Pretest medicine 42Q.

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Infectious Disease
3. A 25-year-old male student presents with the chief complaint of rash.
He denies headache, fever, or myalgia. A slightly pruritic maculopapular rash
is noted over the abdomen, trunk, palms of the hands, and soles of the feet.
Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic,
flat, wartlike lesions are noted around the anal area. aboratory studies show
the following!
Hct! "#$
Hgb! %" g&d
'()! %*,###&
+iff! 5#$ segmented neutrophils, 5#$ lymphocytes
'hich of the following is the most useful laboratory test in this patient,
a. 'eil--eli. titer
b. /enereal +isease 0esearch aboratory 1/+02 test
c. Chlamydia titer
d. (lood cultures
e. (iopsy of perianal lesions
10. A 23-year-old female presents to her internist with a 2-day history of
low-grade fever and lower abdominal pain. 4he denies nausea, vomiting, or
diarrhea. 5n physical e.amination, there is temperature of *3.*) 1%##.6-2
and bilateral lower 7uadrant tenderness, without point or rebound tenderness.
(owel sounds are normal. 5n pelvic e.amination, an e.udate is present and
there is tenderness on motion of the cervi.. Her white blood cell count is
%5,###& and urinalysis shows no red or white blood cells. 4erum -h)8 is
undetectable. 'hich of the following is the best ne.t step in management,
a. 9reatment with ceftria.one and do.ycycline
b. :ndometrial biopsy
c. 4urgical e.ploration
d. +ilation and curettage
e. A;treonam
26. A <#-year-old nursing home resident was admitted to the hospital for
pneumonia and treated for %# days with levoflo.acin. 5n discharge she was
improved but developed diarrhea one week later. 4he had low-grade fever
and mild abdominal pain with 2 to * watery, nonbloody stools per day.
A cell culture cytoto.icity test for Clostridium difficileassociated disease was
positive. 9he patient was treated with oral metronida;ole, but did not improve,
even after %# days. +iarrhea has increased and fever and abdominal pain
continue. 'hat is the best ne.t step in the management of this patient,
a. 5btain C difficile en;yme immunoassay.
b. )ontinue metronida;ole for at least two more weeks.
c. 4witch treatment to oral vancomycin.
d. Hospitali;e patient for fulminant C difficileassociated disease.
e. =se synthetic fecal bacterial enema.
Rheumatology
67. A >>-year-old man complains of a %-year history of low-back and buttock
pain that worsens with walking and is relieved by sitting or bending forward.
He has hypertension and takes hydrochlorothia;ide but has otherwise been
healthy. 9here is no history of back trauma, fever, or weight loss. 5n e.amination,
the patient has a slightly stooped posture, pain on lumbar e.tension,
and has a slightly wide base gait. ?edal pulses are normal and there are no
femoral bruits. :.amination of peripheral @oints and skin is normal. 'hat
is the most likely cause for this patientAs back and buttock pain,
a. umbar spinal stenosis
b. Herniated nucleus pulposus
c. Atherosclerotic peripheral vascular disease
d. -acet @oint arthritis
e. ?rostate cancer
73. ast week a 2#-year-old college student developed acute wrist pain and
swelling. 9his resolved in four days. Besterday, he developed pain and swelling
in his left knee. 9wo months ago he went on a backpacking trip in 0hode Island.
A week or so later he developed an enlarging circular red spot that persisted for
2 weeks and then resolved. 'hat is the most likely diagnosis,
a. Acute rheumatoid arthritis
b. ?arvovirus infection
c. ?soriatic arthritis
d. yme disease
e. Inflammatory bowel disease
64. A "#-year-old man complains of e.7uisite pain and tenderness in the left
ankle. 9here is no history of trauma. 9he patient is taking hydrochlorothia;ide
for hypertension. 5n e.amination, the ankle is very swollen and tender. 9here
are no other physical e.amination abnormalities. 'hich of the following is
the best ne.t step in management,
a. (egin colchicine and broad-spectrum antibiotics.
b. ?erform arthrocentesis.
c. (egin allopurinol if uric acid level is elevated.
d. 5btain ankle .-ray to rule out fracture.
e. Apply a splint or removable cast.
Dermatology
389. A *#-year-old black female has a 2-month history of nonproductive
cough and a painful skin eruption in the lower e.tremities. 4he denies fever
or weight loss. ?hysical e.amination shows several nontender raised pla7ues
around the nares and scattered similar pla7ues around the base of the neck. In
the lower e.tremities she has several erythematous tender nonulcerated nodules,
measuring up to " cm in diameter. )hest .-ray reveals bilateral hilar
adenopathy and a streaky interstitial density in the right upper lobe. 'hat is the
best way to establish a histological diagnosis,
a. ?unch biopsy of one of the pla7ues on the neck
b. Incisional biopsy of one of the lower e.tremity nodules
c. 4putum studies for A-( and fungi
d. Cediastinoscopy and biopsy of one of the hilar or mediastinal nodes
e. 4erum angiotensin-converting en;yme assay
394. A *6-year-old male with a prior history of myocardial infarction complains
of yellow bumps on his elbows and buttocks. Bellow-colored cutaneous
pla7ues are noted in those areas. 9he lesions occur in crops and have
a surrounding reddish halo. 'hich of the following is the best ne.t step in
evaluation of this patient,
a. (iopsy of skin lesions
b. ipid profile
c. =ric acid level
d. )hest .-ray
e. iver en;ymes
399. A **-year-old fair-skinned woman has telangiectasias of the cheeks
and nose along with red papules and occasional pustules. 4he also appears
to have con@unctivitis with dilated scleral vessels. 4he reports fre7uent
flushing and blushing. +rinking red wine produces a severe flushing of the
face. 9here is a family history of this condition. 'hich of the following is the
most likely diagnosis,
a. )arcinoid syndrome
b. ?orphyria cutanea tarda
c. upus vulgaris
d. 0osacea
e. 4eborrheic dermatitis
Allergy an
Immunology
449. A *#-year-old male develops skin rash, pruritus, and mild whee;ing
about 2# minutes after an intravenous pyelogram performed for the evaluation
of renal stone symptoms. 'hich of the following is the best approach
to diagnosis of this patient,
a. ?erform 2"-hour urinary histamine measurement.
b. Ceasure immunoglobulin : to radiocontrast media.
c. +iagnose radiocontrast media sensitivity by history.
d. 0ecommend intradermal skin testing.
e. 9he patient cannot be e.posed to iodinated contrast agents in the future.
4!2. A 55-year-old farmer develops recurrent cough, dyspnea, fever, and
myalgia several hours after entering his barn. He has had similar reactions
several times previously, especially when he feeds hay to his cattle. 'hich
of the following statements is true,
a. 9he presence of fever and myalgia indicates that this is an infectious process.
b. Immediate-type Ig: hypersensitivity is involved in the pathogenesis of his illness.
c. 9he etiological agents are often thermophilic actinomycete antigens.
d. +emonstrating precipitable antibodies to the offending antigen confirms the
diagnosis of hypersensitivity pneumonitis.
e. )hronic lung disease does not occur in this setting.
4!!. A >2-year-old man is diagnosed with neurosyphilis. 4even years ago
he had an anaphylactic reaction to a penicillin shot which was administered
for streptococcal pharyngitis. He re7uired treatment with epinephrine and
reports that he Dalmost died.E 'hat is the best approach to the management
of his neurosyphilis,
a. 5ral do.ycycline
b. Intravenous ceftria.one
c. 5ral erythromycin
d. Fo treatment available
e. ?enicillin desensiti;ation followed by parenteral penicillin 8

"ematology an
#ncology
314. A >"-year-old woman who is receiving chemotherapy for metastatic
breast cancer has been treating midthoracic pain with acetaminophen. 5ver
the past few days she has become weak and unsteady on her feet. 5n the
day of admission she develops urinary incontinence. ?hysical e.amination
reveals fist percussion tenderness over 93 and moderate symmetric muscle
weakness in the legs. Anal sphincter tone is reduced. 'hich of the following
diagnostic studies is most important to order,
a. 4erum calcium
b. (one scan
c. ?lain radiographs of the thoracic spine
d. C0I scan of the spine
e. :lectromyogram with nerve conduction studies
320. A <5-year-old man with a prior history of adenocarcinoma of the
prostate treated with radical prostatectomy presents with pain in the left hip.
9he pain awakens him at night and has become increasingly severe over the
previous * weeks. ?lain radiographs show numerous bilateral osteoblastic
lesions in the hip and sacrum, and the prostate-specific antigen level is
3* mcg&m 1normal # to "2. 'hich of the following is the treatment of choice,
a. 5bservation
b. 0adiation therapy
c. :strogen therapy
d. 8onadotropin-releasing hormone 18n0H2 analogue
e. )hemotherapy
330. A 2>-year-old man complains of heaviness in the left testicle. 9here has
been no recent trauma. ?hysical e.amination reveals a *-cm painless firm
mass that clearly arises from the testicle. 9he physical e.amination is otherwise
unremarkable. Abdominal )9 scan shows matted periaortic lymphadenopathy,
with the largest node appro.imately *.5 cm in si;e. )9 of the chest shows no
abnormalities. In addition to urological referral, what should be the ne.t
diagnostic study,
a. Feedle aspiration biopsy of the retroperitoneal mass
b. Feedle aspiration of the testicular mass
c. Ceasurement of alpha fetoprotein, beta H)8 and lactate dehydrogenase 1+H2
d. ?ositron emission tomography 1?:92 scan
e. Ceasurement of carcinoembryonic antigen 1):A2 and -fetoprotein
$eurology
3!!. A >5-year-old man develops a severe headache and right-sided weakness.
He has a history of osteoarthritis, gout, and hypertension. He regularly keeps his
follow-up visits and is compliant with his medications, which include lisinopril
%# mg po 7 AC for hypertension, allopurinol *## mg po 7 AC to prevent gout,
and acetaminophen for his @oint pains. 0eview of his recent office record shows
that his mean blood pressure has been %2"&<3. 5n physical e.amination the
patient is drowsy but arousable. His blood pressure is %>"&6# and his pulse rate
is 5>. He has a right homonymous hemianopsia and a mild right hemiparesis.
4ensory e.amination is difficult due to poor cooperation. )ardiac e.amination
shows no 4* or 4" gallop and a regular rhythm. He has no ecchymoses or evidence
of abnormal bruising. His :)8 is normal without left ventricular hypertrophy.
)9 of the head without I/ contrast shows an acute hemorrhage in the
left parietal lobeG the basal ganglia and thalamus are uninvolved. 'hat is the
likely pathogenesis of the neurological problem,
a. 4mall vessel vasculitis
b. Intimal damage to penetrating cerebral vessels
c. 9rauma from domestic abuse
d. )oagulopathy
e. Amyloid deposition in the cerebral vasculature
368. A 5*-year-old woman presents with increasing weakness, most noticeable
in the legs. 4he has noticed some cramping and weakness in the upper
e.tremities as well. 4he has more difficulty removing the lids from @ars than
before. 4he has noticed some stiffness in the neck but denies back pain or
in@ury. 9here is no bowel or bladder incontinence. 4he takes napro.en for
osteoarthritis and is on alendronate for osteoporosis. 4he smokes one pack of
cigarettes daily. 9he general physical e.amination reveals decreased range of
motion in the cervical spine. 5n neurological e.amination, the patient has
"&5 strength in the hands with mild atrophy of the interosseous muscles. 4he
also has "&5 strength in the feetG the weakness is more prominent in the distal
musculature. 4he has difficulty with both heel walking and toe walking.
0efle.es are hyperactive in the lower e.tremities. 4ustained clonus is demonstrated
at the ankles. 'hat is the best ne.t step in her management,
a. 5btain C0I scan of the head.
b. (egin rilu;ole.
c. 5btain C0I scan of the cervical spine.
d. )heck muscle en;ymes including creatine kinase and aldolase.
e. 0efer for physical therapy and gait training e.ercises.
3!7. A *2-year-old woman presents to you for evaluation of headache. 9he
headaches began at age %3, were initially unilateral and worse around the
time of her menses. Initially the use of triptans 2 or * times a month would
provide complete relief. 5ver the past several years, however, the headaches
have become more fre7uent and severe. 9riptans provide only partial reliefG
the patient re7uires a combination of acetaminophen, caffeine, and butalbital
to achieve some improvement. ?rophylactic medications including betablockers,
tricyclics, and topiramate have been unsuccessful in preventing the
headaches, and she has been to the emergency room three times over the past
2 weeks for a Dpain shot.E 9he general physical e.amination is unremarkable.
Her funduscopic e.amination shows no evidence of papilledema, and a careful
neurological e.amination is likewise normal. 'hat is the most likely e.planation
for her headache syndrome,
a. 4tatus migranosus
b. Cedication overuse headache
c. 4pace occupying intracerebral lesion
d. )F4 vasculitis
e. ?seudotumor cerebri
%astroenterology
234. A <#-year-old man presents with a complaint of fatigue. 9here is no
history of alcohol abuse or liver diseaseG the patient is taking no medications.
4cleral icterus is noted on physical e.aminationG the liver and spleen
are nonpalpable. 9he patient has a normocytic, normochromic anemia. =rinalysis
shows bilirubinuria with absent urine urobilinogen. 4erum bilirubin
is %2 mg&d, A49 and A9 are normal, and alkaline phosphatase is *## =&
1three times normal2. 'hich of the following is the best ne.t step in evaluation,
a. =ltrasound or )9 scan of the abdomen
b. /iral hepatitis profile
c. 0eticulocyte count
d. 4erum ferritin
e. Antimitochondrial antibodies
237. A >#-year-old woman complains of fever and constant left lower
7uadrant pain of 2 days duration. 4he has not had vomiting or rectal bleeding.
4he has a history of hypertension but is otherwise healthy. 4he has
never had similar abdominal pain, and has had no previous surgeries. Her
only regular medication is lisinopril.
5n e.amination blood pressure is %5#&3#, pulse %%#, and temperature
*3.6) 1%#2-2. 4he has normal bowel sounds and left lower 7uadrant
abdominal tenderness with rebound. A complete blood count reveals '() H
23,###. 4erum electrolytes, (=F, creatinine and liver function tests are normal.
'hat is the ne.t best step in evaluating this patientAs problem,
a. )olonoscopy
b. (arium enema
c. :.ploratory laparotomy
d. =ltrasound of the abdomen
e. )9 scan of the abdomen and pelvis
248. A *"-year-old white woman is treated for a =9I with amo.icillin. Initially
she improves, but 5 days after beginning treatment, she develops
recurrent fever, abdominal bloating, and diarrhea with si. to eight loose
stools per day. 'hat is the best diagnostic test to confirm your diagnosis,
a. Identification of Clostridium difficile to.in in the stool
b. Isolation of C difficile in stool culture
c. 4tool positive for white blood cells 1fecal leukocytes2
d. +etection of Ig8 antibodies against C difficile in the serum
e. /isuali;ation of clue cells on microscopic e.amination of stool
232. A 5>-year-old woman becomes the chief financial officer of a large company
and, several months thereafter, develops upper abdominal pain that she
ascribes to stress. 4he takes an over-the-counter antacid with temporary benefit.
4he uses no other medications. 5ne night she awakens with nausea and
vomits a large volume of coffee grounds-like materialG she becomes weak and
diaphoretic. =pon hospitali;ation, she is found to have an actively bleeding
duodenal ulcer. 'hich of the following statements is true,
a. 9he most likely etiology is adenocarcinoma of the duodenum.
b. 9he etiology of duodenal ulcer is different in women than in men.
c. 9he likelihood that she harbors Helicobacter pylori is greater than 5#$.
d. ifetime residence in the =nited 4tates makes H pylori unlikely as an etiologic
agent.
e. 5rganisms consistent with H pylori are rarely seen on biopsy in patients with
duodenal ulcer.
$e&hrology
273. A >3-year-old woman with stable coronary artery disease undergoes an
aortogram with lower e.tremity run-off studies for symptomatic peripheral
vascular disease. 9he patient is on warfarin 1for recurrent deep vein thrombosis2,
aspirin, lisinopril, metoprolol, and atorvastatin. 4he received a course
of diclo.acillin for cellulitis % week ago. 9hree weeks after angiography the
patient is evaluated for general malaise. ?hysical e.amination reveals a
petechial rash and livedo reticularis on both lower e.tremities. aboratory
evaluation reveals that her creatinine has risen from %.5 to *.< mg&d. 5ther laboratory
abnormalities include an :40 of 6> mm&h, leukocytosis, eosinophilia,
and a reduced third component of complement 1)*2. =rine sodium is
"# m:7&. =rinalysis reveals 5 to %# eosinophils&H?-, %# to 2# '()&H?-, 5 to
%# 0()&H?-, no casts, and %I dipstick proteinuria. 'hich of the following is
the most likely diagnosis,
a. ?rerenal a;otemia
b. 0adiocontrast-induced acute renal failure
c. +rug-induced acute interstitial nephritis
d. Acute glomerulonephritis
e. Atheroembolic renal failure
276. A <*-year-old male undergoes abdominal aortic aneurysm repair.
?ostoperatively, his blood pressure is %%#&<#, heart rate is %%#, surgical
wound is clean, and a -oley catheter is in place. His urine output drops to
"# cc&h, and creatinine rises from %.5 to 2.2 mg&d. Hemoglobin and
hematocrit are stable, J ".>, uric acid 3.2. 'hich initial diagnostic test is
most useful for this patient,
a. =rine sodium&creatinine ratio
b. =rinalysis
c. 0enal ultrasound
d. =rine uric acid&creatinine ratio
e. )9 renal arteriogram
279. A 5>-year-old man presents with hypertension and peripheral
edema. He is otherwise healthy and takes no medications. -amily history
reveals that his father and a brother have kidney disease. His father was on
hemodialysis before his death at age >3 of a stroke. ?hysical e.amination
reveals (? %<"&6> and A/ nicking on funduscopic e.amination. He has a
soft 4" gallop. (ilateral flank masses measuring %> cm in length are palpable.
=rinalysis shows %5 to 2# 0()&H?- and trace protein but is otherwise
normalG his serum creatinine is 2." mg&d.
'hich is the most likely long-term complication of his condition,
a. :nd-stage renal disease re7uiring dialysis or transplantation
b. Calignancy
c. 0uptured cerebral aneurysm
d. (iliary obstruction owing to cystic disease of the pancreas
e. +ementia
289. A *6-year-old woman is admitted to the gynecology service for hysterectomy
for symptomatic uterine fibroids. ?ostoperatively the patient develops
an ileus accompanied by severe nausea and vomitingG ondansetron is
piggybacked into an I/ of +5 %&2 normal saline running at %25 cc&hr. 5n the
second postoperative day the patient becomes drowsy and displays a few
myoclonic @erks. 4tat labs reveal Fa %%3, J *.2, )l 33 H)5* 22, (=F *, creatinine
#.6. =rine studies for Fa and osmolality are sent to the lab. 'hat is the
most appropriate ne.t step,
a. )hange the I/ fluid to #.6$ 1normal2 saline and restrict free-water intake to
>oo cc&d
b. )hange the odansetron to prometha;ine, change the I/ fluid to lactated 0inger
solution and recheck the Fa in " hours.
c. 4tart *$ 1hypertonic2 saline, make the patient F?5 and transfer to the I)=
d. )hange the I/ fluid to normal saline and give furosemide "#mg I/ stat.
e. Cake the patient F?5 and send for stat )9 scan of the head to look for cerebral
edema.
'nocrinology an
(eta)olic Disease
198. A 53-year-old male is referred to your office after evaluation in the
emergency room for abdominal pain. 9he patient was diagnosed with gastritis
but a )9 scan with contrast performed during the workup of his pain
revealed a 2-cm adrenal mass. 9he patient has no history of malignancy and
denies erectile dysfunction. ?hysical e.amination reveals a (? of %22&<3
with no gynecomastia or evidence of )ushing syndrome. His serum potassium
is normal. 'hat is the ne.t step in determining whether this patientAs
adrenal mass should be resected,
a. ?lasma aldosterone&renin ratio.
b. :stradiol level.
c. ?lasma metanephrines and de.amethasone-suppressed cortisol level.
d. 9estosterone level.
e. 0epeat )9 scan in > months.
206. A "#-year-old alcoholic male is being treated for tuberculosis, but he has
not been compliant with his medications. He complains of increasing weakness,
fatigue, weight loss, and nausea over the preceding three weeks. He appears
thin, and his blood pressure is 3#&5# mm Hg. 9here is increased pigmentation
over the elbows and in the palmar creases. )ardiac e.amination is normal.
'hich of the following is the best ne.t step in evaluation,
a. )() with iron and iron-binding capacity
b. :rythrocyte sedimentation rate
c. :arly morning serum cortisol and cosyntropin stimulation
d. (lood cultures
e. :sophagogastroduodenoscopy 1:8+2
212. A 25-year-old woman is admitted for hypertensive crisis. 9he patientAs
urine drug screen is negative. In the hospital, blood pressure is labile and
responds poorly to antihypertensive therapy. 9he patient complains of palpitations
and apprehension. Her past medical history shows that she developed
hypertension during an operation for appendicitis at age 2*.
Hct! "6$ 1*<-"32
'()! %% %#* mm 1".*-%#.32
?lasma glucose! %># mg&d 1<5-%%52
?lasma calcium! %% mg&d 16-%#.52
'hich of the following is the most likely diagnosis,
a. An.iety attack
b. 0enal artery stenosis
c. :ssential hypertension
d. 9ype % diabetes mellitus
e. ?heochromocytoma
217. A 52-year-old man complains of impotence. 5n physical e.amination,
he has an elevated @ugular venous pressure, 4* gallop, and hepatomegaly. He
also appears tanned, with pigmentation along @oint folds. His left knee is
swollen and tender. 9he plasma glucose is 25# mg&d, and liver en;ymes are
elevated. 'hich of the following studies will help establish the diagnosis,
a. +etection of nocturnal penile tumescence
b. +etermination of iron saturation
c. +etermination of serum copper
d. +etection of hepatitis ( surface antigen
e. :chocardiography
219. A *2-year-old woman has a *-year history of oligomenorrhea that
has progressed to amenorrhea during the past year. 4he has observed loss
of breast fullness, reduced hip measurements, acne, increased body hair, and
deepening of her voice. ?hysical e.amination reveals frontal balding, clitoral
hypertrophy, and a male escutcheon. =rinary free cortisol and dehydroepiandrosterone
sulfate 1+H:A42 are normal. Her plasma testosterone
level is > ng&m 1normal is #.2 to #.32. 'hich of the following is the most
likely diagnosis,
a. )ushing syndrome
b. Arrhenoblastoma
c. ?olycystic ovary syndrome
d. 8ranulosa-theca cell tumor
e. 5varian teratoma
*ulmonary Disease
100. A <#-year-old patient with chronic obstructive lung disease re7uires
2 &min of nasal 52 to treat his hypo.ia, which is sometimes associated with
angina. 9he patient develops pleuritic chest pain, fever, and purulent sputum.
'hile using his o.ygen at an increased flow of 5 &min he becomes
stuporous and develops a respiratory acidosis with )52 retention and worsening
hypo.ia. 'hat would be the most appropriate ne.t step in the management
of this patient,
a. 4top o.ygen.
b. (egin medro.yprogesterone.
c. Intubate and begin mechanical ventilation.
d. 5bserve patient 2" hours before changing therapy.
e. (egin sodium bicarbonate.
104. A 23-year-old male with a long history of severe asthma presents to
the emergency room with shortness of breath. He has previously re7uired
admission to the hospital and was once intubated for asthma. 'hich of the
following findings on physical e.amination would predict a benign course,
a. 4ilent chest
b. Hypercapnia
c. 9horacoabdominal parado. 1parado.ical respiration2
d. ?ulsus parado.us of 5 mm Hg
e. Altered mental status
106. A 5<-year-old man develops acute shortness of breath shortly after a
%2-hour automobile ride. 9he patient is admitted to the hospital for shortness
of breath. -indings on physical e.amination are normal e.cept for tachypnea
and tachycardia. He does not have edema or popliteal tenderness. An electrocardiogram
reveals sinus tachycardia but is otherwise normal. 'hich of the
following statements is correct,
a. A normal +-dimer level e.cludes pulmonary embolus.
b. 9he patient should be admitted to the hospital, and, if there is no contraindication
to anticoagulation, full-dose heparin or eno.aparin should be started pending further
testing.
c. Formal findings on e.amination of the lower e.tremities make pulmonary
embolism unlikely.
d. :arly treatment has little effect on overall mortality.
e. A normal lower e.tremity venous +oppler study will rule out a pulmonary
embolus.
111. A >#-year-old male has had a chronic cough with clear sputum production
for over 5 years. He has smoked one pack of cigarettes per day for
2# years and continues to do so. K-ray of the chest shows hyperinflation
without infiltrates. Arterial blood gases show a pH of <.*3, ?)52 of "# mm Hg,
and ?52 of >5 mm Hg. 4pirometry shows an -:/%&-/) of "5$ without
bronchodilator response. 'hich of the following is the most important
treatment modality for this patient,
a. 5ral corticosteroids
b. Home o.ygen
c. (road-spectrum antibiotics
d. 4moking cessation program
e. 5ral theophylline
11!. A *5-year-old female complains of slowly progressive dyspnea. Her
past history is negative, and there is no cough, sputum production, pleuritic
chest pain, or thrombophlebitis. 4he has taken appetite suppressants at different
times. ?hysical e.amination reveals @ugular venous distention, a palpable
right ventricular lift, and a loud ?2 heart sound. )hest .-ray shows
clear lung fields. 5.ygen saturation is 6"$. :)8 shows right a.is deviation.
A perfusion lung scan is normal, with no segmental deficits. 'hich of the
following is the most likely diagnosis,
a. ?rimary pulmonary hypertension
b. 0ecurrent pulmonary emboli
c. 0ight-to-left cardiac shunt
d. Interstitial lung disease
e. eft ventricular diastolic dysfunction
+ariology
1!0. Besterday you admitted a 55-year-old white male to the hospital for
an episode of chest pain, and you are seeking to rule out CI plus assess for
any underlying coronary artery disease. 9he patient tends to be an.ious about
his health. 5n admission, his lungs were clear, but his heart revealed a grade
%&> early systolic murmur at the upper left sternal border without radiation.
(lood pressure readings have consistently been in the %"#&6# to %5#&%##
range. )ardiac en;ymes are normal. A resting :)8 shows only left ventricular
hypertrophy with secondary 49-9 changes 1D/H with strainE2. 'hy would
a treadmill :)8 stress test not be an appropriate test in this patient,
a. Anticipated difficulty with the patientAs an.iety 1ie, he might falsely claim chest
pain during the test2
b. Increased risk associated with high blood pressure readings
c. )oncern about the heart murmur, a relative contraindication to stress testing
d. 9he presence of /H with 49-9 changes on baseline :)8
e. )oncern that this represents the onset of unstable angina with unacceptable
risk of CI with stress testing
1!9. A ><-year-old male presents to your office after community ultrasound
screening revealed an aortic aneurysm measuring *.# *.5 cm. ?hysical
e.amination confirms a palpable, pulsatile, nontender abdominal mass @ust
above the umbilicus. 9he patientAs medical conditions include hypertension,
hyperlipidemia, and tobacco use. 'hat is the best recommendation for the
patient to consider,
a. 'atchful waiting is the best course until the first onset of abdominal pain.
b. 4urgery is indicated e.cept for the e.cess operative risk represented by the
patientAs risk factors.
c. 4erial follow-up with ultrasound, )9, or C0I is indicated, with the ma@or determinant
for surgery being aneurysmal si;e greater than 5 to > cm.
d. 4erial follow-up with ultrasound, )9, or C0I is indicated, with the ma@or determinant
for surgery being involvement of a renal artery.
e. =nlike stents in coronary artery disease, endovascular stent grafts have proven
unsuccessful in the management of AAAs
167. A <#-year-old male with a history of coronary artery disease presents to the
emergency department with 2 hours of substernal chest pressure, diaphoresis,
and nausea. He reports difficulty Dcatching his breath.E An electrocardiogram
shows septal 9-wave inversion. 9he patient is given *25-mg aspirin
and sublingual nitroglycerin while awaiting the results of his blood work.
His troponin I is #.>5 ng&m 1normal < #.#" ng&m2. 9he physician in the
emergency department starts the patient on low-molecular-weight heparin.
His pain is *&%#. (lood pressure is currently %5"&<3 and heart rate is <2.
Bou are asked to assume care of this patient. 'hat is the best ne.t step in
management,
a. Arrange for emergent cardiac catheteri;ation.
b. (egin intravenous thrombolytic therapy.
c. Admit the patient to a monitored cardiac bed and repeat cardiac en;ymes and
:)8 in > hours.
d. (egin intravenous beta-blocker therapy.
e. (egin clopidogrel *## mg po each day.
162. A <#-year-old female has been healthy e.cept for hypertension treated
with a thia;ide diuretic. 4he presents with sudden onset of a severe, tearing chest
pain, which radiates to the back and is associated with dyspnea and diaphoresis.
(lood pressure is 2%#&6". ung auscultation reveals bilateral basilar rales.
A faint murmur of aortic insufficiency is heard. 9he (F? level is elevated at
55# pg&m 1Formal L %##2. :)8 shows nonspecific 49-9 changes. )hest
.-ray suggests a widened mediastinum. 'hich of the following choices
represents the best initial management,
a. I/ furosemide plus I/ loading dose of digo.in
b. ?ercutaneous coronary intervention with consideration of angioplasty and&or
stenting
c. (lood cultures and rapid initiation of vancomycin plus gentamicin, followed by
echocardiography
d. I/ beta-blocker to control heart rate, I/ nitroprusside to control blood pressure,
transesophageal echocardiogram
e. I/ heparin followed by )9 pulmonary angiography
171. A "2-year-old female with acute pericarditis develops @ugular venous
distention and hypotension. 9he :)8 shows electrical alternans. 'hich of
the following is the most likely additional physical finding,
a. (asilar rales halfway up both posterior lung fields
b. 4* gallop
c. ?ulsus parado.us
d. 4trong apical beat
e. :pigastric tenderness
174. A *2-year-old male presents to your office with concern about progressive
fatigue and lower e.tremity edema. He has e.perienced decreased e.ercise
tolerance over the past few months, and occasionally awakens coughing at
night. ?ast medical history is significant for sickle cell anemia and diabetes
mellitus. He has had multiple admissions to the hospital secondary to vasoocclusive
crises since the age of three. ?hysical e.amination reveals a displaced
?CI, but is otherwise unremarkable. :)8 shows a first degree A/ block and
low voltage. )hest .-ray shows an enlarged cardiac silhouette with clear lung
fields. 'hich of the following would be the best initial diagnostic approach,
a. 5rder serum iron, iron-binding capacity, and ferritin level.
b. 5rder brain-natriuretic peptide 1(F?2
c. 5rder )9 scan of the chest.
d. Arrange for placement of a 2"-hour ambulatory cardiac monitor.
e. Arrange for cardiac catheteri;ation.