12-06-2006, 06:46 PM
1 A 67-year-old woman comes to the physician for her first influenza virus vaccination. She has a history of untreated hypertension. Her blood pressure is 160/100 mm Hg, and pulse is 100/min. Shortly after administration of the influenza virus vaccine, she develops shortness of breath, hives, and angioedema. Which of the following is most likely to have prevented this reaction?
A) Inquiry about an egg allergy
B) Heterophile agglutination test
C) Skin test with histamine reagent
D) ß-Adrenergic blocking agent therapy
E) Amantadine therapy
F) Insulin therapy
G) Rimantadine therapy
2. A 7-year-old girl is brought to the physician
because of a 2-day history of fever, headache, sore throat, and swollen glands. She does not have a runny nose, congestion, or cough. She has no allergies to medications. Her temperature is 38.6 C (101.4 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and respirations are
16/min. Examination shows a swollen, erythematous oropharynx with tonsillar exudates. The anterior cervical lymph nodes are enlarged and tender. No other abnormalities are noted. Which of the following is the most likely causal
organism?
A) Adenovirus
B) Corynebacterium diphtheriae
C) Group A streptococcus
D) Haemophilus influenzae
E) Mycoplasma pneumoniae
3 A 70-year-old nursing home resident is admitted to the hospital because of progressive obtundation over the past 2
days. He has tachycardia, tachypnea, and hypotension. Bilateral basilar crackles and an S3 gallop are heard on auscultation. Examination shows jugular venous distention and peripheral edema. Swan-Ganz catheterization shows a cardiac index of 1.8 L/min/m2 (N=2.5“4.2), a mean pulmonary capillary wedge pressure of 23 mm Hg (N=1“10), and markedly increased systemic vascular resistance. Which of the following is the most likely diagnosis?
A) Cardiogenic shock
B) Hypovolemic shock
C) Neurogenic shock
D) Septic shock
4 A 42-year-old man with alcoholism is brought to the emergency
department by a friend because of fever and progressive shortness of breath for
12 hours. His friend reports that they were eating leftover chicken
and drinking beer earlier in the day when the patient suddenly choked and
vomited. Six hours later, he developed sweating, chills, and shortness
of breath. He has not had any subsequent nausea, vomiting,
hematemesis, or abdominal pain. He has smoked two packs of cigarettes daily for
22 years and drinks 12 to 18 beers daily. He is in moderate respiratory
distress. His temperature is 39.3 C (102.8 F), blood
pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min.
Examination shows no jugular venous distention. Breath sounds are
decreased halfway up the left lung with increased dullness. Cardiac
examination shows a normal S1 and S2; no murmurs are heard. There is no
abdominal tenderness. Bowel sounds are hypoactive. X-ray films of the chest
show a left pleural effusion and air in the mediastinum.
Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum
Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid
Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none
Which of the following is the most likely diagnosis?
A) Congestive heart failure
B) Esophageal rupture
C) Pancreatitis
D) Pericarditis
E) Tuberculosis
5. A 2-year-old girl with tricuspid atresia has
increasing respiratory distress for 2 days. She has been recovering uneventfully from an operation 10 days ago to join systemic venous return with pulmonary
arterial circulation. Over the past 4 days, she has been weaned off
mechanical ventilation, started on oral feedings, and is receiving chest
physiotherapy for atelectasis. Her temperature is 37.4 C (99.3 F), blood
pressure is 98/64 mm Hg, pulse is 120/min, and respirations are 46/min.
Examination shows nasal flaring, grunting, and intercostal retractions.
An x-ray film of the chest shows large bilateral pleural effusions.
Thoracentesis yields 300 mL of whitish-yellow fluid. The supernatant
remains uniformly opaque on centrifugation. Which of the following is the
most likely cause of the pleural effusions?
A) Chylothorax
B) Congestive heart failure
C) Empyema
D) Pulmonary embolism
E) Superior vena cava obstruction
6. A 23-year-old man is brought to the physician by his mother
because he has heard a voice over the past month telling him to hurt
himself. His mother says that her son has no friends and is a lifelong loner; since graduating from high school, he has been unable to hold a job.
He admits to smoking marijuana occasionally and drinking six beers
weekly. Examination shows a poorly groomed man with poor eye contact. He
has a flat affect and limited facial expression. He says he has no
intention of harming himself or others. Which of the following is the
most appropriate next step in management?
A) Schedule a follow-up visit in 4 weeks
B) Prescribe oral risperidone and schedule a follow-up visit in 2 weeks
C) Admit him to the partial hospital program and prescribe oral lithium carbonate
D) Admit him to the psychiatric unit for detoxification
E) Admit him to the psychiatric unit and prescribe oral imipramine
8. An 18-month-old boy is brought for a well-child examination. He was
born at 37 weeks' gestation and weighed 2800 g (6 lb 3 oz). There were
no prenatal or perinatal complications. Developmental history indicates
that he is able to run and walk up stairs while holding his mother's
hand. He can hold a crayon but does not scribble spontaneously. He is
at the 40th percentile for length and 50th percentile for weight.
Examination shows a crude pincer grasp. Which of the following is the most
appropriate assessment of fine and gross motor development?
Fine Motor Gross Motor
Development Development
A)Delayed normal
B)Normal delayed
C)Delayed delayed
D)Normal normal
9 Five months after beginning fluoxetine to treat obsessive-compulsive
disorder, a 19-year-old man states that he discontinued his medication 2
months ago because he had begun to worry about taking his medication
every day. His initial response to the medication was good. His
symptoms have now returned, and his morning ritual of cleaning and grooming
consumes so much time that his job is in jeopardy. In addition to
education about the nature of his disorder and its treatment, which of the
following is the most appropriate next step in management?
A) Tell the patient to schedule a return visit as
needed
B) Offer to change the medication
C) Request that the patient's parents supervise
administration of medication
D) Monitor the patient's compliance by weekly blood
tests
E) Begin a trial of cognitive-behavior therapy
10 A 32-year-old woman comes to the physician because of a 3-month
history of increasing pain and stiffness in her wrists, hands, and ankles.
During this period, she also has had progressive fatigue and morning stiffness lasting 2 hours. She has a 1-year history of rheumatoid arthritis treated with naproxen. Examination shows redness, swelling, and warmth over the wrist, hand, and ankle joints
bilaterally. There are nontender subcutaneous nodules over the extensor
surfaces of both elbows. X-ray films of the hands show diffuse osteopenia and
erosions over several of the distal metacarpal bones. Which of the
following is the most
appropriate pharmacotherapy?
A) Add oral cyclophosphamide
B) Add oral gold
C) Add oral methotrexate
D) Add oral penicillamine
E ) Switch to oral ibuprofen
11. A previously healthy 62-year-old man comes to the physician because of a 2-month history of progressive shortness of breath and a mild nonproductive cough. He does not smoke. He worked in a foundry most of his adult life before retiring 2 years ago. Vital
signs are within normal limits. Crackles are heard at both lung bases with no wheezes.
Cardiac examination shows an accentuated P2. The remainder of the examination shows no abnormalities. An x-ray film of the chest shows
prominent interstitial markings at the lung bases. Echocardiography shows
an ejection fraction of 55%. Pulmonary function testing is most likely
to show which of the following?
A) Decreased FEV1:FVC ratio
B) Decreased maximal inspiratory effort
C) Decreased total lung capacity
D) Increased forced vital capacity
E) Normal carbon monoxide diffusion capacity
12. A 55-year-old man is admitted to the hospital
because of progressive shortness of breath for 10 days. He has a
history of chronic venous stasis and deep venous thrombosis. He has been
treated with warfarin since he had several pulmonary emboli 2 years
ago; he takes no other medication. He has smoked two packs of cigarettes
daily for 30 years. He weighs 109 kg (240 lb) and is 165 cm (65 in) tall.
Examination shows jugular venous distention. Echocardiography is
most likely to show which of the following?
A) Left ventricular dilation
B) Mitral stenosis
C) Pericardial thickening and tamponade
D) Right ventricular hypertrophy and dilation
E) Tricuspid stenosis
13. A 32-year-old woman comes to the physician because of weakness
of the lower extremities for 2 days. Three years ago, she had pain and
partial loss of vision of the right eye; the vision returned to normal
after 6 weeks. There is mild pallor of the right optic disc. She has
impaired tandem gait. Babinski's sign is present bilaterally. There
is mild spasticity of the lower extremities and mild weakness of the
iliopsoas and hamstring muscles. Serum creatine
kinase activity is 50U/L. Which of the following is the most likely
diagnosis?
A) Amyotrophic lateral sclerosis
B) Becker's muscular dystrophy
C) Diffuse sensorimotor peripheral neuropathy
D) Duchenne's muscular dystrophy
E) Hyperkalemic periodic paralysis
F) Hypokalemic periodic paralysis
G) Multiple sclerosis
H) Myasthenia gravis
I) Myasthenic (Lambert-Eaton) syndrome
J) Myotonic muscular dystrophy
K) Polymyositis
L) Pontine astrocytoma
M) Pontine infarction
N) Spinal cord tumor
O) Transverse myelitis
14. A healthy 42-year-old man comes to the
physician for a life insurance evaluation. He smoked one-half pack of cigarettes daily for 20
years but quit 10 years ago. His father died of a myocardial infarction at the age of 65 years. The patient weighs 93 kg (205 lb) and is 178 cm (70 in) tall. His blood pressure is 160/110 mm Hg, pulse is 96/min, and respirations are 16/min. Physical examination, ECG, and an x-ray film of the chest show no abnormalities. Laboratory studies are within
normal limits except for a serum cholesterol level of 206 mg/dL. Which of the following is the greatest risk factor for cerebral infarction in this patient?
A) Genetic profile
B) History of smoking
C) Hypercholesterolemia
D) Hypertension
E) Obesity
15. A previously healthy 56-year-old woman comes to the physician
because of jaundice and dark urine for 3 weeks. She has a 1-year history
of generalized pruritus. She takes no medications. Examination shows
jaundice and several ecchymoses over the forearms and thighs. The
liver and spleen are enlarged and nontender. Laboratory studies show:
Prothrombin time 18 sec
Serum Protein
Total 8.5 g/dL
Albumin 3.8 g/dL
Bilirubin
Total 5 mg/dL
Direct 2 mg/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
Antimitochondrial antibody assay is strongly positive.
A CT scan of the abdomen shows hepatosplenomegaly. Endoscopic
retrograde cholangiopancreatography shows no abnormalities.
Because of her condition, this
patient is at greatest risk for which of the following
deficiencies?
A) Niacin
B) Vitamin A
C) Vitamin B2 (riboflavin)
D) Vitamin B12 (cyanocobalamin)
E) Vitamin C
A) Inquiry about an egg allergy
B) Heterophile agglutination test
C) Skin test with histamine reagent
D) ß-Adrenergic blocking agent therapy
E) Amantadine therapy
F) Insulin therapy
G) Rimantadine therapy
2. A 7-year-old girl is brought to the physician
because of a 2-day history of fever, headache, sore throat, and swollen glands. She does not have a runny nose, congestion, or cough. She has no allergies to medications. Her temperature is 38.6 C (101.4 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and respirations are
16/min. Examination shows a swollen, erythematous oropharynx with tonsillar exudates. The anterior cervical lymph nodes are enlarged and tender. No other abnormalities are noted. Which of the following is the most likely causal
organism?
A) Adenovirus
B) Corynebacterium diphtheriae
C) Group A streptococcus
D) Haemophilus influenzae
E) Mycoplasma pneumoniae
3 A 70-year-old nursing home resident is admitted to the hospital because of progressive obtundation over the past 2
days. He has tachycardia, tachypnea, and hypotension. Bilateral basilar crackles and an S3 gallop are heard on auscultation. Examination shows jugular venous distention and peripheral edema. Swan-Ganz catheterization shows a cardiac index of 1.8 L/min/m2 (N=2.5“4.2), a mean pulmonary capillary wedge pressure of 23 mm Hg (N=1“10), and markedly increased systemic vascular resistance. Which of the following is the most likely diagnosis?
A) Cardiogenic shock
B) Hypovolemic shock
C) Neurogenic shock
D) Septic shock
4 A 42-year-old man with alcoholism is brought to the emergency
department by a friend because of fever and progressive shortness of breath for
12 hours. His friend reports that they were eating leftover chicken
and drinking beer earlier in the day when the patient suddenly choked and
vomited. Six hours later, he developed sweating, chills, and shortness
of breath. He has not had any subsequent nausea, vomiting,
hematemesis, or abdominal pain. He has smoked two packs of cigarettes daily for
22 years and drinks 12 to 18 beers daily. He is in moderate respiratory
distress. His temperature is 39.3 C (102.8 F), blood
pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min.
Examination shows no jugular venous distention. Breath sounds are
decreased halfway up the left lung with increased dullness. Cardiac
examination shows a normal S1 and S2; no murmurs are heard. There is no
abdominal tenderness. Bowel sounds are hypoactive. X-ray films of the chest
show a left pleural effusion and air in the mediastinum.
Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum
Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid
Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none
Which of the following is the most likely diagnosis?
A) Congestive heart failure
B) Esophageal rupture
C) Pancreatitis
D) Pericarditis
E) Tuberculosis
5. A 2-year-old girl with tricuspid atresia has
increasing respiratory distress for 2 days. She has been recovering uneventfully from an operation 10 days ago to join systemic venous return with pulmonary
arterial circulation. Over the past 4 days, she has been weaned off
mechanical ventilation, started on oral feedings, and is receiving chest
physiotherapy for atelectasis. Her temperature is 37.4 C (99.3 F), blood
pressure is 98/64 mm Hg, pulse is 120/min, and respirations are 46/min.
Examination shows nasal flaring, grunting, and intercostal retractions.
An x-ray film of the chest shows large bilateral pleural effusions.
Thoracentesis yields 300 mL of whitish-yellow fluid. The supernatant
remains uniformly opaque on centrifugation. Which of the following is the
most likely cause of the pleural effusions?
A) Chylothorax
B) Congestive heart failure
C) Empyema
D) Pulmonary embolism
E) Superior vena cava obstruction
6. A 23-year-old man is brought to the physician by his mother
because he has heard a voice over the past month telling him to hurt
himself. His mother says that her son has no friends and is a lifelong loner; since graduating from high school, he has been unable to hold a job.
He admits to smoking marijuana occasionally and drinking six beers
weekly. Examination shows a poorly groomed man with poor eye contact. He
has a flat affect and limited facial expression. He says he has no
intention of harming himself or others. Which of the following is the
most appropriate next step in management?
A) Schedule a follow-up visit in 4 weeks
B) Prescribe oral risperidone and schedule a follow-up visit in 2 weeks
C) Admit him to the partial hospital program and prescribe oral lithium carbonate
D) Admit him to the psychiatric unit for detoxification
E) Admit him to the psychiatric unit and prescribe oral imipramine
8. An 18-month-old boy is brought for a well-child examination. He was
born at 37 weeks' gestation and weighed 2800 g (6 lb 3 oz). There were
no prenatal or perinatal complications. Developmental history indicates
that he is able to run and walk up stairs while holding his mother's
hand. He can hold a crayon but does not scribble spontaneously. He is
at the 40th percentile for length and 50th percentile for weight.
Examination shows a crude pincer grasp. Which of the following is the most
appropriate assessment of fine and gross motor development?
Fine Motor Gross Motor
Development Development
A)Delayed normal
B)Normal delayed
C)Delayed delayed
D)Normal normal
9 Five months after beginning fluoxetine to treat obsessive-compulsive
disorder, a 19-year-old man states that he discontinued his medication 2
months ago because he had begun to worry about taking his medication
every day. His initial response to the medication was good. His
symptoms have now returned, and his morning ritual of cleaning and grooming
consumes so much time that his job is in jeopardy. In addition to
education about the nature of his disorder and its treatment, which of the
following is the most appropriate next step in management?
A) Tell the patient to schedule a return visit as
needed
B) Offer to change the medication
C) Request that the patient's parents supervise
administration of medication
D) Monitor the patient's compliance by weekly blood
tests
E) Begin a trial of cognitive-behavior therapy
10 A 32-year-old woman comes to the physician because of a 3-month
history of increasing pain and stiffness in her wrists, hands, and ankles.
During this period, she also has had progressive fatigue and morning stiffness lasting 2 hours. She has a 1-year history of rheumatoid arthritis treated with naproxen. Examination shows redness, swelling, and warmth over the wrist, hand, and ankle joints
bilaterally. There are nontender subcutaneous nodules over the extensor
surfaces of both elbows. X-ray films of the hands show diffuse osteopenia and
erosions over several of the distal metacarpal bones. Which of the
following is the most
appropriate pharmacotherapy?
A) Add oral cyclophosphamide
B) Add oral gold
C) Add oral methotrexate
D) Add oral penicillamine
E ) Switch to oral ibuprofen
11. A previously healthy 62-year-old man comes to the physician because of a 2-month history of progressive shortness of breath and a mild nonproductive cough. He does not smoke. He worked in a foundry most of his adult life before retiring 2 years ago. Vital
signs are within normal limits. Crackles are heard at both lung bases with no wheezes.
Cardiac examination shows an accentuated P2. The remainder of the examination shows no abnormalities. An x-ray film of the chest shows
prominent interstitial markings at the lung bases. Echocardiography shows
an ejection fraction of 55%. Pulmonary function testing is most likely
to show which of the following?
A) Decreased FEV1:FVC ratio
B) Decreased maximal inspiratory effort
C) Decreased total lung capacity
D) Increased forced vital capacity
E) Normal carbon monoxide diffusion capacity
12. A 55-year-old man is admitted to the hospital
because of progressive shortness of breath for 10 days. He has a
history of chronic venous stasis and deep venous thrombosis. He has been
treated with warfarin since he had several pulmonary emboli 2 years
ago; he takes no other medication. He has smoked two packs of cigarettes
daily for 30 years. He weighs 109 kg (240 lb) and is 165 cm (65 in) tall.
Examination shows jugular venous distention. Echocardiography is
most likely to show which of the following?
A) Left ventricular dilation
B) Mitral stenosis
C) Pericardial thickening and tamponade
D) Right ventricular hypertrophy and dilation
E) Tricuspid stenosis
13. A 32-year-old woman comes to the physician because of weakness
of the lower extremities for 2 days. Three years ago, she had pain and
partial loss of vision of the right eye; the vision returned to normal
after 6 weeks. There is mild pallor of the right optic disc. She has
impaired tandem gait. Babinski's sign is present bilaterally. There
is mild spasticity of the lower extremities and mild weakness of the
iliopsoas and hamstring muscles. Serum creatine
kinase activity is 50U/L. Which of the following is the most likely
diagnosis?
A) Amyotrophic lateral sclerosis
B) Becker's muscular dystrophy
C) Diffuse sensorimotor peripheral neuropathy
D) Duchenne's muscular dystrophy
E) Hyperkalemic periodic paralysis
F) Hypokalemic periodic paralysis
G) Multiple sclerosis
H) Myasthenia gravis
I) Myasthenic (Lambert-Eaton) syndrome
J) Myotonic muscular dystrophy
K) Polymyositis
L) Pontine astrocytoma
M) Pontine infarction
N) Spinal cord tumor
O) Transverse myelitis
14. A healthy 42-year-old man comes to the
physician for a life insurance evaluation. He smoked one-half pack of cigarettes daily for 20
years but quit 10 years ago. His father died of a myocardial infarction at the age of 65 years. The patient weighs 93 kg (205 lb) and is 178 cm (70 in) tall. His blood pressure is 160/110 mm Hg, pulse is 96/min, and respirations are 16/min. Physical examination, ECG, and an x-ray film of the chest show no abnormalities. Laboratory studies are within
normal limits except for a serum cholesterol level of 206 mg/dL. Which of the following is the greatest risk factor for cerebral infarction in this patient?
A) Genetic profile
B) History of smoking
C) Hypercholesterolemia
D) Hypertension
E) Obesity
15. A previously healthy 56-year-old woman comes to the physician
because of jaundice and dark urine for 3 weeks. She has a 1-year history
of generalized pruritus. She takes no medications. Examination shows
jaundice and several ecchymoses over the forearms and thighs. The
liver and spleen are enlarged and nontender. Laboratory studies show:
Prothrombin time 18 sec
Serum Protein
Total 8.5 g/dL
Albumin 3.8 g/dL
Bilirubin
Total 5 mg/dL
Direct 2 mg/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
Antimitochondrial antibody assay is strongly positive.
A CT scan of the abdomen shows hepatosplenomegaly. Endoscopic
retrograde cholangiopancreatography shows no abnormalities.
Because of her condition, this
patient is at greatest risk for which of the following
deficiencies?
A) Niacin
B) Vitamin A
C) Vitamin B2 (riboflavin)
D) Vitamin B12 (cyanocobalamin)
E) Vitamin C
