04-17-2012, 03:34 PM
4. An 8-year-old boy is brought to the health center by his parents because of a 2-day history of sore throat and fever. Temperature is 38.3°C (101.0°F) and pulse is 88/min; other vital signs are normal. Physical examination shows erythema of the posterior pharynx; the tonsils are enlarged and there are a few spots of whitish exudate on the left tonsil. A few small, nontender posterior cervical lymph nodes are palpable. There is no rash. Rapid streptococcal test is negative. Which of the following is the most appropriate next step?
A) Administer intramuscular penicillin
B) Obtain a throat culture
C) Obtain acute-phase serum for antistreptolysin-O titer
D) Prescribe azithromycin
E) Reassure the patient's parents that he has a viral illness
26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?
A) Determine serum estrogen concentration
B) Order antibody studies for syphilis and HIV
C) Prescribe an oral anti-trichomonal medication and antifungal cream
D) Question the patient regarding the circumstances surrounding her recent break-up
E) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge
27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?
A) CT scan of the head
B) Electromyography and nerve conduction studies of the left upper extremity
C) Measurement of serum B12 (cobalamin) concentration
D) MRI of the cervical spine
E) Radionuclide bone scan
28. A 32-year-old woman, gravida 3, para 2, who is at 38 weeks' gestation, is brought to the office by her coworker 15 minutes after the patient appeared to have had a seizure at work. The coworker says the patient was working at her computer when she suddenly fell to the floor, began shaking, and had incontinence of urine. She was unresponsive to voice until approximately 5 minutes after the episode. The patient has received routine prenatal care throughout her pregnancy. She has a history of mild, persistent asthma treated with corticosteroid inhalers. Vital signs on arrival are temperature 36.7°C (98.0°F), pulse 100/min, respirations 22/min, and blood pressure 160/110 mm Hg. The patient is alert but disoriented to time and place. She has no recollection of the episode. Physical examination shows bruising of her left arm and a bite on the lower lip. Which of the following is the most accurate statement regarding the risk of harm to the fetus?
A) The fetus is at risk for developing intrauterine hypoxia
B) The fetus will die unless it is delivered immediately
C) The risk to the fetus depends on any coexisting respiratory condition
D) The risk to the fetus is minimal because the seizure was short-lived
E) The risk to the fetus will not be increased if the seizure does not recur
29. A 30-year-old African-American woman returns to the office for a second prenatal visit. She is 12 weeks pregnant and this is her first pregnancy. Results of laboratory studies that were ordered at her first visit show:
Blood
Hematocrit 28%
Hemoglobin 9.2 g/dL
Hemoglobin electrophoresis
Hemoglobin A1 64%
Hemoglobin S 32%
Hemoglobin A2 4%
Mean corpuscular hemoglobin (MCH) 26 pg/cell
Mean corpuscular hemoglobin concentration(MCHC) 32% Hb/cell
Mean corpuscular volume (MCV) 74 μm3
Which of the following is the most likely cause of her anemia?
A) α-thalassemia trait
B) β-thalassemia trait
C) Iron deficiency
D) Physiologic anemia of pregnancy
E) Sickle cell trait
32. A 62-year-old woman who was discharged from the hospital several hours ago following evaluation of optic neuritis now has swelling of her ankles. Prior to admission, the patient had a 3-day history of loss of vision and poor color perception in her right eye. Visual acuity on admission was less than 20/200 in her right eye and was 20/40 in her left eye. The remainder of the physical examination was noncontributory. Blood pressure on admission was 140/80 mm Hg. The patient had been otherwise healthy and had been taking no medications. She has never worn corrective lenses. Family history is significant for thyroid disorder. During her hospital stay, the patient received intravenous methylprednisolone therapy for the past four days. Vital signs today are temperature 37.2°C (99.0°F), pulse 100/min, respirations 14/min, and blood pressure 150/95 mm Hg. Physical examination shows ankle edema but is otherwise unchanged from physical examination done on admission. Laboratory studies are obtained. Which of the following serum laboratory study results is most likely in this patient?
A) Decreased magnesium concentration
B) Decreased sodium concentration
C) Increased calcium concentration
D) Increased glucose concentration
E) Increased potassium concentration
33. A 30-year-old white woman comes to the office for a periodic health evaluation. At this visit she asks you about a DNA test that she has heard about that can detect the presence of the adult polycystic kidney disease (APKD) gene in asymptomatic carriers. She has a family history of APKD. She has had no symptoms. Her blood pressure is normal, and renal ultrasound 2 months ago was normal. Serum creatinine concentration obtained 2 months ago was 0.9 mg/dL. Before obtaining blood for this test, it is important to explain to this patient that a positive test result would mean which of the following?
A) She is certain to develop renal failure
B) She may be eligible for disability
C) She may have difficulty obtaining life insurance in the future
D) She should avoid becoming pregnant
E) She should be monitored for development of liver disease
34. A pharmaceutical representative regularly comes to your office about once a month. Her company has introduced a new prescription nonsteroidal anti-inflammatory drug (NSAID) and she has brought samples today. You overhear your receptionist ask the representative to leave some samples for her own use. If the representative leaves the samples for the receptionist, the most significant concern regarding this situation is that it does which of the following?
A) It constitutes practicing medicine without a license
B) It diverts samples intended for use by patients
C) It may constitute a liability risk
D) It promotes the use of a more expensive drug over available alternative medications
E) It provides the representative the opportunity to exert undue influence
36. A 78-year-old retired autoworker from Puerto Rico is brought to the office by his son because of a 4- to 7-kg (9- to 15-lb) weight loss in the past few months. You have been treating this patient for hypertension with hydrochlorothiazide for the past 3 years. Today he reports that he eats only one or two bites of food and feels full and that he has a low energy level. He feels he is just "too old." He has never smoked cigarettes and rarely drinks alcoholic beverages. Which of the following is the most appropriate question to elicit further history that would be helpful in the differential diagnosis of this patient?
A) "Are you having headaches?"
B) "Did you stop taking your medication?"
C) "Have you had a change in bowel habits?"
D) "Have you had any visual changes lately?"
E) "What has been going on in your life recently?
A) Administer intramuscular penicillin
B) Obtain a throat culture
C) Obtain acute-phase serum for antistreptolysin-O titer
D) Prescribe azithromycin
E) Reassure the patient's parents that he has a viral illness
26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?
A) Determine serum estrogen concentration
B) Order antibody studies for syphilis and HIV
C) Prescribe an oral anti-trichomonal medication and antifungal cream
D) Question the patient regarding the circumstances surrounding her recent break-up
E) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge
27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?
A) CT scan of the head
B) Electromyography and nerve conduction studies of the left upper extremity
C) Measurement of serum B12 (cobalamin) concentration
D) MRI of the cervical spine
E) Radionuclide bone scan
28. A 32-year-old woman, gravida 3, para 2, who is at 38 weeks' gestation, is brought to the office by her coworker 15 minutes after the patient appeared to have had a seizure at work. The coworker says the patient was working at her computer when she suddenly fell to the floor, began shaking, and had incontinence of urine. She was unresponsive to voice until approximately 5 minutes after the episode. The patient has received routine prenatal care throughout her pregnancy. She has a history of mild, persistent asthma treated with corticosteroid inhalers. Vital signs on arrival are temperature 36.7°C (98.0°F), pulse 100/min, respirations 22/min, and blood pressure 160/110 mm Hg. The patient is alert but disoriented to time and place. She has no recollection of the episode. Physical examination shows bruising of her left arm and a bite on the lower lip. Which of the following is the most accurate statement regarding the risk of harm to the fetus?
A) The fetus is at risk for developing intrauterine hypoxia
B) The fetus will die unless it is delivered immediately
C) The risk to the fetus depends on any coexisting respiratory condition
D) The risk to the fetus is minimal because the seizure was short-lived
E) The risk to the fetus will not be increased if the seizure does not recur
29. A 30-year-old African-American woman returns to the office for a second prenatal visit. She is 12 weeks pregnant and this is her first pregnancy. Results of laboratory studies that were ordered at her first visit show:
Blood
Hematocrit 28%
Hemoglobin 9.2 g/dL
Hemoglobin electrophoresis
Hemoglobin A1 64%
Hemoglobin S 32%
Hemoglobin A2 4%
Mean corpuscular hemoglobin (MCH) 26 pg/cell
Mean corpuscular hemoglobin concentration(MCHC) 32% Hb/cell
Mean corpuscular volume (MCV) 74 μm3
Which of the following is the most likely cause of her anemia?
A) α-thalassemia trait
B) β-thalassemia trait
C) Iron deficiency
D) Physiologic anemia of pregnancy
E) Sickle cell trait
32. A 62-year-old woman who was discharged from the hospital several hours ago following evaluation of optic neuritis now has swelling of her ankles. Prior to admission, the patient had a 3-day history of loss of vision and poor color perception in her right eye. Visual acuity on admission was less than 20/200 in her right eye and was 20/40 in her left eye. The remainder of the physical examination was noncontributory. Blood pressure on admission was 140/80 mm Hg. The patient had been otherwise healthy and had been taking no medications. She has never worn corrective lenses. Family history is significant for thyroid disorder. During her hospital stay, the patient received intravenous methylprednisolone therapy for the past four days. Vital signs today are temperature 37.2°C (99.0°F), pulse 100/min, respirations 14/min, and blood pressure 150/95 mm Hg. Physical examination shows ankle edema but is otherwise unchanged from physical examination done on admission. Laboratory studies are obtained. Which of the following serum laboratory study results is most likely in this patient?
A) Decreased magnesium concentration
B) Decreased sodium concentration
C) Increased calcium concentration
D) Increased glucose concentration
E) Increased potassium concentration
33. A 30-year-old white woman comes to the office for a periodic health evaluation. At this visit she asks you about a DNA test that she has heard about that can detect the presence of the adult polycystic kidney disease (APKD) gene in asymptomatic carriers. She has a family history of APKD. She has had no symptoms. Her blood pressure is normal, and renal ultrasound 2 months ago was normal. Serum creatinine concentration obtained 2 months ago was 0.9 mg/dL. Before obtaining blood for this test, it is important to explain to this patient that a positive test result would mean which of the following?
A) She is certain to develop renal failure
B) She may be eligible for disability
C) She may have difficulty obtaining life insurance in the future
D) She should avoid becoming pregnant
E) She should be monitored for development of liver disease
34. A pharmaceutical representative regularly comes to your office about once a month. Her company has introduced a new prescription nonsteroidal anti-inflammatory drug (NSAID) and she has brought samples today. You overhear your receptionist ask the representative to leave some samples for her own use. If the representative leaves the samples for the receptionist, the most significant concern regarding this situation is that it does which of the following?
A) It constitutes practicing medicine without a license
B) It diverts samples intended for use by patients
C) It may constitute a liability risk
D) It promotes the use of a more expensive drug over available alternative medications
E) It provides the representative the opportunity to exert undue influence
36. A 78-year-old retired autoworker from Puerto Rico is brought to the office by his son because of a 4- to 7-kg (9- to 15-lb) weight loss in the past few months. You have been treating this patient for hypertension with hydrochlorothiazide for the past 3 years. Today he reports that he eats only one or two bites of food and feels full and that he has a low energy level. He feels he is just "too old." He has never smoked cigarettes and rarely drinks alcoholic beverages. Which of the following is the most appropriate question to elicit further history that would be helpful in the differential diagnosis of this patient?
A) "Are you having headaches?"
B) "Did you stop taking your medication?"
C) "Have you had a change in bowel habits?"
D) "Have you had any visual changes lately?"
E) "What has been going on in your life recently?