01-04-2007, 01:16 PM
31. An 18-year-old man comes to the physician 1 week after he had a blood pressure of 140/110 mm Hg during a routine precollege examination. His temperature is 37.1 C (98.7 F), blood pressure is 140/100 mm Hg, pulse is 92/min, and respirations are 12/min. The upper extremities appear to be more muscular than the lower extremities. Radial pulses are normal; femoral, posterior tibial, and dorsalis pedis pulses are decreased. A grade 2/6 systolic murmur is heard over the precordium, anterior chest, and back. An ECG shows left ventricular hypertrophy. Which of the following is the most appropriate next step in management?
A ) Limiting physical activity
B ) Repeat blood pressure measurement in 1 month
C ) Initiate a low-sodium diet and exercise program
D ) Pharmacologic management
E ) Operative treatment
32. A 77-year-old woman comes to the physician because of a 2-day history of cramping abdominal pain and distention accompanied by nausea and vomiting. She is otherwise healthy and has no history of abdominal operations. Her temperature is 37.4 C (99.4 F), blood pressure is 110/86 mm Hg, pulse is 112/min, and respirations are 24/min. Cardiopulmonary examination shows no abnormalities. Examination of the abdomen shows distention and mild diffuse tenderness; bowel sounds are high-pitched. An x-ray film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver; there is no gas in the colon or free air. Which of the following is the most likely diagnosis?
A
) Adhesive small-bowel obstruction
B
) Cecal cancer
C
) Gallstone ileus
D
) Intussusception
E
) Mesenteric infarction
F
) Ruptured appendicitis
G
) Small bowel lymphoma
33. Four hours after undergoing a cesarean delivery at term followed by tubal ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-controlled epidural analgesia has been moderately effective for pain. Her blood pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are decreased bilaterally. No murmurs are heard. Abdominal examination shows distention and tenderness. Bowel sounds are absent. The incision is intact with no drainage. She is disoriented to person, place, and time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of the following is the most likely cause of the hemodynamic changes?
A
) Epidural-related hypotension
B
) Insufficient intraoperative fluid replacement
C
) Postoperative intra-abdominal hemorrhage
D
) Supine hypotensive syndrome
E
) Underestimated intraoperative blood loss
34. A 42-year-old woman comes to the physician for evaluation of persistently increased blood pressures. At her last two office visits during the past 3 months, her blood pressure has ranged between 150“170/105“115 mm Hg. During this period, she has had occasional headaches. In addition, she has had an increased urine output over the past 6 weeks that she attributes to a diet high in sodium. She is otherwise healthy and takes no medications. Her blood pressure today is 168/115 mm Hg, pulse is 68/min, and respirations are 14/min. Funduscopic examination shows mild arteriovenous nicking. The point of maximal impulse is not displaced. There is no edema, abdominal bruits, or masses. Serum studies show:
Na+
144 mEq/L
Cl“
90 mEq/L
K+
2.9 mEq/L
HCO3“
32 mEq/L
Urea nitrogen (BUN)
20 mg/dL
Creatinine
1.2 mg/dL
Which of the following is the most likely underlying cause of this patient's hypertension?
A
) Autonomous production of aldosterone
B
) Catecholamine-producing tumor
C
) Decreased arterial distensibility caused by atherosclerosis
D
) Excess production of atrial natriuretic peptide
E
) Juxtaglomerular cell hypertrophy and sclerosis
35. A previously healthy 4-year-old girl is brought to the physician because of fever and refusal to walk for 1 day. She appears mildly ill. Her temperature is 38.6 C (101.5 F), pulse is 120/min, and respirations are 22/min. The right knee is erythematous and swollen. She holds her right knee in flexion and resists any attempted movement of her right leg. She cries when the right knee is moved. Which of the following is the most appropriate next step in management?
A
) Acetaminophen with codeine therapy
B
) Arthrocentesis
C
) Bone marrow aspiration
D
) Bone scan
E
) Immobilization and traction
F
) Lyme titer
G
) MRI of the spine
H
) Physical therapy
I
) Reassurance
J
) Serum rheumatoid factor assay
K
) Systemic antibiotic therapy
36. An 18-year-old man comes for an examination prior to participation in school sports. He states that he has had a dull ache in the scrotum since being hit in that area during a basketball game 2 months ago. Examination shows a 2-cm, hard, nontender mass in the right testicle. The mass does not transilluminate or change in size when the patient is placed in the supine position. Which of the following is the most likely cause?
A
) Cystic dilations of the efferent ductules
B
) Dilated pampiniform venous plexus
C
) Fluid accumulation within the tunica vaginalis testis
D
) Germinal cell tumor
E
) Vascular trauma
37. A 14-year-old boy is brought to the physician by his parents because of a 2-year history of increasing academic problems. His parents say that he has always been hyperactive and distractible, but now his academic performance has deteriorated to the point that he is failing ninth grade. His teachers say that his hyperactivity is disrupting the classroom. He weighs 54 kg (120 lb) and is 152 cm (60 in) tall. Sexual development is Tanner stage 5; examination shows macro-orchidism, which was not shown on previous examinations. He has a high forehead and long, protruding ears. He exhibits poor eye contact during the examination. Psychoeducational testing shows an IQ of 70. Which of the following is the most likely diagnosis?
A
) Attention-deficit/hyperactivity disorder
B
) Autistic disorder
C
) Down syndrome
D
) Fetal alcohol syndrome
E
) Fragile X syndrome
F
) Lesch-Nyhan syndrome
G
) Pervasive developmental disorder, not otherwise specified
H
) Prader-Willi syndrome
I
) Rett's disorder
J
) Seminiferous tubule dysgenesis (Klinefelter's syndrome)
38. A 32-year-old woman comes to the physician because of vaginal discharge for 2 weeks. She has been sexually active with one female partner for 5 years. She has not been treated with antibiotics over the past 2 years. Her last Pap smear was 6 years ago when she was sexually active with a male partner. She has not used illicit drugs or alcohol. Examination shows a grayish vaginal discharge with a pH greater than 4.5. A wet mount preparation of the vaginal discharge is most likely to show which of the following?
A
) Budding yeast
B
) Clue cells
C
) Ferning
D
) Leukocytes in sheets
E
) Trichomonas vaginalis
39. A 57-year-old woman with breast cancer comes to the physician because of increasing neck pain over the past 3 days. She has fallen frequently because of muscle weakness. Vital signs are within normal limits. Examination shows hyperreflexia of all extremities. There is tenderness over the cervical spine. Serum calcium level is 11 mg/dL. X-ray films show metastases to the cervical spine. Which of the following is the most appropriate next step in management?
A
) Application of a soft cervical collar
B
) Physical therapy
C
) Mithramycin therapy
D
) Tamoxifen therapy
E
) Spinal cord decompression and cervical stabilization
40. A 57-year-old man comes to the physician because of intermittent urinary incontinence over the past 6 months. He has loss of small amounts of urine when he coughs or sneezes. He has not had pain or blood with urination. He has a 15-year history of type 2 diabetes mellitus with peripheral neuropathy, retinopathy, and gastroparesis. Current medications include metoclopramide and glyburide. He appears well. Rectal examination shows a normal-sized prostate. Neurologic examination shows decreased sensation in a stocking-glove distribution. Achilles tendon reflexes are absent bilaterally. Test of the stool for occult blood is negative. Urinalysis shows 2+ protein with no leukocytes or erythrocytes. His postvoid residual volume is 500 mL. Which of the following is the most likely mechanism of this patient's incontinence?
A
) Central nervous system disorder
B
) Functional incontinence
C
) Intrinsic sphincter deficiency
D
) Overflow incontinence from acontractile bladder
E
) Overflow incontinence from bladder outlet obstruction
F
) Pelvic floor muscle weakness
G
) Retroperitoneal fibrosis
H
) Retroperitoneal lymphadenopathy
I
) Urinary tract infection
41. A 27-year-old primigravid woman at 38 weeks' gestation is admitted in labor. Her pregnancy has been uncomplicated, and a routine prenatal visit 2 days ago showed no abnormalities. On admission, fetal heart tones cannot be heard. Ultrasonography shows little amniotic fluid, fetal edema, and no evidence of a fetal heartbeat. After 1 hour, she delivers a 3175-g (7-lb) stillborn infant; examination of the infant shows no obvious abnormalities except for mild edema. The placenta and membranes appear normal. Which of the following is the most appropriate immediate course of action?
A
) Notify the hospital liability department
B
) Obtain consent for fetal organ donation from the parents
C
) Recommend autopsy of the infant
D
) Tell the mother not to worry since she can get pregnant again
E
) Tell the parents that there is a 1 in 4 chance of recurrence in future pregnancies
42. A previously healthy 16-year-old high school wrestler comes to the physician because of a rash on his forearms and the back of his legs for 1 week. He is allergic to pollen and dust. Examination shows patches of erythema with mild lichenification over the antecubital and popliteal fossae. There are clusters of painful umbilicated vesicles at sites of active skin inflammation. Which of the following is the most likely diagnosis?
A
) Eczema herpeticum
B
) Herpes zoster
C
) Keratosis pilaris
D
) Lichen planus
E
) Pityriasis rosea
43. A 5-week-old boy is brought to the physician because of vomiting for 3 days. Switching from a cow's milk-based formula to a soy-based formula and one bottle of an electrolyte solution has not decreased his vomiting. His mother says that there is no yellow color to the vomitus, but it is forceful and occurs immediately after he has had 1 to 2 ounces of liquid. He appears to vomit more liquid than he drank. He has one mustard-colored seedy stool daily. Examination shows no abnormalities. Which of the following is the most likely explanation for his vomiting?
A
) Duodenal atresia
B
) Gastroesophageal reflux
C
) Hypertrophic pyloric stenosis
D
) Lactose intolerance
E
) Protein malabsorption
F
) Rotavirus infection
44. A 28-year-old woman is hospitalized after taking a massive overdose of acetaminophen tablets in a suicide attempt. She has type 1 diabetes mellitus and major depressive disorder refractory to tricyclic antidepressant therapy. Despite appropriate therapy, she develops rapidly progressive hepatic failure and becomes progressively encephalopathic. On the 6th day of hospitalization, she is comatose. A CT scan of the brain shows mild diffuse swelling. An appropriately crossmatched, size-appropriate donor liver is available. Which of the following is the most appropriate course of action regarding transplantation?
A
) Do not proceed with the transplantation because diabetes mellitus is a contraindication
B
) Do not proceed with the transplantation because hepatic function is likely to return over the next week
C
) Do not proceed with the transplantation because major depressive disorder places the patient at risk for another suicide attempt
D
) Do not proceed with the transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis
E
) Proceed with the transplantation
45. A 3-year-old boy who is HIV positive is brought for a routine examination. His diet is appropriate for age. His medications include three antiretroviral drugs and trimethoprim-sulfamethoxazole for Pneumocystis carinii prophylaxis. Laboratory studies show:
Hemoglobin 8.6 g/dL
Mean corpuscular hemoglobin 38 pg/cell
Mean corpuscular hemoglobin concentration 30% Hb/cell
Mean corpuscular volume 101 μm3
Leukocyte count 5600/mm3
Segmented neutrophils 60% (many hypersegmented)
Bands 3%
Lymphocytes 37%
Red cell distribution width 21% (N=10“16)
Which of the following is most likely to have prevented this patient's anemia?
A
) Folic acid supplementation
B
) Iron supplementation
C
) Thyroid supplementation
D
) Vitamin B12 (cyanocobalamin) supplementation
E
) Monthly intravenous immune globulin therapy
46. A 20-year-old man is brought to the emergency department on a summer day 20 minutes after developing headache, nausea, and unsteady gait while running the last 2 miles of a marathon. On arrival, he is confused and disoriented. His temperature is 40 C (104 F), blood pressure is 100/60 mm Hg, and pulse is 155/min. His skin is warm and dry. Neurologic examination shows no focal findings. Which of the following is the most likely mechanism of this patient's condition?
A
) Depletion of total body potassium
B
) Depletion of total body sodium
C
) High-output cardiac failure
D
) Inadequate dissipation of body heat
E
) Release of creatine kinase from muscle cells
A ) Limiting physical activity
B ) Repeat blood pressure measurement in 1 month
C ) Initiate a low-sodium diet and exercise program
D ) Pharmacologic management
E ) Operative treatment
32. A 77-year-old woman comes to the physician because of a 2-day history of cramping abdominal pain and distention accompanied by nausea and vomiting. She is otherwise healthy and has no history of abdominal operations. Her temperature is 37.4 C (99.4 F), blood pressure is 110/86 mm Hg, pulse is 112/min, and respirations are 24/min. Cardiopulmonary examination shows no abnormalities. Examination of the abdomen shows distention and mild diffuse tenderness; bowel sounds are high-pitched. An x-ray film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver; there is no gas in the colon or free air. Which of the following is the most likely diagnosis?
A
) Adhesive small-bowel obstruction
B
) Cecal cancer
C
) Gallstone ileus
D
) Intussusception
E
) Mesenteric infarction
F
) Ruptured appendicitis
G
) Small bowel lymphoma
33. Four hours after undergoing a cesarean delivery at term followed by tubal ligation, a 37-year-old woman, gravida 2, para 2, has dizziness and confusion. The operation was uncomplicated, and blood loss is estimated to be 800 mL. Patient-controlled epidural analgesia has been moderately effective for pain. Her blood pressure now is 80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse is 152/min, increased from 96/min intraoperatively. Breath sounds are decreased bilaterally. No murmurs are heard. Abdominal examination shows distention and tenderness. Bowel sounds are absent. The incision is intact with no drainage. She is disoriented to person, place, and time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of the following is the most likely cause of the hemodynamic changes?
A
) Epidural-related hypotension
B
) Insufficient intraoperative fluid replacement
C
) Postoperative intra-abdominal hemorrhage
D
) Supine hypotensive syndrome
E
) Underestimated intraoperative blood loss
34. A 42-year-old woman comes to the physician for evaluation of persistently increased blood pressures. At her last two office visits during the past 3 months, her blood pressure has ranged between 150“170/105“115 mm Hg. During this period, she has had occasional headaches. In addition, she has had an increased urine output over the past 6 weeks that she attributes to a diet high in sodium. She is otherwise healthy and takes no medications. Her blood pressure today is 168/115 mm Hg, pulse is 68/min, and respirations are 14/min. Funduscopic examination shows mild arteriovenous nicking. The point of maximal impulse is not displaced. There is no edema, abdominal bruits, or masses. Serum studies show:
Na+
144 mEq/L
Cl“
90 mEq/L
K+
2.9 mEq/L
HCO3“
32 mEq/L
Urea nitrogen (BUN)
20 mg/dL
Creatinine
1.2 mg/dL
Which of the following is the most likely underlying cause of this patient's hypertension?
A
) Autonomous production of aldosterone
B
) Catecholamine-producing tumor
C
) Decreased arterial distensibility caused by atherosclerosis
D
) Excess production of atrial natriuretic peptide
E
) Juxtaglomerular cell hypertrophy and sclerosis
35. A previously healthy 4-year-old girl is brought to the physician because of fever and refusal to walk for 1 day. She appears mildly ill. Her temperature is 38.6 C (101.5 F), pulse is 120/min, and respirations are 22/min. The right knee is erythematous and swollen. She holds her right knee in flexion and resists any attempted movement of her right leg. She cries when the right knee is moved. Which of the following is the most appropriate next step in management?
A
) Acetaminophen with codeine therapy
B
) Arthrocentesis
C
) Bone marrow aspiration
D
) Bone scan
E
) Immobilization and traction
F
) Lyme titer
G
) MRI of the spine
H
) Physical therapy
I
) Reassurance
J
) Serum rheumatoid factor assay
K
) Systemic antibiotic therapy
36. An 18-year-old man comes for an examination prior to participation in school sports. He states that he has had a dull ache in the scrotum since being hit in that area during a basketball game 2 months ago. Examination shows a 2-cm, hard, nontender mass in the right testicle. The mass does not transilluminate or change in size when the patient is placed in the supine position. Which of the following is the most likely cause?
A
) Cystic dilations of the efferent ductules
B
) Dilated pampiniform venous plexus
C
) Fluid accumulation within the tunica vaginalis testis
D
) Germinal cell tumor
E
) Vascular trauma
37. A 14-year-old boy is brought to the physician by his parents because of a 2-year history of increasing academic problems. His parents say that he has always been hyperactive and distractible, but now his academic performance has deteriorated to the point that he is failing ninth grade. His teachers say that his hyperactivity is disrupting the classroom. He weighs 54 kg (120 lb) and is 152 cm (60 in) tall. Sexual development is Tanner stage 5; examination shows macro-orchidism, which was not shown on previous examinations. He has a high forehead and long, protruding ears. He exhibits poor eye contact during the examination. Psychoeducational testing shows an IQ of 70. Which of the following is the most likely diagnosis?
A
) Attention-deficit/hyperactivity disorder
B
) Autistic disorder
C
) Down syndrome
D
) Fetal alcohol syndrome
E
) Fragile X syndrome
F
) Lesch-Nyhan syndrome
G
) Pervasive developmental disorder, not otherwise specified
H
) Prader-Willi syndrome
I
) Rett's disorder
J
) Seminiferous tubule dysgenesis (Klinefelter's syndrome)
38. A 32-year-old woman comes to the physician because of vaginal discharge for 2 weeks. She has been sexually active with one female partner for 5 years. She has not been treated with antibiotics over the past 2 years. Her last Pap smear was 6 years ago when she was sexually active with a male partner. She has not used illicit drugs or alcohol. Examination shows a grayish vaginal discharge with a pH greater than 4.5. A wet mount preparation of the vaginal discharge is most likely to show which of the following?
A
) Budding yeast
B
) Clue cells
C
) Ferning
D
) Leukocytes in sheets
E
) Trichomonas vaginalis
39. A 57-year-old woman with breast cancer comes to the physician because of increasing neck pain over the past 3 days. She has fallen frequently because of muscle weakness. Vital signs are within normal limits. Examination shows hyperreflexia of all extremities. There is tenderness over the cervical spine. Serum calcium level is 11 mg/dL. X-ray films show metastases to the cervical spine. Which of the following is the most appropriate next step in management?
A
) Application of a soft cervical collar
B
) Physical therapy
C
) Mithramycin therapy
D
) Tamoxifen therapy
E
) Spinal cord decompression and cervical stabilization
40. A 57-year-old man comes to the physician because of intermittent urinary incontinence over the past 6 months. He has loss of small amounts of urine when he coughs or sneezes. He has not had pain or blood with urination. He has a 15-year history of type 2 diabetes mellitus with peripheral neuropathy, retinopathy, and gastroparesis. Current medications include metoclopramide and glyburide. He appears well. Rectal examination shows a normal-sized prostate. Neurologic examination shows decreased sensation in a stocking-glove distribution. Achilles tendon reflexes are absent bilaterally. Test of the stool for occult blood is negative. Urinalysis shows 2+ protein with no leukocytes or erythrocytes. His postvoid residual volume is 500 mL. Which of the following is the most likely mechanism of this patient's incontinence?
A
) Central nervous system disorder
B
) Functional incontinence
C
) Intrinsic sphincter deficiency
D
) Overflow incontinence from acontractile bladder
E
) Overflow incontinence from bladder outlet obstruction
F
) Pelvic floor muscle weakness
G
) Retroperitoneal fibrosis
H
) Retroperitoneal lymphadenopathy
I
) Urinary tract infection
41. A 27-year-old primigravid woman at 38 weeks' gestation is admitted in labor. Her pregnancy has been uncomplicated, and a routine prenatal visit 2 days ago showed no abnormalities. On admission, fetal heart tones cannot be heard. Ultrasonography shows little amniotic fluid, fetal edema, and no evidence of a fetal heartbeat. After 1 hour, she delivers a 3175-g (7-lb) stillborn infant; examination of the infant shows no obvious abnormalities except for mild edema. The placenta and membranes appear normal. Which of the following is the most appropriate immediate course of action?
A
) Notify the hospital liability department
B
) Obtain consent for fetal organ donation from the parents
C
) Recommend autopsy of the infant
D
) Tell the mother not to worry since she can get pregnant again
E
) Tell the parents that there is a 1 in 4 chance of recurrence in future pregnancies
42. A previously healthy 16-year-old high school wrestler comes to the physician because of a rash on his forearms and the back of his legs for 1 week. He is allergic to pollen and dust. Examination shows patches of erythema with mild lichenification over the antecubital and popliteal fossae. There are clusters of painful umbilicated vesicles at sites of active skin inflammation. Which of the following is the most likely diagnosis?
A
) Eczema herpeticum
B
) Herpes zoster
C
) Keratosis pilaris
D
) Lichen planus
E
) Pityriasis rosea
43. A 5-week-old boy is brought to the physician because of vomiting for 3 days. Switching from a cow's milk-based formula to a soy-based formula and one bottle of an electrolyte solution has not decreased his vomiting. His mother says that there is no yellow color to the vomitus, but it is forceful and occurs immediately after he has had 1 to 2 ounces of liquid. He appears to vomit more liquid than he drank. He has one mustard-colored seedy stool daily. Examination shows no abnormalities. Which of the following is the most likely explanation for his vomiting?
A
) Duodenal atresia
B
) Gastroesophageal reflux
C
) Hypertrophic pyloric stenosis
D
) Lactose intolerance
E
) Protein malabsorption
F
) Rotavirus infection
44. A 28-year-old woman is hospitalized after taking a massive overdose of acetaminophen tablets in a suicide attempt. She has type 1 diabetes mellitus and major depressive disorder refractory to tricyclic antidepressant therapy. Despite appropriate therapy, she develops rapidly progressive hepatic failure and becomes progressively encephalopathic. On the 6th day of hospitalization, she is comatose. A CT scan of the brain shows mild diffuse swelling. An appropriately crossmatched, size-appropriate donor liver is available. Which of the following is the most appropriate course of action regarding transplantation?
A
) Do not proceed with the transplantation because diabetes mellitus is a contraindication
B
) Do not proceed with the transplantation because hepatic function is likely to return over the next week
C
) Do not proceed with the transplantation because major depressive disorder places the patient at risk for another suicide attempt
D
) Do not proceed with the transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis
E
) Proceed with the transplantation
45. A 3-year-old boy who is HIV positive is brought for a routine examination. His diet is appropriate for age. His medications include three antiretroviral drugs and trimethoprim-sulfamethoxazole for Pneumocystis carinii prophylaxis. Laboratory studies show:
Hemoglobin 8.6 g/dL
Mean corpuscular hemoglobin 38 pg/cell
Mean corpuscular hemoglobin concentration 30% Hb/cell
Mean corpuscular volume 101 μm3
Leukocyte count 5600/mm3
Segmented neutrophils 60% (many hypersegmented)
Bands 3%
Lymphocytes 37%
Red cell distribution width 21% (N=10“16)
Which of the following is most likely to have prevented this patient's anemia?
A
) Folic acid supplementation
B
) Iron supplementation
C
) Thyroid supplementation
D
) Vitamin B12 (cyanocobalamin) supplementation
E
) Monthly intravenous immune globulin therapy
46. A 20-year-old man is brought to the emergency department on a summer day 20 minutes after developing headache, nausea, and unsteady gait while running the last 2 miles of a marathon. On arrival, he is confused and disoriented. His temperature is 40 C (104 F), blood pressure is 100/60 mm Hg, and pulse is 155/min. His skin is warm and dry. Neurologic examination shows no focal findings. Which of the following is the most likely mechanism of this patient's condition?
A
) Depletion of total body potassium
B
) Depletion of total body sodium
C
) High-output cardiac failure
D
) Inadequate dissipation of body heat
E
) Release of creatine kinase from muscle cells