10-01-2007, 01:50 PM
67-year-old man comes to the physician because of a
2-month history
of progressive shortness of breath. He has had a
4.5-kg (10-lb) weight
loss over the past 4 months. He has not had chest
pain. He has
congestive heart failure treated with furosemide,
digoxin, and enalapril. He
has smoked two packs of cigarettes daily for 30 years.
He appears
alert and is in no acute distress. His temperature is
37.2 C (99 F), blood
pressure is 140/85 mm Hg, pulse is 84/min, and
respirations are 18/min.
Examination shows no jugular venous distention. There
is dullness to
percussion, and breath sounds are decreased at the
left base. Cardiac
examination shows a laterally displaced point of
maximal impulse, normal
S1 and S2, and an S3 at the apex. There is 1+ edema
over the
extremities. An x-ray film of the chest shows an
enlarged cardiac silhouette,
left hilar fullness, and a moderate-sized left pleural
effusion.
Thoracentesis yields straw-colored fluid. Laboratory
studies show:
Serum
Glucose 90 mg/dL
Protein 7 g/dL
Lactate dehydrogenase 300 U/L
Pleural fluid
pH 7.25
Glucose 75 mg/dL
Protein 4.5 g/dL
Lactate dehydrogenase 280 U/L
Leukocyte count 2000/mm3
Segmented neutrophils 15%
Lymphocytes 85%
A Gram's stain and acid-fast stains are negative for
any organisms.
Which of the following is the most likely cause of
this patient's pleural
effusion?
A
) Bacterial pneumonia
B
) Collagen vascular disease
C
) Congestive heart failure
D
) Malignancy
E
) Pulmonary embolus with infarction
F
) Viral pleuritis
A 66-year-old man has had numbness and tingling
in the hands and
feet for 2 weeks. He lives in a homeless shelter and
is well fed. He
has been treated for pulmonary tuberculosis for 4
months with
isoniazid, rifampin, ethambutol, and pyrazinamide. He
is compliant with his
medication regimen but continues to abuse alcohol.
His temperature is 37
C (98.6 F), blood pressure is 136/76 mm Hg, pulse is
72/min, and
respirations are 20/min. He is well nourished but
depressed and irritable.
There is decreased sensation to pain and touch in the
hands and feet in
a stocking-glove distribution. Which of the following
is the most
likely nutritional deficiency?
A
) Folic acid
B
) Niacin
C
) Vitamin A
D
) Vitamin B1 (thiamine)
E
) Vitamin B2 (riboflavin)
F
) Vitamin B6
G
) Vitamin B12 (cyanocobalamin)
H
) Vitamin C
I
) Vitamin D
J
A previously healthy 47-year-old nulliparous
woman is brought to
the emergency department by ambulance because of acute
low back pain
radiating to the right posterior leg for 2 hours. The
pain began when
she bent over at work to retrieve a file from the
lowest drawer of a
filing cabinet. She does not smoke cigarettes or
drink alcohol.
Examination shows right paraspinous muscle spasm and
pain in the lower back with
right straight-leg raising at 30 degrees. She says
that she plans to
file a claim for a work-related injury. Which of the
following findings
is the strongest risk factor for a prolonged episode
of pain in this
patient?
A
) Arrival for care in an ambulance
B
) Claim that pain is work-related
C
) Gender
D
) Nulliparity
E
) Positive straight-leg raising test
F
) Radiation of the pain into the posterior lower
extremity
A previously healthy 72-year-old man comes to
the physician
because of a 2-year history of hand tremors and
progressive difficulty
walking. He lives alone and has no close relatives.
He is alert and
oriented. Physical examination shows a decreased rate
of eye blinking.
Neurologic examination shows masked facies and a
pill-rolling resting
tremor of both hands. There is cogwheel rigidity of
the upper extremities
and generalized bradykinesia. His handwriting has
become small and
illegible. He has a slow, shuffling, festinating gait
with a tendency to
lean forward. Postural reflexes are impaired. This
patient is at
greatest risk for injury due to which of the
following?
A
) Bradykinesia
B
) Cogwheel rigidity
C
) Decreased rate of eye blinking
D
) Postural reflex impairment
E
) Tremor
2-month history
of progressive shortness of breath. He has had a
4.5-kg (10-lb) weight
loss over the past 4 months. He has not had chest
pain. He has
congestive heart failure treated with furosemide,
digoxin, and enalapril. He
has smoked two packs of cigarettes daily for 30 years.
He appears
alert and is in no acute distress. His temperature is
37.2 C (99 F), blood
pressure is 140/85 mm Hg, pulse is 84/min, and
respirations are 18/min.
Examination shows no jugular venous distention. There
is dullness to
percussion, and breath sounds are decreased at the
left base. Cardiac
examination shows a laterally displaced point of
maximal impulse, normal
S1 and S2, and an S3 at the apex. There is 1+ edema
over the
extremities. An x-ray film of the chest shows an
enlarged cardiac silhouette,
left hilar fullness, and a moderate-sized left pleural
effusion.
Thoracentesis yields straw-colored fluid. Laboratory
studies show:
Serum
Glucose 90 mg/dL
Protein 7 g/dL
Lactate dehydrogenase 300 U/L
Pleural fluid
pH 7.25
Glucose 75 mg/dL
Protein 4.5 g/dL
Lactate dehydrogenase 280 U/L
Leukocyte count 2000/mm3
Segmented neutrophils 15%
Lymphocytes 85%
A Gram's stain and acid-fast stains are negative for
any organisms.
Which of the following is the most likely cause of
this patient's pleural
effusion?
A
) Bacterial pneumonia
B
) Collagen vascular disease
C
) Congestive heart failure
D
) Malignancy
E
) Pulmonary embolus with infarction
F
) Viral pleuritis
A 66-year-old man has had numbness and tingling
in the hands and
feet for 2 weeks. He lives in a homeless shelter and
is well fed. He
has been treated for pulmonary tuberculosis for 4
months with
isoniazid, rifampin, ethambutol, and pyrazinamide. He
is compliant with his
medication regimen but continues to abuse alcohol.
His temperature is 37
C (98.6 F), blood pressure is 136/76 mm Hg, pulse is
72/min, and
respirations are 20/min. He is well nourished but
depressed and irritable.
There is decreased sensation to pain and touch in the
hands and feet in
a stocking-glove distribution. Which of the following
is the most
likely nutritional deficiency?
A
) Folic acid
B
) Niacin
C
) Vitamin A
D
) Vitamin B1 (thiamine)
E
) Vitamin B2 (riboflavin)
F
) Vitamin B6
G
) Vitamin B12 (cyanocobalamin)
H
) Vitamin C
I
) Vitamin D
J
A previously healthy 47-year-old nulliparous
woman is brought to
the emergency department by ambulance because of acute
low back pain
radiating to the right posterior leg for 2 hours. The
pain began when
she bent over at work to retrieve a file from the
lowest drawer of a
filing cabinet. She does not smoke cigarettes or
drink alcohol.
Examination shows right paraspinous muscle spasm and
pain in the lower back with
right straight-leg raising at 30 degrees. She says
that she plans to
file a claim for a work-related injury. Which of the
following findings
is the strongest risk factor for a prolonged episode
of pain in this
patient?
A
) Arrival for care in an ambulance
B
) Claim that pain is work-related
C
) Gender
D
) Nulliparity
E
) Positive straight-leg raising test
F
) Radiation of the pain into the posterior lower
extremity
A previously healthy 72-year-old man comes to
the physician
because of a 2-year history of hand tremors and
progressive difficulty
walking. He lives alone and has no close relatives.
He is alert and
oriented. Physical examination shows a decreased rate
of eye blinking.
Neurologic examination shows masked facies and a
pill-rolling resting
tremor of both hands. There is cogwheel rigidity of
the upper extremities
and generalized bradykinesia. His handwriting has
become small and
illegible. He has a slow, shuffling, festinating gait
with a tendency to
lean forward. Postural reflexes are impaired. This
patient is at
greatest risk for injury due to which of the
following?
A
) Bradykinesia
B
) Cogwheel rigidity
C
) Decreased rate of eye blinking
D
) Postural reflex impairment
E
) Tremor