MCQ Medicine New

"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 67-year-old man presents with a history of headache for 5 days and 2 days of swelling of the right part of the forehead and right eyesee Plate E. A Tzanck preparation of the lesion reveals multinucleate giant cells on Giemsa stain. The patient was admitted to the hospital and begun on intravenous acyclovir. The most important next step would be A. ophthalmologic consultation B. administration of systemic glucocorticoids to prevent postherpetic neuralgia C. administration of antistaphylococcal antibiotics to prevent secondary bacterialinfection D. application of iodine-containing solution to prevent secondary bacterial infections E. CT scan of the brain"

A

"A 29-year-old tall, thin man presents to the ED after feeling short of breath for 2 days. In the ED, he is in no acute distress. His BP is 115/70 mm Hg, HR is 81 beats per minute, RR is 16 breaths per minute, and oxygen saturation is 98% on room air. Cardiac, lung, and abdominal examinations are normal. An ECG reveals sinus rhythm at a rate of 79. A chest radiograph shows a small right-sidedless than 10% of the hemithorax. spontaneous pneumothorax. A repeat chest x-ray 6 hours later reveals a decreased pneumothorax. Which of the following is the most appropriate next step in management? A. discharge the patient with follow-up in 24 hours B. Perform needle decompression in the second intercostal space, midclavicular line C. Insert a 20F chest tube into right hemithorax D. Observe for another 6 hours E. Admit for pleurodesis"

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 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 12-year-old girl presents with painful epitrochlear lymphadenopathy associated with low-grade fever and malaise. The patient has a cat and also gave a history of a papillary lesion in the left forearm about 1 week or 10 days ago. The most likely etiologic agent in this situation is A. Bartonella henselae B. Staphylococcus aureus C. Epstein-Barr virus D. Sporothrix schenkii E. Yersinia pestis"

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 22-year-old gay man from new Orleans presents with a 2-week history of fever, anorexia, and progressive diffuse lymphadenopathy. Physical findings reveal an emaciated young man who has several tongue ulcers. Hepatomegaly is noted. Laboratory examination reveals pancytopenia, an elevated alkaline phosphatase, and hyperkalemia. A chest radiograph reveals a miliary pattern of diffuse infiltration. A tongue biopsy reveals the presence of hyphae that bear both large and small spores. The correct diagnosis is A. histoplasmosis B. coccidioidomycosis C. cryptococcosis D. blastomycosis E. aspergillosis"

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 32-year-old woman presents to the ED with a persistent fever of 101°F over thelast 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cellsWBC. 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management? A. Obtain four sets of blood cultures, order a transthoracic echocardiogramTTE, and start antibiotic treatment. B. Order a monospot test and recommend that the patient refrain from vigorous activities for 1 month. C. Administer a nonsteroidal anti-inflammatory drugNSAID. and inform the patient she has pericarditis. D. Administer isoniazid INH. and report the patient to the Department of Health. E. Order a Lyme antibody and begin antibiotic therapy."

A

"A 35-year-old HIV-infected homosexual man presents with fever, pain of the right upper quadrant, and a CT of the liver that shows a 10-cm, oval hypoechoic cyst in the right lobe. An ELISA assay detects the presence of antibodies to Entamoeba histolytica; cysts from the same organism are found in a stool specimen. Which of the following is the most appropriate next step in management? A. Administration of metronidazole B. Administration of chloroquine C. Drainage of the hepatic lesion for therapeutic purposes D. Aspiration of the hepatic lesion for diagnosis E. Hepatic resection"

A

"A 35-year-old man with a history of abrasion of the right hand presents with acute pain in the right shoulder. His physical examination reveals a temperature of 39. 5 C 103 F. and rigor, and he appears to be quite ill. There is dusky erythema and edema of the right shoulder and right upper extremity with marked tenderness. Within a few hours the patient is unresponsive and is found to be hypotensive. Laboratory evaluation reveals an elevated serum, creatinine, thrombocytopenia, and elevated hepatic transaminases. The soft tissues in the left upper extremity have begun to necrose. blood culture, obtained at the time of initial presentation, has already turned positive. The organism that is most likely to be responsible for this clinical syndrome is A. group A streptococci B. group D streptococci C. Staphylococcus aureus D. Bacteroides fragilis E. Clostridium septicum"

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 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 47-year-old man with a history of hypertension presents to the ED complaining of continuous left-sided chest pain that began while snorting cocaine 1 hour ago. The patient states he never experienced chest pain in the past when using cocaine. His BP is 170/90 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 98% on room air. The patient states that the only medication he takes is alprazolam to "calm his nerves. " Which of the following medications is contraindicated in this patient? A. metoprolol B. Diltiazem C. Aspirin D. Lorazepam E. Nitroglycerin"

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 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 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

"A previously healthy 28-year-old man describes several episodes of fever, myalgia, and headache that have been followed by abdominal pain and diarrhea. He has experienced up to 10 bowel movements per day. Physical examination is unremarkable. Laboratory findings are notable only for a slightly elevated leukocyte count and an elevated erythrocyte sedimentation rate. Wright's stain of a fecal sample reveals the presence of neutrophils. Colonoscopy reveals is inflamed mucosa. Biopsy of an affected area discloses mucosal infiltration with neutrophils, monocytes, and eosinophils; epithelial damage, including loss of mucus; glandular degeneration; and crypt abscesses. The patient notes that several months ago he was at a church barbecue where several people contracted a diarrhea1 illness. While this patient could have inflammatory bowel disease, which of the following pathogens is most likely to be responsible for his illness? A. Campylobacter B. S. aureus C. E. coli D. Salmonella E. Norwalk agent"

A

"Four months after having undergone a siblingdonor renal allograft, a 38-year-old man is has done well and has had no evidence of graft rejection or major problems stemming from his chronic immunosuppressive therapy cyclosporine and prednisone. . He now develops a fever to 39 C102 F, headache, and a stiff neck. MRI of the brain with gadolinium enhancement reveals no abnormalities. The most likely cause of the patient's current clinical problem is infection with A. Listeria monocytogenes B. Mycobacterium tuberculosis C. Toxoplasma gondi D. H. influenzae E. Epstein-Barr viruse BV."

A

"While eating dinner, a 55-year-old man suddenly feels a piece of steak "get stuck" in his stomach. In the ED, he complains of dysphagia, is drooling, and occasionally retches. On examination, his BP is 130/80 mm Hg, HR is 75 beats per minute, RR is 15 breaths per minute, and oxygen saturation is 99% on room air. He appears in no respiratory distress. Chest x-ray is negative for air under the diaphragm. Which ofthe following is the most appropriate next step in management? A. Administer 1-mg glucagon intravenously while arranging for endoscopy. B. Administer a meat tenderizer such as papain to soften the food bolus. C. Administer 10-mL syrup of ipecac to induce vomiting and dislodge the food bolus. D. Perform the Heimlich maneuver until the food dislodges. E. Call surgery consult to prepare for laparotomy."

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 73-year-old previously healthy man is hospitalized because of the acute onset of dysuria, urinary frequency, fever, and shaking chills. His temperature is 39. 5 C103. 1 F, blood pressure is 100/60 mmHg, pulse is 140 beats per minute, and respiratory rate is 30 breaths per minute. Which of the following interventions would be the most important in the treatment of this acute illness? A. Catheterization of the urinary bladder B. Initiation of antibiotic therapy C. Infusion of Ringer's lactate solution D. Infusion of dopamine hydrochloride E. Intravenous injection of methylprednisolone"

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 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 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 man underwent allogeneic bone marrow transplantation from an unrelated donor for acute myeloid leukemia in second remission. He develops hepatomegaly and fever 3 months after the infusion of the allogeneic cells. Radiographic imaging of the abdomen reveals extensive intraabdominal lymphadenopathy as well as an enlarged liver, which appears to be diffusely infiltrated. There is no ascites noted. Which of the following is the likely mechanism for the patient's current deterioration? A. venoocclusive disease of the liver B. Overgrowth of EBV-infected lymphocytes C. recurrence of acute myeloid leukemia D. Graft-versus-host disease E. Toxoplasmosis"

B

"A 43-year-old nurse whose job requires frequent hand washing has noted a small erosive skin lesion between the third interdigital web of the right hand Plate A. The best therapy for this condition would be A. topical 5-fluorouracil B. topical clotrimazole C. oral griseofulvin D. topical hydrocortisone E. topical tar derivative"

B

"A 50-year-old woman emigrated from El Salvador 10 years ago and currently resides in Washington, DC. She complains of shortness of breath. Chest x-ray reveals biventricular cardiac enlargement. An echocardiographic study shows biventricular enlargement, thin ventricular walls, and an apical aneurysm. The patient has no history of alcohol abuse, thyroid disease, risk factors for atherosclerotic heart disease, or family history of hemochromatosis. In considering a potential etiology for the patient's current problem, which of the following statements is correct? A. The etiologic agent can be demonstrated on Giemsa stain of the peripheral blood. B. Other manifestations of infection could include involvement of the gastrointestinal tract. C. The vector for the transmission of this disease is the tsetse fly. D. Glucocorticoids may be beneficial. E. Given the progressive and ultimately fatal course, cardiac transplantation should be considered."

B

"A 53-year-old black man who received a renal allograft 7 months ago is now receiving azathioprine and prednisone. He presents to the hospital 1 week after developing fever, night sweats, and anorexia. He also complains of coughing and chest pain. Chest film reveals biapical infiltrates with an apparent cavity in the left upper lobe. Auramine-rhodamine staining reveals the presence of microorganisms consistent with tubercle bacilli. The patient's creatinine is 106mol/L 1.2 mg/dL. The treatment of choice at this time would be A. isoniazid, rifampin, and pyrazinamide B. isoniazid, rifampin, pyrazinamide, and ethambutol C. isoniazid and rifampin D. rifampin, pyrazinamide, and ethambutol E. isoniazid, rifampin, pyrazinamide, ethambutol, and streptomycin"

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 59-year-old man presents to the emergency departmented. complaining of new onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolemia, and a 20-pack-year smoking history. His electrocardiogrameCG. is remarkable for T-wave inversions in the lateral leads. Which of the following is the most appropriate next step in management? A. Give the patient two nitroglycerin tablets sublingually and observe if his chest pain resolves. B. Place the patient on a cardiac monitor, administer oxygen, and give aspirin. C. Call the cardiac catheterization laboratory for immediate percutaneous interventionPCI. . D. Order a chest x-ray; administer aspirin, clopidogrel, and heparin. E. Start a β-blocker immediately."

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

"Four days after he and his friends were killing muskrats along a rural creek, a boy becomes ill with headache, fever, and a macular rash. On examination, axillary adenopathy is noted, but otherwise the examination is normal. Which of the following tests would be most helpful in proving that this boy has tularemia? A. blood culture B. Aspiration and culture of an axillary lymph node C. Determination of serum agglutinins for Francisella tularensis D. Bone marrow culture E. Examination of his friends"

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

"An 18-year-old sexually active woman from the innercity presents with fever, pleuritic pain of the right upper quadrant, and lower abdominal pain. Pelvic examination reveals mucopurulent cervicitis and tenderness after the production of cervical motion. The right upper quadrant, uterine fundus, and adnexa are slightly tender. The white blood cell count and erythrocyte sedimentation rate are elevated, but the results of the remainder of the laboratory examination, including liver function tests, are normal. Which of the following agents is the most likely cause of this clinical syndrome? A. Herpes simplex virus B. Treponema pallidum C. neisseria gonorrhoeae D. Chlamydia trachomatis E. Mycoplasma hominis"

C

"For the past 2 days, a 24-year-old woman has had fever and pain in the left wrist, right ankle, and left knee. Nine painful skin lesions are present on the distal extremities, predominantly about the jointsas shown in Plate B. The most likely diagnosis is A. herpes simplex B. meningococcemia C. gonococcemia D. erythema multiforme E. anthrax"

C

"A 10-year-old boy presents with an abnormal appearing face. The boy lives in Rhode Island and has been playing outside a good deal this summer. He has been feeling poorly for a week with complaints of muscle aches and headachE. His mother has noticed that her son has a low-grade fever and an oval rash on the back measuring about 10 cm in diameter. Physical examination reveals evidence of the oral erythema on the posterior thorax and evidence of right facial droop. Routine laboratory studies are unremarkable. A lumbar puncture reveals an opening pressure of 80 mmHg, total protein of 0. 46 g/L46 mg/dL. , and glucose of 5. 0 mmol/L90 mg/dL. with 10 white cells, all of which are lymphocytes. The most specific diagnostic study would be A. polymerase chain reaction- based DNA detection B. Borrelia serology C. blood culture for Borrelia D. cerebrospinal fluid culture for Borrelia E. western blot detection of Borrelia antigen in the cerebrospinal fluid"

C

"A 25-year-old homosexual man presents with a diffuse maculopapular rash over his trunk, head, neck, palms, and soles. Generalized lymphadenopathy is also present. He has a history of 4 weeks of anal pain. Which of the following tests islikely to identify the etiologic agent? A. Antinuclear antibody B. blood culture C. serum rapid plasma reagin RPR. D. Skin biopsy E. serum HIV antibody"

C

"A 25-year-old intravenous drug abuser with fever has blood cultures obtained, and 24 h later a report from the microbiology laboratory indicates the presence of gram-positive cocci in clusters. The identification of the organism and sensitivities are pending. The most appropriate antibiotic choice would be A. penicillin B. nafcillin C. vancomycin D. TMP/SMZ E. ciprofloxacin"

C

"A 31-year-old man who works for a moving company presents to the ED because he thought he was having a heart attack. He does not smoke, and jogs 3 days a week. His father died of a heart attack in his sixties. He describes a gradual onset of chest pain that is worse with activity and resolves when he is at rest. His HR is 68 beats per minute, BP is 120/70 mm Hg, and RR is 14 breaths per minute. On examination, his lungs are clear and there is no cardiac murmur. You palpate tenderness over the left sternal border at the third and fourth rib. An ECG reveals sinus rhythm at a rate of 65. A chest radiograph shows no infiltrates or pneumothorax. Which of the following is the most appropriate next step in management? A. Administer aspirin and send for a troponin. B. Administer aspirin, clopidogrel, and heparin and admit for acute coronarysyndromeACS. C. Administer ibuprofen and reassure the patient that he is not having a heart attack. D. Inject corticosteroid into the costochondral joint to reduce inflammation. E. Observe the patient for 6 hours."

C

"A 35-year-old man is seen 6 months after a cadaveric renal allograft. The patient has been on azathioprine and prednisone since that procedure. He has felt poorly for the past week with fever to 38. 6 C101. 5 F. , anorexia, and a cough productive of thick sputum. Chest x-ray reveals a left lower lobe5 cm. nodule with central cavitation. Examination of the sputum reveals long, crooked, branching, beaded gram-positive filaments. The most appropriate initial therapy would include the administration of which of the following antibiotics? A. Penicillin B. Erythromycin C. Sulfisoxazole D. Ceftazidime E. Tobramycin"

C

"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 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 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 60-year-old insulin-dependent man with diabetes mellitus has had purulent drainage from his left ear for 1 week. Suddenly, fever, increased pain, and vertigo develop. The most likely causative agent is A. Aspergillus B. Mucor C. Pseudomonas D. Staphylococcus aureus E. Haemophilus influenzae"

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 65-year-old man with a history of chronic hypertension presents to the ED with sudden-onset tearing chest pain that radiates to his jaw. His BP is 205/110 mmHg, HR is 90 beats per minute, RR is 20 breaths per minute, and oxygen saturation is 97% on room air. He appears apprehensive. On cardiac examination you hear a diastolic murmur at the right sternal border. A chest x-ray reveals a widened mediastinum. Which of the following is the preferred study of choice to diagnose this patient's condition? A. Electrocardiogram ECG. B. Transthoracic echocardiography TTE. C. Transesophageal echocardiographyte E. D. Computed tomography CT. scan E. Magnetic resonance imaging MRI."

C

"A 65-year-old retired banker who spends the summer on Nantucket Island off the Massachusetts coast returned to his home in Boston early in september. He noted the gradual onset of a febrile illness with chills, sweats, myalgias, and yellow eyes. His doctor palpated the spleen and noted a macrocytic anemia, hyperbilirubinemia, and a high serum level of lactic dehydrogenase on laboratory examination. Which of the following would be the most helpful diagnostic procedure at this point? A. blood culture B. Examination of leukocytes on blood film C. Examination of erythrocytes on blood film D. Splenic biopsy E. Liver biopsy"

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 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 10-year-old boy is seen in a rural Arizona clinic because of prostration, fever of 40 C104 F. , and severe headachE. Examination is negative for rash, stiff neck, joint tenderness, and chest and abdominal abnormalities. However, several tender, enlarged lymph nodes are palpated in the left axilla, which is very edematous. The test most likely to be of greatest help in the immediate management of this boy would be A. blood culture B. examination of a blood smear C. biopsy of an axillary lymph node D. aspiration and Gram stains of an axillary lymph node E. surgical excision of an axillary node"

D

"A 24-year-old man is concerned because of the appearance of several light brown spots on his trunk Plate D. The lesionslimited to the chest, back, abdomen, and upper arms. are flat and sharply marginated and have a fine scale that is easily scraped off. The most appropriate diagnostic study is A. Giemsa stain of scraped material Tzanck preparation. B. bacterial culture of the lesions C. fungal culture of the lesions D. microscopic examination of potassium hydroxide treated scrapings E. examination of the serum for anticardiolipin antibody"

D

"A 26-year-old man from Cape Cod sees his physician because of a 3-week history of an expanding, slightly burning ring of rednessas shown in Plate C. that first surrounded a red papule on the posterior neck. He complains of headaches, generalized muscle aches, anorexia, and malaise. On examination, he is noted to be febrile [38.3 C101 F]; his rash is slightly raised and slightly tender and displays central clearing but no scaling, even after vigorous scraping. Which of the following vectors has been strongly associated with the type of rash described above? A. Kissing bug B. Spider C. Flea D. Tick E. Housefly"

D

"A 28-year-old Egyptian farmer presents with left flank pain. Ultrasonography reveals enlargement of the left ureter and hydronephrosis of the left kidney. Cystoscopy reveals a mass extending from the left ureter into the bladder. Parasitic ova150 by 50 mm. are noted in the urine and in a biopsy of the ureteral mass. Which of the following statements is correct? A. renal failure is likely in the absence of treatment. B. The lesion is not reversible by chemotherapy. C. In the absence of treatment, the patient has an increased risk for transitional cell carcinoma of the bladder. D. The patient is suffering from schistosomiasis. E. The organism causing this problem is spread by fecal oral contact."

D

"A 35-year-old patient undergoing initial therapy for acute myeloid leukemia has tolerated the chemotherapy well. However, 6 days after the initiation of chemotherapy and10 days after the insertion of an indwelling transthoracic intravenous deviceHickman catheter. , he develops a fever. Examination is negative except for erythema and tenderness at the insertion site and along the subcutaneous tunnel. blood cultures and chest x-ray are negative. The most appropriate course of action at this point is to A. remove the line and insert a new one over a guidewire B. begin intravenous vancomycin C. begin intravenous vancomycin and gentamicin D. remove the line E. begin intravenous vancomycin, gentamicin, and amphotericin B"

D

"A 38-year-old woman has undergone allogeneic bone marrow transplantation for acute myelogenous leukemia in second remission from a matched unrelated donor; she now develops pneumonia proven to be due to cytomegalovirus. The patient is placed on ganciclovir, but the pneumonia progresses. Which of the following drugs may potentially be effective in this situation? A. Acyclovir B. IFN-2 C. Almuvidine D. Foscarnet E. Ribovirin"

D

"A 40-year-old Canadian who operates a tropical fish store sees his physician because of a nonhealing ulcer on his left arm. He is afebrile and gives no history of night sweats, weight loss, or other constitutional symptoms. Biopsy of the lesion shows granulomatous inflammation and rare acid-fast organisms. A tuberculin test is negative. This man most likely has an infection caused by A. Mycobacterium tuberculosis B. M. ulcerans C. M. kansasii D. M. marinum E. M. fortuitum"

D

"A 42-year-old man found vomiting in the street is brought to the ED by emergency medical serviceseMS. . He has a known history of alcohol abuse with multiple presentations for intoxication. Today, the patient complains of acute onset, persistent chest pain associated with dysphagia, and pain upon flexing his neck. His BP is 115/70 mm Hg, HR is 101 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 97% on room air. As you listen to his heart, you hear a crunching sound. His abdomen is soft with mild epigastric tenderness. The ECG is sinus tachycardia without ST-T-wave abnormalities. On chest x-ray, you note lateral displacement ofthe left mediastinal pleural. What is the most likely diagnosis? A. Aspiration pneumonia B. Acute pancreatitis C. Pericarditis D. Esophageal perforation E. Aortic dissection"

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 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 60-year-old man from North Carolina presents with a fever and progressive confusion. His wife reports that he experienced1 week of fever, headache, and malaise before the more profound neurologic condition occurred. Just prior to the presentation at the hospital he had a generalized seizure. The IgM capture enzyme immunoassay of the patient's CSF was positive for the eastern equine encephalitis virus. An MRI would most likely reveal A. normal findings B. meningeal enhancement C. hydrocephalus D. lesions in the basal ganglia E. temporal lobe enhancement"

D

"A 62-year-old gardener who has chronic lymphocytic leukemia develops lymphangitis and a painless, nodular lesion on his wrist. Subsequently, he becomes severely ill with cavitary right-upper-lobe pneumonia; Sporothrix schenckii is isolated. He should be treated with A. chloramphenicol B. potassium iodide C. penicillin D. amphotericin B E. flucytosine"

D

"A 65-year-old Greek woman visiting her children in new York City complains of upper abdominal pain. The patient is brought to the family physician, who notices icteric sclera and a mass in the right upper quadrant. CT reveals a 10-cm multiloculated cyst with mural calcification that is compressing the common bile duct. Which of the following statements is correct concerning this clinical situation? A. Treatment with the antiamebic agent chloroquine is indicated. B. Treatment with an antiechinococcal agent such as albendazole is sufficient. C. The adult parasite resides in the patient's intestine. D. Infection was probably caused by exposure to infected dogs. E. Surgery is contraindicated because of the risk of anaphylaxis from dissemination of infectious material."

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

"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 21-year-old woman presents to the ED complaining of lightheadedness. Her symptoms appeared 45 minutes ago. She has no other symptoms and is not on any medications. She has a medical history of mitral valve prolapse. Her HR is 170beats per minute and BP is 105/55 mm Hg. Physical examination is unremarkable. After administering the appropriate medication, her HR slows down and her symptoms resolve. You repeat a 12-lead ECG that shows a rate of 89 beats per minute with a regular rhythm. The PR interval measures 100 msec and there is a slurred upstroke of the QRS complex. Based on this information, which of the following is the most likely diagnosis? A. ventricular tachycardia B. Atrial flutter with 3:1 block C. Atrial fibrillation D. Lown-Ganong-levine LGL. syndrome E. Wolff-Parkinson-WhiteWPW. syndrome"

E

"A 22-year-old female intravenous drug abuser and admitted prostitute is seen in the emergency room with a complaint of vaginal discharge. She is afebrile and has no complaint or physical findings except that she has yellow mucopurulent discharge emanating from the cervical OS. Gram's stain of the discharge reveals polymorphonuclear leukocytes, but organisms are not seen. The patient has no primary care doctor. The most appropriate action at this time is to A. await results of cervical swab cultures B. schedule the patient for colposcopy to cauterize the endocervical cells that have migrated onto the visible ectocervix C. treat for chlamydial infection with doxycycline, 100 mg PO bid for 7 days D. treat for gonorrheal infection with ciprofloxacin, 500 mg PO E. treat for both chlamydial and gonorrheal infection with cefixime, 400 mg PO, plus azithromycin, 1 g PO"

E

"A 23-year-old woman who will be doing Peace Corps work in Bolivia has had all her routine immunizations and has been vaccinated against hepatitis A and B. Which of the following is the most reasonable recommendation for prophylaxis against common infectious diseases in the country of her destination? A. Chloroquine B. mefloquine C. Yellow fever vaccine D. Yellow fever vaccine plus chloroquine E. Yellow fever vaccine plus mefloquine"

E

"A 35-year-old Samoan presents with recurrent fever, headache, photophobia, and painful lymphangitis in the left leg. The best way to diagnose filariasis caused by Wuchereria bancrofti is A. biopsy of any inflamed lymph nodes to demonstrate the adult worm B. serologic studies C. observation of intense itching after a single dose of diethylcarbamazine D. demonstration of microfilariae after injection of blood into mice E. demonstration of microfilariae in blood taken between 9 P. M. and 2 A. M."

E

"A 35-year-old intravenous drug abuser with HIV infection is being managed with combination antiretroviral therapy. The patient was doing well on his current medical regimen, which consists of lamivudine and saquinavir as well as methodone, TMP/SMZ, and fluconazole. Although he has been stable clinically of late, efavirenz has recently been added to his medical regimen in an attempt to decrease a rising viral loaD. After1 week of therapy with efavirenz, the patient develops abdominal cramps, malaise, sweats, and anxiety. The most likely reason for the patient's symptoms is A. primary efavirenz toxicity B. increased fluconazole levels C. infection with Pneumocystis due to decreased TMP/SMZ levels D. lamivudine toxicity secondary to decreased albumin binding E. reduced plasma methadone concentration."

E

"A 36-year-old woman presents to the ED with sudden onset of leftsided chest painand mild shortness of breath that began the night before. She was able to fall asleep without difficulty but woke up in the morning with persistent pain that is worsenedupon taking a deep breath. She walked up the stairs at home and became very shortof breath, which made her come to the ED. Two weeks ago, she took a 7-hour flight from Europe and since then has left-sided calf pain and swelling. What is the most common ECG finding for this patient's presentation? A. S1Q3T3 pattern B. Atrial fibrillation C. Right-axis deviation D. Right-atrial enlargement E. Tachycardia or nonspecific ST-T-wave changes"

E

"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-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 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 59-year-old man presents to the ED with left-sided chest pain and shortness of breath that began 2 hours prior to arrival. He states the pain is pressure-like and radiates down his left arm. He is diaphoretic. His BP is 160/80 mm Hg, HR 86 beats per minute, and RR 15 breaths per minute. ECG reveals 2-mm ST-segment elevation in leads I, aVL, V3 to V6. Which of the following is an absolute contraindication to receiving thrombolytic therapy? A. Systolic BP greater than 180 mm Hg B. Patient on Coumadin and aspirin C. Total hip replacement 3 months ago D. Peptic ulcer disease E. Previous hemorrhagic stroke"

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 with a history of heavy smoking and moderately severe chronic obstructive pulmonary disease COPD. has been feeling poorly. He reports cough, chills, pleuritic chest pain, and low-grade fever. Chest xray reveals a small dense infiltrate in the right lower lobe. Gram's stain of the patient's sputum reveals numerous gram-negative cocci, many of which occur in pairs. The most appropriate therapy would be A. no antimicrobial therapy is required B. tetracycline C. ciprofloxacin D. trimethoprim/sulfamethoxazole TMP/SMZ. E. penicillin/clavulanic acid"

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 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

"An 18-year-old manpictured in Plate F. presents because of unsightly facial inflammation. Which of the following statements is correct? A. Closed comedoneswhiteheads. are less commonly associated with the inflammatory lesions than are open comedonesblackheads. B. Glucocorticoids, although not indicated except in the most severe cases, would likely result in improvement. C. Vigorous scrubbing of the face, which will eliminate surface oils, is indicated. D. Systemic antibiotic therapy is unlikely to be helpful. E. Patients on systemic retinoic acid may experience very dry skin and hypertriglyceridemia."

E