nbme 1 and section 2 1. A 77-year-old woman is brought to the physician by her son for a routine health maintenance examination. She says that she feels well. Her son reports that 1 month ago, she got lost while Form 1--Section 2:--
driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected with glasses is 20/25 in both eyes. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On mental status examination, she is awake, alert, and conversant. Her language function is normal. She is oriented to person, place, and time and recalls one out of three objects after 10 minutes. Which of the following findings in this patient warrants further evaluation?
A
) Decreased deep tendon reflexes at the ankles
B
) Decreased sensation to vibration over the toes
C
) High-frequency hearing loss
D
) Memory loss
E
) Tremor of the outstretched hands
2. A 10-year-old girl is brought to the emergency department because of diffuse, aching abdominal pain, nausea, and recurrent vomiting over the past 5 hours. She has an 8-year history of type 1 diabetes mellitus treated with 20 U of NPH and 6 U of regular insulin in the morning and 14 U of NPH and 5 U of regular insulin in the evening. She appears lethargic but is easily arousable. There is an obvious odor of ketones on her breath. Her blood pressure is 100/70 mm Hg, pulse is 95/min, and respirations are 20/min and deep. Serum studies show:
Na+ 142 mEq/L
K+ 5.3 mEq/L
HCO3“ 6 mEq/L
Glucose 710 mg/dL
Which of the following laboratory findings is most likely to be increased?
A ) Arterial pH
B ) Serum C-peptide level
C ) Serum magnesium level
D ) Serum osmolality
E ) Serum phosphorus level
3. A healthy 24-year-old woman comes for a routine health maintenance examination. Menses occur at regular 28-day intervals and last 5 to 6 days. Her last menstrual period was 3 weeks ago. She takes no medications. Bimanual examination shows a 5-cm, mildly tender left adnexa. A pregnancy test is negative. Which of the following is the most appropriate next step in management?
A
) Repeat examination in 2 weeks
B
) Measurement of serum CA 125 level
C
) Measurement of serum α-fetoprotein level
D
) CT scan of the pelvis
E
) Diagnostic laparoscopy
4. A 24-year-old primigravid woman at 18 weeks' gestation comes for a routine prenatal visit. She has had increased bowel movements over the past 9 weeks; the stools are sometimes covered with mucus and blood. Use of over-the-counter antidiarrheal drugs has not relieved her symptoms. Pregnancy has been otherwise uncomplicated. She has never traveled outside the USA. Examination shows erythematous, tender nodules over the anterior surface of both lower extremities; some of the nodules have a violaceous hue. The uterus is consistent in size with an 18-week gestation. Rectal examination shows no hemorrhoids or fissures. Fetal heart tones are audible by Doppler. Which of the following is the most likely diagnosis?
A
) Amebiasis
B
) Diverticulitis
C
) Hyperperistaltic diarrhea
D
) Inflammatory bowel disease
E
) Viral gastroenteritis
5. A 32-year-old woman at 38 weeks' gestation comes for a routine prenatal visit. During routine screening at 28 weeks' gestation, she tested positive for hepatitis B surface antigen. Her pregnancy has been otherwise uncomplicated. Examination shows a uterus consistent in size with a 38-week gestation. Which of the following measures is most likely to decrease the risk for hepatitis B infection in her newborn?
A
) Recommendation of bottle-feeding rather than breast-feeding
B
) Maternal administration of hepatitis B immune globulin (HBIG) now
C
) Neonatal administration of HBIG after delivery and hepatitis B vaccine at 3 months of age
D
) Neonatal administration of HBIG and hepatitis B vaccine immediately after delivery
E
) Cesarean delivery
6. A 37-year-old woman comes to the physician because of progressive shortness of breath over the past 5 years; she now has fatigue and shortness of breath with mild exertion. She has a history of mitral stenosis secondary to rheumatic fever at the age of 15 years. She was asymptomatic until 5 years ago when she developed severe shortness of breath during pregnancy. She was treated with diuretics, low-sodium diet, and bed rest, and she was able to deliver the baby at term. Her only medication is hydrochlorothiazide. Her temperature is 37 C (98.6 F), blood pressure is 110/80 mm Hg, pulse is 100/min and regular, and respirations are 26/min. Cardiac examination shows an obvious opening snap in S2. A grade 3/6, late diastolic murmur is heard at the apex. A right ventricular lift is palpated along the left sternal border. Which of the following is most likely increased in this patient?
A
) Blood flow to the lower lung fields
B
) Diastolic filling time
C
) Left-to-right shunt of blood
D
) Left ventricular end-diastolic pressure
E
) Pulmonary artery pressure
7. A 5-year-old girl with ventricular septal defect is scheduled for tonsillectomy in 2 weeks. She has no known drug allergies. Her temperature is 37 C (98.6 F). Examination shows no abnormalities. Which of the following is the most appropriate prophylaxis prior to tonsillectomy?
A
) Amoxicillin
B
) Ciprofloxacin
C
) Rifampin
D
) Tetracycline
E
) Trimethoprim-sulfamethoxazole
F
) No prophylaxis indicated
8. An 8-year-old girl with type 1 diabetes mellitus is brought to the emergency department 10 minutes after being involved in a motor vehicle collision. She was in the back seat of a small automobile that was rear-ended. Initially, she was alert during transport and reported bilateral thigh pain, but then she stopped talking, closed her eyes, and became unresponsive to voice; on arrival, she responds to noxious stimuli with brief grimaces and no withdrawal. Her blood pressure is 40/palpable mm Hg, pulse is 148/min, and respirations are 28/min. Air entry is symmetric. The pupils are equal and react to light. No cardiac murmur is heard. The abdomen is soft. There is swelling of the upper portions of both thighs. Her hematocrit is 37%. Which of the following is the most appropriate next step in management?
A
) Measurement of arterial blood gases
B
) X-ray film of the chest
C
) CT scan of the head
D
) Administration of 50% dextrose in water
E
) Infusion of 0.9% saline
9. A previously healthy 16-year-old boy is brought to the emergency department 20 minutes after an episode of left arm shaking that lasted approximately 3 minutes. Over the past 2 days, he has had fever and emotional lability. On arrival, his temperature is 38.9 C (102 F). He is somnolent and disoriented to person, place, and time. He responds poorly to pain. Neurologic examination shows no other abnormalities. Laboratory studies show:
Hematocrit 34%
Leukocyte count 6000/mm3
Segmented neutrophils 50%
Lymphocytes 50%
Platelet count 280,000/mm3
Analysis of cerebrospinal fluid shows:
Leukocyte count 120/mm3
Segmented neutrophils 20%
Lymphocytes 80%
Erythrocyte count 300/mm3
Glucose 60 mg/dL
Protein 400 mg/dL
Which of the following is the most likely cause of this patient's neurologic findings?
A
) Bacterial infection
B
) Congenital malformation
C
) Fungal infection
D
) Hemorrhage
E
) Immune-mediated demyelination
F
) Parasitic infection
G
) Viral infection
10. A 72-year-old man with hypertension has had increasingly severe back pain over the past 2 months. He had a myocardial infarction 4 years ago. He has marked tenderness over T11, T12, L1, and L2. An x-ray film of the lumbosacral spine shows osteoblastic lesions in these vertebrae. Which of the following is the most likely diagnosis?
A
) Abdominal aneurysm
B
) Fibrosarcoma
C
) Metastatic prostate carcinoma
D
) Multiple myeloma
E
) Osteosarcoma
11. A 64-year-old woman has moderately severe postoperative pain 1 day after a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Which of the following is the most appropriate analgesic pharmacotherapy?
A
) Oral aspirin-codeine compound
B
) Oral diazepam
C
) Oral ibuprofen
D
) Intermittent intravenous naloxone
E
) Patient-controlled intravenous morphine
F
) Transcutaneous administration of fentanyl
12. A 37-year-old woman comes to the physician because of a 1-day history of throbbing facial pain. She describes the pain as 7 out of 10 in intensity. Over the past 9 days, she has had nasal congestion, purulent nasal discharge, sore throat, and a nonproductive cough. She does not smoke. Her husband and children have had no recent illness. Her temperature is 38.5 C (101.3 F). Examination shows congested nasal mucosa and purulent discharge on the left. There is tenderness to palpation over the left cheek and no transillumination over the left maxillary sinus. The tympanic membranes are normal, and there is no erythema of the throat. Examination shows no cervical adenopathy. The lungs are clear to auscultation. Which of the following is the most likely causal organism?
A
) Haemophilus influenzae type b
B
) Moraxella catarrhalis
C
) Staphylococcus aureus
D
) Streptococcus pneumoniae
E
) Streptococcus pyogenes (group A)
13. A 42-year-old woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year, she has had increasing fatigue and difficulty sleeping. She has two children who both attend college. She is currently looking for part-time work outside the home. Her husband has been busy in a new start-up business. Examination shows no abnormalities. Laboratory studies show:
Hemoglobin 15 g/dL
Mean corpuscular volume 95 μm3
Leukocyte count 6000/mm3 with a normal differential
Serum
Na+ 145 mEq/L
Cl“ 102 mEq/L
K+ 4.5 mEq/L
HCO3“ 25 mEq/L
Urea nitrogen (BUN) 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 70 U/L
Aspartate aminotransferase
(AST, GOT) 22 U/L
Alanine aminotransferase
(ALT, GPT) 19 U/L
γ-Glutamyltransferase
(GGT) 83 U/L
(N=5“50 U/L)
Which of the following is the most likely explanation for this patient's laboratory abnormalities?
A
) Acetaminophen
B
) Alcohol
C
) Diphenhydramine
D
) Estrogen effect
E
) Ibuprofen
14. Five weeks after vaginal delivery of a healthy full-term newborn, a 22-year-old woman, gravida 1, para 1, is brought to the physician by her mother because of depressed mood for 2 weeks. Her mother is concerned that her daughter is not able to take care of her infant. Physical examination shows no abnormalities. She is quiet and tearful and does not engage in conversation easily. She states that she lives alone with her infant and has had thoughts of suicide and infanticide. Which of the following is the most appropriate next step in management?
A
) Reassurance
B
) Long-term outpatient counseling
C
) Antipsychotic therapy
D
) Selective serotonin reuptake inhibitor therapy
E
) Admission to the hospital for treatment
15. A 72-year-old man comes for a routine follow-up examination. He has chronic obstructive pulmonary disease treated with β-adrenergic agonists and ipratropium by metered-dose inhaler and mild arterial insufficiency of the lower extremities treated with aspirin. His blood pressure is 160/60 mm Hg, pulse is 70/min, and respirations are 12/min. Funduscopic examination shows arteriovenous nicking. Pedal pulses are decreased bilaterally. Which of the following antihypertensive drugs is most likely to cause adverse effects in this patient?
A
) α2-Adrenergic agonist
B
) α-Adrenergic blocking agent
C
) β-Adrenergic blocking agent
D
) Angiotensin-converting enzyme (ACE) inhibitor
E
) Calcium-channel blocking agent
F
) Loop diuretic
G
) Thiazide diuretic
H
) Vasodilator
The response options for the next two items are the same. You will be required to select one answer for each item in the set.
For each patient with loss of consciousness, select the most likely diagnosis.
A
) Aortic stenosis
B
) Carotid sinus hypersensitivity
C
) Conversion reaction
D
) Hypertrophic obstructive cardiomyopathy
E
) Hypoglycemia
F
) Mitral valve prolapse
G
) Orthostatic hypotension
H
) Pulmonary embolus
I
) Seizure
J
) Vasovagal syncope
K
) Vertebrobasilar insufficiency
16. A 15-year-old boy is brought to the emergency department 30 minutes after a 2-minute episode of loss of consciousness after completing a 400-meter race. On awakening, he says that he feels fine except for shortness of breath. He weighs 82 kg (180 lb) and is 191 cm (75 in) tall. His blood pressure is 110/70 mm Hg, pulse is 70/min and regular, and respirations are 15/min. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard at the left sternal border with minimal radiation to the neck; the murmur becomes louder when he stands.
For each patient with loss of consciousness, select the most likely diagnosis.
A
) Aortic stenosis
B
) Carotid sinus hypersensitivity
C
) Conversion reaction
D
) Hypertrophic obstructive cardiomyopathy
E
) Hypoglycemia
F
) Mitral valve prolapse
G
) Orthostatic hypotension
H
) Pulmonary embolus
I
) Seizure
J
) Vasovagal syncope
K
) Vertebrobasilar insufficiency
17. A 62-year-old woman is brought to the emergency department 1 hour after a 1-minute episode of loss of consciousness; her symptoms began when she stood up after she passed a dark, watery stool. She has had diarrhea and dark stools for 2 days. She has been receiving warfarin therapy for deep venous thrombosis for 2 weeks. On arrival, her blood pressure is 82/60 mm Hg, and pulse is 150/min and regular. She is unable to stand. The lungs are clear to auscultation. A grade 2/6 systolic murmur is heard at the second right intercostal space with no radiation. Examination shows a soft, nontender abdomen. There is 1+ edema of the right lower extremity with no tenderness. Test of the stool for occult blood is positive.
18. A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant, sharp chest pain for 4 days. The pain is localized to the center of the chest and is worse while supine. She underwent a right, modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. She has a history of hypothyroidism treated with thyroid replacement therapy. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F), blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg, pulse is 110/min, and respirations are 28/min. Examination shows jugular venous distention to the angle of the mandible. The liver span is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of 70 mm Hg. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Which of the following is the most appropriate next step in management?
A ) Echocardiography
B ) CT scan of the abdomen
C ) Ventilation-perfusion lung scans
D ) Bronchoscopy
E ) Paracentesis
19. A 3-year-old boy is brought to the physician because of a 7-day history of fever and a painful swollen lymph node in his groin. This is his sixth episode of lymph node swelling; the previous episodes resolved after drainage and prolonged antibiotic therapy. He also had pneumonia at the age of 12 months that required chest tube placement for drainage. A maternal uncle died during childhood of recurrent infections. The patient is at the 5th percentile for height and weight. His temperature is 38.5 C (101.3 F). Examination shows a warm, tender, erythematous lymph node in the right inguinal area. There are several healed incisions over the inguinal area and neck from old drainage sites. Laboratory studies show:
Hematocrit 35%
Leukocyte count 17,000/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 25%
Platelet count 350,000/mm3
A Gram's stain of the lymph node aspirate shows numerous segmented neutrophils filled with bacteria; cultures grow Staphylococcus aureus. Which of the following is the most likely mechanism for these findings?
A
) Adenosine deaminase deficiency
B
) Consumption of complement
C
) Defective opsonization
D
) Destruction of CD4+ T lymphocytes
E
) Developmental arrest of maturation of B lymphocytes
F
) Dysmorphogenesis of the third and fourth pharyngeal pouches
G
) Impaired chemotaxis
H
) Impaired phagocytic oxidative metabolism
20. A 67-year-old woman has been intubated for 1 week after undergoing a left lobectomy for lung cancer. She has chronic obstructive pulmonary disease. Her preoperative functional vital capacity was 40% of predicted. She is awake and alert. Her blood pressure is 130/75 mm Hg, and pulse is 72/min. The ventilator settings are a synchronized intermittent mandatory ventilation of 8/min, FIO2 of 40%, and positive-end expiratory pressure of 5 cm H2O. Arterial blood gas analysis shows:
pH 7.42
PCO2 47 mm Hg
PO2 90 mm Hg
O2 saturation 96%
Which of the following is the most appropriate next step in management?
A
) Antibiotic therapy
B
) Bronchodilator therapy
C
) Chest physiotherapy
D
) Decrease inotropes
E
) Diuretic therapy
F
) Fiberoptic bronchoscopy
G
) Heparin therapy
H
) Incentive spirometry
I
) Increase FIO2
J
) Increase inotropes
K
) Increase respiratory rate
L
) Placement of thoracostomy tube
M
) Tracheostomy
N
) Wean from the ventilator
21. A 67-year-old woman is brought to the emergency department because of severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an esophageal stricture caused by reflux. At discharge, she reported no chest pain. Three hours later, she vomited a small amount of blood and had severe pain. She is pale. Her temperature is 38 C (100.4 F), blood pressure is 140/85 mm Hg, pulse is 125/min, and respirations are 22/min. Examination shows crepitus in the neck and moderate epigastric tenderness. The lungs are clear to auscultation, and breath sounds are equal bilaterally. Rectal examination shows no masses; test of the stool for occult blood is positive. Which of the following is the most likely cause of these symptoms?
A
) Bleeding from erosive esophagitis
B
) Esophageal perforation
C
) Mallory-Weiss syndrome
D
) Myocardial infarction
E
) Perforated gastric ulcer
22. An 87-year-old woman is brought to the physician by her son because of progressive memory loss over the past 2 years. Her son says that she repeats herself frequently and has been forgetting to take her routine medications. She takes hydrochlorothiazide for mild systolic hypertension and levothyroxine for hypothyroidism. She had vulvar cancer 10 years ago treated with wide excision. Her blood pressure is 138/78 mm Hg. Physical examination is within normal limits for her age. Mini-Mental State Examination score is 23/30. Laboratory studies, including serum vitamin B12 (cyanocobalamin), thyroxine (T4), and thyroid-stimulating hormone levels, are within normal limits. A CT scan of the head shows mild volume loss. Which of the following is the most appropriate pharmacotherapy?
A
) β-Adrenergic agonist
B
) Cholinesterase inhibitor
C
) Dopamine agonist
D
) Prednisone
E
) Selective serotonin reuptake inhibitor
23.
A newborn is in severe respiratory distress immediately following delivery. She was born at 35 weeks' gestation to a 35-year-old woman, gravida 2, para 1, aborta 1, who did not receive prenatal care. The newborn's pulse is 60/min, and respirations are irregular and labored. Examination shows pallor with perioral cyanosis, anasarca, hepatosplenomegaly, and scattered petechiae. Cord blood hemoglobin is 4 g/dL, and reticulocyte count is 18%. A direct antiglobulin (Coombs') test is positive. Which of the following sets of blood groups is most likely in the mother and her newborn?
Mother Newborn
A
)
A, Rh-positive O, Rh-positive
B
)
A, Rh-positive O, Rh-negative
C
)
A, Rh-negative O, Rh-negative
D
)
O, Rh-positive O, Rh-negative
E
)
O, Rh-negative O, Rh-positive
24. After an uncomplicated laparoscopic cholecystectomy, a 62-year-old man has not had any urine output since the Foley catheter was removed 12 hours ago. During the hour before the operation, the 40 minutes of operating room time, and the 2 hours in the recovery room, his fluid input was 2.5 L and urine output was 1 L. Since that time, he has been receiving intravenous 5% dextrose in water with 0.45% saline and morphine. He is awake and alert and has a moderate amount of abdominal pain. Preoperative serum studies showed:
Na+ 137 mEq/L
K+ 4.2 mEq/L
Urea nitrogen (BUN) 18 mg/dL
Creatinine 1.2 mg/dL
One hour after receiving an intravenous bolus of 0.9% saline, the patient does not produce any urine. Which of the following is the most appropriate next step in management?
A
) Increase in the dose of morphine
B
) Intravenous administration of an additional bolus of 0.9% saline
C
) Intravenous administration of doxazosin
D
) Intravenous administration of furosemide
E
) Reinsertion of a Foley catheter
25. A healthy 55-year-old man comes for an initial health maintenance examination. His last visit to a physician was over 10 years ago. He does not smoke and drinks only on social occasions. Examination shows no abnormalities. Which of the following immunizations should be administered?
A
) Hepatitis A vaccine
B
) Influenza virus vaccine
C
) Measles-mumps-rubella vaccine
D
) Pneumococcal vaccine
E
) Diphtheria-tetanus toxoid
26. A 19-year-old man comes to the physician because of frequent nosebleeds over the past 3 weeks. He has bipolar disorder currently well controlled with lithium carbonate, bupropion, and valproic acid. Physical examination shows no abnormalities except for dried blood in the nares. Mental status examination shows an anxious mood and slight motor restlessness. Serum studies show a lithium carbonate level of 1.3 mEq/L (therapeutic range=0.6“1.2), and valproic acid level of 77 μg/mL (therapeutic range=40“100). Which of the following is the most appropriate next step in management?
A
) Measurement of serum aspartate aminotransferase (AST, GOT) activity
B
) Measurement of serum bupropion level
C
) Platelet count
D
) Discontinuation of lithium carbonate therapy
E
) Discontinuation of valproic acid therapy
27. An asymptomatic 32-year-old man comes for a routine health maintenance examination. He has a 10-year history of frequent sinus and pulmonary infections. He had an anaphylactic reaction to a blood transfusion following a motor vehicle collision 3 years ago. His temperature is 37 C (98.6 F). Examination shows mild erythema in the posterior pharynx. The lungs are clear to auscultation. A complete blood count and serum protein electrophoresis are within normal limits. Which of the following is the most likely cause of the frequent infections?
A
) Colonization with Streptococcus pneumoniae
B
) Common variable immunodeficiency
C
) HIV infection
D
) Selective IgA deficiency
E
) X-linked agammaglobulinemia
28.
A 37-year-old man is brought to the emergency department 6 hours after the onset of constant, increasingly severe abdominal pain and nausea. His symptoms awoke him from sleep, and he has vomited once since that time. He has no history of similar symptoms, and he does not take any medications or use alcohol or illicit drugs. Family history is noncontributory. He is in acute distress and lying in the fetal position. Any movement exacerbates the pain. His temperature is 37.8 C (100 F), blood pressure is 108/68 mm Hg, pulse is 112/min, and respirations are 24/min. The lungs are clear to percussion and auscultation. Examination shows a rigid abdomen; bowel sounds are absent. Laboratory studies show:
Hemoglobin 14 g/dL
Leukocyte count 18,200/mm3
Platelet count 150,000/mm3
Serum
Urea nitrogen (BUN) 34 mg/dL
Creatinine 1.9 mg/dL
Total bilirubin 1.2 mg/dL
An x-ray film of the chest shows a small amount of free air under the left diaphragm. Administration of antibiotics and fluids is begun. Which of the following is the most appropriate next step in management?
A
) Barium swallow
B
) CT scan of the abdomen
C
) Intravenous administration of an H2-receptor blocking agent
D
) Upper endoscopy
E
) Laparotomy
29. A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. She drinks a pint of vodka daily. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus. She also has intermittent episodes of gout. Fasting serum studies show:
Total cholesterol 252 mg/dL
HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL
Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL
Which of the following is the most appropriate next step in management?
A
) Alcohol cessation
B
) Better control of diabetes
C
) Switch from captopril to calcium-channel blocking agent therapy
D
) Gemfibrozil therapy
E
) Thyroid replacement therapy
30. A 23-year-old woman has pain, cramping, and swelling of the right calf 3 days after an uncomplicated labor and delivery. The right foot is swollen, and there is marked tenderness with dorsiflexion and palpation of the right calf. Examination shows no other abnormalities. A complete blood count and serum electrolyte levels are within normal limits. Which of the following is the most likely cause of this condition?
A
) Hypercoagulable state of pregnancy
B
) Hyperuricemia
C
) Peripheral artery aneurysm
D
) Platelet embolus
E
) Prolonged pressure on the vena cava during delivery
31. A 2-month-old boy is brought to the physician for a well-child examination. He smiles spontaneously and vocalizes without crying, but he does not appear to laugh or squeal. He will not work for a toy that is out of his reach. Which of the following is the most appropriate assessment of language and psychosocial development?
Language
Psychosocial
development
development
A
)
Normal
normal
B
)
Normal
delayed
C
)
Delayed
normal
D
)
Delayed
delayed
32. A previously healthy 24-year-old woman comes to the physician because of a low-grade fever and a nonproductive cough for 7 days. She has been able to continue her daily activities. Her temperature is 37.7 C (99.9 F). A few scattered inspiratory crackles are heard in the thorax. An x-ray film of the chest shows patchy infiltrates in both lungs. Which of the following is the most appropriate initial pharmacotherapy?
A
) Amoxicillin
B
) Cefaclor
C
) Ciprofloxacin
D
) Erythromycin
E
) Trimethoprim-sulfamethoxazole
33. A 45-year-old woman comes to the emergency department because of shortness of breath, chest pain, dizziness, and mild numbness and tingling around the lips for 2 hours. She says that she feels like she is going to die. She had three similar episodes last week when she was vacationing at the Grand Canyon; the first episode occurred while crossing a narrow bridge on a donkey. She takes a hypoglycemic drug for type 2 diabetes mellitus, verapamil for hypertension, and sumatriptan as needed for migraine. She is mildly diaphoretic and appears pale. Her blood pressure is 130/90 mm Hg, pulse is 120/min, and respirations are 28/min. Serum glucose level is 120 mg/dL. An ECG shows sinus tachycardia. Sublingual nitroglycerin therapy does not relieve her symptoms and gives her a headache. The most appropriate next step in management is administration of which of the following?
A
) Haloperidol
B
) Lorazepam
C
) Oxygen
D
) Sumatriptan
E
) Verapamil
34. A 67-year-old man is brought to the emergency department 4 hours after the onset of severe midlumbar back pain. He is anxious, pale, and diaphoretic. His temperature is 37.1 C (98.8 F), blood pressure is 105/65 mm Hg, and pulse is 120/min. Examination shows no other abnormalities. X-ray films of the lumbar spine show degenerative disc disease with calcifications anterior to the vertebral bodies. Which of the following is the most likely diagnosis?
A
) Aortoiliac occlusion
B
) Herniated nucleus pulposus
C
) Lumbar discitis
D
) Lumbar strain
E
) Pyelonephritis
F
) Ruptured aortic aneurysm
G
) Spinal stenosis
35. A 17-year-old boy is brought to the emergency department by his parents because of bizarre behavior for 6 hours. Last night he was out with friends, and since returning, he has been confused and has "trashed" his room. His blood pressure is 165/95 mm Hg. He is hypervigilant, has little spontaneous speech, and is disoriented to place and time. He appears catatonic but abruptly becomes assaultive two times and needs to be restrained. Which of the following is the most likely substance taken?
A
) Cocaine
B
) Ecstasy
C
) LSD
D
) Methaqualone
E
) PCP
The response options for the next two items are the same. You will be required to select one answer for each item in the set.
For each patient with back pain, select the most likely diagnosis.
A
) Herniated disc
B
) Lumbar spinal stenosis
C
) Metastatic cancer
D
) Muscle strain
E
) Osteoporotic compression fracture
F
) Sacroiliitis
G
) Spinal epidural abscess
H
) Spondylolisthesis
36. A 57-year-old woman is brought to the physician 2 days after the sudden onset of severe low back pain; the pain does not radiate to the lower extremities. The pain began when she was lifting her grandson. She does not have weakness or sensory loss in the legs and has had no urinary incontinence. She has a 10-year history of rheumatoid arthritis treated with prednisone. Her temperature is 37 C (98.6 F), blood pressure is 130/60 mm Hg, and pulse is 64/min. Examination shows deformities of the interphalangeal joints of the hands and exquisite tenderness to percussion over the lumbar spine. Bilateral straight-leg raising to 80 degrees does not increase the pain. Muscle strength and sensation are intact in the lower extremities. Deep tendon reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally.
For each patient with back pain, select the most likely diagnosis.
A
) Herniated disc
B
) Lumbar spinal stenosis
C
) Metastatic cancer
D
) Muscle strain
E
) Osteoporotic compression fracture
F
) Sacroiliitis
G
) Spinal epidural abscess
H
) Spondylolisthesis
37. A previously healthy 32-year-old plumber comes to the physician because of a 3-week history of constant, dull, low back pain that does not radiate to the extremities. The pain began after he unloaded heavy equipment from his van. It increases with activity and is temporarily relieved by bed rest and ibuprofen. Examination shows tenderness to palpation over the lumbar paraspinal region bilaterally. The pain increases with forward or lateral movements of the spine. Muscle strength and sensation are intact in the lower extremities. Bilateral straight-leg raising to 80 degrees does not increase the pain. Deep tendon reflexes are 2+ bilaterally. Babinski's sign is absent bilaterally.
38. A 72-year-old man comes to the physician because of a 2-month history of urination twice nightly and occasional urinary frequency and urgency. He has a 15-year history of type 2 diabetes mellitus now moderately well controlled with glyburide. His father was diagnosed with prostate cancer at the age of 70 years, and his sister died of complications from systemic lupus erythematosus. His blood pressure is 135/86 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows no suprapubic fullness or tenderness. There is mild enlargement of the prostate with no palpable nodules. His postvoid residual volume is 10 mL. Serum studies show a urea nitrogen (BUN) level of 45 mg/dL and creatinine level of 3.8 mg/dL. Urine dipstick shows 3+ protein. Which of the following is most likely to have prevented progression of this patient's renal disease?
A
) Intermittent Foley catheterization
B
) Intravenous mannitol therapy
C
) Oral cyclophosphamide and prednisone therapy
D
) Oral enalapril therapy
E
) Oral finasteride therapy
F
) Oral prednisone therapy only
G
) Oral terazosin therapy
39. Two hours ago, a 24-year-old man had the sudden onset of pain in the right side of his chest that has become increasingly severe. He is now having difficulty breathing. His temperature, blood pressure, and pulse are normal. An x-ray film of the chest is shown. Which of the following is the most appropriate next step in management?
A
) Bed rest and sedative therapy
B
) Antibiotic therapy
C
) Anticoagulant therapy
D
) Tube thoracostomy
E
) Immediate thoracotomy
40. A 21-year-old college student comes to the physician because of acne that developed 4 days ago while she was taking her medical college admission test. She is concerned about her appearance and plans to be in a wedding in 3 weeks. She has had similar episodes that have resolved completely without treatment. Examination shows acute acne over the face with a predominance of comedones and pustules. There is no evidence of chronic scarring. Which of the following is the most appropriate initial step in treatment?
A
) Dietary restriction of chocolates and simple sugars
B
) Dietary restriction of milk products
C
) Topical acyclovir
D
) Topical hydrocortisone cream
E
) Topical retinoic acid
41. A 67-year-old woman comes for a routine health maintenance examination. She exercises regularly. She is not sexually active. At her last visit 1 year ago, her serum cholesterol level was 180 mg/dL, and fasting serum glucose level was 80 mg/dL; a Pap smear and mammography showed normal findings. Two years ago, flexible sigmoidoscopy showed no abnormalities. Today, she weighs 63 kg (140 lb) and is 165 cm (65 in) tall. Her blood pressure is 120/80 mm Hg. Examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient?
A
) Pap smear
B
) Measurement of serum cholesterol level
C
) Measurement of serum glucose level
D
) Mammography
E
) Flexible sigmoidoscopy
42. A 62-year-old man has had the gradual onset of fatigue and shortness of breath over the past 3 years. There is striking jugular venous distention with a large wave occurring with S2. The carotid upstroke is normal. Cardiac examination shows a lifting systolic motion of the sternum and no palpable point of maximal impulse. A grade 3/6, holosystolic, plateau-shaped murmur that is loudest on inspiration is heard at the lower left sternal border. The liver is enlarged and tender, and the abdomen is swollen with a fluid wave. There is marked ankle edema. Which of the following is the most likely cause of the murmur?
A
) Aortic stenosis
B
) Mitral regurgitation
C
) Mitral stenosis
D
) Tricuspid regurgitation
E
) Ventricular septal defect
43. A 24-year-old woman comes to the physician because of constant, severe pain in her neck, shoulders, and back for 3 months. She has been unable to enjoy her usual activities because of the pain. Use of over-the-counter ibuprofen and aspirin has not relieved her symptoms. She has a history of irritable bowel syndrome. Examination shows multiple tender spots over the neck, shoulders, and lumbar spine. Range of motion of all joints is full. There is no evidence of synovitis. Fluorescent serum antinuclear antibody and rheumatoid factor assays are negative. Which of the following is the most likely diagnosis?
A
) Ankylosing spondylitis
B
) Fibromyalgia
C
) Polymyalgia rheumatica
D
) Polymyositis
E
) Seronegative rheumatoid arthritis
44. A 72-year-old man comes to the physician because of a 6-month history of mild to moderate shortness of breath when climbing stairs. He had a myocardial infarction 2 years ago and has had an ejection fraction of 35% since then. His only medication is a β-adrenergic blocking agent. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. There is no peripheral edema. Laboratory studies are within normal limits. An ECG shows no acute changes. Which of the following is the most appropriate pharmacotherapy?
A
) α-Adrenergic blocking agent
B
) Angiotensin-converting enzyme (ACE) inhibitor
C
) Angiotensin2-receptor blocking agent
D
) Nitrates
E
) Thiazide diuretic
45. A 42-year-old woman comes to the physician because of a 3-month history of a recurrent vivid dream that several men are assaulting her and her children. Upon awakening, she is anxious and distressed by the frightening images. She realizes that it is just a dream but is afraid to go back to sleep. She does not know why she is having this particular dream because she has never been the victim of an assault. She drinks two to three cups of coffee each morning. She does not use illicit drugs. Physical examination shows no abnormalities. There is no evidence of depressed mood or hallucinations. Laboratory studies are within normal limits. Which of the following is the most likely diagnosis?
A
) Acute stress disorder
B
) Nightmare disorder
C
) Panic disorder
D
) Sleep apnea
E
) Sleep terror disorder
46. A 57-year-old man is brought to the emergency department 30 minutes after he was found on the floor of his house; he has left hip pain and shortness of breath. He has renal failure but has missed his last two dialysis treatments. His renal failure was caused by inadvertent ingestion of ethylene glycol. His renal function did not improve, and he is currently on the transplantation list. Medications include amlodipine and doxazosin. On arrival, his temperature is 37.5 C (99.5 F), blood pressure is 150/100 mm Hg, pulse is 95/min and regular, and respirations are 24/min. His breathing is rapid and deep. Crackles are heard in the lung bases. Examination shows a soft abdomen. Bowel sounds are normal. The left lower extremity is externally rotated. Laboratory studies show:
Serum
Na+ 135 mEq/L
Cl“ 102 mEq/L
K+ 7.1 mEq/L
HCO3“ 12 mEq/L
Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula:
pH 7.22
PCO2 31 mm Hg
PO2 61 mm Hg
An ECG shows peaked T-waves. It will be at least 45 minutes before dialysis can be started. Which of the following is the most appropriate next step in management?
A
) Observation until dialysis is initiated
B
) Intravenous calcium gluconate
C
) Intravenous glucose and insulin
D
) Intravenous 0.9% saline
E
) Intravenous sodium bicarbonate
F
) Rectal sodium polystyrene sulfonate (Kayexalate)
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