneous coronary intervention with consideration of angioplasty and/or stenting C. Blood cultures and rapid initiation of vancomycin plus gentamicin, followed by echocardiography D. IV beta-blocker to control heart rate, IV nitroprusside to control blood pressure, transesophageal echocardiogram E. IV heparin followed by CT pulmonary angiography

Answer 59

D. IV beta-blocker to control heart rate, IV nitroprusside to control blood pressure, transesophageal echocardiogram

Question 60

A 30-year-old athlete presents to your office complaining of intermittent wheezing. This wheezing begins shortly after running. The patient admits to smoking 1-2 packs of cigarettes per day for 5 years. What finding would be consistent with asthma? A. Hyperinflation present on chest x-ray B. Improvement in FEV1 after bronchodilator C. Low oxygen saturation on finger oximetry D. Decreased FVC on PFT testing E. Dyspnea on assuming a supine position

Answer 60

B. Improvement in FEV1 after bronchodilator

Question 61

A 25-year-old male presents to the clinic for evaluation of infertility. He has a life-long history of a productive cough and recurrent pulmonary infections. On his review of symptoms he has indicated chronic problems with abdominal pain, diarrhea, and difficulty gaining weight. He also has diabetes mellitus. His chest x-ray suggests bronchiectasis. Which is the most likely diagnosis? A. COPD B. Upper respiratory infections C. Cystic fibrosis D. Intrapulmonary hemorrhage E. Asthma

Answer 61

C. Cystic fibrosis

Question 62

An 82-year-old woman complains of worsening headaches and episodes of transient visual loss and diplopia. When she chews, her jaw muscles ache until she stops chewing. Examination reveals a tender nodular right temporal artery. She has a mild normocytic anemia; sedimentation rate is 95. 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 62

D. Temporal arteritis

Question 63

A 71-year-old woman is brought to the emergency room by her daughter because of sudden onset of right-sided weakness and slurred speech. The patient, a recent immigrant from Southeast Asia, has not seen a doctor in 2 decades. Her symptoms began 75 minutes ago while she was eating breakfast. A stat noncontrast CT scan of the head is normal. Labs are normal. Physical examination reveals an anxious appearing woman with dense hemiplegia of the R upper and lower extremities. Deep tendon reflexes are not discernible on the R side and 2+ on the left. Aspirin has been given. What is the best next step in management of this patient? A. Immediate intravenous unfractionated heparin B. Immediate thrombolytic therapy C. Immediate administration of interferon-beta D. Emergent MRI/MRA of head E. Emergent cardiac catheterization

Answer 63

B. Immediate thrombolytic therapy

Question 64

A 60-year-old male is noted to have mild jaundice and 15-Ib weight loss. The patient has noted pruritus and pale, clay-colored stools. On examination, the gallbladder is palpable. Alkaline phosphatase is very elevated. 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 64

B. Pancreatic carcinoma

Question 65

A 35-year-old right-handed construction worker presents with complaints of nocturnal numbness and pain involving the right hand. Symptoms wake him and are then relieved by shaking his hand. There is some atrophy of the thenar eminence. Tinel sign is positive. Which of the following is the most likely diagnosis? A. Carpal tunnel syndrome B. De Quervain tenosynovitis C. Amyotrophic lateral sclerosis D. Rheumatoid arthritis of the wrist joint E. Guillain-Barré syndrome

Answer 65

A. Carpal tunnel syndrome

Question 66

A 38-year-old man has pain and stiffness of his right knee. This began 2-weeks ago after he fell while skiing. On two occasions he had the sense that his knee was locked in a semiflexed position for a few seconds. He has noted a popping sensation when he bends his knee. On examination there is tenderness over the medial joint line of the knee. Marked flexion and extension of the knee are painful. The Lachman test (anterior displacement of the lower leg with the knee at 20° of flexion) and the anterior drawer test are negative. What is the most likely diagnosis? A. Medial meniscus tear B. Osteoarthritis C. Anterior cruciate ligament tear D. Chondromalacia patella E. Lumbosacral radiculopathy

Answer 66

A. Medial meniscus tear

Question 67

A 43-year-old woman presents to your office as a new patient for musculoskeletal pain and weight gain. Over the past 6 months, she has noted generalized aches and pains of muscles and joints, fatigue, and poor sleep quality. She admits to wanting to stay in bed rather than socialize with her friends and family. She denies fever, night sweats, morning stiffness, joint redness, blood loss, easy bruising, or daytime somnolence. Her physical examination is significant for a normal BMI, normal thyroid, normal cardiovascular examination, normal joints, and no tenderness to palpation. CBC, TSH, ESR, ANA, RF, electrolytes, liver enzymes, and kidney function tests are normal. She wants pain control. Which treatment is most likely to relieve her symptoms? A. Long-acting opiates B. Oral acetaminophen/hydrocodone combination C. Prednisone D. Methotrexate E. An antidepressant

Answer 67

E. An antidepressant

Question 68

A 58-year-old male with long-standing cirrhosis resulting from hepatitis C develops vague right upper quadrant pain and weight loss. A right upper quadrant mass is palpable. Serum alkaline phosphatase is elevated. What is the most likely disease process? A. Primary biliary cirrhosis B. Sclerosing cholangitis C. Anaerobic liver abscess D. Hepatocellular carcinoma E. Hepatitis C F. Hepatitis D G. Hemochromatosis

Answer 68

D. Hepatocellular carcinoma

Question 69

A young woman presents with asthma and eosinophilia. Fleeting pulmonary infiltrates occur with bronchial **plugging**. What is the fungal agent most likely responsible for the disease process described? A. Histoplasma capsulatum B. Blastomyces dermatitidis C. Coccidioides immitis D. Cryptococcus neoformans E. Candida albicans F. Aspergillus fumigatus G. Zygomycosis

Answer 69

F. Aspergillus fumigatus

Question 70

A 68-year-old woman who has had a previous hysterectomy presents with an 8-hour history of cramping periumbilical pain. Each episode of pain lasts 3 to 5 minutes and then abates. Over several hours she develops nausea, vomiting, and abdominal distension. She has been unable to pass stool or flatus for the past 4 hours. 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 70

D. Intestinal obstruction

Question 71

A 30-year-old male patient complains of fever and sore throat for several days. The patient presents to you today with additional complaints of hoarseness, difficulty breathing, and drooling. On examination, the patient is febrile and has inspiratory stridor. Which of the following is the best course of action? A. Begin outpatient treatment with ampicillin. B. Culture throat for B-hemolytic streptococci. C. Admit to intensive care unit and obtain otolaryngology consultation. D. Schedule for chest x-ray. E. Obtain Epstein-Barr serology.

Answer 71

C. Admit to intensive care unit and obtain otolaryngology consultation.

Question 72

A 78-year-old white man with coronary artery disease presents with several months of postprandial generalized abdominal pain that typically lasts 30-60 minutes. He has become fearful of eating and has lost 15 lb of weight. 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 72

F. Mesenteric ischemia

Question 73

A 53-year-old man presents with arthritis and bloody nasal discharge. Urinalysis reveals 4+ proteinuria, RBCs, and RBC casts. ANCA is positive in a cytoplasmic pattern. Antiproteinase 3 (PR3) antibodies are present, but antimyeloperoxidase (MPO) antibodies are absent. Which of the following is the most likely diagnosis? A. Behçet syndrome B. Sarcoidosis C. Wegener granulomatosis D. Henoch-Schönlein purpura E. Classic polyarteritis nodosa

Answer 73

C. Wegener granulomatosis

Question 74

A 92-year-old woman with type 2 diabetes mellitus has developed cellulitis and gangrene of her left foot. She requires alifesaving amputation, but refuses to give consent for the surgery. She has been ambulatory in her nursing home but states that she would be so dependent after surgery that life would not be worth living for her. She has no living relatives; she enjoys walks and gardening. She is competent and of clear mind. Which of the following is the most appropriate course of action? A. Perform emergency surgery. B. Consult a psychiatrist. C. Request permission for surgery from a friend of the patient. D. Follow the patient's wishes. E. Obtain a court order to override the patient's wishes.

Answer 74

C. Request permission for surgery from a friend of the patient.

Question 75

A 60-year-old man had an anterior myocardial infarction 3 months ago. He currently is asymptomatic and has normal vital signs and a normal physical examination. He is on an antiplatelet agent and an ACE inhibitor. What other category of medication would typically be prescribed for secondary prevention of myocardial infarction? A. Alpha-blocker B. Beta-blocker C. Calcium-channel blocker D. Nitrates E. Naproxen sodium

Answer 75

B. Beta-blocker

Question 76

After undergoing surgical resection for carcinoma of the stomach, a 60-year-old male develops numbness in his feet. On examination, he has lost proprioception in the lower extremities and has a wide-based gait and positive Romberg sign. Peripheral blood smear shows macrocytosis and hypersegmented polymorphonuclear leukocytes. The neurologic dysfunction is secondary to a deficiency of which vitamin? A. Folic acid B. Thiamine C. Vitamin K D. Vitamin B12 E. Riboflavin

Answer 76

D. Vitamin B12

Question 77

A 51-year-old female presents to your office with questions about whether postmenopausal hormone therapy (HT) is "dangerous." She heard this on the news and read about it in a women's magazine. She denies hot flushes, irregular menses, emotional lability, or vaginal dryness. She has hypertension but is otherwise healthy. Her family history is negative for breast cancer and cardiovascular disease. According to data from the Women's Health Initiative study, what advice should you give her? A. Start HT for cardiovascular protection. B. HT is not indicated for this patient. C. Start vaginal estrogen cream. D. Start HT for breast cancer risk reduction. E. Hormone therapy is too risky to give to any woman.

Answer 77

B. HT is not indicated for this patient.

Question 78

An African American male develops mild jaundice while being treated for a urinary tract infection. Urine bilirubin is negative. Serum bilirubin is 3 mg/dL, mostly unconjugated. Hemoglobin is 7 g/dL. 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 78

A. Hemolysis secondary to G6PD deficiency

Question 79

Last week a 20-year-old college student developed acute wrist pain and swelling. This resolved in four days. Yesterday, he developed pain and swelling in his left knee. Two months ago he went on a backpacking trip in Rhode Island. A week or so later he developed an enlarging circular red spot that persisted for 2 weeks and then resolved. What is the most likely diagnosis? A. Acute rheumatoid arthritis B. Parvovirus infection C. Psoriatic arthritis D. Lyme disease E. Inflammatory bowel disease

Answer 79

D. Lyme disease

Question 80

An elderly male presents with pain in his shoulders and hips. Temporal arteries are tender to palpation. ESR is 105 mm/L. 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 80

C. Temporal arteritis

Question 81

A 55-year-old woman who is a heavy cigarette smoker complains of cough with small amounts of bright red blood. She has also noted loss of appetite and a 12-lb weight loss. A 3-cm pulmonary nodule with shaggy margins is seen on chest X-ray. What is the most likely diagnosis? A. Tuberculosis B. Primary lung tumor C. Pulmonary embolus D. Metastatic lung cancer E. Asbestosis F. Histoplasmosis G. Idiopathic pulmonary fibrosis

Answer 81

B. Primary lung tumor

Question 82

A 72-year-old woman presents with pruritus for the past 6 weeks. She is careful to moisturize her skin after her daily shower and uses soap sparingly. She has never had this symptom before. The itching is diffuse and keeps her awake at night. Over this time she has lost 15 lb of weight and has noticed diminished appetite. She has previously been healthy and takes no medications. Physical examination shows no evidence of rash; a few excoriations are present. She appears fatigued and shows mild temporal muscle wasting. The general examination is otherwise unremarkable. What is the best next step in her management? A. Topical corticosteroids B. Oral antihistamines C. Psychiatric referral for management of depression D. Skin biopsy at the edge of one of the excoriations E. Laboratory testing including CBC, comprehensive metabolic panel, and thyroid studies

Answer 82

E. Laboratory testing including CBC, comprehensive metabolic panel, and thyroid studies

Question 83

A 65-year-old man develops the onset of severe knee pain over 24 hours. The knee is red, swollen, and tender. He has a history of diabetes mellitus and cardiomyopathy. An x-ray of the knee shows linear calcification. Definitive diagnosis is best made by which of the following? A. Serum uric acid B. Serum calcium C. Arthrocentesis and identification of positively birefringent rhomboid crystals D. Rheumatoid factor E. ANA

Answer 83

C. Arthrocentesis and identification of positively birefringent rhomboid crystals

Question 84

An 88-year-old white woman with osteoarthritis has noticed mild epigastric discomfort for several weeks. Naproxen has helped her joint symptoms. She suddenly develops hematemesis and hypotension. What is the most likely diagnosis? A. Gastric ulcer B. Aortoenteric fistula C. Mallory-Weiss tear D. Esophageal varices E. Hereditary hemorrhagic telangiectasia (HHT) F. Colon polyp

Answer 84

A. Gastric ulcer

Question 85

A 47-year-old dentist consults you because of tremor, which is interfering with his work. The tremor has come on gradually over the past several years and seems more prominent after the ingestion of caffeine; he notices that, in the evening after work, an alcoholic beverage will decrease the tremor. No one in his family has a similar tremor. He is otherwise healthy and takes no medications. On examination his vital signs are normal. Except for the tremor, his neurological examination is normal; in particular there is no focal weakness, rigidity, or bradykinesia. When he holds out his arms and extends his fingers, you detect a rapid fine tremor of both hands; the tremor goes away when he rests his arms at his side. What is the next best step in the management of this patient? A. MRI scan to visualize the basal ganglia B. Electromyogram and nerve conduction studies to more fully characterize the tremor C. Therapeutic trial of propranolol D. Therapeutic trial of primidone E. Neurology referral to rule out motor neuron disease

Answer 85

C. Therapeutic trial of propranolol

Question 86

A 65-year-old man has had symptoms of progressive cognitive dysfunction over a 1-year period. Memory and calculation ability are worsening. The patient has also had episodes of paranoia and delusions. Antipsychotic medication resulted in extrapyramidal signs and was stopped. The patient has recently complained of several months of visual hallucinations. There is no history of alcohol abuse. Which of the following is the most likely diagnosis? A. Lewy body dementia B. Alzheimer disease C. Early parkinsonism D. Delirium E. Vascular dementia

Answer 86

A. Lewy body dementia

Question 87

A 15-year-old male presents to your office on the advice of his football coach. The patient started playing football this year and suffered a syncopal episode at practice yesterday. He reports that he was sprinting with the rest of the team and became lightheaded. He lost consciousness and fell to the ground, regaining consciousness within one or two minutes. He suffered no trauma during the event. He has no prior history of head injury or recent illness. He has had no prior episodes of syncope. The patient is adopted and family history unavailable. Physical examination is unremarkable. What is the best course of action regarding this patient's syncopal episode? A. Perform an ECG and echocardiogram. The patient may not return to competitive sports until results are available. B. Perform an ECG. The patient may not return to competitive sports until results are available. C. Perform an ECG. The patient may return to competitive sports pending the results. D. Reassurance. The patient may return to competitive sports provided he increases his water consumption during practice times. E. Reassurance. The patient may return to competitive sports with no restrictions.

Answer 87

A. Perform an ECG and echocardiogram. The patient may not return to competitive sports until results are available.

Question 88

A 40-year-old school teacher develops nausea and vomiting at the beginning of the fall semester. Over the summer she had taught preschool children in a small town in Mexico. She is sexually active, but has not used intravenous drugs and has not received blood products. Physical examination reveals scleral icterus, right upper quadrant tenderness, and a palpable liver. Liver function tests show aspartate aminotransferase of 750 U/L (normal < 40) and alanine aminotransferase of 1020 U/L (normal < 45). The bilirubin is 13 mg/dL (normal < 1.4) and the alkaline phosphatase is normal. What further diagnostic test is most likely to be helpful? A. Liver biopsy B. Abdominal ultrasound C. IgM antibody to hepatitis A D. Antibody to hepatitis B surface antigen E. Determination of hepatitis C RNA

Answer 88

C. IgM antibody to hepatitis A

Question 89

A 24-year-old male presents with gynecomastia and infertility. On examination, he has small, firm testes and eunuchoid features. He has scant axillary and pubic hair. Which of the following is correct? A. The patient has Turner syndrome. B. The patient will have a normal testosterone level. C. His most likely karyotype is 47 XXY. D. The patient will have normal sperm count. E. The patient is likely to have low levels of gonadotropins.

Answer 89

C. His most likely karyotype is 47 XXY.

Question 90

A 50-year-old woman presents with fatigue for 2 months. She has recently started having shortness of breath, dizziness, and nausea while walking up the stairs at work. She feels normal after resting at the top of the stairs for a moment. She denies chest pain, orthopnea, paroxysmal nocturnal dyspnea, or recent respiratory infection. Past medical history is significant for hypertension for 10 years and hyperlipidemia for 5 years. She denies tobacco use and exercises regularly. Family history is positive for heart attacks and strokes in her mother's family, but she cannot give details. On physical examination, her waist circumference is 38 in, lungs are clear, and cardiovascular examination is unremarkable and without murmurs. ECG reveals poor R wave progression in V, through V 2 and nonspecific ST-T wave changes in the anterolateral leads. Chest x-ray is normal. Pulse oximetry is 99%. Laboratory evaluation shows a normal complete blood count, cholesterol 250, HDL 29 mg/dL, LDL 160 mg/dL, and a random glucose of 250 mg/dL. Which medication(s) should you recommend? A. Aspirin and statin B. Warfarin C. Selective serotonin reuptake inhibitor D. Proton pump inhibitor and over-the-counter antacid E. Albuterol

Answer 90

A. Aspirin and statin

Question 91

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 91

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

Question 92

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 92

C. Renal ultrasound

Question 93

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 93

b. Vascular (multi-infarct) dementia

Question 94

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 94

a. Huntington disease

Question 95

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 95

a. Nasal continuous positive airway pressure

Question 96

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 96

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