01-04-2007, 01:15 PM
11. A 5-month-old boy is brought for a follow-up examination. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite treatment with nebulized and oral bronchodilators and oral corticosteroids. His diet consists of 32 ounces of iron-fortified cow's milk-based formula daily. He appears well nourished and happy. On examination, there is moderate relief of wheezing with extension of the neck. Which of the following is the most likely mechanism of this infant's wheezing?
A ) Allergic reaction to cow's milk
B ) Aspiration of a foreign body
C ) Compression of the airway by a vascular ring
D ) Concurrent upper respiratory tract infection
E ) Persistent immaturity of lungs
12. An 18-month-old boy is brought to the emergency department because he has not used his left arm since he fell while walking and holding hands with his 8-year-old sister 2 hours ago. On examination, he holds his left upper extremity at his side with his forearm pronated. There is no tenderness of the left lower extremity, but there is restricted movement of the elbow. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate initial step in management?
A ) Passive hypersupination of the forearm
B ) Application of figure-of-8 strap
C ) Administration of analgesics and application of ice
D ) Aspiration of the elbow joint
E ) In-place splint immobilization of the elbow
13. A 6-month-old girl is brought to the physician for a routine health maintenance examination. She was born with a lumbosacral myelomeningocele which was successfully repaired at 2 days of age. The anterior fontanelle is 6 x 8 cm and bulging, and the posterior fontanelle is 3 x 4 cm and bulging. She has severe motor and sensory deficits involving both lower extremities. A head growth chart shows the following values:
Age
Head circumference (cm)
Birth
34.2
1 month
36.6
2 months
38
4 months
44
6 months
47
Which of the following is the most likely cause of increased intracranial pressure?
A ) Acute cerebral edema
B ) Decreased absorption of cerebrospinal fluid
C ) Dilation of cerebral arteries
D ) Intracranial mass lesion
E ) Obstruction of lateral sinus
F ) Obstruction of superior vena cava
G ) Obstruction of cerebrospinal fluid flow
H ) Overproduction of cerebrospinal fluid
14. An 18-year-old primigravid woman comes for her initial prenatal visit at 16 weeks' gestation. She is not sure about the date of her last menstrual period but says that the pregnancy probably occurred immediately after she stopped taking oral contraceptives 5 months ago. Maternal serum α-fetoprotein (MSAFP) level is increased to 3 multiples of the median. Which of the following is the most appropriate next step in management?
A ) Repeat measurement of MSAFP level
B ) Triple screening for MSAFP, serum β-hCG, and serum estriol levels
C ) Ultrasonography
D ) Amniocentesis for measurement of α-fetoprotein level
E ) Amniocentesis for chromosomal analysis
15. A 28-year-old man is brought to the emergency department by police because of severe pain in the right lower quadrant of the abdomen for 36 hours. He has been incarcerated in the county jail, and his court hearing is scheduled in 12 hours. He takes no medications. Abdominal examination shows no rebound. Complete blood count, liver tests, and erythrocyte sedimentation rate are within normal limits. An x-ray film of the abdomen shows a normal gas pattern. Test of the stool for occult blood is negative. Which of the following is the most likely diagnosis?
A ) Adjustment disorder
B ) Conversion disorder
C ) Depressive disorder not otherwise specified
D ) Factitious disorder
E ) Hypochondriasis
F ) Malingering
G ) Somatization disorder
16. A 6-year-old girl is brought to the physician because of a 4-week history of headache, fatigue, and decreased appetite. During this period, she has had nausea and vomiting. At the age of 4 years, she was diagnosed with poststreptococcal glomerulonephritis. She is at the 15th percentile for height and the 10th percentile for weight. Examination shows no abnormalities. Her serum urea nitrogen (BUN) level is 50 mg/dL. Which of the following is most likely to limit progression of this patient's renal failure?
A
) Increased potassium and sodium bicarbonate intake
B
) Decreased sodium and daily calorie intake
C
) Low-protein diet
D
) Strict fluid restriction
E
) Dialysis
17. A previously healthy 62-year-old man comes to the emergency department because of abdominal pain for 48 hours. His temperature is 38.6 C (101.5 F), blood pressure is 130/80 mm Hg, pulse is 110/min, and respirations are 15/min. Abdominal examination shows diffuse left lower quadrant tenderness with no peritoneal signs. Rectal examination shows no abnormalities; test of the stool for occult blood is negative. His leukocyte count is 14,700/mm3. Which of the following is the most appropriate next step in diagnosis?
A
) Barium enema
B
) CT scan of the abdomen
C
) Colonoscopy
D
) Cystoscopy
E
) Exploratory laparotomy
18. A previously healthy 3-month-old girl is brought to the emergency department because of a 3-day history of grunting and increasing difficulty breathing. She appears ill. Her temperature is 36.7 C (98 F), pulse is 160/min, and respirations are 76/min. Examination shows grunting, nasal flaring, and marked intercostal retractions. Bronchial breath sounds and occasional bilateral crackles are heard on auscultation. Serum studies show:
Ca2+ 5.6 mg/dL
Phosphorus 11 mg/dL
Alkaline phosphatase 250 U/L
Capillary blood gas analysis on 100% oxygen:
pH 7.36
PCO2 38 mm Hg
PO2 46 mm Hg
An x-ray film of the chest shows bilateral, diffuse interstitial infiltrates and absence of the thymic shadow. Bronchoalveolar lavage is positive for numerous Pneumocystis carinii. Which of the following is the most likely mechanism of these findings?
A ) Adenosine deaminase deficiency
B ) Consumption of complement
C ) Defective opsonization
D ) Destruction of CD4+ T lymphocytes
E ) Developmental arrest of maturation of B lymphocytes
F ) Dysmorphogenesis of the third and fourth pharyngeal pouches
G ) Impaired chemotaxis
H ) Impaired phagocytic oxidative metabolism
19. A 4-year-old boy is brought to the emergency department 20 minutes after being involved in a motor vehicle collision. He was an unrestrained passenger. On arrival, his blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 32/min with grunting and retractions. Examination shows multiple bruises over the chest. Arterial blood gas analysis while breathing 40% oxygen shows:
pH 7.38
PCO2 34 mm Hg
PO2 66 mm Hg
An x-ray film of the chest obtained 4 hours later shows diffuse infiltrates on the right side. Which of the following is the most likely diagnosis?
A
) Acute respiratory distress syndrome
B
) Aspiration pneumonia
C
) Fat embolism
D
) Hemothorax
E
) Pulmonary contusion
20. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry eyes and mouth. He also has had a 10.4-kg (23-lb) weight loss over the past 4 months despite no change in appetite. He has smoked one and a half packs of cigarettes daily for 50 years. He drinks 4 oz of alcohol daily. He has peptic ulcer disease and emphysema. Medications include cimetidine, theophylline, and low-dose prednisone. Examination shows mild ptosis. He has a barrel-shaped chest. Breath sounds are distant. There is moderate weakness of the proximal muscles of the lower extremities. Reflexes are absent. He has difficulty rising from a chair. Sensory examination shows no abnormalities. An x-ray film shows a hyperinflated chest and a 3 x 4-cm mass in the right hilum. His neurologic findings are most likely due to a lesion involving which of the following?
A
) Muscle membrane
B
) Parasympathetic nervous system
C
) Peripheral nerve
D
) Presynaptic neuromuscular junction
E
) Sympathetic nervous system
21. A 42-year-old man comes to the emergency department because of a 2-week history of increasingly severe headaches and a 2-day history of nausea, vomiting, neck stiffness, and unsteadiness. He has type 2 diabetes mellitus treated with glyburide. His temperature is 38.1 C (100.5 F). Funduscopic examination shows bilateral papilledema. Neurologic examination shows mild meningismus and diffusely brisk deep tendon reflexes. He walks with a moderately broad-based gait. He is able to recall two out of three objects after 5 minutes and makes several errors on serial sevens. A CT scan of the head shows no abnormalities. Cerebrospinal fluid analysis shows a glucose level of 18 mg/dL, a protein level of 108 mg/dL, and a leukocyte count of 59/mm3 (1% segmented neutrophils and 99% lymphocytes); a cryptococcal antigen assay is positive. Which of the following is the most appropriate pharmacotherapy for this patient?
A
) Acyclovir
B
) Amphotericin B
C
) Itraconazole
D
) Penicillin
E
) Vancomycin
22. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants. Examination shows genital condylomata acuminata in the perineal, peri-introital, labial, and anal areas. Some of the pedunculated condylomata appear to have caused the bleeding. She has no visible intravaginal condylomata or vaginal or anal tears. Her mother has a palmar wart on her hand but no history of condylomata acuminata. Her mother has a boyfriend who does not live with them and who has never been left alone with the girl. They live with the mother's 27-year-old brother who only baby-sits the children when they are asleep. Which of the following is the most appropriate next step in management?
A
) Psychiatric assessment of the mother
B
) DNA typing of the mother's palmar wart for papillomavirus
C
) Treatment of the mother's palmar wart
D
) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the child
E
) Laser therapy of the condylomata acuminata in the child
23. A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin as needed and one aspirin daily. He has smoked two packs of cigarettes daily for 30 years. Examination shows normal heart sounds and no carotid or femoral bruits. Treatment with a β-adrenergic blocking agent is most likely to improve his symptoms due to which of the following mechanisms?
A
) Decreasing diastolic relaxation
B
) Decreasing myocardial contractility
C
) Dilating the coronary arteries
D
) Peripheral vasodilation
E
) Preventing fibrin and platelet plugs
24. A previously healthy 52-year-old woman comes to the physician because she has had a large pimple on her right hand for 2 weeks that has failed to heal. She resides in southeastern USA where she owns a nursery and garden shop. Examination shows a painless red papule on the hand with several nontender subcutaneous nodular lesions above it. Which of the following is the most likely diagnosis?
A ) Blastomycosis
B ) Candidiasis
C ) Coccidioidomycosis
D ) Histoplasmosis
E ) Sporotrichosis
25. A 28-year-old woman at 28 weeks' gestation reports excessive fatigability and dyspnea. Her blood pressure is 118/74 mm Hg, pulse is 110/min and regular, and lungs are clear to auscultation. The cardiac apex is not palpable. S1 is loud, and there is a sharp sound after S2. A low-frequency diastolic murmur is heard at the apex that increases in intensity before S1. Which of the following is the most likely diagnosis?
A
) Aortic regurgitation
B
) Ebstein's anomaly
C
) Mitral regurgitation
D
) Mitral stenosis
E
) Tricuspid regurgitation
26. A 27-year-old woman comes to the physician because of a 2-year history of intermittent diarrhea and severe cramping abdominal pain. The stools are watery, occasionally foul-smelling, and nonbloody. She is currently pain-free and has not had diarrhea for 2 days. She also has intermittent constipation. She has not had fever or weight loss. She returned from a trip to Mexico 3 months ago. She had an appendectomy at the age of 12 years and a cesarean delivery 4 years ago. Examination shows no abnormalities. Which of the following is the most likely diagnosis?
A
) Bacterial gastroenteritis
B
) Crohn's disease
C
) Intermittent small-bowel obstruction
D
) Irritable bowel syndrome
E
) Laxative abuse
27. An asymptomatic 21-year-old woman is found to have an adnexal mass on pelvic examination. She uses oral contraceptives. A photograph of the mass is shown. Which of the following is the most likely diagnosis?
A
) Benign cystic teratoma
B
) Corpus luteum cyst
C
) Dysgerminoma
D
) Endometrioma
E
) Mucinous cystoadenoma
28. A 16-year-old girl is brought to the physician because of episodes of palpitations over the past 6 months. The episodes occur when she runs or plays basketball. She is otherwise asymptomatic. Her blood pressure is 124/46 mm Hg, pulse is 78/min, and respirations are 18/min. She weighs 55 kg (121 lb) and is 180 cm (71 in) tall. Her arm span is 188 cm (74 in), and the upper segment to lower segment ratio is 0.85. Her fingers appear long and are hyperextensible. A grade 4/6, early diastolic murmur is heard along the upper and middle left sternal border with radiation to the apex. Peripheral pulses are bounding. Which of the following is the most likely cause of these findings?
A
) Aortic incompetence
B
) Aortic stenosis
C
) Mitral incompetence
D
) Mitral stenosis
E
) Pulmonary incompetence
F
) Pulmonary stenosis
G
) Tricuspid incompetence
H
) Tricuspid stenosis
29. A previously healthy 87-year-old woman comes to the physician because of a 4-month history of vulvar itching. Examination shows excoriated areas from scratching and a white, thin vulva. The labia minora are absent, and there are small fissures at the introitus. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
A
) Escherichia coli infection
B
) Lichen sclerosus
C
) Squamous cell carcinoma
D
) Trichomoniasis
E
) Vulvar melanoma
F
) Vulvar vestibulitis
30. One month after undergoing an uneventful renal transplant for chronic renal failure secondary to glomerulonephritis, a 38-year-old woman is hospitalized because of increased serum urea nitrogen (BUN) and creatinine levels. Prior to transplantation, she had been receiving hemodialysis for 3 years. Current medications include cyclosporine and prednisone. Examination shows no abnormalities. Over the past 48 hours, urine output has remained stable. Both renal biopsy and a radionuclide scan confirm the diagnosis of acute rejection. Which of the following is the most effective treatment?
A
) Immediate discontinuation of cyclosporine
B
) Increased dosage of corticosteroids
C
) Diuresis and alkalinization of the urine
D
) Renal dialysis for 1“2 weeks
E
) Transplant nephrectomy
A ) Allergic reaction to cow's milk
B ) Aspiration of a foreign body
C ) Compression of the airway by a vascular ring
D ) Concurrent upper respiratory tract infection
E ) Persistent immaturity of lungs
12. An 18-month-old boy is brought to the emergency department because he has not used his left arm since he fell while walking and holding hands with his 8-year-old sister 2 hours ago. On examination, he holds his left upper extremity at his side with his forearm pronated. There is no tenderness of the left lower extremity, but there is restricted movement of the elbow. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate initial step in management?
A ) Passive hypersupination of the forearm
B ) Application of figure-of-8 strap
C ) Administration of analgesics and application of ice
D ) Aspiration of the elbow joint
E ) In-place splint immobilization of the elbow
13. A 6-month-old girl is brought to the physician for a routine health maintenance examination. She was born with a lumbosacral myelomeningocele which was successfully repaired at 2 days of age. The anterior fontanelle is 6 x 8 cm and bulging, and the posterior fontanelle is 3 x 4 cm and bulging. She has severe motor and sensory deficits involving both lower extremities. A head growth chart shows the following values:
Age
Head circumference (cm)
Birth
34.2
1 month
36.6
2 months
38
4 months
44
6 months
47
Which of the following is the most likely cause of increased intracranial pressure?
A ) Acute cerebral edema
B ) Decreased absorption of cerebrospinal fluid
C ) Dilation of cerebral arteries
D ) Intracranial mass lesion
E ) Obstruction of lateral sinus
F ) Obstruction of superior vena cava
G ) Obstruction of cerebrospinal fluid flow
H ) Overproduction of cerebrospinal fluid
14. An 18-year-old primigravid woman comes for her initial prenatal visit at 16 weeks' gestation. She is not sure about the date of her last menstrual period but says that the pregnancy probably occurred immediately after she stopped taking oral contraceptives 5 months ago. Maternal serum α-fetoprotein (MSAFP) level is increased to 3 multiples of the median. Which of the following is the most appropriate next step in management?
A ) Repeat measurement of MSAFP level
B ) Triple screening for MSAFP, serum β-hCG, and serum estriol levels
C ) Ultrasonography
D ) Amniocentesis for measurement of α-fetoprotein level
E ) Amniocentesis for chromosomal analysis
15. A 28-year-old man is brought to the emergency department by police because of severe pain in the right lower quadrant of the abdomen for 36 hours. He has been incarcerated in the county jail, and his court hearing is scheduled in 12 hours. He takes no medications. Abdominal examination shows no rebound. Complete blood count, liver tests, and erythrocyte sedimentation rate are within normal limits. An x-ray film of the abdomen shows a normal gas pattern. Test of the stool for occult blood is negative. Which of the following is the most likely diagnosis?
A ) Adjustment disorder
B ) Conversion disorder
C ) Depressive disorder not otherwise specified
D ) Factitious disorder
E ) Hypochondriasis
F ) Malingering
G ) Somatization disorder
16. A 6-year-old girl is brought to the physician because of a 4-week history of headache, fatigue, and decreased appetite. During this period, she has had nausea and vomiting. At the age of 4 years, she was diagnosed with poststreptococcal glomerulonephritis. She is at the 15th percentile for height and the 10th percentile for weight. Examination shows no abnormalities. Her serum urea nitrogen (BUN) level is 50 mg/dL. Which of the following is most likely to limit progression of this patient's renal failure?
A
) Increased potassium and sodium bicarbonate intake
B
) Decreased sodium and daily calorie intake
C
) Low-protein diet
D
) Strict fluid restriction
E
) Dialysis
17. A previously healthy 62-year-old man comes to the emergency department because of abdominal pain for 48 hours. His temperature is 38.6 C (101.5 F), blood pressure is 130/80 mm Hg, pulse is 110/min, and respirations are 15/min. Abdominal examination shows diffuse left lower quadrant tenderness with no peritoneal signs. Rectal examination shows no abnormalities; test of the stool for occult blood is negative. His leukocyte count is 14,700/mm3. Which of the following is the most appropriate next step in diagnosis?
A
) Barium enema
B
) CT scan of the abdomen
C
) Colonoscopy
D
) Cystoscopy
E
) Exploratory laparotomy
18. A previously healthy 3-month-old girl is brought to the emergency department because of a 3-day history of grunting and increasing difficulty breathing. She appears ill. Her temperature is 36.7 C (98 F), pulse is 160/min, and respirations are 76/min. Examination shows grunting, nasal flaring, and marked intercostal retractions. Bronchial breath sounds and occasional bilateral crackles are heard on auscultation. Serum studies show:
Ca2+ 5.6 mg/dL
Phosphorus 11 mg/dL
Alkaline phosphatase 250 U/L
Capillary blood gas analysis on 100% oxygen:
pH 7.36
PCO2 38 mm Hg
PO2 46 mm Hg
An x-ray film of the chest shows bilateral, diffuse interstitial infiltrates and absence of the thymic shadow. Bronchoalveolar lavage is positive for numerous Pneumocystis carinii. Which of the following is the most likely mechanism of these findings?
A ) Adenosine deaminase deficiency
B ) Consumption of complement
C ) Defective opsonization
D ) Destruction of CD4+ T lymphocytes
E ) Developmental arrest of maturation of B lymphocytes
F ) Dysmorphogenesis of the third and fourth pharyngeal pouches
G ) Impaired chemotaxis
H ) Impaired phagocytic oxidative metabolism
19. A 4-year-old boy is brought to the emergency department 20 minutes after being involved in a motor vehicle collision. He was an unrestrained passenger. On arrival, his blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 32/min with grunting and retractions. Examination shows multiple bruises over the chest. Arterial blood gas analysis while breathing 40% oxygen shows:
pH 7.38
PCO2 34 mm Hg
PO2 66 mm Hg
An x-ray film of the chest obtained 4 hours later shows diffuse infiltrates on the right side. Which of the following is the most likely diagnosis?
A
) Acute respiratory distress syndrome
B
) Aspiration pneumonia
C
) Fat embolism
D
) Hemothorax
E
) Pulmonary contusion
20. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry eyes and mouth. He also has had a 10.4-kg (23-lb) weight loss over the past 4 months despite no change in appetite. He has smoked one and a half packs of cigarettes daily for 50 years. He drinks 4 oz of alcohol daily. He has peptic ulcer disease and emphysema. Medications include cimetidine, theophylline, and low-dose prednisone. Examination shows mild ptosis. He has a barrel-shaped chest. Breath sounds are distant. There is moderate weakness of the proximal muscles of the lower extremities. Reflexes are absent. He has difficulty rising from a chair. Sensory examination shows no abnormalities. An x-ray film shows a hyperinflated chest and a 3 x 4-cm mass in the right hilum. His neurologic findings are most likely due to a lesion involving which of the following?
A
) Muscle membrane
B
) Parasympathetic nervous system
C
) Peripheral nerve
D
) Presynaptic neuromuscular junction
E
) Sympathetic nervous system
21. A 42-year-old man comes to the emergency department because of a 2-week history of increasingly severe headaches and a 2-day history of nausea, vomiting, neck stiffness, and unsteadiness. He has type 2 diabetes mellitus treated with glyburide. His temperature is 38.1 C (100.5 F). Funduscopic examination shows bilateral papilledema. Neurologic examination shows mild meningismus and diffusely brisk deep tendon reflexes. He walks with a moderately broad-based gait. He is able to recall two out of three objects after 5 minutes and makes several errors on serial sevens. A CT scan of the head shows no abnormalities. Cerebrospinal fluid analysis shows a glucose level of 18 mg/dL, a protein level of 108 mg/dL, and a leukocyte count of 59/mm3 (1% segmented neutrophils and 99% lymphocytes); a cryptococcal antigen assay is positive. Which of the following is the most appropriate pharmacotherapy for this patient?
A
) Acyclovir
B
) Amphotericin B
C
) Itraconazole
D
) Penicillin
E
) Vancomycin
22. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants. Examination shows genital condylomata acuminata in the perineal, peri-introital, labial, and anal areas. Some of the pedunculated condylomata appear to have caused the bleeding. She has no visible intravaginal condylomata or vaginal or anal tears. Her mother has a palmar wart on her hand but no history of condylomata acuminata. Her mother has a boyfriend who does not live with them and who has never been left alone with the girl. They live with the mother's 27-year-old brother who only baby-sits the children when they are asleep. Which of the following is the most appropriate next step in management?
A
) Psychiatric assessment of the mother
B
) DNA typing of the mother's palmar wart for papillomavirus
C
) Treatment of the mother's palmar wart
D
) Vaginal, anal, and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the child
E
) Laser therapy of the condylomata acuminata in the child
23. A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks. He had a myocardial infarction 2 months ago. He takes nitroglycerin as needed and one aspirin daily. He has smoked two packs of cigarettes daily for 30 years. Examination shows normal heart sounds and no carotid or femoral bruits. Treatment with a β-adrenergic blocking agent is most likely to improve his symptoms due to which of the following mechanisms?
A
) Decreasing diastolic relaxation
B
) Decreasing myocardial contractility
C
) Dilating the coronary arteries
D
) Peripheral vasodilation
E
) Preventing fibrin and platelet plugs
24. A previously healthy 52-year-old woman comes to the physician because she has had a large pimple on her right hand for 2 weeks that has failed to heal. She resides in southeastern USA where she owns a nursery and garden shop. Examination shows a painless red papule on the hand with several nontender subcutaneous nodular lesions above it. Which of the following is the most likely diagnosis?
A ) Blastomycosis
B ) Candidiasis
C ) Coccidioidomycosis
D ) Histoplasmosis
E ) Sporotrichosis
25. A 28-year-old woman at 28 weeks' gestation reports excessive fatigability and dyspnea. Her blood pressure is 118/74 mm Hg, pulse is 110/min and regular, and lungs are clear to auscultation. The cardiac apex is not palpable. S1 is loud, and there is a sharp sound after S2. A low-frequency diastolic murmur is heard at the apex that increases in intensity before S1. Which of the following is the most likely diagnosis?
A
) Aortic regurgitation
B
) Ebstein's anomaly
C
) Mitral regurgitation
D
) Mitral stenosis
E
) Tricuspid regurgitation
26. A 27-year-old woman comes to the physician because of a 2-year history of intermittent diarrhea and severe cramping abdominal pain. The stools are watery, occasionally foul-smelling, and nonbloody. She is currently pain-free and has not had diarrhea for 2 days. She also has intermittent constipation. She has not had fever or weight loss. She returned from a trip to Mexico 3 months ago. She had an appendectomy at the age of 12 years and a cesarean delivery 4 years ago. Examination shows no abnormalities. Which of the following is the most likely diagnosis?
A
) Bacterial gastroenteritis
B
) Crohn's disease
C
) Intermittent small-bowel obstruction
D
) Irritable bowel syndrome
E
) Laxative abuse
27. An asymptomatic 21-year-old woman is found to have an adnexal mass on pelvic examination. She uses oral contraceptives. A photograph of the mass is shown. Which of the following is the most likely diagnosis?
A
) Benign cystic teratoma
B
) Corpus luteum cyst
C
) Dysgerminoma
D
) Endometrioma
E
) Mucinous cystoadenoma
28. A 16-year-old girl is brought to the physician because of episodes of palpitations over the past 6 months. The episodes occur when she runs or plays basketball. She is otherwise asymptomatic. Her blood pressure is 124/46 mm Hg, pulse is 78/min, and respirations are 18/min. She weighs 55 kg (121 lb) and is 180 cm (71 in) tall. Her arm span is 188 cm (74 in), and the upper segment to lower segment ratio is 0.85. Her fingers appear long and are hyperextensible. A grade 4/6, early diastolic murmur is heard along the upper and middle left sternal border with radiation to the apex. Peripheral pulses are bounding. Which of the following is the most likely cause of these findings?
A
) Aortic incompetence
B
) Aortic stenosis
C
) Mitral incompetence
D
) Mitral stenosis
E
) Pulmonary incompetence
F
) Pulmonary stenosis
G
) Tricuspid incompetence
H
) Tricuspid stenosis
29. A previously healthy 87-year-old woman comes to the physician because of a 4-month history of vulvar itching. Examination shows excoriated areas from scratching and a white, thin vulva. The labia minora are absent, and there are small fissures at the introitus. The remainder of the examination shows no abnormalities. Which of the following is the most likely diagnosis?
A
) Escherichia coli infection
B
) Lichen sclerosus
C
) Squamous cell carcinoma
D
) Trichomoniasis
E
) Vulvar melanoma
F
) Vulvar vestibulitis
30. One month after undergoing an uneventful renal transplant for chronic renal failure secondary to glomerulonephritis, a 38-year-old woman is hospitalized because of increased serum urea nitrogen (BUN) and creatinine levels. Prior to transplantation, she had been receiving hemodialysis for 3 years. Current medications include cyclosporine and prednisone. Examination shows no abnormalities. Over the past 48 hours, urine output has remained stable. Both renal biopsy and a radionuclide scan confirm the diagnosis of acute rejection. Which of the following is the most effective treatment?
A
) Immediate discontinuation of cyclosporine
B
) Increased dosage of corticosteroids
C
) Diuresis and alkalinization of the urine
D
) Renal dialysis for 1“2 weeks
E
) Transplant nephrectomy