MCQ Medicine 4
"A 58-year-old chronic alcoholic and heavy smoker presents with a 3-cm, firm, right midcervical neck mass. An excisional biopsy reveals squamous cell carcinoma. Which of the following is the most appropriate approach at this time? A. Bronchoscopy, esophagoscopy, and laryngoscopy B. CT of the neck C. CT of the brain D. neck dissection E. Radiation therapy"
A
"A 43-year-old man presents with severe mid-thoracic back pain. His past medical history is remarkable for the removal of a malignant melanomadepth 1.5 mm approximately 3 years ago. The patient's back pain is severe and has been waking him up at night over the past week. Physical examination is unremarkable. Plain films of the spine reveal loss of the left pedicle in the fifth thoracic vertebrA. Magnetic resonance images are obtained, and the patient is begun on steroids. Which of the following treatment modalities is most appropriate in this situation? A. Surgery B. Radiation therapy C. Chemotherapy D. Hormonal therapy E. Immunotherapy"
A
"A 15-year-old boy is concerned about his lack of pubic hair, deep voice, and muscle growth. On physical examination you confirm that his testicles have not enlarged and he lacks pubic hair. Which of the following statements about this situation is correct? A. The patient will most likely progress through puberty without intervention B. testosterone should be administered C. Growth hormone should be given D. A hormonally active adrenal tumor is likely E. Prednisone will result in an amelioration of the symptoms"
A
"A 21-year-old woman with relapsed acute lymphoblastic leukemia is treated with a five-drug induction regimencyclophosphamide, daunorubicin, vincristine, prednisone, and L-asparaginase. On the sixth day after the initiation of this therapy the patient develops a fever and is started on intravenous ceftazidime. The patient defervesces but develops another fever 5 days later and is started on amphotericin B. ten days later the patient, still on oral steroids, remains febrile, neutropenic, and thrombocytopenic and is noted to have shortness of breath. Chest x-rays show a densely consolidated pulmonary infiltrate in the left lung zone. A sputum culture demonstrates normal oral flora and several colonies of Aspergillus. The most appropriate conclusion to draw is that A. the patient most likely has invasive pulmonary aspergilliosis B. the Aspergillus is a contaminant; the patient most likely has bacterial pneumonia C. biopsy is not required for a definitive diagnosis D. the patient most likely has viral pneumonitis E. the patient is colonized with Aspergillus, but the most likely etiology of the infiltrate is drug toxicity"
A
"A 23-year-old individual who believes in megavitamin therapy develops severe headaches. Ophthalmologic examination discloses papilledema. The cause for this problem is A. vitamin A intoxication B. vitamin B intoxication 6 C. vitamin D intoxication D. vitamin E intoxication E. not likely related to vitamin excess"
A
"A 25-year-old man who was recently admitted to a psychiatric hospital with the diagnosis of severe depression complicated by psychosis is brought to the emergency room because of worsening mental status and fever. The patient is unable to give a history because he is profoundly confused and claims to be on Mars. The psychiatrist informs you that the patient has been started recently on haloperidol and amitriptyline. Physical findings include a rectal temperature of 40. 6 C105 F. , muscle rigidity, and dry skin. A cooling blanket is ordered, and you administer acetaminophen. Which of the following agents would be most appropriately ordered at this time? A. Bromocriptine B. Atropine C. levarterenol D. Chlorpheniramine E. methylprednisolone"
A
"A 25-year-old, previously healthy woman presents with jaundice, confusion, and fever. Initial physical examination is unremarkable except for scattered petechiae on the lower extremities, scleral icterus, and disorientation on mental status examination. Laboratory examination discloses the following: hematocrit, 27%; white cell count, 12,000/ L; platelet count, 10,000/ L; bilirubin, 85 mol/ L5 mg/dL. ; direct bilirubin, 10mol/L0.6 mg/dL. ; urea nitrogen, 21 mmol/L60 mg/dL; creatinine,400mol/L 4.5 mg/dL red blood cell smear discloses fragmented red blood cells and nucleated red blood cells. Prothrombin, thrombin, and partial thromboplastin times are all normal. The most effective and appropriate therapeutic maneuver is likely to be A. plasmapheresis B. administration of aspirin C. administration of high-dose glucocorticoids D. administration of high-dose glucocorticoids plus cyclophosphamide E. splenectomy"
A
"A 26-year-old woman has painful mouth ulcers. Six weeks ago, she was started on propylthiouracil for hyperthyroidism. She is afebrile, and physical examination is unremarkable except for several small oral aphthous ulcers. White blood cell count is 200/ L15% neutrophils, 80% lymphocytes, 5% monocytes. ; hemoglobin concentration, hematocrit, and platelet count are normal. The woman's physician should stop the prophylthiouracil and A. schedule a follow-up outpatient appointment B. arrange for HLA typing of her siblings in preparation for bone marrow transplantation C. prescribe oral prednisone, 1 mg/kg D. hospitalize her for broad-spectrum antibiotic therapy E. hospitalize her for white blood cell transfusion"
A
"A 30-year-old Hispanic woman in the second trimester of pregnancy receives a 100-g oral glucose challengE. She has elevated values of serum glucose at each of the 1-,2-, and 3-h time points. Which of the following statements concerning this clinical situation is correct? A. A trial of caloric restriction and minimal intake of concentrated sweets should be undertaken B. The patient should be given subcutaneous insulin therapy C. The patient should be treated with oral hypoglycemic agents D. The patient should be treated with magnesium sulfate E. The patient should receive insulin by continuous intravenous infusion"
A
"A 30-year-old presents to her GP with reduced vision in her left eye. She has previously presented with abnormal sensory changes in her leg which have now resolved. On examination her visual acuity is greatly reduced and there is evdence of a relevant afferent pupil defect. All movements of the eye are very painful. On fundoscopy and neurological examination there is nil of note. What is the most likely diagnosis? A. Optic neuritis B. Age related macular degeneration C. Orbital tumour D. retinal vein occlusion E. Thyrotoxicosis"
A
"A 32-year-old obese woman presents to you for advice regarding weight loss. She has no significant medical problems at this time. She requests a pill to help her lose weight. You should A. tell her that a low-calorie diet and exercise are the best ways to lose weight B. prescribe phentermine C. prescribe fenfluramine D. prescribe a combination of phenylpropanolamine plus fenfluramine E. prescribe L-thyroxine"
A
"A 35-year-old woman with a severe anxiety neurosis develops acute appendicitis. The primary care physician, the surgical consultant, and the infectious disease consultant all recommend urgent appendectomy. The patient wants to be treated only with antibiotics because she is concerned about the risks of anesthesia. The patients states she understands the reasons for the physician's recommendations and that she might die if she does not have this operation, yet she feels strongly that this is what is best for her. At this point the most appropriate course of action would be to A. call a psychiatrist B. tell the patient that you cannot treat her and refer her to another hospital C. declare the patient legally incompetent, restrain her, and perform surgery since it will be life saving D. treat the patient with antibiotics E. call a lawye"
A
"A 38-year-old man of Chinese descent who smokes 60 cigarettes per day presents to his GP. He is developing pain at rest in his legs, and is unable to walk more than a few yards due to ischaemic pain. On examination there is prolonged capillary refill and necrotic ulcers at the tips of his toes. There is also evidence of thrombophlebitis. What diagnosis fits best with this clinical picture? A. Buerger's disease B. Simple peripheral vascular disease C. Polyarteritis nodosa D. Familial hypercholesterolaemia E. temporal arteritis"
A
"A 52-year-old man noted a pigmented lesion in the area of his left flank. Excisional biopsy revealed a malignant melanoma 2.5 mm in thickness. The patient then underwent a definitive resection of the tumor with 2-cm margins that were not involved. Chest x-ray and liver function tests are normal. The patient should receive A. interferon B. interleukin-2 C. dacarbazine D. dacarbazine plus carmustine E. observation"
A
"A 65-year-old male patient with stable angina complains of shortness of breath after walking two flights of stairs. He has normal left ventricular function on the echocardiogram and a positive exercise tolerance test (3 mm ST depression at stage III). What is the most appropriate therapy? A. Atenolol B. Simvastatin C. Isosorbide mononitrate D. Angiotensin-converting enzyme (ACE) inhibitor E. Nicardipine"
A
"A 65-year-old woman complains of a 20-lb weight loss over the past 6 months. She is of average build and has not been on a diet. She states that she has just not been very hungry. Physical examination is unrevealing. Complete blood count is normal, as is urinalysis, multiphased chemical screen, thyroid-stimulating hormone, chest x-ray, and stool for blood. The next most appropriate study would be A. abdominal CT B. serum protein electrophoresis C. colonoscopy D. blood cultures E. short ACTH test"
A
"A 65-year-old woman on hemodialysis for chronic renal failure requires an urgent dental extraction for an abscessed tooth. Of the following, the most appropriate agent to administer to reduce the risk of significant bleeding would be A. desmopressin B. conjugated estrogen C. erythropoietin D. fresh-frozen plasma E. Aminocaproic acid"
A
"A 65-year-old woman presents with severe pelvic pain with radiation down both legs. There is no evidence of a sensory level. Physical examination is unremarkable except for a colostomy in the right lower quadrant. There is a history of an abdominal-perineal resection for rectal cancer 3 years ago. Postoperatively she received pelvic irradiation and adjuvant chemotherapy with 5-FU. The most likely cause for this patient's pain is A. pelvic recurrence of rectal cancer B. bony metastasis C. secondary leukemia with bone pain D. post-radiation radiculitis E. sciatic nerve inflammation"
A
"You are evaluating a 45-year-old homeless individual with known chronic schizophrenia. He appears to be generally malnourished with decreased temporal and proximal extremity muscle mass. Which of the following immunologic/hematologic abnormalities is most likely to be found in this situation? A. Depressed absolute lymphocyte count B. Depressed absolute monocyte count C. Depressed absolute granulocyte count D. Hypogammaglobulinema E. Microcytic red cells"
A
"A 65-year-old female patient with severe heart failure presents with increasing shortness of breath. Her current pharmacological treatment consists of an angiotensin-converting enzyme (ACE) inhibitor, loop diuretic and β-blocker. What is the most appropriate management? A. Add digoxin B. Add spironolactone C. Stop β-blocker D. Stop ACE inhibitor E. Add simvastatin"
B
"A 67-year-old lady during pre-operative assessment is found to have a small pericardial effusion located posteriorly on routine Echocardiography. Electrocardiogram (ECG) is entirely normal. What is the next most appropriate step in her management? A. Cardiac catheterisation B. reassure C. Pericardiocentesis D. Diuretics E. Computed tomography (CT) of the heart"
B
"A 67-year-old man with chronic heart failure is reviewed in terms of his drug therapy. Which of the following treatments has no proven mortality benefit? A. Bisoprolol B. Digoxin C. Enalapril D. Nitrates and hydralazine E. Spironolactone"
B
"A 16-year-old adolescent is seen in your clinic. On physical examination you notethat he has small testes for his stated age and has poorly developed secondary sexual characteristics. In addition, on physical examination there is notable gynecomastia. He is rather tall, with abnormally long upper and lower limbs. A buccal smear is obtained and examined microscopically. How many chromatinpositive inclusion bodies are seen? A. 0 B. 1 C. 2 D. 3 E. 4"
B
"A 23-year-old woman presents for a routine physical examination. The patient gives a history of trying to diet, but she also admits to binge intake and extensive useof laxatives. The physical examination discloses a woman of normal height and weight and is unremarkable except for chipping and erosion of the front teeth. This patient is likely to A. have disrupted menstrual cycles B. experience a normal life span C. have osteopenic bones D. have elevated serum anti-goblet cell antibodies E. be unconcerned about body shape and weight"
B
"A 27-year-old woman presents with stage IIbreast and lymph node involvement. right breast cancer. Her family history is markedly positive for other tumors. One of her sisters developed an osteogenic sarcoma at age 17, her brother was diagnosed with acute leukemia at age 5, her mother died of breast cancer, and she has two uncles with soft-tissue sarcomas, both developing this disease when in their thirties. This patient's peripheral blood lymphocytes would be most likely to reveal which of the following abnormalities? A. retinoblastoma gene mutation B. p53 gene mutation C. Translocation between chromosomes 9 and 22 D. Translocation between chromosomes 8 and 14 E. Mutations of epidermal growth factor receptor gene"
B
"A 3-month-old child arrives in your clinic who has profound hypotonia. On physical examination, in addition to the hypotonia, he is noted to have a brachycephalic head with a flat occiput and a low bridge nasal structure. The hands are short and broad, and a single crease is noted on the fifth finger. The feet show a characteristic wide gap between the first and second toes and the furrow is extending along the proximal plantar surface. A full karyotype is performed and shows an abnormality. However, the total number of chromosomes is normal at 46. What is the most likely explanation for this child's clinical syndrome? A. Fragile X syndrome B. Down's syndrome C. Prader-Willi syndrome D. Cri-du-chat syndrome E. Isochromosome X"
B
"A 30-year-old black woman with long-standing sickle cell anemia presents with severe pain in the chest and abdomen1 week after having an upper respiratory infection. No intrathoracic or intraabdominal pathology was immediately obvious on routine physical examination and laboratory evaluation. The most appropriate therapeutic intervention at this point is A. hypertransfusion B. hydration and narcotic analgesia C. hydroxyurea D. broad-spectrum antibiotics E. exploratory laparotomy"
B
"A 30-year-old man is referred to the dermatology clinic and found to have café-au-lait spots. Which of the following features subsequently found in the eye clinic suggests a diagnosis of neurofibromatosis? A. Busacca nodules B. Lisch nodules C. Brushfield spots D. Koeppe nodules E. Heterochromia iridis"
B
"A 35-year-old woman comes to your clinic for a consultation. She is 17 weeks pregnant with her second chilD. She is G2 P1. Her prior pregnancy was complicated by neonatal alloimmune thrombocytopeniaNATP. . Analysis of the patient's serum reveals circulating anti-Pia1 antibodies. Which of the following statements concerning NATP is true? A. If the gene frequency of Pia2 is 0. 02, then the likelihood of her second child having NATP is low B. Given the gene frequency of Pia2 of 0. 02, then the likelihood of her second child having NATP approaches 100% C. The incidence of NATP is approximately 1/20,000 neonates D. NATP is unrelated to the circulating anti-Pia1 antibodies because IgG antibodies do not cross the placental barrier E. NATP is unrelated to the entity referred to as posttransfusion purpura"
B
"A 35-year-old woman develops a generalized seizure and is brought to the emergency room. Your goal is to reduce the chance for additional seizures by therapy that will achieve a therapeutic plasma phenytoin level as soon as possible. However, you infuse the phenytoin at a rate of 50 mg/min over 20 min. What is the reason for not administering the drug more rapidly? A. Rapid administration slows drug clearance B. High blood levels during a rapid load could produce drug toxicity C. The equilibrium phase would be reached too quickly D. High levels can exacerbate the seizures E. If administered too rapidly, first-pass effect will cause rapid catabolism"
B
"A 35-year-old woman pregnant with her first child develops edema. She presents to her obstetrician, who finds that her blood pressure is 170/115 and that she has bipedal edema and bilateral rales on pulmonary examination. Laboratory studies reveal 6 g protein in a 24-h urine collection, elevated hepatic transaminases, and a platelet count of 80,000/ L. The patient is currently at 31 weeks of pregnancy and is admitted to the hospital and put on bedrest. Her blood pressure and the status of the fetus are closely monitored. Which of the following additional measures represents the most appropriate treatment? A. Magnesium sulfate: 6-g bolus over 15 min followed by 1 to 3 g/h by continuous infusion pump B. Intravenous labetalol C. Intravenous diazepam D. Oral losaarten E. Oral captopril around the clock"
B
"A 42-year-old painter presents to A&E with symptoms of vertigo, diplopia and gait unsteadiness at the end of a busy afternoon painting the interior of a property. On examination there is a markedly lower blood pressure in the left arm. What diagnosis fits best with this clinical picture? A. Anterior circulation transient ischaemic attack B. Subclavian steal syndrome C. vestibular neuronitis D. Posterior circulation transient ischaemic attack E. Unexplained cardiac arrhythmia"
B
"A 55-year-old man with a history of seasonal allergic rhinitis develops a low-grade fever and cough. He complains to his physician that he is producing copious amounts of greenish sputum and coughing quite a bit. Since the patient is known to be allergic to penicillin, the physician prescribes erythromycin. The patient is also taking terfenadine because of his allergic symptoms. Which of the following is a potential complication in this clinical scenario? A. Decreased bioavailability of erythromycin with failure to treat pulmonary infection B. Congestive heart failure C. Increased bleeding D. Stevens-Johnson syndrome E. A disulfiram-like reaction if ethanol is ingested"
B
"A 58-year-old man presents with fatigue. His physical examination is normal except for the presence of splenomegaly. CBC discloses hematocrit, 29%; platelet count, 90,000/ L; WBC, 2700/ L; and an essentially normal red cell morphologydifferential 12% monocytes, 12% granulocytes, and 76% lymphocytes. A bone marrow aspirate and biopsy were performed. The aspirate was dry and the biopsy is pending. Based on the available information, the most likely diagnosis in this case is A. chronic lymphocytic leukemia CLL. B. hairy cell leukemia C. chronic myeloid leukemia CML. D. myelofibrosis E. multiple myeloma"
B
"A 68 year old femalee presents with central visual blurring. On examination there appears to be small yellow deposits within the maculae and a small haemorrhage at the maculae. Fluoroscein angiography is performed and shows neovascularisation within the macula of both eyes. You suspect wet age related macular degeneration. Which of the following is an important risk factor for the development? A. Hypertension B. Smoking C. Cataract surgery D. Glaucoma E. diabetes"
B
"A 75-year-old patient with advanced metastatic prostate cancer and a long history of renal failure has severe bone pain. He is given meperidine. Two days later he develops a generalized seizure. What is the likely mechanism of this complication? A. Buildup of meperidine B. Buildup of meperidine metabolite levels C. Brain metastases D. Hypercalcemia E. Worsening renal failure"
B
"A 75-year-old widower who lives alone is brought to his primary care physician by his daughter because she feels that he has been confused over the past few days. Prior to this he was quite independent and cognitively intact. The patient has a history of hypertension and is on hydrochlorothiazide. He is due for bilateral cataract extraction in 2 months. Of note, he reports a fall in his living room about two weeks earlier, at which time he sustained a hip bruise and bumped his head. At this time his general physical examination is unremarkable; his neurologic examination is normal except for the mental status component, which discloses defects in short-term memory. Which of the following diagnostic studies is most likely to explain this patient's condition? A. neuropsychiatric battery B. CT scan of head C. Electroencephalogram D. serum chemistry panel E. Urinary screen for toxic substances"
B
"A 9 year old boy is brought to his GP. his mother has noticed him tripping up frequently. he states he has difficulty seeing in the dark. He is otherwise very well. A full neurological examination is performed and is normal. Fundoscopy is performed and reveals mid peripheral bone spicules. Which of the following is the most likely diagnosis? A. retinoblastoma B. retinitis Pigmentosa C. Glaucoma D. Alport's Syndrome E. Usher's Syndrome"
B
"A patient is being referred to the eye clinic with suspected early diabetic retinopathy. Which of the following tests, if abnormal, most strongly supports the diagnosis? A. Electroretinography (ERG) B. Fluorescein angiography C. Ocular ultrasound D. Visual evoked potentials (VEP) E. Pupillometry"
B
"An elderly gentleman is admitted with syncope. He also complains of shortness of breath and is diagnosed as having aortic stenosis. Which of the following conditions when associated with aortic stenosis would indicate a poor prognosis? A. Aortic regurgitation B. left ventricular failure C. Electrocardiography (ECG) changes D. Endocarditis E. Valvular calcification"
B
"Which of the following is a correct statement concerning the differences in the etiology and incidence of ischemic heart disease in men and women? A. The incidence of ischemic heart disease is higher in women than in men B. Women are more likely to present with angina as the initial symptom of ischemic heart disease, and men with myocardial infarction C. The risk of morbidity and mortality after a myocardial infarction is lower in women than men D. Women have a lower perioperative mortality rate after coronary artery bypass surgery than men E. men have more frequent problems secondary to bleeding complications with antithrombotic therapy "
B
"A 35-year-old woman develops hirsutism, deepening voice, and clitorimegaly. A pelvic examination reveals a left ovarian mass. Assuming appropriate diagnosticand staging tests are performed, given this clinical presentation, if the patient requires chemotherapy she should be treated in a fashion analogous to the management of A. epithelial ovarian cancer B. lymphoma C. testicular cancer D. soft tissue sarcoma E. carcinoid tumor"
C
"A 35-year-old-woman of African origin presents with a 4-month history of increasing swelling over her feet and abdominal distension. She has no history of cough, orthopnoea or breathlessness on exertion. Her heart rate is 98 beats/minute: irregularly irregular. Her JVP is markedly raised and she has pitting lower limb oedema. The heart sounds are soft, and there are no audible murmurs. Abdominal examination reveals hepatomegaly along with ascites. Chest X-ray reveals a normal cardiac size and clear lung fields. A lateral X-ray shows calcification around the heart border. Urinalysis is normal. Her ECG shows a low QRS voltage and lateral T-wave changes. What is the likely diagnosis? A. Dilated cardiomyopathy B. Cirrhosis of the liver C. Constrictive pericarditis D. restrictive cardiomyopathy E. Hypertrophic cardiomyopathy"
C
"A 40-year-old man presents to his GP with unequal pupils. The GP considers that IIIrd (oculomotor) nerve palsy is the likely diagnosis. Which of the following statements is true? A. The pupil on the affected side is smaller B. The pupil on the affected side reacts normally to light C. The pupil on the contralateral side reacts normally to light D. The pupil on the affected side reacts normally to accommodation E. The pupil size difference is equal in bright and dim surroundings"
C
"A 45-year-old man comes to your office with a history of stage I colon cancer. The patient's father was diagnosed at age 49 with colon cancer, and his brotherthe patient's uncle. also had colon cancer diagnosed at age 47. The patient's grandmother had endometrial cancer diagnosed at age 51. This patient most likely has a defect in which of the following genes? A. p53 B. APC C. MSH-2 gene affecting DNA mismatched repair D. retinoblastoma geneRB. E. A reciprocal translocation involving chromosomes 8 and 14, t 8;14."
C
"A 46-year-old man is admitted with shortness of breath, headache, blood pressure 190/110 mmHg and fundoscopy showing retinal haemorrhages and papilloedema. ECG revealed left ventricular hypertrophy, chest x-ray did not reveal any evidence of left ventricular failure. Which of the following agents would be the most appropriate management? A. Intravenous labetalol B. Intravenous sodium nitroprusside C. Atenolol D. Doxasosin MR oral E. Nifedipine sublingual"
C
"A 52-year-old postmenopausal woman comes for a routine visit to her primary care physician. She asks about the value of hormone replacement therapy. Which of the following statements is correct regarding this situation? A. Use of tamoxifen slows the development of osteoporosis but has no effect on the incidence of breast cancer B. The use of tamoxifen reduces the risk of breast cancer but has no effect on osteoporosis C. The use of tamoxifen reduces both the risk of osteoporosis and breast cancer D. Calcium and estrogen slow the development of osteoporosis and reduce the frequency of breast cancer E. Alendronate has no effect on the development of osteoporosis"
C
"A 55-year-old man who has sustained an acute MI subsequently presents with heart failure. As well as other treatments the cardiologist has recommended that abeta-blocker be commenced. According to currently available evidence which of the following beta-blockers would be most appropriate? A. Celiprolol B. Labetalol C. Bisoprolol D. Propranolol E. Sotalol"
C
"A 56-year-old man has known tricuspid regurgitation. Which part of the jugular venous waveform is likely to be most prominent? A. a wave B. c wave C. v wave D. x descent E. y descent"
C
"A 62-year-old patient presents with atrial fibrillation of unknown duration. Which drug may slow his ventricular rate over a prolonged period but is unlikely to result in cardioversion? A. Adenosine B. Amlodipine C. Digoxin D. Flecanide E. Amiodarone"
C
"A 65-year-old man develops superficial thrombophlebitis in multiple sites including the arms and chest. He has had several episodes in the past couple of months, each of which lasted a few days. Which of the following neoplasms is most closely associated with this patient's clinical problem? A. Prostate carcinoma B. Lung carcinoma C. Pancreatic carcinoma D. Acute promyelocytic leukemia E. Paroxysmal nocturnal hemoglobinuria"
C
"A 70-year-old woman presents with a sudden loss of vision in one eye. Which of the following investigations most strongly supports a diagnosis of temporal arteritis? A. An ESR of 40 mm/hour B. Abnormal CRP C. Giant-cell infiltrate in a temporal artery biopsy D. Homonymous hemianopia on visual field E. Positive TPHA"
C
"A 70-year-old-man reverts to atrial fibrillation after several attempts at cardioversion, but remains symptomatic despite rate control with digoxin and metoprolol. He developed pulmonary fibrosis with amiodarone. Which of the following will be the next step in the management of this patient? A. Switch metoprolol to amlodipine B. Double the dose of digoxin C. Perform radiofrequency ablation of the AV node, and implant a pacemaker D. Make another attempt at cardioversion E. Implant a cardiovertor defibrillator"
C
"A 75 year old gentleman with type 2 diabetes melllitus presents for his retinal screening. On the retinal photograph there is evidence of cotton wool spots and flame haemorrhages. There also appears to be new vessel formation very close to the optic disc. What is the next stage in management? A. Fenofibrate B. Insulin C. referral for laser photocoagulation D. referral for fluorescein angiography E. Optimal glycaemic control"
C
"A diabetic patient with diplopia is found to have a third nerve palsy. Which of the following clinical features would most point to a compressive cause? A. Ptosis B. Impaired adduction C. Pupil involvement D. Impaired elevation E. Nystagmoid jerks"
C
"A patient is referred to the dermatology clinic with facial flushing and early rhinophyma. The dermatologist seeks an ophthalmic opinion. Which of the following findings supports a diagnosis of acne rosacea? A. Iritis B. Cataract C. Central retinal vein occlusion D. Keratitis E. Raised intraocular pressure"
C
"A patient with underlying ischaemic heart disease had two transient episodes of loss of consciousness but feels fine at present. Both episodes were preceded by afeeling of dizziness, ""vision going black"" and witnesses report that the subject went very pale and then collapsed, lying motionless for a few seconds before making a rapid recovery. No abnormal movements were seen during the period of unconsciousness. What investigation will you order next? A. Echocardiography B. Computed tomography (CT) of the head C. 24-hour electrocardiogram (ECG) D. Cardiac catheterisation E. Treadmill test"
C
"What is the most important principle in discussions with a surrogate decision maker for a patient who is unconscious and incapable of making an important decision regarding advanced care, especially if there is no documentation of the patient's desires? A. Without knowing the patient's specific wishes, prolongation of life must be carried out at all costs B. The physician should make a judgment based on the medical facts C. The physician should decide as the patient would under the circumstances, assuming the patient knew all information D. The surrogate makes the decision based on what he or she thinks is best for the patient E. The hospital ethics board must decide"
C
"A 55-year-old Japanese businessman visiting the United States has been in excellent health until 6 months ago, when he first noted mild upper abdominal fullness after meals. On examination the man is noted to have hyperpigmented, heaped-up velvety lesionsas shown in Plate S.confined to the neck, axillae, and groin. Which of the following conditions is associated with the skin findings? A. Non-Hodgkin's lymphoma B. Anorexia nervosa C. Acute leukemia D. Adenocarcinoma of the stomach E. Addison's disease"
D
"A 17-year-old youth is brought to the GP by his mother. He was previously seen 2 weeks earlier suffering from acute pharyngitis. His teeth are in generally poor condition, but otherwise there is no previous medical history. On examination he is febrile with a temperature of 38. 2 A°C, and has a polyarthritis affecting his knees, ankles, wrists and elbows. He also appears to have subcutaneous nodules over his elbows, and mitral regurgitation on cardiovascular examination. What diagnosis fits best with this clinical picture? A. Bacterial endocarditis B. Juvenile rheumatoid arthritis C. Scarlet fever D. Rheumatic fever E. Congenital valvular heart disease"
D
"A 30-year-old man, under investigation for abdominal cramps and passing blood rectally, presents with an acutely painful, red and photophobic eye. What is the most likely sign on ocular examination? A. Conjunctival purulent discharge B. White corneal stromal infiltrate C. Mydriasis of the affected eye D. Hypopyon E. Swollen optic disc"
D
"A 32-year-old woman with rheumatoid arthritis presents to the rheumatology clinic with a complaint of severe pain and reduced vision in one of her eyes. The medical SpR notes that one eye is dusky red in colour and that the vision in this eye is reduced to 6/36. What is the appropriate management? A. The patient should be booked for an urgent CT scan B. The patient should be started on artificial tears C. The patient should be started immediately on immunosuppressant therapy D. The patient should be referred urgently to the ophthalmology clinic E. The patient should be investigated urgently for coexisting inflammatory bowel disease"
D
"A 34-year-old professional footballer is evaluated for symptoms of 'dizziness' during exercise. Physical examination reveals a laterally displaced apical impulse. On auscultation, there is a 2/6 mid-systolic murmur in the aortic area that increases on sudden standing. The ECG shows LVH and Q waves in the V2-V5 leads. What is the most likely diagnosis? A. Young-onset hypertension B. Acute MI C. Aortic stenosis D. Hypertrophic cardiomyopathy E. Atrial septal defect"
D
"A 45-year-old man with a strong family history of ischaemic heart disease presents with atypical chest pains. Electrocardiographic (ECG) exercise testing shows J point depression of 1 mm with a heart rate of 120 beats/min (bpm). What is the most appropriate next step? A. Coronary angiography B. Dobutamine stress echocardiography C. Radionuclide myocardial perfusion scanning D. reassure and discharge E. repeat ECG exercise testing on anti-anginal medication"
D
"A 50-year-old man with recent acute pancreatitis receiving his third week of nutritional support via a central venous catheter might be expected to develop which of the following complications at this time? A. Zinc deficiency B. Osteomalacia C. Microcytic anemia D. Hyperosmolar coma E. Hypophosphatemia"
D
"A 52-year-old woman sees her physician for an "insurance physical. " Physical examination reveals only a pigmented lesionas shown in Plate Q. present on one foot. The woman states that the lesion apparently was present at birth and does not itch or bleed; it is, however, not as homogeneous in color as it used to be. Which of the following statements about the condition described is true? A. Bleeding and tenderness would be the first signs of malignant degeneration. B. It is unlikely that the lesion, present since birth, is malignant. C. The diagnostic procedure of choice is an incisional biopsy of this lesion. D. change in color of the lesion is a suspicious sign for potential malignancy. E. Early diagnosis of this lesion would not affect prognosis."
D
"A 56-year-old man presents with a cardiac rhythm disorder. Which one of the following scenarios would be an indication for temporary transvenous cardiac pacemaker insertion? A. Asymptomatic 2. 8 s sinus pauses B. A short period of complete heart block complicating inferior myocardial infarction, (pre-thrombolysis) with blood pressure 110/70 mmHg C. Asymptomatic complete heart block with broad complex ventricular complexes at 35 bpm D. Mobitz II AV block complicating anterior myocardial infarction with blood pressure 110/70 mmHg E. Bifascicular block prior to aortic aneurysm repair"
D
"A 67-year-old lady is found to have a small pericardial effusion located posteriorly on routine echocardiography. There is no haemodynamic compromise. What is the next most appropriate step in her management? A. Diagnostic tap B. Mammography C. Tuberculosis screen D. reassure E. Right heart catheter examination"
D
"A 78-year-old-man presents to Casualty with a history of syncope. An ECG shows complete heart block. Which of the following physical signs is consistent with the diagnosis? A. regular cannon 'a' waves on JVP B. Soft first heart sound C. Low-volume pulse D. Basal systolic murmur E. Loud second heart sound"
D
"A diabetic 46-year-old man is found in the diabetic clinic to have reduced visual acuity. During a telephone referral to the eye clinic, the ophthalmologist asks if the patient has any risk factors for macular oedema. Which of the following should the referring physician bring to his attention? A. Background diabetic retinopathy B. Low glycosylated haemoglobin C. Hypercholesterolaemia D. Proteinuria E. Peripheral vascular disease"
D
"A patient is examined in the diabetic clinic and found to have dark cluster haemorrhages in both fundi. What is the most likely diagnosis? A. Normal fundi B. Background retinopathy C. Maculopathy D. Pre-proliferative retinopathy E. Proliferative retinopathy"
D
"A patient is seen with features of proliferative retinopathy in one eye and background diabetic retinopathy in the other. Which of the following tests is most likely to provide an explanation? A. Chest X-ray B. Electrocardiography C. Coagulation screen D. Carotid Doppler E. 24-hour urinary protein"
D
"A patient with a myelodysplastic syndromesubtype, refractory anemia with ringed sideroblasts. has been transfusion-dependent for the past 2 years. The patient has received a total of 50 units of packed red blood cells. His physical examination is normal except for hyperpigmentation. Laboratory evaluation reveals mild glucose intolerance. A trial of erythropoietin was unsuccessful. Which of the following would be the most important therapeutic approach at this time? A. Granulocyte colony-stimulating factor G-CSF. B. Phlebotomy C. Ascorbic acid D. Desferrioxamine E. Hypertransfusionmaintain hematocrit at 40%."
D
"An 80-year-old woman with severe osteoarthritis is wheelchair-bound. She develops a pressure ulcer on her right buttock that involves the dermis; however, subcutaneous tissues and deeper structures do not appear to be involved. In addition to efforts to increase mobility and to relieve pressure, the most appropriate therapy is A. surgical debridement B. dry dressings C. wet dressings changed when dry D. wet dressings changed when wet E. topical antibiotics"
D
"An elderly man is admitted to the icU and put on intermittent positive-pressure ventilation. Which of the following statements is true when compared to spontaneous ventilation? A. Lung volumes are decreased B. Pulmonary vascular resistance is decreased C. Systemic blood pressure rises D. venous return and cardiac output fall E. Intrathoracic pressure is decreased"
D
"The medical SHO telephones the consultant to say she has diagnosed a patient as having behçet's disease. The patient presented to A&E with reduction in vision in one eye. Which of the following features supports her diagnosis? A. The patient is of Celtic extraction B. There is a strong family history of blindness C. The patient has a small-joint polyarthropathy D. The patient has active oral ulceration E. The patient's visual loss is due to retinal artery occlusion"
D
"Which of the following ocular signs would you find in acne rosacea? A. Cataract B. Uveitis C. Ptosis D. Keratitis E. Swollen optic disc"
D
"Why do patients with the carcinoid syndrome develop pellagraloss of appetite, generalized weakness, abdominal pain, vomiting, stomatis and bright red glossitis, and a skin rash that is pigmented and scaling in sunlightexposed areas. ? A. Failure to elaborate serotonin B. Vitamin B deficiency 12 C. Thiamine deficiency D. Niacin deficiency E. Pyridoxine deficiency"
D
"A 36-year-old woman presents with a firm painless mass in her right thigh just superior to her knee. A CT scan reveals a 4by 5-cm solid mass attached to the muscle. You refer the patient to a surgeon, who performs an incisional biopsy. The pathology indicates high-grade fibrosarcoma with several mitoses per 10 high-power fields. The most appropriate management at this point is A. observation B. radiation therapy C. chemotherapy with a doxorubicin-containing regimen D. radiation therapy plus chemotherapy with a doxorubicin containing regimen E. complete excision of the mass"
E
"A 40-old woman with AIDS presents to the GU clinic with a shadow in her vision in one eye. Which of the following supports a diagnosis of cytomegalovirus retinitis? A. Conjunctival injection B. Mydriasis on the affected side C. Disc swelling D. Macular oedema E. retinal haemorrhages"
E
"A 40-year-old man is noted to have palmar crease xanthomas. Which form of lipid disorder is most likely? A. Familial hypercholesterolaemia B. Familial mixed hypercholesterolaemia C. Hyperchylomicronaemia D. Familial hypertriglyceridaemia E. Broad b disease"
E
"A 40-year-old woman undergoes her first mammogram. The study reveals a cluster of microcalcifications in the right breast. needle biopsy reveals a focus of lobular carcinoma in situno invasion. At this point the patient should be offered A. quadrantectomy and lymph node dissection on the ipsilateral side B. quadrantectomy with irradiation C. right breast mastectomy with irradiation depending on lymph node status at the time of surgery D. irradiation therapy to the right breast E. resection followed by annual mammography and semiannual physical exam"
E
"A 45-year-old truck driver is involved in a serious motor vehicle accident. He has fractured multiple bones and sustained a pneumothorax and a hepatic laceration requiring emergency surgery. In order to maintain energy balance, what must this patient receive per day? A. 2000 kcal B. 2500 kcal C. 3500 kcal D. 4500 kcal E. 5500 kcal"
E
"A 50-year-old woman presents with an acute myocardial infarction, and thrombolysis is being considered. Which one of the following would be an absolute contraindication for thrombolytic therapy? A. Background diabetic retinopathy B. Past history of a minor stroke 5 years ago with full recovery and no evidence of underlying cerebrovascular lesion C. menstruation D. Dyspeptic symptoms E. resting blood pressure 220/130 mmHg"
E
"A 51-year-old married father of three presents with epigastric abdominal pain and weight loss. Computed tomographyCT. of the abdomen reveals an extensive midpancreatic mass with obvious liver metastases. needle biopsy of one of the hepatic lesions is consistent with pancreatic adenocarcinomA. At this point the patient's primary care physician should tell the patient A. that a referral to an oncologist will be made B. the nature of histology and refer the patient to an oncologist and defer discussionof the prognosis C. to get his affairs in order as quickly as possible D. that we now have effective therapy for pancreatic carcinoma E. that he has an extremely serious life-threatening illness, but that all measures will be undertaken to extend the quantity and quality of the patient's life"
E
"A 55-year-old man complains of numbness in both legs and progressive inability to walk over the past 2 months. Physical examination is normal except for a decreased perception of light touch and pain in the lower extremities as well as bilateral leg weakness. There is no sensory level. Laboratory workup is remarkable for a hematocrit of 30% and elevated total protein. serum protein electrophoresis reveals an M spikE. The etiology of this patient's weakness is most likely A. necrosis of central nervous system gray and white matter B. inflammation of dorsal root ganglia C. loss of cerebellar Purkinje cells D. elaboration of tumor-associated protein that elicits an immune response that is cross-reactive with peripheral nerves E. tumor-elaborated immunoglobulin that is reacting with myelin components"
E
"A 55-year-old man who recently underwent hip surV-92. Continued. gery develops a pulmonary embolism and is placed on unfractionated heparin. After 3 days of therapy, his platelet countpreviously normal. is now 50,000/ l. What is the mechanism of the thrombocytopenia in this case? A. The induction of an anti-platelet antibody B. Platelet-heparin binding causing platelet aggregation C. Splenomegaly causing platelet pooling D. Heparin-induced bone marrow suppression E. Platelet aggregation due to the formation of a heparin platelet factor IV antibody complex"
E
"A 55-year-old woman presents to the emergency department because her family notes that she has yellow skin. The patient has lost 7 kg15 lbs. over the past 3 months but states that this is because she has been dieting in preparation for her daughter's wedding. Her past medical history is significant only for vitiligo. Her physical examination is unremarkable except for the presence of scleral icterus and a yellow tinge to the skin. Laboratory evaluation reveals hematocrit of 17%, WBC count of 2500/ L, and platelet count of 70,000/ L. serum chemistries are normal except for direct bilirubin of 51mol/L3 mg/dL. and indirect bilirubin of 12mol/L0. 7 mg/dL. The patient's reticulocyte count is 3%. MCV is 108 fL. Which one of the following additional laboratory findings would most likely be associated with this patient's clinical syndrome? A. Clonal chromosomal abnormalities on karyotypic analysis of the bone marrow B. Positive direct Coombs' test C. Extrahepatic biliary obstruction D. Decreased gastric fluid pH E. Antiparietal cell antibody"
E
"A 65-year-old woman with a history of heavy smoking presents for review. She has woken during the early hours of the morning for the second time with shortness of breath so bad that she had to fling open the windows. On examination there are crackles in the lung bases, her chest X-ray shows bilateral fluffy perihilar shadowing. ECG reveals small anterior Q waves and a sinus tachycardia of 105 bpm. What diagnosis fits best with this clinical picture? A. Cryptogenic fibrosing alveolitis B. Pulmonary embolus C. Exacerbation of COPD D. Sarcoidosis E. Pulmonary oedema"
E
"A 65-year-old woman with a history of heavy smoking presents for review. She has woken during the early hours of the morning for the second time with shortness of breath so bad that she had to fling open the windows. On examination there are crackles in the lung bases, her chest X-ray shows bilateral fluffy perihilar shadowing. ECG reveals smallanterior Q waves and a sinus tachycardia of 105 bpm. What diagnosis fits best with this clinical picture? A. Cryptogenic fibrosing alveolitis B. Pulmonary embolus C. Exacerbation of COPD D. Sarcoidosis E. Pulmonary oedema"
E
"A 68 year old male with previous history of Tia presents with unilateral painless vision loss. The retina is pale and the macula appears as a cherry red spot. What is the most likely cause of the vision loss? A. retinal detachment B. Vitreous haemorrhage C. Age related macular degeneration D. retinal vein occlusion E. Central retinal artery occlusion"
E
"A 69-year-old man has been admitted to the emergency department with syncope. He felt hot, complained of nausea and then fainted. His electrocardiogram (ECG) was normal. His brother suffers from adult onset epilepsy. What is the most appropriate investigation? A. Electroencephalogram (EEG) B. 24-h ECG C. Computed tomography (CT) of the brain D. Echocardiography E. Tilt test"
E
"A 70-year-old man of Irish descent returns to his physician for a routine check of his blood pressure. He is a vigorous, retired executive who except for mild hypertension is healthy. After his examination, as he is getting dressed, he states that his wife has been nagging him to mention a spot on his noseas shown in Plate P. He is certain that this lesion, which has been present for several years, is of no significancE. The most likely diagnosis for this lesion is A. dermal nevus B. sebaceous hyperplasia C. clear cell acanthoma D. xanthoma E. basal cell carcinoma"
E
"A 70-year-old man undergoes successful DC cardioversion for atrial fibrillation (AF). Which one of the following factors best predicts long-term maintenance of sinus rhythm following this procedure? A. Age under 75 years B. Normal left ventricular function C. Warfarin therapy D. No alcohol intake E. AF duration less than 6 months prior to cardioversion"
E
"A 72-year-old man with chronic atrial fibrillation presents with bruising. He is otherwise well, although he admits to being concerned about a failing memory andis taking a host of over-the-counter remedies in an effort to deal with this problem. His only medicines are furosemide, digoxin, and warfarin. His physical examination, with the exception of ecchymoses and irregular heartbeat, is normal; there is no evidenceof cognitive impairment. His serum chemistry profile and complete blood count are normal. However, coagulation tests reveal an INRof 7. What is the most likely cause of this patient's coagulopathy? A. Warfarin overdose B. Interaction between digoxin and warfarin C. Dietary change D. Interaction between furosemide and warfarin E. Use of dietary herbal supplements"
E
"A 72-year-old man with known benign prostatic hypertrophy develops fever and flank pain. He rapidly becomes very ill. He presents to the emergency room with a blood pressure of 80/40 mmHg, heart rate of 120, and a temperature of 39.5 C103 F. His urine shows numerous white cells. His laboratory examination is remarkable for a white count of 2000, hematocrit of 28%, and platelet count of 10,000. The PT and PTT are elevated. The most appropriate way to deal with this patient's coagulopathy is A. intravenous-aminocaproic acid B. intravenous heparin C. platelets and fresh-frozen plasma D. antithrombin 3 concentrates E. intravenous antibiotics"
E
"A 76-year-old man has developed over the past 3 months a large number of occasionally pruritic lesions on his trunkPlate T. . These lesions are probably a manifestation of A. hypertriglyceridemia B. systemic vasculitis C. severe drug reaction D. disseminated candidiasis E. malignancy"
E
"A patient is examined in the diabetic clinic and found to have a vitreous haemorrhage precluding a view of his fundi. He is admitted for bed rest. After 3 days the fundi can be visualised. What is the most likely diagnosis? A. Normal fundi B. Background retinopathy C. Maculopathy D. Preproliferative retinopathy E. Proliferative retinopathy"
E
"A strain of obese mice homozygous for a mutation in the ob gene has a failure to elaborate normal amounts of the peptide leptin. Which of the following statements about leptin is correct? A. leptin is secreted by cells in the hypothalamus B. Overproduction causes increased energy expenditure. C. Aberrant leptin physiology has never been shown to be a cause of obesity in humans. D. Obese people have normal levels of serum leptin. E. Patients with nongenetic causes of obesity do not respond to exogenous leptin."
E
"What is the most likely lipid abnormality in a 48-year-old Asian man with good glycaemic control? A. Elevated high-density lipoprotein (HDL) B. Elevated low-density lipoprotein (LDL) C. Elevated LDL/elevated triglycerides D. Low HDL/elevated LDL E. Low HDL/elevated triglycerides"
E
