01-10-2007, 03:07 PM
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1. An 83-year-old woman who has dementia, Alzheimer type, is brought to the office for a return visit by her daughter, with whom she lives. While intermittently somewhat confused, until recently the patient had been able to handle most of her activities of daily living. In the past month, however, she has shown little interest in eating and is awake most of the night. The daughter says the patient has been seeing things, especially at night. She has been accusing her daughter of stealing from her, and has also hit her daughter. The patient has fallen twice on her way to the bathroom at night. The daughter has been giving her diphenhydramine for 1 month to help her sleep, but she says it does not seem to be helping. You have also been treating the patient with ranitidine for esophageal reflux and with amitriptyline for depression. Vital signs are normal, and physical examination is unchanged from the last visit. Her mental status has deteriorated from her last visit 4 months ago. Today she is oriented only to name, does not seem to recognize you and appears to be visually hallucinating. Her daughter says she herself is overwhelmed and wonders if it is time to consider a nursing home for the patient. Which of the following is the most appropriate response?
A) "Her increased confusion may be due to her medicines. Let's explore that possibility first."
B) "Her worsening mental status may be due to an inadequate diet. Let's explore that first."
C) "It is a hard step to take, but I agree the time has come to arrange nursing home placement."
D) "It is a little premature for that. Let's try some home health services first."
E) "It is possible that medication might make her more manageable. Let's try a course of haloperidol."
2. A 12-year-old boy is brought to the office by his parents for a follow-up visit after starting treatment with carbamazepine 3 months ago for temporal lobe seizures. He has been seizure-free since having attained a therapeutic serum carbamazepine level 2 months ago. He says that he feels well, is doing much better in school, and has no new symptoms or complaints. It is most appropriate to tell him and his parents that with this drug therapy, he will need monitoring to assess for which of the following conditions?
A) Agranulocytosis
B) Cardiac arrhythmias
C) Gastric ulcers
D) Proteinuria
E) Renal failure
3. A 72-year-old professor emeritus comes to the office saying, "I am worried that I have Alzheimer's or small strokes or something." During the past year, he has noted increasing difficulty with his memory, especially for names, which has created several awkward moments professionally and socially. He adds, "I'll be doing fine, when all of a sudden my mind goes blank. I can't recall something I should easily know, and then suddenly it will come back to me a couple of minutes later." He complains that he frequently misplaces items like his keys, which is very unlike him. He also complains that his sleep is not restful anymore and that he tosses and turns all night. His wife has told him that she is not sleeping either, because he snores loudly. He says, "I'm tired much of the time, and I doze off whenever I try to read." He also complains of frequent headaches in the morning. Past medical history includes hypertension, which is well-controlled with diltiazem; peptic ulcer disease for which he takes ranitidine; and lumbar osteoarthritis, for which he takes ibuprofen. Height is 175 cm (5 ft 9 in) and weight is 72 kg (160 lb). Vital signs are: temperature 36.9°C (98.4°F), pulse 80/min and regular, respirations 12/min and blood pressure 158/100 mm Hg. Physical examination, including neurologic examination, is normal. He scores 29 out of 30 on the Mini-mental state test. Which of the following is the most appropriate next step?
A) Order CT scan of the head
B) Order electroencephalography
C) Reassure him that his symptoms are probably normal
D) Refer him for neuropsychological testing
E) Refer him for polysomnography
4. An 8-year-old boy is brought to the office because of a 5-day history of fever, coryza and cough that coincides with an epidemic of influenza in the community. Today he is unable to walk because of pain in the calves. His mother has been giving him acetaminophen for fever and pain. Physical examination shows a temperature of 38.3°C (101.0°F). He is alert, interactive and well-hydrated. He has clear rhinorrhea, mild pharyngeal erythema and a clear chest. His calves are tender to palpation. Strength cannot be tested because of pain. Neurologic examination, including deep tendon reflexes, is normal. Which of the following is the most appropriate therapy?
A) Acetaminophen, orally, as needed
B) Amantadine, orally
C) Immune globulin, intravenously
D) Influenza virus vaccine, intramuscularly
E) Prednisone, orally
5. A 55-year-old Hispanic welder comes to the office for an initial visit because of a lesion in his right eye that has been present for several months. During this time his right and left eyes have been increasingly sensitive to wind. He has not had double vision and has not seen "spots" in his field of vision. He says that he has been generally healthy and has not seen a physician during the past 30 years. He takes no medications. He does not wear corrective lenses. Family history is significant for blindness in his mother at age 77 years. The patient has smoked a half pack of cigarettes daily for the past 40 years, and he drinks an occasional six-pack of beer on weekends. Vital signs today are temperature 37.2°C (99.0°F), pulse 110/min, respirations 20/min, and blood pressure 140/85 mm Hg. Examination of the right eye discloses the finding shown in the photograph. Visual acuity is 20/40 in both eyes. Musculoskeletal examination discloses symmetric enlargement of the proximal and distal interphalangeal joints of both hands. The joints are firm to palpation and cool to the touch. The remainder of the physical examination is noncontributory. Which of the following is the most likely diagnosis?
A) Corneal abrasion
B) Glaucoma
C) Keratitis
D) Pterygium
E) Stye
6. A 3-year-old African-American boy who is a new patient is brought to the office by his grandmother. She says, "He was OK until this afternoon, when he suddenly developed a fever. He's been spitting a lot. He keeps his mouth open and he refuses to lie down. He won't eat." You learn that the child has received only one set of vaccinations at the age of 2 months. Vital signs are: temperature 39.4°C (103.0°F), pulse 110/min, respirations 24/min and blood pressure 110/70 mm Hg. On physical examination the child sits in a tripod position and salivation is evident. Which of the following is the most appropriate next step?
A) Administration of cefotaxime, intravenously
B) Complete blood count and blood culture
C) Determination of arterial blood gas values
D) Immediate otorhinolaryngology consultation
E) Lateral neck x-ray film
7. 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
13. A 47-year-old woman returns to the office because of gastrointestinal symptoms. She says, "I still have burning pain in my stomach that travels up my chest to my neck after I eat." During the past 5 years she has been treated with antacids, H2-blocking medications, proton pump inhibitors and motility agents, with only mild relief. She smokes one pack of cigarettes per day and drinks one cup of coffee in the morning. There is no family history of peptic ulcer disease. Previous endoscopies, the last of which was 6 months ago, have shown lower esophagitis secondary to reflux with healing ulcers and scarring. Gastric and duodenal cultures for Helicobacter pylori have been negative. Vital signs today are normal. Physical examination, including rectal examination, is normal. Which of the following is the most appropriate next step?
A) Consider an alternative pharmacotherapeutic regimen
B) Continue current treatment
C) Do esophageal pH monitoring
D) Obtain surgical consultation
E) Repeat endoscopy
14. A 38-year-old woman with systemic lupus erythematosus but no evidence of nephritis comes to the office because of a 3-week history of mood swings with crying spells, irritability and insomnia. She is especially upset because she has been yelling at her children "over small, everyday things." One month ago she started corticosteroid therapy. She is currently taking prednisone, 60 mg/day. Her other medications include an oral contraceptive (the same one for the past 6 years) and ibuprofen. She smokes one-half pack of cigarettes daily, drinks one to two beers 5 nights weekly and three cups of coffee each morning. Which of the following is the most appropriate intervention for her mood disturbance?
A) Add amitriptyline at bedtime
B) Discontinue the oral contraceptive
C) Reduce the prednisone dosage
D) Replace ibuprofen with acetaminophen
E) Urge her to stop smoking and to reduce her alcohol and caffeine intake
15. A 76-year-old retired pharmacist is brought to the health center by his wife, who says, "He's afraid to go to sleep, Doctor. Tell him, Henry." He tells you that he was mugged and assaulted 1 week ago while he was out for a walk early in the morning. The patient proceeds to tell you that he has been having nightmares, not about the assault, but of being in vulnerable situations. He also feels anxious during the day but he is able to leave the house without difficulty. In addition to supportive therapy, which of the following pharmacotherapies is most appropriate to prescribe?
A) Amitriptyline
B) Clonazepam
C) Diphenhydramine
D) Gabapentin
E) Risperidone
16. A 58-year-old white store manager comes to the office for a periodic health evaluation. You have been treating both the patient and his wife for the past 15 years. Today the patient is tearful and agitated. He says that he is having difficulty with his son, who is age 32 years and has schizophrenia. The son has been living intermittently in a group home or on the streets. The patient says that his son is noncompliant with his antipsychotic medications. Recently, the son has been calling the patient's house asking for money, which the patient suspects his son uses to buy alcohol and illicit drugs. It is most appropriate to advise the patient to do which of the following?
A) Arrange an involuntary commitment to a psychiatric hospital for his son
B) Ask his son's psychiatrist to adjust his medication
C) Change his phone number
D) Contact the local chapter of the National Alliance for the Mentally Ill for support and advice
E) Obtain a restraining order against his son
17. A 20-year-old man comes to the health center because of ankle pain. Two days ago he sustained an inversion injury of his left ankle in a basketball game. He has been able to walk unassisted since the injury. Today he has pain and moderate swelling and discoloration over the lateral malleolus. Physical examination shows tenderness on palpation over the anterolateral corner of the ankle joint. He has had two similar injuries in the past. Which of the following is the most appropriate initial management?
A) An ankle-strengthening exercise program
B) Application of a long-leg cast for 3 weeks
C) Application of a short-leg cast for 3 weeks
D) Protected weight bearing
E) Surgical repair of the ankle ligaments
18. A 52-year-old woman comes to the office because of a 4-day history of increasing pain of the right hip and thigh. The pain is exacerbated by lying on her right side while sleeping. She says the pain often awakens her and is accompanied by a burning sensation along the right side of her posterior thigh that radiates to her knee. She usually has stiffness and pain in the hip during the following morning that gradually diminishes as she walks around her house and does house chores. She says the pain is also triggered by sitting with her right leg crossed over the left leg. The patient is otherwise healthy and takes no medications. She is 168 cm (5 ft 6 in) tall and weighs 63 kg (140 lb); BMI is 23 kg/m2. Vital signs are normal. Physical examination discloses tenderness on deep palpation of the right trochanter. Which of the following is the most likely diagnosis?
A) Arthritis of the hip
B) Aseptic necrosis of the femoral head
C) Bursitis
D) Gout
E) Osteosarcoma of the femoral head
19. An 18-year-old man comes to the health center because he has had pain in his right leg for the past 5 days. He says that he recently added jogging to his weight-lifting workouts, and he started running 5 miles per day 2 weeks ago. He is 180 cm (5 ft 11 in) tall and weighs 83 kg (185 lb). On physical examination he has moderate tenderness over the midtibia. X-ray of the leg will most likely show which of the following?
A) A bone cyst
B) Displaced fracture
C) Metastatic disease
D) Soft-tissue calcification
E) Normal findings
20. A 58-year-old woman comes to the office for follow-up of fibromyalgia. You had been treating her for the past several years for nonspecific muscular aches and pains. In the past you noted that occasionally the pain could be reproduced on physical examination by applying pressure to certain muscles; however, these trigger points seemed to change on each physical examination. Fibromyalgia was diagnosed 3 months ago and amitriptyline therapy was started at that time. At a follow-up visit 3 weeks ago she showed little response to the amitriptyline therapy, and naproxen was added to her regimen. Today she returns to the office complaining that "every time I get the least little bump on my hands the skin seems to tear." Her physical examination is unchanged except for the lesions shown. Which of the following is the most appropriate management?
A) Discontinue the amitriptyline
B) Discontinue the naproxen
C) Prescribe oral corticosteroids
D) Prescribe topical corticosteroids
E) Prescribe topical 5-fluorouracil
21. A 10-year-old Asian girl is brought to the office by her mother because of a painful swelling in the girl's neck. The child says that for the past 4 days the right side of her neck has been sore. Today she showed it to her mother, who noticed a red swelling. She does not have fever or chills. She has not missed any days of school. She lives with her parents and two siblings in a suburban community. Further discussion discloses that the family recently adopted an 8-week old kitten from the animal shelter. Vital signs now are: temperature 37.2°C (98.9°F), pulse 80/min, and respirations 24/min. On physical examination, the girl has a 2H4-cm, red, tender mass with overlying erythema and induration in the right submandibular area. There is a crusted papule on the right cheek. Which of the following is the most likely cause of this patient's condition?
A) Bartonella henselae
B) Branchial cleft cyst
C) Epstein-Barr virus
D) Trauma
E) Untreated impetigo
22. A 64-year-old retired teacher comes to the office with her husband. She has felt fatigued for several months and feels she is losing her memory. She says, "I feel slowed and can't remember what happened yesterday." Her husband reaffirms this history and notes that she recently got lost in a local mall and called him at home to come and get her. She was frightened by this episode and had insomnia that night, even though she otherwise has been sleeping longer than usual. She has a good appetite. There is a family history of senile dementia in her father and two uncles. Her only medication is daily conjugated estrogen. Her height is 163 cm (5 ft 4 in) and her weight is 64 kg (142 lb), which is an increase of 2.5 kg (6 lb) since you saw her 8 months ago. Pulse is 54/min and regular, and blood pressure is 140/86 mm Hg. On physical examination she appears pale. Deep tendon reflexes have a slow relaxation phase; the remainder of the examination is normal. A Mini-mental state test shows a delayed recall of one of three items and failure on serial 7s. She cannot recall any past presidents but she knows the current president. Based on these findings, which of the following is the most likely working diagnosis?
A) Early dementia, Alzheimer type
B) Hypothyroidism
C) Pernicious anemia
D) A transient ischemic attack
E) Vascular dementia
23. A 38-year-old obese woman with a 2-year history of type 2 diabetes mellitus has not lost weight despite persistent advice concerning diet and exercise. She has also been irregular in keeping appointments and has failed to take her medication on a regular basis. There is increasing concern that serious complications will occur unless she becomes more cooperative. You decide to terminate the physician-patient relationship, hoping that another physician can establish better rapport and help her with her problems. The most appropriate way to terminate the relationship is to do which of the following?
A) Give her a copy of her medical records at the next appointment and advise her to find another physician
B) Give her a list of three physicians and ask her to pick one, to whom you will send her medical records
C) Refuse further treatment unless she loses 2.7 kg (6 lb) before her next appointment in 1 month
D) Tell her 19-year-old daughter, who brings her to the office, to convince her mother to find another physician and tell her the reasons for this suggestion
E) Tell her that the relationship will be terminated in 1 month, give her reasons for this decision, and offer her a list of three physicians' names
24. A 56-year-old Native American man returns to the office to discuss results of studies obtained during a previous visit 8 weeks ago. The patient has a 19-year history of diabetes mellitus treated with sulfonylurea. He checks his serum glucose concentration approximately once daily. He does not smoke cigarettes and rarely drinks alcoholic beverages. He is 183 cm (6 ft) tall and weighs 76 kg (168 lb); BMI is 23 kg/m2. Vital signs during the previous visit were temperature 36.9°C (98.4°F), pulse 82/min, and blood pressure 130/85 mm Hg. Physical examination of the neck disclosed a right-sided carotid bruit. Examination of the extremities disclosed diminished pulses with associated hair loss over both legs. Hemoglobin A1c was 7.2%. Urine albumin-creatine ratio was 62 mg/g/24 h (N<30). Ankle-brachial index (ABI) was 0.89 on the left and 0.98 on the right; duplex carotid ultrasonography showed nonulcerated plaque with 70% stenosis in the right internal carotid artery. The patient was referred to an ophthalmologist, who diagnosed him with nonproliferative background diabetic retinopathy. Which of the following findings in this patient is of most concern?
A) 70% stenosis of the right carotid artery
B) Hemoglobin A1c of 7.2%
C) Left ABI of 0.89
D) Nonproliferative diabetic retinopathy
E) Urine albumin-creatine ratio of 62 mg/g/24 h
25. A 25-year-old woman returns to the office because of intermenstrual spotting since beginning oral contraceptive therapy 6 months ago. This is her first attempt at oral contraceptive therapy; she and her partner primarily used condoms for contraception in the past. Before this current therapy her menstrual periods had always been regular. Which of the following is the most appropriate management?
A) Advise her to take two pills daily until the bleeding stops
B) Discontinue the oral contraceptive therapy and have her resume use of condoms for birth control
C) Reassure her that the bleeding problem will resolve in a few months
D) Switch the current oral contraceptive pill to one containing a higher estrogen dose
E) Switch to a progestin-only oral contraceptive pill
The following vignette applies to the next 2 items.
A 17-year-old girl is brought to the health center by her mother because the girl has had only two menstrual periods in the past 8 months. She had regular menstrual periods from menarche at age 14 years until 18 months ago. For the past 18 months she has been training as a long-distance runner.
Item 1 of 2
26. The underlying mechanism of her menstrual dysfunction is best defined by an abnormality in which of the following serum concentrations?
A) Androstenedione
B) Creatine kinase
C) Luteinizing hormone
D) Testosterone
E) Thyroid-stimulating hormone (TSH)
Item 2 of 2
27. Which of the following is the most likely cause of the menstrual irregularity?
A) High-carbohydrate diet
B) Increased basal body temperature
C) Increased muscle mass
D) Loss of body fat
E) Repeated volume depletion
28. A 23-year-old white nulligravid woman returns to the office for follow-up of a 2-year history of primary infertility. Menstrual periods occur at regular 28-day intervals. She has a history of chronic pelvic pain. Analysis of her husband's semen shows a sperm count of 40 million with 65% motility and normal morphology. Diagnostic laparoscopy with hydrotubation shows normal pelvic anatomy, with no evidence of endometriosis or pelvic adhesions. Both fallopian tubes spill methylene blue dye. The patient's basal body temperatures recorded during the past month are shown. Which of the following is the most likely cause of the patient's inability to conceive?
A) Anovulation
B) Male factor infertility
C) Old pelvic inflammatory disease
D) Polycystic ovary syndrome
E) No cause can be identified at this time
29. In the course of routine prenatal care at the health center, a 30-year-old Hispanic woman is found to have gestational diabetes. This is her first pregnancy and she is at 20 weeks' gestation. She should be counseled that adequate prenatal care, including regular determination of blood glucose concentrations and adherence to a controlled dietary regimen, may reduce the possibility of which of the following?
A) The fetus developing macrosomia
B) Her developing essential hypertension
C) Her developing type 1 diabetes mellitus in the future
D) Intrauterine growth restriction
E) Premature delivery
30. A 20-year-old woman returns to the office for the results of her prenatal laboratory studies. By date of her last menstrual period she is 14 weeks pregnant with her second child. Her first pregnancy, which you followed, resulted in an uncomplicated vaginal delivery approximately 11 months ago. Her prenatal serology screening for syphilis is positive with a titer of 1:126, and a fluorescent treponemal antibody absorption (FTA-ABS) test is positive. The patient denies having lesions consistent with syphilis, and her current physical examination shows no lesions. Serology during her first pregnancy was negative. At this time, which of the following is the most appropriate management?
A) Do an amniocentesis to obtain fluid for darkfield evaluation
B) Follow the treatment regimen recommended for primary or secondary syphilis
C) Postpone treatment until the patient is at least 20 weeks pregnant
D) Schedule a lumbar puncture before instituting treatment
E) Withhold treatment until further studies rule out a biologic false-positive
31. A 34-year-old man comes to the office with his wife and daughter because he has had some dusky lesions on his shoulder for the past 2 months. He says that two have become larger during the past week. He and his wife have recently adopted an 18-month-old girl from the Ukraine who has a similar rash. He is an environmental scientist and his work requires him to travel overseas and work outdoors. He is concerned about the possibility of skin cancer. Vital signs are normal. Physical examination shows a cluster of six discrete papular lesions on his left shoulder that are slightly tender. These lesions have a central depression containing some pus-like material. There is no axillary or cervical adenopathy. His rash is shown. Which of the following is the most appropriate management for the patient?
A) Acyclovir
B) Scabicidal cream
C) Topical corticosteroid cream
D) Topical fluconazole
E) Topical liquid nitrogen
32. A 25-year-old Latino man comes to the health center for a periodic health evaluation. He tells you that he has attended a day-treatment program for his schizophrenia, paranoid type, since his discharge from the hospital 1 year ago. The patient's most recent psychiatrist is moving away and he now wants you to refill his medications. He takes haloperidol, benztropine and valproic acid. He says, "The voices aren't telling me to harm myself anymore. And I know now that my food is not poisoned." The patient is 183 cm (6 ft) tall and weighs 86 kg (190 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 72/min, respirations 14/min and blood pressure 130/86 mm Hg. Physical examination is significant for darting and protruding movements of the tongue and some facial grimacing. Which of the following is the most appropriate change in pharmacotherapy?
A) Prescribe vitamin A
B) Increase the dose of benztropine
C) Increase the dose of haloperidol
D) Replace haloperidol with risperidone
E) Replace valproic acid with lithium
33. A third-year medical student returns to the student health service for the third time because he thinks he has ulcerative colitis. After a thorough history and physical examination, he is told that no organic disease is present. Despite that reassurance, the student continues to test his stool for blood and continues to believe that his physicians have missed the correct diagnosis. This behavior is most characteristic of which of the following?
A) Conversion disorder
B) Depersonalization
C) Hypochondriasis
D) Munchausen syndrome
E) Somatization disorder
34. A 10-year-old Asian-American boy is brought to the office for a sports physical examination. He has been healthy except for a few episodes of otitis media as an infant. He has had no shortness of breath, syncope or chest pain in the past. Growth has been normal. Vital signs are: temperature 36.6°C (97.8°F), pulse 80/min, respirations 16/min, and blood pressure 110/76 mm Hg. Cardiac examination discloses an early systolic click at the apex, a midsystolic ejection murmur at the right upper sternal border and a thrill in the suprasternal notch. The remainder of the physical examination is normal. The patient is referred to the cardiologist and the diagnosis of aortic stenosis is confirmed by echocardiogram. Close follow-up and graded exercise testing are recommended. The patient is at increased risk for which of the following?
A) Atrial arrhythmias
B) Complete heart block
C) Coronary artery disease
D) Pulmonary hypertension
E) Sudden death
35. A 12-year-old Haitian boy is brought to the health center for the first time by his mother and maternal grandmother. The mother states, "There was a voodoo curse placed on my family and now my son is having problems because of that." She reports that for the past 6 months he has been talking back to his teachers, has been suspended from school for skipping class, and has been defiant with all adults. He is failing two subjects in school and will need to attend summer classes. His medical history is significant for an allergy to sulfa drugs, a positive PPD skin test for which he was treated prophylactically at age 10 years, and encopresis that resolved. He currently takes no medications. The patient is 163 cm (5 ft 4 in) tall and weighs 49 kg (108 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 80/min, respirations 18/min and blood pressure 90/50 mm Hg. Which of the following is the most appropriate opening statement to the mother?
A) "Do you think your son may be taking drugs?"
B) "I suggest you consult a voodoo priest for help with this problem."
C) "Tell me more about the voodoo and its effect on your son's behavior."
D) "There is no such thing as voodoo."
E) "Voodoo does not cause children to have bad behavior."
36. You are invited to a council meeting of Native-Americans to discuss a heptavalent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar7) for use in the community's children, many of whom are younger than age 12 months. All of the infants and children in the community are up-to-date on standard recommended vaccinations. The council spokesperson says, "We are skeptical about the safety of giving our sons and daughters yet another vaccine." Which of the following is the most compelling reason to recommend vaccination of all infants younger than 12 months of age?
A) Administration of the vaccine will decrease the incidence of invasive pneumococcal disease among the children in the community
B) Administration of the vaccine will decrease the likelihood of secondary pneumonia during respiratory syncytial virus (RSV) season
C) Administration of the vaccine will significantly decrease the severity of acute otitis media and prevent hearing loss
D) Native-American children make ineffective antibodies when the 23-valent pneumococcal vaccine alone is administered to them
E) The peak incidence of pneumococcal disease occurs in children younger than 12 months of age