08-17-2008, 08:21 AM
. A 19-year-old college student comes to the student health center because of palpitations, shortness of breath and a runny nose. He has asthma that he has treated with an over-the-counter cold preparation and an epinephrine metered-dose inhaler every 2 to 3 hours at night. He just used the bronchodilator in the waiting room. Vital signs are: temperature 38.2°C (100.8°F), pulse 82/min and respirations 18/min. He appears to be somewhat anxious and his breathing is labored. Auscultation discloses mildly diminished breath sounds in all lung fields accompanied by scattered wheezing. Which of the following is the most appropriate management?
A) Add oral aminophylline therapy
B) Admit him to the hospital for respiratory therapy
C) Prescribe decongestant/antihistamine therapy
D) Prescribe antihistamine therapy
E) Substitute an albuterol nebulizer for the epinephrine
The following vignette applies to the next 2 items.
A 6-month-old African-American girl is brought to the office in January for a well-child visit. She was born at 32 weeks' gestation after a pregnancy complicated by an incompetent cervix and premature labor. She has a 3-year-old brother. Her birth weight was 2700 g (6 lb). At birth, she had mild respiratory distress syndrome and required mechanical ventilation for 36 hours. She also has gastroesophageal reflux disease for which she is given ranitidine, daily. Vaccinations are up-to-date. Developmental milestones are appropriate for her adjusted chronological age. Head circumference and growth charts are shown.
Item 1 of 2
8. Regarding the results on the head circumference chart, which of the following is the most appropriate conclusion?
A) The growth pattern is most likely due to neonatal intraventricular hemorrhage
B) Her growth is normal for a premature infant
C) An MRI should be done to rule out a brain tumor
D) The parents' head circumferences should be measured to evaluate the infant for familial macrocephaly
E) She should be examined for possible papilledema to rule out hydrocephalus
Item 2 of 2
9. Two weeks later the girl is brought back by her mother because of a runny nose and difficulty breathing for the past 3 days. The mother says, "She's up every 2 hours now, and last night she had a fever. I think her brother picked up a cold from preschool and gave it to her. I can't keep him away from her." Vital signs now are temperature 38.5°C (101.3°F), pulse 144/min, and respirations 60/min. On physical examination she is alert but in mild respiratory distress with slight nasal flaring. Auscultation of the chest discloses fine expiratory wheezes bilaterally, and mild intercostal retractions. Which of the following is the most likely cause of the infant's illness?
A
) Aspiration pneumonia
B
) Asthma
C
) Bronchopulmonary dysplasia
D
) Mycoplasma pneumoniae
E
) Respiratory syncytial virus
10. A 72-year-old woman comes to the health center for the first time because of palpitations for the past 3 weeks. She says she has felt tense and has had trouble sleeping. Vital signs are: temperature 37.0°C (98.6°F), pulse 104/min, respirations 18/min and blood pressure 142/80 mm Hg. Physical examination is normal except for a mild bilateral hand tremor. Electrocardiogram shows sinus tachycardia but is otherwise normal. Which of the following diagnostic studies will most likely rule out an organic cause for her symptoms?
A
) 2-Hour postprandial serum glucose concentration
B
) Echocardiography
C
) Holter monitoring
D
) Serum thyroid-stimulating hormone concentration
E
) Toxicologic screening of the urine
11. A 48-year-old man who smokes cigarettes has had progressive claudication in the left calf for the past month. He says the pain lasts about 5 minutes and then subsides. Physical examination shows absent pulses in the left foot and normal pulses in the right foot. Atrophic changes are noted in both legs. Doppler examination shows a 0.40 left ankle/brachial ratio; there is no change with exercise. Which of the following is the most likely diagnosis?
A) Aortic occlusive disease
B) Femoral popliteal occlusive disease
C) Leriche syndrome
D) Peripheral small-vessel occlusive disease
E) Thromboangiitis obliterans
12. A 52-year-old Hispanic computer technician comes to the office because of a 3-week history of substernal chest discomfort when she climbs stairs or eats a heavy meal. She first noticed the discomfort after climbing two flights of stairs. The discomfort is nonradiating and sometimes only involves the left side of the chest. She has hypertension and type 2 diabetes mellitus. Current medications include metformin and an ACE inhibitor. She has recently had increased stress because her company is experiencing financial difficulty. Her husband receives medical disability benefits, and they are dependent on her income. Physical examination shows no abnormalities. Which of the following risk factors is most important to consider when assessing her chest pain?
A) Age
B) Diabetes mellitus
C) Gender
D) Hypertension
E) Stress level
A) Add oral aminophylline therapy
B) Admit him to the hospital for respiratory therapy
C) Prescribe decongestant/antihistamine therapy
D) Prescribe antihistamine therapy
E) Substitute an albuterol nebulizer for the epinephrine
The following vignette applies to the next 2 items.
A 6-month-old African-American girl is brought to the office in January for a well-child visit. She was born at 32 weeks' gestation after a pregnancy complicated by an incompetent cervix and premature labor. She has a 3-year-old brother. Her birth weight was 2700 g (6 lb). At birth, she had mild respiratory distress syndrome and required mechanical ventilation for 36 hours. She also has gastroesophageal reflux disease for which she is given ranitidine, daily. Vaccinations are up-to-date. Developmental milestones are appropriate for her adjusted chronological age. Head circumference and growth charts are shown.
Item 1 of 2
8. Regarding the results on the head circumference chart, which of the following is the most appropriate conclusion?
A) The growth pattern is most likely due to neonatal intraventricular hemorrhage
B) Her growth is normal for a premature infant
C) An MRI should be done to rule out a brain tumor
D) The parents' head circumferences should be measured to evaluate the infant for familial macrocephaly
E) She should be examined for possible papilledema to rule out hydrocephalus
Item 2 of 2
9. Two weeks later the girl is brought back by her mother because of a runny nose and difficulty breathing for the past 3 days. The mother says, "She's up every 2 hours now, and last night she had a fever. I think her brother picked up a cold from preschool and gave it to her. I can't keep him away from her." Vital signs now are temperature 38.5°C (101.3°F), pulse 144/min, and respirations 60/min. On physical examination she is alert but in mild respiratory distress with slight nasal flaring. Auscultation of the chest discloses fine expiratory wheezes bilaterally, and mild intercostal retractions. Which of the following is the most likely cause of the infant's illness?
A
) Aspiration pneumonia
B
) Asthma
C
) Bronchopulmonary dysplasia
D
) Mycoplasma pneumoniae
E
) Respiratory syncytial virus
10. A 72-year-old woman comes to the health center for the first time because of palpitations for the past 3 weeks. She says she has felt tense and has had trouble sleeping. Vital signs are: temperature 37.0°C (98.6°F), pulse 104/min, respirations 18/min and blood pressure 142/80 mm Hg. Physical examination is normal except for a mild bilateral hand tremor. Electrocardiogram shows sinus tachycardia but is otherwise normal. Which of the following diagnostic studies will most likely rule out an organic cause for her symptoms?
A
) 2-Hour postprandial serum glucose concentration
B
) Echocardiography
C
) Holter monitoring
D
) Serum thyroid-stimulating hormone concentration
E
) Toxicologic screening of the urine
11. A 48-year-old man who smokes cigarettes has had progressive claudication in the left calf for the past month. He says the pain lasts about 5 minutes and then subsides. Physical examination shows absent pulses in the left foot and normal pulses in the right foot. Atrophic changes are noted in both legs. Doppler examination shows a 0.40 left ankle/brachial ratio; there is no change with exercise. Which of the following is the most likely diagnosis?
A) Aortic occlusive disease
B) Femoral popliteal occlusive disease
C) Leriche syndrome
D) Peripheral small-vessel occlusive disease
E) Thromboangiitis obliterans
12. A 52-year-old Hispanic computer technician comes to the office because of a 3-week history of substernal chest discomfort when she climbs stairs or eats a heavy meal. She first noticed the discomfort after climbing two flights of stairs. The discomfort is nonradiating and sometimes only involves the left side of the chest. She has hypertension and type 2 diabetes mellitus. Current medications include metformin and an ACE inhibitor. She has recently had increased stress because her company is experiencing financial difficulty. Her husband receives medical disability benefits, and they are dependent on her income. Physical examination shows no abnormalities. Which of the following risk factors is most important to consider when assessing her chest pain?
A) Age
B) Diabetes mellitus
C) Gender
D) Hypertension
E) Stress level