1.
A 78-year-old woman, who is a resident of an assisted living facility, is evaluated because of a 2-week history of right-sided headache, fatigue, and aching pain in her shoulders and hips. She also has had pain in her jaw when chewing, difficulty getting out of a chair, and reduced appetite during this time. Medical history is significant for hypertension and macular degeneration. Medications include lisinopril, calcium, and vitamin D. She is 160 cm (5 ft 3 in) tall and weighs 54 kg (120 lb); BMI is 21 kg/m2. Vital signs are temperature 37.6°C (99.7°F), pulse 80/min, respirations 16/min, and blood pressure 140/80 mm Hg. Visual acuity is 20/100 in both eyes. The remainder of the cranial nerve examination discloses no abnormalities. Muscle strength is 5/5 throughout all extremities. Deep tendon reflexes are 1+ diffusely and symmetrically. Babinski sign is absent. Sensation to vibration is reduced at the toes. Which of the following is the most appropriate diagnostic study at this time?
A) Determination of serum creatine kinase concentration
B) Electromyography and nerve conduction studies
C) Erythrocyte sedimentation rate
D) MRI of the brain
E) Serum rheumatoid factor assay
2.
A 3-day-old neonate is seen in the hospital because of severe weakness since birth requiring mechanical ventilation. She was born at term via uncomplicated vaginal delivery to a 26-year-old primigravid woman, who has mild mental retardation, and was noted to have contractures of multiple joints at birth. Pregnancy was complicated by poor fetal motility in the third trimester. Prenatal ultrasonography demonstrated polyhydramnios. Apgar scores were 4 and 6 at 1 and 5 minutes, respectively. Family history is remarkable for diabetes mellitus in several maternal relatives. The neonate's mother has a long, drawn face with a slack jaw. She has difficulty releasing her grip after shaking hands during the introduction. The neonate's length, weight, and head circumference are at the 25th percentile. Vital signs are temperature 36.1°C (97.0°F), pulse 130/min, respirations 32/min, and blood pressure 65/30 mm Hg. She is awake and has severe weakness of her face and extremities. Flexion deformities and clubfeet are present bilaterally. Deep tendon reflexes are difficult to elicit. Which of the following is the most likely initial working diagnosis?
A) Cerebral palsy
B) Congenital myotonic dystrophy
C) Hydranencephaly
D) Transient neonatal myasthenia gravis
E) Werdnig-Hoffmann spinal muscular atrophy
3.
A 67-year-old African American man is admitted to the hospital through the emergency department because of swelling in his feet and a recent elevation in his blood pressure. On arrival the patient's blood pressure was increased and serum creatinine and urea nitrogen concentrations were 3.6 mg/dL and 60 mg/dL, respectively. Medical history is remarkable for hypertension that has been well controlled in the past. He also has hypercholesterolemia, periodic angina, and chronically elevated serum creatinine concentrations that have averaged 2.1 mg/dL during the past year. Medications include metoprolol, furosemide, minoxidil, atorvastatin, 81-mg aspirin, and sublingual nitroglycerin as needed. He has smoked two packs of cigarettes daily for the past 35 years. Vital signs on admission are temperature 37.3°C (99.1°F), pulse 64/min, respirations 18/min, and blood pressure 188/94 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 92%. Auscultation of the lungs discloses bilateral basilar crackles. Cardiac examination discloses an S4 gallop and a grade 2/6 systolic ejection murmur at the apex. Abdominal examination discloses a right-sided bruit but no tenderness. Which of the following is the most appropriate initial diagnostic study?
A) Determination of serum catecholamine concentrations
B) Intravenous urography
C) Renal duplex scan
D) Spiral CT scan of the abdomen
4.
A 24-year-old white woman gives birth to a healthy term 3714 g (8 lb 3 oz) neonate via spontaneous vaginal delivery. Pregnancy and labor were uncomplicated. The mother's blood type is O, Rh-negative. Results of laboratory studies obtained at admission show a hematocrit of 37% and are otherwise normal. Ten minutes after delivery of the placenta, the patient has heavy vaginal bleeding. Vital signs are normal. In addition to increasing the intravenous rate, which of the following is the most appropriate initial step?
A) Administer oxytocin
B) Begin transfusion of packed erythrocytes
C) Do uterine curettage
D) Pack the uterus with sterile packing sponges
E) Prepare for immediate hysterectomy
5.
A 15-year-old girl is admitted to the hospital through the emergency department because of a 4-hour history of continuous vomiting and severe abdominal pain. The pain began after the patient ate lunch, which included a salad she made from plants in her parents' garden. The patient and her family do not accept medical care because of their religious beliefs. Despite the patient's objections, her friends brought her to the emergency department. The patient agrees to a physical examination and observation via a heart monitor, but she refuses any treatment. Vital signs on admission are temperature 36.9°C (98.4°F), pulse 30/min, respirations 18/min, and blood pressure 80/40 mm Hg. Examination of the abdomen discloses hyperactive bowel sounds. The remainder of the physical examination discloses no abnormalities. The patient understands that she is seriously ill and that she may die without treatment, but she continues to refuse any further intervention. Rhythm strip is shown. All attempts to reach her parents since the patient's arrival have been unsuccessful.
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Which of the following is the most appropriate management at this time?
A) Begin intravenous fluid hydration now while awaiting contact with her parents
B) Proceed with necessary emergency medical interventions
C) Provide general comfort care only
D) Seek a court order before proceeding with medical intervention
E) Seek assistance from a religious advisor of her faith
6.
A 54-year-old man was admitted to the hospital through the emergency department 5 days ago because of fever and lower abdominal pain. CT scan of the abdomen showed thickening and mesenteric edema around the sigmoid colon. Sigmoid diverticulitis was diagnosed. Administration of intravenous fluids and antibiotic therapy was begun. During the next 4 days the patient's fever, leukocytosis, and abdominal pain resolved. Today, the fifth day in the hospital, the patient has increasingly frequent, watery bowel movements. Vital signs are temperature 37.6°C (99.7°F), pulse 92/min, and respirations 16/min. Stool is positive for Clostridium difficile toxin. The most appropriate first step in management is to administer which of the following?
A) Ampicillin
B) Loperamide
C) Metronidazole
D) Vancomycin
E) No therapy
7.
A 42-year-old white man has been hospitalized for the past 3 months for severe soft-tissue and orthopaedic injuries sustained in a motor vehicle collision. He has recently developed low-grade fevers to 38.2°C (100.7°F) on a daily basis. Chest x-ray shows a diffuse interstitial infiltrate. Before admission he had a history of chronic intravenous drug abuse. Which of the following laboratory determinations is most likely to provide immediate prognostic importance in this patient?
A) An anergy panel
B) CD4+ T-lymphocyte count
C) Cytomegalovirus serology (IgG FA)
D) HIV serology by western blot analysis
E) A leukocyte count
8.
A 45-year-old white man was admitted to the hospital 3 days ago after he fell off a stepladder and sustained a femur fracture that required open reduction with internal fixation. He has a history of hypertension. Today, he became confused. Vital signs are pulse 96/min and regular, respirations 24/min, and blood pressure 130/80 mm Hg. Physical examination discloses fine crackles over both lungs. Heart examination is normal. Petechiae are seen over his chest and axillae. He has no edema or calf tenderness. Neurologic examination shows disorientation and confusion, with minimal right arm weakness. The patient is hypoxic. Oxygen therapy corrects the hypoxia but does not improve his neurologic findings. Physical examination shows livedo reticularis in his legs. Laboratory studies are normal. MRI of the brain shows multiple, small hyperintense lesions, bilaterally. Which of the following is the most likely explanation for his neurologic change?
A) Bilateral brain contusions sustained in the fall
B) Deep venous thrombosis with pulmonary and brain emboli
C) Fat emboli to the brain
D) Small infarcts caused by hypoxia
E) Small strokes caused by atherosclerotic emboli
9.
A 60-year-old woman, who is recovering in the hospital 4 days after undergoing uncomplicated right hemicolectomy for cecal carcinoma, reports increasing shortness of breath during the past 6 hours. Medical history is also significant for type 2 diabetes mellitus, dyslipidemia, mild renal insufficiency, and myocardial infarction 4 years ago. Current medications include insulin, metoprolol, and low-dose enoxaparin. She is receiving intravenous 5% dextrose in 0.45% saline. On admission, she was 163 cm (5 ft 4 in) tall and weighed 113 kg (249 lb); BMI was 43 kg/m2. Weight today is 118 kg (260 lb); BMI is 45 kg/m2. Vital signs are temperature 38.0°C (100.4°F), pulse 130/min, respirations 20/min, and blood pressure 110/70 mm Hg. Pulse oximetry on 5 L of oxygen via nasal cannula shows an oxygen saturation of 93%. Auscultation of the lungs discloses decreased breath sounds bilaterally. Heart rate is regular without murmurs; an S3 gallop is audible. The abdomen is obese and mildly distended; bowel sounds are hypoactive. There is 2+ edema of the lower extremities, bilaterally. Which of the following is the most appropriate initial pharmacotherapy for this patient's symptoms?
A) Amiodarone
B) Aspirin
C) Captopril
D) Furosemide
E) Nitroglycerin
10.
An 80-year-old Native American man is admitted to the hospital for treatment of a hip fracture sustained today as he walked across his driveway. His wife reports that her husband has felt weak and has not been steady on his feet during the past 6 months. She says his feet often spread apart with his knees bent, and he often seems on the verge of falling. She notes that he has had progressive memory loss of names and where he put his glasses. She thinks he also often forgets to go to the bathroom, as he has had several episodes of urinary incontinence. He has type 2 diabetes mellitus controlled with diet. His medications include a multivitamin, glucosamine, chondroitin, and acetaminophen. He is 180 cm (5 ft 11 in) tall and weighs 73 kg (160 lb); BMI is 22 kg/m2. Vital signs are temperature 37.0°C (98.6°F), pulse 65/min, respirations 12/min, and blood pressure 120/82 mm Hg. These findings are most characteristic of which of the following?
A) Alzheimer disease
B) Brain tumor
C) Multi-infarct (vascular) dementia
D) Neurosyphilis
E) Normal pressure hydrocephalus
Love the company.
can anybody clear this case. Anyway answer was C
... As master Fischer says .... It doesn't matter as long as you get all right