12-02-2009, 09:01 AM
1. A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal
failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours
ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg.
Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness.
Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step?
A ) X-ray films of the abdomen
B ) Comparison of abdominal fluid amylase with serum amylase activity
C ) Gram's stain of abdominal fluid
D ) Ultrasonography of the abdomen
E ) CT scan of the abdomen and pelvis
2. A 5-year-old girl is brought to the physician because of temperatures to 40 C (104 F), tachypnea,
and a nonproductive cough for 12 hours. Four days ago she was treated with an oral antibiotic for
suspected pneumococcal pneumonia. Examination shows diminished breath sounds over the lower
right lung fields and dullness to percussion at the right costophrenic angle. Which of the following is
the most likely diagnosis?
A ) Bronchopleural fistula
B ) Empyema
C ) Lung abscess
D ) Pleurodynia
E ) Pneumothorax
3. A 40-year-old man is brought to the emergency department 1 hour after a high-speed motor
vehicle collision. On arrival, he is awake and alert but has severe pain over the sternum. His systolic
blood pressure is 80 mm Hg, pulse is 80/min, and respirations are 10/min. An ECG shows multifocal
premature ventricular contractions but no ST-segment changes. His PO2 is 100 mm Hg. After 1 L of
lactated Ringer's solution is administered, his PO2 decreases to 60 mm Hg while breathing 4 L/min
of oxygen by nasal cannula. Pulmonary capillary wedge pressure has increased from 14 mm Hg to
24 mm Hg (N=1“10). Which of the following is the most likely explanation for the patient's poor
response to fluid resuscitation?
A ) Inadequate administration of fluids
B ) Myocardial contusion
C ) Myocardial infarction
D ) Pulmonary contusion
E ) Traumatic rupture of the aorta
4. A 21-year-old African American college student has had increasing fatigue over the past 3 weeks.
Since an episode of cystitis treated with trimethoprim-sulfamethoxazole 3 weeks ago, he has been
unable to keep up with his physical education classes. For 6 months, he has been following a
vegetarian diet that has been supervised by student health services. Examination shows no
abnormalities. His hemoglobin level is 10 g/dL, mean corpuscular volume is 85 μm3, and
reticulocyte count is 15%. Which of the following is the most likely cause of anemia in this patient?
A ) Anemia secondary to infection
B ) Antibiotic therapy
C ) Gastrointestinal blood loss
D ) Sickle cell disease
E ) Vegetarian diet
5. An 87-year-old nursing home resident with dementia, Alzheimer's type, is admitted to the
hospital because of progressive lethargy and decreased appetite for 3 days. She had a flu-like
illness followed by a deep cough 1 week ago. Over the past 10 months, she has been hospitalized
once for bacterial pneumonia. She is responsive only to painful stimuli. Her temperature is 38.6 C
(101.5 F), blood pressure is 110/60 mm Hg, pulse is 123/min and regular, and respirations are
28/min. Examination shows dry mucous membranes. There is no adenopathy. Crackles are heard in
the right lung base. An x-ray film of the chest shows an infiltrate at the right lung base. The
remainder of the examination shows no abnormalities. Which of the following is the most likely
predisposing factor for this patient's pneumonia?
A ) Decreased airway elasticity
B ) Decreased baroreflex
C ) Decreased gag reflex
D ) Decreased thyroid function
E ) Diastolic cardiac dysfunction
F ) Impaired cardiac response to exercise
G ) Impaired T-lymphocyte function
H ) Impaired thirst
I ) Increased lung compliance
J ) Renal salt wastin
failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours
ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg.
Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness.
Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step?
A ) X-ray films of the abdomen
B ) Comparison of abdominal fluid amylase with serum amylase activity
C ) Gram's stain of abdominal fluid
D ) Ultrasonography of the abdomen
E ) CT scan of the abdomen and pelvis
2. A 5-year-old girl is brought to the physician because of temperatures to 40 C (104 F), tachypnea,
and a nonproductive cough for 12 hours. Four days ago she was treated with an oral antibiotic for
suspected pneumococcal pneumonia. Examination shows diminished breath sounds over the lower
right lung fields and dullness to percussion at the right costophrenic angle. Which of the following is
the most likely diagnosis?
A ) Bronchopleural fistula
B ) Empyema
C ) Lung abscess
D ) Pleurodynia
E ) Pneumothorax
3. A 40-year-old man is brought to the emergency department 1 hour after a high-speed motor
vehicle collision. On arrival, he is awake and alert but has severe pain over the sternum. His systolic
blood pressure is 80 mm Hg, pulse is 80/min, and respirations are 10/min. An ECG shows multifocal
premature ventricular contractions but no ST-segment changes. His PO2 is 100 mm Hg. After 1 L of
lactated Ringer's solution is administered, his PO2 decreases to 60 mm Hg while breathing 4 L/min
of oxygen by nasal cannula. Pulmonary capillary wedge pressure has increased from 14 mm Hg to
24 mm Hg (N=1“10). Which of the following is the most likely explanation for the patient's poor
response to fluid resuscitation?
A ) Inadequate administration of fluids
B ) Myocardial contusion
C ) Myocardial infarction
D ) Pulmonary contusion
E ) Traumatic rupture of the aorta
4. A 21-year-old African American college student has had increasing fatigue over the past 3 weeks.
Since an episode of cystitis treated with trimethoprim-sulfamethoxazole 3 weeks ago, he has been
unable to keep up with his physical education classes. For 6 months, he has been following a
vegetarian diet that has been supervised by student health services. Examination shows no
abnormalities. His hemoglobin level is 10 g/dL, mean corpuscular volume is 85 μm3, and
reticulocyte count is 15%. Which of the following is the most likely cause of anemia in this patient?
A ) Anemia secondary to infection
B ) Antibiotic therapy
C ) Gastrointestinal blood loss
D ) Sickle cell disease
E ) Vegetarian diet
5. An 87-year-old nursing home resident with dementia, Alzheimer's type, is admitted to the
hospital because of progressive lethargy and decreased appetite for 3 days. She had a flu-like
illness followed by a deep cough 1 week ago. Over the past 10 months, she has been hospitalized
once for bacterial pneumonia. She is responsive only to painful stimuli. Her temperature is 38.6 C
(101.5 F), blood pressure is 110/60 mm Hg, pulse is 123/min and regular, and respirations are
28/min. Examination shows dry mucous membranes. There is no adenopathy. Crackles are heard in
the right lung base. An x-ray film of the chest shows an infiltrate at the right lung base. The
remainder of the examination shows no abnormalities. Which of the following is the most likely
predisposing factor for this patient's pneumonia?
A ) Decreased airway elasticity
B ) Decreased baroreflex
C ) Decreased gag reflex
D ) Decreased thyroid function
E ) Diastolic cardiac dysfunction
F ) Impaired cardiac response to exercise
G ) Impaired T-lymphocyte function
H ) Impaired thirst
I ) Increased lung compliance
J ) Renal salt wastin
) still think that it is myocardial contusion.