08-20-2009, 08:36 PM
11. A 62-year-old man comes to the emergency department
because of
progressive shortness of breath for 3 days. He has
not had chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. He
completed chemotherapy for
small cell carcinoma of the lung 10 months ago. He
has a history of twice
nightly nocturia that has resolved over the past 3
days. He smoked two
packs of cigarettes daily for 30 years but quit 1 year
ago. His blood
pressure is 96/60 mm Hg, and pulse is 116/min. There
is jugular venous
distention to the angle of the jaw. The lungs are
clear to
auscultation. Cardiac examination shows distant heart
sounds, an S1 and S2, and no
gallops or rubs. The liver has a span of 12 cm and is
tender. There
is no pedal edema. Laboratory studies show:
Hemoglobin 10 g/dL
Serum
Na+ 135 mEq/L
Cl“ 110 mEq/L
K+ 4.2 mEq/L
HCO3“ 22 mEq/L
Urea nitrogen (BUN) 40 mg/dL
Creatinine 1.6 mg/dL
An ECG shows diminished amplitude of the QRS
complexes. An x-ray film
of the chest shows clear lung fields with an enlarged
cardiac
silhouette. Which of the following findings is most
likely to be accentuated?
A
) Cardiac output
B
) Fall in systolic arterial pressure with
inspiration
C
) Left ventricular end-diastolic pressure
D
) Mitral regurgitation
E
) Ventricular septal wall motion
12. A 35-year-old woman comes to the physician
because of two
12-hour episodes of dizziness over the past 3 months.
During episodes, she
experiences the acute onset of rotatory vertigo and
imbalance, decreased
hearing, tinnitus, a sense of fullness of the right
ear, and vomiting.
Examination shows a mild hearing loss of the right
ear. Which of the
following is the most likely diagnosis?
A
) Acoustic neuroma
B
) Benign positional vertigo
C
) Brain stem transient ischemic attacks
D
) Meniere's disease
E
) Viral labyrinthitis
3. An obese 33-year-old woman has had four 12-hour
episodes of
severe, sharp, penetrating pain in the right upper
quadrant of the abdomen
associated with vomiting but no fever. She has no
diarrhea, dysuria, or
jaundice and is asymptomatic between episodes. There
is slight
tenderness to deep palpation in the right upper
quadrant. Which of the
following is the most appropriate next step in
diagnosis?
A
) Supine and erect x-ray films of the abdomen
B
) Upper gastrointestinal series
C
) Ultrasonography of the upper abdomen
D
) CT scan of the abdomen
E
) HIDA scan of the biliary tract
14. An otherwise healthy 19-year-old woman comes to
the physician
because of a 3-year history of intermittent facial
blemishes. She drinks
wine occasionally on weekends. She takes no
medications. Examination
shows multiple 1- to 2-mm red and white papules and
larger red nodules
on the forehead and cheeks. Which of the following is
the most
appropriate initial pharmacotherapy?
A
) Oral isotretinoin
B
) Systemic corticosteroids
C
) Topical benzoyl peroxide
D
) Topical corticosteroids
E
) Topical metronidazole
15. A previously healthy 67-year-old man comes to
the physician
because of a 4-month history of hand weakness,
intermittent tingling of the
small fingers of his hands, and mild neck pain.
Examination shows
wasting, weakness, and fasciculations of the
interossei muscles. Sensation
is decreased to pinprick and vibration in the small
fingers of each
hand. Triceps tendon reflexes are decreased. Which
of the following is
the most likely diagnosis?
A
) Amyotrophic lateral sclerosis
B
) Cervical spondylosis
C
) Multiple sclerosis
D
) Myasthenia gravis
E
) Myasthenic (Lambert-Eaton) syndrome
F
) Myotonic muscular dystrophy
G
) Polymyalgia rheumatica
H
) Polymyositis
I
) Progressive neuropathic (peroneal) muscular
atrophY
because of
progressive shortness of breath for 3 days. He has
not had chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. He
completed chemotherapy for
small cell carcinoma of the lung 10 months ago. He
has a history of twice
nightly nocturia that has resolved over the past 3
days. He smoked two
packs of cigarettes daily for 30 years but quit 1 year
ago. His blood
pressure is 96/60 mm Hg, and pulse is 116/min. There
is jugular venous
distention to the angle of the jaw. The lungs are
clear to
auscultation. Cardiac examination shows distant heart
sounds, an S1 and S2, and no
gallops or rubs. The liver has a span of 12 cm and is
tender. There
is no pedal edema. Laboratory studies show:
Hemoglobin 10 g/dL
Serum
Na+ 135 mEq/L
Cl“ 110 mEq/L
K+ 4.2 mEq/L
HCO3“ 22 mEq/L
Urea nitrogen (BUN) 40 mg/dL
Creatinine 1.6 mg/dL
An ECG shows diminished amplitude of the QRS
complexes. An x-ray film
of the chest shows clear lung fields with an enlarged
cardiac
silhouette. Which of the following findings is most
likely to be accentuated?
A
) Cardiac output
B
) Fall in systolic arterial pressure with
inspiration
C
) Left ventricular end-diastolic pressure
D
) Mitral regurgitation
E
) Ventricular septal wall motion
12. A 35-year-old woman comes to the physician
because of two
12-hour episodes of dizziness over the past 3 months.
During episodes, she
experiences the acute onset of rotatory vertigo and
imbalance, decreased
hearing, tinnitus, a sense of fullness of the right
ear, and vomiting.
Examination shows a mild hearing loss of the right
ear. Which of the
following is the most likely diagnosis?
A
) Acoustic neuroma
B
) Benign positional vertigo
C
) Brain stem transient ischemic attacks
D
) Meniere's disease
E
) Viral labyrinthitis
3. An obese 33-year-old woman has had four 12-hour
episodes of
severe, sharp, penetrating pain in the right upper
quadrant of the abdomen
associated with vomiting but no fever. She has no
diarrhea, dysuria, or
jaundice and is asymptomatic between episodes. There
is slight
tenderness to deep palpation in the right upper
quadrant. Which of the
following is the most appropriate next step in
diagnosis?
A
) Supine and erect x-ray films of the abdomen
B
) Upper gastrointestinal series
C
) Ultrasonography of the upper abdomen
D
) CT scan of the abdomen
E
) HIDA scan of the biliary tract
14. An otherwise healthy 19-year-old woman comes to
the physician
because of a 3-year history of intermittent facial
blemishes. She drinks
wine occasionally on weekends. She takes no
medications. Examination
shows multiple 1- to 2-mm red and white papules and
larger red nodules
on the forehead and cheeks. Which of the following is
the most
appropriate initial pharmacotherapy?
A
) Oral isotretinoin
B
) Systemic corticosteroids
C
) Topical benzoyl peroxide
D
) Topical corticosteroids
E
) Topical metronidazole
15. A previously healthy 67-year-old man comes to
the physician
because of a 4-month history of hand weakness,
intermittent tingling of the
small fingers of his hands, and mild neck pain.
Examination shows
wasting, weakness, and fasciculations of the
interossei muscles. Sensation
is decreased to pinprick and vibration in the small
fingers of each
hand. Triceps tendon reflexes are decreased. Which
of the following is
the most likely diagnosis?
A
) Amyotrophic lateral sclerosis
B
) Cervical spondylosis
C
) Multiple sclerosis
D
) Myasthenia gravis
E
) Myasthenic (Lambert-Eaton) syndrome
F
) Myotonic muscular dystrophy
G
) Polymyalgia rheumatica
H
) Polymyositis
I
) Progressive neuropathic (peroneal) muscular
atrophY