09-16-2008, 06:15 PM
sorry for the delay
but couldnt upload it on rapidshare....
Block 1
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1. An 83-year-old woman who has dementia, Alzheimer type, is brought to the office for a return visit by her daughter, with whom she lives. While intermittently somewhat confused, until recently the patient had been able to handle most of her activities of daily living. In the past month, however, she has shown little interest in eating and is awake most of the night. The daughter says the patient has been seeing things, especially at night. She has been accusing her daughter of stealing from her, and has also hit her daughter. The patient has fallen twice on her way to the bathroom at night. The daughter has been giving her diphenhydramine for 1 month to help her sleep, but she says it does not seem to be helping. You have also been treating the patient with ranitidine for esophageal reflux and with amitriptyline for depression. Vital signs are normal, and physical examination is unchanged from the last visit. Her mental status has deteriorated from her last visit 4 months ago. Today she is oriented only to name, does not seem to recognize you and appears to be visually hallucinating. Her daughter says she herself is overwhelmed and wonders if it is time to consider a nursing home for the patient. Which of the following is the most appropriate response?
[A) "Her increased confusion may be due to her medicines. Let's explore that possibility first."]
B) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."
C) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."
D) "It is a little premature for that. Let's try some home health services first."
E) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."
2. A 12-year-old boy is brought to the office by his parents for a follow-up visit after starting treatment with carbamazepine 3 months ago for temporal lobe seizures. He has been seizure-free since having attained a therapeutic serum carbamazepine level 2 months ago. He says that he feels well, is doing much better in school, and has no new symptoms or complaints. It is most appropriate to tell him and his parents that with this drug therapy, he will need monitoring to assess for which of the following conditions?
[A) Agranulocytosis]
B) Cardiac arrhythmias
C) Gastric ulcers
D) Proteinuria
E) Renal failure
3. A 72-year-old professor emeritus comes to the office saying, "I am worried that I have Alzheimer's or small strokes or something." During the past year, he has noted increasing difficulty with his memory, especially for names, which has created several awkward moments professionally and socially. He adds, "I'll be doing fine, when all of a sudden my mind goes blank. I can't recall something I should easily know, and then suddenly it will come back to me a couple of minutes later." He complains that he frequently misplaces items like his keys, which is very unlike him. He also complains that his sleep is not restful anymore and that he tosses and turns all night. His wife has told him that she is not sleeping either, because he snores loudly. He says, "I'm tired much of the time, and I doze off whenever I try to read." He also complains of frequent headaches in the morning. Past medical history includes hypertension, which is well-controlled with diltiazem; peptic ulcer disease for which he takes ranitidine; and lumbar osteoarthritis, for which he takes ibuprofen. Height is 175 cm (5 ft 9 in) and weight is 72 kg (160 lb). Vital signs are: temperature 36.9°C (98.4°F), pulse 80/min and regular, respirations 12/min and blood pressure 158/100 mm Hg. Physical examination, including neurologic examination, is normal. He scores 29 out of 30 on the Mini-mental state test. Which of the following is the most appropriate next step?
A) Order CT scan of the head
B) Order electroencephalography
C) Reassure him that his symptoms are probably normal
D) Refer him for neuropsychological testing
[E) Refer him for polysomnography]
4. An 8-year-old boy is brought to the office because of a 5-day history of fever, coryza and cough that coincides with an epidemic of influenza in the community. Today he is unable to walk because of pain in the calves. His mother has been giving him acetaminophen for fever and pain. Physical examination shows a temperature of 38.3°C (101.0°F). He is alert, interactive and well-hydrated. He has clear rhinorrhea, mild pharyngeal erythema and a clear chest. His calves are tender to palpation. Strength cannot be tested because of pain. Neurologic examination, including deep tendon reflexes, is normal. Which of the following is the most appropriate therapy?
[A) Acetaminophen, orally, as needed]
B) Amantadine, orally
C) Immune globulin, intravenously
D) Influenza virus vaccine, intramuscularly
E) Prednisone, orally
5. A 55-year-old Hispanic welder comes to the office for an initial visit because of a lesion in his right eye that has been present for several months. During this time his right and left eyes have been increasingly sensitive to wind. He has not had double vision and has not seen "spots" in his field of vision. He says that he has been generally healthy and has not seen a physician during the past 30 years. He takes no medications. He does not wear corrective lenses. Family history is significant for blindness in his mother at age 77 years. The patient has smoked a half pack of cigarettes daily for the past 40 years, and he drinks an occasional six-pack of beer on weekends. Vital signs today are temperature 37.2°C (99.0°F), pulse 110/min, respirations 20/min, and blood pressure 140/85 mm Hg. Examination of the right eye discloses the finding shown in the photograph. Visual acuity is 20/40 in both eyes. Musculoskeletal examination discloses symmetric enlargement of the proximal and distal interphalangeal joints of both hands. The joints are firm to palpation and cool to the touch. The remainder of the physical examination is noncontributory. Which of the following is the most likely diagnosis?
A) Corneal abrasion
B) Glaucoma
C) Keratitis
[D) Pterygium]
E) Stye
6. A 3-year-old African-American boy who is a new patient is brought to the office by his grandmother. She says, "He was OK until this afternoon, when he suddenly developed a fever. He's been spitting a lot. He keeps his mouth open and he refuses to lie down. He won't eat." You learn that the child has received only one set of vaccinations at the age of 2 months. Vital signs are: temperature 39.4°C (103.0°F), pulse 110/min, respirations 24/min and blood pressure 110/70 mm Hg. On physical examination the child sits in a tripod position and salivation is evident. Which of the following is the most appropriate next step?
A) Administration of cefotaxime, intravenously
B) Complete blood count and blood culture
C) Determination of arterial blood gas values
[D) Immediate otorhinolaryngology consultation]
E) Lateral neck x-ray film
7. A 19-year-old college student comes to the student health center because of palpitations, shortness of breath and a runny nose. He has asthma that he has treated with an over-the-counter cold preparation and an epinephrine metered-dose inhaler every 2 to 3 hours at night. He just used the bronchodilator in the waiting room. Vital signs are: temperature 38.2°C (100.8°F), pulse 82/min and respirations 18/min. He appears to be somewhat anxious and his breathing is labored. Auscultation discloses mildly diminished breath sounds in all lung fields accompanied by scattered wheezing. Which of the following is the most appropriate management?
A) Add oral aminophylline therapy
B) Admit him to the hospital for respiratory therapy
C) Prescribe decongestant/antihistamine therapy
D) Prescribe antihistamine therapy
[E) Substitute an albuterol nebulizer for the epinephrine]
The following vignette applies to the next 2 items.
A 6-month-old African-American girl is brought to the office in January for a well-child visit. She was born at 32 weeks' gestation after a pregnancy complicated by an incompetent cervix and premature labor. She has a 3-year-old brother. Her birth weight was 2700 g (6 lb). At birth, she had mild respiratory distress syndrome and required mechanical ventilation for 36 hours. She also has gastroesophageal reflux disease for which she is given ranitidine, daily. Vaccinations are up-to-date. Developmental milestones are appropriate for her adjusted chronological age. Head circumference and growth charts are shown.
Item 1 of 2
8. Regarding the results on the head circumference chart, which of the following is the most appropriate conclusion?
?A) The growth pattern is most likely due to neonatal intraventricular hemorrhage
B) Her growth is normal for a premature infant
C) An MRI should be done to rule out a brain tumor
D) The parents' head circumferences should be measured to evaluate the infant for familial macrocephaly
[E) She should be examined for possible papilledema to rule out hydrocephalus]
Item 2 of 2
9. Two weeks later the girl is brought back by her mother because of a runny nose and difficulty breathing for the past 3 days. The mother says, "She's up every 2 hours now, and last night she had a fever. I think her brother picked up a cold from preschool and gave it to her. I can't keep him away from her." Vital signs now are temperature 38.5°C (101.3°F), pulse 144/min, and respirations 60/min. On physical examination she is alert but in mild respiratory distress with slight nasal flaring. Auscultation of the chest discloses fine expiratory wheezes bilaterally, and mild intercostal retractions. Which of the following is the most likely cause of the infant's illness?
A) Aspiration pneumonia
B) Asthma
C) Bronchopulmonary dysplasia
D) Mycoplasma pneumoniae
[E) Respiratory syncytial virus]
10. A 72-year-old woman comes to the health center for the first time because of palpitations for the past 3 weeks. She says she has felt tense and has had trouble sleeping.Vital signs are: temperature 37.0°C (98.6°F), pulse 104/min, respirations 18/min and blood pressure 142/80 mm Hg. Physical examination is normal except for a mild bilateral hand tremor. Electrocardiogram shows sinus tachycardia but is otherwise normal. Which of the following diagnostic studies will most likely rule out an organic cause for her symptoms?
A) 2-Hour postprandial serum glucose concentration
B) Echocardiography
C) Holter monitoring
[D) Serum thyroid-stimulating hormone concentration]
E) Toxicologic screening of the urine
11. A 48-year-old man who smokes cigarettes has had progressive claudication in the left calf for the past month. He says the pain lasts about 5 minutes and then subsides. Physical examination shows absent pulses in the left foot and normal pulses in the right foot. Atrophic changes are noted in both legs. Doppler examination shows a 0.40 left ankle/brachial ratio; there is no change with exercise. Which of the following is the most likely diagnosis?
A) Aortic occlusive disease
B) Femoral popliteal occlusive disease
C) Leriche syndrome
D) Peripheral small-vessel occlusive disease
[E) Thromboangiitis obliterans]
12. A 52-year-old Hispanic computer technician comes to the office because of a 3-week history of substernal chest discomfort when she climbs stairs or eats a heavy meal. She first noticed the discomfort after climbing two flights of stairs. The discomfort is nonradiating and sometimes only involves the left side of the chest. She has hypertension and type 2 diabetes mellitus. Current medications include metformin and an ACE inhibitor. She has recently had increased stress because her company is experiencing financial difficulty. Her husband receives medical disability benefits, and they are dependent on her income. Physical examination shows no abnormalities. Which of the following risk factors is most important to consider when assessing her chest pain?
A) Age
[B) Diabetes mellitus]
C) Gender
D) Hypertension
E) Stress level
13. A 47-year-old woman returns to the office because of gastrointestinal symptoms. She says, "I still have burning pain in my stomach that travels up my chest to my neck after I eat." During the past 5 years she has been treated with antacids, H2-blocking medications, proton pump inhibitors and motility agents, with only mild relief. She smokes one pack of cigarettes per day and drinks one cup of coffee in the morning. There is no family history of peptic ulcer disease. Previous endoscopies, the last of which was 6 months ago, have shown lower esophagitis secondary to reflux with healing ulcers and scarring. Gastric and duodenal cultures for Helicobacter pylori have been negative. Vital signs today are normal. Physical examination, including rectal examination, is normal. Which of the following is the most appropriate next step?
A) Consider an alternative pharmacotherapeutic regimen
B) Continue current treatment
C) Do esophageal pH monitoring
[D) Obtain surgical consultation]
E) Repeat endoscopy
14. A 38-year-old woman with systemic lupus erythematosus but no evidence of nephritis comes to the office because of a 3-week history of mood swings with crying spells, irritability and insomnia. She is especially upset because she has been yelling at her children "over small, everyday things." One month ago she started corticosteroid therapy. She is currently taking prednisone, 60 mg/day. Her other medications include an oral contraceptive (the same one for the past 6 years) and ibuprofen. She smokes one-half pack of cigarettes daily, drinks one to two beers 5 nights weekly and three cups of coffee each morning. Which of the following is the most appropriate intervention for her mood disturbance?
A) Add amitriptyline at bedtime
B) Discontinue the oral contraceptive
?C) Reduce the prednisone dosage
D) Replace ibuprofen with acetaminophen
[E) Urge her to stop smoking and to reduce her alcohol and caffeine intake]
15. A 76-year-old retired pharmacist is brought to the health center by his wife, who says, "He's afraid to go to sleep, Doctor. Tell him, Henry." He tells you that he was mugged and assaulted 1 week ago while he was out for a walk early in the morning. The patient proceeds to tell you that he has been having nightmares, not about the assault, but of being in vulnerable situations. He also feels anxious during the day but he is able to leave the house without difficulty. In addition to supportive therapy, which of the following pharmacotherapies is most appropriate to prescribe?
A) Amitriptyline
[B) Clonazepam]
C) Diphenhydramine
D) Gabapentin
E) Risperidone
16. A 58-year-old white store manager comes to the office for a periodic health evaluation. You have been treating both the patient and his wife for the past 15 years. Today the patient is tearful and agitated. He says that he is having difficulty with his son, who is age 32 years and has schizophrenia. The son has been living intermittently in a group home or on the streets. The patient says that his son is noncompliant with his antipsychotic medications. Recently, the son has been calling the patient's house asking for money, which the patient suspects his son uses to buy alcohol and illicit drugs. It is most appropriate to advise the patient to do which of the following?
?A) Arrange an involuntary commitment to a psychiatric hospital for his son
B) Ask his son's psychiatrist to adjust his medication
C) Change his phone number
[D) Contact the local chapter of the National Alliance for the Mentally Ill for support and advice]
E) Obtain a restraining order against his son
17. A 20-year-old man comes to the health center because of ankle pain. Two days ago he sustained an inversion injury of his left ankle in a basketball game. He has been able to walk unassisted since the injury. Today he has pain and moderate swelling and discoloration over the lateral malleolus. Physical examination shows tenderness on palpation over the anterolateral corner of the ankle joint. He has had two similar injuries in the past. Which of the following is the most appropriate initial management?
A) An ankle-strengthening exercise program
B) Application of a long-leg cast for 3 weeks
C) Application of a short-leg cast for 3 weeks
D) Protected weight bearing
[E) Surgical repair of the ankle ligaments]
18. A 52-year-old woman comes to the office because of a 4-day history of increasing pain of the right hip and thigh. The pain is exacerbated by lying on her right side while sleeping. She says the pain often awakens her and is accompanied by a burning sensation along the right side of her posterior thigh that radiates to her knee. She usually has stiffness and pain in the hip during the following morning that gradually diminishes as she walks around her house and does house chores. She says the pain is also triggered by sitting with her right leg crossed over the left leg. The patient is otherwise healthy and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses tenderness on deep palpation of the right trochanter. Which of the following is the most likely diagnosis?
[A) Arthritis of the hip]
B) Aseptic necrosis of the femoral head
C) Bursitis
D) Gout
E) Osteosarcoma of the femoral head
19. An 18-year-old man comes to the health center because he has had pain in his right leg for the past 5 days. He says that he recently added jogging to his weight-lifting workouts, and he started running 5 miles per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and weighs 83 kg (185 lb). On physical examination he has moderate tenderness over the midtibia. X-ray of the leg will most likely show which of the following?
A) A bone cyst
B) Displaced fracture
C) Metastatic disease
D) Soft-tissue calcification
[E) Normal findings]
20. A 58-year-old woman comes to the office for follow-up of fibromyalgia. You had been treating her for the past several years for nonspecific muscular aches and pains. In the past you noted that occasionally the pain could be reproduced on physical examination by applying pressure to certain muscles; however, these trigger points seemed to change on each physical examination. Fibromyalgia was diagnosed 3 months ago and amitriptyline therapy was started at that time. At a follow-up visit 3 weeks ago she showed little response to the amitriptyline therapy, and naproxen was added to her regimen. Today she returns to the office complaining that "every time I get the least little bump on my hands the skin seems to tear." Her physical examination is unchanged except for the lesions shown. Which of the following is the most appropriate management?
A) Discontinue the amitriptyline
[B) Discontinue the naproxen]
C) Prescribe oral corticosteroids
D) Prescribe topical corticosteroids
E) Prescribe topical 5-fluorouracil
21. A 10-year-old Asian girl is brought to the office by her mother because of a painful swelling in the girl's neck. The child says that for the past 4 days the right side of her neck has been sore. Today she showed it to her mother, who noticed a red swelling. She does not have fever or chills. She has not missed any days of school. She lives with her parents and two siblings in a suburban community. Further discussion discloses that the family recently adopted an 8-week old kitten from the animal shelter. Vital signs now are: temperature 37.2°C (98.9°F), pulse 80/min, and respirations 24/min. On physical examination, the girl has a 2H4-cm, red, tender mass with overlying erythema and induration in the right submandibular area. There is a crusted papule on the right cheek. Which of the following is the most likely cause of this patient's condition?
[A) Bartonella henselae]
B) Branchial cleft cyst
C) Epstein-Barr virus
D) Trauma
E) Untreated impetigo
22. A 64-year-old retired teacher comes to the office with her husband. She has felt fatigued for several months and feels she is losing her memory. She says, "I feel slowed and can't remember what happened yesterday." Her husband reaffirms this history and notes that she recently got lost in a local mall and called him at home to come and get her. She was frightened by this episode and had insomnia that night, even though she otherwise has been sleeping longer than usual. She has a good appetite. There is a family history of senile dementia in her father and two uncles. Her only medication is daily conjugated estrogen. Her height is 163 cm (5 ft 4 in) and her weight is 64 kg (142 lb), which is an increase of 2.5 kg (6 lb) since you saw her 8 months ago. Pulse is 54/min and regular, and blood pressure is 140/86 mm Hg. On physical examination she appears pale. Deep tendon reflexes have a slow relaxation phase; the remainder of the examination is normal. A Mini-mental state test shows a delayed recall of one of three items and failure on serial 7s. She cannot recall any past presidents but she knows the current president. Based on these findings, which of the following is the most likely working diagnosis?
A) Early dementia, Alzheimer type
[B) Hypothyroidism]
C) Pernicious anemia
D) A transient ischemic attack
E) Vascular dementia
23. A 38-year-old obese woman with a 2-year history of type 2 diabetes mellitus has not lost weight despite persistent advice concerning diet and exercise. She has also been irregular in keeping appointments and has failed to take her medication on a regular basis. There is increasing concern that serious complications will occur unless she becomes more cooperative. You decide to terminate the physician-patient relationship, hoping that another physician can establish better rapport and help her with her problems. The most appropriate way to terminate the relationship is to do which of the following?
A) Give her a copy of her medical records at the next appointment and advise her to find another physician
B) Give her a list of three physicians and ask her to pick one, to whom you will send her medical records
C) Refuse further treatment unless she loses 2.7 kg (6 lb) before her next appointment in 1 month
D) Tell her 19-year-old daughter, who brings her to the office, to convince her mother to find another physician and tell her the reasons for this suggestion
[E) Tell her that the relationship will be terminated in 1 month, give her reasons for this decision, and offer her a list of three physicians' names]
24. A 56-year-old Native American man returns to the office to discuss results of studies obtained during a previous visit 8 weeks ago. The patient has a 19-year history of diabetes mellitus treated with sulfonylurea. He checks his serum glucose concentration approximately once daily. He does not smoke cigarettes and rarely drinks alcoholic beverages. He is 183 cm (6 ft) tall and weighs 76 kg (168 lb); BMI is 23 kg/m2. Vital signs during the previous visit were temperature 36.9°C (98.4°F), pulse 82/min, and blood pressure 130/85 mm Hg. Physical examination of the neck disclosed a right-sided carotid bruit. Examination of the extremities disclosed diminished pulses with associated hair loss over both legs. Hemoglobin A1c was 7.2%. Urine albumin-creatine ratio was 62 mg/g/24 h (N
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Ankle-brachial index (ABI) was 0.89 on the left and 0.98 on the right; duplex carotid ultrasonography showed nonulcerated plaque with 70% stenosis in the right internal carotid artery. The patient was referred to an ophthalmologist, who diagnosed him with nonproliferative background diabetic retinopathy. Which of the following findings in this patient is of most concern?
[A) 70% stenosis of the right carotid artery]
B) Hemoglobin A1c of 7.2%
C) Left ABI of 0.89
D) Nonproliferative diabetic retinopathy
E) Urine albumin-creatine ratio of 62 mg/g/24 h
25. A 25-year-old woman returns to the office because of intermenstrual spotting since beginning oral contraceptive therapy 6 months ago. This is her first attempt at oral contraceptive therapy; she and her partner primarily used condoms for contraception in the past. Before this current therapy her menstrual periods had always been regular. Which of the following is the most appropriate management?
A) Advise her to take two pills daily until the bleeding stops
B) Discontinue the oral contraceptive therapy and have her resume use of condoms for birth control
C) Reassure her that the bleeding problem will resolve in a few months
[D) Switch the current oral contraceptive pill to one containing a higher estrogen dose]
E) Switch to a progestin-only oral contraceptive pill
The following vignette applies to the next 2 items.
A 17-year-old girl is brought to the health center by her mother because the girl has had only two menstrual periods in the past 8 months. She had regular menstrual periods from menarche at age 14 years until 18 months ago. For the past 18 months she has been training as a long-distance runner.
Item 1 of 2
26. The underlying mechanism of her menstrual dysfunction is best defined by an abnormality in which of the following serum concentrations?
A) Androstenedione
B) Creatine kinase
[C) Luteinizing hormone]
D) Testosterone
E) Thyroid-stimulating hormone (TSH)
Item 2 of 2
27. Which of the following is the most likely cause of the menstrual irregularity?
A) High-carbohydrate diet
B) Increased basal body temperature
C) Increased muscle mass
[D) Loss of body fat]
E) Repeated volume depletion
28. A 23-year-old white nulligravid woman returns to the office for follow-up of a 2-year history of primary infertility. Menstrual periods occur at regular 28-day intervals. She has a history of chronic pelvic pain. Analysis of her husband's semen shows a sperm count of 40 million with 65% motility and normal morphology. Diagnostic laparoscopy with hydrotubation shows normal pelvic anatomy, with no evidence of endometriosis or pelvic adhesions. Both fallopian tubes spill methylene blue dye. The patient's basal body temperatures recorded during the past month are shown. Which of the following is the most likely cause of the patient's inability to conceive?
?A) Anovulation
B) Male factor infertility
C) Old pelvic inflammatory disease
D) Polycystic ovary syndrome
[E) No cause can be identified at this time]
29. In the course of routine prenatal care at the health center, a 30-year-old Hispanic woman is found to have gestational diabetes. This is her first pregnancy and she is at 20 weeks' gestation. She should be counseled that adequate prenatal care, including regular determination of blood glucose concentrations and adherence to a controlled dietary regimen, may reduce the possibility of which of the following?
[A) The fetus developing macrosomia]
B) Her developing essential hypertension
C) Her developing type 1 diabetes mellitus in the future
D) Intrauterine growth restriction
E) Premature delivery
30. A 20-year-old woman returns to the office for the results of her prenatal laboratory studies. By date of her last menstrual period she is 14 weeks pregnant with her second child. Her first pregnancy, which you followed, resulted in an uncomplicated vaginal delivery approximately 11 months ago. Her prenatal serology screening for syphilis is positive with a titer of 1:126, and a fluorescent treponemal antibody absorption (FTA-ABS) test is positive. The patient denies having lesions consistent with syphilis, and her current physical examination shows no lesions. Serology during her first pregnancy was negative. At this time, which of the following is the most appropriate management?
A) Do an amniocentesis to obtain fluid for darkfield evaluation
[B) Follow the treatment regimen recommended for primary or secondary syphilis]
C) Postpone treatment until the patient is at least 20 weeks pregnant
D) Schedule a lumbar puncture before instituting treatment
E) Withhold treatment until further studies rule out a biologic false-positive
31. A 34-year-old man comes to the office with his wife and daughter because he has had some dusky lesions on his shoulder for the past 2 months. He says that two have become larger during the past week. He and his wife have recently adopted an 18-month-old girl from the Ukraine who has a similar rash. He is an environmental scientist and his work requires him to travel overseas and work outdoors. He is concerned about the possibility of skin cancer. Vital signs are normal. Physical examination shows a cluster of six discrete papular lesions on his left shoulder that are slightly tender. These lesions have a central depression containing some pus-like material. There is no axillary or cervical adenopathy. His rash is shown. Which of the following is the most appropriate management for the patient?
?A) Acyclovir
B) Scabicidal cream
C) Topical corticosteroid cream
D) Topical fluconazole
[E) Topical liquid nitrogen]
32. A 25-year-old Latino man comes to the health center for a periodic health evaluation. He tells you that he has attended a day-treatment program for his schizophrenia, paranoid type, since his discharge from the hospital 1 year ago. The patient's most recent psychiatrist is moving away and he now wants you to refill his medications. He takes haloperidol, benztropine and valproic acid. He says, "The voices aren't telling me to harm myself anymore. And I know now that my food is not poisoned." The patient is 183 cm (6 ft) tall and weighs 86 kg (190 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 72/min, respirations 14/min and blood pressure 130/86 mm Hg. Physical examination is significant for darting and protruding movements of the tongue and some facial grimacing. Which of the following is the most appropriate change in pharmacotherapy?
A) Prescribe vitamin A
B) Increase the dose of benztropine
C) Increase the dose of haloperidol
[D) Replace haloperidol with risperidone]
E) Replace valproic acid with lithium
33. A third-year medical student returns to the student health service for the third time because he thinks he has ulcerative colitis. After a thorough history and physical examination, he is told that no organic disease is present. Despite that reassurance, the student continues to test his stool for blood and continues to believe that his physicians have missed the correct diagnosis. This behavior is most characteristic of which of the following?
A) Conversion disorder
B) Depersonalization
[C) Hypochondriasis]
D) Munchausen syndrome
E) Somatization disorder
34. A 10-year-old Asian-American boy is brought to the office for a sports physical examination. He has been healthy except for a few episodes of otitis media as an infant. He has had no shortness of breath, syncope or chest pain in the past. Growth has been normal. Vital signs are: temperature 36.6°C (97.8°F), pulse 80/min, respirations 16/min, and blood pressure 110/76 mm Hg. Cardiac examination discloses an early systolic click at the apex, a midsystolic ejection murmur at the right upper sternal border and a thrill in the suprasternal notch. The remainder of the physical examination is normal. The patient is referred to the cardiologist and the diagnosis of aortic stenosis is confirmed by echocardiogram. Close follow-up and graded exercise testing are recommended. The patient is at increased risk for which of the following?
A) Atrial arrhythmias
B) Complete heart block
C) Coronary artery disease
D) Pulmonary hypertension
[E) Sudden death]
35. A 12-year-old Haitian boy is brought to the health center for the first time by his mother and maternal grandmother. The mother states, "There was a voodoo curse placed on my family and now my son is having problems because of that." She reports that for the past 6 months he has been talking back to his teachers, has been suspended from school for skipping class, and has been defiant with all adults. He is failing two subjects in school and will need to attend summer classes. His medical history is significant for an allergy to sulfa drugs, a positive PPD skin test for which he was treated prophylactically at age 10 years, and encopresis that resolved. He currently takes no medications. The patient is 163 cm (5 ft 4 in) tall and weighs 49 kg (108 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 80/min, respirations 18/min and blood pressure 90/50 mm Hg. Which of the following is the most appropriate opening statement to the mother?
A) "Do you think your son may be taking drugs?"
B) "I suggest you consult a voodoo priest for help with this problem."
[C) "Tell me more about the voodoo and its effect on your son's behavior."]
D) "There is no such thing as voodoo."
E) "Voodoo does not cause children to have bad behavior."
36. You are invited to a council meeting of Native-Americans to discuss a heptavalent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar7) for use in the community's children, many of whom are younger than age 12 months. All of the infants and children in the community are up-to-date on standard recommended vaccinations. The council spokesperson says, "We are skeptical about the safety of giving our sons and daughters yet another vaccine." Which of the following is the most compelling reason to recommend vaccination of all infants younger than 12 months of age?
A) Administration of the vaccine will decrease the incidence of invasive pneumococcal disease among the children in the community
B) Administration of the vaccine will decrease the likelihood of secondary pneumonia during respiratory syncytial virus (RSV) season
[C) Administration of the vaccine will significantly decrease the severity of acute otitis media and prevent hearing loss]
D) Native-American children make ineffective antibodies when the 23-valent pneumococcal vaccine alone is administered to them
E) The peak incidence of pneumococcal disease occurs in children younger than 12 months of age
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triplehelix - 05/12/08 13:38
Block 2
1. A 76-year-old woman is admitted to the hospital after a fall at her home earlier in the day. She has been followed in your practice for several years and is in generally good health. She drinks socially, does not smoke and has been active in senior citizen groups. She takes ibuprofen occasionally for pain, but no other medications. On admission she is alert and oriented, and complains only of pain in her left leg. Her temperature is 36.1°C (97.0°F), pulse is 72/min and regular, and blood pressure is 140/85 mm Hg. X-ray films taken upon arrival show a fracture of the left femoral shaft. Surgical repair of the fracture is done the next morning. The patient receives 2 U of packed erythrocytes during the procedure. Postoperative medications include morphine, prophylactic cephalothin and low-dose warfarin. On the evening of the operation, the patient becomes combative, begins to hallucinate and has a brief, generalized seizure. A fine petechial rash is noted on her chest. Which of the following is the most likely cause of her seizure?
A) Antibiotic allergy
B) Blood transfusion reaction
[C) Fat emboli]
D) Hemorrhagic stroke
E) Unrecognized cerebral concussion
2. A 72-year-old woman with metastatic rectal cancer is admitted to the hospital because of weakness and altered mental status. She has bilateral ureteral stents due to prior obstruction from the cancer. She has been using a fentanyl patch for several weeks. Physical examination on admission is notable for lethargy and 3-mm reactive pupils but no focal neurologic signs. She is afebrile and has a blood pressure of 120/82 mm Hg. Laboratory studies show serum urea nitrogen (BUN) concentration of 60 mg/dL and a serum creatinine concentration of 6.2 mg/dL. Serum bilirubin concentration is normal. One week ago serum BUN concentration was 30 mg/dL and serum creatinine concentration was 3.0 mg/dL. Which of the following is the most likely explanation for her altered mental status?
A) Fentanyl intoxication
B) Hepatic encephalopathy
C) Hypercalcemia
[D) Uremia]
E) Urosepsis
3. A 54-year-old African American woman has been in the intensive care unit (ICU) for the past 10 hours because she has failed to regain consciousness after passing out at a restaurant 11 hours ago. Upon initial arrival at the emergency department the patient's friend stated that the patient had remarked about the sudden onset of a terrible headache and neck stiffness while they were having lunch. A few minutes after the onset of the headache, she became confused, vomited, and lost consciousness. She regained consciousness briefly en route to the hospital, but she has been unconscious since admission. On arrival she was intubated and mechanically ventilated and transferred to the ICU, where intravenous fluids were started. Vital signs are: pulse 110/min and blood pressure 174/96 mm Hg. She exhibits no spontaneous movement and is unresponsive to verbal or painful stimuli. Lung fields are clear to auscultation. CT angiogram confirms subarachnoid hemorrhage from a ruptured cerebral aneurysm and impaired intracranial circulation. The family should be counseled regarding which of the following?
A) The futility of continued life support
B) The need for screening of first-degree relatives for aneurysms
C) The need for them to sustain hope
[D) The need to have a guardian ad litem appointed to make informed decisions about the patient's care]
E) The probability that the patient will not regain consciousness
4. A previously healthy 3-year-old boy is admitted to the hospital through the emergency department because he has been having generalized seizures. He had a fever this morning and had one seizure at home and another on the way to the emergency department. While in the emergency department he had several additional seizures that were controlled with intravenous lorazepam. Vital signs on arrival at the emergency department were temperature 39.6°C (103.3°F), pulse 110/min, respirations 24/min, and blood pressure 85/60 mm Hg. Physical examination showed no abnormalities except for left otitis media and lethargy. Intravenous phenytoin was administered. Spinal fluid examination, serum electrolyte concentrations and complete blood count were normal. Now in the hospital, the patient has another seizure. The patient is managed appropriately and the seizure stops. When discussing this child's management and prognosis with the parents, it is most appropriate to counsel them about which of the following?
A) Their child has an increased risk for attention-deficit/hyperactivity disorder
B) Their child has an increased risk for developing a brain tumor
C) Their child is likely to be developmentally delayed
D) Their child will have a seizure every time he has a fever
[E) Their child will probably become seizure-free as he becomes older]
5. A 21-year-old Asian-American man who sustained a closed head injury in a motorcycle accident is admitted to the hospital. He is intubated and is receiving mechanical ventilation in the intensive care unit. On repeat physical examinations during the next 2 days, he shows no clinical signs of cerebral activity and has no spontaneous respiration. His pupils are fixed in mid-position and he has no vestibulo-ocular reflexes. Electroencephalograms obtained 24 hours apart have nearly flat tracings. His driver's license indicates his desire to be an organ donor. When you inform his parents that he is brain dead, you remind them of his donor statement and request permission to harvest usable organs. The parents are shocked; they say they are unaware of his desire to be an organ donor and refuse to grant permission. Because the patient meets the clinical criteria for brain death, which of the following is most appropriate?
[A) Explain how their son's death can contribute to another person's life]
B) Have a potential organ recipient talk with the family
C) Obtain a court order authorizing removal of usable organs
D) Order cerebral angiography to convince the parents that their son is brain dead
?E) Proceed with organ removal because the patient is an adult
6. A 52-year-old woman is admitted to the hospital for diagnostic evaluation of a slight aphasia and change in her personality, as noted by her husband. CT scan of the head discloses a 3-cm mass in the left temporal lobe and a 5-cm mass in the right frontal lobe. Because she is a chronic cigarette smoker, you have been obtaining annual chest x-ray films, which have been reported as normal. Her chest x-ray film on admission today is reported as showing a "2-cm spiculated mass in the left subapical region." No reference is made to comparing this film with the prior films. The radiologist then calls you and admits to you that the lesion was present on her prior films but it was overlooked. Which of the following is the most appropriate next step?
A) Agree with the radiologist that informing the patient and her family will do more harm than good
B) Ask the radiologist to inform the patient and her family of the problem
C) Compliment the radiologist for finding what will probably be the primary lesion accounting for the two CNS lesions
D) Consult with your attorney regarding avoidance of litigation for yourself
[E) Inform the radiologist of your responsibility to inform the patient and her family of the problem]
The following vignette applies to the next 2 items.
While making rounds in a rehabilitation facility, you see a 76-year-old white woman who has been your patient for 25 years. One month ago she was diagnosed with metastatic non-small cell carcinoma of the lung with metastases to the other lung, liver and brain. She now has moderate left hemiparesis that limits walking. She also has multiple, asymptomatic, deep venous thrombi of both legs that are being treated with a vena caval filter. Despite discussion with the patient and her family about her illness, her son tells you that she is apparently unaware that her condition is terminal.
Item 1 of 2
7. Which of the following is the most appropriate next step?
A) Arranging transfer to the in-patient psychiatric ward
B) Beginning anxiolytic therapy
[C) Discussing the prognosis again with the patient]
D) Encouraging the family to discuss the patient's prognosis with her
E) Explaining to the son that it is inappropriate for you to speak about his mother's illness
Item 2 of 2
8. The patient is not in severe pain and she currently has no respiratory distress. She has chosen not to have further intervention and she probably has about 3 months to live. Her husband is an active 75-year-old man with recently diagnosed type 2 diabetes mellitus. Two of their three sons live 1 hour away. The patient has many concerned neighbors and friends. The patient's family asks for your advice regarding appropriate care for her for the remainder of her illness.
Which of the following is the most appropriate recommendation?
A) Continued care in the rehabilitation center until she is able to ambulate on her own
B) Home health care for as long as she qualifies for skilled nursing services
[C) Home hospice care with physical therapy]
D) Placement under intermediate (nonskilled) care in a local nursing home
E) Placement under skilled care in a local nursing home
9. An 18-year-old woman gave birth to a healthy neonate 72 hours ago. The woman now has the acute onset of tachypnea. Vital signs are normal. Diffuse wheezing is noted on auscultation of the chest. Chest x-ray film is normal. Electrocardiogram shows evidence of right heart strain. Which of the following is the most likely diagnosis?
A) Adult respiratory distress syndrome
B) Aspiration pneumonia
C) Bronchopneumonia
D) Congestive heart failure
[E) Pulmonary embolism]
10. A 34-year-old woman undergoes a middle ear operation with oral intubation and general anesthesia. During the 4-hour procedure she was in a semi-lateral position with her head maximally turned to the right and her chin tucked on her chest. She awakens normally at the end of the procedure and is extubated without difficulty. Approximately 30 minutes later she appears anxious and is sitting upright. She leans forward and says, "I'm not getting enough air." Her voice is barely audible and very hoarse and she appears to be struggling to take a deep breath. Vital signs are: pulse 94/min, respirations 28/min and blood pressure 128/72 mm Hg. Oxygen saturation is 92% with an FIO2 of 0.4. Oxygen flow is maximally increased and O2 saturation is 93%. Auscultation of the chest discloses bilateral breath sounds with crowing sounds on inspiration and expiration. Which of the following is the most appropriate pharmacotherapy?
A) Midazolam
B) Naloxone
[C) Nebulized racemic epinephrine]
D) Neostigmine
E) Succinylcholine
11. A 67-year-old man with a history of poorly controlled hypertension is admitted to the hospital because of increasing fatigue, weight loss and dyspnea on exertion for the past 6 weeks. Medical history includes tonsillectomy, adenoidectomy, mitral valve commissurotomy and a sigmoid colon resection for diverticulitis. Vital signs are: pulse 90/min, respirations 14/min and blood pressure 190/100 mm Hg. The patient appears chronically ill but is in no acute distress. Laboratory studies show:
Serum
Urine
Na+
140 mEq/L
WBC
0/hpf
K+
4.5 mEq/L
RBC
4/hpf
Cl-
100 mEq/L
HCO3-
25 mEq/L
Which of the following is the most likely finding on echocardiography?
A) Ejection fraction of 60%
[B) Left ventricular wall thickening]
C) Pericardial fluid
D) Septal dyskinesia
E) Thoracic aortic aneurysm
the following vignette applies to the next 2 items.
You have been treating a 5-month-old child in the neonatal intensive care unit (NICU). He was delivered at 26 weeks' gestation by cesarean delivery because of premature rupture of membranes. The mother is 18 years old and is unemployed. There are two other children in the home. The father is not living with them, and he has not been in contact with the mother. The mother rarely visits the NICU. The infant had severe respiratory distress syndrome at birth and required dopamine for blood pressure support. His condition progressed to pulmonary interstitial emphysema and bronchopulmonary dysplasia by 4 weeks of age. At 4 months of age he required a tracheostomy and medication for control of his blood pressure. Now, at 5 months of age, the boy has a cardiac arrest requiring resuscitation and placement of chest tubes. He then develops seizures that are eventually controlled with medication. The neonatologist feels that the child will always require life support. The mother refuses to discuss the possibility of withdrawing life support. Her insurance is Medicaid. The hospital bill for this child is now $350,000.
Item 1 of 2
12. To guide further treatment at this time, it is most important to assess which of the following?
[A) The extent of neurologic injury]
B) The financial impact on the family
C) The mother's level of understanding of the child's prognosis
D) Whether another family member is better suited to make decisions about the patient's care
E) Your state's law regarding futile care
Item 2 of 2
13. One week later the mother and the attending physician are unable to reach an agreement on the management plan. Which of the following is the most appropriate next step?
A) Ask the court to appoint a guardian
B) Defer major decisions until the father can be located
[C) Have the social worker contact Medicaid regarding further coverage]
D) Involve the hospital bioethics committee
E) Maintain the patient on a respirator but transfer him out of the NICU
14. A 42-year-old African-American man with hepatitis C is admitted to the hospital for evaluation of a 3-day history of fever and right upper quadrant abdominal pain. The pain is steady and does not change with position. He has had associated nausea but has not vomited. He has a history of alcohol dependence but has not had an alcoholic beverage since being diagnosed with hepatitis C 4 years ago. He does not take any medications. On admission, vital signs are: temperature 38.5°C (101.3°F), pulse 115/min, respirations 24/min and blood pressure 100/60 mm Hg. Physical examination shows scleral icterus. Abdominal examination discloses mild distention and right upper quadrant tenderness to palpation; the liver spans 25 cm. There is no rebound tenderness and bowel sounds are normal. Ultrasonography of the right upper quadrant shows three small gallstones, dilated right and left intrahepatic ducts and normal common bile duct. Laboratory studies show:
Serum
Blood
ALT
650 U/L
Hematocrit
35%
AST
442 U/L
WBC
22,000/mm3
Alkaline phosphatase
342 U/L
PT
14 sec
Bilirubin
7.0 mg/dL
PTT
28 sec
Na+
140 mEq/L
INR
1.2
K+
4.2 mEq/L
Cl-
104 mEq/L
HCO3-
23 mEq/L
Fluid resuscitation is begun. Which of the following is the most appropriate next step?
A) Biopsy of the liver
?B) Cholecystectomy
C) CT scan of the abdomen
[D) Endoscopic retrograde cholangiopancreatography with st]
15. A 16-year-old Mexican American girl who is 28 weeks pregnant comes to the health center with her boyfriend because of epigastric pain radiating to her back. She says, "I have had pain for many days, especially after eating." She has been taking acetaminophen for the pain several times a day for the past week. She admits to drinking an occasional bottle of light beer. She has been receiving prenatal care at the health center. Vital signs today are temperature 37.5°C (99.5°F), pulse 110/min, respirations 15/min, and blood pressure 110/70 mm Hg. Height is 157 cm (5 ft 2 in) and weight is 90 kg (200 lb). Physical examination shows scleral icterus and epigastric and right upper quadrant tenderness. Uterus is appropriately enlarged for her gestational stage. The patient is admitted to the hospital for observation. Results of laboratory studies are shown:
Serum
ALT
55 U/L
AST
58 U/L
Alkaline phosphatase
350 U/L
Amylase
3000 U/L
Bilirubin
Total
7.3 mg/dL
Direct
5.9 mg/dL
Lipase
475 U/L (N=10140)
These laboratory results are most indicative of which of the following?
A) Acetaminophen-induced hepatic necrosis
B) Alcoholic pancreatitis
[C) Biliary pancreatitis]
D) Hepatitis C infection
E) Mononucleosis
16. A 22-year-old woman is in her 5th hospital day following admission for evaluation of severe right lower quadrant abdominal pain. During the previous 8 months, she has had episodes of abdominal pain with associated recurrent diarrhea, which sometimes contained blood. The pain and diarrhea became increasingly severe during the 5 days prior to admission. During that time, she lost 2 kg (5 lb) and had a temperature to 39.0°C (102.0°F). Abdominal examination on admission disclosed a right lower quadrant mass. Blood hemoglobin concentration was 15.5 g/dL and leukocyte count was 24,000/mm3. Colonoscopy showed linear ulcerations with discontinuous areas of inflammation. Biopsy of the lower intestine disclosed noncaseating granulomas. Serum antibody test to Saccharomyces cerevisiae was positive. Treatment with intravenous hydrocortisone therapy was begun. Today, the patient's abdominal pain and diarrhea are resolved. Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 12/min, and blood pressure 122/74 mm Hg. The abdomen is soft and nontender to palpation; bowel sounds are normal. Which of the following is the most appropriate pharmacotherapy for this patient?
A) Azathioprine
[B) Mesalamine]
C) Metronidazole
D) Prednisone
E) Ranitidine
The following vignette applies to the next 2 items.
A 28-year-old man who lives in a small rural township is admitted to the hospital because of gastrointestinal bleeding. On admission the patient is pale and has orthostatic hypotension. Hemoglobin concentration is 8 g/dL. His condition is stabilized. Emergent upper endoscopy shows a visible gastric vessel, which is treated appropriately.
Item 1 of 2
17. Specific additional history should be obtained regarding which of the following?
?A) Consumption of alcoholic beverages
B) Family history of cancer
C) Source of drinking water
D) Travel history
[E) Use of tobacco products]
Item 2 of 2
18. Which of the following is the most appropriate laboratory study?
[A) Antibodies for Helicobacter pylori]
B) Vitamin B12 (cyanocobalamin) concentration
?C) Ferritin concentration
D) Gastrin concentration
E) Iron concentration
19. A 74-year-old woman is admitted to the hospital for treatment of a hip fracture. Her only medical problem is chronic insomnia; she told the nurse, "I have taken sleeping pills for years." Two days after the operation she has a tonic clonic seizure. Vital signs now are: temperature 38.0°C (100.4°F), pulse 110/min and blood pressure 180/100 mm Hg. She is confused, has diaphoresis and is trembling. Which of the following is the most likely diagnosis?
[A) Barbiturate withdrawal]
B) Diphenhydramine withdrawal
C) Propoxyphene withdrawal
D) Pulmonary embolus
E) Stroke
20. You have just returned from a trip out of town and learn that your long-time patient with end-stage chronic obstructive pulmonary disease has been hospitalized and is on a ventilator. On the way to the intensive care unit to visit him, you are informed that the patient has just died. On your way into the patient's room you meet the patient's 68-year-old wife. Which of the following is most appropriate to say to her?
A) "How do you feel?"
[B) "I am sorry for your loss."]
C) "I know you are upset."
D) "What happened while I was gone?"
E) "Your husband didn't suffer."
21. A 3-day-old Latina infant is in the hospital awaiting routine physical examination. She was born to a 28-year-old woman by cesarean delivery at term because of breech presentation. She is the woman's first child and the pregnancy was uncomplicated. The infant weighed 3686 g (8 lb 2 oz) at birth. Physical examination discloses asymmetry in the number of thigh skin folds and uneven knee levels when the hips and knees are flexed. Barlow test is done and a palpable "click" is felt in the left hip. Without prompt treatment, this child is at increased risk for which of the following?
[A) Dysplasia of the hip]
B) Femoral head anteversion
C) Legg-Calve-Perthe disease
D) Metatarsus adductus
E) Slipped capital femoral epiphysis
The following vignette applies to the next 2 items.
An 83-year-old woman is admitted to a nursing home for ongoing management of Parkinson disease. Her husband can no longer care for her at home because she is moderately demented, has difficulty walking, has fallen several times and has urinary incontinence. She has difficulty swallowing her pills, and she needs assistance with feeding. Despite her husband's attentive care, she has lost 9 kg (20 lb), going from 47.1 kg (104 lb) to 38 kg (84 lb) during the past 9 months. After 2 weeks in the nursing home, the nursing staff notes that the patient frequently eats and drinks very little and often coughs after she swallows. Her current medications include fluoxetine, selegiline, carbidopa-levodopa, trazodone, estrogen and sorbitol. Vital signs now are: temperature 36.4°C (97.6°F), axillary; pulse 88/min; respirations 18/min and blood pressure 102/84 mm Hg, supine. Physical examination shows a frail and thin woman. Voice is soft and low. Chest is clear to auscultation. Heart rate is regular without murmurs or gallops. Abdomen is soft and nontender with decreased bowel sounds. Rectal examination is normal. She is generally stiff with low amplitude tremors at rest. Laboratory results show:
Serum
BUN
47 mg/dL
Creatinine
1.9 mg/dL
Na+
161 mEq/L
K+
3.9 mEq/L
Cl-
120 mEq/L
HCO3-
24 mEq/L
When the nursing home calls you with the laboratory results, the office staff informs you that the patient's husband telephoned earlier that afternoon and "fired" you from the case. There are no written notes from the staff and you have not spoken to the husband yourself.
Item 1 of 2
22. The most appropriate next step is to contact which of the following?
A) Husband and give him the names of other physicians who attend patients in the nursing home
[B) Husband and inform him of the laboratory results, their implications and management options]
C) Nursing home and inform them that you are no longer the patient's physician
D) Nursing home and initiate nasogastric rehydration in the facility
E) Nursing home and order the immediate transfer of the patient to the hospital
Item 2 of 2
23. Which of the following complications is most likely to develop if her hypernatremia is corrected too quickly?
A) Disseminated intravascular coagulation
B) Intravascular hemolysis
[C) Pontine myelinolysis]
D) Pulmonary edema
E) Seizures
24. A 68-year-old woman with stage IV ovarian cancer is in the hospital following initial staging and a debulking operation. She refuses chemotherapy and the physician agrees to follow her wishes. This is an example of which ethical principle?
A) Authority
[B) Autonomy]
C) Beneficence
D) Justice
E) Nonmaleficence
25. You assist in the delivery of a neonate born to a couple who have been your patients for the past 7 years. The husband is 50 years old and the wife is 45 years old. The wife had been offered maternal serum triple-marker screening and amniocentesis during the pregnancy because of her advanced age, and she had declined the testing. At the delivery, the neonate has features suggestive of Down syndrome. Apgar score is 9 at 1 minute and 9 at 5 minutes. Initial physical examination demonstrates no cyanosis and no heart murmur. In the delivery room, which of the following is the best initial statement to make to the parents?
A) "Do you remember the tests we discussed early in your pregnancy?"
B) "I am concerned about your infant because she may have Down syndrome."
C) "I am sorry to have to tell you this, but I suspect your baby has Down syndrome."
D) "We are going to have to take the baby to the nursery for some tests."
[E) "Your daughter is doing well, but I am concerned about some of her physical features."]
26. A 26-year-old primigravid woman at 38 weeks' gestation is admitted to the hospital because she is in labor; contractions occur every 3 minutes and last 60 seconds. The patient's prenatal course has been uncomplicated. Labor curve is now normal and fetal heart rate tracing shows good variability with an occasional mild deceleration. Her patient chart indicates that a previous physician thought she might have a platypellic pelvis. She is now 10-cm dilated. The fetus is at +1 station with a mentum-anterior face presentation. Which of the following is the most appropriate management at this time?
A) Deliver the child vaginally after manually rotating the fetus to a mentum-posterior presentation
B) Deliver the child vaginally with the aid of forceps
C) Deliver the child vaginally with the aid of vacuum extraction
[D) Deliver the child vaginally without intervention]
E) Deliver the child via emergency cesarean delivery
27. A full-term, 3402-g (7-lb 8-oz) neonate aspirated meconium at delivery. Apgar score is 3 at 1 minute and 3 at 5 minutes. He is intubated and assisted ventilation is established using a respirator. His condition stabilizes for 30 minutes but the arterial blood gas values suddenly deteriorate. Which of the following is the most appropriate first step?
[A) Auscultate the chest]
B) Check the respirator settings
C) Increase the oxygen flow
D) Recheck the arterial blood gas values
E) Reposition the endotracheal tube
28. A 56-year-old man who is alcohol-dependent is admitted to the hospital because of fever, encephalopathy and increasing abdominal girth. The patient has no family and has been living on the street. An abdominal paracentesis is consistent with spontaneous bacterial peritonitis, which is treated with antibiotic therapy. During the next 10 days, the patient's renal function deteriorates and his serum creatinine concentration increases to 11.3 mg/dL, with a serum urea nitrogen (BUN) concentration of 144 mg/dL. He becomes progressively more obtunded, develops respiratory failure and is intubated. He requires vasopressors to maintain his blood pressure. There is general agreement from the gastrointestinal and renal services that he will not recover and that further treatment, including dialysis, is futile. The patient is thrashing about in bed, moaning and grimacing periodically. Which of the following is the most appropriate next step in management?
A) Do a liver biopsy to identify the cause of the patient's liver failure
[B) Initiate lactulose treatment to reduce his encephalopathy]
C) Initiate analgesic therapy to palliate the patient's apparent discomfort
D) Stop all antibiotic therapy to reduce the chance of further renal toxicity
E) Stop all medical treatment
The following vignette applies to the next 2 items.
A 38-year-old woman is admitted to the hospital for an elective breast-reduction operation. She is in good health and has never been admitted to the hospital or had previous operations. Her only medication is an oral contraceptive pill. Shortly after the administration of general anesthesia she develops muscular rigidity, temperature increases to 40.6°C (105.0°F), pulse increases to 130/min and blood pressure decreases from 110/70 mm Hg to 80/40 mm Hg. Arterial blood gas values show:
PO2
60 mm Hg
PCO2
40 mm Hg
pH
7.12
Total CO2
18 mm Hg
O2 saturation
88%
Item 1 of 2
29. Which of the following is the most appropriate intravenous pharmacotherapy to administer at this time?
[A) Dantrolene]
B) Diazepam
C) Epinephrine
D) Magnesium sulfate
E) Succinylcholine
Item 2 of 2
30. Which of the following is the most likely cause of this reaction?
[A) Abnormal increase in intracellular calcium]
B) Hypothalamic dysfunction
C) Hypovolemia
D) Inability to sweat
E) Inhibition of protein synthesis
The following vignette applies to the next 2 items.
You are asked to see a 63-year-old woman who is in the hospital after undergoing an operation 4 days ago for a displaced tibia-fibula fracture. The operation was uncomplicated. Preoperative chest x-ray film was normal. She has a transurethral urinary catheter, which was placed during the operation 4 days ago. Today she has a temperature of 37.9°C (100.2°F). Laboratory studies disclose mild leukocytosis. Urinalysis shows greater than 100 WBC/hpf and many bacteria. You suspect that she has a urinary tract infection.
Item 1 of 2
31. Which of the following would have been the most appropriate method of preventing a urinary tract infection in this patient?
A) Cleaning the perineum twice daily with povidone-iodine
B) Irrigating the bladder every 8 hours
[C) Removing the catheter immediately post-operation]
D) Treating the patient with prophylactic antibiotics
E) Using only silver-coated urinary catheters
Item 2 of 2
32.Incidence of Bacteruria Related to Catheter Use
Study Randomized Suprapubic Catheter Transurethral Catheter Odds Ratio +95% CI
A No 2/25 21/31 0.04(0.01-0.24)
B Yes 10/48 20/44 0.32(0.11-0.86)
C Yes 2/32 16/34 0.08(0.01-0.41)
D Yes 8/32 5/40 1.87(0.48-8.01)
*CI=confidence interval
A Colleague suggests to you that suprapubic catheters can decrease a patient's risk for bacterial colonization. You identify four studies in the medical literature that compare the incidence of bacteruria in patients with a transurethral catheter versus patients with a suprapubic catheter. The study results are shown. Which of the following is the most important criterion related to the validity of these data?
A) Confidence interval
B) The number of patients with bacteriuria
C) Odds ratio
[D) Sample size]
E) Study design
The following vignette applies to the next 2 items.
A 67-year-old woman with a 2-month history of cough was admitted to the hospital after chest x-ray film and CT scan showed a lung mass with suspected mediastinal extension. Biopsies obtained during bronchoscopy and mediastinoscopy showed poorly differentiated squamous cell carcinoma in the peritracheal lymph nodes. A pulmonary consultant has determined that the tumor is
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1. An 83-year-old woman who has dementia, Alzheimer type, is brought to the office for a return visit by her daughter, with whom she lives. While intermittently somewhat confused, until recently the patient had been able to handle most of her activities of daily living. In the past month, however, she has shown little interest in eating and is awake most of the night. The daughter says the patient has been seeing things, especially at night. She has been accusing her daughter of stealing from her, and has also hit her daughter. The patient has fallen twice on her way to the bathroom at night. The daughter has been giving her diphenhydramine for 1 month to help her sleep, but she says it does not seem to be helping. You have also been treating the patient with ranitidine for esophageal reflux and with amitriptyline for depression. Vital signs are normal, and physical examination is unchanged from the last visit. Her mental status has deteriorated from her last visit 4 months ago. Today she is oriented only to name, does not seem to recognize you and appears to be visually hallucinating. Her daughter says she herself is overwhelmed and wonders if it is time to consider a nursing home for the patient. Which of the following is the most appropriate response?
[A) "Her increased confusion may be due to her medicines. Let's explore that possibility first."]
B) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."
C) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."
D) "It is a little premature for that. Let's try some home health services first."
E) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."
2. A 12-year-old boy is brought to the office by his parents for a follow-up visit after starting treatment with carbamazepine 3 months ago for temporal lobe seizures. He has been seizure-free since having attained a therapeutic serum carbamazepine level 2 months ago. He says that he feels well, is doing much better in school, and has no new symptoms or complaints. It is most appropriate to tell him and his parents that with this drug therapy, he will need monitoring to assess for which of the following conditions?
[A) Agranulocytosis]
B) Cardiac arrhythmias
C) Gastric ulcers
D) Proteinuria
E) Renal failure
3. A 72-year-old professor emeritus comes to the office saying, "I am worried that I have Alzheimer's or small strokes or something." During the past year, he has noted increasing difficulty with his memory, especially for names, which has created several awkward moments professionally and socially. He adds, "I'll be doing fine, when all of a sudden my mind goes blank. I can't recall something I should easily know, and then suddenly it will come back to me a couple of minutes later." He complains that he frequently misplaces items like his keys, which is very unlike him. He also complains that his sleep is not restful anymore and that he tosses and turns all night. His wife has told him that she is not sleeping either, because he snores loudly. He says, "I'm tired much of the time, and I doze off whenever I try to read." He also complains of frequent headaches in the morning. Past medical history includes hypertension, which is well-controlled with diltiazem; peptic ulcer disease for which he takes ranitidine; and lumbar osteoarthritis, for which he takes ibuprofen. Height is 175 cm (5 ft 9 in) and weight is 72 kg (160 lb). Vital signs are: temperature 36.9°C (98.4°F), pulse 80/min and regular, respirations 12/min and blood pressure 158/100 mm Hg. Physical examination, including neurologic examination, is normal. He scores 29 out of 30 on the Mini-mental state test. Which of the following is the most appropriate next step?
A) Order CT scan of the head
B) Order electroencephalography
C) Reassure him that his symptoms are probably normal
D) Refer him for neuropsychological testing
[E) Refer him for polysomnography]
4. An 8-year-old boy is brought to the office because of a 5-day history of fever, coryza and cough that coincides with an epidemic of influenza in the community. Today he is unable to walk because of pain in the calves. His mother has been giving him acetaminophen for fever and pain. Physical examination shows a temperature of 38.3°C (101.0°F). He is alert, interactive and well-hydrated. He has clear rhinorrhea, mild pharyngeal erythema and a clear chest. His calves are tender to palpation. Strength cannot be tested because of pain. Neurologic examination, including deep tendon reflexes, is normal. Which of the following is the most appropriate therapy?
[A) Acetaminophen, orally, as needed]
B) Amantadine, orally
C) Immune globulin, intravenously
D) Influenza virus vaccine, intramuscularly
E) Prednisone, orally
5. A 55-year-old Hispanic welder comes to the office for an initial visit because of a lesion in his right eye that has been present for several months. During this time his right and left eyes have been increasingly sensitive to wind. He has not had double vision and has not seen "spots" in his field of vision. He says that he has been generally healthy and has not seen a physician during the past 30 years. He takes no medications. He does not wear corrective lenses. Family history is significant for blindness in his mother at age 77 years. The patient has smoked a half pack of cigarettes daily for the past 40 years, and he drinks an occasional six-pack of beer on weekends. Vital signs today are temperature 37.2°C (99.0°F), pulse 110/min, respirations 20/min, and blood pressure 140/85 mm Hg. Examination of the right eye discloses the finding shown in the photograph. Visual acuity is 20/40 in both eyes. Musculoskeletal examination discloses symmetric enlargement of the proximal and distal interphalangeal joints of both hands. The joints are firm to palpation and cool to the touch. The remainder of the physical examination is noncontributory. Which of the following is the most likely diagnosis?
A) Corneal abrasion
B) Glaucoma
C) Keratitis
[D) Pterygium]
E) Stye
6. A 3-year-old African-American boy who is a new patient is brought to the office by his grandmother. She says, "He was OK until this afternoon, when he suddenly developed a fever. He's been spitting a lot. He keeps his mouth open and he refuses to lie down. He won't eat." You learn that the child has received only one set of vaccinations at the age of 2 months. Vital signs are: temperature 39.4°C (103.0°F), pulse 110/min, respirations 24/min and blood pressure 110/70 mm Hg. On physical examination the child sits in a tripod position and salivation is evident. Which of the following is the most appropriate next step?
A) Administration of cefotaxime, intravenously
B) Complete blood count and blood culture
C) Determination of arterial blood gas values
[D) Immediate otorhinolaryngology consultation]
E) Lateral neck x-ray film
7. A 19-year-old college student comes to the student health center because of palpitations, shortness of breath and a runny nose. He has asthma that he has treated with an over-the-counter cold preparation and an epinephrine metered-dose inhaler every 2 to 3 hours at night. He just used the bronchodilator in the waiting room. Vital signs are: temperature 38.2°C (100.8°F), pulse 82/min and respirations 18/min. He appears to be somewhat anxious and his breathing is labored. Auscultation discloses mildly diminished breath sounds in all lung fields accompanied by scattered wheezing. Which of the following is the most appropriate management?
A) Add oral aminophylline therapy
B) Admit him to the hospital for respiratory therapy
C) Prescribe decongestant/antihistamine therapy
D) Prescribe antihistamine therapy
[E) Substitute an albuterol nebulizer for the epinephrine]
The following vignette applies to the next 2 items.
A 6-month-old African-American girl is brought to the office in January for a well-child visit. She was born at 32 weeks' gestation after a pregnancy complicated by an incompetent cervix and premature labor. She has a 3-year-old brother. Her birth weight was 2700 g (6 lb). At birth, she had mild respiratory distress syndrome and required mechanical ventilation for 36 hours. She also has gastroesophageal reflux disease for which she is given ranitidine, daily. Vaccinations are up-to-date. Developmental milestones are appropriate for her adjusted chronological age. Head circumference and growth charts are shown.
Item 1 of 2
8. Regarding the results on the head circumference chart, which of the following is the most appropriate conclusion?
?A) The growth pattern is most likely due to neonatal intraventricular hemorrhage
B) Her growth is normal for a premature infant
C) An MRI should be done to rule out a brain tumor
D) The parents' head circumferences should be measured to evaluate the infant for familial macrocephaly
[E) She should be examined for possible papilledema to rule out hydrocephalus]
Item 2 of 2
9. Two weeks later the girl is brought back by her mother because of a runny nose and difficulty breathing for the past 3 days. The mother says, "She's up every 2 hours now, and last night she had a fever. I think her brother picked up a cold from preschool and gave it to her. I can't keep him away from her." Vital signs now are temperature 38.5°C (101.3°F), pulse 144/min, and respirations 60/min. On physical examination she is alert but in mild respiratory distress with slight nasal flaring. Auscultation of the chest discloses fine expiratory wheezes bilaterally, and mild intercostal retractions. Which of the following is the most likely cause of the infant's illness?
A) Aspiration pneumonia
B) Asthma
C) Bronchopulmonary dysplasia
D) Mycoplasma pneumoniae
[E) Respiratory syncytial virus]
10. A 72-year-old woman comes to the health center for the first time because of palpitations for the past 3 weeks. She says she has felt tense and has had trouble sleeping.Vital signs are: temperature 37.0°C (98.6°F), pulse 104/min, respirations 18/min and blood pressure 142/80 mm Hg. Physical examination is normal except for a mild bilateral hand tremor. Electrocardiogram shows sinus tachycardia but is otherwise normal. Which of the following diagnostic studies will most likely rule out an organic cause for her symptoms?
A) 2-Hour postprandial serum glucose concentration
B) Echocardiography
C) Holter monitoring
[D) Serum thyroid-stimulating hormone concentration]
E) Toxicologic screening of the urine
11. A 48-year-old man who smokes cigarettes has had progressive claudication in the left calf for the past month. He says the pain lasts about 5 minutes and then subsides. Physical examination shows absent pulses in the left foot and normal pulses in the right foot. Atrophic changes are noted in both legs. Doppler examination shows a 0.40 left ankle/brachial ratio; there is no change with exercise. Which of the following is the most likely diagnosis?
A) Aortic occlusive disease
B) Femoral popliteal occlusive disease
C) Leriche syndrome
D) Peripheral small-vessel occlusive disease
[E) Thromboangiitis obliterans]
12. A 52-year-old Hispanic computer technician comes to the office because of a 3-week history of substernal chest discomfort when she climbs stairs or eats a heavy meal. She first noticed the discomfort after climbing two flights of stairs. The discomfort is nonradiating and sometimes only involves the left side of the chest. She has hypertension and type 2 diabetes mellitus. Current medications include metformin and an ACE inhibitor. She has recently had increased stress because her company is experiencing financial difficulty. Her husband receives medical disability benefits, and they are dependent on her income. Physical examination shows no abnormalities. Which of the following risk factors is most important to consider when assessing her chest pain?
A) Age
[B) Diabetes mellitus]
C) Gender
D) Hypertension
E) Stress level
13. A 47-year-old woman returns to the office because of gastrointestinal symptoms. She says, "I still have burning pain in my stomach that travels up my chest to my neck after I eat." During the past 5 years she has been treated with antacids, H2-blocking medications, proton pump inhibitors and motility agents, with only mild relief. She smokes one pack of cigarettes per day and drinks one cup of coffee in the morning. There is no family history of peptic ulcer disease. Previous endoscopies, the last of which was 6 months ago, have shown lower esophagitis secondary to reflux with healing ulcers and scarring. Gastric and duodenal cultures for Helicobacter pylori have been negative. Vital signs today are normal. Physical examination, including rectal examination, is normal. Which of the following is the most appropriate next step?
A) Consider an alternative pharmacotherapeutic regimen
B) Continue current treatment
C) Do esophageal pH monitoring
[D) Obtain surgical consultation]
E) Repeat endoscopy
14. A 38-year-old woman with systemic lupus erythematosus but no evidence of nephritis comes to the office because of a 3-week history of mood swings with crying spells, irritability and insomnia. She is especially upset because she has been yelling at her children "over small, everyday things." One month ago she started corticosteroid therapy. She is currently taking prednisone, 60 mg/day. Her other medications include an oral contraceptive (the same one for the past 6 years) and ibuprofen. She smokes one-half pack of cigarettes daily, drinks one to two beers 5 nights weekly and three cups of coffee each morning. Which of the following is the most appropriate intervention for her mood disturbance?
A) Add amitriptyline at bedtime
B) Discontinue the oral contraceptive
?C) Reduce the prednisone dosage
D) Replace ibuprofen with acetaminophen
[E) Urge her to stop smoking and to reduce her alcohol and caffeine intake]
15. A 76-year-old retired pharmacist is brought to the health center by his wife, who says, "He's afraid to go to sleep, Doctor. Tell him, Henry." He tells you that he was mugged and assaulted 1 week ago while he was out for a walk early in the morning. The patient proceeds to tell you that he has been having nightmares, not about the assault, but of being in vulnerable situations. He also feels anxious during the day but he is able to leave the house without difficulty. In addition to supportive therapy, which of the following pharmacotherapies is most appropriate to prescribe?
A) Amitriptyline
[B) Clonazepam]
C) Diphenhydramine
D) Gabapentin
E) Risperidone
16. A 58-year-old white store manager comes to the office for a periodic health evaluation. You have been treating both the patient and his wife for the past 15 years. Today the patient is tearful and agitated. He says that he is having difficulty with his son, who is age 32 years and has schizophrenia. The son has been living intermittently in a group home or on the streets. The patient says that his son is noncompliant with his antipsychotic medications. Recently, the son has been calling the patient's house asking for money, which the patient suspects his son uses to buy alcohol and illicit drugs. It is most appropriate to advise the patient to do which of the following?
?A) Arrange an involuntary commitment to a psychiatric hospital for his son
B) Ask his son's psychiatrist to adjust his medication
C) Change his phone number
[D) Contact the local chapter of the National Alliance for the Mentally Ill for support and advice]
E) Obtain a restraining order against his son
17. A 20-year-old man comes to the health center because of ankle pain. Two days ago he sustained an inversion injury of his left ankle in a basketball game. He has been able to walk unassisted since the injury. Today he has pain and moderate swelling and discoloration over the lateral malleolus. Physical examination shows tenderness on palpation over the anterolateral corner of the ankle joint. He has had two similar injuries in the past. Which of the following is the most appropriate initial management?
A) An ankle-strengthening exercise program
B) Application of a long-leg cast for 3 weeks
C) Application of a short-leg cast for 3 weeks
D) Protected weight bearing
[E) Surgical repair of the ankle ligaments]
18. A 52-year-old woman comes to the office because of a 4-day history of increasing pain of the right hip and thigh. The pain is exacerbated by lying on her right side while sleeping. She says the pain often awakens her and is accompanied by a burning sensation along the right side of her posterior thigh that radiates to her knee. She usually has stiffness and pain in the hip during the following morning that gradually diminishes as she walks around her house and does house chores. She says the pain is also triggered by sitting with her right leg crossed over the left leg. The patient is otherwise healthy and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses tenderness on deep palpation of the right trochanter. Which of the following is the most likely diagnosis?
[A) Arthritis of the hip]
B) Aseptic necrosis of the femoral head
C) Bursitis
D) Gout
E) Osteosarcoma of the femoral head
19. An 18-year-old man comes to the health center because he has had pain in his right leg for the past 5 days. He says that he recently added jogging to his weight-lifting workouts, and he started running 5 miles per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and weighs 83 kg (185 lb). On physical examination he has moderate tenderness over the midtibia. X-ray of the leg will most likely show which of the following?
A) A bone cyst
B) Displaced fracture
C) Metastatic disease
D) Soft-tissue calcification
[E) Normal findings]
20. A 58-year-old woman comes to the office for follow-up of fibromyalgia. You had been treating her for the past several years for nonspecific muscular aches and pains. In the past you noted that occasionally the pain could be reproduced on physical examination by applying pressure to certain muscles; however, these trigger points seemed to change on each physical examination. Fibromyalgia was diagnosed 3 months ago and amitriptyline therapy was started at that time. At a follow-up visit 3 weeks ago she showed little response to the amitriptyline therapy, and naproxen was added to her regimen. Today she returns to the office complaining that "every time I get the least little bump on my hands the skin seems to tear." Her physical examination is unchanged except for the lesions shown. Which of the following is the most appropriate management?
A) Discontinue the amitriptyline
[B) Discontinue the naproxen]
C) Prescribe oral corticosteroids
D) Prescribe topical corticosteroids
E) Prescribe topical 5-fluorouracil
21. A 10-year-old Asian girl is brought to the office by her mother because of a painful swelling in the girl's neck. The child says that for the past 4 days the right side of her neck has been sore. Today she showed it to her mother, who noticed a red swelling. She does not have fever or chills. She has not missed any days of school. She lives with her parents and two siblings in a suburban community. Further discussion discloses that the family recently adopted an 8-week old kitten from the animal shelter. Vital signs now are: temperature 37.2°C (98.9°F), pulse 80/min, and respirations 24/min. On physical examination, the girl has a 2H4-cm, red, tender mass with overlying erythema and induration in the right submandibular area. There is a crusted papule on the right cheek. Which of the following is the most likely cause of this patient's condition?
[A) Bartonella henselae]
B) Branchial cleft cyst
C) Epstein-Barr virus
D) Trauma
E) Untreated impetigo
22. A 64-year-old retired teacher comes to the office with her husband. She has felt fatigued for several months and feels she is losing her memory. She says, "I feel slowed and can't remember what happened yesterday." Her husband reaffirms this history and notes that she recently got lost in a local mall and called him at home to come and get her. She was frightened by this episode and had insomnia that night, even though she otherwise has been sleeping longer than usual. She has a good appetite. There is a family history of senile dementia in her father and two uncles. Her only medication is daily conjugated estrogen. Her height is 163 cm (5 ft 4 in) and her weight is 64 kg (142 lb), which is an increase of 2.5 kg (6 lb) since you saw her 8 months ago. Pulse is 54/min and regular, and blood pressure is 140/86 mm Hg. On physical examination she appears pale. Deep tendon reflexes have a slow relaxation phase; the remainder of the examination is normal. A Mini-mental state test shows a delayed recall of one of three items and failure on serial 7s. She cannot recall any past presidents but she knows the current president. Based on these findings, which of the following is the most likely working diagnosis?
A) Early dementia, Alzheimer type
[B) Hypothyroidism]
C) Pernicious anemia
D) A transient ischemic attack
E) Vascular dementia
23. A 38-year-old obese woman with a 2-year history of type 2 diabetes mellitus has not lost weight despite persistent advice concerning diet and exercise. She has also been irregular in keeping appointments and has failed to take her medication on a regular basis. There is increasing concern that serious complications will occur unless she becomes more cooperative. You decide to terminate the physician-patient relationship, hoping that another physician can establish better rapport and help her with her problems. The most appropriate way to terminate the relationship is to do which of the following?
A) Give her a copy of her medical records at the next appointment and advise her to find another physician
B) Give her a list of three physicians and ask her to pick one, to whom you will send her medical records
C) Refuse further treatment unless she loses 2.7 kg (6 lb) before her next appointment in 1 month
D) Tell her 19-year-old daughter, who brings her to the office, to convince her mother to find another physician and tell her the reasons for this suggestion
[E) Tell her that the relationship will be terminated in 1 month, give her reasons for this decision, and offer her a list of three physicians' names]
24. A 56-year-old Native American man returns to the office to discuss results of studies obtained during a previous visit 8 weeks ago. The patient has a 19-year history of diabetes mellitus treated with sulfonylurea. He checks his serum glucose concentration approximately once daily. He does not smoke cigarettes and rarely drinks alcoholic beverages. He is 183 cm (6 ft) tall and weighs 76 kg (168 lb); BMI is 23 kg/m2. Vital signs during the previous visit were temperature 36.9°C (98.4°F), pulse 82/min, and blood pressure 130/85 mm Hg. Physical examination of the neck disclosed a right-sided carotid bruit. Examination of the extremities disclosed diminished pulses with associated hair loss over both legs. Hemoglobin A1c was 7.2%. Urine albumin-creatine ratio was 62 mg/g/24 h (N
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Ankle-brachial index (ABI) was 0.89 on the left and 0.98 on the right; duplex carotid ultrasonography showed nonulcerated plaque with 70% stenosis in the right internal carotid artery. The patient was referred to an ophthalmologist, who diagnosed him with nonproliferative background diabetic retinopathy. Which of the following findings in this patient is of most concern?
[A) 70% stenosis of the right carotid artery]
B) Hemoglobin A1c of 7.2%
C) Left ABI of 0.89
D) Nonproliferative diabetic retinopathy
E) Urine albumin-creatine ratio of 62 mg/g/24 h
25. A 25-year-old woman returns to the office because of intermenstrual spotting since beginning oral contraceptive therapy 6 months ago. This is her first attempt at oral contraceptive therapy; she and her partner primarily used condoms for contraception in the past. Before this current therapy her menstrual periods had always been regular. Which of the following is the most appropriate management?
A) Advise her to take two pills daily until the bleeding stops
B) Discontinue the oral contraceptive therapy and have her resume use of condoms for birth control
C) Reassure her that the bleeding problem will resolve in a few months
[D) Switch the current oral contraceptive pill to one containing a higher estrogen dose]
E) Switch to a progestin-only oral contraceptive pill
The following vignette applies to the next 2 items.
A 17-year-old girl is brought to the health center by her mother because the girl has had only two menstrual periods in the past 8 months. She had regular menstrual periods from menarche at age 14 years until 18 months ago. For the past 18 months she has been training as a long-distance runner.
Item 1 of 2
26. The underlying mechanism of her menstrual dysfunction is best defined by an abnormality in which of the following serum concentrations?
A) Androstenedione
B) Creatine kinase
[C) Luteinizing hormone]
D) Testosterone
E) Thyroid-stimulating hormone (TSH)
Item 2 of 2
27. Which of the following is the most likely cause of the menstrual irregularity?
A) High-carbohydrate diet
B) Increased basal body temperature
C) Increased muscle mass
[D) Loss of body fat]
E) Repeated volume depletion
28. A 23-year-old white nulligravid woman returns to the office for follow-up of a 2-year history of primary infertility. Menstrual periods occur at regular 28-day intervals. She has a history of chronic pelvic pain. Analysis of her husband's semen shows a sperm count of 40 million with 65% motility and normal morphology. Diagnostic laparoscopy with hydrotubation shows normal pelvic anatomy, with no evidence of endometriosis or pelvic adhesions. Both fallopian tubes spill methylene blue dye. The patient's basal body temperatures recorded during the past month are shown. Which of the following is the most likely cause of the patient's inability to conceive?
?A) Anovulation
B) Male factor infertility
C) Old pelvic inflammatory disease
D) Polycystic ovary syndrome
[E) No cause can be identified at this time]
29. In the course of routine prenatal care at the health center, a 30-year-old Hispanic woman is found to have gestational diabetes. This is her first pregnancy and she is at 20 weeks' gestation. She should be counseled that adequate prenatal care, including regular determination of blood glucose concentrations and adherence to a controlled dietary regimen, may reduce the possibility of which of the following?
[A) The fetus developing macrosomia]
B) Her developing essential hypertension
C) Her developing type 1 diabetes mellitus in the future
D) Intrauterine growth restriction
E) Premature delivery
30. A 20-year-old woman returns to the office for the results of her prenatal laboratory studies. By date of her last menstrual period she is 14 weeks pregnant with her second child. Her first pregnancy, which you followed, resulted in an uncomplicated vaginal delivery approximately 11 months ago. Her prenatal serology screening for syphilis is positive with a titer of 1:126, and a fluorescent treponemal antibody absorption (FTA-ABS) test is positive. The patient denies having lesions consistent with syphilis, and her current physical examination shows no lesions. Serology during her first pregnancy was negative. At this time, which of the following is the most appropriate management?
A) Do an amniocentesis to obtain fluid for darkfield evaluation
[B) Follow the treatment regimen recommended for primary or secondary syphilis]
C) Postpone treatment until the patient is at least 20 weeks pregnant
D) Schedule a lumbar puncture before instituting treatment
E) Withhold treatment until further studies rule out a biologic false-positive
31. A 34-year-old man comes to the office with his wife and daughter because he has had some dusky lesions on his shoulder for the past 2 months. He says that two have become larger during the past week. He and his wife have recently adopted an 18-month-old girl from the Ukraine who has a similar rash. He is an environmental scientist and his work requires him to travel overseas and work outdoors. He is concerned about the possibility of skin cancer. Vital signs are normal. Physical examination shows a cluster of six discrete papular lesions on his left shoulder that are slightly tender. These lesions have a central depression containing some pus-like material. There is no axillary or cervical adenopathy. His rash is shown. Which of the following is the most appropriate management for the patient?
?A) Acyclovir
B) Scabicidal cream
C) Topical corticosteroid cream
D) Topical fluconazole
[E) Topical liquid nitrogen]
32. A 25-year-old Latino man comes to the health center for a periodic health evaluation. He tells you that he has attended a day-treatment program for his schizophrenia, paranoid type, since his discharge from the hospital 1 year ago. The patient's most recent psychiatrist is moving away and he now wants you to refill his medications. He takes haloperidol, benztropine and valproic acid. He says, "The voices aren't telling me to harm myself anymore. And I know now that my food is not poisoned." The patient is 183 cm (6 ft) tall and weighs 86 kg (190 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 72/min, respirations 14/min and blood pressure 130/86 mm Hg. Physical examination is significant for darting and protruding movements of the tongue and some facial grimacing. Which of the following is the most appropriate change in pharmacotherapy?
A) Prescribe vitamin A
B) Increase the dose of benztropine
C) Increase the dose of haloperidol
[D) Replace haloperidol with risperidone]
E) Replace valproic acid with lithium
33. A third-year medical student returns to the student health service for the third time because he thinks he has ulcerative colitis. After a thorough history and physical examination, he is told that no organic disease is present. Despite that reassurance, the student continues to test his stool for blood and continues to believe that his physicians have missed the correct diagnosis. This behavior is most characteristic of which of the following?
A) Conversion disorder
B) Depersonalization
[C) Hypochondriasis]
D) Munchausen syndrome
E) Somatization disorder
34. A 10-year-old Asian-American boy is brought to the office for a sports physical examination. He has been healthy except for a few episodes of otitis media as an infant. He has had no shortness of breath, syncope or chest pain in the past. Growth has been normal. Vital signs are: temperature 36.6°C (97.8°F), pulse 80/min, respirations 16/min, and blood pressure 110/76 mm Hg. Cardiac examination discloses an early systolic click at the apex, a midsystolic ejection murmur at the right upper sternal border and a thrill in the suprasternal notch. The remainder of the physical examination is normal. The patient is referred to the cardiologist and the diagnosis of aortic stenosis is confirmed by echocardiogram. Close follow-up and graded exercise testing are recommended. The patient is at increased risk for which of the following?
A) Atrial arrhythmias
B) Complete heart block
C) Coronary artery disease
D) Pulmonary hypertension
[E) Sudden death]
35. A 12-year-old Haitian boy is brought to the health center for the first time by his mother and maternal grandmother. The mother states, "There was a voodoo curse placed on my family and now my son is having problems because of that." She reports that for the past 6 months he has been talking back to his teachers, has been suspended from school for skipping class, and has been defiant with all adults. He is failing two subjects in school and will need to attend summer classes. His medical history is significant for an allergy to sulfa drugs, a positive PPD skin test for which he was treated prophylactically at age 10 years, and encopresis that resolved. He currently takes no medications. The patient is 163 cm (5 ft 4 in) tall and weighs 49 kg (108 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 80/min, respirations 18/min and blood pressure 90/50 mm Hg. Which of the following is the most appropriate opening statement to the mother?
A) "Do you think your son may be taking drugs?"
B) "I suggest you consult a voodoo priest for help with this problem."
[C) "Tell me more about the voodoo and its effect on your son's behavior."]
D) "There is no such thing as voodoo."
E) "Voodoo does not cause children to have bad behavior."
36. You are invited to a council meeting of Native-Americans to discuss a heptavalent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar7) for use in the community's children, many of whom are younger than age 12 months. All of the infants and children in the community are up-to-date on standard recommended vaccinations. The council spokesperson says, "We are skeptical about the safety of giving our sons and daughters yet another vaccine." Which of the following is the most compelling reason to recommend vaccination of all infants younger than 12 months of age?
A) Administration of the vaccine will decrease the incidence of invasive pneumococcal disease among the children in the community
B) Administration of the vaccine will decrease the likelihood of secondary pneumonia during respiratory syncytial virus (RSV) season
[C) Administration of the vaccine will significantly decrease the severity of acute otitis media and prevent hearing loss]
D) Native-American children make ineffective antibodies when the 23-valent pneumococcal vaccine alone is administered to them
E) The peak incidence of pneumococcal disease occurs in children younger than 12 months of age
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Block 2
1. A 76-year-old woman is admitted to the hospital after a fall at her home earlier in the day. She has been followed in your practice for several years and is in generally good health. She drinks socially, does not smoke and has been active in senior citizen groups. She takes ibuprofen occasionally for pain, but no other medications. On admission she is alert and oriented, and complains only of pain in her left leg. Her temperature is 36.1°C (97.0°F), pulse is 72/min and regular, and blood pressure is 140/85 mm Hg. X-ray films taken upon arrival show a fracture of the left femoral shaft. Surgical repair of the fracture is done the next morning. The patient receives 2 U of packed erythrocytes during the procedure. Postoperative medications include morphine, prophylactic cephalothin and low-dose warfarin. On the evening of the operation, the patient becomes combative, begins to hallucinate and has a brief, generalized seizure. A fine petechial rash is noted on her chest. Which of the following is the most likely cause of her seizure?
A) Antibiotic allergy
B) Blood transfusion reaction
[C) Fat emboli]
D) Hemorrhagic stroke
E) Unrecognized cerebral concussion
2. A 72-year-old woman with metastatic rectal cancer is admitted to the hospital because of weakness and altered mental status. She has bilateral ureteral stents due to prior obstruction from the cancer. She has been using a fentanyl patch for several weeks. Physical examination on admission is notable for lethargy and 3-mm reactive pupils but no focal neurologic signs. She is afebrile and has a blood pressure of 120/82 mm Hg. Laboratory studies show serum urea nitrogen (BUN) concentration of 60 mg/dL and a serum creatinine concentration of 6.2 mg/dL. Serum bilirubin concentration is normal. One week ago serum BUN concentration was 30 mg/dL and serum creatinine concentration was 3.0 mg/dL. Which of the following is the most likely explanation for her altered mental status?
A) Fentanyl intoxication
B) Hepatic encephalopathy
C) Hypercalcemia
[D) Uremia]
E) Urosepsis
3. A 54-year-old African American woman has been in the intensive care unit (ICU) for the past 10 hours because she has failed to regain consciousness after passing out at a restaurant 11 hours ago. Upon initial arrival at the emergency department the patient's friend stated that the patient had remarked about the sudden onset of a terrible headache and neck stiffness while they were having lunch. A few minutes after the onset of the headache, she became confused, vomited, and lost consciousness. She regained consciousness briefly en route to the hospital, but she has been unconscious since admission. On arrival she was intubated and mechanically ventilated and transferred to the ICU, where intravenous fluids were started. Vital signs are: pulse 110/min and blood pressure 174/96 mm Hg. She exhibits no spontaneous movement and is unresponsive to verbal or painful stimuli. Lung fields are clear to auscultation. CT angiogram confirms subarachnoid hemorrhage from a ruptured cerebral aneurysm and impaired intracranial circulation. The family should be counseled regarding which of the following?
A) The futility of continued life support
B) The need for screening of first-degree relatives for aneurysms
C) The need for them to sustain hope
[D) The need to have a guardian ad litem appointed to make informed decisions about the patient's care]
E) The probability that the patient will not regain consciousness
4. A previously healthy 3-year-old boy is admitted to the hospital through the emergency department because he has been having generalized seizures. He had a fever this morning and had one seizure at home and another on the way to the emergency department. While in the emergency department he had several additional seizures that were controlled with intravenous lorazepam. Vital signs on arrival at the emergency department were temperature 39.6°C (103.3°F), pulse 110/min, respirations 24/min, and blood pressure 85/60 mm Hg. Physical examination showed no abnormalities except for left otitis media and lethargy. Intravenous phenytoin was administered. Spinal fluid examination, serum electrolyte concentrations and complete blood count were normal. Now in the hospital, the patient has another seizure. The patient is managed appropriately and the seizure stops. When discussing this child's management and prognosis with the parents, it is most appropriate to counsel them about which of the following?
A) Their child has an increased risk for attention-deficit/hyperactivity disorder
B) Their child has an increased risk for developing a brain tumor
C) Their child is likely to be developmentally delayed
D) Their child will have a seizure every time he has a fever
[E) Their child will probably become seizure-free as he becomes older]
5. A 21-year-old Asian-American man who sustained a closed head injury in a motorcycle accident is admitted to the hospital. He is intubated and is receiving mechanical ventilation in the intensive care unit. On repeat physical examinations during the next 2 days, he shows no clinical signs of cerebral activity and has no spontaneous respiration. His pupils are fixed in mid-position and he has no vestibulo-ocular reflexes. Electroencephalograms obtained 24 hours apart have nearly flat tracings. His driver's license indicates his desire to be an organ donor. When you inform his parents that he is brain dead, you remind them of his donor statement and request permission to harvest usable organs. The parents are shocked; they say they are unaware of his desire to be an organ donor and refuse to grant permission. Because the patient meets the clinical criteria for brain death, which of the following is most appropriate?
[A) Explain how their son's death can contribute to another person's life]
B) Have a potential organ recipient talk with the family
C) Obtain a court order authorizing removal of usable organs
D) Order cerebral angiography to convince the parents that their son is brain dead
?E) Proceed with organ removal because the patient is an adult
6. A 52-year-old woman is admitted to the hospital for diagnostic evaluation of a slight aphasia and change in her personality, as noted by her husband. CT scan of the head discloses a 3-cm mass in the left temporal lobe and a 5-cm mass in the right frontal lobe. Because she is a chronic cigarette smoker, you have been obtaining annual chest x-ray films, which have been reported as normal. Her chest x-ray film on admission today is reported as showing a "2-cm spiculated mass in the left subapical region." No reference is made to comparing this film with the prior films. The radiologist then calls you and admits to you that the lesion was present on her prior films but it was overlooked. Which of the following is the most appropriate next step?
A) Agree with the radiologist that informing the patient and her family will do more harm than good
B) Ask the radiologist to inform the patient and her family of the problem
C) Compliment the radiologist for finding what will probably be the primary lesion accounting for the two CNS lesions
D) Consult with your attorney regarding avoidance of litigation for yourself
[E) Inform the radiologist of your responsibility to inform the patient and her family of the problem]
The following vignette applies to the next 2 items.
While making rounds in a rehabilitation facility, you see a 76-year-old white woman who has been your patient for 25 years. One month ago she was diagnosed with metastatic non-small cell carcinoma of the lung with metastases to the other lung, liver and brain. She now has moderate left hemiparesis that limits walking. She also has multiple, asymptomatic, deep venous thrombi of both legs that are being treated with a vena caval filter. Despite discussion with the patient and her family about her illness, her son tells you that she is apparently unaware that her condition is terminal.
Item 1 of 2
7. Which of the following is the most appropriate next step?
A) Arranging transfer to the in-patient psychiatric ward
B) Beginning anxiolytic therapy
[C) Discussing the prognosis again with the patient]
D) Encouraging the family to discuss the patient's prognosis with her
E) Explaining to the son that it is inappropriate for you to speak about his mother's illness
Item 2 of 2
8. The patient is not in severe pain and she currently has no respiratory distress. She has chosen not to have further intervention and she probably has about 3 months to live. Her husband is an active 75-year-old man with recently diagnosed type 2 diabetes mellitus. Two of their three sons live 1 hour away. The patient has many concerned neighbors and friends. The patient's family asks for your advice regarding appropriate care for her for the remainder of her illness.
Which of the following is the most appropriate recommendation?
A) Continued care in the rehabilitation center until she is able to ambulate on her own
B) Home health care for as long as she qualifies for skilled nursing services
[C) Home hospice care with physical therapy]
D) Placement under intermediate (nonskilled) care in a local nursing home
E) Placement under skilled care in a local nursing home
9. An 18-year-old woman gave birth to a healthy neonate 72 hours ago. The woman now has the acute onset of tachypnea. Vital signs are normal. Diffuse wheezing is noted on auscultation of the chest. Chest x-ray film is normal. Electrocardiogram shows evidence of right heart strain. Which of the following is the most likely diagnosis?
A) Adult respiratory distress syndrome
B) Aspiration pneumonia
C) Bronchopneumonia
D) Congestive heart failure
[E) Pulmonary embolism]
10. A 34-year-old woman undergoes a middle ear operation with oral intubation and general anesthesia. During the 4-hour procedure she was in a semi-lateral position with her head maximally turned to the right and her chin tucked on her chest. She awakens normally at the end of the procedure and is extubated without difficulty. Approximately 30 minutes later she appears anxious and is sitting upright. She leans forward and says, "I'm not getting enough air." Her voice is barely audible and very hoarse and she appears to be struggling to take a deep breath. Vital signs are: pulse 94/min, respirations 28/min and blood pressure 128/72 mm Hg. Oxygen saturation is 92% with an FIO2 of 0.4. Oxygen flow is maximally increased and O2 saturation is 93%. Auscultation of the chest discloses bilateral breath sounds with crowing sounds on inspiration and expiration. Which of the following is the most appropriate pharmacotherapy?
A) Midazolam
B) Naloxone
[C) Nebulized racemic epinephrine]
D) Neostigmine
E) Succinylcholine
11. A 67-year-old man with a history of poorly controlled hypertension is admitted to the hospital because of increasing fatigue, weight loss and dyspnea on exertion for the past 6 weeks. Medical history includes tonsillectomy, adenoidectomy, mitral valve commissurotomy and a sigmoid colon resection for diverticulitis. Vital signs are: pulse 90/min, respirations 14/min and blood pressure 190/100 mm Hg. The patient appears chronically ill but is in no acute distress. Laboratory studies show:
Serum
Urine
Na+
140 mEq/L
WBC
0/hpf
K+
4.5 mEq/L
RBC
4/hpf
Cl-
100 mEq/L
HCO3-
25 mEq/L
Which of the following is the most likely finding on echocardiography?
A) Ejection fraction of 60%
[B) Left ventricular wall thickening]
C) Pericardial fluid
D) Septal dyskinesia
E) Thoracic aortic aneurysm
the following vignette applies to the next 2 items.
You have been treating a 5-month-old child in the neonatal intensive care unit (NICU). He was delivered at 26 weeks' gestation by cesarean delivery because of premature rupture of membranes. The mother is 18 years old and is unemployed. There are two other children in the home. The father is not living with them, and he has not been in contact with the mother. The mother rarely visits the NICU. The infant had severe respiratory distress syndrome at birth and required dopamine for blood pressure support. His condition progressed to pulmonary interstitial emphysema and bronchopulmonary dysplasia by 4 weeks of age. At 4 months of age he required a tracheostomy and medication for control of his blood pressure. Now, at 5 months of age, the boy has a cardiac arrest requiring resuscitation and placement of chest tubes. He then develops seizures that are eventually controlled with medication. The neonatologist feels that the child will always require life support. The mother refuses to discuss the possibility of withdrawing life support. Her insurance is Medicaid. The hospital bill for this child is now $350,000.
Item 1 of 2
12. To guide further treatment at this time, it is most important to assess which of the following?
[A) The extent of neurologic injury]
B) The financial impact on the family
C) The mother's level of understanding of the child's prognosis
D) Whether another family member is better suited to make decisions about the patient's care
E) Your state's law regarding futile care
Item 2 of 2
13. One week later the mother and the attending physician are unable to reach an agreement on the management plan. Which of the following is the most appropriate next step?
A) Ask the court to appoint a guardian
B) Defer major decisions until the father can be located
[C) Have the social worker contact Medicaid regarding further coverage]
D) Involve the hospital bioethics committee
E) Maintain the patient on a respirator but transfer him out of the NICU
14. A 42-year-old African-American man with hepatitis C is admitted to the hospital for evaluation of a 3-day history of fever and right upper quadrant abdominal pain. The pain is steady and does not change with position. He has had associated nausea but has not vomited. He has a history of alcohol dependence but has not had an alcoholic beverage since being diagnosed with hepatitis C 4 years ago. He does not take any medications. On admission, vital signs are: temperature 38.5°C (101.3°F), pulse 115/min, respirations 24/min and blood pressure 100/60 mm Hg. Physical examination shows scleral icterus. Abdominal examination discloses mild distention and right upper quadrant tenderness to palpation; the liver spans 25 cm. There is no rebound tenderness and bowel sounds are normal. Ultrasonography of the right upper quadrant shows three small gallstones, dilated right and left intrahepatic ducts and normal common bile duct. Laboratory studies show:
Serum
Blood
ALT
650 U/L
Hematocrit
35%
AST
442 U/L
WBC
22,000/mm3
Alkaline phosphatase
342 U/L
PT
14 sec
Bilirubin
7.0 mg/dL
PTT
28 sec
Na+
140 mEq/L
INR
1.2
K+
4.2 mEq/L
Cl-
104 mEq/L
HCO3-
23 mEq/L
Fluid resuscitation is begun. Which of the following is the most appropriate next step?
A) Biopsy of the liver
?B) Cholecystectomy
C) CT scan of the abdomen
[D) Endoscopic retrograde cholangiopancreatography with st]
15. A 16-year-old Mexican American girl who is 28 weeks pregnant comes to the health center with her boyfriend because of epigastric pain radiating to her back. She says, "I have had pain for many days, especially after eating." She has been taking acetaminophen for the pain several times a day for the past week. She admits to drinking an occasional bottle of light beer. She has been receiving prenatal care at the health center. Vital signs today are temperature 37.5°C (99.5°F), pulse 110/min, respirations 15/min, and blood pressure 110/70 mm Hg. Height is 157 cm (5 ft 2 in) and weight is 90 kg (200 lb). Physical examination shows scleral icterus and epigastric and right upper quadrant tenderness. Uterus is appropriately enlarged for her gestational stage. The patient is admitted to the hospital for observation. Results of laboratory studies are shown:
Serum
ALT
55 U/L
AST
58 U/L
Alkaline phosphatase
350 U/L
Amylase
3000 U/L
Bilirubin
Total
7.3 mg/dL
Direct
5.9 mg/dL
Lipase
475 U/L (N=10140)
These laboratory results are most indicative of which of the following?
A) Acetaminophen-induced hepatic necrosis
B) Alcoholic pancreatitis
[C) Biliary pancreatitis]
D) Hepatitis C infection
E) Mononucleosis
16. A 22-year-old woman is in her 5th hospital day following admission for evaluation of severe right lower quadrant abdominal pain. During the previous 8 months, she has had episodes of abdominal pain with associated recurrent diarrhea, which sometimes contained blood. The pain and diarrhea became increasingly severe during the 5 days prior to admission. During that time, she lost 2 kg (5 lb) and had a temperature to 39.0°C (102.0°F). Abdominal examination on admission disclosed a right lower quadrant mass. Blood hemoglobin concentration was 15.5 g/dL and leukocyte count was 24,000/mm3. Colonoscopy showed linear ulcerations with discontinuous areas of inflammation. Biopsy of the lower intestine disclosed noncaseating granulomas. Serum antibody test to Saccharomyces cerevisiae was positive. Treatment with intravenous hydrocortisone therapy was begun. Today, the patient's abdominal pain and diarrhea are resolved. Vital signs are temperature 37.0°C (98.6°F), pulse 76/min, respirations 12/min, and blood pressure 122/74 mm Hg. The abdomen is soft and nontender to palpation; bowel sounds are normal. Which of the following is the most appropriate pharmacotherapy for this patient?
A) Azathioprine
[B) Mesalamine]
C) Metronidazole
D) Prednisone
E) Ranitidine
The following vignette applies to the next 2 items.
A 28-year-old man who lives in a small rural township is admitted to the hospital because of gastrointestinal bleeding. On admission the patient is pale and has orthostatic hypotension. Hemoglobin concentration is 8 g/dL. His condition is stabilized. Emergent upper endoscopy shows a visible gastric vessel, which is treated appropriately.
Item 1 of 2
17. Specific additional history should be obtained regarding which of the following?
?A) Consumption of alcoholic beverages
B) Family history of cancer
C) Source of drinking water
D) Travel history
[E) Use of tobacco products]
Item 2 of 2
18. Which of the following is the most appropriate laboratory study?
[A) Antibodies for Helicobacter pylori]
B) Vitamin B12 (cyanocobalamin) concentration
?C) Ferritin concentration
D) Gastrin concentration
E) Iron concentration
19. A 74-year-old woman is admitted to the hospital for treatment of a hip fracture. Her only medical problem is chronic insomnia; she told the nurse, "I have taken sleeping pills for years." Two days after the operation she has a tonic clonic seizure. Vital signs now are: temperature 38.0°C (100.4°F), pulse 110/min and blood pressure 180/100 mm Hg. She is confused, has diaphoresis and is trembling. Which of the following is the most likely diagnosis?
[A) Barbiturate withdrawal]
B) Diphenhydramine withdrawal
C) Propoxyphene withdrawal
D) Pulmonary embolus
E) Stroke
20. You have just returned from a trip out of town and learn that your long-time patient with end-stage chronic obstructive pulmonary disease has been hospitalized and is on a ventilator. On the way to the intensive care unit to visit him, you are informed that the patient has just died. On your way into the patient's room you meet the patient's 68-year-old wife. Which of the following is most appropriate to say to her?
A) "How do you feel?"
[B) "I am sorry for your loss."]
C) "I know you are upset."
D) "What happened while I was gone?"
E) "Your husband didn't suffer."
21. A 3-day-old Latina infant is in the hospital awaiting routine physical examination. She was born to a 28-year-old woman by cesarean delivery at term because of breech presentation. She is the woman's first child and the pregnancy was uncomplicated. The infant weighed 3686 g (8 lb 2 oz) at birth. Physical examination discloses asymmetry in the number of thigh skin folds and uneven knee levels when the hips and knees are flexed. Barlow test is done and a palpable "click" is felt in the left hip. Without prompt treatment, this child is at increased risk for which of the following?
[A) Dysplasia of the hip]
B) Femoral head anteversion
C) Legg-Calve-Perthe disease
D) Metatarsus adductus
E) Slipped capital femoral epiphysis
The following vignette applies to the next 2 items.
An 83-year-old woman is admitted to a nursing home for ongoing management of Parkinson disease. Her husband can no longer care for her at home because she is moderately demented, has difficulty walking, has fallen several times and has urinary incontinence. She has difficulty swallowing her pills, and she needs assistance with feeding. Despite her husband's attentive care, she has lost 9 kg (20 lb), going from 47.1 kg (104 lb) to 38 kg (84 lb) during the past 9 months. After 2 weeks in the nursing home, the nursing staff notes that the patient frequently eats and drinks very little and often coughs after she swallows. Her current medications include fluoxetine, selegiline, carbidopa-levodopa, trazodone, estrogen and sorbitol. Vital signs now are: temperature 36.4°C (97.6°F), axillary; pulse 88/min; respirations 18/min and blood pressure 102/84 mm Hg, supine. Physical examination shows a frail and thin woman. Voice is soft and low. Chest is clear to auscultation. Heart rate is regular without murmurs or gallops. Abdomen is soft and nontender with decreased bowel sounds. Rectal examination is normal. She is generally stiff with low amplitude tremors at rest. Laboratory results show:
Serum
BUN
47 mg/dL
Creatinine
1.9 mg/dL
Na+
161 mEq/L
K+
3.9 mEq/L
Cl-
120 mEq/L
HCO3-
24 mEq/L
When the nursing home calls you with the laboratory results, the office staff informs you that the patient's husband telephoned earlier that afternoon and "fired" you from the case. There are no written notes from the staff and you have not spoken to the husband yourself.
Item 1 of 2
22. The most appropriate next step is to contact which of the following?
A) Husband and give him the names of other physicians who attend patients in the nursing home
[B) Husband and inform him of the laboratory results, their implications and management options]
C) Nursing home and inform them that you are no longer the patient's physician
D) Nursing home and initiate nasogastric rehydration in the facility
E) Nursing home and order the immediate transfer of the patient to the hospital
Item 2 of 2
23. Which of the following complications is most likely to develop if her hypernatremia is corrected too quickly?
A) Disseminated intravascular coagulation
B) Intravascular hemolysis
[C) Pontine myelinolysis]
D) Pulmonary edema
E) Seizures
24. A 68-year-old woman with stage IV ovarian cancer is in the hospital following initial staging and a debulking operation. She refuses chemotherapy and the physician agrees to follow her wishes. This is an example of which ethical principle?
A) Authority
[B) Autonomy]
C) Beneficence
D) Justice
E) Nonmaleficence
25. You assist in the delivery of a neonate born to a couple who have been your patients for the past 7 years. The husband is 50 years old and the wife is 45 years old. The wife had been offered maternal serum triple-marker screening and amniocentesis during the pregnancy because of her advanced age, and she had declined the testing. At the delivery, the neonate has features suggestive of Down syndrome. Apgar score is 9 at 1 minute and 9 at 5 minutes. Initial physical examination demonstrates no cyanosis and no heart murmur. In the delivery room, which of the following is the best initial statement to make to the parents?
A) "Do you remember the tests we discussed early in your pregnancy?"
B) "I am concerned about your infant because she may have Down syndrome."
C) "I am sorry to have to tell you this, but I suspect your baby has Down syndrome."
D) "We are going to have to take the baby to the nursery for some tests."
[E) "Your daughter is doing well, but I am concerned about some of her physical features."]
26. A 26-year-old primigravid woman at 38 weeks' gestation is admitted to the hospital because she is in labor; contractions occur every 3 minutes and last 60 seconds. The patient's prenatal course has been uncomplicated. Labor curve is now normal and fetal heart rate tracing shows good variability with an occasional mild deceleration. Her patient chart indicates that a previous physician thought she might have a platypellic pelvis. She is now 10-cm dilated. The fetus is at +1 station with a mentum-anterior face presentation. Which of the following is the most appropriate management at this time?
A) Deliver the child vaginally after manually rotating the fetus to a mentum-posterior presentation
B) Deliver the child vaginally with the aid of forceps
C) Deliver the child vaginally with the aid of vacuum extraction
[D) Deliver the child vaginally without intervention]
E) Deliver the child via emergency cesarean delivery
27. A full-term, 3402-g (7-lb 8-oz) neonate aspirated meconium at delivery. Apgar score is 3 at 1 minute and 3 at 5 minutes. He is intubated and assisted ventilation is established using a respirator. His condition stabilizes for 30 minutes but the arterial blood gas values suddenly deteriorate. Which of the following is the most appropriate first step?
[A) Auscultate the chest]
B) Check the respirator settings
C) Increase the oxygen flow
D) Recheck the arterial blood gas values
E) Reposition the endotracheal tube
28. A 56-year-old man who is alcohol-dependent is admitted to the hospital because of fever, encephalopathy and increasing abdominal girth. The patient has no family and has been living on the street. An abdominal paracentesis is consistent with spontaneous bacterial peritonitis, which is treated with antibiotic therapy. During the next 10 days, the patient's renal function deteriorates and his serum creatinine concentration increases to 11.3 mg/dL, with a serum urea nitrogen (BUN) concentration of 144 mg/dL. He becomes progressively more obtunded, develops respiratory failure and is intubated. He requires vasopressors to maintain his blood pressure. There is general agreement from the gastrointestinal and renal services that he will not recover and that further treatment, including dialysis, is futile. The patient is thrashing about in bed, moaning and grimacing periodically. Which of the following is the most appropriate next step in management?
A) Do a liver biopsy to identify the cause of the patient's liver failure
[B) Initiate lactulose treatment to reduce his encephalopathy]
C) Initiate analgesic therapy to palliate the patient's apparent discomfort
D) Stop all antibiotic therapy to reduce the chance of further renal toxicity
E) Stop all medical treatment
The following vignette applies to the next 2 items.
A 38-year-old woman is admitted to the hospital for an elective breast-reduction operation. She is in good health and has never been admitted to the hospital or had previous operations. Her only medication is an oral contraceptive pill. Shortly after the administration of general anesthesia she develops muscular rigidity, temperature increases to 40.6°C (105.0°F), pulse increases to 130/min and blood pressure decreases from 110/70 mm Hg to 80/40 mm Hg. Arterial blood gas values show:
PO2
60 mm Hg
PCO2
40 mm Hg
pH
7.12
Total CO2
18 mm Hg
O2 saturation
88%
Item 1 of 2
29. Which of the following is the most appropriate intravenous pharmacotherapy to administer at this time?
[A) Dantrolene]
B) Diazepam
C) Epinephrine
D) Magnesium sulfate
E) Succinylcholine
Item 2 of 2
30. Which of the following is the most likely cause of this reaction?
[A) Abnormal increase in intracellular calcium]
B) Hypothalamic dysfunction
C) Hypovolemia
D) Inability to sweat
E) Inhibition of protein synthesis
The following vignette applies to the next 2 items.
You are asked to see a 63-year-old woman who is in the hospital after undergoing an operation 4 days ago for a displaced tibia-fibula fracture. The operation was uncomplicated. Preoperative chest x-ray film was normal. She has a transurethral urinary catheter, which was placed during the operation 4 days ago. Today she has a temperature of 37.9°C (100.2°F). Laboratory studies disclose mild leukocytosis. Urinalysis shows greater than 100 WBC/hpf and many bacteria. You suspect that she has a urinary tract infection.
Item 1 of 2
31. Which of the following would have been the most appropriate method of preventing a urinary tract infection in this patient?
A) Cleaning the perineum twice daily with povidone-iodine
B) Irrigating the bladder every 8 hours
[C) Removing the catheter immediately post-operation]
D) Treating the patient with prophylactic antibiotics
E) Using only silver-coated urinary catheters
Item 2 of 2
32.Incidence of Bacteruria Related to Catheter Use
Study Randomized Suprapubic Catheter Transurethral Catheter Odds Ratio +95% CI
A No 2/25 21/31 0.04(0.01-0.24)
B Yes 10/48 20/44 0.32(0.11-0.86)
C Yes 2/32 16/34 0.08(0.01-0.41)
D Yes 8/32 5/40 1.87(0.48-8.01)
*CI=confidence interval
A Colleague suggests to you that suprapubic catheters can decrease a patient's risk for bacterial colonization. You identify four studies in the medical literature that compare the incidence of bacteruria in patients with a transurethral catheter versus patients with a suprapubic catheter. The study results are shown. Which of the following is the most important criterion related to the validity of these data?
A) Confidence interval
B) The number of patients with bacteriuria
C) Odds ratio
[D) Sample size]
E) Study design
The following vignette applies to the next 2 items.
A 67-year-old woman with a 2-month history of cough was admitted to the hospital after chest x-ray film and CT scan showed a lung mass with suspected mediastinal extension. Biopsies obtained during bronchoscopy and mediastinoscopy showed poorly differentiated squamous cell carcinoma in the peritracheal lymph nodes. A pulmonary consultant has determined that the tumor is