MCQ Basic Science 8

"A 35-year-old woman presents to your office complaining of fatigue and global achiness. She states that she has ""not been myself"" since she developed a bad whiplash after a motor vehicle accident. Her health has otherwise been good. About 3 years ago, she saw a cardiologist for chest pain. A full evaluation ensued including heart catheterization that showed no coronary disease, although her cholesterol levels were elevated and a statin was prescribed. She sleeps poorly and notes that she has gained a considerable amount of weight. She has seen a gastroenterologist who has told her that her abdominal pain and alternating constipation and diarrhea are because of irritable bowel syndrome. Physical examination shows that her height is 5 ft 2 in. and her weight is 240 lb. blood pressure is 126/78. Pulse is 86 and regular. Heart and lung examinations are completely normal. Her pharynx is normal and she has no lymphadenopathy. Abdominal examination shows diffuse mild tenderness, but no masses, rebound, guarding, or organomegaly. rectal and pelvic examinations are normal. Muscular strength is 4/5 distally and proximally, but there is a considerable give way secondary to pain. She is tender bilaterally at the occiput across the trapezius, iliac crest at the greater trochanteric, anserine bursae bilaterally, and at the second intercostal space bilaterally. In this patient, which of the following conditions may also be exacerbating her symptoms? A. sleep apnea B. hyperthyroidism C. RA D. celiac sprue E. medication side effect"

A

"A 45-year-old male has received intravenous contrast dye prior to CT scan of the abdomen. Twenty minutes later the patient reports severe pruritus. He denies respiratory distress, syncope, or palpitations. His blood pressure is 98/54, pulse is 90, and respiratory rate is 22. On physical examination, he has widespread urticaria. His lungs are clear to auscultation. The next appropriate step would be which of the following? A. administration of 0. 5 mL of 1:1000 epinephrine subcutaneously B. administration of 0. 5 mL of 1:100,000 epinephrine subcutaneously C. administration of 25 mg of diphenhydramine subcutaneously D. administration of intravenous glucocorticoids E. careful observation but no medications"

A

"A 45-year-old male receives a cadaveric liver transplant for alcoholic cirrhosis. Postoperatively, the patient is taken to the surgical intensive care unit (SicU). There is concern for primary nonfunction of the allograft. Which of the following is a sign of this? A. coagulopathy with an INR of 2 B. normalizing albumin level C. hyperglycemia requiring an insulin drip D. initial rise of transaminases E. high urine output"

A

"A 46-year-old female presents to your office with rectal bleeding, itching, and irritation. On examination, a 3-cm ulcerating lesion is seen in the anal canal. Biopsy of the lesion reveals squamous cell carcinoma (SCC). Which of the following is the most appropriate treatment? A. chemotherapy and pelvic radiation protocol B. low anterior resection C. abdominal perineal resection D. wide local excision of the lesion E. wide local excision of the lesion and bilateral inguinal lymph node dissection"

A

"A 48-year-old male truck driver presents for evaluation of bright red rectal bleeding with bowel movements. He also has the feeling that something protrudes through his anus while he strains to move his bowels but that it withdraws into the bowel when he relaxes. He has no abdominal pain, weight loss, or other symptoms. A colonoscopy reveals no polyps or tumors but does note internal hemorrhoids. Which of the following is the best initial treatment for him? A. high fiber diet, frequent sitz baths, and topical steroid ointment B. rubber band ligation C. sclerotherapy injection D. infrared coagulation E. surgical hemorrhoidectomy"

A

"A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4 day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sLEEPing 1214 hours per day, and at times she seems confused. CT scan of the brain revealsno abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most appropriate initial therapy for the patient's hypercalcemia? A. volume resuscitation with normal saline B. administration of furosemide every 6 hours C. subcutaneous calcitonin D. intravenous zoledronate E. treatment of the patient's underlying malignancy with chemotherapy"

A

"A 50-year-old man comes to the emergency room (ER) with a history of vomiting of 3 days' duration. His past history reveals that for approximately 20 years he has been experiencing epigastric pain that lasts for 23 weeks during spring and autumn. He remembers getting relief from pain by taking milk and antacids. Physical examination showed fullness in the epigastric area with visible peristalsis, absence of tenderness, and normal active bowel sounds. What is the most likely diagnosis? A. gastric outlet obstruction B. small bowel obstruction C. volvulus of the colon D. incarcerated umbilical hernia E. cholecystitis"

A

"A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in ""excellent health. "" He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. Which of the following is true of this patient's skin condition? A. It is the most common malignancy in the United States. B. Total body skin examination reduces the morbidity and mortality associated with this condition. C. Metastasis is common. D. The cure rate is approximately 50%. E. If appropriately treated, the rate of recurrence (development of a second lesion) is equal to that found in the general population."

A

"A 59-year-old White male with a 40 pack-year history of smoking presents to your clinic complaining of three prior episodes of a ""shade passing over his left eye"" over the last 2 months. He reports that last week he experienced some weakness in his right arm, which resolved after 5 minutes. Appropriate management and counseling for this patient includes which of the following? A. Initial management of this patient should include bilateral cerebral vessel duplex ultrasonography. B. Explanation to him that he has had a stroke and will be referred to a neurologist for management. C. The most common cause of strokes in these patients is related to decreased blood flow. D. Presence of a carotid bruit confirms the diagnosis and may lead to operative intervention without the need for imaging studies. E. The presence of a 50% stenosis in the right carotid artery should lead to bilateral surgical repair."

A

"A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. An abnormal result of which of the following laboratory tests would be most likely to explain the cause of this condition? A. TSH B. troponin T C. BUN and creatinine D. serum glucose E. arterial blood gas"

A

"A 64-year-old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an antiinflammatorymedication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. Climbing stairs seems to be tolerated well, but walking greatly exacerbates the pain. He denies bladder or bowel incontinence or retention, point tenderness or anesthesia in the lower back along the spinal cord or in the saddle area. Which of the following imaging studies would be most helpful to confirm the diagnosis? A. an MRI of the lumbosacral spine B. an x-ray of the lumbosacral spine C. an indium-tagged WBC scan D. a bone scan of the sacrum E. nerve conduction study of the legs bilaterally"

A

"A 70-year-old male is seen in the office for chest pain. He reports that he is getting substernal chest pain, without radiation, when he mows his lawn. The pain resolves with 1015 minutes of rest. He has never had pain at rest. He has no other cardiac complaints and his review of systems is otherwise negative. He has an unremarkable medical history and takes only a baby aspirin a day. On examination, his blood pressure is 160/70, pulse 85, and respiratory rate 16. His cardiac examination is notable for a harsh, 3/6 systolic ejection murmur along the sternal border that radiates to the carotid arteries. His carotid pulsation is noted to rise slowly and is small and sustained. His lungs are clear. The remainder of his examination is normal. Which of the following would be the most appropriate test to order next? A. echocardiogram B. exercise stress test C. cardiac catheterization D. 24-hour Holter monitor E. electrophysiologic studies"

A

"A 72-year-old man with a diagnosis of prostate cancer was recently seen in the clinic for restaging and reevaluation. His bone scan showed development of widespread osseous metastases and his PSA was rising. He was started on leuprolide acetate, a gonadotropin releasing-hormone (GnRH) agonist. He now returns to the clinic complaining of new severe mid-thoracic back pain, which is worse with recumbency and worse with Valsalva maneuver. He also reports that he has a brief but intense electric shock sensation in his lower extremities when he bends over to tie his shoes. On physical exam, he had localized tenderness over the mid-thoracic spine, but his motor strength, sensation, and deep tendon reflexes are all intact. What is the most appropriate next step? A. Obtain an MRI of the thoracic spine. B. refer for neurosurgical evaluation. C. Initiate radiation therapy to the affected thoracic spine. D. Start the patient on scheduled narcotics for relief of the back pain and follow up in 1 week. E. Stop the leuprolide and schedule the patient to return to clinic in 1 week for re-evaluation."

A

"A mobile mass is found on rectal examination in a 77-year-old male with complaints of blood in his stool. On workup, he is found to have a stage I (Dukes' A), well differentiated adenocarcinoma. The most appropriate intervention is which of the following? A. transanal excision B. abdominal perineal resection C. low anterior resection D. placement of endorectal wallstent E. neoadjuvant chemotherapy followed by transanal resection"

A

"A patient presents with a new neck mass. On examination, she has a palpable thyroid nodule and a palpable cervical lymph node on the same side. Needle biopsy of the thyroid nodule shows amyloid in the stroma. The treatment for this patient is which of the following? A. total thyroidectomy and modified neck dissection B. resection of the involved thyroid lobe, isthmusectomy, and removal of the palpable lymph node C. total thyroidectomy and radiation therapy D. resection of the involved lobe and part of the contralateral lobe, isthmusectomy, and removal of the palpable lymph node E. radioactive iodine administration"

A

"A1-month-old female presents after an episode of bilious emesis. She became irritable 12 hours ago, began vomiting 6 hours ago, and is now lethargic. She had one small stool that was somewhat bloody 2 hours ago. Which of the following statements is true? A. An upper GI contrast study should be obtained immediately. B. The most likely explanation is pyloric stenosis. C. The patient should be admitted for IV fluid resuscitation and observation. If she does not improve over the next 24 hours, a surgical consultation should be obtained. D. An air contrast enema is the most appropriate next step. E. A nasogastric tube should be inserted and IV antibiotics started to treat probable necrotizing enterocolitis."

A

"A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. You order a CXR. Which of the following are you most likely to find? A. normal B. diffuse pulmonary congestion C. increased bronchial wall markings D. cardiomegaly E. flattening of the diaphragms"

A

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? A. the Breslow depth of the tumor B. the Clark level of the tumor C. the location of the tumor D. the age of the patient E. the number of prior severe blistering sunburns"

A

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? Which of the following interventions is most appropriate in addition to wide local excision of the patient's melanoma? A. sentinel lymph node biopsy B. no further intervention is warranted C. adjuvant therapy with interferon alpha-2 for 1 year D. single-agent chemotherapy E. complete lymph node dissection"

A

"A24-year-old female presents to your office for excision of a nevus. After obtaining consent and prepping the site, you anesthetize the area with 1% lidocaine. However, as you start the procedure, you note that the patient is not sufficiently anesthetized. Your partner suggests the use of lidocaine with epinephrine. The addition of epinephrine with local anesthetics is useful because of which of the following properties? A. It prolongs and increases the depth of local anesthesia. B. It neutralizes the irritant action of the local anesthetic agent. C. It increases the rate of systemic absorption and therefore hastens the onset of action of the anesthetic agent. D. It increases the pH of the anesthetic so that less anesthetic is required to produce nerve block. E. It blocks neurotransmitter release (thus decreasing pain perception) via stimulation of presynaptic alpha-adrenergic receptors."

A

"A27-year-old female whose father had a colon resection for adenocarcinoma undergoes her first colonoscopy. Over 100 small polyps are seen distributed mainly in her sigmoid and rectum. Multiple polyps are removed and histologic review reveals tubular adenomas with no evidence of atypia or dysplasia. The most appropriate next step in her management is which of the following? A. total proctocolectomy with ileoanal J pouch reconstruction B. surveillance colonoscopy in 5 years C. surveillance colonoscopy every 2 years until all polyps are removed D. flexible sigmoidoscopy with representative biopsy every 6 months for 2 years, then yearly for 3 years, then every 35 years E. abdominal perineal resection with sigmoid resection and end colostomy"

A

"A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. Infection with which of the following agents is most likely to have resulted in her cancer? A. human papillomavirus type 16 B. hepatitis C virus C. hepatitis B virus D. Chlamydia trachomatis E. human papillomavirus type 11"

A

"A32-year-old female presents for her first pap smear in more than 10 years. She has a history of heavy alcohol use and IV drug use and has performed sexual acts for drugs on numerous occasions. testing performed today reveals her to have chlamydia cervicitis and trichomonas vaginalis and to be seropositive for hepatitis B and hepatitis C. HIV testing is negative. Her pap smear subsequently returns with carcinoma in-situ of the cervix. Subsequent work-up confirms the presence of micro-invasive cervical carcinoma [Stage Ia]. What would be the most appropriate treatment? A. simple hysterectomy B. radical hysterectomy with pelvic lymph node dissection C. cervical radiation therapy D. cervical radiation followed by chemotherapy E. hysterectomy followed by chemotherapy"

A

"A40-year-old woman presents with headaches and visual disturbances for the past 6 months. She suddenly developed amenorrhea 2 years ago. One year ago, she noticed milky discharge from her left breast. The most likely diagnosis is which of the following? A. prolactinoma B. premature ovarian failure C. Kallman syndrome D. Sheehan syndrome E. polycystic ovarian syndrome (PCOS)"

A

"A45-year-old man undergoes a distal esophagectomy for Barrett's esophagus. During his hospital course, a left chest tube is placed for an effusion. Milky white fluid is found to come out through the tube. Which of the following statements is most accurate about this condition? A. Diagnosis can be confirmed by checking the lymphocyte count and triglyceride level in the fluid. B. This condition requires immediate surgical intervention to repair. C. The chest tube should be removed due to the possibility of an iatrogenic source of infection. D. Usually found on the right if due to a traumatic source. E. The use of TPN is contraindicated until the condition resolves."

A

"A54-year-old man without significant past medical history presents to his primary care physician complaining of epigastric discomfort and early satiety. He subsequently undergoes an endoscopic procedure revealing an ulcerated mucosal lesion. The biopsy of this lesion is interpreted as a well differentiated lymphoma. Which of the following statements regarding his treatment and prognosis is most accurate? A. His prognosis is poorer than if he were diagnosed with a gastric adenocarcinoma. B. This lymphoma is not associated with Helicobacter pylori infection. C. Antibiotic therapy may induce regression of the lesion in the majority of cases. D. Treatment will not offer curative potential, so he should be referred for hospice care. E. Gastric resection is recommended for well-differentiated, bbut not higher grade, lymphomas."

A

"A64-year-old man with a long history of smoking but no significant past medical history presents to his physician's office complaining of a 12 week history of worsening dyspnea, facial swelling, and discoloration. He has also had swelling and discomfort of his right arm. Physical examination reveals edema with plethora of the face and right arm, with prominent collateral veins over the chest wall. Following the establishment of a diagnosis, what is the most appropriate initial therapy? A. elevation of the head and monitoring for airway obstruction B. urgent radiation therapy C. administration of glucocorticoids D. empiric chemotherapy for suspected lung cancer E. surgical evaluation for resection of the obstructing mass"

A

"Apatient with a known family history of multiple endocrine neoplasia (MEN) I, now presents with intractable ulcer disease. Which of the following statements about his condition is most accurate? A. diarrhea is a frequent complaint. B. Tumors are rarely multiple. C. Tumors are rarely malignant. D. An elevated fasting gastrin level is diagnostic for the Zollinger-Ellison syndrome. E. CT is useful in localizing the tumor in greater than 75% of patients."

A

"Avascular necrosis is most likely to occur in fracture dislocations involving which of the following? A. the femoral head B. the shaft of the femur C. the shaft of the humerus D. the scapula E. the clavicle"

A

"Biopsy of a 4-cm sessile polyp of the cecum during a routine screening colonoscopy reveals it to be a villous adenoma with atypia. Attempt at piecemeal snare polypectomy through the colonoscope is unsuccessful. Which of the following is the most appropriate management? A. right hemicolectomy B. colonoscopy with electrocoagulation of the tumor C. colonoscopy with repeat biopsy in 6 months D. open surgery with colotomy and excision of polyp E. external beam radiation"

A

"Gastrin secretion is enhanced by which of the following? A. antral distention B. antral acidification C. presence of fat in the antrum D. sympathetic nerve stimulation E. duodenal acidification"

A

"Which of the following is characteristic of Hirschsprung's disease? A. Constipation is the most frequent presenting feature. B. severity of the symptoms corresponds with the extent of bowel involvement. C. Acetylcholinesterase activity is decreased in the aganglionic segment. D. The proximal colon is most commonly affected. E. It presents most commonly in young adults."

A

"Which of the following structures can be found outside of the spermatic cord during a hernia repair? A. direct hernia sac B. indirect hernia sac C. vas deferens D. testicular artery E. ovary"

A

"You perform an upper endoscopy on a patient and find changes suggestive of Barrett's esophagus. How do you explain this to the patient and his family? A. Is a condition where the normal esophageal lining is replaced by columnar epithelium. B. Is a condition where the normal esophageal lining is replaced by dysplastic squamous cells. C. Two biopsies with histologic changes are needed to confirm the diagnosis. D. The main risk associated with Barrett's esophagus is bleeding. E. It is related to peptic ulcer disease."

A

"A 17-year-old male presents for evaluation of shortness of breath. He has episodes where he will audibly wheeze and have chest tightness. His symptoms worsen if he tries to exercise, especially when it is cold. He has used an OTC inhaler with good relief of his symptoms, but he finds that his symptoms are worsening. He now has episodes of wheezing on a daily basis and will have nighttime wheezing and coughing, on average, five or six times a month. You suspect a diagnosis of asthma. Which of the following would confirm your suspicion of the diagnosis of asthma? A. presence of expiratory wheezing on examination B. increase in FEV1 of 15% after giving inhaled albuterol C. a decreased serum IgE level D. presence of eosinophils on a sputum sample E. a peak expiratory flow measurement 30% below the predicted normal value for the patient"

B

"A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy. Which of the following is typically seen as a feature of tumor lysis syndrome? A. hypokalemia B. hypocalcemia C. hypophosphatemia D. acute necrosis of renal tubules E. urine alkalinization"

B

"A 23-year-old pregnant woman with type 1 diabetes was admitted to the Obstetrics service for DKA. The DKA was appropriately treated and has resolved. You were consulted for medical management of the diabetes, as her sugars have been labile throughout the hospital stay. Your history and review of records reveals that the patient has a long-standing history of noncompliance with diet and medication regimens. She currently uses any insulin she can get and does not eat regular meals. She has fluctuating blood sugars with episodes of hypoglycemia. You counsel the patient extensively, order nutrition and diabetic teaching consults, and discuss keeping home glucose logs. Assuming the patient will follow your advice, which regimen would you recommend to minimize fluctuating glucose readings? A. NPH insulin twice daily B. insulin glargine once daily and insulin lispro before meals C. Humulin 70/30 twice daily D. NPH twice daily and regular insulin three times daily with meals E. insulin glargine twice daily"

B

"A 34-year-old male presents with a penile lesion. Your history, physical examination, and serology confirm a diagnosis of syphilis. The patient reports that his mother told him he was ""allergic"" to penicillin. He does not recall any personal history of anaphylaxis or rash to antibiotics however he has never been ""sick. "" How would you manage this patient? A. Admit to the ICU for penicillin desensitization as you don't want to risk anaphylaxis especially with the uncertain history. B. Do skin testing for penicillin allergy. C. Avoid penicillin or cephalosporins in future. D. Treat with erythromycin. E. Treat with penicillin as he is not likely to have a true allergy."

B

"A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable. Which of the following is true of the patient's condition? A. It commonly presents in premenopausal women. B. It commonly presents as a monoarticular arthritis. C. Episodes of pain and inflammation become more frequent but resolve more quickly as the disease progresses. D. The presence of tophi is a common early finding. E. A blood test is the diagnostic gold standard."

B

"A 45-year-old male with type II diabetes, hypertension, and hyperlipidemia presents to your clinic as a new patient. He has been out of his cholesterol medications and came to your office requesting a refill. The patient brought his most recent lipid profile (done after he was off his cholesterol medication for 3 months) which revealed: Cholesterol (total): 242 mg/dL HDL cholesterol: 38 mg/dL Triglycerides (TGs): 660 mg/dL LDL cholesterol = unable to calculate due to high TGs He also had recent liver function tests that were normal. Based on Adult Treatment Panel (ATP) III guidelines, which of the following medications should be the initial pharmacologic treatment for this patient? A. atorvostatin B. gemfibrozil C. cholestyramine D. omega-3 fatty acids E. nicotinic acid"

B

"A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Before doing so, you explain to the patient that antibiotics such as gentamicin are often associated with which of the following? A. hepatotoxicity B. nephrotoxicity C. interstitial pulmonary fibrosis D. pulmonary edema E. splenomegaly"

B

"A 48-year-old woman complaining of dysuria is diagnosed with a UTI by urinalysis. Urine culture and sensitivities reveal that the causative organism belongs to the genus Klebsiella and is resistant to multiple antibiotics. Based upon the results available, you decide to begin therapy with gentamicin. Which of the following would lead to the classification of this patient's infection as ""complicated?"" A. a history of recurrent UTIs B. a diagnosis of type II DM C. the patient's gender D. a history of undergoing a laparoscopic appendectomy 1 month ago E. a postvoid residual volume of 25 cc"

B

"A 48-year-old woman with metastatic breast cancer presents to the Emergency Center complaining of a 4 day history of nausea, anorexia, and generalized weakness. Her husband reports that she has been more somnolent, sLEEPing 1214 hours per day, and at times she seems confused. CT scan of the brain reveals no abnormalities. Initial laboratory evaluation reveals a normal CBC, but her BUN is elevated at 32 mg/dL with a slight elevation of serum creatinine above her baseline. Her serum calcium is elevated at 15 mg/dL. What is the most likely cause of her hypercalcemia? A. widespread osteolytic metastases B. ectopic production of a parathyroid hormone-related protein C. excessive administration of oral calcium and Vitamin D supplementation to prevent osteoporosis D. undiagnosed primary hyperparathyroidism E. side effect of medications such as thiazide diuretics"

B

"A 50-year-old female presents to your office for evaluation of solid food dysphagia without weight loss. Symptoms have been present for 6 months and are progressive. The patient has had two episodes of near impaction, but copious water ingestion and repeated swallows allowed the food bolus to pass. She has never had to present to the ER for disimpaction. She drinks five to six beers per day, loves spicy foods, and smokes a pack of cigarettes daily with a total lifetime history of 30 pack-years. She has had intermittent heartburn symptoms for years and has not sought treatment. She takes hydrochlorothiazide for hypertension. review of symptoms reveals chronic cough. Physical examination is unremarkable. Upper endoscopy reveals a distal esophageal stricture with inflammatory changes. Esophageal biopsies reveal benign mucosa with chronic inflammation. Gastric biopsies are unremarkable. Helicobacter pylori testing is negative. The patient is at increased risk for which of the following illnesses? A. esophageal squamous cell cancer B. esophageal adenocarcinoma C. gastric cancer D. gastric lymphoma E. duodenal adenocarcinoma"

B

"A 50-year-old man presents to your office with fatigue and weakness. He first noticed it a few weeks ago while trying to hang pictures with his wife. His legs have begun to ache as he walks up stairs. He has lost about 20 lbs in the last 3 months. Most recently, he has found that he is more constipated and has trouble rising from the commode. Your physical examination reveals modest proximal weakness, no articular swelling, rash, or any other pertinent findings. blood work from a recent insurance examination revealed: Sodium 142 meq/L; potassium 3. 8 meq/L; chloride 107 meq/L; bicarbonate 29 meq/L; BUN 30 mg/dL; Cr 1. 6 mg/dL; WBC 6. 8; Hgb 13. 6 g/dL; HCT 40%; MCV 88. 0 m3; platelets 240,000/mm3; AST 200 U/L; ALT 250 U/L; alkaline phosphatase 70 U/L; bilirubin 0. 3 mg/dL; ESR 40 mm/h. Along with a creatine phosphokinase (CPK), which of the following tests should be ordered first? A. muscle biopsy B. gamma glutamyl transferase (GGT) C. MRI of the lumbar spine D. ultrasound of the liver and gallbladder E. kidney ultrasound with renal artery Doppler"

B

"A 55-year-old male is brought to the ED, by ambulance, because of crushing chest pain radiating to his left shoulder and arm that started 1 hour ago. He has a history of hypertension, high cholesterol, and has smoked a pack of cigarettes a day for 30 years. He has never had symptoms like this before. Fortunately, the patient survives this episode. As part of his long-term treatment, which of the following would be an appropriate therapeutic intervention to initiate due to its proven effect on survival rate? A. flecainide B. captopril C. quinidine D. digoxin E. nitroglycerin"

B

"A 58-year-old male presents to your office for a well-male examination. It has been several years since he last visited a doctor, but he states that he has been in ""excellent health. "" He denies any history of drinking, smoking, or using illegal drugs. He maintains a diet low in sodium and fat. An avid sports enthusiast, he also spends at least 2 hours per day engaged in some type of outdoor physical activity. On physical examination, you discover a translucent waxy papule with raised borders on the posterior aspect of his left shoulder. The treatment modality associated with the lowest recurrence rate is which of these? A. radiation therapy B. Mohs micrographic surgery C. surgical excision D. electrodesiccation with curettage E. cryotherapy"

B

"A 64-year-old male with a history of hypertension and tobacco abuse presents for follow-up after a routine physical during which he was found to have 45 red blood cells (RBCs) per high-power field (HPF) on a screening urinalysis. The urinalysis was negative for leukocytes, nitrites, epithelial cells, and ketones. The patient denies any complaints and the review of systems is essentially negative. A. change of antihypertensive agent and recommendation to patient to discontinue smoking. B. image the upper and lower urinary tracts C. antibiotics for 1 month D. expectant management with follow-up urinalysis in 6 months E. nephrology consultation"

B

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. On further evaluation, the patient is found to be diabetic. He has an elevated HgbA1C and fasting hyperglycemia. The patient is sent for diabetic teaching sessions and begun on insulin therapy, but is unable to achieve euglycemia. He experiences frequent bouts of symptomatic hypoglycemia requiring ER visits. What is the most likely cause for these episodes? A. insulin overdose B. impaired glucagon production C. inadequate oral intake D. vitamin K deficiency E. vitamin B12 deficiency"

B

"A 72-year-old man comes to your clinic for the first time, accompanied by his wife. His wife states that she is concerned because he has been growing increasingly forgetful over the past year. Within the past month, he has forgotten to turn off the stove and has got lost while walking to the post office one block away from their home. His past medical history is significant for well-controlled diabetes and chronic lower back pain. He has no history of falls or traumatic injury to the head. Examination of the patient is significant for a score of 18 on a Mini Mental Status Examination (MMse). During the administration of the MMse, the patient blurts out that his wife brought him to the doctor because she is having an extramarital relationship. Use of which of the following medications would be the most likely to lead to worsening of symptoms in this patient? A. risperidone B. amitriptyline C. olanzapine D. quetiapine E. trazodone"

B

"A 74-year-old male with gout, osteoporosis, and type II diabetes presents for routine followup. As you review his medication list you note that he is on insulin, vitamin D, glypizide, quinidine, and allopurinol. You now diagnose him with hypertension that requires pharmacologic management. Which of the following medications would be contraindicated in this patient? A. enalapril B. hydrochlorothiazide C. diltiazem D. losartan E. atenolol"

B

"A previously healthy 34-year-old man, a lifelong nonsmoker, sought medical care at an Urgent Care Center for an upper respiratory infection. A chest x-ray was obtained, which revealed a peripherally located right lower lobe lung nodule. A follow-up CT of the chest showed the 1. 8 cm nodule with multiple nonspecific calcifications, and no associated hilar or mediastinal adenopathy. What is the most appropriate next step? A. refer the patient to a thoracic surgeon to evaluate for wedge resection for suspected malignancy. B. repeat the CT chest in 3 months to assess for stability of the nodule. C. refer the patient for a percutaneous needle biopsy of the lesion to rule out malignancy. D. refer the patient to a pulmonologist to evaluate for possible bronchoscopy with transbronchial biopsy. E. Treat with empiric antibiotics for possible pneumonia and repeat the chest x-ray in6 weeks to see if the nodular opacity has resolved."

B

"A19-year-old male who moved to your city 3 months ago comes to your office complaining of dry cough for the past 23 months. Along with the cough, he has had some shortness of breath with exertion. He denies fever, chills, nausea, vomiting, wheezing, and sneezing. The cough occurs mostly in the morning and improves as the day goes on. He denies similar complaints in the past and has no history of allergies. He says that his father had eczema and an allergy to eggs. What is the single best treatment for preventing symptoms in this patient? A. long-acting beta-2 agonists B. an inhaled steroid C. an inhaled anticholinergic D. leukotriene modifiers E. long-acting oral bronchodilators"

B

"A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Six hours after treating this patient, he calls your office with complaints of new-onset headache, myalgia, and malaise. He also states that he felt feverish immediately prior to calling and measured his temperature, which was 99. 8°F. Which of the following is most appropriate at this time? A. Advise transport to the nearest ED for immediate evaluation. B. Advise use of acetaminophen and provide reassurance. C. Advise immediate use of Benadryl and then have the patient go to the nearest ED. D. Start treatment with levaquin. E. Start treatment with oral corticosteroids."

B

"A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a ""pink eye"" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. What would be the appropriate management for this patient's arthritis? A. Screen him for the suspected disease with HLA-B27 testing. B. Treat with daily indomethacin (150-200 mg daily). C. Start him on empiric antibiotics. D. Start treatment with prednisone 10 mg daily. E. Assume that the patient is not being honest and perform the appropriate urogenital testing to confirm gonorrhea."

B

"A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. How would you counsel this patient? A. The primary treatment for this problem is with medications. B. Weight loss is key to her management. C. Her hypertension would be best treated with a thiazide diuretic. D. regardless of her lipid panel result, she should be on a statin. E. Her infertility is due to lack of estrogen production."

B

"A57-year-old male presents for annual examination. On history, you note a history of colon cancer that was successfully surgically resected 2 years ago. He had a negative postoperative colonoscopy 6 months later and another negative colonoscopy last year. Which of the following would be the most appropriate colon cancer screening regimen for this patient? A. colonoscopy or virtual colonoscopy in 1 year B. colonoscopy in 3 years C. colonoscopy or double contrast barium enema in 5 years D. colonoscopy annually E. digital examination and fecal occult blood test (FOBT) annually with colonoscopy in 10 years"

B

"A64-year-old man with hypertension presents for routine follow-up of his blood pressure. His home blood pressure log reveals readings in the 150/70 range. His home monitor had previously been verified by clinic BP readings. He denies any complaints. His current medications include HCTZ 25 mg daily, metoprolol 100 mg twice daily, enalapril 20 mg twice daily, and amlodipine 10 mg daily. He states he is adherent to his medication, drug, and exercise regimen as you recommended. At this time, how would you advise the patient? A. You need to take another blood pressure medication. B. I need to order some tests to look for secondary causes of high blood pressure. C. In spite of your efforts, you need to exercise more and lose more weight. D. Your blood pressure is acceptable where it is. Continue your current regimen. E. I need to refer you to a cardiologist."

B

"A72-year-old African American male presents for a routine health examination. He states that he would like to have a ""screening for cancer. "" In the United States, based on his sex, race, and age, what is the most likely malignancy for this patient? A. lung cancer B. prostate cancer C. colon cancer D. testicular cancer E. multiple myeloma"

B

"An 18-year-old female presents for evaluation of facial acne. On examination, she has multiple comedones, papules, and pustules on her forehead, nose, cheeks, and chin. She also has several distinct nodules, each greater than 5 mm in diameter. After 6 months of appropriate treatment, the severity of your patient's acne remains essentially unchanged. You rule out several potential causes for the patient's recalcitrant acne and decide that more aggressive therapy is warranted. As you discuss this option with your patient, which of the following side effects of the proposed treatment necessitates extensive counseling prior to initiation of therapy? A. pseudotumor cerebri B. teratogenicity C. hepatotoxicity D. nephrotoxicity E. cardiotoxicity"

B

"Apatient you see routinely in the clinic has elevated liver function tests. ALT is 89, AST is 75, and the total bilirubin and alkaline phosphatase are normal. The patient has no past history of hepatitis, taking medications, or excessive drinking. You order hepatitis serologies. The results are as follows: Positive: HBsAg and anti-HBc. Negative: anti-HBs, anti-HBc IgM, anti-HAV, and anti-HCV What is the most appropriate next step for this patient? A. verify the diagnosis with a qualitative hepatitis B viral load. B. Vaccinate the patient with hepatitis A vaccine. C. Vaccinate the patient with hepatitis B vaccine. D. Investigate other causes of hepatitis, such as cytomegalovirus (CMV) and Epstein-Barr virus. E. recommend the patient's spouse receive hepatitis A vaccine."

B

"Vitamin D supplementation can be helpful in treating which disease? A. hyperparathyroidism B. hypoparathyroidism C. alcoholic neuritis D. pernicious anemia E. scurvy"

B

"A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy. Which of the following is an appropriate medication to use as a preventative measure prior to and during her treatment for leukemia? A. indomethacin B. colchicine C. allopurinol D. probenecid E. sulfinpyrazone"

C

"A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101. 1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis? A. erythematous tonsils B. cough C. tonsillar exudates D. posterior cervical lymphadenopathy E. halitosis"

C

"A 24-year-old male presents with sore throat, subjective fever, abdominal pain, and bad breath. He says that a neighbor's child is currently being treated for strep throat. On examination, his temperature is 101. 1° F and his other vital signs are normal. He appears well. His throat is erythematous and his tonsils are enlarged, but there are no pharyngeal or tonsillar exudates. He has no cervical adenopathy. He has an occasional cough but his lungs are clear. His abdominal examination is normal. The presence of which of the following findings is a clinical predictor for the diagnosis of streptococcal pharyngitis? Which of the following is the recommended first-line agent for the treatment of group A streptococcal pharyngitis? A. levofloxacin B. amoxicillin C. penicillin D. amoxicillin-clavulinic acid E. clindamycin"

C

"A 25-year-old woman presents to your office complaining of cold hands. She describes them turning white as she reaches for orange juice in the frozen food section of the supermarket. It seems to be getting worse lately. She has no other symptoms but does note that she and her husband are contemplating pregnancy. Her examination today is unremarkable. In this patient, which of the following studies would be most likely to describe an increased risk of future systemic disease? A. echocardiogram B. nerve conduction study C. ANA D. joint aspiration E. arterial Doppler of the upper limbs with cold stimulation"

C

"A 25-year-old woman with acute myelocytic leukemia is undergoing induction chemotherapy and presents to the Emergency Center complaining of a 1-day history of fever to 102º F with no other symptoms. Other than having a fever, her vital signs and physical examination are normal. Laboratory evaluation reveals pancytopenia, with a WBC count of 0. 3 k/L, hemoglobin concentration of 9. 2 mg/dL, and platelet count of 23,000/L. What is the most appropriate initial management? A. Obtain blood cultures, urine culture, a chest x-ray, and discharge patient to home with follow-up in 12 days to review culture results. B. Obtain blood cultures, urine culture, a chest x-ray, and admit the patient to the hospital for observation with plan to institute antibiotics if any culture becomes positive. C. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric broadspectrum antibiotics with Gram-negative coverage. D. Obtain blood culture, urine culture, a chest x-ray, and admit the patient to the hospital for empiric antibiotics with Gram-positive coverage. E. Forego cultures and admit the patient to the hospital for empiric antibiotics with both Gram-positive and Gram-negative coverage."

C

"A 26-year-old HIV-positive man is admitted to the hospital for treatment of a varicella-zoster infection. On the fourth day of treatment, he develops an acute renal insufficiency. What is the most likely treatmentrelated mechanism accounting for the patient's acute renal insufficiency? A. the formation of toxic metabolites B. decreased glomerular filtration rate C. the precipitation of acyclovir in renal tubules D. direct tubular cytotoxic injury E. hypersensitivity interstitial nephritis"

C

"A 29-year-old woman complains of fatigue and decreased exercise tolerance. She takes no medications and denies changes in the color of the stool. Physical examination is significant for pale skin and conjunctivae. Stool was negative for blood. Laboratory evaluation revealed Hgb of 7. 8 g/dL, reticulocytopenia, microcytosis, and hypochromia. In vitamin B12 or folate deficiency, which of the following statements is correct? A. High serum levels of homocysteine and decreased levels of methylmalonic acid are reliable indicators of cobalamin deficiency. B. The recommended amount of dietary folate is 800 g/day. C. The peripheral smear in patients with cobalamin deficiency is identical to that found in folate deficiency. D. The most common cause of cobalamin deficiency is hypersecretion of gastric acid (i. e. , Zollinger-Ellison syndrome). E. Because body folate stores are high, individuals with low consumption of folate will take several years to become anemic."

C

"A 32-year-old man comes to the office for his annual checkup. He is asymptomatic and his physical exam is normal. He reports that his father died of colon cancer at age 46 and his older brother was recently diagnosed with colon cancer at age 37. His paternal aunt was previously diagnosed and treated for endometrial cancer. He is concerned about his family history of malignancy and wants to discuss cancer screening. What would be the most appropriate recommendation at this time? A. flexible sigmoidoscopy B. fecal occult blood testing, with referral for endoscopy if positive C. screening colonoscopy D. screening colonoscopy starting at age 50 E. prophylactic colectomy"

C

"A 32-year-old woman complains of episodic confusion in the morning for the past 6 months. During one of these episodes, she was brought to the ER and her serum glucose was found to be 40 mg/dL. She was given intravenous dextrose and her symptoms resolved within 15 minutes. She has gained approximately 25 lbs during the past year. Which of the following would be the most appropriate next step? A. measure serum insulin and proinsulin 2 hours after a mixed meal B. MRI of the pancreas C. measure insulin, C-peptide, and sulfonylurea level on the initial blood sample in ER D. octreotide scan E. advise a high protein diet with frequent feedings"

C

"A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98. 8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following is a common finding in this condition? A. macroglossia B. hyperkeratosis C. infiltrative ophthalmopathy D. cerebellar ataxia E. pericardial effusion"

C

"A 32-year-old woman presents with complaints of irritability, heat intolerance, hyperdefecation, and frequent palpitations. She has lost 20 lb over the past six months. She has always been in good health and does not take any prescription or OTC medications. She denies any prior history of thyroid disease or exposure to head/neck irradiation, but she states that one of her relatives was diagnosed with a thyroid disorder at roughly the same age. Vital signs are as follows: BP 138/78, HR 112, RR 22, temp. 98. 8°F. On examination, her thyroid is diffusely enlarged and smooth. Auscultation of the thyroid reveals a bruit. Her hair is fine in texture, and she has warm velvety skin. She has hyperactive deep tendon reflexes. There is a fine tremor in her outstretched hands. Which of the following sets of laboratory results would be consistent with this patient's presentation? TSH free T3 free T4 A. low lowhigh B. low normal normal C. low high high D. highlow low E. high high high"

C

"A 35-year-old woman schedules an appointment in an outpatient clinic for evaluation and treatment of a ""mouth problem. "" She says that she has white spots in her mouth that have been present for a few weeks. In response to your questioning, she states that she has been experiencing fatigue and a 20-lb weight loss over the past several months, although she attributes these symptoms to a dramatic increase in work hours at her job over the same period of time. She denies having any other chronic medical issues and does not use any prescription or OTC medications. As you examine her, you note the presence of white plaques on her buccal mucosa, palate, and tongue. Scraping of the plaques with a tongue depressor elicits pain as well as a small amount of bleeding. Nontender generalized cervical and submandibular lymphadenopathy is present. Which of the following questions would potentially yield the most useful information in this patient's diagnosis and treatment? A. ""Do you have a family history of cancer?"" B. ""Have you traveled outside of the country within the past 12 months?"" C. ""Have you engaged in unprotected sexual intercourse?"" D. ""Do you have any sick contacts?"" E. ""How much do you smoke?"""

C

"A 39-year-old HIV-positive male presents for routine follow-up. He is on highly active antiretroviral therapy. A CD4 count is 250/L. His vital signs are within normal limits and his examination is normal. He has a PPD placed and follows up in 48 hours. At the site of the injection you find 6 mm of induration. A CXR is normal. He has never been treated for tuberculosis or a positive PPD before. Which management option is most appropriate? A. Collect sputum samples for 3 days to send for AFB (acid fast bacilli) staining. B. Empirically start four-drug therapy for active tuberculosis. C. Empirically start isoniazid daily for 9 months. D. Have the patient return in 1 week for a second PPD to assess for the presence of a ""booster"" phenomenon; treat with isoniazid if 10 mm induration. E. No intervention at this time but repeat the test in 6 months."

C

"A 43-year-old patient presents with his fourth episode of culture-proven shingles in a T7 distribution. What is the most likely associated underlying condition? A. leukemia B. lymphoma C. acquired immunodeficiency syndrome (AIDS) D. chro"

C

"A 60-year-old male with a history of hypertension and hyperlipidemia undergoes an evaluation for angina. He states that he routinely experiences dyspnea, fatigue, and retrosternal chest discomfort when performing activities such as walking around the block on which his house is located or climbing the flight of stairs within his home. Besides taking medications for his blood pressure and cholesterol, he uses nitroglycerin which successfully alleviates his symptoms. Which of the following best describes the severity of this patient's angina? A. class I B. class II C. class III D. class IV E. Prinzmetal angina"

C

"A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. A transesophageal echocardiogram (teE) is performed which reveals a left ventricular ejection fraction (LveF) of 30%. Which of the following accurately describes this patient and his condition? A. A transthoracic echocardiogram (Tte) would give a more accurate estimation of the patient's true LveF. B. He has diastolic heart failure. C. Digoxin would be an appropriate choice in attempting to control symptoms. D. He has class I heart failure according to the New York Heart Association (NYHA) classification. E. Hypertension is the most common cause."

C

"A 60-year-old morbidly obese man presents with complaints of fatigue, worsening exertional dyspnea, three-pillow orthopnea, lower extremity edema, and cough occasionally productive of frothy sputum. He has a long-standing history of type II diabetes and hypertension. On examination, you note the presence of bibasilar rales, an S3 gallop, jugular venous distention, and 2+ pitting edema in both legs up to the knees. There does not appear to be an arrhythmia present. Which of the following medications should be given initially? A. metoprolol B. diltiazem C. furosemide D. carvedilol E. lisinopril"

C

"A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes (""although I know they are bad for me"") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After a thorough discussion with your patient, you determine that pharmacologic intervention would be beneficial given the severity of her osteoporosis. Which of the following is most appropriate for your patient? A. estrogen replacement therapy B. combined HRT with estrogen and progestin C. alendronate D. calcitonin intranasal spray E. raloxifene"

C

"A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes (""although I know they are bad for me"") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. After performing the appropriate imaging study, you determine that your patient has osteoporosis. Of the following choices, which is risk factor most likely contributing to her osteoporosis? A. active lifestyle B. late menopause C. cigarette smoking D. frequency of alcohol intake E. her intake of calcium and vitamin D"

C

"A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chest pains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following is most likely to be found on an ECG? A. saw-tooth P waves B. wide QRS complexes C. absent P waves D. Q waves in leads II, III, and aVF E. peaked T waves"

C

"A 63-year-old male presents to your office with palpitations for the past 3 weeks. He has had no chestpains or dyspnea. He has no significant medical history and takes no medications. He does not smoke cigarettes and a recent lipid panel was normal. On examination, he is in no apparent distress. His pulse is 115 bpm and irregular. His BP is 125/77. His lungs are clear and his cardiac examination reveals an irregularly irregular rhythm with no murmurs, rubs, or gallops. Which of the following studies would be most appropriate to order at this time? A. radionuclide ventriculography B. exercise stress test C. echocardiogram D. cardiac catheterization E. electrophysiologic studies"

C

"A 64-year-old male has been suffering from lower back pain for over 10 years. You have been following him for this period. You have prescribed stretching exercises and, occasionally, an antiinflammatory medication to alleviate his pain. Although he has had no neurologic deficits in the past, today he has shown up in your office unexpectedly, complaining of bilateral lower back pain with numbness and tingling over the dorsal aspect of both feet. His symptoms have become progressively worse over the past 2 weeks and he is now unable to stand for more than 5 minutes without developing extreme pain and numbness. His symptoms are much improved by sitting down or kneeling over a chair. Climbing stairs seems to be tolerated well, but walking greatly exacerbates the pain. He denies bladder or bowel incontinence or retention, point tenderness or anesthesia in the lower back along the spinal cord or in the saddle area. What is the likely diagnosis? A. spondyloathropathy of the sacroiliac joint B. age-related early degenerative joint disease (DJD) of the hips C. spinal stenosis of the lumbosacral area D. muscle spasm of the lower back E. cauda equina syndrom"

C

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. What would be the best initial test to do in this patient? A. spot fecal fat collection B. 72-hour fecal fat collection C. CT scan of the abdomen D. ERCP E. upper endoscopy"

C

"A 72-year-old diabetic is transferred to your hospital for fever and altered mental status in the late summer. Symptoms started in this patient 1 week prior to admission. On physical examination, the patient was disoriented. There were no focal neurologic findings. There was a fine rash on the patient's trunk. On oral examination, there were tongue fasciculations. A lumbar puncture was performed which showed a glucose of 71 and a protein of 94; microscopy of the cerebrospinal fluid (CSF) revealed 9 RBC and 14 WBC (21 P, 68 L, 11 H). The creatinine phosphokinase was 506. An electroencephalogram and MRI of the brain were normal. What is the best interpretation of these findings? A. The patient may have cryptococcal meningitis. B. The patient may have disseminated candidiasis. C. The patient may have West Nile virus. D. The patient may have Coccidioides immitis infection. E. The patient may have rhinocerebral mucormycosis."

C

"A 72-year-old previously healthy woman was diagnosed with Stage II breast cancer and was initiated on FAC chemotherapy (5-fluorouracil, doxorubicin, cyclophosphamide) 3 months ago. She now presents to the emergency room complaining of exertional dyspnea, orthopnea, and lower extremity edema. Her vital signs are normal, her EKG is normal, and her chest x-ray shows cardiomegaly and pulmonary vascular congestion. What is the most likely cause of the patient's new symptoms? A. malignant pericardial effusion with cardiac tamponade B. acute pericarditis due to viral infection C. anthracycline-induced cardiomyopathy D. valvular aortic stenosis E. acute myocardial infarction"

C

"A 74-year-old male with a history of hypertension, type II diabetes, myopia, and cataract surgery 2 weeks ago presents with the sudden onset of severe flashes of light and multiple new floaters in his right eye. He denies photophobia, ocular trauma, or diplopia. He also states that he feels as if there is a curtain lowering over his right eye. Your examination and a stat ophthalmology consultation confirm your clinical diagnosis. Of the choices listed below, what would be the most appropriate next step to provide definite treatment for this patient? A. lens removal and surgical replacement B. corneal transplant C. removal of vitreous humor (posterior vitrectomy) D. intraocular antibiotics E. stat angiogram and thrombolytics if needed"

C

"A20-year-old male has had a recent wide local excision of a 1. 5 mm melanoma from the right ankle. There is no evidence of metastatic disease. The most important prognostic factor for this patient is which of the following? Which of the following is true regarding melanoma? A. Chest radiographs are not recommended as a part of a patient's follow-up surveillance. B. Timely treatment of metastatic melanoma has been shown to have an effect on mean survival. C. Elevated serum LDH suggests metastatic melanoma. D. Patients without clinical lymphadenopathy are not at risk for metastatic involvement. E. High mitotic rate and a lower Clark level are poor prognostic signs."

C

"A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. The drug of choice for treating this patient works by which of the following mechanisms? A. interfering with protein synthesis at the ribosome B. attaching to sterols in cell membranes C. inhibiting bacterial cell wall synthesis D. inhibiting the transport of amino acids into bacteria E. inhibiting dihydrofolate reductase"

C

"A28-year-old male, well known to your clinic, presents for management of swelling, pain, and tenderness that has developed in his left ankle and right knee. It has persisted for 1 month. Your patient reports that he developed severe diarrhea after a picnic 1 month prior to the onset of his arthritis. During the interval between the diarrhea and onset of arthritis, he developed a ""pink eye"" that lasted for 4 days. He denies any symptoms of back pain or stiffness. You remember that he was treated with ceftriaxone and doxycycline for gonorrhea 2 years ago, which he acquired from sexual activity with multiple partners. Since that time, he has been in a monogamous relationship with his wife and has not had any genitourinary symptoms. He promises that he has been faithful to his wife and has not engaged in unprotected sexual activity outside his marriage. His physical examination is notable for a swollen left ankle, swollen right knee, and the absence of penile discharge or any skin lesions. Which of the following is the most likely diagnosis? A. pseudogout B. gout C. reactive arthritis D. resistant gonococcal arthritis E. ankylosing spondylitis"

C

"A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. Which of the following laboratory studies is most likely to be abnormal in this patient? A. TSH B. prolactin C. glucose tolerance test D. growth hormone E. cosyntropin (Cortrosyn) stimulation test"

C

"A28-year-old woman presents for evaluation of primary infertility. She has had fewer than four periods per year since menarche at age 14, facial hirsutism, acne, and weight gain. On examination, she has a BP 150/100. Her body mass index (BMI) is 40. Acanthosis nigricans is noted along the posterior surface of her neck. Which of the following would be her most likely fasting lipid profile? A. high TGs, high HDL B. low TGs, low HDL C. high TGs, low HDL D. high LDL cholesterol E. normal lipid profile"

C

"A54-year-old Asian female with no significant medical history presents with frontal headache, eye pain, nausea, and vomiting. Her abdominal examination shows mild diffuse tenderness but no rebound or guarding. Her mucous membranes are dry. Her vision is blurry in both eyes, her eyes are injected but her extraocular muscles are intact. Her pupils are mid-dilated and fixed Which of the following is the most likely diagnosis? A. diabetic ketoacidosis (DKA) B. appendicitis C. angle closure glaucoma D. perforated colon due to inflammatory bowel disease (IBD) E. cerebellar malignancy"

C

"C1 deficiency has three subcomponents, of which the most common is deficiency of C1q. Most of those patients will have clinical and serologic findings typical of which of these? A. polymyositis B. RA C. SLE D. recurrent Streptococcus pneumoniae infections E. recurrent H. influenzae type B infections."

C

"Which of the following risk factors has the strongest association with the development of malignant melanoma? A. dark skin and hair color with tendency to tan easily and not to burn easily B. personal history of sunburn, especially early in life C. pigmented lesion with asymmetric irregular borders, color variegation, and diameter 8 mm D. family history of non-melanoma skin cancer E. development of actinic keratosis"

C

"A 31-year-old female health care worker presents to your clinic after a needlestick injury from a patient who subsequently left against medical advice prior to laboratory analysis for HIV or hepatitis. You advise your colleague that: A. If the patient had HIV, her risk of seroconversion is 20%. B. If the patient had Hepatitis B, her risk of seroconversion is 2%. C. If the patient had Hepatitis C, her risk of seroconversion is 5%. D. If the patient had HIV, her risk of seroconversion is 0. 3%. E. If the patient had Hepatitis C, her risk of seroconversion is 50%."

D

"A 60-year-old woman arrives at your office for a routine physical examination. During the course of her examination she asks you about osteoporosis. She is concerned about her risk for osteoporosis, as her mother suffered from multiple vertebral compression fractures at the age of 60. Your patient reports that she still smokes cigarettes (""although I know they are bad for me"") and has one alcoholic beverage a week. She reports having had menopause 5 years ago and experiencing a deep venous thrombosis approximately 20 years ago. She is proud of the fact that she regularly exercises at the local fitness center. She has been taking 1500 mg of calcium with 800 IU of vitamin D every day. You suspect that she is at risk for osteoporosis. Which of the following tests is best to detect and monitor osteoporosis? A. plain film radiography B. dual photon absorptiometry C. single photon absorptiometry D. dual-energy x-ray absorptiometry (DEXA) E. quantitative CT scan"

D

"A 65-year-old man presents to your office for evaluation of abdominal pain. The patient states that he has epigastric pain that radiates to his back. The pain is worse with eating and improves with fasting. The pain has been present for 6 months and is gradually worsening. The patient has lost 15 lbs but feels his oral intake has been adequate. He complains of greasy stools and frequent thirst and urination. Examination reveals a thin male with temporal wasting and oderate abdominal pain with palpation. The patient consumes approximately 1015 beers per day and smokes a pack of cigarettes per day for the past 20 years. On further questioning, the patient reports that he recently had a motor vehicle accident at night because he felt he could not see clearly. The most likely cause of this symptom is which of the following? A. vitamin B12 deficiency B. vitamin C deficiency C. vitamin D deficiency D. vitamin A deficiency E. vitamin K deficiency"

D

"A22-year-old male presents to an acute care clinic in order to have two genital lesions evaluated. He first noticed the lesions about 2 weeks ago, but delayed seeking medical care because he believed they were harmless due to the lack of any discomfort. He states that he does engage in unprotected sexual intercourse, with the most recent time being 1 month ago. On examination, the glans penis features two distinct nontender papules with elevated edges surrounding ulcerated craters. They each measure 1 cm in diameter. There is also nontender bilateral inguinal lymphadenopathy. Which of the following is true about this patient's condition? A. The causative agent is a virus. B. Light microscopy of fluid from the lesions will reveal gram-negative rods in chains. C. The presence of multiple distinct lesions is uncommon. D. There is a latent phase in which patients are asymptomatic. E. Although associated with persistent symptoms if left untreated, it does not carry a significant risk for mortality."

D