MD 1001-1200 ចម្លើយពេញ

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1005 A 43-year-old man presents to the ED complaining of progressively worsening abdominal pain over the past 2 days. The pain is constant and radiates to his back. He also describes nausea and vomiting and states he usually drinks 6 pack of beer daily, but has not had a drink for 2 days. His BP is 144/75 mm Hg, HR is 101 beats per minute, temperature is 99.8°F, and RR is 14 breaths per minute. He is lying on his side with his knees flexeD. Examination shows voluntary guarding and tenderness to palpation of his epigastrium. Laboratory results reveal WBC 10,500/μL, hematocrit 51%, platelets 225/μL, and lipase 620 IU. An abdominal radiograph reveals a nonspecific bowel gas pattern. There is no free air under the diaphragm. Which of the following is the most appropriate next step in management? A Admit to the hospital for medical management and supportive care B Send home with antibiotic therapy C Admit to the hospital for endoscopy D Admit to the hospital for exploratory laparotomy

1006 A 58-year-old woman is brought to the emergency department ED. by emergency medical service EMS. after slipping on a patch of ice while walking to work and hitting her head on the cement pavement. Bystanders acknowledged that the patient was unconscious for approximately 1 minute. On arrival, her vital signs are: blood pressure BP. 155/75 mm Hg, heart rate HR. 89 beats per minute, respiratory rate RR. 18 breaths per minute, and pulse oxygenation 98% on room air. She has a 5-cm laceration to the back of her head that is actively bleeding. You ask the patient what happened but she cannot remember. You inform her that she is in the hospital as a result of a fall. Over the next 10 minutes she asks you repeatedly what happened and where she is. You do not find any focal neurologic deficits. As you bring the patient to the CT scanner she vomits once. CT results show a normal brain scan. Which of the following is the most likely diagnosis? A Cerebral concussion B Diffuse axonal injury C Cerebral contusion D Posttraumatic epilepsy

1014 An 18-year-old man presents to the ED after getting stabbed in his abdomen. His HR is 140 beats per minute and BP is 90/40 mm Hg. He is yelling that he is in pain. Two large bore IVs are inserted into his antecubital fossa and fluids are running wide open. After 2 L of fluids, his BP does not improve. Which of the following is the most common organ injured in stab wounds? A Liver B Small bowel C Stomach D Colon

1019 Which type of health care delivery system encourages physicians to see more patients but to provide fewer services? A Capitation B Fee-for-service C Fixed salary compensation D Out-of-pocket

1021 A patient is seen in the clinic for evaluation of chest pain. The patient is 35 years old and has no medical illnesses. She reports occasional intermittent chest pain that is unrelated to exercise but is related to eating spicy food. The physician's pretest probability for coronary artery disease causing these symptoms is low; however, the patient is referred for an exercise treadmill test, which shows ST depression after moderate exercise. Using Bayes' theorem, how does one interpret these test results? A The pretest probability is low, and the sensitivity and specificity of exercise treadmill testing in females are poor; therefore, the exercise treadmill test is not helpful in clinical decision making in this case. B Regardless of the pretest probability, the abnormal result of this exercise treadmill testing requires further evaluation. C Because the pretest probability for coronary artery disease is low, the patient should be referred for further testing to rule out this diagnosis. D Because the pretest probability was low in this case, a diagnostic test with a low sensitivity and specificity is sufficient to rule out the diagnosis of coronary artery disease.

1032 A 56-year-old patient arrives in your clinic with worsening somnolence, per his wife. You have followed him for several years for his long-standing liver disease related to heavy alcohol use in the past and hepatitis C infection, as well as chronic low back pain related to trauma. He has recently developed ascites but has had a good response to diuretic therapy. He has no history of gastrointestinal bleeding, he denies fever, chills, abdominal pain, tremor, or any recent change in his medicines, which include furosemide, 40 mg daily; spironolactone, 80 mg daily; and extended-release morphine, 30 mg twice a day. He is afebrile with normal vital signs. His weight is down 5 kg since initiating diuretic therapy. Physical examination is notable for a somnolent but conversant man with mild jaundice, pinpoint pupils, palmar erythema, spider hemangiomas on his chest, a palpable nodular liver edge at the costal margin, and bilateral 1+ lower extremity edema. He does not have asterixis, abdominal tenderness, or an abdominal fluid wave. Laboratory results compared to 3 months previously reveal an increased INR, from 1.4 to 2.1; elevated total bilirubin, from 1.8 to 3.6 mg/dL; and decreased albumin from 3.4 to 2.9 g/L; as well as baseline elevations of his aspartate and alanine aminotransferases (54 U/L and 78 U/L, respectively). Serum NH4 is 16. What would be a sensible next step for this patient? A Decrease his morphine dose by 50% and reevaluate him in a few days B Initiate antibiotic therapy C Initiate haloperidol therapy D Initiate lactulose therapy

1036 Which of the following class of medicines has been linked to the occurrence of hip fractures in the elderly? A Benzodiazepines B Opiates C Angiotensin-converting enzyme inhibitors D Beta blockers

1042 A 40-year-old female is exposed to mustard gas during a terrorist bombing of her office building. She presents to the emergency department immediately after exposure without complaint. The physical examination is normal. What is the next step? A Admit the patient for observation because symptoms are delayed 2 h to 2 days after exposure and treat supportively as needed. B Administer 2-pralidoxime as an antidote and observe for symptoms. C Irrigate the patient's eyes and apply ocular glucocorticoids to prevent symptoms from developing. D Discharge the patient to home as she is unlikely to develop symptoms later.

1049 A 68-year-old alcoholic arrives in the emergency department after being found in the snow on a cold winter night in Chicago. His core temperature based on rectal and esophageal probe is 27°C. Pulse is 30 beats/min and blood pressure is 75/40 mmHg. He is immobile and lacks corneal, oculocephalic, and peripheral reflexes. He is immediately intubated and placed on a cardiac monitor. He then converts to ventricular fibrillation: a defibrillation attempt at 2 J/kg is not successful. What should be the next immediate step in management? A Active rewarming with forced-air heating blankets, heated humidified oxygen, heated crystalloid infusion B Amiodarone infusion C Insertion of a transvenous pacemaker D Passive rewarming with numerous blankets for insulation

1060 Which of the following is the best indicator of prognosis and longevity in a geriatric patient? A Functional status B Life span of first-degree relatives C Marital status D Number of medical comorbidities

1061 Diagnostic criteria for delirium as a cause of a confused state in a hospitalized patient include all of the following except A agitation B altered level of consciousness C disorganized thinking D fluctuating mental status

1066 A 32-year-old man with a history of HIV infection presents to the hospital with nausea, abdominal distention and projectile vomiting that developed over the previous 8-12 h. He denies fevers, chills, diaphoresis, melena, or diarrhea. Over the past 3 months, he has lost 30 lb in the context of advanced HIV infection. He has never had abdominal surgery. On examination, his abdomen is distended, with high-pitched intermittent bowel sounds and guarding but no rebound. A periumbilical bruit is also detected. Abdominal x-ray reveals a small bowel obstruction with a probable cut-off point in the mid duodenum. What is the diagnostic test of choice for diagnosing the cause of the underlying obstruction? A Abdominal CT with abdominal angiogram B Enteroscopy C Laparoscopy D Serum carcinoembryonic antigen (CEA) level

1072 A 35-year-old woman comes to your clinic complaining of shortness of breath. It is immediately apparent that she has a bluish tinge of her face, trunk, extremities, and mucus membranes. Which of the following diagnoses is most likely? A Atrial septal defect B Myocarditis C Raynaud's phenomenon D Sepsis

1084 A wide-based gait with irregular lurching and erratic foot placement but no subjective dizziness characterizes which type of gait ataxia? A Cerebellar dysfunction B Frontal gait abnormality C Inner ear dysfunction D Parkinsonian syndromes

1088 Which of the following methods is most effective for the diagnosis of corneal abrasions? A Fluorescein and cobalt-blue light examination B Intraocular pressure measurement C Lid eversion for foreign body examination D Oculoplegia and dilation

1093 A 69-year-old male dialysis patient with poorly controlled diabetes, heart failure and chronic indwelling catheters presents with fever and loss of vision in the left eye developing over the past 6 h. Vital signs are notable for a temperature of 101.3°F, heart rate of 105/min, and blood pressure of 125/85. Which test is most likely to confirm the diagnosis? A Blood cultures B Blood smear C Brain MRI D Rheumatic panel

1099 A 35-year-old woman with a history of degenerative joint disease comes to clinic complaining of dark urine over the past several weeks. She has had arthritis in her hips, knees, and shoulders for about 2 years. On examination, she is noted to have gray-brown pigmentation of the helices of both ears. Which of the following disorders is most likely? A Alkaptonuria B Hawkinsinuria C Homocystinuria D Hyperprolinemia type I

1105 In what percentage of pregnancies do chromosomal disorders occur? A 10-25% B 0.1-0.5% C 1-2% D 2-5%

1115 Diseases that are inherited in a multifactorial genetic fashion (i.e., not autosomal dominant, autosomal recessive, or X-linked) and are seen more frequently in persons bearing certain histocompatibility antigens include A gluten-sensitive enteropathy B neurofibromatosis C adult polycystic kidney disease D Wilson's disease

1120 The presence of Howell-Jolly bodies, Heinz bodies, basophilic stippling, and nucleated red blood cells in a patient with hairy cell leukemia prior to any treatment intervention implies which of the following? A Diffuse splenic infiltration by tumor B Disseminated intravascular coagulation (DIC) C Hemolytic anemia D Pancytopenia

1121 Which of the following is true regarding infection risk after elective splenectomy? A Patients are at no increased risk of viral infection after splenectomy. B Patients should be vaccinated 2 weeks after splenectomy. C Splenectomy patients over the age of 50 are at greatest risk for postsplenectomy sepsis. D Staphylococcus aureus is the most commonly implicated organism in postsplenectomy sepsis.

1122 A 64-year-old man comes to your office complaining of erectile dysfunction. He is not able to generate an erection. His past medical history is significant for coronary artery bypass grafting many years ago, status post-carotid endarterectomy, and a mildly reduced left ventricular ejection fraction. His medications include aspirin, carvedilol, simvastatin, lisinopril and furosemide. He does not take nitrates. On physical examination, you note normal-sized testes and a normal prostate. There are no fibrotic changes along the penile corpora. His libido is intact. What is the most likely cause of this patient's erectile dysfunction? A Disturbance of blood flow B Low testosterone C Medication related D Psychogenic

1126 You are conducting research on a novel nonsteroidal anti-inflammatory drug (NSAID). To ascertain the safety profile of the drug you recruit 100 volunteers who lack the ability to produce IgE. All subjects receive the drug. A minority of participants experience an anaphylactic reaction within minutes of ingesting the drug. IgE levels are undetectable in all 100 subjects. What is the most likely explanation for this phenomenon? A The drug itself directly triggered the immune system in a minority of patients. B The IgE receptor in the patients with anaphylaxis is constitutively activated. C The patients who had anaphylaxis have received this drug before. D The patients who had anaphylaxis overexpress CD8+ T cells.

1134 A patient with metabolic acidosis, reduced anion gap, and increased osmolal gap is most likely to have which of the following toxic ingestions? A Lithium B Methanol C Oxycodone D Propylene glycol

1144 In the developed world, seroprevalence of Helicobacter pylori infection is currently A decreasing B increasing C staying the same D unknown

1147 Sensitive and specific serum or urine diagnostic tests exist for all of the following invasive fungal infections except A blastomycosis B coccidioidomycosis C cryptococcosis D histoplasmosis

1154 All of the following clinical features are common in patients with anorexia nervosa except A Avoid food-related occupations B Distorted body image C Engage in binge eating D Exercise extensively

1156 It is hospital day 16 for a 49-year-old homeless patient who is recovering from alcohol withdrawal and delirium tremens. She spent the first 9 days of this hospitalization in the intensive care unit but is now awake, alert, and conversant. She has a healing decubitus ulcer, and her body mass index is 19 kg/m2. Laboratory data show an albumin of 2.9 g/dL and a prothrombin time of 18 s (normal range). Is this patient malnourished? A Cannot be determined, need more information. B No. Given her heavy alcohol intake, her prothrombin time is expected to be delayed. C No. She has a low resting energy expenditure and her intact mental state argues against malnutrition. D Yes, this degree of hypoalbuminemia is uncommon in cirrhosis and is likely due to malnutrition.

1172 A patient with alcoholic cirrhosis has increasing ascites despite dietary sodium control and diuretics. A paracentesis shows clear, turbid fluid. There are 2300 white blood cells (WBCs) and 150 red blood cells per mi- croliter. The WBC differential shows 75% lymphocytes. Fluid protein is 3.2 g/dL and the serum-ascites albumin gradient (SAAG) is 1.0 g/dL. What is the most appropriate next study in this patient's management? A Adenosine deaminase activity of the ascitic fluid B CT scan of the liver C Peritoneal biopsy D None; consider transplant evaluation

1174 A 45-year-old woman presents to the emergency room for evaluation of fatigue, fever, and acute onset of joint pain and swelling of the right knee, left ankle, and right second toe. She reports that she was ill with a diarrheal illness about 2 weeks ago. She did not seek evaluation as the symptoms resolved spontaneously over 48 h. She did lose about 2.3 kg, which she has been unable to regain. Three days ago, she developed a feeling of malaise with fevers and pain in her right second toe. Additional IX-17. (Continued) joints have become inflamed over the ensuing 72 h. She denies any prior similar episodes. She is not currently sexually active and estimates her last sexual activity to be 8 months prior to presentation. She has a history of seasonal rhinitis, but is taking no medications currently. On examination, she is febrile at 38.4°C. Her left eye has evidence of conjunctival injection. There is a superficial ulcer on the inside of her lower lip that is not painful. The right knee is warm to touch with an effusion. Passive movement results in pain. The left ankle is similarly warm and painful. The right second great toe has the appearance of a "sausage digit." There is also pain with palpation at the tendinous insertion of both Achilles tendons. There are no genital ulcers or discharge. No rash is present. Arthrocentesis is performed and is consistent with inflammatory arthritis without crystals or organisms seen on Gram stain. Cervical probes for Neisseria gonorrhoeae and Chlamydia trachomatis are negative. Reactive arthritis following Campylobacter infection is suspected with positive serum antibodies to C. jejuni. Which of the following statements is true regarding this diagnosis? A Chronic joint symptoms affect 15% of individuals, and recurrences of the acute syndrome may occur. B Presence of HLA-B27 antigen predicts individuals who are likely to have a better prognosis. C Reactive arthritis is self-limited and should be expected to resolve spontaneously over the next 2 weeks. D The causative organism has no effect on long-term outcomes following an initial episode of reactive arthritis.

1183 You are asked to see a 15-year-old African-American girl because of anovulation. She has never experienced menarche, and her mother is concerned since most women in her family experience menarche around 13 years of age. The patient has prominent nipples and the areola are part of the breast. Pubic hair is dark, curly, and coarse and is abundant in the pubic area and inner thigh. There is no facial hair, and muscular development is age and sex appropriate. She does have cyclical pelvic pain. What is the next step in her evaluation? A Examination with a speculum B MRI of the abdomen and pelvis C Serum follicle-stimulating hormone (FSH) D Serum prolactin

1185 A 38-year-old homeless man presents to the emergency room with a transient ischemic attack characterized by a facial droop and left arm weakness lasting 20 min, and left upper quadrant pain. He reports intermittent subjective fevers, diaphoresis, and chills for the past 2 weeks. He has had no recent travel or contact with animals. He has taken no recent antibiotics. Physical examination reveals a slightly distressed man with disheveled appearance. His temperature is 38.2°C; heart rate is 90 beats per minute; blood pressure is 127/74 mmHg. He has poor dentition. Cardiac examination reveals an early diastolic murmur over the left 3d intercostal space. His spleen is tender and 2 cm descended below the costal margin. He has tender painful red nodules on the tips of the third finger of his right hand and on the fourth finger of his left hand that are new. He has nits evident on his clothes, consistent with body louse infection. White blood cell count is 14,500, with 5% band forms and 93% polymorphonuclear cells. Blood cultures are drawn followed by empirical vancomycin therapy. These cultures remain negative for growth 5 days later. He remains febrile but hemodynamically stable but does develop a new lesion on his toe similar to those on his fingers on hospital day 3. A transthoracic echocardiogram reveals a 1-cm mobile vegetation on the cusp of his aortic valve and moderate aortic regurgitation. A CT scan of the abdomen shows an enlarged spleen with wedge-shaped splenic and renal infarctions. What test should be sent to confirm the most likely diagnosis? A Bartonella serology B Epstein-Barr virus (EBV) heterophile antibody C HIV polymerase chain reaction (PCR) D Peripheral blood smear E Q fever serology

1200 A 79-year-old man has had a diabetic foot ulcer overlying his third metatarsal head for 3 months but has not been compliant with his physician's request to offload the affected foot. He presents with dull, throbbing foot pain and subjective fevers. Examination reveals a putrid-smelling wound notable also for a pus-filled 2.5 cm wide ulcer. A metal probe is used to probe the wound and it detects bone as well as a 3-cm deep cavity. Gram stain of the pus shows gram-positive cocci in chains, gram-positive rods, gram-negative diplococci, enteric-appearing gram-negative rods, tiny pleomorphic gram-negative rods, and a predominance of neutrophils. Which of the following empirical antibiotic regimens is recommended while blood and drainage cultures are processed? A Ampicillin/sulbactam, 1.5 g IV q4h B Clindamycin, 600 mg PO tid C Linezolid, 600 mg IV bid D Metronidazole, 500 mg PO qid E Vancomycin, 1g IV bid

1038 A recent 18-year-old immigrant from Kenya presents to a university clinic with fever, nasal congestion, severe fatigue, and a rash. The rash started with discrete lesions at the hairline that coalesced as the rash spread caudally. There is sparing of the palms and soles. Small white spots with a surrounding red halo are noted on examination of the palate. The patient is at risk for developing which of the following in the future? A Encephalitis B Epiglottitis C Opportunistic infections D Postherpetic neuralgia

1161 An elevation in which of the following hormones is consistent with the effects of anorexia nervosa? A Cortisol B Gonadotropin-releasing hormone (GnRH) C Leptin D Thyroxine (T4)

1184 A 24-year-old man with advanced HIV infection presents to the emergency department with a tan painless nodule on the lower extremity (Figure IV-2, Color Atlas). He is afebrile and has no other lesions. He does not take antiretroviral therapy, and his last CD4+ T cell count was 20/μL. He lives with a friend who has cats and kittens. A biopsy shows lobular proliferation of blood vessels lined by enlarged endothelial cells and a mixed acute and chronic inflammatory infiltrate. Tissue stains show gram negative bacilli. Which of the following is most likely to be effective therapy for the lesion? A Azithromycin B Cephazolin C Interferon α D Penicillin E Vancomycin

1080 All of the following should be components of the routine evaluation of any patient undergoing medium- or high-risk non-cardiac surgery except A 12-lead resting electrocardiogram B chest radiograph C detailed history D physical examination

1094 Exposure to which of the following types of radiation would result in thermal injury and burns but would not cause damage to internal organs because the particle size is too large to cause internal penetration? A Alpha radiation B Beta radiation C Gamma radiation D Neutron particles

1024 How many patients will have to be treated with drug X to prevent one death? A 2 B 8 C 12.5 D 50

1085 A patient with a narrow-based gait instability complains that he needs to look at his feet while he walks to prevent falling. He feels wobbly standing with his eyes closed and notes frequent falls. On examination, he has no difficulty initiating gait, his stride is regular, strength is normal, and there is no tremor. Review of routine blood work drawn 3 months prior reveals a hematocrit of 29% with an elevated mean corpuscular volume. Which of the following is the most likely diagnosis? A Amyotrophic lateral sclerosis B Cerebellar tumor C Pernicious anemia D Parkinson's disease

1130 All the following are well-documented physical effects of smoking marijuana except A decreased sperm count B chronic bronchial irritation C delayed gastric emptying D exercise-induced angina

1150 You are seeing a patient in follow-up 2 weeks after hospitalization. The patient is recovering from nosocomial pneumonia due to a resistant Pseudomonas spp. His hospital course was complicated by a deep venous thrombosis. The patient is currently on IV piperacillin/ tazobactam and tobramycin via a tunneled catheter, warfarin, lisinopril, hydrochlorothiazide, and metoprolol. Laboratory data this morning show an INR of 8.2. At hospital discharge his INR was stable at 2.5. He has no history of liver disease. What is the most likely cause of the elevated INR? A The patient has inadvertently overdosed. B The patient has developed a recurrent deep venous thrombosis, which has affected the laboratory data. C The patient is deficient in vitamin K and needs supplementation. D The warfarin prescription was written incorrectly at the time of discharge.

1001 A 22-year-old woman is brought to the ED by ambulance complaining of sudden onset of severe abdominal pain for 1 hour. The pain is in the RLQ and is not associated with nausea, vomiting, fever, or diarrhea. On the pelvic examination you palpate a tender right adnexal mass. The patient's last menstrual period was 6 weeks ago. Her BP is 95/65 mm Hg, HR is 124 beats per minute, temperature is 99.8°F, and RR is 20 breaths per minute. Which of the following are the most appropriate next steps in management? A Provide her oxygen via face mask and administer morphine sulfate. B Administer morphine sulfate, order an abdominal CT with contrast, and call an emergent surgery consult. C Send the patient's urine for analysis and order an abdominal CT. D Bolus 2-L NS, order a type and crossmatch and β-hCG, and call gynecology for possible surgery.

1002 A 33-year-old woman presents to the ED complaining of fever, vomiting, and gradually worsening RUQ pain. She states that her pain radiates to her back. Her BP is 130/75 mm Hg, HR is 90 beats per minute, temperature is 100.9°F, and RR is 17 breaths per minute. While examining her abdomen you palpate her RUQ and notice that she momentarily stops her inspiration. What is the name of this classic sign? A Grey-Turner sign B Kernig sign C McMurray sign D Murphy sign

1008 A 25-year-old man is brought into the trauma resuscitation room after his motorcycle is struck by another vehicle. EMS reports that the patient was found 20 ft away from his motorcycle, which was badly damaged. His vital signs include a BP of 90/60 mm Hg, HR of 115 beats per minute, RR of 22 breaths per minute, and pulse oxygenation of 100% on facemask. Which of the following is the smallest amount of blood loss that produces a decrease in the systolic BP in adults? A Loss of 5% of blood volume B Loss of 10% of blood volume C Loss of 15% to 30% of blood volume D Loss of 30% to 40% of blood volume

1009 You are notified by the EMS dispatcher that there is a multiple-car collision on the local highway with many injuries. He states that there are two people dead at the scene, one person is critically injured and hypotensive, and three people have significant injuries, but with stable vital signs. Which of the following is the leading cause of death and disability in trauma victims? A Abdominal injury B Thoracic injury C Back injury D Head injury

1011 A 20-year-old man presents to the ED with multiple stab wounds to his chest. His BP is 85/50 mm Hg and HR is 123 beats per minute. Two large-bore IVs intravenous. are established and running wide open. On examination, the patient is mumbling incomprehensibly, has good air entry on lung examination, and you notice jugular venous distension. As you are listening to his heart, the nurse calls out that the patient has lost his pulse and that she cannot get a BP reading. Which of the following is the most appropriate next step in management? A Atropine B Epinephrine C Bilateral chest tubes D ED thoracotomy

1012 A 22-year-old man calls the ED from a local bar stating that he was punched in the face 10 minutes ago and is holding his front incisor tooth in his hand. He wants to know what is the best way to preserve the tooth. Which of the following is the most appropriate advice to give the caller? A Place the tooth in a napkin and bring it to the ED B Place the tooth in a glass of water and bring it to the ED C Place the tooth in a glass of beer and bring it to the ED D Pour some water over the tooth and place it immediately back into the socket

1015 A 61-year-old man presents to the ED with chest wall pain after a motor vehicle collision. He is speaking full sentences, breath sounds are equal bilaterally, and his extremities are well-perfused. His BP is 150/75 mm Hg, HR is 92 beats per minute, and oxygen saturation is 97% on room air. Chest radiography reveals fractures of the seventh and eighth ribs of the right anterolateral chest. He has no other identifiable injuries. Which of the following is the most appropriate treatment for this patient's rib fractures? A Apply adhesive tape on the chest wall perpendicular to the rib fractures B Insert a chest tube into the right thorax C Bring the patient to the OR for surgical fixation D Analgesia and incentive spirometry

1022 An effective way to measure the accuracy of a diagnostic test is a positive likelihood ratio [sensitivity/(1 - specificity)], which is also defined as the ratio of the probability of a positive test result in a patient with disease to the probability of a positive test result in a patient without disease. What other piece of information is needed along with a positive likelihood ratio to estimate the possibility of a given disease in a certain patient with a positive test result? A Disease prevalence in the patient's geographic region B Negative predictive value of the test C Positive predictive value of the test D Pretest probability of the disease in a patient

1025 A healthy 23-year-old female is referred to your clinic after being seen in the emergency department for intermittent severe chest pain. During her visit, she is ruled out for cardiac ischemia, with negative biomarkers for cardiac ischemia and unremarkable electrocardiograms. An exercise single photon emission CT (SPECT) myocardial perfusion test was performed, and a reversible exercise-induced perfusion defect was noted. The test was read as positive. The patient was placed on aspirin. She is quite concerned that she continues to have chest pain intermittently on a daily basis without any consistency in regards to time or antecedent activity. She is otherwise active and feeling well. She smokes socially on weekends. She has no family history of early coronary disease. What would be the best next course of action? A Cardiac catheterization B CT of her coronary arteries C Dobutamine stress echocardiogram D Evaluation for non-cardiac source of her chest pain

1027 All of the following statements regarding women's health are true except A Coronary heart disease mortality rates have been falling in men over the past 30 years, while increasing in women. B Women have longer QT intervals on resting ECG, predisposing them to higher rates of ventricular arrhythmia. C Women are more likely than men to have atypical symptoms of angina such as nausea, vomiting, and upper back pain. D Women with myocardial infarction (MI) are more likely to present with ventricular tachycardia, whereas men are more likely to present with cardiogenic shock.

1028 When ordering an evaluation of coronary artery disease in a female patient, all of the following are true except A Exercise stress testing has more false positives in women than in men. B Exercise stress testing has more false negatives in women than in men. C Women are less likely than men to undergo angioplasty and coronary artery bypass grafting (CABG). D Women undergoing coronary artery bypass surgery have lower 5- and 10-year survival rates than men.

1029 Which of the following statements regarding cardiovascular risk is true? A Aspirin is effective as a means of primary prevention in women for coronary heart disease. B Cholesterol-lowering drugs are less effective in women than in men for primary and secondary prevention of coronary heart disease. C Low high-density lipoprotein (HDL) and diabetes mellitus are more important risk factors for men than for women for coronary heart disease. D Total triglyceride levels are an independent risk factor for coronary heart disease in women but not in men.

1031 You prescribe an extended-release antihypertensive agent for your patient at a dosing interval of 24 h. The half-life of the agent is 48 h. Three days later the patient's blood pressure is not controlled. At this point you should A add a second agent B double the dose of the current agent C increase the frequency of the current dose to twice/day D recheck the blood pressure in 1 week

1039 You are a physician working in an urban emergency department when several patients are brought in after the release of an unknown gas at the performance of a symphony. You are evaluating a 52-year-old female who is not able to talk clearly because of excessive salivation and rhinorrhea, although she is able to tell you that she feels as if she lost her sight immediately upon exposure. At present, she also has nausea, vomiting, diarrhea, and muscle twitching. On physical examination the patient has a blood pressure of 156/92, a heart rate of 92, a respiratory rate of 30, and a temperature of 37.4°C (99.3°F). She has pinpoint pupils with profuse rhinorrhea and salivation. She also is coughing profusely, with production of copious amounts of clear secretions. A lung examination reveals wheezing on expiration in bilateral lung fields. The patient has a regular rate and rhythm with normal heart sounds. Bowel sounds are hyperactive, but the abdomen is not tender. She is having diffuse fasciculations. At the end of your examination, the patient abruptly develops tonic-clonic seizures. Which of the following agents is most likely to cause this patient's symptoms? A Arsine B Cyanogen chloride C Nitrogen mustard D Sarin

1040 All the following should be used in the treatment of this patient except A atropine B decontamination C diazepam D phenytoin

1046 A 50-year-old alcoholic woman with well-controlled cirrhosis eats raw oysters from the Chesapeake Bay at a cookout. Twelve hours later she presents to the emergency department with fever, hypotension, and altered sensorium. Her extremity examination is notable for diffuse erythema with areas of hemorrhagic bullae on her shins. What is the most likely diagnosis? A Escherichia coli sepsis B Hemolytic uremic syndrome C Meningococcemia D Vibrio vulnificus infection

1048 A patient in the intensive care unit develops a temperature of 40.8°C, profoundly rigid tone, and hemodynamic shock 2 min after a succinylcholine infusion is started. Immediate therapy should include A intravenous dantrolene sodium B acetaminophen C external cooling devices D A and C

1051 Fecal occult blood testing (FOBT) was shown to decrease colon cancer-related mortality from 8.8/1000 persons to 5.9/1000 persons over a 13-year period. What is the approximate absolute risk reduction (ARR) of this intervention in the studied population? A 0.5 B 0.3 C 0.03 D 0.003

1055 For which of the following herbal remedies is there the best evidence for efficacy in treating the symptoms of benign prostatic hypertrophy? A Saint John's wort B Gingko C Kava D Saw palmetto

1056 Which of the following personality traits is most likely to describe a young female with anorexia nervosa? A Depressive B Borderline C Anxious D Perfectionist

1062 Fall risks in the elderly include all of the following except A creatinine clearance <65 mL/min B diabetes mellitus C fear of falling D Hypertension

1064 A 74-year-old woman complains of leaking urine when she coughs, laughs, or lifts her groceries. She denies polydipsia and polyuria. She delivered four children vaginally and underwent total abdominal hysterectomy for fibroids 20 years earlier. She has mild fasting hyperglycemia that is controlled with diet. What is likely to be the best management for her problem? A Bladder retraining exercises (planned urinations every 2 h) B Doxazosin plus finasteride C Metformin D Surgery

1068 A 42-year-old man with a history of end-stage renal disease is on hemodialysis and has been taking a medication chronically for nausea and vomiting. Over the past week he has developed new-onset involuntary lip smacking, grimacing, and tongue protrusion. This side effect is most likely due to which of the following antiemetics? A Erythromycin B Methylprednisolone C Ondansetron D Prochlorperazine

1069 Which of the following is not a common cause of persistent cough lasting more than 3 months in a nonsmoker? A Asthma B Gastroesophageal reflux disease C Lisinopril D Mycoplasma infection

1070 A 74-year-old man with known endobronchial carcinoma of his left mainstem bronchus develops massive hemoptysis (1 L of frank hemoptysis productive of bright red blood) while hospitalized. All of the following should be considered in his initial management except A bronchial artery embolization B cough suppressants C direct bronchoscopic electrocautery D placing the patient in the lateral decubitus position with his right side down

1074 A 30-year-old woman complains of lower extremity swelling and abdominal distention. It is particularly troublesome after her daily shift as a toll booth operator and is at its worst during hot weather. She denies shortness of breath, orthopnea, dyspnea on exertion, jaundice, foamy urine, or diarrhea. Her symptoms occur independently of her menstrual cycle. Physical examination is notable for 2+ lower extremity edema, flat jugular venous pulsation, no hepatojugular reflex, normal S1 and S2 with no extra heart sounds, clear lung fields, a benign slightly distended abdomen with no organomegaly, and normal skin. A complete metabolic panel is within normal limits, and a urinalysis shows no proteinuria. What is the most likely diagnosis? A Cirrhosis B Congestive heart failure C Cyclical edema D Idiopathic edema

1075 All the following factors are associated with a greater risk of ventricular arrhythmia versus anxiety/panic attack in a patient complaining of palpitations except A history of congestive heart failure B history of coronary artery disease C history of diabetes mellitus D palpitations lasting >15 min

1076 A 25-year-old healthy woman visits your office during the fifth month of pregnancy. Her blood pressure is 142/86 mmHg. What should be your next step in management? A Have her return to your clinic in 2 weeks for a blood pressure check B Initiate an angiotensin-converting enzyme inhibitor C Initiate a beta blocker D Recheck her blood pressure in the seated position in 6 h

1077 A 33-year-old woman with diabetes mellitus and hypertension presents to the hospital with seizures during week 37 of her pregnancy. Her blood pressure is 156/92 mmHg. She has 4+ proteinuria. Management should include all of the following except A emergent delivery B intravenous labetalol C intravenous magnesium sulfate D intravenous phenytoin

1078 Which cardiac valvular disorder is the most likely to cause death during pregnancy? A Aortic regurgitation B Aortic stenosis C Mitral regurgitation D Mitral stenosis

1087 A patient complains of blurred vision in both eyes particularly in the periphery with the right being worse than the left. Visual field examination with finger confrontation reveals a decreased vision in the left periphery in the left eye and right periphery in the right eye. Where is there most likely to be a lesion? A Bilateral optic nerves B Left lateral geniculate body C Left occipital cortex D Suprasellar space

1091 A 34-year-old male patient is referred to your clinic after a new diagnosis of anterior uveitis. All of the following diseases should be screened for by history and physical and/or laboratory examination because they may cause anterior uveitis except A ankylosing spondylitis B Lyme disease C sarcoidosis D toxoplasmosis

1095 A "dirty" bomb is detonated in downtown Boston. The bomb was composed of cesium- 137 with trinitrotoluene. In the immediate aftermath, an estimated 30 people were killed due to the power of the blast. The fallout area was about 0.5 mile, with radiation exposure of ~1.8 gray (Gy). An estimated 5000 people have been potentially exposed to beta and gamma radiation. Most of these individuals show no sign of any injury, but about 60 people have evidence of thermal injury. What is the most appropriate approach to treating the injured victims? A All individuals who have been exposed should be treated with potassium iodide. B All individuals who have been exposed should be treated with Prussian blue. C All individuals should be decontaminated prior to transportation to the nearest medical center for emergency care to prevent exposure of health care workers. D Severely injured individuals should be transported to the hospital for emergency care after removing the victims' clothes, as the risk of exposure to health care workers is low.

1101 An enzymatic assay of muscle tissue is sent and a diagnosis is made. Which of the following represents a major source of morbidity in this disease which should be explained thoroughly to the patient? A Fulminant liver failure B Myocarditis and subsequent heart failure C Progressive proximal muscle weakness D Rhabdomyolysis leading to renal failure

1107 An 18-year-old female is evaluated in an outpatient clinic for a complaint of amenorrhea. She reports that she feels as if she never developed normally compared with other girls her age. She has never had a menstrual period and complains that she has had only minimal breast growth. Past medical history is significant for a diagnosis of borderline hypertension. In childhood the patient frequently had otitis media and varicella infections. She received the standard vaccinations. She recently graduated from high school and has no learning difficulties. She is on no medications. On physical examination, the patient is of short stature with a height of 56 in. Blood pressure is 142/88. The posterior hairline is low. The nipples appear widely spaced, with only breast buds present. The patient has minimal escutcheon consistent with Tanner stage 2 development. Her external genitalia appear normal. Bimanual vaginal examination reveals an anteverted, anteexed uterus. The ovaries are not palpable. What is the most likely diagnosis? A Hypothyroidism B Hyperthyroidism C Malnutrition D Turner syndrome (gonadal dysgenesis)

1112 All the following are inherited disorders of connective tissue except A Alport syndrome B Ehlers-Danlos syndrome C Marfan syndrome D McArdle's disease

1113 A 30-year-old male comes to your office for genetic counseling. His brother died at age 13 years with Tay Sachs disease. His sister is unaffected. The patient and his wife wish to have children. Which of the following statements concerning Tay Sachs disease is true? A It is seen most commonly in Scandinavian populations. B It is caused by mutations in the galactosidase gene. C Most patients die in the third or fourth decade of life. D Death occurs as a result of progressive neurologic decline.

1114 All the following statements about Gaucher disease are true except A Bone pain is common. B Disease frequency is highest in Ashkenazi Jews. C Inheritance is autosomal recessive. D Splenomegaly is rare.

1123 You perform a nocturnal tumescence study on the patient in the preceding scenario. He does not have any erections during rapid-eye-movement sleep. Which treatment modality do you offer at this time? A Couple sex therapy B Implantation of a penile prosthesis C Intraurethral alprostadil D Vardenafil

1127 Anthrax spores can remain dormant in the respiratory tract for how long? A 1 week B 2 weeks C 3 weeks D 6 weeks

1128 Twenty recent attendees at a National Football League game arrive at the emergency department complaining of shortness of breath, fever, and malaise. Chest roentgenograms show mediastinal widening on several of these patients, prompting a concern for inhalational anthrax as a result of a bioterror attack. Antibiotics are initiated and the Centers for Disease Control and Prevention is notified. What form of isolation should be instituted for these patients? A Airborne B Contact C Droplet D None

1132 Which of the following is a distinguishing feature of amphetamine overdose versus other causes of sympathetic overstimulation due to drug overdose or withdrawal? A Hallucination B Hot, dry, flushed skin and urinary retention C History of benzodiazepine abuse D Markedly increased blood pressure, heart rate, and end-organ damage in the absence of hallucination

1133 Which of the following findings suggests an opiate overdose? A Anion gap metabolic acidosis with a normal lactate B Hypotension and bradycardia in an alert patient C Mydriasis D Therapeutic response to naloxone

1136 A 28-year-old man with bipolar disorder, who is on lithium, is found in his room 2 days after not showing up to work. He is arousable but dysarthric and has a markedly abnormal gait when trying to walk. Upon arrival at the emergency department, he has a grand mal seizure. The seizure is not sustained but recurs an hour after 6 mg lorazepam is infused IV. In the postictal stage, he is not arousable to sternal rub and lacks a gag reflex. His serum sodium returns at 158 meq/L. In reference to his seizures, all of the following are next steps in his management except A barbiturates B benzodiazepines C endotracheal intubation D phenytoin

1139 A 36-year-old man with HIV/AIDS (CD4+ lymphocyte count = 112/μL) develops a scaly, waxy, yellowish, patchy, crusty, pruritic rash on and around his nose. The rest of his skin examination is normal. Which of the following is the most likely diagnosis? A Molluscum contagiosum B Psoriasis C Reactivation herpes zoster D Seborrheic dermatitis

1143 In the inpatient setting, extended-spectrum β-lactamase (ESBL)-producing gram-negative infections are most likely to occur after frequent use of which of the following classes of antibiotics? A Carbapenems B Macrolides C Quinolones D Third-generation cephalosporins

1145 In a patient who has undergone a traumatic splenectomy, what test can be ordered to establish lack of splenic function? A CT scan of the abdomen B Neutrophil migration studies C Peripheral blood flow cytometry D Peripheral blood smear

1151 A 51-year-old alcoholic man is admitted to the hospital for upper gastrointestinal bleeding. From further history and physical examination, it becomes apparent that his bleeding is from gingival membranes. He is intoxicated and complains of fatigue. Reviewing his chart you find that he had a hemarthrosis evacuated 6 months ago and has been lost to follow-up since then. He takes no medications. Laboratory data show platelets of 250,000, INR of 0.9. He has a diffuse hemorrhagic eruption on his legs (Figure 3, Color Atlas). What is the recommended treatment for this patient's underlying disorder? A Folate B Niacin C Thiamine D Vitamin C

1155 You diagnose anorexia nervosa in one of your new clinic patients. When coordinating a treatment program with the psychiatrist, what characteristics should prompt consideration for inpatient treatment instead of scheduling an outpatient assessment? A Amenorrhea B Exaggeration of food intake C Irrational fear of gaining weight D Weight <75% of expected body weight

1158 Doing rounds in the oncology center, you are see a patient with carcinoid syndrome. Due to the increased conversion of tryptophan to serotonin, this patient has developed niacin deficiency. All of the following are components of the pellagra syndrome except A dermatitis B dementia C diarrhea D dyslipidemia

1162 14. Which of the following statements regarding anorexia nervosa (AN) and bulimia nervosa (BN) is true? A Patients with the purging subtype of BN tend to be heavier than those with the non purging subtype. B Patients with the restricting subtype of AN are more emotionally labile than those with the purging subtype. C Patients with the restricting subtype of AN are more likely to abuse illicit drugs than those with the purging subtype. D The mortality of BN is lower than that of AN.

1163 You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of symptoms including diarrhea, alopecia, muscle wasting, depression, and a rash involving the face, extremities, and perineum. The child has hypogonadism and dwarfism. You astutely make the diagnosis of zinc deficiency, and laboratory test confirm this (zinc level <70 μL/dL). What other clinical findings is this patient likely to manifest? A Dissecting aortic aneurysm B Hypochromic anemia C Hypoglycemia D Hypopigmented hair

1164 You are rotating on a medical trip to impoverished areas of China. You are examining an 8-year-old child whose mother complains of him being clumsy and sickly. He has had many episodes of diarrheal illnesses and pneumonia. His "clumsiness" is most pronounced in the evening when he has to go outside and do his chores. On examination, you notice conjunctival dryness with white patches of keratinized epithelium on the sclera. What is the cause of this child's symptoms? A Autoimmune neutropenia B Congenital rubella C Spinocerebellar ataxia (SCA) type 1 D Vitamin A deficiency

1167 Which of these features represents a critical distinction between anorexia nervosa and bulimia nervosa? A Binge eating B Electrolyte abnormalities C Self-induced vomiting D Underweight

1168 You are counseling a patient who is recovering from long-standing anorexia nervosa (AN). She is a 22-yearold woman who suffered the effects of AN for 8 years with a nadir body mass index of 17 kg/m2 and many laboratory abnormalities during that time. Which of the following characteristics of AN is least likely to improve despite successful lasting treatment of the disorder? A Amenorrhea B Delayed gastric emptying C Lanugo D Low bone mass

1169 Which source of stem cell is incorrectly paired with the challenge associated with their clinical application? A Bone marrow mesenchymal stem cells: Transplanted cells may not differentiate into the desired cell type B Embryonic stem cells: High potential to form teratomas C Organ-specific multipotent stem cells: Difficult to isolate from tissues other than bone marrow D Umbilical cord blood stem cells: Graft-versus-host disease

1178 At the midpoint of the menstrual cycle, a luteinizing hormone (LH) surge occurs via an estrogen-mediated pathway. Though chronic low levels of estrogen are inhibitory to LH release, gradually rising estrogen levels stimulate LH secretion. This relationship between estrogen and LH is an example of which endocrine regulatory system? A Autocrine regulation B Negative feedback control C Paracrine regulation D Positive feedback control

1180 You are researching a cell line with an altered membrane structure that makes the cell membrane impermeable to extracellular molecules of all size and charge. You then expose the cell line to varying concentrations of various hormones. Of the following hormones, which one should no longer exert an effect on this cell line? A Dopamine B Gonadotropin-releasing hormone C Insulin D Vitamin D

1191 A 48-year-old female presents to her physician with a 2-day history of fever, arthralgias, diarrhea, and headache. She recently returned from an ecotour in tropical sub-Saharan Africa, where she went swimming in inland rivers. Notable findings on physical examination include a temperature of 38.7°C (101.7°F); 2-cm tender mobile lymph nodes in the axilla, cervical, and femoral regions; and a palpable spleen. Her white blood cell count is 15,000/μL with 50% eosinophils. She should receive treatments with which of the following medications? A Chloroquine B Mebendazole C Metronidazole D Praziquantel E Thiabendazole

1193 A 17-year-old woman presents to the clinic complaining of vaginal itchiness and malodorous discharge. She is sexually active with multiple partners, and she is interested in getting tested for sexually transmitted diseases. A wet-mount microscopic examination is performed, and trichomonal parasites are identified. Which of the following statements regarding trichomoniasis is true? A A majority of women are asymptomatic. B No treatment is necessary as disease is self-limited. C The patient's sexual partner need not be treated. D Trichomoniasis can only be spread sexually. E Trichomoniasis is 100% sensitive to metronidazole.

1195 When given as a first-line agent for invasive Aspergillus infection, voriconazole commonly causes all of the following side effects except A drug-drug interactions B hepatotoxicity C photosensitivity skin rashes D renal toxicity E visual disturbances

1196 A 42-year-old man with AIDS and a CD4+ lymphocyte count of 23 presents with shortness of breath and fatigue in the absence of fevers. On examination, he appears chronically ill with pale conjunctiva. Hematocrit is 16%. Mean corpuscular volume is 84. Red cell distribution width is normal. Bilirubin, lactose dehydrogenase, and haptoglobin are all within normal limits. Reticulocyte count is zero. White blood cell count is 4300, with an absolute neutrophil count of 2500. Platelet count is 105,000. Which of the following tests is most likely to produce a diagnosis? A Bone marrow aspirate and biopsy B Iron studies C Parvovirus B19 IgG D Parvovirus B19 polymerase chain reaction (PCR) E Parvovirus B19 IgM

1198 A 38-year-old female pigeon keeper who has no significant past medical history, is taking no medications, has no allergies, and is HIV-negative presents to the emergency room with a fever, headache, and mild nuchal rigidity. Neurologic examination is normal. Head CT examination is normal. Lumbar puncture is significant for an opening pressure of 20 cmH2O, white blood cell count of 15 cells/ μL (90% monocytes), protein of 0.5 g/L (50 mg/mL), glucose of 2.8 mmol/L (50 mg/dL), and positive India ink stain. What is the appropriate therapy for this patient? A Amphotericin B for 2 weeks B Amphotericin B with flucytosine for 2 weeks C Amphotericin B for 2 weeks followed by oral fluconazole, 400 mg daily D Amphotericin B for 10 weeks followed by oral fluconazole, 400 mg daily for 6-12 months E Ceftriaxone and vancomycin for 2 weeks

1192 A 39-year-old woman received a liver transplant 2 years ago and is maintained on prednisone, 5 mg, and cyclosporine A, 8 mg/kg per day. She has had two episodes of rejection since transplant, as well an episode of cytomegalovirus syndrome and Nocardia pneumonia. She intends on taking a 2-week gorilla-watching trip to Rwanda and seeks your advice regarding her health while abroad. Which of the following potential interventions is strictly contraindicated? A Malaria prophylaxis B Meningococcal vaccine C Rabies vaccine D Typhoid purified polysaccharid vaccine E Yellow fever vaccine

1194 The most common clinical presentation of infection with Babesia microti is A acute hepatitis B chronic meningitis C generalized lymphadenopathy D overwhelming hemolysis, high-output congestive heart failure, respiratory failure, and disseminated intravascular coagulation E self-limited flulike illness

1007 A 41-year-old man, the restrained driver in a high-speed motor vehicle collision, is brought to the ED by EMS. The patient is breathing without difficulty with bilateral and equal breaths sounds. He has strong pulses peripherally indicating a BP of at least 90 mm Hg. The HR is 121 beats per minute. His Glasgow Coma Scale GCS. is 14. A secondary survey reveals chest wall bruising. You suspect a cardiac injury. Which of the following locations most commonly involve cardiac contusions? A Right atrium B Right ventricle C Left atrium D Left ventricle

1023 Drug X is investigated in a meta-analysis for its effect on mortality after a myocardial infarction. It is found that mortality drops from 10 to 2% when this drug is administered. What is the absolute risk reduction conferred by drug X? A 0.02 B 0.08 C 0.2 D 2

1033 A homeless male is evaluated in the emergency department. He has noted that after he slept outside during a particularly cold night his left foot has become clumsy and feels "dead." On examination, the foot has hemorrhagic vesicles distributed throughout the foot distal to the ankle. The foot is cool and has no sensation to pain or temperature. The right foot is hyperemic but does not have vesicles and has normal sensation. The remainder of the physical examination is normal. Which of the following statements regarding the management of this disorder is true? A Active foot rewarming should not be attempted. B During the period of rewarming, intense pain can be anticipated. C Heparin has been shown to improve outcomes in this disorder. D Immediate amputation is indicated.

1035 All of the following statements regarding medications in the geriatric population are true except A Falling albumin levels in the elderly lead to increased free (active) levels of some medications, including warfarin. B Fat-soluble drugs have a shorter half-life in geriatric patients. C Hepatic clearance decreases with age. D The elderly have a decreased volume of distribution for many medications because of a decrease in total body water.

1050 In the evaluation of malnutrition, which of the following proteins has the shortest half-life and thus is most predictive of recent nutritional status? A Albumin B Fibronectin C Retinol-binding protein complex D Prealbumin

1052 Which preventative intervention leads to the largest average increase in life expectancy for a target population? A A regular exercise program for a 40-year-old man B Getting a 35-year-old smoker to quit smoking C Mammography in women aged 50-70 D Pap smears in women aged 18-65

1053 All of the following patients should receive a lipid screening profile except A a 16-year-old male with type 1 diabetes B a17-year-old female teen who recently began smoking C a 23-year-old healthy male who is starting his first job D a 48-year-old woman beginning menopause

1059 Diabetes is associated with all of the following in the elderly except A cerebrovascular accident B cognitive decline C fall risk D myocardial infarction

1063 A stage 1 decubitus ulcer (nonblanchable erythema of intact skin or edema and induration over a bony pressure point) can progress to a stage 4 decubitus ulcer (full-thickness skin loss with tissue necrosis as well as damage to bone, muscle and tendons) over what period of time? A Several hours B 1-2 days C 1-2 weeks D 1-2 months

1065 A 38-year-old man with multiple sclerosis develops acute flaccid weakness in his left arm and left leg. Physical examination reveals normal sensorium, normal cranial nerve function, 1/5 strength in his left upper extremity, 0/5 strength in his left lower extremity, impaired proprioception in his left leg, intact proprioception in his right leg, decreased pain and temperature sensation in his right arm and leg, and normal light touch/pain and temperature sensation in his right leg. Where is his causative lesion most likely to be? A Cervical nerve roots B High cervical spinal cord C Medulla D Pons

1071 A patient with proteinuria has a renal biopsy that reveals segmental collapse of the glomerular capillary loops and overlying podocyte hyperplasia. The patient most likely has A diabetes B HIV infection C multiple myeloma D systemic lupus erythematosus

1082 A 72-year-old white man with New York Heart Association II ischemic cardiomyopathy, diabetes mellitus, and chronic renal insufficiency (creatinine clearance = 42 mL/ min) undergoes dobutamine echocardiography prior to carotid endarterectomy. He is found to have 7-mm ST depressions in his lateral leads during the test and develops dyspnea at 70% maximal expected dosage, requiring early cessation of the stress test. His current medicines include an angiotensin-converting enzyme inhibitor, a beta blocker, and aspirin. What would be your advice to the patient? A Cancel the carotid endarterectomy B Proceed to cardiac catheterization C Maximize medical management D Proceed directly to carotid endarterectomy

1083 Parkinson's disease can often be differentiated from the atypical Parkinsonian syndromes (multiple system atrophy, progressive supranuclear palsy) by the presence of which of the following? A Axial stiffness B Pill-rolling tremor C Shuffling gait D Stooped posture

1086 A 23-year-old female patient complains of visual blurriness. On examination, her pupils are equally round. Shining a flashlight into her right eye causes equal, strong constriction in both of her eyes. When the light is flashed into her left eye, both pupils dilate slightly though not to their previous size prior to light confrontation. Where is there most likely to be anatomic damage? A Left cornea B Left optic nerve or retina C Optic chiasm D Right cornea

1089 Which of the following criteria best differentiates episcleritis from conjunctivitis? A Concurrent connective tissue disease such as lupus B Lack of discharge C More diffuse ocular involvement D Reduced eye motility

1090 Which diagnosis can be easily confused with adenoviral conjunctivitis and is a major cause of blindness in the United States? A Endophthalmitis B Herpes simplex virus keratitis C Angle-closure glaucoma D Uveitis

1092 A 22-year-old female is referred to your clinic after being started on glucocorticoids for a new diagnosis of left optic neuritis seen on examination with disc pallor, and it is confirmed with quantitative visual field mapping. What further evaluation is indicated? A Antinuclear antibodies B Brain MRI C Erythrocyte sedimentation rate D No further evaluation unless symptoms recur

1098 A 7-month-old child is brought to clinic by his parents. He was the product of a healthy pregnancy, and there were no perinatal complications. The parents are concerned that there is something wrong; he is very hyperactive and is noted to have a 'mousy' odor. On examination the child is found to have mild microcephaly, hypopigmentation and eczema. Laboratory studies are sent and a diagnosis is made. How could this clinical scenario have been prevented? A Screening at 6 months of age for urine ketones B Screening at birth for phenylalanine in blood C Screening at birth for chromosomal abnormalities D Genetic screening of parents prior to delivery

1108 A 30-year-old male is seen for a physical examination when obtaining life insurance. The last time he saw a physician was 15 years ago. He has no complaints. Past medical history is notable for scoliosis that was surgically corrected when the patient was a teenager and a recent shoulder dislocation. He takes no medications and does not smoke, drink, or use illicit drugs. Family history is notable for a father and a brother with colon cancer at ages 45 and 50 years, respectively. Physical examination is notable for normal vital signs, a tall habitus with hypermobile joints, normal skin, and ectopia lentis. Rectal examination is normal, and stool is guaiac-negative. The remainder of the examination is normal. Appropriate recommendations for follow-up should include which of the following annual studies? A Colonoscopy B Echocardiography C Fecal occult blood testing D Serum periodic acid-Schiff (PSA) measurement

1111 Prader-Willi syndrome (PWS) is a rare disorder that is characterized by diminished fetal activity, obesity, mental retardation, and short stature. A deletion on the paternal copy of chromosome 15 is the cause. A deletion on the same site on chromosome 15, but on the maternal copy, results in a different syndrome: Angelman's syndrome. This syndrome is characterized by mental retardation, seizures, ataxia, and hypotonia. What is the name of the genetic mechanism that results in this phenomenon? A Genetic anticipation B Genetic imprinting C Lyonization D Somatic mosaicism

1117 Which of the following would be present in an individual who has lost nondeclarative memory? A Inability to recall a spouse's birthday B Inability to recall how to tie one's shoe C Inability to recognize a photo that was taken at one's wedding D Inability to recognize a watch as an instrument for keeping time

1125 A 54-year-old male patient of yours presents to your clinic complaining of unexplained weight loss. On review of his chart, you do notice that he has lost 8% of his total body weight in the past year. He has well-treated hypertension for which he takes a thiazide diuretic. Other than recently being widowed, he has no pertinent social history. He is a lifelong nonsmoker and worked as a hospital administrator. An extensive review of systems is unrevealing. Your physical examination reveals no masses or other pathology. A brief psychiatric examination shows no signs of depression. You perform initial testing with a complete blood count; electrolytes, renal function, liver function, urinalysis, thyroid-stimulating hormone, and a chest x-ray, which are unrevealing. He is up to date on his routine cancer screening. What is the next step in the workup of this patient? A Chest CT scan B Close follow-up C Positron emission tomography (PET) scan D Total-body CT scan

1131 A young man is brought to the emergency department by his parents. For the past 12 h he has barricaded himself in his room out of fear of being taken away by "the guys in black." He fears he is losing control and fears that he is going to die. His parents found him trembling and sweating in his room with various pills and plant leaves in his possession. He feels like he is choking and that he is about to die at any minute. On examination, his pupils are dilated and he has a heart rate of 143 beats/min. What substance is most likely to have caused these symptoms? A Heroin B Lysergic acid diethylamide (LSD) C Marijuana D Methamphetamine

1135 Which of the following is true regarding drug effects after an overdose in comparison to a reference dose? A Drug effects begin earlier, peak earlier, and last longer B Drug effects begin earlier, peak later, and last longer C Drug effects begin earlier, peak later, and last shorter D Drug effects begin later, peak earlier, and last shorter.

1138 Which type of bite represents a potential medical emergency in an asplenic patient? A Cat bite B Dog bite C Fish bite D Human bite

1140 A 28-year-old woman returns from a 6-week trip to Tanzania in March. She calls your office 2 weeks later complaining of new symptoms of fever, mild abdominal pain, and headache. She feels like she has the flu. What should you do next? A Ask her to come to the clinic in the next 24 h. B Emergently refer her to the emergency department. C Write her a prescription for oseltamivir and call her in 24 h to ensure improvement. D Write her a prescription for a respiratory fluoroquinolone.

1148 A 34-year-old man seeks the advice of his primary care physician because of an asymptomatic rash on his chest. There are coalescing light brown to salmon-colored macules present on the chest. A scraping of the lesions is viewed after a wet preparation with 10% potassium hydroxide solution. There are both hyphal and spore forms present, giving the slide an appearance of "spaghetti and meatballs." In addition, the lesions fluoresce to a yellow green appearance under a Wood's lamp. Tinea versicolor is diagnosed. Which of the following microorganisms is responsible for this skin infection? A Fusarium solani B Malassezia furfur C Sporothrix schenkii D Trichophyton rubrum

1153 The resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. Of these two patients with stable weights, which person has the highest resting energy expenditure (REE): Patient A, a 40-year-old man who weighs 90 kg and is sedentary, or Patient B, a 40year-old man who weighs 70 kg and is very active? A 40-year-old man who weighs 90 kg and is sedentary B 40-year-old man who weighs 70 kg and is very active C REE is the same D Not enough information given to calculate the REE

1157 A 42-year-old male patient wants your opinion about vitamin E supplements. He has read that taking high doses of vitamin E can improve his sexual performance and slow the aging process. He is not vitamin E deficient. You explain to him that these claims are not based on good evidence. What other potential side effect should he be concerned about? A Deep venous thrombosis B Hemorrhage C Night blindness D Peripheral neuropathy

1170 You are seeing a patient in follow-up in whom you have begun an evaluation for an elevated hematocrit. You suspect polycythemia vera based on a history of aquagenic pruritus and splenomegaly. Which set of laboratory tests are consistent with the diagnosis of polycythemia vera? A Elevated red blood cell mass, high serum erythropoietin levels, normal oxygen saturation B Elevated red blood cell mass, low serum erythropoietin levels, normal oxygen saturation C Normal red blood cell mass, high serum erythropoietin levels, low arterial oxygen saturation D Normal red blood cell mass, low serum erythropoietin levels, low arterial oxygen saturation

1173 You are managing a patient who complains of abdominal pain. The pain is located in the epigastric area and radiates to the back. Leaning forward improves the pain. The rest of the physical examination is unremarkable and there is no jaundice. The total bilirubin is 0.7 mg/ dL and CA 19-9 level is within the normal range. An ultra- sound of the abdomen shows a 2.5-cm well-circumscribed mass in the tail of the pancreas. There is no ductal dilation. A CT scan confirms the presence of a 2.5-cm spiculated mass in the tail of the pancreas with no surrounding lymphadenopathy or local extension. What is the next most appropriate step in this patient's management? A Magnetic resonance cholangiopancreatography B Refer for surgical resection C Serial CA 19-9 measurement D Ultrasound-guided biopsy

1179 The mineralocorticoid receptor in the renal tubule is responsible for the sodium retention and potassium wasting that is seen in mineralocorticoid excess states such as aldosteronesecreting tumors. However, states of glucocorticoid excess (e.g., Cushing's syndrome) can also present with sodium retention and hypokalemia. What characteristic of the mineralocorticoid-glucocorticoid pathways explain this finding? A Higher affinity of the mineralocorticoid receptor for glucocorticoids B Oversaturation of the glucocorticoid degradation pathway in states of glucocorticoid excess C Similar, but distinct, DNA binding sites producing the same metabolic effect D Upregulation of the mineralocorticoid-binding protein in states of glucocorticoid excess

1187 A 51-year-old woman is diagnosed with Plasmodium falciparum malaria after returning from a safari in Tanzania. Her parasitemia is 6%, hematocrit is 21%, bilirubin is 7.8 mg/dL, and creatinine is 2.7 mg/dL. She is still making 60 mL of urine per hour. She rapidly becomes obtunded. Intensive care is initiated, with frequent creatinine checks, close monitoring for hypoglycemia, infusion of phenobarbital for seizure prevention, mechanical ventilation for airway protection, and exchange transfusion to address her high parasitemia. Which of the following regimens is recommended as first-line treatment for her malarial infection? A Chloroquine B Intravenous artesunate C Intravenous quinine D Intravenous quinidine E Mefloquine

1188 A 9-year-old boy is brought to a pediatric emergency room by his father. He has had 2 days of headache, neck stiffness, and photophobia and this morning had a temperature of 38.9°C (102°F). He has also had several episodes of vomiting and diarrhea overnight. A lumbar puncture is performed, which reveals pleocytosis in the cerebrospinal fluid (CSF). Which of the following is true regarding enteroviruses as a cause of aseptic meningitis? A An elevated CSF protein rules out enteroviruses as a cause of meningitis. B Enteroviruses are responsible for up to 90% of aseptic meningitis in children. C Lymphocytes will predominate in the CSF early on, with a shift to neutrophils at 24 h. D Symptoms are more severe in children than in adults. E They occur more commonly in the winter and spring.

1189 A 56-year-old man with a history of hypertension and cigarette smoking is admitted to the intensive care unit after 1 week of fever and nonproductive cough. Imaging shows a new pulmonary infiltrate, and urine antigen test for Legionella is positive. Each of the following is likely to be an effective antibiotic except A azithromycin B aztreonam C levofloxacin D tigecycline E trimethoprim/sulfamethoxazole

1199 While attending the University of Georgia, a group of friends go on a 5-day canoeing and camping trip in rural southern Georgia. A few weeks later, one of the campers develops a serpiginous, raised, pruritic, erythematous eruption on the buttocks. Strongyloides larvae are found in his stool. Three of his companions, who are asymptomatic, are also found to have strongyloides larvae in their stool. Which of the following is indicated in the asymptomatic carriers? A Fluconazole B Ivermectin C Mebendazole D Mefloquine E Treatment only for symptomatic illness

1003 A 21-year-old girl presents to the ED complaining of diarrhea, abdominal cramps, fever, anorexia, and weight loss for 3 days. Her BP is 127/75 mm Hg, HR is 91 beats per minute, and temperature is 100.8°F. Her abdomen is soft and nontender without rebound or guarding. WBC is 9200/μL, β-hCG is negative, urinalysis is unremarkable, and stool is guaiac positive. She tells you that she has had this similar presentation four times over the past 2 months. Which of the following extraintestinal manifestations is associated with Crohn disease but not ulcerative colitis? A Ankylosing spondylitis B Erythema nodosum C Nephrolithiasis D Thromboembolic disease

1004 A 23-year-old woman presents to the ED complaining of pain with urination. She has no other complaints. Her symptoms started 3 weeks ago. During this time, she has been to the clinic twice, with negative urine cultures each time. Her condition has not improved with antibiotic therapy with sulfonamides or quinolones. Physical examination is normal. Which of the following organisms is most likely responsible for the patient's symptoms? A Staphylococcus aureus B Herpes simplex virus C Chlamydia trachomatis D Escherichia coli

1010 Paramedics bring a 17-year-old high school football player to the ED on a backboard and with a cervical collar. During a football game, the patient "speared" another player with his helmet and subsequently experienced severe neck pain. He denies paresthesias and is able to move all of his extremities. A cervical spine CT scan reveals multiple fractures of the first cervical vertebra. Which of the following best describes this fracture? A Odontoid fracture B Hangman's fracture C Jefferson fracture D Clay-shoveler's fracture

1013 A 19-year-old man is brought into the trauma room by EMS after a head on cycling accident. The patient was not wearing a helmet. Upon presentation his BP is 125/75 mm Hg, HR is 105 beats per minute, RR is 19 breaths per minute, and oxygen saturation is 100% on mask. His eyes are closed, but open to command. He can move his arms and legs on command. When you ask him questions, he is disoriented but able to converse. What is this patient's GCS score? A 11 B 12 C 13 D 14

1016 A 27-year-old man bought to the ED by paramedics after a motor vehicle collision. His RR is 45 breaths per minute, oxygen saturation is 89%, HR is 112 beats per minute, and BP is 115/75 mm Hg. You auscultate his chest and hear decreased breath sounds on the left. Which of the following is the most appropriate next step in management? A Order a STAT chest radiograph B Perform a pericardiocentesis C Perform a tube thoracostomy D Perform an ED thoracotomy

1017 A physician is deciding whether to use a new test to screen for disease X in his practice. The prevalence of disease X is 5%. The sensitivity of the test is 85%, and the specificity is 75%. In a population of 1000, how many patients will have the diagnosis of disease X missed by this test? A 50 B 42 C 8 D 4

1018 How many patients will be erroneously told they have diagnosis X on the basis of the results of this test? A 713 B 505 C 237 D 42

1020 The curve that graphically represents the family of cutoff points for a positive vs. negative test is a receiver operating characteristic (ROC) curve. The area under this curve is a quantitative measure of the information content of a test. The ROC axes are A negative predictive value vs. (1 - positive predictive value) B positive predictive value vs. (1 - negative predictive value) C sensitivity vs. (1 - specificity) D specificity vs. (1 - sensitivity)

1026 Which of the following statements regarding gender health is true? A Alzheimer's disease affects men and women at equal rates. B Alzheimer's disease affects men two times more commonly than women. C In a recent placebo-controlled trial, postmenopausal hormone therapy did not show improvement in disease progression in women with Alzheimer's disease. D Women with Alzheimer's disease have higher levels of circulating estrogen than women without Alzheimer's disease.

1030 Which of the following alternative medicines has shown proven benefit compared to placebo in a large randomized clinical trial? A Echinacea root for respiratory infection B Ginkgo biloba for improving cognition in the elderly C Glucosamine/chondroitin sulfate for improving performance and slowing narrowing of the joint space in patients with moderate to severe osteoarthritis D Saw palmetto for men with symptomatic benign prostatic hyperplasia (BPH)

1034 A 78-year-old female is seen in the clinic with complaints of urinary incontinence for several months. She finds that she is unable to hold her urine at random times throughout the day; this is not related to coughing or sneezing. The leakage is preceded by an intense need to empty the bladder. She has no pain associated with these episodes, though she finds them very distressing. The patient is otherwise independent in the activities of daily living, with continued ability to cook and clean for herself. Which of the following statements is true? A The abrupt onset of similar symptoms should prompt cystoscopy. B First-line therapy for this condition consists of desmopressin. C Indwelling catheters are rarely indicated for this disorder. D Referral to a genitourinary surgeon is indicated for surgical correction.

1037 Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice? A Amoxicillin B Aspirin C Atorvastatin D Prevacid

1041 A 24-year-old male is brought to the emergency department after taking cyanide in a suicide attempt. He is unconscious on presentation. What drug should be used as an antidote? A Atropine B Methylene blue C Sodium nitrite with sodium thiosulfate D Sodium nitrite alone

1043 A 24-year-old healthy man who has just returned from a 1-week summer camping trip to the Ozarks presents to the emergency room with fever, a severe headache, mild abdominal pain, and severe myalgias. He is discharged home but 1 day later feels even worse and therefore returns. Temperature is 38.4°C; heart rate is 113 beats/min; blood pressure is 120/ 70. Physical examination is notable for a well-developed, well-nourished, but diaphoretic and distressed man. He is alert and oriented to time and place. His lungs are clear to auscultation. He has no heart murmur. His abdomen is mildly tender with normal bowel sounds. Neurologic examination is nonfocal. There is no evidence of a rash. Laboratory evaluation is notable for a platelet count of 84,000/μL. A lumbar puncture is notable for 5 monocytes, no red blood cells, normal protein levels, and normal glucose levels. What should be the next step in this patient's management? A Atovaquone B Blood cultures and observation C Doxycycline D Rimantadine

1044 A 23-year-old woman with a chronic lower extremity ulcer related to prior trauma presents with rash, hypotension, and fever. She has had no recent travel or outdoor exposure and is up to date on all of her vaccinations. She does not use IV drugs. On examination, the ulcer looks clean with a well-granulated base and no erythema, warmth, or pustular discharge. However, the patient does have diffuse erythema that is most prominent on her palms, conjunctiva, and oral mucosa. Other than profound hypotension and tachycardia, the remainder of the examination is nonfocal. Laboratory results are notable for a creatinine of 2.8 mg/dL, aspartate aminotransferase of 250 U/L, alanine aminotransferase of 328 U/L, total bilirubin of 3.2 mg/dL, direct bilirubin of 0.5 mg/dL, INR of 1.5, activated partial thromboplastin time of 1.6 × control, and platelets at 94,000/μL. Ferritin is 1300 μg/mL. The patient is started on broad-spectrum antibiotics after appropriate blood cultures are drawn and is resuscitated with IV fluid and vasopressors. Her blood cultures are negative at 72 h: at this point her fingertips start to desquamate. What is the most likely diagnosis? A Juvenile rheumatoid arthritis (JRA) B Leptospirosis C Staphylococcal toxic shock syndrome D Streptococcal toxic shock syndrome

1045 The Centers for Disease Control and Prevention (CDC) has designated several biologic agents as category A in their ability to be used as bioweapons. Category A agents include agents that can be easily disseminated or transmitted, result in high mortality, can cause public panic, and require special action for public health preparedness. All the following agents are considered category A except A Bacillus anthracis B Francisella tularensis C ricin toxin from Ricinus communis D smallpox

1047 Hyperthermia is defined as A a core temperature >40.0°C B a core temperature >41.5°C C an uncontrolled increase in body temperature despite a normal hypothalamic temperature setting D an elevated temperature that normalizes with antipyretic therapy

1054 A 46-year-old female presents to her primary care doctor complaining of a feeling of anxiety. She notes that she always had been what she describes as a "worrier," even in grade school. The patient has always avoided speaking in public and recently is becoming anxious to the extent where she is having difficulty functioning at work and in social situations. She has difficulty falling asleep at night and finds that she is always "fidgety" and has a compulsive urge to move. The patient owns a real estate company that has been in decline since a downturn in the local economy. She recently has been avoiding showing homes for sale. Instead, she defers to her partners because she finds that she is nervous to the point of being unable to speak to her clients. She has two children, ages 16 and 12, who are very active in sports. She feels overwhelmed with worry over the possibility of injury to her children and will not attend their sports events. You suspect that the patient has a generalized anxiety disorder. All of the following statements regarding this diagnosis are true except A The age at onset of symptoms is usually before 20 years, although the diagnosis usually occurs much later in life. B Over 80% of these patients will have concomitant mood disorders such as major depression, dysthymia, or social phobia. C As in panic disorder, shortness of breath, tachycardia, and palpitations are common. D Experimental work suggests that the pathophysiology of generalized anxiety disorder involves impaired binding of benzodiazepines at the γ-aminobutyric acid (GABA) receptor.

1057 Why is it necessary to coadminister vitamin B6 (pyridoxine) with isoniazid? A Vitamin B6 requirements are higher in tuberculosis patients. B Isoniazid causes decarboxylation of γ-carboxyl groups in vitamin K-dependent enzymes. C Isoniazid interacts with pyridoxal phosphate. D Isoniazid causes malabsorption of vitamin B6.

1058 The prevalence of hypertension in American persons aged >65 years old is A 10-35% B 35-60% C 60-85% D >85%

1067 A 64-year-old man with primary light chain amyloidosis develops orthostatic symptoms despite maintaining adequate oral intake. He also notes early satiety, with bloating and vomiting if he eats too rapidly. To combat this, he has decreased the size of his meals but eats twice as frequently during the day, with some positive effect. What is the most likely explanation for his gastrointestinal symptoms? A Diverticulosis B Gastric cancer C Gastroparesis D Irritable bowel syndrome

1073 A 43-year-old man with alcoholic liver disease complains of dyspnea upon sitting up. Physical examination is notable for chest spider angiomas and palmar erythema. His arterial oxygen saturations fall from 96% to 88% upon transition from lying to sitting. His lung fields are clear and heart sounds are crisp. Abdominal examination is notable for a palpable nodular liver edge but no fluid wave or shifting dullness. He has 1+ lower extremity edema. What is the most likely cause of his dyspnea? A Chronic thromboembolic disease B Congestive heart failure C Pulmonary arteriovenous fistula D Portal hypertension

1079 A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left lower extremity ultrasonogram reveals a left iliac vein deep vein thrombosis (DVT). Proper management includes A bedrest B catheter-directed thrombolysis C enoxaparin D inferior vena cava filter placement

1081 Noninvasive cardiac imaging/stress testing should be considered in patients with how many of the following six proven risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes mellitus, and renal insufficiency) for perioperative cardiac events (including pulmonary edema, myocardial infarction, and heart block)? A 1 B 2 C 3 D 4

1096 A 54-year-old man is admitted to the hospital with severe nausea, vomiting, and diarrhea. These symptoms began 36 h ago. He briefly improved for a few hours yesterday, but today has progressively worsened. He states he is concerned about possible poisoning because of his role in espionage and counterterrorism for the U.S. government. He met with an informant 2 days previously at a hotel bar, where he drank three cups of coffee but did not eat. He does state that he left the table to place a phone call during the meeting and is concerned that his coffee may have been contaminated. He otherwise is quite healthy and takes no medications. On physical examination, he appears ill. The vital signs are: blood pressure 98/60 mmHg, heart rate 112 beats/min, respiratory rate 24 breaths/min, SaO2 94%, and temperature 37.4°C. Head, ears, eyes, nose, and throat examination shows pale mucous membranes. Cardiovascular examination is tachycardic, but regular. His lungs are clear. The abdomen is slightly distended with hyperactive bowel sounds. There is no tenderness or rebound. Extremities show no edema, but a few scattered petechiae are present. Neurologic examination is normal. A complete blood count is performed. The results are: white blood cell (WBC) count 150/μL, red blood cell count 1.5/μL, hemoglobin 4.5 g/dL, hematocrit 15%, platelet count 11,000/μL. The differential on the WBC count is 98% PMNs, 2% monocytes, and 0% lymphocytes. A blood sample is held for HLA testing. A urine sample is positive for the presence of radioactive isotopes, which are determined to be polonium-210, a strong emitter of alpha radiation. The mode of exposure is presumed to be ingestion. What is the best approach to the treatment of this patient? A Bone marrow transplantation B Gastric lavage C Supportive care and dimercaprol D Supportive care only

1097 Several victims are brought to the emergency room after a terrorist attack in the train station. An explosive was detonated that dispersed an unknown substance throughout the station, but several people reported a smell like that of horseradish or burned garlic. Prior to transport to the emergency room, exposed individuals had their clothing removed and underwent showering and decontamination. On initial presentation, there was no apparent injury except eye irritation. Over the next few hours, most of those exposed complain of nasal congestion, sinus pain, and burning in the nares. Beginning about 2 h after exposure, many of the exposed individuals began to notice diffuse redness of the skin, particularly in the neck, axillae, antecubital fossae, and external genitalia. In addition, a few people also developed blistering of the skin. Hoarseness, cough, and dyspnea are noted as well. What is the most likely chemical agent that was released in the terrorist attack? A Chlorine B Cyanide C Mustard gas D Phosgene oxime

1100 A 22-year-old man presents to a local emergency room with severe muscle cramps and exercise intolerance. His symptoms have been worsening over a period of months. He has noticed that his urine is frequently dark. Examination reveals tenderness over all major muscle groups. A creatine phosphokinase (CK) is markedly elevated. He reports a normal childhood but since age 18 has noticed worsening exercise intolerance. He no longer plays basketball and recently noticed leg fatigue at two flights of stairs. After intense exercise, he occasionally has red-colored urine. Which of the following is the most likely diagnosis? A Glucose-6-phosphatase deficiency B Lactate dehydrogenase deficiency C McArdle disease (type V glycogen storage disease) D Pyruvate kinase deficiency

1102 A 21-year-old woman comes to clinic to establish new primary care. She has a history of type III glycogen storage disease (debranching deficiency), for which she takes a high protein, high-carbohydrate diet. She has a normal physical examination except for short stature, mild weakness, and a slightly enlarged liver. She works as an administrative assistant and is planning to be married in the next 6 months. She is concerned about her long-term prognosis and the chances of the disease developing in a child. All of the following statements about her prognosis are true except A Cardiomyopathy is a possible complication. B Chronic liver disease is a possible complication. C Dementia is a possible complication. D Her child will not have the disease unless her fiancé is a carrier.

1103 A 36-year-old man comes to your office asking for genetic testing for Alzheimer's disease. He has no cognitive complaints but notes that all four of his grandparents have had Alzheimer's and his father has mild cognitive impairment at the age of 62. His Mini- Mental Status Examination is 29/30, losing one point on the serial-7's examination. He requests testing for the apolipoprotein E allele (ε4). This request is an example of which of the following? A Early-onset dementia B Genetic discrimination C Predisposition testing D Presymptomatic testing

1104 A recently married couple comes to see you in clinic for prenatal counseling. They are both in their mid-thirties and have read extensively on the internet about pregnancy and increasing maternal age. They want to know the risk of miscarriage as well as the risk of having a child with Down syndrome. Which of the following is true regarding chromosome disorders and increasing maternal age? A About half of trisomy conceptions will survive to term. B In women under the age of 25, trisomy occurs in <1% of all pregnancies. C Women over the age of 42 have a 33% chance of a trisomic conception. D The risk of Down syndrome increases 1% per year of maternal age.

1106 All the following disorders can cause ambiguous sexual differentiation except A 21-hydroxylase deficiency B androgen insensitivity syndrome C Klinefelter syndrome D mixed gonadal dysgenesis

1109 All the following diseases are caused by errors in DNA repair except A ataxia-telangiectasia (AT) B Fanconi's anemia (FA) C fragile X (FX) syndrome D hereditary nonpolyposis colorectal cancer (HNPCC)

1110 A 45-year-old male is evaluated for weakness and a progressive change in mental status. After extensive evaluation, he is diagnosed with a mitochondrial disorder. All of the following statements about mitochondrial disorders are true except A The mitochondrial genome does not recombine. B Inheritance is maternal. C The proportion of wild-type and mutant mitochondria in different tissues is identical. D Cardiomyopathy is a feature of many mitochondrial disorders.

1116 Chronic hypoxia causes biochemical changes whereby oxygen delivery to tissues is not impaired. In comparison to someone living at sea level, which of the following changes would be expected in a healthy person acclimated to living at high altitude? A Basal temperature <37°C B Serum pH >7.45 C Increased red blood cell levels of 2,3-diphosphoglycerate D Hemoglobin concentration <10 mg/dL

1118 A 24-year-old woman presents for a routine checkup and complains only of small masses in her groin. She states that they have been present for at least 3 years. On physical examination, she is noted to have several palpable 1-cm inguinal lymph nodes that are mobile, nontender, and discrete. There is no other lymphadenopathy on examination. What should be the next step in management? A Bone marrow biopsy B CT scan of the chest, abdomen, and pelvis C Reassurance D Fine-needle aspiration for culture and cytopathology

1119 All the following diseases are associated with massive splenomegaly (spleen extends 8 cm below the costal margin or weighs >1000 g) except A autoimmune hemolytic anemia B chronic lymphocytic leukemia C cirrhosis with portal hypertension D none of the above

1124 The wife of the patient in the preceding scenario also reports to you that she has experienced a low sexual desire lately. She is not distressed by this and the couple reports no conflict as a result of her low desire. She is 61 years old and also has a history of a coronary artery bypass graft remotely. She experienced menopause at the age of 53. Her medications include an aspirin, metoprolol, simvastatin, verapamil, and a multivitamin. She asks whether an oral agent will assist with her sexual desire. What is the best answer for this patient? A Phosphodiesterase type 5 (PDE-5) inhibitors have been shown to improve sexual function in premenopausal women B PDE-5 inhibitors have been shown to improve sexual function in postmenopausal women C PDE-5 inhibitors have no role in the treatment of female sexual dysfunction D PDE-5 inhibitors treat orgasmic disorder but not sexual arousal disorder

1129 You are working in an urban-based intensive care unit and two cases of severe pneumonia are admitted. Francisella tularensis is cultured from both patients' sputum samples. Neither patient recalls contact with wild or domesticated animals in the past 2 weeks. You should do all of the following except A Alert the Centers for Disease Control and Prevention (CDC) authorities about the potential for a bioterrorist attack. B Alert the microbiology laboratory director. C Institute droplet precaution for the involved patients. D Treat with broad-spectrum antibiotics.

1137 What is the main contributor to the resting energy expenditure of an individual? A Adipose tissue B Exercise level C Lean body mass D Resting heart rate

1141 A 30-year-old female with end-stage renal disease who receives her dialysis through a tunneled catheter in her shoulder presents with fever and severe low back pain. On examination, she is uncomfortable and diaphoretic but hemodynamically stable. She has a soft 2/6 early systolic flow murmur. Her line site is red and warm with no pustular exudates. She is very tender over her lower back. Neurologically, she is completely intact. There is no evidence of Janeway lesions, Osler nodes, or Roth spots. Her white count is 16,700 with 12% bands. Immediate evaluation should include all of the following except A MRI of the lumbar spine B removal of her dialysis catheter C transthoracic echocardiogram D two sets of blood cultures followed by vancomycin as well as gram-negative coverage

1142 Which of the following scenarios is most likely associated with the lowest risk of HIV transmission to a health care provider after an accidental needle stick from a patient with HIV? A The needle is visibly contaminated with the patient's blood. B The needle stick injury is a deep tissue injury to the health care provider. C The patient whose blood is on the contaminated needle has been on antiretroviral therapy for many years with a history of resistance to many available agents but most recently has had successful viral suppression on current therapy. D The patient whose blood is on the contaminated needle was diagnosed with acute HIV infection 2 weeks ago.

1146 A 26-year-old female college student presents with tender epitrochlear and axillary tender, firm, 3-cm lymph nodes on her left side. She has a 0.5-cm painless nodule on her left second finger. She reports low-grade fever and malaise over 2 weeks. She enjoys gardening, exotic fish collecting, and owns several pets including fish, kittens, and a puppy. She is sexually active with one partner. She traveled extensively throughout rural Southeast Asia 2 years before her current illness. The differential diagnosis includes all of the following except A Bartonella henselae infection B lymphoma C Sporothrix schenkii infection D Staphylococcal infection

1149 A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. She develops wound dehiscence on postoperative day 10. Laboratory data show a white blood cell count of 4000/ μL, hematocrit 35%, albumin 2.1 g/dL, total protein 5.8 g/dL, transferrin 54 mg/dL, and iron-binding capacity 88 mg/dL. You are considering initiating nutritional therapy on hospital day 11. Which of the following is true regarding the etiology and treatment of malnutrition in this patient? A She has marasmus, and nutritional support should be started slowly. B She has kwashiorkor, and nutritional support should be aggressive. C She has marasmic kwashiorkor, kwashiorkor predominant, and nutritional support should be aggressive. D She has marasmic kwashiorkor, marasmus predominant, and nutritional support should be slow.

1152 While working in the intensive care unit, you admit a 57-year-old woman with acute pancreatitis and oliguric renal failure. Respiratory rate is 26 breaths/min, heart rate is 125 beats/min, and temperature is 37.2°C. Physical examination shows marked abdominal tenderness with normoactive bowel sounds. A CT scan shows an inflamed pancreas without hemorrhage. You calculate her APACHE-I score to be 28. When deciding on when to initiate nutritional replacement in this patient, which of the following statements is true? A Bowel rest is the cornerstone of treatment for acute pancreatitis. B Administering parenteral nutrition within 24 h will decrease the risk of infection and mortality. C Enteral feeding supports gut function by secretion of gastrointestinal hormones that stimulate gut trophic activity. D In severe systemic response to inflammation, feeding can be withheld initially because the patient is likely to have adequate, spontaneous oral intake in the first 7 days.

1159 An 86-year-old woman with chronic obstructive pulmonary disease (COPD), congestive heart failure, and insulin-requiring type 2 diabetes mellitus is admitted to the intensive care unit with an exacerbation of her COPD. She is intubated and treated with glucocorticoids and nebulized albuterol. She is also continued on her glargine insulin, aspirin, pravastatin, furosemide, enalapril, and metoprolol. On hospital day 8, parenteral nutrition is begun via catheter in the subclavian vein. Her insulin requirements increase on hospital day 9 due to episodes of hyperglycemia. On hospital day 10, she develops rales and an increasing oxygen requirement. A chest radiograph shows bilateral pulmonary edema. Laboratory data show hypokalemia, hypomagnesemia, and hypophosphatemia and a normal creatinine. Her weight has increased by 3 kg since admission. Urine sodium is <10 meq/dL. All of the following changes in her nutritional regimen will improve her volume status except A combination of glucose and fat in the parenteral nutrition mixture B decreasing the sodium content of the mixture to <40 meq per day C increasing the protein content of the parenteral nutrition mixture D reducing the overall glucose content

1160 A new study has been published showing a benefit of 25 mg/day of vitamin X. The recommended estimated average requirement of vitamin X is 10 mg/day, 2 standard deviations below the amount published in the study. The tolerable upper limit of vitamin X is unknown. Your patient wants to know if it is safe to consume 25 mg/day of vitamin X. Which is the most appropriate answer? A Two standard deviations above the estimated average requirement defines the tolerable upper limit. B 25 mg/day is probably too much vitamin X in 1 day. C 25 mg/day is statistically in a safe range of the estimated average requirement. D The study was not designed to assess safety and therefore should not influence practice.

1165 After being stranded alone in the mountains for 8 days, a 26-year-old hiker is brought to the hospital for evaluation of a right femoral neck fracture. He has not had anything to eat or drink for the past 6 days. Vital signs are within normal limits. Weight is 79.5 kg, which is 1.8 kg less than he weighed 6 months ago. Laboratory data show a creatinine of 2.5 mg/dL, blood urea nitrogen of 52 mg/dL, glucose 96 mg/dL, albumin 4.1 mg/dL, chloride 105 meq/L, and ferritin on 173 ng/mL. Which of the following statements is true regarding his risk of malnourishment? A He has protein-calorie malnutrition due to the rate of weight loss. B He has protein-calorie malnutrition due to his elevated ferritin. C He is at risk, but a normal individual can tolerate 7 days of starvation. D He is not malnourished because he is not hypoglycemic after 6 days of no food or water.

1166 You are doing rounds in the intensive care unit on an intubated patient who is recovering from a stroke and has diabetic gastroparesis. When suctioning the patient in the morning, she coughs profusely, with thick green secretions. You are concerned about the possibility of aspiration pneumonia. All of the following measures are useful in preventing aspiration pneumonia in an intubated patient except A combined enteral and parenteral nutrition B elevating the head of the bed to 30° C physician-directed methods for formula advancement D post-ligament of Treitz feeding

1171 A new screening test for thyroid cancer has been introduced into the population. In the first year, 1000 positive tests lead to correct identification of thyroid cancer in the screened population. Over the next year, 250 cases of thyroid cancer are detected among those who initially had a negative test. What is the sensitivity of this new screening test? A 0.25 B 0.67 C 0.8 D Not enough information to calculate

1175 An 18-year-old man with ankylosing spondylitis (AS) is concerned about the development of disability due to his disease. Which of the following statements is true regarding the development and treatment of disability in AS? A Anti-TNF-α (tumor necrosis factor α) inhibitors are now first-line therapy and have been shown to limit disability while being safe for long-term therapy. B Despite the development of ankylosis of the spine, spinal fracture is a rare complication, affecting <10% of individuals with AS. C Maintenance of an exercise program to maintain posture and range of motion is important in limiting disability. D Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease pain but have no effect on the development of disability in AS.

1176 A 42-year-old woman is brought to the emergency room by ambulance for altered mental status. The glucose level by fingerstick monitoring was below the measurement capabilities of the monitor (<40 mg/dL). After 2 ampules of 50% dextrose, the patient's fingerstick glucose remains at 42 mg/dL. She remains unconscious and had a 1-min seizure while in transport. She has no history of diabetes mellitus. Her family denies that she has been recently ill, but recently she has been depressed. She works as a registered nurse on a medical floor of the hospital. Which of the following tests would confirm an overdose of exogenous insulin? A Plasma glucose <55 mg/dL, plasma insulin >18 pmol/L, and plasma C-peptide levels undetectable B Plasma glucose <55 mg/dL, plasma insulin >18 pmol/L, and plasma C-peptide levels >0.6 ng/mL C Plasma glucose <55 mg/dL, plasma insulin <18 pmol/L, and plasma glucagon <12 pmol/L D Plasma glucose <55 mg/dL, plasma insulin <18 pmol/L, and C-peptide levels undetectable

1177 Differentiating primary dysmenorrhea from other causes of chronic cyclical pelvic pain is important because there is a specific treatment for primary dysmenorrhea. What is the pathophysiology/treatment for primary dysmenorrhea? A Ectopic endometrium/oral contraceptives B History of sexual abuse/counseling C Increased stores of prostaglandin precursors/antiinflammatory medication D Ruptured graafian follicle/oral contraceptives

1181 The parents of a 14-year-old boy want your opinion about treatment of their child's lipid disorder. The family emigrated from South Africa to the United States recently. The child has had cutaneous xanthomas on the hands, elbows, heels, and buttocks since childhood. In South Africa, he underwent thoracotomy for a problem with his aortic valve 3 years ago. He currently experiences exertional dyspnea, and his diet consists mostly of unhealthy, fatty foods. On examination, you appreciate bruits in the femoral arteries and abdominal aorta. His most recent lipid profile shows a total cholesterol of 734 mg/dL and a low-density lipoprotein (LDL) of 376 mg/dL. What is the most appropriate step in this patient's evaluation? A Genetic test for familial defective apoB100 B Rule out congenital syphilis C Rule out hypothyroidism D Screen the parents for Münchhausen-by-proxy syndrome

1182 A 62-year-old woman presents to your clinic complaining of fatigue and lethargy over a period of 6 months. She cannot recall exactly when these symptoms started, but feels that they are worsening with time. She describes dry skin and has noted that she is losing hair. On examination she is mildly bradycardic at 52 beats/min with normal blood pressure and has dry, coarse skin. There are areas of alopecia and mild lower extremity edema is noted. Which of the following is the most likely clinical diagnosis and which test would be indicated for screening for the diagnosis? A Hyperthyroidism: thyroid-stimulating hormone (TSH) B Hyperthyroidism: unbound T4 C Hypothyroidism: TSH D Hypothyroidism: unbound T4

1186 A 26-year-old woman comes to your clinic complaining of 3-4 weeks of a malodorous white vaginal discharge. She recently began having unprotected sexual intercourse with a new male partner. He is asymptomatic. Her only medication is oral contraceptives. Examination reveals a thin white discharge that evenly coats the vagina. Further examination of the discharge reveals that it has a pH of 5.0 and has a "fishy" odor when 10% KOH is added to the discharge. Microscopic examination reveals vaginal cells coated with coccobacillary organisms. Which of the following therapies is indicated? A Acyclovir, 400 mg PO tid × 7 days B Metronidazole, 2 g PO × 1 C Metronidazole, 500 mg PO bid × 7 days D Fluconazole, 100 mg PO × 1 E Vaginal douching

1190 Which of the following statements regarding HIV epidemiology in the United States is true as of 2005? A HIV incidence is currently decreasing among men who sleep with men. B Heterosexual contact accounts for the majority of current HIV cases. C Minority women aged 13-19 from the southeastern United States account for a growing proportion of prevalent HIV cases. D The proportion of cases due to high-risk heterosexual contact has decreased dramatically over the past 20 years. E The proportion of prevalent HIV cases due to injection drug use is currently increasing.

1197 All of the following are risk factors for the development of Legionella pneumonia except A glucocorticoid use B HIV infection C neutropenia D recent surgery E tobacco use

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