01-05-2007, 02:37 PM
21.) 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
22.) 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
23.) 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
24.) 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
25.) 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
26.) 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 3oz). 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
27.) 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 superviseadministration of medication
D) Monitor the patient's compliance by weekly blood tests
E) Begin a trial of cognitive-behavior therapy
28.) 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
28.) 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
29.) 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
30.) 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 50 U/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
31.) 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 (205lb) 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
32.) 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
33.) An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?
A
) Bicarbonate
B
) Calcium lactate
C
) Methenamine mandelate
D
) Probenecid
E
) Thiazide diuretic
34.
A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become
severe and generalized. Over the past month, she has
had mild upper
abdominal discomfort that is relieved by eating. She
has a history of
recurrent migraines treated with sumatriptan as
needed. Her temperature
is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is
110/min. Abdominal examination shows mild distention;
there is marked
rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal
examination shows no abnormalities; test of the stool
for occult blood is
negative. Laboratory studies show:
Hematocrit 36%
Leukocyte count 16,500/mm3
Serum
Na+ 145 mEq/L
Cl“ 106 mEq/L
K+ 3.8 mEq/L
HCO3“ 19 mEq/L
Urea nitrogen (BUN) 32 mg/dL
Which of the following is the most appropriate next
step in diagnosis?
A
) X-ray films of the abdomen while supine and
standing
B
) Abdominal ultrasonography
C
) Upper gastrointestinal series with contrast
D
) HIDA scan
E
) Fiberoptic endoscopy of the upper
gastrointestinal tract
35. An 18-year-old man comes to the physician
because of itchy
lesions on his penis for 2 weeks and itching around
his wrists and ankles
for 1 week. He is sexually active and does not
consistently use condoms.
Examination shows scattered, crusted lesions on the
penis and no
significant inguinal lymphadenopathy. There are
excoriated papules on the
wrists and ankles, a few papules between the fingers,
and excoriations
along the belt line. Which of the following is the
most likely
diagnosis?
A
) Disseminated primary herpes simplex
B
) Eczema
C
) Scabies
D
) Secondary syphilis
E
) Vasculitis
36. An asymptomatic 62-year-old man comes for a
follow-up visit.
One month ago, he had acute cystitis treated with
ciprofloxacin. At his
initial visit, a urine culture grew Klebsiella
pneumoniae. He has a
2-year history of chronic prostatitis and has had four
episodes of
cystitis over the past year. His temperature is 36.9
C (98.4 F).
Examination, including prostate examination, shows no
abnormalities. Which of
the following is the most appropriate measure to
prevent recurrent
episodes of cystitis in this patient?
A
) Trimethoprim-sulfamethoxazole prophylaxis
B
) Insertion of a Foley catheter
C
) Total prostatectomy
D
) Transurethral prostatectomy
E
) No treatment is available
37. A 32-year-old woman comes for a routine health
maintenance
examination. Examination shows a bloody discharge
from the nipple of her
left breast. There is no palpable mass. On
questioning, she says that
she never noted the discharge and does not perform
breast
self-examinations. Which of the following is the most
likely diagnosis?
A
) Breast abscess
B
) Breast cyst
C
) Breast hematoma
D
) Fibroadenoma
E
) Fibrocystic changes of the breast
F
) Intraductal adenoma
38. A 35-year-old woman is brought to the physician
by her husband
because of increasing memory loss and involuntary
"dancing" movements
over the past 6 weeks. She has had difficulty
remembering things,
particularly recent events. She has had no
disturbances in sleep or appetite.
Her medical history is unremarkable. She does not
remember her mother
who died 25 years ago, but her father told her that
her mother had
similar symptoms several years before her death.
Neurologic examination
shows involuntary choreiform movements. She has a
childlike affect. She
describes her mood as good. On recall testing, she
can remember one out
of three objects after 3 minutes with distraction; she
cannot remember
the other objects with prompting. She cannot remember
the date of her
marriage or her previous address. The most likely
cause of these
symptoms is a lesion at which of the following
locations?
A
) Caudate nucleus
B
) Parietal lobe
C
) Prefrontal lobe
D
) Putamen
E
) Temporal lobe
39. A 67-year-old man comes to the physician
because of insomnia for
2 years. He goes to bed at 11:00 PM after taking a
bath but does not
fall asleep until midnight. He usually wakes up twice
each night: once
around 3:00 AM to void and again at 6:00 AM. He stays
in bed until his
alarm goes off at 7 AM. He is concerned because he
used to sleep 8
hours daily. He recently retired from his job as an
attorney. He takes
no medications. He drinks one beer with lunch 3 days
each week and one
glass of wine with dinner each evening. He walks 1
mile daily after
dinner. Physical examination shows no abnormalities.
His mood is
neutral, and cognition is intact. Urine toxicology
screening is negative.
Which of the following is the most likely cause of
this patient's
symptoms?
A
) Advanced sleep phase syndrome
B
) Alcohol abuse
C
) Delayed sleep phase syndrome
D
) Major depressive disorder
E
) Melatonin deficiency
F
) Poor sleep hygiene
G
) Normal aging
40. An asymptomatic 37-year-old woman comes for a
follow-up
examination 1 year after receiving a renal transplant.
Current medications
include felodipine, enalapril, cyclosporine,
pravastatin, and penicillin
G. She appears well. Her temperature is 36.8 C (98.2
F), blood
pressure is 160/95 mm Hg, pulse is 80/min, and
respirations are 12/min.
Examination shows no other abnormalities. Which of
the following
medications is the most likely cause of this patient's
hypertension?
A
) Cyclosporine
B
) Enalapril
C
) Felodipine
D
) Penicillin G
E
) Pravastatin
41. A 4080-g (9-lb) male newborn is delivered at
term to a
32-year-old woman, gravida 2, para 1. Apgar scores
are 8 and 9 at 1 and 5
minutes, respectively. Examination in the delivery
room shows fracture of
the right clavicle. Which of the following is the
most likely sequela
of this condition?
A
) Correction only with casting
B
) Correction only with physical therapy
C
) Left-hand dominance
D
) Permanent nerve damage
E
) Spontaneous healing without treatment
42. A 22-year-old man with schizoaffective disorder
is brought to
the emergency department 2 hours after the sudden
onset of neck and back
pain. The symptoms began after taking one of his
medications for his
psychiatric disorder. The dosage was increased
yesterday, but he does
not recall the names of either of his medications. He
has no other
history of serious illness. Physical examination
shows rigid contraction
of the neck and back muscles with arching. On mental
status
examination, he is alert and cooperative and hears a
faint voice that tells him to
wash windows. He is oriented to person, place, and
time. Which of the
following medications is most likely responsible for
this patient's
symptoms?
A
) Clozapine
B
) Haloperidol
C
) Lithium carbonate
D
) Trazodone
E
) Valproic acid
43. A 52-year-old woman, gravida 3, para 3, comes
to the physician
because of irregular vaginal bleeding over the past 2
months. She has
hypertension treated with enalapril and type 2
diabetes mellitus well
controlled with diet. Menopause occurred 2 years ago.
Her maternal aunt
had breast cancer at the age of 70 years. The patient
weighs 88 kg
(195 lb) and is 160 cm (63 in) tall. Examination
shows no other
abnormalities. An endometrial biopsy specimen shows
adenocarcinoma. Which of
the following is the most significant predisposing
factor for this
patient's endometrial cancer?
A
) Heredity
B
) Hypertension
C
) Parity
D
) Type 2 diabetes mellitus
E
) Weight
44. A 67-year-old man is brought to the emergency
department 2 hours
after the onset of weakness and double vision. He has
hypertension and
hyperlipidemia treated with metoprolol, captopril, and
atorvastatin.
His blood pressure is 190/106 mm Hg. Neurologic
examination shows
left-sided facial weakness including the forehead.
There is palsy of left
conjugate gaze, and the left eye fails to adduct on
right gaze.
Vertical eye movements are intact. Muscle strength is
3/5 in the right upper
and lower extremities. Deep tendon reflexes are
brisk, and Babinski's
sign is present on the right. Which of the following
is the most
likely location of this patient's lesion?
A
) Bilateral thalamic
B
) Left frontal
C
) Left pontine
D
) Right caudate
E
) Right midbrain
45. Six weeks after spontaneous drainage of an anal
abscess, a
32-year-old man has persistent blood-stained purulent
fluid on his
underwear. He has not had significant anal pain since
drainage of the boil.
Bowel movements are normal. Which of the following is
the most likely
diagnosis?
A
) Anal fissure
B
) Fistula in ano
C
) Pruritus ani
D
) Thrombosed external hemorrhoids
E
) Thrombosed internal hemorrhoids
46. A previously healthy 14-year-old girl is
brought to the
physician because of a 2-day history of fever and pain
and swelling of the
right knee. She remembers injuring the knee while
playing soccer last
week, but she was able to finish the game. She has no
history of rash or
joint pain. Her sister has inflammatory bowel
disease. The patient's
temperature is 39 C (102.2 F), blood pressure is
110/80 mm Hg, pulse is
95/min, and respirations are 20/min. Examination of
the right knee
shows swelling, tenderness, warmth, and erythema;
range of motion is
limited. Which of the following is the most
appropriate next step in
management?
A
) X-ray film of the right knee
B
) Gastrointestinal series with small-bowel
follow-through
C
) Nuclear scan of the right knee
D
) MRI of the right knee
E
) Antibiotic therapy
F
) Arthrocentesis
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
22.) 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
23.) 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
24.) 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
25.) 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
26.) 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 3oz). 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
27.) 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 superviseadministration of medication
D) Monitor the patient's compliance by weekly blood tests
E) Begin a trial of cognitive-behavior therapy
28.) 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
28.) 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
29.) 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
30.) 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 50 U/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
31.) 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 (205lb) 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
32.) 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
33.) An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?
A
) Bicarbonate
B
) Calcium lactate
C
) Methenamine mandelate
D
) Probenecid
E
) Thiazide diuretic
34.
A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become
severe and generalized. Over the past month, she has
had mild upper
abdominal discomfort that is relieved by eating. She
has a history of
recurrent migraines treated with sumatriptan as
needed. Her temperature
is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is
110/min. Abdominal examination shows mild distention;
there is marked
rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal
examination shows no abnormalities; test of the stool
for occult blood is
negative. Laboratory studies show:
Hematocrit 36%
Leukocyte count 16,500/mm3
Serum
Na+ 145 mEq/L
Cl“ 106 mEq/L
K+ 3.8 mEq/L
HCO3“ 19 mEq/L
Urea nitrogen (BUN) 32 mg/dL
Which of the following is the most appropriate next
step in diagnosis?
A
) X-ray films of the abdomen while supine and
standing
B
) Abdominal ultrasonography
C
) Upper gastrointestinal series with contrast
D
) HIDA scan
E
) Fiberoptic endoscopy of the upper
gastrointestinal tract
35. An 18-year-old man comes to the physician
because of itchy
lesions on his penis for 2 weeks and itching around
his wrists and ankles
for 1 week. He is sexually active and does not
consistently use condoms.
Examination shows scattered, crusted lesions on the
penis and no
significant inguinal lymphadenopathy. There are
excoriated papules on the
wrists and ankles, a few papules between the fingers,
and excoriations
along the belt line. Which of the following is the
most likely
diagnosis?
A
) Disseminated primary herpes simplex
B
) Eczema
C
) Scabies
D
) Secondary syphilis
E
) Vasculitis
36. An asymptomatic 62-year-old man comes for a
follow-up visit.
One month ago, he had acute cystitis treated with
ciprofloxacin. At his
initial visit, a urine culture grew Klebsiella
pneumoniae. He has a
2-year history of chronic prostatitis and has had four
episodes of
cystitis over the past year. His temperature is 36.9
C (98.4 F).
Examination, including prostate examination, shows no
abnormalities. Which of
the following is the most appropriate measure to
prevent recurrent
episodes of cystitis in this patient?
A
) Trimethoprim-sulfamethoxazole prophylaxis
B
) Insertion of a Foley catheter
C
) Total prostatectomy
D
) Transurethral prostatectomy
E
) No treatment is available
37. A 32-year-old woman comes for a routine health
maintenance
examination. Examination shows a bloody discharge
from the nipple of her
left breast. There is no palpable mass. On
questioning, she says that
she never noted the discharge and does not perform
breast
self-examinations. Which of the following is the most
likely diagnosis?
A
) Breast abscess
B
) Breast cyst
C
) Breast hematoma
D
) Fibroadenoma
E
) Fibrocystic changes of the breast
F
) Intraductal adenoma
38. A 35-year-old woman is brought to the physician
by her husband
because of increasing memory loss and involuntary
"dancing" movements
over the past 6 weeks. She has had difficulty
remembering things,
particularly recent events. She has had no
disturbances in sleep or appetite.
Her medical history is unremarkable. She does not
remember her mother
who died 25 years ago, but her father told her that
her mother had
similar symptoms several years before her death.
Neurologic examination
shows involuntary choreiform movements. She has a
childlike affect. She
describes her mood as good. On recall testing, she
can remember one out
of three objects after 3 minutes with distraction; she
cannot remember
the other objects with prompting. She cannot remember
the date of her
marriage or her previous address. The most likely
cause of these
symptoms is a lesion at which of the following
locations?
A
) Caudate nucleus
B
) Parietal lobe
C
) Prefrontal lobe
D
) Putamen
E
) Temporal lobe
39. A 67-year-old man comes to the physician
because of insomnia for
2 years. He goes to bed at 11:00 PM after taking a
bath but does not
fall asleep until midnight. He usually wakes up twice
each night: once
around 3:00 AM to void and again at 6:00 AM. He stays
in bed until his
alarm goes off at 7 AM. He is concerned because he
used to sleep 8
hours daily. He recently retired from his job as an
attorney. He takes
no medications. He drinks one beer with lunch 3 days
each week and one
glass of wine with dinner each evening. He walks 1
mile daily after
dinner. Physical examination shows no abnormalities.
His mood is
neutral, and cognition is intact. Urine toxicology
screening is negative.
Which of the following is the most likely cause of
this patient's
symptoms?
A
) Advanced sleep phase syndrome
B
) Alcohol abuse
C
) Delayed sleep phase syndrome
D
) Major depressive disorder
E
) Melatonin deficiency
F
) Poor sleep hygiene
G
) Normal aging
40. An asymptomatic 37-year-old woman comes for a
follow-up
examination 1 year after receiving a renal transplant.
Current medications
include felodipine, enalapril, cyclosporine,
pravastatin, and penicillin
G. She appears well. Her temperature is 36.8 C (98.2
F), blood
pressure is 160/95 mm Hg, pulse is 80/min, and
respirations are 12/min.
Examination shows no other abnormalities. Which of
the following
medications is the most likely cause of this patient's
hypertension?
A
) Cyclosporine
B
) Enalapril
C
) Felodipine
D
) Penicillin G
E
) Pravastatin
41. A 4080-g (9-lb) male newborn is delivered at
term to a
32-year-old woman, gravida 2, para 1. Apgar scores
are 8 and 9 at 1 and 5
minutes, respectively. Examination in the delivery
room shows fracture of
the right clavicle. Which of the following is the
most likely sequela
of this condition?
A
) Correction only with casting
B
) Correction only with physical therapy
C
) Left-hand dominance
D
) Permanent nerve damage
E
) Spontaneous healing without treatment
42. A 22-year-old man with schizoaffective disorder
is brought to
the emergency department 2 hours after the sudden
onset of neck and back
pain. The symptoms began after taking one of his
medications for his
psychiatric disorder. The dosage was increased
yesterday, but he does
not recall the names of either of his medications. He
has no other
history of serious illness. Physical examination
shows rigid contraction
of the neck and back muscles with arching. On mental
status
examination, he is alert and cooperative and hears a
faint voice that tells him to
wash windows. He is oriented to person, place, and
time. Which of the
following medications is most likely responsible for
this patient's
symptoms?
A
) Clozapine
B
) Haloperidol
C
) Lithium carbonate
D
) Trazodone
E
) Valproic acid
43. A 52-year-old woman, gravida 3, para 3, comes
to the physician
because of irregular vaginal bleeding over the past 2
months. She has
hypertension treated with enalapril and type 2
diabetes mellitus well
controlled with diet. Menopause occurred 2 years ago.
Her maternal aunt
had breast cancer at the age of 70 years. The patient
weighs 88 kg
(195 lb) and is 160 cm (63 in) tall. Examination
shows no other
abnormalities. An endometrial biopsy specimen shows
adenocarcinoma. Which of
the following is the most significant predisposing
factor for this
patient's endometrial cancer?
A
) Heredity
B
) Hypertension
C
) Parity
D
) Type 2 diabetes mellitus
E
) Weight
44. A 67-year-old man is brought to the emergency
department 2 hours
after the onset of weakness and double vision. He has
hypertension and
hyperlipidemia treated with metoprolol, captopril, and
atorvastatin.
His blood pressure is 190/106 mm Hg. Neurologic
examination shows
left-sided facial weakness including the forehead.
There is palsy of left
conjugate gaze, and the left eye fails to adduct on
right gaze.
Vertical eye movements are intact. Muscle strength is
3/5 in the right upper
and lower extremities. Deep tendon reflexes are
brisk, and Babinski's
sign is present on the right. Which of the following
is the most
likely location of this patient's lesion?
A
) Bilateral thalamic
B
) Left frontal
C
) Left pontine
D
) Right caudate
E
) Right midbrain
45. Six weeks after spontaneous drainage of an anal
abscess, a
32-year-old man has persistent blood-stained purulent
fluid on his
underwear. He has not had significant anal pain since
drainage of the boil.
Bowel movements are normal. Which of the following is
the most likely
diagnosis?
A
) Anal fissure
B
) Fistula in ano
C
) Pruritus ani
D
) Thrombosed external hemorrhoids
E
) Thrombosed internal hemorrhoids
46. A previously healthy 14-year-old girl is
brought to the
physician because of a 2-day history of fever and pain
and swelling of the
right knee. She remembers injuring the knee while
playing soccer last
week, but she was able to finish the game. She has no
history of rash or
joint pain. Her sister has inflammatory bowel
disease. The patient's
temperature is 39 C (102.2 F), blood pressure is
110/80 mm Hg, pulse is
95/min, and respirations are 20/min. Examination of
the right knee
shows swelling, tenderness, warmth, and erythema;
range of motion is
limited. Which of the following is the most
appropriate next step in
management?
A
) X-ray film of the right knee
B
) Gastrointestinal series with small-bowel
follow-through
C
) Nuclear scan of the right knee
D
) MRI of the right knee
E
) Antibiotic therapy
F
) Arthrocentesis