Módulo 3 Med. Interna Flashcards
A 60-year-old man comes to his physician with complaints of easy fatigability and palpitations for the past 6 months. Physical examination is remarkable for pallor of skin and mucous membranes. No evidence of cardiac or respiratory disease is found. Hematologic studies show:
- Hemoglobin: 8.4 g/dL
- Mean corpuscular volume (MCV): 75 fl
- Leukocyte count 9000/mm3
- Platelet count 380,000/mm3
Serum chemistry studies show a ferritin of 25 ng/L and serum bilirubin within normal values. Peripheral blood smear shows small erythrocytes with marked variability in size. Which of the following is the most appropriate next step in management?
(A) Bone marrow biopsy
(B) Coombs test for anti-red blood cell antibodies
(C) Hemoglobin electrophoresis
(D) Test for occult blood in the stool
(E) Therapeutic trial with oral ferrous sulfate
(F) Treatment with vitamin B12 and folic acid
A 28-year-old woman presents with painful swelling of her right hand and fingers of 2 days’ duration. She has a low-grade fever and is currently menstruating. She denies a past history of sexually transmitted diseases. On examination, her temperature is 38.6 C
(101.4 F), blood pressure is 130/70 mm Hg, pulse is 110/min, and respirations are 20/min. The digits on her right hand are swollen and held in mild flexion, with papules and vesicles in the web spaces. Her left knee and ankle are swollen and tender to touch. Laboratory evaluation shows:
- Leukocytes 12,000 with 86% neutrophils
- Hemoglobin 14.0 g/dL
- Platelets 220,000/mm3
- Erythrocyte sedimentation rate 43 mm/h
X-ray films of the hand, knee, and ankle show no evidence of fracture. Which of the following tests is most likely to confirm the likely diagnosis?
(A) Cultures of cervix, rectum, throat, and blood
(B) Blood cultures
(C) Arthrocentesis for bacterial cultures
(D) Synovial fluid analysis for cell count
(E) Synovial fluid Gram stain
A 39-year-old California rancher consults a physician because of
chronic abdominal pain. The man has been a sheepherder for 23 years. Physical examination is notable for a palpable liver mass but is otherwise unremarkable. Ultrasound demonstrates a 15-cm cyst bearing multiple daughter cysts in the liver. CT confirms the presence of the cysts and demonstrates the presence of a finely calcified cyst rim. Which of the following is the most likely diagnosis?
(A) Ascariasis
(B) Echinococcosis
(C) Fascioliasis
(D) Schistosomiasis
(E) Toxocariasis
A solitary nodule is detected on a chest x-ray film in an otherwise healthy 25-year-old man. The patient has been smoking 10 cigarettes daily for 3 years. The nodule is located in the right middle lobe and measures approximately 1.5 cm. Previous chest x-ray films are not available for comparison. CT scan reveals a solitary lung nodule with a smooth contour and diffuse calcifications. No other pulmonary lesions are found. Physical examination and routine laboratory tests are normal. Which of the following is the most likely diagnosis?
(A) Aspergilloma
(B) Bronchogenic carcinoma
(C) Hamartoma
(D) Pulmonary abscess
(E) Sarcoidosis
(F) Secondary (reactivated) tuberculosis
A 65-year-old woman is admitted with a 3-week history of headache over the right temporal region, malaise, fever, morning stiffness, and weight loss. On physical examination, scalp tenderness is appreciated. Her temperature is 38.5 C (101.3 F), blood pressure is 142/84 mm Hg, pulse is 85/min, and respirations are 14/min. There is no loss of visual acuity, and funduscopic examination is unremarkable. Laboratory studies show the following:
- Hematocrit: 40.3%
- Hemoglobin: 11.9 g/dL
- Leukocytes: 7800/mL (neutrophils 68%)
- Erythrocyte sedimentation rate (ESR): 80 mm/h
After reviewing the results, the physician initiates highdose prednisone therapy. Which of the following is most likely to confirm the diagnosis?
(A) CT scan of the head
(B) Lumbar puncture
(C) Muscle biopsy
(D) Temporal artery biopsy
(E) Visual evoked potentials
A 35-year-old man goes to the emergency department because he has developed a severe case of hives. He has never had hives before. Physical examination demonstrates multiple wheals and
erythematous patches over his body, which respond to subcutaneous epinephrine. The patient’s sclera are slightly yellow-tinged. Results of the chest and abdomen examination are within normal limits. Screening biochemistry tests demonstrate an AST (SGOT) of 350 U/L and an ALT (SGPT) of 300 U/L. Which of the following is the
most likely diagnosis?
(A) Alcoholic cirrhosis
(B) Alpha1-antitrypsin deficiency
(C) Hemochromatosis
(D) Hepatitis A
(E) Hepatitis B
A 47-year-old Brazilian immigrant presents with fatigue and dyspnea. He has been healthy for the past 10 years. The patient denies fever, cough, chills, or weight loss. On physical examination there are no murmurs, the pulse and the rhythm are regular, S1 is normal, and S2 is split. This split increases with inspiration and persists with expiration. Which of the following ECG findings is most consistent with the auscultatory findings in this patient?
(A) Acute ST segment elevation in the anterior leads
(B) Decreased PR interval
(C) Early repolarization
(D) Marked T wave inversion
(E) Right bundle branch block
An otherwise healthy 60-year-old man undergoes a health
maintenance examination. Physical examination and medical history are unremarkable. A blood chemistry panel is normal except for a serum calcium level of 11 mg/dL when corrected for serum albumin. The measurement is repeated two times, giving values of 10.5 mg/dL and 11.2 mg/dL, respectively. Serum phosphorus is 2.5 mg/dL, and alkaline phosphatase is 50 U/L. Immunoradiometric assay (IRMA) reveals higher than normal serum levels of parathyroid hormone. Urine calcium excretion is within normal limits. The patient denies previous renal colic or urinary tract infections. Which of the following is the most appropriate next step in management?
(A) Bone x-ray films
(B) Extensive cancer screening
(C) Generous fluid intake
(D) Treatment with bisphosphonates (e.g., alendronate)
(E) Surgical exploration of the neck
A 27-year-old African American man visits his primary care
physician because of recent onset of “yellowness in the white of his eyes.” His recent history is significant for a “chest cold” for which he is taking trimethoprim-sulfamethoxazole; he is also taking fluoxetine for depression. On examination, the sclera are icteric and the mucosa beneath the tongue appears yellow. No hepatosplenomegaly is present. Laboratory studies are as follows:
- Hemoglobin 11.1 g/dL
- Hematocrit 34%
- Total bilirubin 6.2 mg/dL
- Conjugated (direct) bilirubin 0.8 mg/dL
- Alkaline phosphatase 77
- AST (SGOT) 24
- ALT (SGPT) 22
Which of the following is the most likely explanation for this patient’s jaundice?
(A) Acute infectious hepatitis
(B) Cholestatic liver disease
(C) Drug reaction from fluoxetine
(D) Drug reaction from trimethoprim-sulfame-thoxazole
A 26-year-old woman complains of painful and frequent urination for 2 days. She has no significant medical history and has had a monogamous sexual relationship with another woman for the past year. Her temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 68/min, and respirations are 12/min. There is no costovertebral angle tenderness, the abdomen is soft, and there is mild suprapubic tenderness. The pelvic examination is within normal limits except for tenderness at the urethral meatus. Urinalysis reveals 23 white blood cells per high-power field. Which of the following is the most likely pathogen?
(A) Chlamydia trachomatis
(B) Escherichia coli
(C) Klebsiella pneumoniae
(D) Proteus sp.
(E) Staphylococcus saprophyticus
A 72-year-old man complains of malaise and easy fatigability for the past 3 weeks. His past medical history is significant for gout and pneumonia. He lives alone and usually drinks two six-packs of beer daily. His temperature is 36.9 C (98.4 F), blood pressure is 160/90 mm Hg, pulse is 88/min, and respirations are 19/min. Thyroid palpation is normal, and heart, lung, and abdomen examination results are within normal limits. There is a diffuse ecchymotic rash spreading out from hair follicles on the limbs and trunk. The patient most likely has a deficiency of which of the following vitamins?
(A) Niacin
(B) Thiamin
(C) Vitamin B12
(D) Vitamin C
(E) Vitamin D
A 40-year-old man with a history of type V hyperlipoproteinemia is brought to the emergency department 3 hours following the abrupt onset of severe deep epigastric pain, nausea, and vomiting. The pain is steady and radiates to the back. The patient is agitated and has cool, clammy skin. His temperature is 38.5 C (101 F), blood pressure is 100/70 mm Hg, pulse is 110/min, and respirations are 22/min. Abdominal examination reveals tenderness in the upper abdomen, without guarding. A plain x-ray film shows an air-filled intestinal loop in the left upper quadrant. Laboratory investigations:
Glucose: 150 mg/dL
LDH: 150 U/L
ALT: 90 U/L
AST: 80 U/L
Amylase: 120 U/L
Lipase: 30 U/L
Calcium: 7 mg/dL
C-reactive protein: 1.2 mg/dL
Which of the following is the most likely diagnosis?
(A) Acute cholecystitis
(B) Acute hepatitis
(C) Acute pancreatitis
(D) Bowel perforation
(E) Mesenteric ischemia
(F) Ureteral lithiasis
An 18-year-old man has had rhinorrhea and a sore throat for 2 days. He has no significant past medical history. His temperature is 39.3 C (102.6 F), pulse is 110/min, and respirations are 20/min. He has tender anterior and posterior cervical lymphadenopathy and an erythematous pharynx with white exudates on the tonsils. The remainder of his examination is normal. Which of the following is the most likely causal organism?
(A) Candida albicans
(A) Candida albicans
(B) Haemophilus influenzae
(C) Staphylococcus aureus
(D) Streptococcus pneumoniae
(E) Streptococcus pyogenes
Due to a recent and sudden death of a rival college football player, a local university wishes to implement changes in its health care policies. The school is particularly concerned about the risk for sudden cardiac death in players with previously undiagnosed heart conditions. A preparticipation evaluation is to be performed on all of the school’s athletes. Which of the following is considered the most cost-effective method of screening young athletes at risk for sudden cardiac death?
(A) Careful medical history and examination
(B) Chest x-ray
(C) Echocardiography
(D) Exercise electrocardiography
(E) Resting electrocardiography
A 20-year-old male college student is participating in the New York City Marathon and collapses one third of the way through the race. He is a well developed, athletic man who frequently plays basketball and tennis. He has no past medical history, except for a tonsillectomy at 9 years of age. There were no symptoms before he collapsed to the ground and lost consciousness. The patient is immediately rushed to the nearest emergency room but is pronounced dead on arrival. Which of the following is the most likely underlying cause of his sudden death?
(A) Aortic stenosis
(B) Arrhythmogenic right ventricular dysplasia
(C) Coronary anomalies
(D) Hypertrophic cardiomyopathy
(E) Isolated left ventricular hypertrophy
(F) Myocarditis
(G) Ruptured aorta
A seriously ill AIDS patient is admitted to a hospital. He has multiple infections, including Pneumocystis carinii pneumonia, pulmonary cytomegalovirus infection, and candidiasis of the esophagus and possibly other sites. Screening chemistry studies are drawn, including electrolytes. Which of the following abnormalities would be most likely seen in this setting?
(A) Hyperkalemia
(B) Hypermagnesemia
(C) Hypocalcemia
(D) Hyponatremia
(E) Hypophosphatemia
A 31-year-old man is admitted to the hospital for suspicion of gastrointestinal bleeding. He has no significant past medical history but takes daily nonsteroidal antiinflammatory agents for pain in his knee. He presented to the hospital 6 hours ago after he noticed melanotic stools while at home. He is observed to have copious bright red blood per rectum. On physical examination, he is tachycardic, and his peripheral pulses are faint but present. His mental status appears normal. His extremities are cool to the touch. An intravenous line is placed. Which of the following is the most appropriate next step in management?
(A) Order an urgent type and cross match for blood
(B) Order an urgent hematocrit level
(C) Begin parenteral administration of large volumes of normal saline solution
(D) Begin parenteral administration of large volumes of colloid solution
(E) Place two additional large bore peripheral intravenous catheters
A 40-year-old man presents to the physician because of exertional dyspnea of recent onset. The patient appears comfortable at rest but says that he becomes short of breath with minimal effort. His temperature is 37 C (98.6 F), blood pressure is 162/65 mm Hg, pulse is 92/min with a rapid rise and fall, and respirations are 15/min. Chest examination reveals a prominent and laterally displaced apical impulse. A soft diastolic decrescendo murmur is heard along the left sternal border. Bilateral crackles are present at the lung base. The liver is not palpable, and there is no sign of peripheral edema. Which of the following is the most likely diagnosis?
(A) Aortic insufficiency
(B) Aortic stenosis
(C) Hypertrophic obstructive cardiomyopathy
(D) Infective endocarditis
(E) Mitral stenosis
(F) Ventricular septal defect
A 42-year-old man with AIDS presents with a chief complaint of
persistent watery, non-bloody diarrhea. He is not on any medications
and denies recent travel or fever. On physical examination, his
abdomen is slightly bloated, with mild tenderness to palpation.
There is no occult blood in his stool. Stool samples for leukocytes, culture, ova, and parasites are all negative × 3. Which of the
following is the most appropriate next step in diagnosis?
(A) Abdominal CT
(B) Cytomegalovirus (CMV) antigenemia
(C) Modified acid-fast stain of the stool
(D) PPD test
(E) Small bowel biopsy
A previously healthy 23-year-old man comes to the physician because of a febrile illness that developed over a 2-day period. He has had temperatures to 39.4 C (102.9 F), with rigors, cough productive of mucopurulent sputum, and right chest pain. At this time, his temperature is 38.7 C (101.7 F), blood pressure is 132/80 mm Hg, pulse is 110/min, and respirations are 22/min. There is no cyanosis. Diminished tactile fremitus, dullness on percussion, and bronchial breathing are present in the right lower lung. A chest x-ray film shows consolidation of the right lower lobe. Microscopic examination of the sputum reveals gram-positive diplococci. The patient denies previous allergic drug reactions. Which of the following is the most appropriate pharmacotherapy?
(A) Cefazolin
(B) Erythromycin
(C) Penicillin
(D) Tetracyclines
(E) Trimethoprim-sulfamethoxazole
(F) Vancomycin
An otherwise healthy 22-year-old woman presents to her physician because of daily headaches over the past 2 weeks. The headaches have a vise-like character, seem to be more intense in the back of the head, and are often precipitated by emotional stress. Physical examination fails to disclose focal neurologic or visual deficits. Which of the following is the most appropriate initial step in patient care?
(A) Antidepressant drugs
(B) Calcium-channel antagonists
(C) Ergotamine-containing preparations
(D) Nonsteroidal anti-inflammatory drugs (NSAIDs)
(E) Sumatriptan
A 42-year-old woman presents to her physician because of recent urinary tract infections (UTIs). She has been on an unknown oral antibiotic chronically. She has a temperature of 37.2 C (99 F), and costovertebral angle tenderness is noted on the left side. A plain film of the abdomen reveals a radiopaque density filling the left renal pelvis and calyces. Which of the following is the most likely pathogen?
(A) Bacteroides fragilis
(B) Clostridium difficile
(C) Escherichia coli
(D) Proteus mirabilis
(E) Streptococcus bovis
A 35-year-old woman has developed marked thickening of the skin of her hands, particularly her fingers. This thickening is accompanied by hyperpigmentation and is so marked as to limit the range of motion of her fingers. If this patient goes on to develop gastrointestinal problems, which of the following is most likely?
(A) Carcinoid tumor
(B) Duodenal peptic ulcer
(C) Esophageal dysfunction
(D) Pneumatosis cystoides intestinalis
(E) Sacculations of the colon
(F) Small bowel adhesions
A 23-year-old man presents with a 3-month history of cough with blood-tinged sputum, shortness of breath, and gross hematuria. His temperature is 37.5 C (99.5 F), blood pressure is 158/94 mm Hg, pulse is 87/min, and respirations are 22/min. Examination reveals bilateral crackles at the lung base and mild edema of the palpebrae and feet. A chest x-ray film shows scattered pulmonary infiltrates in a distribution different from that present on a film taken 2 months ago. Examination of the sputum shows hemosiderin-laden macrophages but no microorganisms. Laboratory investigations show modest iron-deficiency anemia and no evidence of ANCA- type antibodies. Urinalysis shows gross hematuria and modest proteinuria. A renal biopsy demonstrates the presence of glomerulonephritis with linear deposition of IgG and complement components along the glomerular basement membrane. Which of the following is the most likely diagnosis?
(A) Churg-Strauss syndrome
(B) Goodpasture syndrome
(C) Idiopathic pulmonary hemosiderosis
(D) Postinfectious glomerulonephritis
(E) Wegener granulomatosis
A 67-year-old man comes to the physician because of insomnia, irritability, and palpitations for 3 months. He is currently taking amiodarone for cardiac arrhythmias, fluoxetine for depression, and enalapril for hypertension. His blood pressure is 130/70 mm Hg, and his pulse is 90/min and regular. Which of the following is the most appropriate next step?
(A) Measurements of thyroxine and TSH
(B) Administration of propranolol
(C) Referral for psychiatric consultation
(D) Substitution of antidepressant drug
(E) Substitution of antihypertensive drug
An unconscious 35-year-old man is brought to the emergency department by his wife. She explains that the patient takes phenytoin for chronic epilepsy. An hour ago, the patient had a seizure but did not regain consciousness. Physical examination reveals that his temperature is 38.5 C (101.3 F), blood pressure is 92/40 mm Hg, pulse is 110/min, and respirations are 20/min. During the examination, the physician observes the sudden onset of tonic-clonic convulsions. Which of the following is the most common precipitating cause of this emergency?
(A) Alcohol withdrawal
(B) Drug noncompliance
(C) Head trauma
(D) Hypoxia
(E) Intracranial infection
A 26-year-old librarian presents with chronic daytime somnolence, which has frequently caused him to fall asleep at work. He does not smoke but drinks 1 to 2 glasses of wine daily. He says he frequently awakens at night but denies any visual or auditory hallucinations on falling asleep. His height is 186 cm (73 in), and his weight is 60% greater than expected. Chest examination reveals no specific findings other than distant breath sounds. Arterial blood gas analysis during normal ventilation shows:
- Pao2: 82 mm Hg
- Paco2: 55 mm Hg
After the patient voluntarily hyperventilates for 1 minute, blood gas analysis returns within normal limits. Which of the following will have the greatest benefit on this patient’s symptoms?
(A) Benzodiazepines at bedtime
(B) Daily acetazolamide
(C) Morning administration of dextroamphetamine
(D) Supplemental oxygen at night
(E) Weight loss
A 35-year-old man with a history of chronic heroin abuse comes to the physician because of progressive swelling of his feet and hands. His blood pressure is 155/90 mm Hg. Laboratory studies show:
- Creatinine 1.6 mg/dL
- BUN 20 mg/dL
- Urinalysis Protein 4+
- Erythrocytes 10/hpf
The amount of protein measured in a 24-hour urine collection is 4.5 g. Which of the following is the most likely diagnosis?
(A) Acute proliferative glomerulonephritis
(B) Crescentic glomerulonephritis
(C) Focal segmental glomerulosclerosis
(D) Minimal change disease
(E) Nodular glomerulosclerosis (Kimmelstiel-Wilson disease)
A 61-year-old man presents for an elective surgical incision and drainage procedure. The patient has an 8-year history of hepatitis C infection with well-documented cirrhosis and portal hypertension. He has a large hematoma on his thigh that is suspected to have necrotic tissue underlying it and therefore requires debridement. On preoperative screening, his prothrombin time is noted to be 17.4 seconds. Transfusion of which of the following is the most appropriate next step in management of this patient prior to his procedure?
(A) Cryoprecipitate
(B) Fresh frozen plasma
(C) Packed red blood cells
(D) Platelets
(E) Whole blood
**A 55-year-old woman with long-standing diabetes mellitus and a 2-year history of progressive renal failure comes to medical attention because of chest pain for 12 hours. The pain is substernal and continuous, with radiation to the neck. She is on a strict dietary regimen with protein, fluid, and salt restriction. Her temperature is 37.2 C (99 F), blood pressure is 150/85 mm Hg, pulse is 82/min and regular, and respirations are 16/min. There is no jugular vein distention or pitting edema. Auscultation reveals a rubbing sound in the precordial region and slightly distant but normal heart sounds. Lungs are clear to auscultation. The patient is admitted, and laboratory studies show:
- Hematocrit: 33%
- Hemoglobin: 11.2 g/dL
- Leukocyte count: 12,500/mm3
- BUN: 102 mg/dL
- Serum glucose: 128 mg/dL
- Na: 142 mEq/L
- K: 5.3 mEq/L
- Cl: 103 mEq/L
*Arterial blood
- pH 7.38
- Po2 92 mm Hg
- Pco2 39 mm Hg
A chest x-ray film shows a normal cardiac outline, and an ECG shows nonspecific ST changes. Echocardiogram reveals mild fluid collection within the pericardial sac. Which of the following is the most appropriate next step in management?
(A) Water and salt intake reduction
(B) Antibiotic treatment
(C) Antihypertensive treatment
(D) Anti-inflammatory treatment
(E) Erythropoietin administration
(F) Hemodialysis
(G) Pericardiocentesis
(H) Pericardial biopsy
(I) Partial pericardiectomy
A 28-year-old man comes to the emergency department
complaining of abdominal pain. He has no significant past medical history, has had no recent illnesses, and denies any alcohol or drug abuse. He reports that 3 days ago, he developed acute pain in his right upper quadrant. The pain was nonradiating and was associated with nausea and two episodes of nonbloody, nonbilious emesis. He also reports that 2 days ago, he began to turn “yellow.” On examination, he is afebrile and has scleral icterus with mild jaundice of his skin. His right upper quadrant is tender, with no palpable gallbladder and no Murphy’s sign. Determination of which of the following is the most appropriate next step in diagnosis?
(A) Serum hepatitis A IgG titer
(B) Serum hepatitis A IgM titer
(C) Serum hepatitis B surface antibody titer
(D) Serum hepatitis C antibody
(E) Serum hepatitis C RNA level
A 40-year-old woman comes to the physician because of a 6-month history of increasing respiratory difficulty that occurs during mild exercise, such as walking uphill. She is 165 cm (65 in) tall and weighs 58 kg (129 lb), but says that she has lost 4 kg (9 lb) over the past 3 months. Her blood pressure is 120/75 mm Hg, pulse is 85/min, and respirations are is 16/min. Chest examination reveals
crackles at both lung bases and a diastolic murmur near the cardiac apex. The characteristics of the murmur change with the patient’s position. Echocardiography reveals a solid mass that partially fills the left atrium and results in obstruction of the mitral flow. Which of the following is the most likely diagnosis?
(A) Fibroelastoma
(B) Metastasis
(C) Mural thrombus
(D) Myxoma
(E) Sarcoma
A 45-year-old woman with rheumatoid arthritis develops pain, erythema, and swelling of the cartilaginous portion of both of her external ears. This is accompanied by pain localized to the costochondral joints. Which of the following is the most likely diagnosis?
(A) Ankylosing spondylitis
(B) Behcet syndrome
(C) Gout
(D) Reiter syndrome
(E) Relapsing polychondritis
An otherwise healthy 40-year-old woman comes to the physician because she discovered a painless nodule in her neck. On physical examination, palpation reveals a firm 1-cm nodule in the left cervical region, which moves upward as the patient swallows. Thyroid function tests are normal. Fine needle aspiration is positive for papillary carcinoma. Which of the following is a recognized risk factor for this form of cancer?
(A) Amiodarone treatment
(B) Dietary iodine supplementation
(C) Family history of multiple endocrine neoplasia (MEN)
(D) Graves disease
(E) Hashimoto thyroiditis
(F) Radiation to the neck
(G) Subacute thyroiditis
(H) Thyroglossal duct anomalies
A 40-year-old man is admitted for chemotherapy for treatment of acute myelogenous leukemia. A central line through his subclavian vein is inserted to facilitate infusion of chemotherapeutic agents. Ten days after this procedure, he develops a temperature of 39.4 C (103.0 F). Physical examination is remarkable for tachycardia and tenderness around the central line insertion site. Blood cultures and a chest x-ray film are negative. Which of the following is the most appropriate next step in management?
(A) Repeat blood cultures and wait for culture results to guide therapy
(B) Administer amphotericin
(C) Administer vancomycin
(D) Remove the central line
(E) Remove the central line and insert a new one over a guide wire
A recently widowed 35-year-old woman who has an anxiety disorder, for which she has been treated with alprazolam and imipramine, is brought to the emergency department for a multiple drug overdose. Her daughter states that she may have taken 30-40 tablets of 50-mg imipramine and 35-40 tablets of 1-mg alprazolam. On route to the hospital, she became apneic and was intubated. Her blood pressure is 130/84 mm Hg, and her pulse is 120/min. The patient is unresponsive to painful stimuli, and her pupils react very sluggishly, but there are no other neurologic findings. The ECG shows a normal sinus rhythm with a widened QRS complex. Which of the following is the most appropriate intervention?
(A) DC cardioversion
(B) Flumazenil
(C) Ipecac
(D) Lidocaine bolus
(E) Maintenance of serum pH at 7.5
A 38-year-old woman visits the clinic because of oral tenderness and soreness in her jaw for the past 2 months. She admits that swallowing food has become more painful. She notices that her mouth is chronically dry and that drinking lots of fluids seems to reduce the pain. She has a normal appetite but reports that she has lost 2 kg (5 lb) and is eating less because of the pain upon swallowing most foods. Physical examination reveals parched lips, dry oral mucous membranes, and bilaterally enlarged parotid glands with a firm, smooth texture. Needle biopsy of the salivary gland tissue reveals a dense, lymphocytic infiltrate with loss of many glands. Residual glands have prominent intraductal cellular proliferation. Which of the following is the most likely diagnosis in this patient?
(A) Mucoepidermoid carcinoma
(B) Pleomorphic adenoma
(C) Sarcoidosis
(D) Sjögren syndrome
(E) Squamous cell carcinoma
(F) Warthin tumor
A 52-year-old man with a 30-pack-year history of cigarette smoking presents to a physician after moving to a new city. He was told that he had “high cholesterol” about 2 years ago, and he has a history of mild hypertension for which he has never been treated. He had a myocardial infarction (MI) 6 months ago. His post-MI course has been uncomplicated, his exercise stress test was satisfactory, and he has experienced no subsequent chest pain. His medications include one aspirin tablet every other day. Physical examination is normal except for a fourth heart sound. Which of the following is the most appropriate next step in management to prevent significant morbidity and mortality?
(A) Add a beta blocker
(B) Add enalapril
(C) Add nifedipine
(D) Increase the aspirin to one tablet three times daily
(E) Prescribe nitroglycerin for angina
A 17-year-old boy of Jewish descent is taken to the emergency
department by his mother because of bloody diarrhea. Over the past 2 weeks, the boy has reported frequent urges to defecate that are accompanied by abdominal cramping. Over the past several days, the stools have become looser, and mucus was present around the feces. One hour ago, he saw fresh blood on his stool. On questioning, the boy notes that similar symptoms have occurred over the past 2 years, except for the blood in his stool. His temperature is 37.5 C (99.5 F), blood pressure is 120/70 mm Hg, pulse is 65/min, and respirations are 16/min. His abdomen is soft, without guarding, and there is localized tenderness in the right lower quadrant. Which of the following is the most likely diagnosis?
(A) Appendicitis
(B) Colon cancer
(C) Diverticulitis
(D) Mesenteric lymphadenitis
(E) Pseudomembranous colitis
(F) Ulcerative colitis
A 32-year-old man with AIDS has a CD4+ T-cell count of
40/mm3. He complains of a gradual onset of decreased vision in his right eye over the past few days. He is afebrile and has temporal wasting. There is a thick, cheesy, white exudate on his tongue and oropharynx, and there are deficits in the acuity and the visual fields of his right eye. The remainder of the cranial nerve examination is normal. Infection with which of the following pathogens is the most likely cause of his decreased vision?
(A) Candida albicans
(B) Cytomegalovirus (CMV)
(C) Herpes simplex virus 1 (HSV-1)
(D) Mycobacterium avium-intracellulare (MAI)
(E) Pneumocystis carinii
(F) Toxoplasmosis
A 5-year-old boy is brought to the emergency department 4 hours after sudden onset of fever and chills. He was bitten in his right hand by the family’s dog 24 hours ago. Examination reveals superficial lacerations of the ulnar aspect of the right hand consistent with a history of dog bite. The wound is surrounded by extensive skin erythema and soft tissue swelling. Palpable lymph nodes are found in the right axilla. His temperature is 38.9 C (102F). Which of the following is the most likely pathogen or pathogens?
(A) Capnocytophaga canimorsus
(B) Eikenella corrodens
(C) Mixed aerobic and anaerobic bacteria
(D) Pasteurella multocida
(E) Staphylococci
(F) Streptococci
A 65-year-old woman consults a physician with complaints of severe pain and stiffness of the neck, shoulders, and hips. These symptoms are worst in the morning and after inactivity. The woman has also been experiencing a variety of systemic symptoms, including malaise, lowgrade fever, depression, and some weight loss. On physical examination, there is no evidence of erosive or destructive joint disease, no point tenderness when pressure is applied to small joints, no selective muscle weakness or muscle atrophy, and no rheumatoid nodules. Blood studies demonstrate a mild normochromic normocytic anemia, dramatically elevated erythrocyte sedimentation rate, and elevated c-reactive protein. Thyroid-stimulating hormone (TSH) is 0.75 mIU/mL. Rheumatoid factor is negative. Electromyography and muscle biopsy fail to demonstrate conclusive evidence of muscle disease. This patient’s most likely condition has the strongest association with which of the following?
(A) Crohn disease
(B) Dermatomyositis
(C) Discoid lupus erythematosus
(D) Sjögren syndrome
(E) Temporal arteritis
A 71-year-old man with a long history of poorly controlled hypertension presents to the emergency department with headache and visual changes. His blood pressure is 220/130 mm Hg. Current medications include atenolol, nifedipine, thiazide, and clonidine. An IV sodium nitroprusside drip is started. The patient is then transferred to the intensive care unit, where his blood pressure is 135/75 mm Hg; however, he becomes hypoxemic with room air saturations falling to 80%. Which of the following is the most likely reason for this patient’s hypoxemia?
(A) Elevation of carboxyhemoglobin levels
(B) Elevation of methemoglobin level
(C) Hypoventilation
(D) Loss of hypoxic pulmonary vasoconstriction
(E) Pulmonary embolism
A 45-year-old man with alcoholism is admitted with a diagnosis of acute pancreatitis. He requires large volumes of fluid to maintain blood pressure and urine output, but 24 hours after admission, he appears in stable condition. On the fourth hospital day, the patient develops rapidly progressive respiratory distress, with labored breathing and tachypnea. His temperature is 37.0 C (98.6 F), pulse is 100/min, blood pressure is 128/75 mm Hg, and respirations are 24/min. Intercostal retraction and crackles are appreciated on chest examination. Blood tests show:
- Hematocrit: 42%
- Leukocytes: 9800/mm3
- Glucose: 110 mg/dL
- BUN: 20 mg/dL
- AST: 98 U/L
- ALT: 60 U/L
- Amylase: 280 U/L
*Arterial blood gas (room air)
- pH 7.32
- Pao2 52 mm Hg
- Paco2 51 mm Hg
A chest x-ray film reveals diffuse bilateral infiltrates and air bronchograms, a normal cardiac silhouette, and minimal pleural effusions. Which of the following is the most likely diagnosis?
(A) Acute bilateral bronchopneumonia
(B) Adult respiratory distress syndrome (ARDS)
(C) Cardiogenic pulmonary edema
(D) Exacerbation of acute pancreatitis
(E) Pulmonary embolism
A 47-year-old woman comes to the physician because she has had several episodes of severe chest pain that awoke her in the early morning. She has no history of major physical illness or drug abuse, drinks alcohol only occasionally, and does not smoke. Her temperature is 37.0 C (98.6 F), blood pressure is 126/78 mm Hg, pulse is 78/min and regular, and respirations are 12/min. An ECG reveals no abnormalities. No further studies are undertaken, and the physician tells the patient that her pain is probably of psychological origin. After a few days, the patient comes to the emergency department at 5 AM complaining of chest pain. An ECG reveals sinus rhythm with ST segment elevation. The patient is admitted, and coronary arteriography is performed, revealing no stenotic lesions. Intravenous administration of ergonovine during arteriography triggers chest pain accompanied by ST elevation on ECG. Which of the following is the most likely diagnosis?
(A) Myocardial infarction
(B) Prinzmetal angina
(C) Psychological chest pain
(D) Stable angina
(E) Unstable angina
A 34-year-old female flight attendant presents with a recurring, sharp pain radiating from her left ear to her mouth. She describes the pain as intense but intermittent, precipitated by cold, light touch, and chewing. Neurologic examination is normal. A tentative diagnosis of trigeminal neuralgia is made, and carbamazepine is prescribed. She returns 6 weeks later complaining of the same pain on both sides of her face and a new onset of urinary incontinence. Which of the following is the most likely diagnosis?
(A) Acoustic neuroma
(B) Amyotrophic lateral sclerosis
(C) Bell palsy
(D) Multiple sclerosis
(E) Myasthenia gravis
A 32-year-old woman is brought to the emergency department following the rapid onset of profound malaise and fever. On arrival, the patient’s temperature is 39.7 C (103.5 F), blood pressure is 110/75 mm Hg, pulse is 110/min and regular, and respirations are 17/min. On examination, needle tracks and scars are noted on the forearms and thighs. Chest examination reveals a systolic murmur along the left lower sternal border. Blood tests show 16,000 leukocytes/mm3 and an erythrocyte sedimentation rate of 90/min. Which of the following is the most appropriate next step in management?
(A) Broad spectrum antibiotic therapy
(B) Echocardiographic studies
(C) Three sets of blood cultures
(D) Toxicologic studies on blood and urine
(E) Ventilation-perfusion lung scans
An 18-year-old man comes to clinic for evaluation of weakness and fatigue lasting 6 weeks. Before these past 6 weeks, he reports being fairly healthy. He did, however, have a recent case of “the flu.” On reviewing his medical records, it seems that approximately 2 months ago the patient had a mild hepatitis of unclear etiology (serologies for hepatitis A, B, and C were negative) that has since resolved. Before this illness, he has been healthy, takes no medications, and knows of no diseases that run in his family. He does not use illicit substances, does not smoke, rarely drinks alcohol, has never received a blood transfusion, has never had sex, and does not have any tattoos. Physical examination reveals marked pallor and a 2/6 nonradiating systolic murmur heard best at the right upper sternal border. Abdominal examination reveals a few scattered petechiae but no hepato-splenomegaly. Laboratory studies show:
- Hematocrit: 15%
- Hemoglobin: 5.0 g/dL
- Leukocytes: 4,000/mm3 (normal differential)
- Platelets: 15,500/mm3
- Reticulocytes: 0.5%
The rest of the patient’s laboratory studies, including a set of chemistries and liver function tests, are unremarkable. The patient is admitted to the hospital and receives a transfusion with leukocyte-reduced blood products. A bone marrow biopsy is performed the next morning that shows cellularity of less than 5% with normal cellular morphology and no organisms on Gram stain. Which of the following is the most appropriate treatment?
(A) Antithymocyte globulin
(B) Bone marrow transplant
(C) Broad-spectrum antibiotics
(D) Colony-stimulating factor
(E) Intravenous corticosteroids
A 70-year-old woman has been in good health until 3 months ago, when she noted the appearance of plaques in her axillae and groin. She has also experienced anorexia and easy fatigability for the past few months. The patient has no history of major disease, and her family history is unremarkable. She is 165 cm tall (65 in) and weighs 53 kg (117 lb). Examination reveals several slightly raised, brown plaques with a velvety surface in the flexural regions of neck, axilla, and groin. A biopsy is consistent with acanthosis nigricans.
(A) Allergen skin testing
(B) Bacterial cultures of skin scrapings
(C) Blood glucose measurement
(D) Gluten-free diet trial
(E) HIV testing
(F) Microscopic examination of KOH-treated skin scrapings
(G) Serum IgE assays (RAST or ELISA)
(H) Stroking on skin lesions with a blunt object
A 40-year-old man presents with numerous brown spots on the skin. He reports a history of chronic diarrhea and generalized itching, the latter manifesting frequently after he takes aspirin or drinks alcoholic beverages. He has noticed that slight rubbing on affected skin results in redness and itching. He has had recurrent asthmatic episodes in the past few years. His recent medical history is also significant for 8-kg (18-lb) weight loss in the past 6 months. On examination, there are dozens of small, red-brown macules on the trunk and upper limbs. The spleen is palpable 4 cm below the left costal arch. A biopsy of these macules reveals a dense dermal infiltrate of cells that stain positively for toluidine blue.
(A) Allergen skin testing
(B) Bacterial cultures of skin scrapings
(C) Blood glucose measurement
(D) Gluten-free diet trial
(E) HIV testing
(F) Microscopic examination of KOH-treated skin scrapings
(G) Serum IgE assays (RAST or ELISA)
(H) Stroking on skin lesions with a blunt object
