USMLE forum
 
USMLE Forum
Step 1
Step 2 CK
Step 2 CS
Matching & Residency
Step 3
Classifieds
 
Archives
 
 
  <<   < *  Step 2 CK   *  >   >>  

* block 4 qs
 #136444  
  dolly123 - 11/07/06 21:05
 
 

BLOCK 4:--

1. A previously healthy 2-year-old boy is brought
to the physician
20 minutes after an episode of cyanosis and loss of
consciousness that
lasted 3 minutes. The symptoms occurred after his
mother scolded him
for climbing onto the dining room table. The mother
says that the child
began to cry, let out a deep sigh, stopped breathing,
and jerked his
arms and legs back and forth. On arrival, he is alert
and active.
Neurologic examination shows no focal findings. Which
of the following is
the most appropriate next step in management?

A
) Reassurance

B
) Electroencephalography

C
) CT scan of the head

D
) Anticonvulsant therapy

E
) Lumbar puncture



2. A case-control study is conducted to assess the
risk for
intussusception in infants under the age of 1 year who
receive the rotavirus
vaccine. The medical records of all those who
received the vaccine and
those who did not receive the vaccine over a 6-month
period are
reviewed. Results show 125 cases per 100,000
infant-years for infants who
received the vaccine compared to 45 cases per 100,000
infant-years for
infants who did not receive the vaccine. The
investigators conclude that
the relative risk for intussusception is 1.9 times
greater in infants
who receive the rotavirus vaccine (95% confidence
interval of 0.5–7.7 and
p=0.39). Which of the following is the most accurate
interpretation of
these results?

A
) The results do not show an association between
rotavirus vaccine
and intussusception, but they may be related

B
) The results show sufficient statistical power to
identify an
association between rotavirus vaccine and
intussusception

C
) Rotavirus vaccine is associated with a 39% risk
for
intussusception

D
) Rotavirus vaccine causes intussusception in 1.9%
of infants

E
) Rotavirus vaccine prevents 80 cases of
intussusception per 100,000
infant-years



3.

A 42-year-old woman, gravida 3, para 3, comes to the
emergency
department 24 hours after the onset of moderate
epigastric pain radiating to
the back. Her last menstrual period was 3 weeks ago.
She has no history
of serious illness and has never undergone an
operative procedure. She
weighs 72 kg (160 lb) and is 157 cm (62 in) tall. Her
temperature is
37.2 C (99 F), blood pressure is 130/90 mm Hg, and
pulse is 100/min.
Abdominal examination shows mild distention,
epigastric tenderness, and
voluntary guarding. Test of the stool for occult
blood is negative.
Laboratory studies show:


Hematocrit 44%
Leukocyte count 12,000/mm3
Serum
Na+ 138 mEq/L
Cl– 100 mEq/L
K+ 4 mEq/L
HCO3– 25 mEq/L
Bilirubin, total 1.6 mg/dL
Alkaline phosphatase 100 U/L
Aspartate aminotransferase
(AST, GOT) 14 U/L
Alanine aminotransferase
(ALT, GPT) 12 U/L
Amylase 1100 U/L

Ultrasonography shows gallstones; the gallbladder wall
is 1 mm and the
common bile duct is 5 mm in diameter. Which of the
following is the
most likely diagnosis?

A
) Acute cholecystitis

B
) Acute pancreatitis

C
) Acute perihepatitis

D
) Ascending cholangitis

E
) Duodenal ulcer

F
) Viral hepatitis


4. A 13-year-old girl is brought to the emergency
department because
of shortness of breath for 2 hours. The symptoms
began after consuming
chili, cornbread, and fruit salad with strawberries,
kiwi, and bananas.
She has a 1-year history of shortness of breath while
playing soccer or
baseball and uses a bronchodilator inhaler as needed
while exercising.
She is allergic to penicillin and pineapples. Her
blood pressure is
80/60 mm Hg, pulse is 120/min and regular, and
respirations are 20/min
with use of accessory muscles. Examination of the
lungs shows poor air
entry bilaterally with diffuse expiratory wheezes.
Which of the
following is the most appropriate initial
pharmacotherapy?

A
) Inhaled bronchodilators

B
) Inhaled cromolyn sodium

C
) Inhaled ipratropium bromide

D
) Intravenous corticosteroids

E
) Subcutaneous epinephrine


5.

A 52-year-old woman comes to the emergency department
6 days after knee
arthroplasty because of constant, right-sided chest
pain and shortness
of breath for 24 hours. Her blood pressure is 110/50
mm Hg, pulse is
114/min, and respirations are 24/min. Examination of
the heart, lungs,
and extremities shows no abnormalities. Arterial
blood gas analysis on
room air shows:


pH 7.49
PCO2 29 mm Hg
PO2 66 mm Hg

Ventilation-perfusion lung scans show a low
probability for pulmonary
embolus. An ECG shows sinus tachycardia; an x-ray
film of the chest
shows no abnormalities. After the evaluation, the
patient is pain-free
and wishes to go home. Which of the following is the
most appropriate
next step in management?

A
) Discharge home and reexamination in 2 weeks

B
) Exercise stress test

C
) Pulmonary function tests

D
) Echocardiography

E
) Pulmonary angiography

F
) Ibuprofen therapy

6. A 25-year-old woman comes to the physician
because of "spells"
characterized by sweating, palpitations, and shortness
of breath that
have awakened her at night several times over the past
3 months. She
resigned from her job as a sales clerk 6 months ago
and now works from home
as a telemarketer. She recently began going to the
grocery store late
at night because she is too nervous around people.
She says that she
has been feeling sad lately. On mental status
examination, she is fully
oriented, and her range of affect is full. Which of
the following is
the most likely diagnosis?

A
) Adjustment disorder with anxiety

B
) Adjustment disorder with depressed mood

C
) Dysthymic disorder

D
) Generalized anxiety disorder

E
) Major depressive disorder

F
) Panic disorder with agoraphobia

G
) Post-traumatic stress disorder



7. A 65-year-old woman has a 6-month history of
progressive
irritability, palpitations, heat intolerance, frequent
bowel movements, and a
6.8-kg (15-lb) weight loss. She has had a neck mass
for more than 10
years. 131I scan shows an enlarged thyroid gland with
multiple areas of
increased and decreased uptake. Which of the
following is the most
likely diagnosis?

A
) Defect in thyroxine (T4) biosynthesis

B
) Graves' disease

C
) Multinodular goiter

D
) Riedel's thyroiditis

E
) Thyroid carcinoma

F
) Thyroiditis

G
) Toxic adenoma

H
) Triiodothyronine (T3) thyrotoxicosis


A
) Acute gastrointestinal bleeding

B
) Adrenal insufficiency

C
) Aortic valve rupture

D
) Cardiac tamponade


E
) Congestive heart failure

F
) Pneumonia

G
) Pulmonary embolism

H
) Sepsis

8. A previously healthy 62-year-old man is brought
to the emergency
department by paramedics 40 minutes after the sudden
onset of severe
shortness of breath while dressing this morning. He
is unable to provide
additional medical history. He is in severe
respiratory distress. His
temperature is 37.8 C (100 F), blood pressure is 90/60
mm Hg, pulse is
120/min and regular, and respirations are 24/min.
Examination shows
marked jugular venous distention. The lungs are clear
to auscultation.
Cardiac examination shows a nondisplaced and discrete
point of maximal
impulse and normal S1 and S2; there is an S4 and a
right parasternal
heave. Abdominal examination shows no abnormalities.
There is no edema
of the lower extremities. Laboratory studies show:


Hematocrit 40%
Leukocyte count 14,000/mm3
Platelet count 350,000/mm3


Arterial blood gas analysis on 5 L/min of oxygen:


pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg


A previously healthy 67-year-old woman is brought to
the emergency
department by paramedics 40 minutes after the sudden
onset of shortness of
breath while shopping. She is unable to provide
additional medical
history. She is in severe respiratory distress. Her
temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is
120/min and regular,
and respirations are 24/min. Examination shows marked
jugular venous
distention. Diffuse crackles are heard throughout all
lung fields.
Cardiac examination shows an enlarged point of maximal
impulse and normal
S1 and S2; there is an S3. Abdominal examination
shows no
abnormalities. There is no edema of the lower
extremities. Laboratory studies
show:


Hematocrit 38%
Leukocyte count 12,000/mm3
Platelet count 350,000/mm3


Arterial blood gas analysis on 5 L/min of oxygen:


pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg




10. A mentally competent 76-year-old man is in the
terminal stage of
multiple myeloma. He is unable to move and requires
24-hour nursing
care. Increasing doses of narcotics are needed to
control severe pain.
As a result, when he is pain-free, respiratory
function is impaired and
consciousness is clouded. The patient says he cannot
live with this
degree of pain and asks to be given a lethal injection
of pain
medication. Which of the following is the most
appropriate step regarding the
pain medication?

A
) Reduce the dosage so as not to impair respiration

B
) Administer the dosage necessary to control pain
despite
respiratory impairment

C
) Administer the dosage necessary to control pain
and add a
centrally acting stimulant

D
) Appeal to the family to convince the patient to
tolerate a bit
more pain




11. A 2-day-old newborn is brought to the physician
because of a
generalized rash for 6 hours. The newborn is active,
alert, and feeding
well. His temperature is 36.9 C (98.4 F).
Examination shows a rash
consisting of numerous white and pale yellow papules
with a large base of
macular erythema over the trunk and extremities.
Wright's stain of
scrapings from the lesions shows eosinophils. Which
of the following is
the most appropriate next step in management?

A
) Reassurance

B
) Topical corticosteroid therapy

C
) Intravenous acyclovir therapy

D
) Intravenous ampicillin and gentamicin therapy

E
) Intravenous nafcillin therapy



12. A 4-year-old boy is brought for a well-child
examination. He
uses two-word phrases, can say his first name but not
his last name, and
cannot identify colors. He is just beginning toilet
training. His
7-year-old sister has a learning disability and
attends special education
classes. Genital development is Tanner stage 1;
testes are large.
Which of the following is the most appropriate next
step in diagnosis?

A
) Reexamination in 6 months

B
) Thyroid function tests

C
) DNA testing

D
) Measurement of bone age

E
) CT scan of the head



3. A 72-year-old man is brought to the physician
because of a 2-day
history of nausea and vomiting. The vomitus has been
clear, and no
blood has been noted. He has had a decreased appetite
for the past week.
There is no associated pain or altered bowel function.
He reports that
he is not seeing things correctly. He takes warfarin
and digoxin for
atrial fibrillation, hydrochlorothiazide for
hypertension, and potassium
supplements that he discontinued 3 weeks ago when he
ran out of
tablets. His temperature is 37 C (98.6 F), blood
pressure is 144/88 mm Hg,
and pulse is 52/min and irregular. Bowel sounds are
normal. The abdomen
is soft and nontender without rebound or guarding. No
organomegaly or
masses are palpated. Which of the following is the
most likely
diagnosis?

A
) Acute pancreatitis

B
) Brain tumor

C
) Diabetic gastroparesis

D
) Diabetic ketoacidosis

E
) Drug toxicity

F
) Food poisoning

G
) Gastric bezoar

H
) Gastric carcinoma

I
) Pyloric channel ulcer

J
) Small-bowel obstruction

K
) Uremia


14. A 27-year-old primigravid woman at 12 weeks'
gestation comes to
the emergency department 2 hours after the sudden
onset of bright red
vaginal bleeding. She has not had abdominal cramping.
Pelvic
examination shows a small amount of brownish blood in
the posterior fornix of
the vagina. The cervix is closed. The uterus is
palpable 3 cm above the
pelvic brim. Fetal heart tones are easily audible at
167/min by
Doppler. Which of the following is the most likely
diagnosis?

A
) Abruptio placentae

B
) Ectopic pregnancy

C
) Incomplete abortion

D
) Placenta previa

E
) Threatened abortion

F
) Normal pregnancy


15. A 72-year-old man is brought to the physician
by his son because
of a 4-day history of increasing confusion and memory
problems. The
son says that his father's ability to function
independently has been
generally declining over the past few years, and he
has become much more
impaired over the past week. The patient has had at
least three to four
previous episodes of a sudden decline of cognitive
functioning over the
past 3 years without full recovery. He has a history
of hypertension.
His blood pressure is 160/95 mm Hg without orthostatic
changes.
Neurologic examination shows no focal findings.
Mini-Mental State Examination
score is 21/30. Which of the following is the most
likely underlying
pathophysiologic process?

A
) Central nervous system demyelination

B
) Central nervous system infection

C
) Diffuse axonal injury

D
) Diffuse cortical atrophy

E
) Left temporal lobe infarction

F
) Multiple, small, central nervous system
infarctions

G
) Subdural hematoma



16. A 72-year-old woman comes for a routine health
maintenance
examination. She has a 3-year history of occasional
loss of small amounts
of urine when she coughs or sneezes. She has had no
pain or burning
with urination. She has hypertension treated with
daily
hydrochlorothiazide. She underwent an appendectomy at
the age of 10 years. She has
three children and had uncomplicated pregnancies.
Examination shows no
abnormalities except for a moderate cystocele. Which
of the following is
the most likely cause of this patient's urinary
symptoms?

A
) Chronic infectious trigonitis

B
) Large intravesical calculus

C
) Obstetric trauma

D
) Polycystic kidney disease

E
) Spastic neurogenic bladder


17. A 47-year-old woman is brought to the emergency
department by
her husband because of hallucinations and agitation
for 6 hours. She has
a 10-year history of alcoholism. Her last alcoholic
drink was 48 hours
ago. She is agitated and inattentive. Her
temperature is 38.3 C (101
F), blood pressure is 190/120 mm Hg, and pulse is
110/min. She is
oriented to person but not to place or time. During
the examination, she
shrieks, "Make the lizards go away." Which of the
following is the most
appropriate initial step in management?

A
) Electroencephalography

B
) CT scan of the head

C
) Intravenous ampicillin therapy

D
) Intravenous haloperidol therapy

E
) Intravenous lorazepam therapy


18. A 27-year-old woman comes to the physician
because of a 3-week
history of fever, night sweats, rash on both legs,
nonproductive cough,
and pain and swelling in her wrists and knees. She
has not had weight
loss. Her temperature is 37.7 C (99.8 F), blood
pressure is 110/70 mm
Hg, pulse is 96/min, and respirations are 14/min. The
lungs are clear
to auscultation. Cardiac examination shows no
abnormalities. There is
swelling and warmth over the wrists and knees
bilaterally and tender
red nodules on the anterior surface of both lower
extremities. An x-ray
film of the chest shows bilateral hilar fullness.
Which of the
following is the most likely diagnosis?

A
) Carcinoma of the lung

B
) Histoplasmosis

C
) Hodgkin's disease

D
) Sarcoidosis

E
) Tuberculosis


19. A 52-year-old woman comes to the physician
because of difficulty
climbing stairs for 4 months. She has also noted that
her thighs hurt
when she presses on them. She has had increasing
difficulty combing
her hair because she tires easily. On examination,
she pushes herself
out of the chair with her arms. There is weakness of
the proximal
muscles of the extremities. Which of the following is
the most likely
diagnosis?

A
) Cauda equina syndrome

B
) Cerebellar degeneration

C
) Cervical spinal cord compression

D
) Diabetic polyneuropathy

E
) Femoral artery insufficiency

F
) Guillain-Barré syndrome

G
) Lumbar spinal stenosis

H
) Multiple sclerosis

I
) Normal-pressure hydrocephalus

J
) Polymyositis

K
) Sensory neuropathy

L
) Tabes dorsalis




20. A 72-year-old man comes to the physician
because of generalized
weakness and night sweats for 6 months. During this
period he has had
a 5-kg (11-lb) weight loss. He has had polycythemia
vera for 12 years
treated with hydroxyurea and multiple phlebotomies.
Examination shows
cachexia. The liver is enlarged and nontender with a
span of 13 cm;
the spleen is enlarged. Hematocrit is 27%, leukocyte
count is 3200/mm3,
and platelet count is 150,000/mm3. A blood smear is
shown. Which of
the following is the most likely diagnosis?

A
) Acute myelogenous leukemia

B
) Cirrhosis of the liver

C
) Hodgkin's disease

D
) Miliary tuberculosis

E
) Myelofibrosis



21. A 30-year-old man has had increasingly severe
low back pain
since lifting a heavy object at work 3 days ago. The
pain does not radiate
and is not associated with bowel or bladder problems.
He has a history
of occasional stiffness and mild pain in his lower
back. There is
bilateral paravertebral muscle tenderness in the
lumbar region and limited
flexion of the lumbosacral spine. Examination of the
lower extremities
shows normal muscle strength and sensation;
straight-leg raising is
negative bilaterally. Deep tendon reflexes at the
knees and ankles are
normal. Which of the following is the most
appropriate next step in
management?

A
) Exercises to strengthen abdominal muscles

B
) Exercises to strengthen paravertebral muscles

C
) Bed rest for 5 to 7 days

D
) Use of a muscle relaxant

E
) Use of a nonsteroidal anti-inflammatory drug




22. A 42-year-old woman, gravida 2, para 2, has had
increasing
fatigue, dyspnea, orthopnea, and paroxysmal nocturnal
dyspnea over the past
2 days. She has had several episodes of hemoptysis;
she had one
episode of pulmonary edema during pregnancy 2 years
ago. A loud S1, a
snapping sound in diastole, and a rumbling diastolic
murmur are heard at the
apex. Which of the following is the most likely cause
of her
condition?

A
) Atrial myxoma

B
) Bicuspid aortic valve

C
) Postpartum cardiomyopathy

D
) Rheumatic heart disease

E
) Viral myocarditis


3. A 37-year-old woman has had unilateral breast
pain, fever, and
chills for 24 hours. She breast-feeds her 1-month-old
newborn. Her
temperature is 38 C (100.4 F). Examination shows
swelling, erythema, and
localized tenderness of the left breast. Which of the
following is the
most appropriate next step in management?

A
) Application of ice packs to the affected breast

B
) Use of a breast pump

C
) Immediate discontinuation of breast-feeding

D
) Bromocriptine therapy

E
) Penicillinase-resistant antibiotic therapy


24. A 19-year-old woman, gravida 2, para 1, at 39
weeks' gestation
is admitted in labor. Contractions occur every 2 to 3
minutes. The
cervix is 4 cm dilated and 80% effaced. She requests
an epidural for pain
control. Ten minutes after the epidural is
administered, she becomes
nauseated and diaphoretic and vomits. Her blood
pressure is 60/palpable
mm Hg. A fetal heart tracing shows sustained fetal
decelerations. The
cervix is now 8 cm dilated. The most appropriate next
step in
management is administration of which of the
following?

A
) Ephedrine

B
) Magnesium sulfate

C
) Nifedipine

D
) Oxytocin

E
) Terbutaline


25. An asymptomatic 47-year-old man comes for a
routine follow-up
examination 3 weeks after sustaining an inferior wall
myocardial
infarction. His recovery was complicated by transient
premature ventricular
contractions during the first 2 days of
hospitalization. An exercise
stress test prior to discharge showed no pain at 70%
of his predicted
maximum exercise capacity. Medications include daily
aspirin and
pravastatin. His blood pressure is 136/80 mm Hg,
pulse is 80/min and regular,
and respirations are 16/min. Cardiopulmonary
examination shows no
abnormalities. Which of the following is the most
appropriate additional
pharmacotherapy for this patient?

A
) Clonidine

B
) Metoprolol

C
) Quinidine

D
) Sulfinpyrazone

E
) Verapamil



26. A 35-year-old woman is brought to the emergency
department by
her family because of shortness of breath, tightness
in her chest, and
palpitations for 2 hours. Over the past 11 months,
she has had five
similar episodes; during the last episode 3 weeks ago,
she was treated with
an intravenous medication that caused conversion to
sinus rhythm. Her
blood pressure is 95/60 mm Hg, and pulse is 165/min
and regular. The
lungs are clear to auscultation. Which of the
following is the most
likely underlying dysrhythmia?

A
) Accelerated idioventricular rhythm

B
) Accelerated junctional rhythm

C
) Atrial fibrillation

D
) Multifocal atrial tachycardia

E
) Normal sinus rhythm

F
) Paroxysmal supraventricular tachycardia

G
) Premature supraventricular beats

H
) Premature ventricular beats

I
) Sick sinus syndrome

J
) Sinus bradycardia

K
) Sinus tachycardia

L
) Ventricular fibrillation

M
) Ventricular tachycardia





27.

A 4-year-old boy is brought to the emergency
department because of a
1-day history of fever and increasing difficulty
breathing. Over the
past year, he has had recurrent bacterial infections
including cervical
lymphadenitis, septic arthritis, and pneumonia. His
temperature is 38.9
C (102 F), blood pressure is 80/60 mm Hg, pulse is
115/min, and
respirations are 38/min and labored. Breath sounds
are decreased over the
left anterior chest. Scattered crackles are heard on
auscultation. A
thoracentesis shows purulent fluid. Laboratory
studies show:


Hematocrit 36%
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Lymphocytes 15%
Platelet count 200,000/mm3
Pleural fluid
Leukocyte count 75,000/mm3
Segmented neutrophils 98%
Lymphocytes 2%

Nitroblue tetrazolium test is abnormal. A Gram's
stain of the pleural
fluid shows numerous gram-positive cocci in the
segmented neutrophils.
An x-ray film of the chest shows left lower lobe
pneumonia with pleural
effusion. The most likely cause of this patient's
symptoms is a defect
of which of the following?

A
) Chemotaxis

B
) Immotile cilia

C
) Opsonization

D
) Phagocytic oxidative metabolism

E
) Phagocytosis

F
) T-lymphocyte function



28. A 59-year-old woman comes to the emergency
department 45 minutes
after the onset of chest discomfort that is not
relieved by three
nitroglycerin tablets. Over the past 3 months, she
has had similar episodes
characterized by nonradiating pain and a feeling of
heaviness; the
episodes were exacerbated by exertion or heavy meals
and were slowly
relieved by rest. Sublingual nitroglycerin has
provided rapid relief of
symptoms in the past. She has hypercholesterolemia,
type 2 diabetes
mellitus, and peptic ulcer disease. She smoked two
packs of cigarettes daily
for 25 years but quit 5 years ago. She appears
anxious and diaphoretic
and is nauseated. Examination shows no other
abnormalities except for
an S4. Which of the following is the most likely
diagnosis?

A
) Acute aortic dissection

B
) Angina pectoris

C
) Esophageal spasm

D
) Myocardial infarction

E
) Pulmonary embolism



29. A 27-year-old woman comes to the physician
because of
increasingly severe daily headaches over the past 3
months. The headaches are
diffuse and often occur at the base of the skull. For
the past month,
she has had brief episodes of visual darkening when
standing. She has
been amenorrheic for the past year and has had an
18-kg (40-lb) weight
gain during this period. She now weighs 118 kg (260
lb) and is 152 cm
(60 in) tall. Funduscopic examination shows
papilledema, several flame
hemorrhages, and an enlarged blind spot bilaterally.
Visual acuity is
20/20 bilaterally. A CT scan of the head shows no
abnormalities. Which
of the following is the most likely underlying cause
of these findings?

A
) Cerebral venous occlusion

B
) Communicating hydrocephalus

C
) Cytotoxic edema

D
) Idiopathic intracranial hypertension

E
) Impaired absorption of cerebrospinal fluid

F
) Infratentorial mass lesion

G
) Interstitial edema

H
) Overproduction of cerebrospinal fluid

I
) Vasogenic edema



30. A 75-year-old man with a 3-year history of
progressive cognitive
impairment due to dementia, Alzheimer's type, has had
nocturnal
disorientation for 2 weeks. He lives at home with his
wife. He is otherwise
healthy and takes no medications. Physical
examination shows normal
findings. He is disoriented to time and place, has
poor short-term
memory, is unable to do simple arithmetic, and has a
poor understanding of
general information. Which of the following is the
most appropriate
initial step in management?

A
) Increase in home nighttime lighting

B
) Prescription for chloral hydrate

C
) Prescription for diazepam

D
) Prescription for haloperidol

E
) Use of nighttime mechanical restraints



31. A 62-year-old woman comes to the physician
because of severe
pain and swelling of her right knee for 1 day. She
has no history of
joint disease or trauma to the knee. She has
hypertension treated with
hydrochlorothiazide and type 2 diabetes mellitus
treated with glyburide.
She is sexually active only with her husband, and they
have sexual
intercourse one to two times each week. Her
temperature is 37 C (98.6 F),
blood pressure is 140/84 mm Hg, and pulse is 80/min.
Examination of
the right knee shows edema, erythema, and exquisite
tenderness to light
touch; there is an effusion. The remainder of the
examination shows no
abnormalities. Which of the following is the most
likely mechanism of
these findings?

A
) Immune complex deposition

B
) Inflammatory reaction to antisynovial antibodies

C
) Inflammatory reaction to monosodium urate
crystals

D
) Neisseria gonorrhoeae infection

E
) Streptococcus pneumoniae infection


32. Two days after a cholecystectomy, a 42-year-old
woman has
shortness of breath. Her temperature is 37.5 C (99.5
F), blood pressure is
110/70 mm Hg, pulse is 103/min, and respirations are
24/min. There is
abdominal tenderness. Examination shows no other
abnormalities. An
x-ray film of the chest shows minimal linear markings
in the right lower
lobe. Arterial blood gas analysis on 45% oxygen
shows:

pH 7.41
PCO2 40 mm Hg
PO2 52 mm Hg

Which of the following is the most likely explanation
for her hypoxia?

A
) Acute respiratory distress syndrome

B
) Atelectasis

C
) Congestive heart failure

D
) Fat embolism syndrome

E
) Pneumonia

F
) Pneumothorax



33. A 37-year-old woman comes to the emergency
department because of
a 3-day history of increasingly severe abdominal pain,
nausea, and
vomiting. Twelve years ago, she had a hysterectomy
because of severe
dysfunctional uterine bleeding. Her temperature is 37
C (98.6 F), blood
pressure is 106/70 mm Hg, pulse is 110/min, and
respirations are 12/min.
Examination shows a distended, tympanic abdomen with
diffuse tenderness
but no guarding; bowel sounds are hypoactive. Her
leukocyte count is
10,000/mm3, and hematocrit is 44%. An x-ray film of
the abdomen is
shown. Which of the following is the most appropriate
initial step in
management?

A
) CT scan of the abdomen

B
) Intravenous neostigmine therapy

C
) Esophagogastroduodenoscopy

D
) Nasogastric intubation

E
) Laparotomy



34. A healthy 27-year-old woman comes for a routine
health
maintenance examination. Her blood pressure is 185/90
mm Hg. Examination shows
no other abnormalities except for hypertensive
retinopathy. Serum
studies show a sodium level of 140 mEq/L, potassium
level of 4 mEq/L, and
creatinine level of 1.1 mg/dL. A complete blood
count, serum
catecholamine levels, and urinalysis are within normal
limits. At two subsequent
visits, her blood pressure is 190/100 mm Hg and 182/96
mm Hg,
respectively. Which of the following is the most
appropriate next step in
diagnosis?

A
) 24-Hour urine collection for measurement of
creatinine clearance

B
) 24-Hour urine collection for measurement of
17-hydroxycorticosteroid and total 17-ketosteroid
levels

C
) Measurement of serum aldosterone level

D
) Magnetic resonance angiography of renal vessels

E
) CT scan of the abdomen



35. A 76-year-old man has had fatigue and loss of
interest in daily
activities over the past 4 months. He sleeps poorly
and has had a
4.5-kg (10-lb) weight loss during this period. He
states that he has
probably lived long enough. His blood pressure is
110/78 mm Hg, and pulse
is 68/min. Examination shows a slow return of deep
tendon reflexes.
Measurement of which of the following serum levels is
the most
appropriate next step in management?

A
) Calcium

B
) Creatinine

C
) Glucose

D
) Testosterone

E
) Thyroid-stimulating hormone


36. A 29-year-old woman is brought to the physician
by her father.
She has been working continuously without sleep for 3
days on a project
which she claims "Allah and Jesus have told me to do"
that will "unify
all knowledge in physics and medicine and philosophy."
She hears the
voice of her dead brother telling her that she will be
"the next Virgin
Mary." Her father states that she was treated for
depression for 1 year
at the age of 19 years. Which of the following is the
most likely
diagnosis?

A
) Bipolar disorder

B
) Borderline personality disorder

C
) Major depressive disorder

D
) Schizophrenia

E
) Substance-induced mood disorder



37. A 67-year-old man is hospitalized for treatment
of renal
insufficiency. Three days after admission, his pulse
is 40/min. An ECG shows
tall, tented T waves. Serum studies show a sodium
level of 134 mEq/L,
potassium level of 6.9 mEq/L, and glucose level of 85
mg/dL. The most
appropriate next step in management is intravenous
administration of
which of the following?

A
) Calcium, furosemide, and 3% saline

B
) Calcium, insulin, and digitalis

C
) Calcium, insulin, and glucose

D
) Glucose, furosemide, and phosphate

E
) Glucose, glucagon, and bicarbonate


38. Six months after the delivery of her fourth
child, a 37-year-old
woman undergoes laparoscopic tubal ligation. Menses
occur at regular
28-day intervals. During the operation, she is found
to have a small
dark lesion in the cul-de-sac and filmy adhesions
surrounding the
ovaries. A biopsy specimen of a cul-de-sac lesion
confirms the diagnosis of
endometriosis. Which of the following is the most
appropriate next step
in management?

A
) Danazol therapy

B
) Gonadotropin-releasing hormone agonist therapy

C
) Oral contraceptive therapy

D
) Total abdominal hysterectomy and bilateral
salpingo-oophorectomy

E
) No further treatment indicated


A
) Administration of parenteral antibiotics

B
) Admission to the hospital for medical management

C
) Admission to the hospital for operative
management

D
) Colon contrast studies

E
) Discharge for follow-up by personal physician

F
) Endoscopy

G
) MRI of the abdomen

H
) Observation in the emergency department

39. A previously healthy 6-month-old boy is brought
to the emergency
department because of a 12-hour history of
intermittent episodes of
inconsolable crying associated with drawing up of the
legs. Over the past
6 hours, he has had intermittent diarrhea that is
reddish and mucoid,
and for the past 3 hours he has been somnolent. On
examination, he is
sleepy but arousable. His temperature is 38.1 C
(100.6 F), blood
pressure is 90/55 mm Hg, pulse is 140/min, and
respirations are 38/min. He
cries when his abdomen is palpated; a mass is felt in
the right lower
quadrant. His leukocyte count is 12,400/mm3 (50%
segmented neutrophils,
8% bands, 1% eosinophils, 40% lymphocytes, and 1%
monocytes). Serum
electrolyte levels are within normal limits. An x-ray
film of the
abdomen shows no free air.


A
) Administration of parenteral antibiotics

B
) Admission to the hospital for medical management

C
) Admission to the hospital for operative
management

D
) Colon contrast studies

E
) Discharge for follow-up by personal physician

F
) Endoscopy

G
) MRI of the abdomen

H
) Observation in the emergency department

40. A previously healthy 14-year-old girl is
brought to the
emergency department because of abdominal pain for 12
hours. She has a 1-week
history of brownish vaginal discharge. Menarche was
at the age of 12
years, and her periods have occurred at regular 28-day
intervals over
the past year. Her last menstrual period was 7 weeks
ago. Her
temperature is 37 C (98.6 F), blood pressure is 85/55
mm Hg, pulse is 145/min,
and respirations are 24/min. Abdominal examination
shows generalized
tenderness, and there is guarding with rebound in the
right lower
quadrant. Her hematocrit is 24%, and leukocyte count
is 9400/mm3 (60%
segmented neutrophils, 3% bands, 1% eosinophils, 35%
lymphocytes, and 1%
monocytes). Serum electrolyte levels are within
normal limits.


41. A 49-year-old woman is admitted to the hospital
because of renal
failure. She has had episodes of flank pain over the
past 20 years.
She has also had nocturia 2 to 3 times nightly for 10
years. Her blood
pressure is 160/100 mm Hg. Examination shows pale
mucous membranes. A
mass is palpated in the right flank. Which of the
following is the
most likely diagnosis?

A
) Horseshoe kidney

B
) Nephrolithiasis

C
) Papillary necrosis

D
) Polycystic kidney disease

E
) Renal cell carcinoma


42. On routine annual screening, an asymptomatic
27-year-old man has
a positive PPD skin test. One year ago, a PPD skin
test was negative.
He works as a nurse. Three years ago, he was
diagnosed with hepatitis
A after a trip to South America. Examination shows no
abnormalities.
His serum aspartate aminotransferase (AST, GOT)
activity is 10 U/L, and
serum alanine aminotransferase (ALT, GPT) activity is
14 U/L. An x-ray
film of the chest shows no abnormalities. Which of
the following is
the most appropriate chemoprophylaxis?

A
) Isoniazid and folic acid supplementation

B
) Isoniazid and rifampin

C
) Isoniazid and vitamin B1 (thiamine)
supplementation

D
) Isoniazid and vitamin B6 supplementation

E
) No prophylaxis indicated


43.

A 4-month-old boy is brought to the physician because
of a 2-day
history of fever and progressive redness around his
right eye. He has had
persistent diarrhea and oral candidiasis since birth
and was treated for
pneumococcal pneumonia at the age of 2 months. He
appears ill. His
temperature is 39 C (102.2 F), pulse is 130/min, and
respirations are
25/min. Examination shows violaceous preseptal
(periorbital) cellulitis
and oral candidiasis. Laboratory studies show:


Hemoglobin 10 g/dL
Leukocyte count 3000/mm3
Segmented neutrophils 85%
Lymphocytes 15%
Platelet count 350,000/mm3
Serum
IgA <5 mg/dL
IgG 300 mg/dL
IgM <5 mg/dL

Which of the following is the most likely diagnosis?

A
) AIDS

B
) Chronic granulomatous disease

C
) Severe combined immunodeficiency

D
) Thymic-parathyroid dysplasia (DiGeorge syndrome)

E
) X-linked agammaglobulinemia



44. One week after undergoing an uncomplicated
liver transplant for
biliary atresia, a 3-year-old boy appears jaundiced.
Examination shows
scleral icterus. His serum aspartate aminotransferase
(AST, GOT)
activity has increased to 1300 U/L, and serum alanine
aminotransferase (ALT,
GPT) activity has increased to 2500 U/L. His serum
bilirubin level is
3.5 mg/dL, and serum alkaline phosphatase activity is
100 U/L. Which
of the following is the most likely artery responsible
for this
patient's gastrointestinal symptoms?

A
) Hepatic

B
) Ileocolic

C
) Inferior mesenteric

D
) Left gastric

E
) Left gastroepiploic

F
) Middle colic

G
) Posterior penetrating

H
) Right colic

I
) Right gastroepiploic

J
) Splenic

K
) Superior hemorrhoidal

L
) Superior mesenteric



45. A 2-year-old girl has had fever and bloody
diarrhea for 10 days.
A stool culture obtained 7 days ago grew Salmonella
species sensitive
to amoxicillin. A blood culture was negative.
Despite beginning oral
amoxicillin therapy 4 days ago, her diarrhea has
persisted. Current
examination shows no other abnormalities except for a
temperature of 38.6 C
(101.5 F). Which of the following is the most likely
explanation for
the failure of amoxicillin to improve her symptoms?

A
) Amoxicillin does not alter the course of
Salmonella enteritidis

B
) Amoxicillin has caused pseudomembranous colitis

C
) Amoxicillin is absorbed at the level of the
jejunum, leaving no
drug to be delivered to the colon

D
) Oral amoxicillin is not absorbed into the
systemic circulation in
the presence of diarrhea

E
) Salmonella has expressed an inducible ß-lactamase
that inactivates
amoxicillin


46.

A 23-year-old man comes to the physician because of a
1-month history
of intermittent right-sided abdominal pain, nausea,
and vomiting. He
has sickle cell disease and has been treated several
times for painful
crises. Examination of the abdomen shows tenderness
to palpation of the
right upper quadrant on inspiration. Laboratory
studies show:


Hematocrit 25%
Leukocyte count 11,000/mm3
Serum
Bilirubin
Total 3.2 mg/dL
Direct 0.3 mg/dL
Alkaline phosphatase 56 U/L

Ultrasonography of the gallbladder shows a filling
defect. Which of
the following is the most likely cause of this
patient's
hyperbilirubinemia?

A
) Aggregation of cholesterol in the gallbladder

B
) Inhibition of glucuronosyltransferase

C
) Lysis of erythrocytes

D
) Malnutrition-induced cirrhosis

E
) Neoplastic growth in the gallbladder


Report Abuse
 
Report Abuse

 
 

          Page 1 of 1          

[<<First]   [<Prev]  ... Message ...  [Next >]   [Last >>]

 
Logon to post a new Message/Reply
 
 
 
 

 

 

Google
  Web USMLEforum.com
 

Step 1 Step 2 CK Step 2 CS Matching & Residency Step 3 Classifieds
LoginUSMLE LinksHome