01-05-2007, 05:48 AM
31. An asymptomatic 47-year-old man comes for a preemployment examination. He has never been hospitalized. He is a computer programmer, and he plays handball once weekly. His maternal grandmother had type 2 diabetes mellitus, and a paternal uncle had heart disease. The patient's blood pressure is 126/80 mm Hg. Examination shows no abnormalities. His total serum cholesterol level is 225 mg/dL. Which of the following is the most appropriate next step in management?
A
) Step 2 American Heart Association cardiac diet
B
) Serum lipid studies while fasting
C
) Exercise stress test
D
) Oral cholestyramine and niacin therapy
E
) Oral pravastatin therapy at bedtime
32. A 25-year-old woman comes to the physician because of a 3-month history of the unexplained urge to eat a few tablespoons of cornstarch daily. The amount of cornstarch ingested has increased gradually during this time. She has leiomyomata uteri; she is otherwise healthy. Her weight is unchanged from her last visit 1 year ago; she weighs 61 kg (135 lb) and is 168 cm (66 in) tall. Her blood pressure is 120/80 mm Hg, and pulse is 100/min. Physical examination shows mild pallor. Neurologic examination shows no abnormalities. She is embarrassed about her problem. She has no compulsive behavior or obsessive thoughts. An ECG shows sinus tachycardia. Which of the following is the most appropriate next step in management?
A
) Psychiatric assessment
B
) Complete blood count
C
) Thyroid function studies
D
) Urine toxicology screening
E
) Admission to an eating disorders clinic
F
) Antipsychotic therapy
G
) Folic acid supplementation
H
) Selective serotonin reuptake inhibitor therapy
33. A 30-year-old woman comes to the physician for a follow-up examination 4 months after starting treatment with lithium carbonate; during this period she has had a 3.2-kg (7-lb) weight gain. Her medication was prescribed soon after the birth of her son to treat racing thoughts, increased spending, and overtalkativeness; she has had difficulty sleeping for more than 2 hours nightly. Her symptoms decreased after 2 weeks of lithium carbonate therapy. She continues to take lithium carbonate (300 mg three times daily). Her temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 70/min. Examination shows normal findings. The most appropriate next step is measurement of which of the following?
A
) Fasting serum glucose level
B
) Leukocyte count
C
) Serum alkaline phosphatase activity
D
) Serum creatinine level
E
) Serum thyroid-stimulating hormone level
34. On a routine examination, a 2-year-old boy has a hemoglobin level of 10.5 g/dL, hematocrit of 30%, and mean corpuscular volume of 72 μm3. He drinks four to five 8-oz bottles of milk daily. He maintains a regular diet but does not eat vegetables. Which of the following is the most likely diagnosis?
A
) Folic acid deficiency
B
) Iron deficiency
C
) Sickle cell disease
D
) Thalassemia
E
) Vitamin B6 deficiency
35. A 57-year-old man is brought to the physician by his wife because his skin has appeared yellow for 3 weeks. Examination shows jaundice and scleral icterus. His total serum bilirubin level is 8 mg/dL with a direct component of 6.2 mg/dL. A CT scan of the abdomen shows a large lesion in the head of the pancreas. When the results are initially discussed, the patient says that he does not want to hear the report, and his wife agrees to abide by his wishes. Which of the following is the most appropriate course of action?
A
) Withhold the results as the patient wishes
B
) Contact the patient's children to discuss the results
C
) Consult with the hospital ethics committee
D
) Insist on telling the patient the results
E
) Refer him to another physician
36. A previously healthy 52-year-old man comes to the physician because of a 3-month history of increased urinary volume and increased urinary frequency at night. He has had a 6.8-kg (15-lb) weight loss during this period despite no change in appetite. His father has hypertension, and his mother has hypertension and type 2 diabetes mellitus. He currently weighs 95 kg (210 lb) and is 178 cm (70 in) tall. His blood pressure is 160/85 mm Hg in both arms. Examination shows no other abnormalities. His nonfasting serum glucose level is 280 mg/dL. Which of the following serum levels is most likely to be increased in this patient?
A
) Bicarbonate
B
) Glucagon
C
) HDL-cholesterol
D
) Insulin
E
) Ketones
37. Three days after hospitalization for heparin treatment of deep venous thrombosis of a left superficial femoral vein, a 52-year-old woman has prolonged bleeding from a venipuncture site. She had a pulmonary embolus 2 years ago. Her temperature is 37.5 C (99.5 F). Examination shows multiple ecchymoses at the venipuncture sites with oozing of fresh blood. Laboratory studies show:
Hemoglobin
10.5 g/dL
Platelet count
25,000/mm3
Prothrombin time
14 sec (INR=1.3)
Partial thromboplastin time
65 sec
Plasma fibrinogen
300 mg/dL (N=200“400)
Serum creatinine
1.1 mg/dL
Which of the following is the most likely diagnosis?
A
) Adverse drug reaction
B
) Disseminated intravascular coagulation
C
) Excessive blood loss from anticoagulation
D
) Factor VIII deficiency
E
) Factor IX deficiency
F
) Immune thrombocytopenic purpura
G
) Thrombotic thrombocytopenic purpura
38. A 37-year-old woman comes to the physician because of an itchy rash over her trunk for 2 weeks. She has not had fever, chills, shortness of breath, chest pain, or gastrointestinal symptoms. She has a history of recurrent urinary tract infections and has been taking trimethoprim-sulfamethoxazole prophylaxis for the past year. She is in mild distress. Her temperature is 37.5 C (99.5 F), blood pressure is 96/62 mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows a maculopapular erythematous rash over the trunk. Laboratory studies show:
Leukocyte count 10,500/mm3
Segmented neutrophils 72%
Bands 1%
Eosinophils 15%
Lymphocytes 4%
Monocytes 8%
Serum
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.9 mg/dL
Urine
WBC 2/hpf
RBC 2/hpf
Which of the following is the most likely cause of these findings?
A
) Eczema
B
) Medication adverse effect
C
) Staphylococcal skin infection
D
) Streptococcal skin infection
E
) Urinary tract infection
39. A 19-year-old primigravid woman at 34 weeks' gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated. She has no history of serious illness. She takes no medications and has no known allergies. Examination shows a uterus consistent in size with a 34-week gestation. A routine clean-catch urine culture grows greater than 100,000 colonies/mL of Escherichia coli. Which of the following is the most appropriate pharmacotherapy?
A
) Ampicillin
B
) Ciprofloxacin
C
) Clindamycin
D
) Doxycycline
E
) Trimethoprim-sulfamethoxazole
40. A 13-year-old girl is brought for a well-child examination. Menses have occurred every other month since menarche 10 months ago. Her last menstrual period was 1 week ago. She is not sexually active. Sexual development is Tanner stage 3. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?
A
) Discussion of pregnancy prevention
B
) Measurement of serum luteinizing and follicle-stimulating hormone levels
C
) Urine β-hCG test
D
) Pelvic examination
E
) Estrogen therapy
F
) Diagnostic laparoscopy
41. A 72-year-old man comes to the emergency department after a 5-minute episode of blindness in the right eye. Over the past month, he has had headache and pain in the jaw with chewing. His temperature is 38.1 C (100.6 F). Examination shows tender, nodular temporal arteries with decreased pulses. His erythrocyte sedimentation rate is 92 mm/h. Which of the following is the most appropriate immediate step in management?
A
) Carotid ultrasonography
B
) Aspirin therapy
C
) Cefotaxime therapy
D
) Corticosteroid therapy
E
) Temporal artery biopsy
42. A 42-year-old man comes for a routine health maintenance examination. There is no family history of coronary artery disease, and he does not smoke. His weight is appropriate for his height. His blood pressure is 120/80 mm Hg. Serum lipid studies show a total cholesterol level of 190 mg/dL, HDL-cholesterol level of 40 mg/dL, and triglyceride level of 150 mg/dL. Which of the following is the most appropriate next step in management?
A
) Recommend the Step 2 National Cholesterol Education Program diet
B
) Measure serum LDL-cholesterol level now
C
) Measure total serum cholesterol level in 5 years
D
) Prescribe prophylactic aspirin
E
) Begin treatment with lovastatin
43. A 28-month-old boy has a history of cyanosis since birth with episodes of syncope. Examination shows cyanosis and clubbing. The lungs are clear to auscultation. There is a right ventricular heave, a systolic click, a single S2, and a grade 3/6 systolic murmur. Which of the following is the most likely diagnosis?
A
) Bicuspid aortic valve
B
) Coarctation of the aorta
C
) Mitral stenosis
D
) Patent ductus arteriosus
E
) Tetralogy of Fallot
44. A healthy 18-year-old woman comes for a routine health maintenance examination. Menses occur at regular 28-day intervals. Her last menstrual period was 2 weeks ago. She is sexually active with one partner, and she and her partner use condoms inconsistently for contraception. Her maternal grandmother was diagnosed with breast cancer at the age of 65 years, her paternal grandfather was diagnosed with colon cancer at the age of 72 years, and her maternal grandfather died of a myocardial infarction at the age of 66 years. Examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient?
A
) Complete blood count
B
) Fasting serum lipid studies
C
) Test of the stool for occult blood
D
) Testing for Neisseria gonorrhoeae and Chlamydia trachomatis
E
) Urinalysis
The response options for the next two items are the same. You will be required to select one answer for each item in the set.
For each child with fever and cough, select the most likely diagnosis.
A
) α1-Antitrypsin deficiency
B
) Cystic fibrosis
C
) Pneumothorax
D
) Pulmonary alveolar proteinosis
E
) Pulmonary aspergillosis
F
) Pulmonary hemorrhage
G
) Pulmonary tuberculosis
45. A 20-month-old girl is brought to the physician because of fever and cough for 2 days. She has had several similar episodes since the age of 4 months. Three months ago, she and her family visited her grandmother in Finland for 2 weeks. She is at the 25th percentile for length and 5th percentile for weight. She appears thin and pale. Her temperature is 38 C (100.4 F), pulse is 150/min, and respirations are 40/min. Examination shows mild clubbing. Wheezing and bilateral crackles are heard at the lung bases. An x-ray film of the chest shows streaky densities bilaterally with mild hyperinflation.
For each child with fever and cough, select the most likely diagnosis.
A
) α1-Antitrypsin deficiency
B
) Cystic fibrosis
C
) Pneumothorax
D
) Pulmonary alveolar proteinosis
E
) Pulmonary aspergillosis
F
) Pulmonary hemorrhage
G
) Pulmonary tuberculosis
46. A previously healthy 16-year-old boy is brought to the physician because of fever and cough with right-sided chest pain for 2 weeks. Six months ago, he visited his grandparents in Albania for 2 weeks. He weighs 54 kg (120 lb) and is 173 cm (68 in) tall. He appears thin and pale. His temperature is 38.2 C (100.8 F), pulse is 76/min, and respirations are 36/min. Examination shows shallow respirations with decreased breath sounds at the right lung base. An x-ray film of the chest shows a right pleural effusion and hilar adenopathy.
__________________________________________________________________________________________________________________________________
A
) Step 2 American Heart Association cardiac diet
B
) Serum lipid studies while fasting
C
) Exercise stress test
D
) Oral cholestyramine and niacin therapy
E
) Oral pravastatin therapy at bedtime
32. A 25-year-old woman comes to the physician because of a 3-month history of the unexplained urge to eat a few tablespoons of cornstarch daily. The amount of cornstarch ingested has increased gradually during this time. She has leiomyomata uteri; she is otherwise healthy. Her weight is unchanged from her last visit 1 year ago; she weighs 61 kg (135 lb) and is 168 cm (66 in) tall. Her blood pressure is 120/80 mm Hg, and pulse is 100/min. Physical examination shows mild pallor. Neurologic examination shows no abnormalities. She is embarrassed about her problem. She has no compulsive behavior or obsessive thoughts. An ECG shows sinus tachycardia. Which of the following is the most appropriate next step in management?
A
) Psychiatric assessment
B
) Complete blood count
C
) Thyroid function studies
D
) Urine toxicology screening
E
) Admission to an eating disorders clinic
F
) Antipsychotic therapy
G
) Folic acid supplementation
H
) Selective serotonin reuptake inhibitor therapy
33. A 30-year-old woman comes to the physician for a follow-up examination 4 months after starting treatment with lithium carbonate; during this period she has had a 3.2-kg (7-lb) weight gain. Her medication was prescribed soon after the birth of her son to treat racing thoughts, increased spending, and overtalkativeness; she has had difficulty sleeping for more than 2 hours nightly. Her symptoms decreased after 2 weeks of lithium carbonate therapy. She continues to take lithium carbonate (300 mg three times daily). Her temperature is 37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 70/min. Examination shows normal findings. The most appropriate next step is measurement of which of the following?
A
) Fasting serum glucose level
B
) Leukocyte count
C
) Serum alkaline phosphatase activity
D
) Serum creatinine level
E
) Serum thyroid-stimulating hormone level
34. On a routine examination, a 2-year-old boy has a hemoglobin level of 10.5 g/dL, hematocrit of 30%, and mean corpuscular volume of 72 μm3. He drinks four to five 8-oz bottles of milk daily. He maintains a regular diet but does not eat vegetables. Which of the following is the most likely diagnosis?
A
) Folic acid deficiency
B
) Iron deficiency
C
) Sickle cell disease
D
) Thalassemia
E
) Vitamin B6 deficiency
35. A 57-year-old man is brought to the physician by his wife because his skin has appeared yellow for 3 weeks. Examination shows jaundice and scleral icterus. His total serum bilirubin level is 8 mg/dL with a direct component of 6.2 mg/dL. A CT scan of the abdomen shows a large lesion in the head of the pancreas. When the results are initially discussed, the patient says that he does not want to hear the report, and his wife agrees to abide by his wishes. Which of the following is the most appropriate course of action?
A
) Withhold the results as the patient wishes
B
) Contact the patient's children to discuss the results
C
) Consult with the hospital ethics committee
D
) Insist on telling the patient the results
E
) Refer him to another physician
36. A previously healthy 52-year-old man comes to the physician because of a 3-month history of increased urinary volume and increased urinary frequency at night. He has had a 6.8-kg (15-lb) weight loss during this period despite no change in appetite. His father has hypertension, and his mother has hypertension and type 2 diabetes mellitus. He currently weighs 95 kg (210 lb) and is 178 cm (70 in) tall. His blood pressure is 160/85 mm Hg in both arms. Examination shows no other abnormalities. His nonfasting serum glucose level is 280 mg/dL. Which of the following serum levels is most likely to be increased in this patient?
A
) Bicarbonate
B
) Glucagon
C
) HDL-cholesterol
D
) Insulin
E
) Ketones
37. Three days after hospitalization for heparin treatment of deep venous thrombosis of a left superficial femoral vein, a 52-year-old woman has prolonged bleeding from a venipuncture site. She had a pulmonary embolus 2 years ago. Her temperature is 37.5 C (99.5 F). Examination shows multiple ecchymoses at the venipuncture sites with oozing of fresh blood. Laboratory studies show:
Hemoglobin
10.5 g/dL
Platelet count
25,000/mm3
Prothrombin time
14 sec (INR=1.3)
Partial thromboplastin time
65 sec
Plasma fibrinogen
300 mg/dL (N=200“400)
Serum creatinine
1.1 mg/dL
Which of the following is the most likely diagnosis?
A
) Adverse drug reaction
B
) Disseminated intravascular coagulation
C
) Excessive blood loss from anticoagulation
D
) Factor VIII deficiency
E
) Factor IX deficiency
F
) Immune thrombocytopenic purpura
G
) Thrombotic thrombocytopenic purpura
38. A 37-year-old woman comes to the physician because of an itchy rash over her trunk for 2 weeks. She has not had fever, chills, shortness of breath, chest pain, or gastrointestinal symptoms. She has a history of recurrent urinary tract infections and has been taking trimethoprim-sulfamethoxazole prophylaxis for the past year. She is in mild distress. Her temperature is 37.5 C (99.5 F), blood pressure is 96/62 mm Hg, pulse is 78/min, and respirations are 14/min. Examination shows a maculopapular erythematous rash over the trunk. Laboratory studies show:
Leukocyte count 10,500/mm3
Segmented neutrophils 72%
Bands 1%
Eosinophils 15%
Lymphocytes 4%
Monocytes 8%
Serum
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.9 mg/dL
Urine
WBC 2/hpf
RBC 2/hpf
Which of the following is the most likely cause of these findings?
A
) Eczema
B
) Medication adverse effect
C
) Staphylococcal skin infection
D
) Streptococcal skin infection
E
) Urinary tract infection
39. A 19-year-old primigravid woman at 34 weeks' gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated. She has no history of serious illness. She takes no medications and has no known allergies. Examination shows a uterus consistent in size with a 34-week gestation. A routine clean-catch urine culture grows greater than 100,000 colonies/mL of Escherichia coli. Which of the following is the most appropriate pharmacotherapy?
A
) Ampicillin
B
) Ciprofloxacin
C
) Clindamycin
D
) Doxycycline
E
) Trimethoprim-sulfamethoxazole
40. A 13-year-old girl is brought for a well-child examination. Menses have occurred every other month since menarche 10 months ago. Her last menstrual period was 1 week ago. She is not sexually active. Sexual development is Tanner stage 3. Examination shows no abnormalities. Which of the following is the most appropriate next step in management?
A
) Discussion of pregnancy prevention
B
) Measurement of serum luteinizing and follicle-stimulating hormone levels
C
) Urine β-hCG test
D
) Pelvic examination
E
) Estrogen therapy
F
) Diagnostic laparoscopy
41. A 72-year-old man comes to the emergency department after a 5-minute episode of blindness in the right eye. Over the past month, he has had headache and pain in the jaw with chewing. His temperature is 38.1 C (100.6 F). Examination shows tender, nodular temporal arteries with decreased pulses. His erythrocyte sedimentation rate is 92 mm/h. Which of the following is the most appropriate immediate step in management?
A
) Carotid ultrasonography
B
) Aspirin therapy
C
) Cefotaxime therapy
D
) Corticosteroid therapy
E
) Temporal artery biopsy
42. A 42-year-old man comes for a routine health maintenance examination. There is no family history of coronary artery disease, and he does not smoke. His weight is appropriate for his height. His blood pressure is 120/80 mm Hg. Serum lipid studies show a total cholesterol level of 190 mg/dL, HDL-cholesterol level of 40 mg/dL, and triglyceride level of 150 mg/dL. Which of the following is the most appropriate next step in management?
A
) Recommend the Step 2 National Cholesterol Education Program diet
B
) Measure serum LDL-cholesterol level now
C
) Measure total serum cholesterol level in 5 years
D
) Prescribe prophylactic aspirin
E
) Begin treatment with lovastatin
43. A 28-month-old boy has a history of cyanosis since birth with episodes of syncope. Examination shows cyanosis and clubbing. The lungs are clear to auscultation. There is a right ventricular heave, a systolic click, a single S2, and a grade 3/6 systolic murmur. Which of the following is the most likely diagnosis?
A
) Bicuspid aortic valve
B
) Coarctation of the aorta
C
) Mitral stenosis
D
) Patent ductus arteriosus
E
) Tetralogy of Fallot
44. A healthy 18-year-old woman comes for a routine health maintenance examination. Menses occur at regular 28-day intervals. Her last menstrual period was 2 weeks ago. She is sexually active with one partner, and she and her partner use condoms inconsistently for contraception. Her maternal grandmother was diagnosed with breast cancer at the age of 65 years, her paternal grandfather was diagnosed with colon cancer at the age of 72 years, and her maternal grandfather died of a myocardial infarction at the age of 66 years. Examination shows no abnormalities. Which of the following is the most appropriate screening test for this patient?
A
) Complete blood count
B
) Fasting serum lipid studies
C
) Test of the stool for occult blood
D
) Testing for Neisseria gonorrhoeae and Chlamydia trachomatis
E
) Urinalysis
The response options for the next two items are the same. You will be required to select one answer for each item in the set.
For each child with fever and cough, select the most likely diagnosis.
A
) α1-Antitrypsin deficiency
B
) Cystic fibrosis
C
) Pneumothorax
D
) Pulmonary alveolar proteinosis
E
) Pulmonary aspergillosis
F
) Pulmonary hemorrhage
G
) Pulmonary tuberculosis
45. A 20-month-old girl is brought to the physician because of fever and cough for 2 days. She has had several similar episodes since the age of 4 months. Three months ago, she and her family visited her grandmother in Finland for 2 weeks. She is at the 25th percentile for length and 5th percentile for weight. She appears thin and pale. Her temperature is 38 C (100.4 F), pulse is 150/min, and respirations are 40/min. Examination shows mild clubbing. Wheezing and bilateral crackles are heard at the lung bases. An x-ray film of the chest shows streaky densities bilaterally with mild hyperinflation.
For each child with fever and cough, select the most likely diagnosis.
A
) α1-Antitrypsin deficiency
B
) Cystic fibrosis
C
) Pneumothorax
D
) Pulmonary alveolar proteinosis
E
) Pulmonary aspergillosis
F
) Pulmonary hemorrhage
G
) Pulmonary tuberculosis
46. A previously healthy 16-year-old boy is brought to the physician because of fever and cough with right-sided chest pain for 2 weeks. Six months ago, he visited his grandparents in Albania for 2 weeks. He weighs 54 kg (120 lb) and is 173 cm (68 in) tall. He appears thin and pale. His temperature is 38.2 C (100.8 F), pulse is 76/min, and respirations are 36/min. Examination shows shallow respirations with decreased breath sounds at the right lung base. An x-ray film of the chest shows a right pleural effusion and hilar adenopathy.
__________________________________________________________________________________________________________________________________