Professional Documents
Culture Documents
a)
Block 1
C) Post-streptococcal glomerulonephritis
D) Rhabdomyolysis
E) Traumatic injury to the kidney
7.) A 16-year-old girl comes to the physician for her first prenatal
visit at 12 weeks' gestation. She has not had any immunizations since
the age of 5 years. She has received the following immunizations at the
recommended ages:
5
3
1
4
Diphtheria-tetanus-pertussis
Hepatitis B
Measles-mumps-rubella
Oral poliovirus
H) Gilbert's syndrome
I) Infectious hepatitis
J) Intravascular hemolysis
K) Primary biliary cirrhosis
12.) A 24-year-old third-year medical student comes to the student health clinic for
evaluation of jaundice which he noticed this morning. He has had no abdominal
pain, itching, or weight change. He takes no medications. He describes recent
anxiety over anticipation of the upcoming Step 2 examination. His temperature is
37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 76/min, and respirations
are 12/min. Examination shows no abnormalities except for scleral icterus.
Laboratory studies show:
Hemoglobin 15 g/dL Serum
Leukocyte count 7000/mm3
Alkaline phosphatase 90U/L
Platelet count 240,000/mm3
Aspartate aminotransferase Serum (AST, GOT) 23 U/L
Bilirubin, total 3.5 mg/dL
Alanine aminotransferase Direct 0.7 mg/dL (ALT, GPT) 27 U/L
A) Acute toxic hepatitis
B) Alcoholic hepatitis
C) Cholangiocarcinoma
D) Chronic idiopathic cirrhosis
E) Common bile duct calculus
F) Congestive hepatitis
G) Gallstone pancreatitis
H) Gilbert's syndrome
I) Infectious hepatitis
J) Intravascular hemolysis
K) Primary biliary cirrhosis
13.) A 37-year-old woman with a 2-year history of hypertension comes for a follow-up
examination; her hypertension has worsened despite treatment with a low-sodium
diet and a -adrenergic blocking agent. She has a history of rheumatic fever and
Graves' disease treated with 131I. Her blood pressure is 160/106 mm Hg, and
pulse is 80/min. Serum studies show:
Na+ 135 mEq/L
Cl 100 mEq/L
K+ 3.4 mEq/L
HCO3 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.8 mg/dL
Urinalysis is within normal limits. Renal ultrasonography shows a left kidney with a
markedly irregular contour; it is 2.8 cm smaller than the right.
A) Adrenal cortex
B) Adrenal medulla
C) Aorta
D) Renal arteries
E) Renal glomeruli
F) Thyroid gland
14.) A 27-year-old woman comes to the physician because of muscle weakness and
cramps for 2 weeks. She has been taking a -adrenergic blocking agent for
hypertension for 2 years. She had chronic lymphocytic thyroiditis (Hashimoto's
disease) 1 year ago. Her blood pressure is 160/108 mm Hg, and pulse is 60/min.
Serum studies show:
Na+ 140 mEq/L
Cl 110 mEq/L
K+ 2.2 mEq/L
HCO3 30 mEq/L
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1 mg/dL
Magnetic resonance angiography of the abdomen shows normal findings.
A) Adrenal cortex
B) Adrenal medulla
C) Aorta
D) Renal arteries
E) Renal glomeruli
F) Thyroid gland
15.) A 24-year-old man is hospitalized for treatment of a posterior dislocation of the
right knee sustained in a motorcycle collision. Six hours after closed reduction,
previously present distal pulses in his foot are absent, but the foot has remained
warm. Which of the following is the most appropriate next step in management?
A) Elevation of the limb and observation for 24hours
B) Nitroprusside therapy
C) Sympathetic block
D) Femoral arteriography
E) Embolectomy with a Fogarty catheter through aproximal arteriotomy
D) Inflammation of the origin of the plantar fascia
16.) A healthy 4-year-old girl is brought for a well-child examination. A grade 2/6
systolic ejection murmur is heard along the upper left sternal border. S2 is widely
split and does not vary with respiration. A soft mid-diastolic murmur is heard along
the lower left sternal border. Examination shows no other abnormalities. Which of
the following is the most likely diagnosis?
A) Aortic stenosis
B) Atrial septal defect
C) Coarctation of the aorta
D) Mitral valve prolapse
E) Patent ductus arteriosus
F) Pulmonary stenosis
G) Tetralogy of Fallot
H) Transposition of the great arteries
I) Ventricular septal defect
J) Normal heart
18.) A previously healthy 57-year-old woman comes to the physician because of three
episodes of blurred vision in the right eye over the past 3 weeks; each episode
lasts approximately 5minutes. Retinal examination shows a small refractile body at
The bifurcation of a retinal artery. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate next step in
diagnosis?
A) Cerebral angiography
B) Echocardiography
C) Electroencephalography
D) Duplex scan of the carotid arteries
E) MRI of the brain
19.) A 67-year-old woman comes to the physician for her first influenza virus
vaccination. She has a history of untreated hypertension. Her blood pressure is
160/100 mm Hg, and pulse is 100/min. Shortly after administration of the
influenza virus vaccine, she develops shortness of breath, hives, and angioedema.
Which of the following is most likely to have prevented this reaction?
A) Inquiry about an egg allergy
B) Heterophile agglutination test
C) Skin test with histamine reagent
20.) A 7-year-old girl is brought to the physician because of a 2-day history of fever,
headache, sore throat, and swollen glands. She does not have a runny nose,
congestion, or cough. She has no allergies to medications. Her temperature is
38.6C (101.4 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and
respirations are 16/min. Examination shows a swollen, erythematous oropharynx
With tonsillar exudates. The anterior cervical lymph nodes are enlarged and
tender. No other abnormalities are noted. Which of the following is the most likely
causal organism?
A) Adenovirus
B) Corynebacterium diphtheriae
C) Group A streptococcus
D) Haemophilus influenzae
E) Mycoplasma pneumoniae
21.) A 70-year-old nursing home resident is admitted to the hospital because of
progressive obtundation over the past 2 days. He has tachycardia, tachypnea, and
hypotension. Bilateral basilar crackles and an S3 gallop are heard on auscultation.
Examination shows jugular venous distention and peripheral edema. Swan-Ganz
catheterization shows a cardiac index of 1.8 L/min/m2 (N=2.54.2), a mean
Pulmonary capillary wedge pressure of 23 mm Hg (N=110), and markedly
Increased systemic vascular resistance. Which of the following is the most likely
diagnosis?
A) Cardiogenic shock
B) Hypovolemic shock
C) Neurogenic shock
D) Septic shock
hypoactive. X-ray films of the chest show a left pleural effusion and air in the
mediastinum. Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none
Which of the following is the most likely diagnosis?
A) Congestive heart failure
B) Esophageal rupture
C) Pancreatitis
D) Pericarditis
E) Tuberculosis
23.) A 2-year-old girl with tricuspid atresia has increasing respiratory distress for 2
days. She has been recovering uneventfully from an operation 10 days ago to join
systemic venous return with pulmonary arterial circulation. Over the past 4 days,
she has been weaned off mechanical ventilation, started on oral feedings, and
is receiving chest physiotherapy for atelectasis. Her temperature is 37.4 C (99.3 F),
blood pressure is 98/64 mm Hg, pulse is 120/min, and respirations are 46/min.
Examination shows nasal flaring, grunting, and intercostal retractions. An x-ray
film of the chest shows large bilateral pleural effusions. Thoracentesis yields 300
mL of whitish-yellow fluid. The supernatant remains uniformly opaque on
centrifugation. Which of the following is the most likely cause of the pleural
effusions?
A) Chylothorax
B) Congestive heart failure
C) Empyema
D) Pulmonary embolism
E) Superior vena cava obstruction
24.) A 23-year-old man is brought to the physician by his mother because he has heard
a voice over the past month telling him to hurt himself. His mother says that her
son has no friends and is a lifelong loner; since graduating from high school, he
has been unable to hold a job. He admits to smoking marijuana occasionally and
drinking six beers weekly. Examination shows a poorly groomed man with poor
eye contact. He has a flat affect and limited facial expression. He says he has no
intention of harming himself or others. Which of the following is the most
25.) A 23-year-old man is brought to the physician by his mother because he has heard
a voice over the past month telling him to hurt himself. His mother says that her
son has no friends and is a lifelong loner; since graduating from high school, he
has been unable to hold a job. He admits to smoking marijuana occasionally and
Drinking six beers weekly. Examination shows a poorly groomed man with poor
Eye contact. He has a flat affect and limited facial expression. He says he
has no intention of harming himself or others. Which of the following is the most
appropriate next step in management?
A) Schedule a follow-up visit in 4 weeks
B) Prescribe oral risperidone and schedule a follow-up visit in 2 weeks
C) Admit him to the partial hospital program and prescribe oral lithium carbonate
D) Admit him to the psychiatric unit for detoxification
E) Admit him to the psychiatric unit and prescribe oral imipramine
to the medication was good. His symptoms have now returned, and his morning
ritual of cleaning and grooming consumes so much time that his job is in jeopardy.
In addition to education about the nature of his disorder and its treatment, which
of the following is the most appropriate next step in management?
A) Tell the patient to schedule a return visit as needed
B) Offer to change the medication
C) Request that the patient's parents superviseadministration of medication
D) Monitor the patient's compliance by weekly blood tests
E) Begin a trial of cognitive-behavior therapy
28.) A previously healthy 62-year-old man comes to the physician because of a 2-month
history of progressive shortness of breath and a mild nonproductive cough. He
does not smoke. He worked in a foundry most of his adult life before retiring 2
years ago. Vital signs are within normal limits. Crackles are heard at both lung
Bases with no wheezes. Cardiac examination shows an accentuated P2. The
remainder of the examination shows no abnormalities. An x-ray film of the chest
shows prominent interstitial markings at the lung bases. Echocardiography shows
an ejection fraction of 55%. Pulmonary function testing is most likely to show
which of the following?
A) Decreased FEV1:FVC ratio
B) Decreased maximal inspiratory effort
C) Decreased total lung capacity
D) Increased forced vital capacity
E) Normal carbon monoxide diffusion capacity
31.) A healthy 42-year-old man comes to the physician for a life insurance evaluation.
He smoked one-half pack of cigarettes daily for 20 years but quit 10 years ago. His
father died of a myocardial infarction at the age of 65 years. The patient weighs 93
kg (205lb) and is 178 cm (70 in) tall. His blood pressure is 160/110 mm Hg,
pulse is 96/min, and respirations are 16/min. Physical examination, ECG, and an xray film of the chest show no abnormalities. Laboratory studies are within normal
limits except for a serum cholesterol level of 206 mg/dL. Which of the following is
the greatest risk factor for cerebral infarction in this patient?
A) Genetic profile
B) History of smoking
C) Hypercholesterolemia
D) Hypertension
E) Obesity
32.) A previously healthy 56-year-old woman comes to the physician because of
jaundice and dark urine for 3 weeks. She has a 1-year history of generalized
pruritus. She takes no medications. Examination shows jaundice and several
ecchymoses over the forearms and thighs. The liver and spleen are enlarged and
nontender. Laboratory studies show:
Prothrombin time 18 sec
Serum Protein Total 8.5 g/dL
Albumin 3.8 g/dL
Bilirubin Total 5 mg/dL
Direct 2 mg/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
Antimitochondrial antibody assay is strongly positive.
A CT scan of the abdomen shows hepatosplenomegaly.
Endoscopic retrograde cholangiopancreatography shows no abnormalities.
Because of her condition, this patient is at greatest risk for which of the following
deficiencies?
A) Niacin
B) Vitamin A
C) Vitamin B2 (riboflavin)
D) Vitamin B12 (cyanocobalamin)
E) Vitamin C
33.) An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?
A) Bicarbonate
B) Calcium lactate
C) Methenamine mandelate
D) Probenecid
E) Thiazide diuretic
34. A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become severe and generalized. Over the past month, she has
had mild upper abdominal discomfort that is relieved by eating. She
has a history of recurrent migraines treated with sumatriptan as
needed. Her temperature is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is 110/min. Abdominal examination shows mild distention;
there is marked rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal examination shows no abnormalities; test of the stool
for occult blood is negative. Laboratory studies show:
Hematocrit 36%
Leukocyte count 16,500/mm3
Serum
Na+ 145 mEq/L
Cl 106 mEq/L
K+ 3.8 mEq/L
HCO3 19 mEq/L
Urea nitrogen (BUN) 32 mg/dL
Which of the following is the most appropriate next
step in diagnosis?
A) X-ray films of the abdomen while supine and
standing
B) Abdominal ultrasonography
C) Upper gastrointestinal series with contrast
D) HIDA scan
E) Fiberoptic endoscopy of the upper
gastrointestinal tract
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dolly123 - 11/07/06 17:58 #548028
) Brucella melitensis
C
) Francisella tularensis
D
) Leptospira interrogans
E
) Rickettsia rickettsii
4. A 57-year-old woman comes to the physician
because of a 2-year
history of increasing menstrual flow. She has not had
hot flashes,
insomnia, or change in bowel or bladder function. Her
last menstrual period
was 2 weeks ago. Pelvic examination shows a
normal-appearing vulva,
vagina, and cervix. The uterus is consistent in size
with an 8-week
gestation. Bimanual examination shows a 4-cm, firm,
nontender left ovary. An
endometrial biopsy specimen shows atypical complex
endometrial
hyperplasia. Which of the following is the most likely
cause of this patient's
hyperplasia?
A
) Adrenal adenoma
B
) Brenner tumor
C
) Carcinoid tumor
D
) Granulosa cell tumor
E
) Hyperthecosis
F
) Islet cell tumor
G
) Sertoli-Leydig cell tumor
5. A 67-year-old woman comes to the physician
because of vaginal
bleeding for 10 days. She has been soaking one
sanitary pad daily.
Menopause was 10 years ago. Her last Pap smear 5
years ago showed normal
findings. Her temperature is 37 C (98.6 F), blood
pressure is 128/78 mm
Hg, pulse is 70/min, and respirations are 12/min.
Pelvic examination
Hemoglobin 10 g/dL
Serum
Na+ 135 mEq/L
Cl 110 mEq/L
K+ 4.2 mEq/L
HCO3 22 mEq/L
Urea nitrogen (BUN) 40 mg/dL
Creatinine 1.6 mg/dL
An ECG shows diminished amplitude of the QRS
complexes. An x-ray film
of the chest shows clear lung fields with an enlarged
cardiac
silhouette. Which of the following findings is most
likely to be accentuated?
A) Cardiac output
B) Fall in systolic arterial pressure with
inspiration
C) Left ventricular end-diastolic pressure
D) Mitral regurgitation
E) Ventricular septal wall motion
B) Donepezil
C) Fluoxetine
D) Haloperidol
E) Methylphenidate
F) Valproic acid
17. A 42-year-old woman comes for a follow-up examination.
Two weeks ago, her blood pressure was 152/94 mm Hg during a routine
visit. Her blood pressure today is 150/94 mm Hg, pulse is 76/min, and
respirations are 14/min. Examination shows no other abnormalities.
Serum studies show:
Na+ 142 mEq/L
Cl 105 mEq/L
K+ 4 mEq/L
HCO3 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Glucose 101 mg/dL
Creatinine 0.8 mg/dL
An ECG shows no abnormalities. Which of the following is the most
appropriate next step in management?
A) Measurement of plasma renin activity
B) Serum lipid studies
C) 24-Hour urine collection for measurement of
metanephrine level
D) Echocardiography
E) Captopril renal scan
18. A 6-year-old boy with cystic fibrosis is brought to the
physician by his mother because his skin has been cool and clammy for 30
minutes. Earlier in the day, he had been playing outdoors, and the
temperature was 99 F. When returning indoors, he was
thirsty and restless. His blood pressure is 70/40 mm Hg, and pulse is 120/min.
Examination shows dry mucous membranes. Serum sodium level is 128
mEq/L, and serum chloride level is 87 mEq/L. Which of the following is
the most likely explanation for these findings?
A) Excessive sweat electrolyte level
B) Excessive sweat volume
C) Excessive urinary output
D) Excessive vasopressor secretion
E) Inadequate sweat production
prevented this
condition?
A) Hepatitis A vaccine
B) Typhoid vaccine
C) Oral isoniazid prophylaxis
D) Oral mefloquine prophylaxis
E) Oral trimethoprim-sulfamethoxazole prophylaxis
F) Intramuscular immune globulin
month, she has had two episodes of painful sunburn despite her mother's
efforts, including SPF 25 sunblock just before she goes swimming and urging
her to wear a hat and long-sleeved garments. The child takes no
medications. She has blond hair, blue eyes, and a fair complexion. The
mother seeks advice about preventing further sun damage to her child's
skin. Which of the following is the most appropriate recommendation?
A) Prohibit swimming on cloudless days
B) Apply the sunblock lotion 45 minutes before
swimming
C) Change to a higher-level SPF lotion
D) Apply Burrow's solution compresses after each
overexposure
E) Daily use of antioxidant vitamin supplement
F) Early treatment of any sun overexposure with
topical corticosteroids
34. Two days after admission to the hospital because of a 3-day
history of slurred speech, double vision, and dysphagia, a 24-year-old
woman becomes quadriplegic and requires intubation and mechanical
ventilation. Her medical history is unremarkable. One week ago, she attended a
family picnic; several of her family members have had abdominal cramps
and diarrhea since the picnic. Her temperature is 37 C (98.6 F), blood
pressure is 120/80 mm Hg, and pulse is 120/min. Examination shows dry
mucous membranes, large unreactive pupils, ophthalmoplegia, and
profound facial weakness. There is areflexia, quadriplegia, and no movement
of the palate and tongue. Sensation is normal. Babinski's sign is absent. Which of the
following is the most appropriate pharmacotherapy?
A) Antitoxin
B) Azathioprine
C) Interferon
D) Pyridostigmine
E) Riluzole
35. A 2325-g (5 lb 2 oz) male newborn is delivered at 33 weeks'
gestation; Apgar scores are 7 and 8 at 1 and 5 minutes, respectively. The
13-year-old mother had no prenatal care and did not know how much
weight she gained. During the pregnancy, the mother smoked marijuana and
took over-the-counter vitamins occasionally; she did not drink alcohol
and had no illness except for an upper respiratory tract infection 4
months ago. She did not know she was pregnant until 2 weeks ago; her
family is unaware of her condition. She has had one sexual partner. During
the hospital stay, the newborn and his mother have no complications.
The newborn is at greatest risk for morbidity and mortality from which of the following?
A) Child abuse
B) Congenital syphilis
C) Hypocalcemia
D) Lead poisoning
E) Seizures
36. A 2-month-old girl is brought to the physician because of a
2-week history of progressive difficulty breathing and poor feeding. She
has had rapid and labored breathing and sweating during feedings. There
is no history of fever or viral illness. Her temperature is 37 C (98.6 F), blood pressure is
80/60 mm Hg, pulse is 130/min, and respirations mare 40/min. Bilateral crackles are heard
at both lung bases. A grade 4/6 holosystolic murmur is heard along the left
sternal border; the precordium is hyperdynamic. The liver edge is palpated 4 cm below the
right costal margin. An x-ray film of the chest shows cardiomegaly and
pulmonary congestion. Which of the following is the most likely underlying mechanism for
this child's condition?
A) Decreased systemic vascular resistance
B) Increased pulmonary vascular resistance
C) Increased systemic vascular resistance
D) Intracardiac left-to-right shunt
E) Intracardiac right-to-left shunt
Glucose 90 mg/dL
Protein 7 g/dL
Lactate dehydrogenase 300 U/L
Pleural fluid
pH 7.25
Glucose 75 mg/dL
Protein 4.5 g/dL
Lactate dehydrogenase 280 U/L
Leukocyte count 2000/mm3
Segmented neutrophils 15%
Lymphocytes 85%
A Gram's stain and acid-fast stains are negative for any organisms.
Which of the following is the most likely cause of this patient's pleural
effusion?
A) Bacterial pneumonia
B) Collagen vascular disease
C) Congestive heart failure
D) Malignancy
E) Pulmonary embolus with infarction
F) Viral pleuritis
39. A previously healthy 67-year-old woman is admitted to the
hospital because of a 2-week history of dark urine, clay-colored stools, and
increasing jaundice. She has had a 9-kg (20-lb)weight loss over the
past 2 months due to loss of appetite. She also has had generalized
itching that is most severe at night. She has not had any abdominal pain.
Examination shows no abnormalities except for jaundice. Which of the
following is the most likely diagnosis?
A) Common bile duct stone
B) Drug-induced jaundice
C) Hemolytic jaundice
D) Pancreatic carcinoma
E) Viral hepatitis
40. A 2-year-old boy is brought to the physician because of fever
and listlessness for 12 hours. He has had recurrent episodes of
pneumonia and otitis media over the past year. Two maternal uncles died of
pneumonia in early childhood. One year ago, he was at the 50th percentile
for height and weight; he is currently at the 25th percentile for height and 10th percentile
for weight. He appears ill. His temperature is 39 C (102.2 F), blood pressure is 60/40 mm
Hg, pulse is 160/min, and respirations are 36/min. Examination shows cool and mottled
extremities. A blood culture grows Streptococcus pneumoniae. Serum IgE, IgG, and IgM
levels are markedly decreased. Which of the following diagnostic tests is most likely to be
abnormal?
A) Candidal skin test
B) Flow cytometry identification of B lymphocytes
43. A 6-year-old boy has been unable to walk for 2 days because of a sore right knee.
Three weeks ago he had a sore throat and fever that resolved within 2 days. He appears
acutely ill. His temperature is 39.2 C (102.5 F), and pulse is 120/min. A grade 2/6
pansystolic murmur is heard at the apex. The right knee is red, tender, and swollen; any
motion is painful. His leukocyte count is 15,000/mm3, and erythrocyte sedimentation rate
is 120 mm.
44. A 70-year-old woman comes to the physician because of fatigue
and increasing difficulty in her daily functioning over the past 2 months. During the day, she
lies in bed for hours and cries. She has had a 10.9-kg (24-lb) weight loss over the past 4
weeks, eats only cookies, has lost interest in almost everything, and wishes to
kill herself. Her husband died 4 months ago. Physical examination and laboratory studies
show normal findings except for decreased serum albumin and total protein levels. Which of
the following is the most likely diagnosis?
A) Adjustment disorder with depressed mood
B) Bereavement
C) Bipolar disorder, depressed
D) Dysthymic disorder
E) Major depressive disorder
45. A 42-year-old woman comes to the physician because of increasing
low back pain for 2 days. She is a daily intravenous drug user. She has a history of
pyelonephritis, abscesses at injection sites, and pelvic inflammatory disease. Her
temperature is 39 C (102.2 F), blood pressure is 130/70 mm Hg, pulse is 84/min, and
respirations are 20/min. Examination shows warm, dry skin, a supple neck, and
no jugular venous distention. There is tenderness over L4. Pelvic examination shows mild
erythema around the cervical os and scant discharge; there is no adnexal or cervical motion
tenderness. Her hematocrit is 30%, leukocyte count is 10,600/mm3, and serum glucose
level is 110 mg/dL. Urinalysis is within normal limits. Which of the following is the most
appropriate next step in management?
A) Echocardiography
B) Renal ultrasonography
C) MRI of the back
D) Colposcopy
E) Laparoscopy
46. A 13-year-old boy is brought to the physician by his mother
because of frequent headaches over the past 5 weeks. He describes the
headaches as dull pain across his forehead; they occur four to five times
weekly. Acetaminophen does not relieve the pain. His mother states
that occasionally he has nausea without vomiting. He has schizophrenia well controlled with
risperidone. Physical examination shows no abnormalities. An MRI of the brain is most likely
to show which of the following?
A) Bilateral increased caudate nuclei
B) Decreased cerebellar volume
C) Hippocampal symmetry
D) Increased lateral ventricle size
E) Multiple white-matter hyperintensities
block 3:---
Cardiac and
renal ultrasonography shows no abnormalities. Which
of the following is
the most appropriate next step in management?
A
) Exercise and weight reduction program
B
) Measurement of urine catecholamine levels
C
) Measurement of urine corticosteroid levels
D
) Captopril therapy
E
) Hydrochlorothiazide therapy
respirations are
18/min. Examination shows no other abnormalities.
The most appropriate
next step in diagnosis is serum measurement of which
of the following?
A
) Fasting gastrin level
B
) Fasting insulin and glucose levels
C
) Glucagon level
D
) Glucose and somatostatin level
E
) Glucose and vasoactive intestinal
5. An otherwise healthy 15-year-old girl is brought
to the physician
because she has never had a menstrual period. She
reports that breast
development started 1 year ago and pubic and axillary
hair development
began 6 months ago. Examination shows normal
genitalia. Breast
development is Tanner stage 4, and pubic hair
development is Tanner stage 3.
Which of the following is the most appropriate next
step in management?
A
) Reexamination in 1 year if the patient has not
had menarche
B
) Measurement of serum follicle-stimulating hormone
and luteinizing
hormone levels
C
) Measurement of serum thyroid-stimulating hormone
and prolactin
levels
D
) Karyotype analysis
E
) Progesterone withdrawal test
F
) Pelvic ultrasonographypolypeptide levels
6.
) Abdominal ultrasonography
C
) Doppler ultrasonography of the arteries of the
legs
D
) Abdominal aortography
E
) Intravenous pyelography
11.
A previously healthy 15-year-old boy is brought to the
physician
because of a 5-day history of fever, intractable
nausea and vomiting, sore
throat, and muscle pain. His mother has been giving
him ibuprofen and
amoxicillin that was remaining from a previous
streptococcal throat
infection. He appears ill, and his lips are parched.
His temperature is
38.9 C (102 F), blood pressure is 120/74 mm Hg while
supine and 100/70 mm
Hg while standing, and pulse is 92/min while supine
and 120/min while
standing. Examination shows dry mucous membranes.
The oropharynx is
erythematous without exudate. There is shotty
cervical adenopathy. The
abdomen is soft without organomegaly. Laboratory
studies show:
Serum
Na+ 138 mEq/L
Cl 98 mEq/L
K+ 3.4 mEq/L
HCO3 21 mEq/L
Urea nitrogen (BUN) 55 mg/dL
Glucose 105 mg/dL
Creatinine 1.3 mg/dL
Amylase 40 U/L
Urine
Ketones moderate
WBC negative
RBC negative
Na+ 8 mEq/L
Protein negative
Which of the following is the most likely explanation
for this
patient's renal insufficiency?
A
) Acute tubular necrosis
B
) Amoxicillin-induced acute interstitial nephritis
C
) Ibuprofen-induced renal failure
D
) Post-streptococcal glomerulonephritis
E
) Severe volume depletion
16.
A 57-year-old woman is extubated and transferred to
the recovery room
after a cholecystectomy. She appears restless. Her
blood pressure is
120/70 mm Hg, pulse is 80/min, and respirations are
10/min. Arterial
blood gas analysis on room air shows:
pH 7.24
PCO2 85 mm Hg
PO2 60 mm Hg
Intravenous naloxone therapy is begun, but she does
not improve. Which
of the following is the most appropriate next step in
management?
A
) Encouraging deep breathing and cough
B
) Administration of 40% oxygen via nasal cannula
C
) Administration of furosemide
D
) Transfusion of 1 unit of packed red blood cells
E
) Reintubation and mechanical ventilation
episodes, she
jerks her arms and legs wildly. Each episode lasts up
to 1 hour; between
episodes, her behavior is normal. She is planning to
move to another
state because of her husband's work. She has been
extremely anxious and
upset about the move because she will have to leave
her mother, who was
recently diagnosed with breast cancer. There is no
family history of
seizure disorder. Her temperature is 36.7 C (98 F),
blood pressure is
130/80 mm Hg, pulse is 84/min, and respirations are
18/min. Neurologic
examination shows no abnormalities.
Electroencephalography shows
normal findings during an episode of shaking. Which
of the following is the
most likely underlying cause?
A
) Catatonia
B
) Complex partial seizure
C
) Conversion reaction
D
) Dissociative fugue
E
) Malingering
F
) Tonic-clonic seizure
no other
abnormalities. Which of the following is the most
likely diagnosis?
A
) Alcoholic peripheral neuropathy
B
) Ankylosing spondylitis
C
) Guillain-Barr syndrome
D
) Herniated intervertebral disc
E
) Multiple sclerosis
F
) Polymyositis
G
) Syringomyelia
F
) Transfusion of 2 units of packed red blood cells
20.
A 47-year-old woman who is visiting from Australia
comes to the
physician because of increasing urine output over the
past month. She has had
no dysuria or hematuria. She has a history of chronic
headaches,
peptic ulcer disease, and urinary tract infections.
An evaluation 18 months
ago for headaches, including CT scan of the head,
showed no
abnormalities; treatment with ibuprofen and phenacetin
was initiated at that time,
and her headaches have been well controlled. Her
temperature is 37.1 C
(98.8 F), blood pressure is 140/82 mm Hg, pulse is
78/min, and
respirations are 14/min. Examination shows no
abnormalities. Laboratory
studies show:
Hematocrit 32%
Mean corpuscular volume 88 m3
Serum
Glucose 130 mg/dL
Creatinine 1.7 mg/dL
Urine
Protein 2+
WBC 810/hpf
RBC none
Bacteria none
Nitrates none
Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in management?
A
) Intravenous pyelography
B
) Discontinue current medication
C
) Antibiotic therapy for recurrent urinary tract
infections
D
) Insulin therapy for diabetes mellitus
E
) Upper endoscopy
20.
A 47-year-old woman who is visiting from Australia
comes to the
physician because of increasing urine output over the
past month. She has had
no dysuria or hematuria. She has a history of chronic
headaches,
peptic ulcer disease, and urinary tract infections.
An evaluation 18 months
ago for headaches, including CT scan of the head,
showed no
abnormalities; treatment with ibuprofen and phenacetin
was initiated at that time,
and her headaches have been well controlled. Her
temperature is 37.1 C
(98.8 F), blood pressure is 140/82 mm Hg, pulse is
78/min, and
respirations are 14/min. Examination shows no
abnormalities. Laboratory
studies show:
Hematocrit 32%
Mean corpuscular volume 88 m3
Serum
Glucose 130 mg/dL
Creatinine 1.7 mg/dL
Urine
Protein 2+
WBC 810/hpf
RBC none
Bacteria none
Nitrates none
Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in management?
A
) Intravenous pyelography
B
) Discontinue current medication
C
) Antibiotic therapy for recurrent urinary tract
infections
D
) Insulin therapy for diabetes mellitus
E
) Upper endoscopy
months. On
sigmoidoscopy, he is found to have a constricting
adenocarcinoma of the
sigmoid colon; imaging studies show three 1-cm
metastases to the liver.
Which of the following is the most appropriate next
step in management?
A
) No treatment
B
) Radiation therapy
C
) Chemotherapy
D
) Combination radiation therapy and
chemotherapy
E
) Resection of the colon tumor
22. An 8-year-old girl with asthma is brought to
the physician 1
week after an acute exacerbation treated with a 5-day
taper course of oral
prednisone. This was her first asthma attack of the
fall season.
Medications include an inhaled corticosteroid daily
and a bronchodilator
metered-dose inhaler as needed. Her last
immunizations were at the age
of 5 years prior to entering kindergarten. Her
temperature is 37 C
(98.6 F), pulse is 92/min, and respirations are
28/min. Examination shows
end-expiratory wheezing with forced expiration.
Administration of
which of the following vaccines is most appropriate at
this visit?
A
) Haemophilus influenzae type b
B
) Influenza virus
C
) Meningococcal
D
) 23-Valent pneumococcal
E
) Varicella
) Pericardiocentesis
30. A 57-year-old man comes for a routine follow-up
examination. He
has a 10-year history of an intermittent facial rash.
He has been
taking propranolol for 2 months for hypertension.
Examination shows
several erythematous pustules and papules involving
the nose and central
face. There are telangiectasias at the base of the
papules. Which of the
following is the most likely explanation for these
findings?
A
) Acne rosacea
B
) Acne vulgaris
C
) Basal cell carcinoma
D
) Discoid lupus erythematosus
E
) Seborrheic dermatitis
D
) Begin ganciclovir therapy
E
) Begin heparin therapy
32. A 5-month-old boy is brought to the physician
because of a
24-hour history of fever, cough, noisy breathing, and
difficulty feeding.
His symptoms began 3 days ago with nasal discharge,
mild cough, and
chest congestion. He appears somewhat irritable and
is crying. His
temperature is 38.5 C (101.3 F), pulse is 108/min, and
respirations are
32/min and shallow with a prolonged expiratory phase.
On examination, the
throat appears normal. A few small anterior and
posterior cervical
nodes are palpable. Both eardrums are pink but have
normal landmarks and
mobility. There is good air entry with diffuse
bilateral expiratory
wheezes on auscultation. An x-ray film of the chest
shows hyperinflation.
Which of the following is the most likely pathogen?
A
) Adenovirus
B
) Haemophilus influenzae
C
) Mycoplasma pneumoniae
D
) Respiratory syncytial virus
E
) Streptococcus pneumoniae
3. Three days after undergoing a right hip
replacement for
rheumatoid arthritis, a 77-year-old man is brought to
the physician because of a
2-day history of pain, burning, and itching of his
left eye and left
side of his forehead. He has the sensation that there
is a speck of dirt
in his left eye. Current medications include
prednisone and
methotrexate. Examination of the left eye shows
conjunctival injection and
swelling of the upper eyelid. There is an
erythematous rash over the left
side of the forehead and tenderness to palpation from
the upper eyelid
to the vertex. A photograph of the rash is shown.
Which of the
following is the most appropriate next step in
management?
A
) Measurement of erythrocyte sedimentation rate
B
) MRI of the brain with contrast
C
) Acyclovir therapy
D
) Corticosteroid therapy
E
) Lumbar puncture
34. A 54-year-old man with chronic obstructive
pulmonary disease
undergoes a total hip arthroplasty for avascular
necrosis of the femoral
head. On the second postoperative day, he has
diffuse, profound
weakness and vomiting. His blood pressure is 85/50 mm
Hg, and pulse is
100/min. The operative site is clean and dry, with
minimal output from the
drains. Hemoglobin level is 13.8 g/dL, serum sodium
level is 132 mEq/L,
and serum potassium level is 5.8 mEq/L. Which of the
following is most
likely to confirm the diagnosis?
A
) Measurement of serum thyroid-stimulating hormone
level
B
) Direct antiglobulin (Coombs') test
C
) ACTH stimulation test
D
) Ventilation-perfusion lung scans
E
) Echocardiography
35. A previously healthy 47-year-old nulliparous
woman is brought to
the emergency department by ambulance because of acute
low back pain
radiating to the right posterior leg for 2 hours. The
pain began when
she bent over at work to retrieve a file from the
lowest drawer of a
filing cabinet. She does not smoke cigarettes or
drink alcohol.
Examination shows right paraspinous muscle spasm and
pain in the lower back with
right straight-leg raising at 30 degrees. She says
that she plans to
file a claim for a work-related injury. Which of the
following findings
is the strongest risk factor for a prolonged episode
of pain in this
patient?
A
) Arrival for care in an ambulance
B
) Claim that pain is work-related
C
) Gender
D
) Nulliparity
E
) Positive straight-leg raising test
F
) Radiation of the pain into the posterior lower
extremity
B
) Niacin
C
) Vitamin A
D
) Vitamin B1 (thiamine)
E
) Vitamin B2 (riboflavin)
F
) Vitamin B6
G
) Vitamin B12 (cyanocobalamin)
H
) Vitamin C
I
) Vitamin D
J
) Vitamin E
K
) Vitamin K
) Lithium carbonate
E
) Nortriptyline
42. An 82-year-old man comes to the physician
because of a 3-day
history of low back pain that radiates to the right
leg. He also has had
a lesion over the right shin and weakness of the right
foot. He began
taking prednisone 2 weeks ago for acute bronchitis.
He has chronic
obstructive pulmonary disease, benign prostatic
hypertrophy, and glaucoma.
Examination shows numerous papular and vesicular
lesions over the right
anterior and posterior shin. There is weakness of
right knee flexion,
ankle dorsiflexion, plantar flexion, eversion, and
inversion; the right
ankle reflex is absent. Sensation to pinprick and
cold is decreased
over the right lower extremity. Which of the
following is the most
likely causal organism?
A
) Borrelia burgdorferi
B
) Epstein-Barr virus
C
) Herpes simplex virus 1
D
) Poliovirus
E
) Treponema pallidum
F
) Varicella-zoster virus
a 4-month history
of fatigue, cough, and shortness of breath with
exertion. She has had
two episodes of pneumonia and one episode of severe
sinusitis over the
past 2 years. She has never smoked. She takes no
medications.
Crackles are heard at the left lung base. An x-ray
film of the chest shows a
left lower lobe infiltrate and scarring of the right
base.
46. A 32-year-old man is brought to the emergency
department 30
minutes after being involved in a motor vehicle
collision. He was the
restrained driver. On arrival, he is alert and has
shortness of breath.
His blood pressure is 80/50 mm Hg, pulse is 130/min,
and respirations
are 30/min. Examination shows jugular venous
distention and abrasions
over the left hemithorax. The trachea is deviated to
the right. Breath
sounds are absent on the left. Which of the following
is the most
likely cause of the hypotension?
A
) Cardiogenic shock
B
) Congestive heart failure
C
) Decreased systemic vascular resistance
D
) Decreased venous return
E
) Hypovolemic hypoperfusion
F
) Increased systemic vascular resistance
BLOCK 4:-1. A previously healthy 2-year-old boy is brought
to the physician
20 minutes after an episode of cyanosis and loss of
consciousness that
lasted 3 minutes. The symptoms occurred after his
mother scolded him
for climbing onto the dining room table. The mother
says that the child
began to cry, let out a deep sigh, stopped breathing,
and jerked his
arms and legs back and forth. On arrival, he is alert
and active.
Neurologic examination shows no focal findings. Which
of the following is
the most appropriate next step in management?
A
) Reassurance
B
) Electroencephalography
C
) CT scan of the head
D
) Anticonvulsant therapy
E
) Lumbar puncture
E
) Rotavirus vaccine prevents 80 cases of
intussusception per 100,000
infant-years
3.
A 42-year-old woman, gravida 3, para 3, comes to the
emergency
department 24 hours after the onset of moderate
epigastric pain radiating to
the back. Her last menstrual period was 3 weeks ago.
She has no history
of serious illness and has never undergone an
operative procedure. She
weighs 72 kg (160 lb) and is 157 cm (62 in) tall. Her
temperature is
37.2 C (99 F), blood pressure is 130/90 mm Hg, and
pulse is 100/min.
Abdominal examination shows mild distention,
epigastric tenderness, and
voluntary guarding. Test of the stool for occult
blood is negative.
Laboratory studies show:
Hematocrit 44%
Leukocyte count 12,000/mm3
Serum
Na+ 138 mEq/L
Cl 100 mEq/L
K+ 4 mEq/L
HCO3 25 mEq/L
Bilirubin, total 1.6 mg/dL
Alkaline phosphatase 100 U/L
Aspartate aminotransferase
(AST, GOT) 14 U/L
Alanine aminotransferase
(ALT, GPT) 12 U/L
Amylase 1100 U/L
Ultrasonography shows gallstones; the gallbladder wall
is 1 mm and the
common bile duct is 5 mm in diameter. Which of the
following is the
most likely diagnosis?
A
) Acute cholecystitis
B
) Acute pancreatitis
C
) Acute perihepatitis
D
) Ascending cholangitis
E
) Duodenal ulcer
F
) Viral hepatitis
4. A 13-year-old girl is brought to the emergency
department because
of shortness of breath for 2 hours. The symptoms
began after consuming
chili, cornbread, and fruit salad with strawberries,
kiwi, and bananas.
She has a 1-year history of shortness of breath while
playing soccer or
baseball and uses a bronchodilator inhaler as needed
while exercising.
She is allergic to penicillin and pineapples. Her
blood pressure is
80/60 mm Hg, pulse is 120/min and regular, and
respirations are 20/min
with use of accessory muscles. Examination of the
lungs shows poor air
entry bilaterally with diffuse expiratory wheezes.
Which of the
following is the most appropriate initial
pharmacotherapy?
A
) Inhaled bronchodilators
B
) Inhaled cromolyn sodium
C
) Inhaled ipratropium bromide
D
) Intravenous corticosteroids
E
) Subcutaneous epinephrine
5.
A 52-year-old woman comes to the emergency department
6 days after knee
arthroplasty because of constant, right-sided chest
pain and shortness
of breath for 24 hours. Her blood pressure is 110/50
mm Hg, pulse is
114/min, and respirations are 24/min. Examination of
the heart, lungs,
and extremities shows no abnormalities. Arterial
blood gas analysis on
room air shows:
pH 7.49
PCO2 29 mm Hg
PO2 66 mm Hg
G
) Pulmonary embolism
H
) Sepsis
8. A previously healthy 62-year-old man is brought
to the emergency
department by paramedics 40 minutes after the sudden
onset of severe
shortness of breath while dressing this morning. He
is unable to provide
additional medical history. He is in severe
respiratory distress. His
temperature is 37.8 C (100 F), blood pressure is 90/60
mm Hg, pulse is
120/min and regular, and respirations are 24/min.
Examination shows
marked jugular venous distention. The lungs are clear
to auscultation.
Cardiac examination shows a nondisplaced and discrete
point of maximal
impulse and normal S1 and S2; there is an S4 and a
right parasternal
heave. Abdominal examination shows no abnormalities.
There is no edema
of the lower extremities. Laboratory studies show:
Hematocrit 40%
Leukocyte count 14,000/mm3
Platelet count 350,000/mm3
Arterial blood gas analysis on 5 L/min of oxygen:
pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg
A previously healthy 67-year-old woman is brought to
the emergency
department by paramedics 40 minutes after the sudden
onset of shortness of
breath while shopping. She is unable to provide
additional medical
history. She is in severe respiratory distress. Her
temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is
120/min and regular,
and respirations are 24/min. Examination shows marked
jugular venous
distention. Diffuse crackles are heard throughout all
lung fields.
Cardiac examination shows an enlarged point of maximal
impulse and normal
S1 and S2; there is an S3. Abdominal examination
shows no
abnormalities. There is no edema of the lower
He reports that
he is not seeing things correctly. He takes warfarin
and digoxin for
atrial fibrillation, hydrochlorothiazide for
hypertension, and potassium
supplements that he discontinued 3 weeks ago when he
ran out of
tablets. His temperature is 37 C (98.6 F), blood
pressure is 144/88 mm Hg,
and pulse is 52/min and irregular. Bowel sounds are
normal. The abdomen
is soft and nontender without rebound or guarding. No
organomegaly or
masses are palpated. Which of the following is the
most likely
diagnosis?
A
) Acute pancreatitis
B
) Brain tumor
C
) Diabetic gastroparesis
D
) Diabetic ketoacidosis
E
) Drug toxicity
F
) Food poisoning
G
) Gastric bezoar
H
) Gastric carcinoma
I
) Pyloric channel ulcer
J
) Small-bowel obstruction
K
) Uremia
14. A 27-year-old primigravid woman at 12 weeks'
gestation comes to
the emergency department 2 hours after the sudden
onset of bright red
vaginal bleeding. She has not had abdominal cramping.
Pelvic
examination shows a small amount of brownish blood in
the posterior fornix of
the vagina. The cervix is closed. The uterus is
palpable 3 cm above the
pelvic brim. Fetal heart tones are easily audible at
167/min by
Doppler. Which of the following is the most likely
diagnosis?
A
) Abruptio placentae
B
) Ectopic pregnancy
C
) Incomplete abortion
D
) Placenta previa
E
) Threatened abortion
F
) Normal pregnancy
15. A 72-year-old man is brought to the physician
by his son because
of a 4-day history of increasing confusion and memory
problems. The
son says that his father's ability to function
independently has been
generally declining over the past few years, and he
has become much more
impaired over the past week. The patient has had at
least three to four
previous episodes of a sudden decline of cognitive
functioning over the
past 3 years without full recovery. He has a history
of hypertension.
His blood pressure is 160/95 mm Hg without orthostatic
changes.
Neurologic examination shows no focal findings.
Mini-Mental State Examination
score is 21/30. Which of the following is the most
likely underlying
pathophysiologic process?
A
) Central nervous system demyelination
B
) Central nervous system infection
C
) Diffuse axonal injury
D
) Diffuse cortical atrophy
E
) Left temporal lobe infarction
F
) Multiple, small, central nervous system
infarctions
G
) Subdural hematoma
C
) Intravenous ampicillin therapy
D
) Intravenous haloperidol therapy
E
) Intravenous lorazepam therapy
18. A 27-year-old woman comes to the physician
because of a 3-week
history of fever, night sweats, rash on both legs,
nonproductive cough,
and pain and swelling in her wrists and knees. She
has not had weight
loss. Her temperature is 37.7 C (99.8 F), blood
pressure is 110/70 mm
Hg, pulse is 96/min, and respirations are 14/min. The
lungs are clear
to auscultation. Cardiac examination shows no
abnormalities. There is
swelling and warmth over the wrists and knees
bilaterally and tender
red nodules on the anterior surface of both lower
extremities. An x-ray
film of the chest shows bilateral hilar fullness.
Which of the
following is the most likely diagnosis?
A
) Carcinoma of the lung
B
) Histoplasmosis
C
) Hodgkin's disease
D
) Sarcoidosis
E
) Tuberculosis
19. A 52-year-old woman comes to the physician
because of difficulty
climbing stairs for 4 months. She has also noted that
her thighs hurt
when she presses on them. She has had increasing
difficulty combing
her hair because she tires easily. On examination,
she pushes herself
out of the chair with her arms. There is weakness of
the proximal
muscles of the extremities. Which of the following is
the most likely
diagnosis?
A
) Cauda equina syndrome
B
) Cerebellar degeneration
C
) Cervical spinal cord compression
D
) Diabetic polyneuropathy
E
) Femoral artery insufficiency
F
) Guillain-Barr syndrome
G
) Lumbar spinal stenosis
H
) Multiple sclerosis
I
) Normal-pressure hydrocephalus
J
) Polymyositis
K
) Sensory neuropathy
L
) Tabes dorsalis
D
) Miliary tuberculosis
E
) Myelofibrosis
B
) Bicuspid aortic valve
C
) Postpartum cardiomyopathy
D
) Rheumatic heart disease
E
) Viral myocarditis
3. A 37-year-old woman has had unilateral breast
pain, fever, and
chills for 24 hours. She breast-feeds her 1-month-old
newborn. Her
temperature is 38 C (100.4 F). Examination shows
swelling, erythema, and
localized tenderness of the left breast. Which of the
following is the
most appropriate next step in management?
A
) Application of ice packs to the affected breast
B
) Use of a breast pump
C
) Immediate discontinuation of breast-feeding
D
) Bromocriptine therapy
E
) Penicillinase-resistant antibiotic therapy
24. A 19-year-old woman, gravida 2, para 1, at 39
weeks' gestation
is admitted in labor. Contractions occur every 2 to 3
minutes. The
cervix is 4 cm dilated and 80% effaced. She requests
an epidural for pain
control. Ten minutes after the epidural is
administered, she becomes
nauseated and diaphoretic and vomits. Her blood
pressure is 60/palpable
mm Hg. A fetal heart tracing shows sustained fetal
decelerations. The
cervix is now 8 cm dilated. The most appropriate next
step in
management is administration of which of the
following?
A
) Ephedrine
B
) Magnesium sulfate
C
) Nifedipine
D
) Oxytocin
E
) Terbutaline
25. An asymptomatic 47-year-old man comes for a
routine follow-up
examination 3 weeks after sustaining an inferior wall
myocardial
infarction. His recovery was complicated by transient
premature ventricular
contractions during the first 2 days of
hospitalization. An exercise
stress test prior to discharge showed no pain at 70%
of his predicted
maximum exercise capacity. Medications include daily
aspirin and
pravastatin. His blood pressure is 136/80 mm Hg,
pulse is 80/min and regular,
and respirations are 16/min. Cardiopulmonary
examination shows no
abnormalities. Which of the following is the most
appropriate additional
pharmacotherapy for this patient?
A
) Clonidine
B
) Metoprolol
C
) Quinidine
D
) Sulfinpyrazone
E
) Verapamil
27.
A 4-year-old boy is brought to the emergency
department because of a
1-day history of fever and increasing difficulty
breathing. Over the
past year, he has had recurrent bacterial infections
including cervical
lymphadenitis, septic arthritis, and pneumonia. His
temperature is 38.9
C (102 F), blood pressure is 80/60 mm Hg, pulse is
115/min, and
respirations are 38/min and labored. Breath sounds
are decreased over the
left anterior chest. Scattered crackles are heard on
auscultation. A
thoracentesis shows purulent fluid. Laboratory
studies show:
Hematocrit 36%
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Lymphocytes 15%
Platelet count 200,000/mm3
Pleural fluid
Leukocyte count 75,000/mm3
Segmented neutrophils 98%
Lymphocytes 2%
Nitroblue tetrazolium test is abnormal. A Gram's
stain of the pleural
fluid shows numerous gram-positive cocci in the
segmented neutrophils.
An x-ray film of the chest shows left lower lobe
pneumonia with pleural
effusion. The most likely cause of this patient's
symptoms is a defect
of which of the following?
A
) Chemotaxis
B
) Immotile cilia
C
) Opsonization
D
) Phagocytic oxidative metabolism
E
) Phagocytosis
F
) T-lymphocyte function
H
) Overproduction of cerebrospinal fluid
I
) Vasogenic edema
these findings?
A
) Immune complex deposition
B
) Inflammatory reaction to antisynovial antibodies
C
) Inflammatory reaction to monosodium urate
crystals
D
) Neisseria gonorrhoeae infection
E
) Streptococcus pneumoniae infection
32. Two days after a cholecystectomy, a 42-year-old
woman has
shortness of breath. Her temperature is 37.5 C (99.5
F), blood pressure is
110/70 mm Hg, pulse is 103/min, and respirations are
24/min. There is
abdominal tenderness. Examination shows no other
abnormalities. An
x-ray film of the chest shows minimal linear markings
in the right lower
lobe. Arterial blood gas analysis on 45% oxygen
shows:
pH 7.41
PCO2 40 mm Hg
PO2 52 mm Hg
Which of the following is the most likely explanation
for her hypoxia?
A
) Acute respiratory distress syndrome
B
) Atelectasis
C
) Congestive heart failure
D
) Fat embolism syndrome
E
) Pneumonia
F
) Pneumothorax
nausea, and
vomiting. Twelve years ago, she had a hysterectomy
because of severe
dysfunctional uterine bleeding. Her temperature is 37
C (98.6 F), blood
pressure is 106/70 mm Hg, pulse is 110/min, and
respirations are 12/min.
Examination shows a distended, tympanic abdomen with
diffuse tenderness
but no guarding; bowel sounds are hypoactive. Her
leukocyte count is
10,000/mm3, and hematocrit is 44%. An x-ray film of
the abdomen is
shown. Which of the following is the most appropriate
initial step in
management?
A
) CT scan of the abdomen
B
) Intravenous neostigmine therapy
C
) Esophagogastroduodenoscopy
D
) Nasogastric intubation
E
) Laparotomy
rsonality disorder
C
) Major depressive disorder
D
) Schizophrenia
E
) Substance-induced mood disorder
B
) Admission to the hospital for medical management
C
) Admission to the hospital for operative
management
D
) Colon contrast studies
E
) Discharge for follow-up by personal physician
F
) Endoscopy
G
) MRI of the abdomen
H
) Observation in the emergency department
40. A previously healthy 14-year-old girl is
brought to the
emergency department because of abdominal pain for 12
hours. She has a 1-week
history of brownish vaginal discharge. Menarche was
at the age of 12
years, and her periods have occurred at regular 28-day
intervals over
the past year. Her last menstrual period was 7 weeks
ago. Her
temperature is 37 C (98.6 F), blood pressure is 85/55
mm Hg, pulse is 145/min,
and respirations are 24/min. Abdominal examination
shows generalized
tenderness, and there is guarding with rebound in the
right lower
quadrant. Her hematocrit is 24%, and leukocyte count
is 9400/mm3 (60%
segmented neutrophils, 3% bands, 1% eosinophils, 35%
lymphocytes, and 1%
monocytes). Serum electrolyte levels are within
normal limits.
41. A 49-year-old woman is admitted to the hospital
because of renal
failure. She has had episodes of flank pain over the
past 20 years.
She has also had nocturia 2 to 3 times nightly for 10
years. Her blood
pressure is 160/100 mm Hg. Examination shows pale
mucous membranes. A
mass is palpated in the right flank. Which of the
following is the
most likely diagnosis?
A
) Horseshoe kidney
B
) Nephrolithiasis
C
) Papillary necrosis
D
) Polycystic kidney disease
E
) Renal cell carcinoma
42. On routine annual screening, an asymptomatic
27-year-old man has
a positive PPD skin test. One year ago, a PPD skin
test was negative.
He works as a nurse. Three years ago, he was
diagnosed with hepatitis
A after a trip to South America. Examination shows no
abnormalities.
His serum aspartate aminotransferase (AST, GOT)
activity is 10 U/L, and
serum alanine aminotransferase (ALT, GPT) activity is
14 U/L. An x-ray
film of the chest shows no abnormalities. Which of
the following is
the most appropriate chemoprophylaxis?
A
) Isoniazid and folic acid supplementation
B
) Isoniazid and rifampin
C
) Isoniazid and vitamin B1 (thiamine)
supplementation
D
) Isoniazid and vitamin B6 supplementation
E
) No prophylaxis indicated
43.
A 4-month-old boy is brought to the physician because
of a 2-day
history of fever and progressive redness around his
right eye. He has had
persistent diarrhea and oral candidiasis since birth
and was treated for
pneumococcal pneumonia at the age of 2 months. He
appears ill. His
temperature is 39 C (102.2 F), pulse is 130/min, and
respirations are
25/min. Examination shows violaceous preseptal
(periorbital) cellulitis
and oral candidiasis. Laboratory studies show:
Hemoglobin 10 g/dL
Leukocyte count 3000/mm3
Segmented neutrophils 85%
Lymphocytes 15%
Platelet count 350,000/mm3
Serum
IgA <5 mg/dL
IgG 300 mg/dL
IgM <5 mg/dL
Which of the following is the most likely diagnosis?
A
) AIDS
B
) Chronic granulomatous disease
C
) Severe combined immunodeficiency
D
) Thymic-parathyroid dysplasia (DiGeorge syndrome)
E
) X-linked agammaglobulinemia
) Middle colic
G
) Posterior penetrating
H
) Right colic
I
) Right gastroepiploic
J
) Splenic
K
) Superior hemorrhoidal
L
) Superior mesenteric
1-month history
of intermittent right-sided abdominal pain, nausea,
and vomiting. He
has sickle cell disease and has been treated several
times for painful
crises. Examination of the abdomen shows tenderness
to palpation of the
right upper quadrant on inspiration. Laboratory
studies show:
Hematocrit 25%
Leukocyte count 11,000/mm3
Serum
Bilirubin
Total 3.2 mg/dL
Direct 0.3 mg/dL
Alkaline phosphatase 56 U/L
Ultrasonography of the gallbladder shows a filling
defect. Which of
the following is the most likely cause of this
patient's
hyperbilirubinemia?
A
) Aggregation of cholesterol in the gallbladder
B
) Inhibition of glucuronosyltransferase
C
) Lysis of erythrocytes
D
) Malnutrition-induced cirrhosis
E
) Neoplastic growth in the gallbladder