01-07-2007, 07:57 PM
. 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
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
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