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Thread: Internal Medicine - 50 Questions

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    Default Internal Medicine - 50 Questions

    1) A family physician cares for a family consisting of a 45-year old husband, 43-year-old wife and a 12-year-old daughter. The family reports that recently the 77-year-old maternal grandmother who lived with them died after a prolonged respiratory infection. Autopsy subsequently confirms that she had active pulmonary tuberculosis at the time of death. The organism tested sensitive to all anti-tuberculosis drugs. In responding to the grandmother's illness, which of the following is the most appropriate step in management?
    A. Obtain leukocyte counts on all family members
    B. Obtain sputum cultures for acid fast bacilli
    C. Obtain chest computerized tomograms on all members
    D. Place protein purified derivative (PPD) test on all members
    E. Schedule bronchoscopy lavage for the adults

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    2) A 57-year-old man comes to the emergency department because of excruciating pain in his right big toe. He describes the pain as so severe that it woke him from a deep sleep. He has no chronic medical conditions, does not take any medications, and denies any similar episodes in the past. He admits to a few "drinking binges" over
    the past 2 weeks. His temperature is 38.1 C (100.5 F), blood pressure is 130/90 mm Hg, and pulse is 80/min. Examination shows an erythematous, warm, swollen, and exquisitely tender right great toe. The skin overlying the first metatarsophalangeal joint is dark red, tense, and shiny. Synovial fluid analysis reveals negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes (PMNs). Laboratory studies show:
    Serum
    Leukocytes........16,000/mm3
    Uric acid...........15 mg/dL
    Calcium.............9 mg/dL
    Which of the following is the most appropriate pharmacotherapy?
    A. Allopurinol
    B. Ceftriaxone
    C. Indomethacin
    D. Probenecid
    E. Sulfinpyrazone

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    3) A 35-year-old woman arrives on the floor after an uneventful hysteroscopy to evaluate her long history of uterine fibroids. About 30 minutes after her arrival, she begins to complain of nausea and has two episodes of vomiting. The physician administers 0.625 mg of droperidol and 400 mg of acetaminophen by mouth. On follow-up evaluation, the patient's neck is involuntarily flexed to one side. She is alert, oriented, and conversant and has an otherwise normal neurologic examination. Which of the following is the most likely diagnosis?
    A. Cerebral vascular accident
    B. Conversion disorder
    C. Dystonic reaction to droperidol
    D. Munchausen syndrome
    E. Seizure

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    4) A 50-year-old nurse consults a physician because of a rash above both her ankles. Physical examination demonstrates marked ankle edema with erythema, mild scaling, and brown discoloration of the overlying skin of the distal lower legs. Varicose veins are also noted. Which of the following is the most likely diagnosis?
    A. Atopic dermatitis
    B. Cellulitis
    C. Lichen simplex chronicus
    D. Nummular dermatitis
    E. Stasis dermatitis

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    5) An AIDS patient develops symptoms suggestive of a severe, persistent pneumonia with cough, fever, chills, chest pain, weakness, and weight loss. The patient does not respond to penicillin therapy, but goes on to develop very severe headaches. The presence of focal neurologic abnormalities leads the clinician to order a CT scan of the head. This demonstrates several metastatic brain abscesses. Biopsy of one of these lesions demonstrates beaded, branching, filamentous gram-positive bacteria that are weakly acid fast. Which of the following is the most likely causative organism?
    A. Actinomyces
    B. Aspergillus
    C. Burkholderia
    D. Francisella
    E. Nocardia

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    6) A 28-year-old patient with end-stage renal disease (ESRD) on continuous ambulatory peritoneal dialysis (CAPD) for two months presents with fever, abdominal pain and cloudy dialysis fluid. There is no diarrhea or vomiting and the pain has been present for about 12 hours. The patient has ESRD secondary to chronic glomerulonephritis, there is no history of diabetes, urinary infections or antibiotic use. Examination reveals a temperature of 38.9 C (102 F), and blood pressure of 110/70 mm Hg. The throat is clear, as are the lungs. Cardiac examination reveals a grade 2/6 systolic murmur. Abdominal examination reveals decreased bowel sounds with diffuse tenderness. There is mild rebound. There is no edema or skin rash. A complete blood count shows a leukocyte count of 14,200/mm3, hemoglobin is 12.5 g/dL. Peritoneal fluid is cloudy with 1,000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram's stain of fluid is negative. Cultures of blood and peritoneal dialysis fluid are taken. Which of the following is the most appropriate initial step in management?
    A. Fluconazole
    B. Immediate removal of dialysis catheter.
    C. Intravenous vancomycin
    D. Intravenous gentamicin
    E. Oral ciprofloxacin

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    7) A 54-year-old man presents for a periodic health examination. His family history is significant for his mother who died of a cerebrovascular accident at age 72, his father who died of a myocardial infarction at age 68, and a brother who developed sigmoid cancer at age 60. The patient is on no medications except for aspirin, 81 mg daily. His physical examination is unremarkable. The patient asks for a recommendation regarding current cancer screening. Which of the following is the most appropriate screening test for this patient?
    A. Annual digital rectal examination and fecal occult blood testing
    B. Flexible sigmoidoscopy
    C. Flexible sigmoidoscopy and barium enema
    D. Colonoscopy
    E. Genetic testing for the p53 gene

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    8) An AIDS patient under treatment with a nucleoside analog and a protease inhibitor comes to medical attention with complaints of leg weakness and incontinence. His vital signs are within normal limits. Physical examination reveals reduced strength in the lower extremities with accompanying mild spasticity. There is also diminished sensation in the feet and legs bilaterally. Lumbar puncture shows:
    Opening pressure.....100 mm H20
    Cell count................5 lymphocytes/mm3
    Glucose...................48 mg/dL
    Proteins, total..........33 mg/dL
    Gamma globulin.......8% total protein
    Additional laboratory investigations show normal hematologic parameters, vitamin B12 within normal values, and negative serology for syphilis. MRI of the head fails to reveal any focal abnormality. Which of the following is the most likely diagnosis?

    A. AIDS dementia complex
    B. CMV polyradiculopathy
    C. Cryptococcal meningoencephalitis
    D. Vacuolar (HIV) myelopathy
    E. Zidovudine-related toxicity

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    9) A 45-year-old man is involved in an automobile accident and sustains severe injuries with considerable blood loss and hypotension. He is transferred from the emergency department to an intensive care unit, where he develops multiorgan failure. During the first 2 days in the intensive care unit, his plasma phosphate was within normal limits. Subsequently, it began to rise, eventually reaching 6.0 mg/dL. Failure of which of the following organs would most likely have this effect?
    A. Heart
    B. Kidneys
    C. Liver
    D. Lungs
    E. Pancreas

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    10) A 28-year-old woman is diagnosed with lupus nephritis, World Health Organization (WHO) type IV. She has a malar rash, diffuse arthritis, and edema. Her blood pressure is 190/110 mm Hg. Her creatinine is 2.1 mg/dL with a blood urea nitrogen of 28 mg/dL. Her urine reveals 25 red blood cells per hpf, and 3+ protein. One red blood cell cast is seen. A 24-hour urine collection reveals a protein of 11 grams with a creatinine of 1 gram. Which of the following would be the most appropriate management?
    A. Oral azathioprine
    B. Oral cyclophosphamide
    C. Oral gold
    D. Oral prednisone
    E. Pulse IV cyclophosphamide

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    11) A 48-year-old woman is seen by a clinician. She has a bright red, sharply demarcated, oozing and crusting rash involving one breast in the areola area. She has had this lesion for six months and states that it is slowly growing. The lesion does not respond to antibiotic ointment, antifungal ointment, or steroid ointment. This lesion is most likely related to which of the following conditions?
    A. Breast cancer
    B. Crohn disease
    C. Gastric cancer
    D. Rheumatoid arthritis
    E. Systemic lupus erythematosus

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    12) A recent article in a prominent medical journal explored the disparity of resource utilization between men and women. More men than women have major cardiac procedures, including catheterization, performed. This is thought to be because of which of the following reasons?
    A. Fewer outcome studies have studied women with these disease
    B. The incidence of cardiovascular disease is lower in women
    C. Men have better health insurance
    D. Men receive too many cardiovascular procedures
    E. Provider attitudes has led to this situation

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    13) A 43-year-old man presents with a 4-year history of joint pain. The distribution is asymmetric, involving the proximal and distal small joints of the right hand, the left knee, the ankle, and right elbow. Pain and morning stiffness are moderate. Physical examination reveals mild nail pitting, and the distal third interphalangeal joint is partially subluxated. X-rays of the hands show resorption of the distal end of the phalanx. The erythrocyte sedimentation rate (ESR) is elevated to 46 mm/hr, and rheumatoid factor is negative. Which of the following is the most likely diagnosis?
    A. Primary generalized osteoarthritis
    B. Pseudogout
    C. Psoriatic arthritis
    D. Rheumatoid arthritis

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    14) A 45-year-old man presents to a physician with complaints of weakness, fatigue, and feeling near fainting when he stands up quickly. Screening chemistry studies demonstrate sodium, 128 mEq/L; potassium, 5.2 mEq/L; bicarbonate, 17 mEq/L; and urea nitrogen, 45 mg/dL. The physician is considering Addison disease in his differential diagnosis. Which of the following features on physical examination would be most suggestive of this diagnosis?
    A. Black freckles on the shoulders
    B. Large, furrowed tongue
    C. Many spider angiomas
    D. Protruding eyeballs
    E. Small glistening bumps on the lips

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    15) A 71-year-old man presents to the emergency department with fever and cough. He has known hypercholesterolemia and is status post a right hemicolectomy for colon cancer. The patient states that he has had 3 days of fever to 102 F, cough productive of green sputum, as well as general malaise and weakness. His physical examination is remarkable for decreased breath sounds at the left base, left basilar egophony and dullness to percussion. A complete blood count reveals a leukocyte count of 15000/mm3. A chest radiograph reveals a left lower lobe infiltrate. Which of the following is the most important part of the history to ascertain prior to initiating therapy?
    A. Influenza immunization status
    B. Plasma lipid profile
    C. Stage of the colon cancer
    D. Social support structure for home therapy
    E. Recently hospitalizations

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    16) A 49-year-old woman presents to the office because of complaints of fatigue. She has had progressive exercise intolerance over the prior 6 months. On physical examination, she is pale and afebrile. Her blood pressure is 112/68 mm Hg, and her pulse is 88/min. Heart and lung examinations are normal except for a I/VI systolic flow murmur at the left sternal border. Routine laboratory results reveal hemoglobin of 8.3 g/dL, a mean corpuscular volume of 118 µL/m3, and a B12 of 82 pg/mL (normal >210 pg/mL). She undergoes a Schilling test, which reveals malabsorption of radiolabeled B12. Intrinsic factor is administered and the radiolabeled B12 is subsequently absorbed. Which of the following is the diagnosis?
    A. Atrophic gastritis
    B. Bacterial overgrowth
    C. Chronic pancreatitis
    D. Crohn disease
    E. Gastric ulcer

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    17) A 65-year-old woman consults a physician because of a 3-month history of weight loss, burning sensation of the tongue, fatigue, anorexia, and poorly localized abdominal pain. The woman appears pale to the physician. Intraoffice hematocrit is 35% with peripheral smear showing large erythrocytes and hypersegmented neutrophils. Serum folate is 2.4 ng/mL (normal greater that 1.9 ng/mL) and serum vitamin B12 is 100 pg/mL (normal 200-800 pg/mL). Stomach biopsy demonstrates chronic gastritis. Autoantibodies to which of the following are most likely involved in this patient's condition?
    A. Basement membrane
    B. Insulin receptor
    C. Intrinsic factor
    D. SS-B
    E. TSH receptor

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    18) A previously healthy 50-year-old woman comes to the physician because of double vision for three days. Her temperature is 37 C (98.6 F). The patient denies nausea or vomiting. Examination reveals ptosis and slight divergence of the right eye. Extraocular movements are limited in all directions, except laterally. The right pupil is larger than the left and poorly reactive to light. Examination of the fundus fails to reveal papilledema. Which of the following is the most likely underlying condition?
    A. Aneurysm of the posterior communicating artery
    B. Carcinoma of the right pulmonary apex
    C. Diabetes mellitus
    D. Giant cell arteritis
    E. Syphilis
    F. Systemic hypertension

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    19) A patient with a history of chronic bacterial sinusitis presents to the emergency department with a very severe headache. While waiting to be seen, he develops a generalized grand mal seizure. Physical examination, after the seizure is over, demonstrates high fever, exophthalmos, papilledema, and nerve palsies of the VI and III cranial nerves on one side. Which of the following is the most appropriate next step?
    A. Admit to the medical floor for monitoring of progression of symptoms
    B. Emergency CT scan
    C. Emergency exploratory surgery
    D. Emergency ultrasound
    E. Keep in emergency department for monitoring of progression of symptoms

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    20) A 41-year-old man presents with complaints of mild intermittent heartburn after meals for the past 6 months. He has tried various over-the-counter antacids and H2 receptor antagonists with only minimal relief. He denies any dysphagia or odynophagia, and is otherwise in good health. He is concerned about the risk of developing cancer, because his father died of gastric cancer at age 49. His physical examination is unremarkable. Which of the following would be the most appropriate next step in management?
    A. Avoidance of a high-protein diet
    B. Avoidance of aspirin
    C. Avoidance of acetaminophen
    D. Elevation of the head of his bed
    E. Increased consumption of carbohydrates

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    21) A 40-year-old woman is brought to the emergency department following a suicide attempt with imipramine. Her fiancee found her unresponsive, with an empty bottle of the imipramine at her side. The imipramine had been his, and the prescription had been filled that morning. Her past medical history is significant for hypertension, atrial fibrillation, diabetes, and asthma. Her medications include furosemide, procainamide, glyburide, prednisone, and albuterol. She has no known drug allergies. She is afebrile, has a blood pressure of 100/60 mm Hg, pulse of 62/min, and respirations of 22/min. A gastric lavage yields multiple pill fragments. She is confused and somnolent, and has shallow respirations. Her physical examination is otherwise unremarkable. On an ECG, which of the following abnormalities would most likely reflect possible cardiac toxicity?
    A. Left deviation of the QRS axis
    B. Prolongation of the QRS interval
    C. Shortening of the QT interval
    D. ST segment depression
    E. T wave inversion

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    22) A 43-year-old bus driver presents to his gastroenterologist with complaints of difficulty swallowing solid foods. The evaluation demonstrates a smooth, tapered stricture of the distal esophagus, and biopsies reveal changes consistent with chronic esophagitis and fibrosis. The stricture is dilated with an endoscopic balloon dilator, and the patient's symptoms resolve. He reports that although he has had dysphagia for the past 2 months prior to the endoscopy, he rarely has heartburn and uses an over-the-counter antacid only occasionally. Which of the following is the most appropriate future management of this patient?
    A. Famotidine
    B. Lansoprazole
    C. Magnesium hydroxide
    D. Metoclopramide
    E. No medication is necessary

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    23) A 23-year-old professional basketball player presents to the team physician 3 hours before game time complaining of abdominal pain. The symptoms began approximately 8 hours earlier in a diffuse fashion. Two hours later, he began feeling nauseated and vomited twice. Over the past 4 hours, the abdominal pain has become more severe and well localized in the right lower quadrant. His examination now reveals well-localized pain in the right lower quadrant inferolateral to the umbilicus. Which of the following is the most likely diagnosis?
    A. Acute obstruction of the appendiceal lumen by a fecalith
    B. Acute onset of ileocolitis
    C. Acute onset of ischemic colitis
    D. Acute Yersinia infection
    E. Obstruction of the ileocecal valve by a mass

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    24) A 31-year-old homeless woman is brought to the emergency department after being found face down on the street. The woman has a long history of admissions to the hospital for alcohol-related issues, including seizures, withdrawal, and hallucinations. Today, she was seen to fall in the street, have what were described as "convulsions" and then vomit. She remained face down in the street until the paramedics arrived. On physical examination, she has dry mucous membranes, a jugular venous pressure of less than 5 cm, and diffuse ecchymoses on her face, body, and breasts. Which of the following vitamins should be administered prior to volume resuscitation with IV fluids containing glucose?
    A. Vitamin B1 (Thiamin)
    B. Vitamin B3 (Niacin)
    C. Vitamin B12 (Cobalamin)
    D. Vitamin C
    E. Vitamin K

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    25) A 36-year-old man develops rapid mental status deterioration two days after sustaining a femoral fracture in a skiing accident. Physical examination shows multiple petechiae in the anterior chest and abdomen. On the third day, the patient lapses into coma and dies. Postmortem examination of the brain reveals numerous petechial hemorrhages in the corpus callosum and centrum semiovale. Which of the following is the most likely diagnosis?
    A. Diffuse axonal injury
    B. Fat embolism
    C. Septic embolism
    D. Systemic thromboembolism
    E. Watershed infarction

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    26) A 45-year-old man consults a physician because of dysuria. The patient is treated with antibiotics, but symptoms recur one week after antibiotic therapy is stopped. A different antibiotic is tried, but symptoms again recur after cessation of the antibiotic. Rectal examination demonstrates an enlarged prostate with areas of tenderness and fluctuance. Which of the following is the most likely diagnosis?
    A. Benign prostatic hyperplasia
    B. Chronic nonbacterial prostatitis
    C. Prostadynia
    D. Prostatic abscess
    E. Prostatic carcinoma

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    27) A 31-year-old woman presents at the hospital for a pre-employment physical examination prior to beginning her year as a medical intern. She is sexually inactive and denies alcohol use. She had infectious mononucleosis while in college and received the recombinant hepatitis B vaccine before starting medical school. Which of the following would describe her hepatitis B serologic profile?
    A. Hepatitis B surface antigen positive, core antibody positive, and surface antibody negative
    B. Hepatitis B surface antigen negative, core antibody positive, and surface antibody positive
    C. Hepatitis B surface antigen positive, core antibody negative, and surface antibody negative
    D. Hepatitis B surface antigen negative, core antibody negative, and surface antibody positive
    E. Hepatitis B surface antigen negative, core antibody negative, and surface antibody negative.

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    28) A 57-year-old man presents to his physician for a preoperative evaluation. He has been a long-time patient in this office and has been treated for hypertension and gastritis. He has been scheduled for an elective open cholecystectomy in 2 days. He currently takes omeprazole for his gastritis and thiazide for his hypertension daily. He smokes two packs of cigarettes per day. His home blood pressure log shows that his systolic pressures range from 150 to 190 mm Hg, and his diastolic pressures range from 80 to 105 mm Hg, indicating that his blood pressure may be not adequately controlled for the surgical procedure. Which of the following medications is most appropriate in the perioperative period for added blood pressure control?
    A. Captopril
    B. Clonidine
    C. Metoprolol
    D. Nifedipine
    E. Prazosin

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    29) A 66-year-old man presents to the clinic complaining of progressively worsening shortness of breath and nonproductive cough over the past 2 years. He retired 1 year ago, after working as a rock miner for more than 30 years. He has no other significant past medical history. On physical examination, he is a thin man who appears tachypneic at rest. His lungs have reduced chest expansion and dry inspiratory rales in the upper lobes bilaterally. The remainder of his examination is normal. A chest x-ray film reveals multiple round opacities in the upper lobes accompanied by hilar lymphadenopathy with lymph node calcification. Which of the following is the most likely diagnosis?
    A. Asbestosis
    B. Aspergillosis
    C. Cystic fibrosis
    D. Silicosis
    E. Tuberculosis

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    30) A 55-year-old woman with a long-standing history of atrial fibrillation secondary to mitral regurgitation presents to the emergency department with a painful right foot. The patient reports that, over the past few hours, her foot has become more painful and now is nearly insensate. She describes the pain as burning and states that it is not relieved by any intervention. She takes coumadin, atenolol, digoxin, and aspirin. On physical examination, her pulse is irregularly irregular. Her lungs are clear, and she has a loud holosystolic murmur heard best at the apex. Her right foot is gray and cool to the touch and has poor capillary refill. Dorsalis pedis and posterior tibial pulses are absent on the right. Her prothrombin time is 14.4 seconds (INR 1.4). Which of the following is the most appropriate course of action?
    A. Arrange for her to be seen by a vascular surgeon in the emergency department now
    B. Arrange for her to be seen by a neurologist within the next few days
    C. Arrange for her to undergo an MRI of the head that day
    D. Ask her to make an appointment to be in seen in your office within 1 week
    E. Instruct her to soak her leg in warm water and to place a fitted stocking on her affected leg

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    31) A 50-year-old man is brought to the emergency department complaining of light-headedness. He has a history of lung cancer, which was diagnosed a month ago and found to be widely metastatic to the bone and pericardium. On physical examination, his blood pressure is 70/40 mm Hg, and his pulse is 100/min. His heart sounds are distant and soft. His ECG demonstrates low voltage, and electrical alternans is present. A chest x-ray film shows that the cardiac silhouette has a "water bottle" appearance.Which of the following is the most appropriate intervention in this patient?
    A. Beta-blockers
    B. Nonsteroidal anti-inflammatory drugs
    C. Steroids
    D. Pericardiocentesis
    E. Cardiac catheterization

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    32) A 62-year-old man with a 110 pack-year history of smoking presents with chest pain. He states that for the past few months, he has been getting chest "pressure" localized to the substernal region, radiating to the left arm on occasion. The pain occurs with mild exertion, but never at rest. He further states that when he gets the pain, it usually last about 5 minutes but goes away with rest. He reports that his exercise tolerance is moderate, and he gets dyspnea on exertion after a few blocks of walking. On physical examination, he has no chest wall tenderness to palpation, but a carotid bruit is heard, and his dorsalis pedis pulses are decreased. He has no history of coronary disease but his family history is significant for his father having a myocardial infarction at age 56. He denies chest pain at this time. In addition to ascertaining his other coronary risk factors, which of the following is the most appropriate diagnostic intervention?
    A. Obtain a resting electrocardiogram
    B. Schedule the patient for a cardiac echocardiogram
    C. Schedule the patient for an exercise treadmill test
    D. Schedule the patient for non-urgent coronary angiography
    E. Schedule the patient for immediate coronary angiography

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    33) A 35-year-old man comes to the physician for a health maintenance examination. He received blood transfusions for hypovolemic shock following a gunshot wound 10 years earlier. He is currently in good health, and physical examination is unremarkable. A serum chemistry panel shows:
    ALT 250 U/L
    AST 140 U/L
    Alkaline phosphatase 70 U/L
    Serologic evaluation for viral hepatitis reveals positive antibodies to hepatitis C virus (HCV). A percutaneous liver biopsy shows marked portal inflammatory infiltrate disrupting the limiting plate of hepatic lobules. Which of the following is the incidence rate of this complication following HCV infection?
    A. 5%
    B. 10%
    C. 20%
    D. 40%
    E. 80%

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    34) A 71-year-old woman is admitted to the hospital for pneumonia. The patient presented to the hospital 2 days ago for cough and fever. She reported temperatures to 38.9 C (102 F) and a cough productive of green, copious sputum. She also reported pleuritic chest pain with deep inspiration. The initial examination revealed diminished breath sounds in the left lower lobe with dullness to percussion, and a chest radiograph revealed a dense left lower lobe infiltrate. Which of the following organisms is most likely responsible for her pneumonia?
    A. Bordetella pertussis
    B. Klebsiella pneumoniae
    C. Mycoplasma pneumoniae
    D. Pneumococcus
    E. Staphylococcus aureus

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    35) A 69-year-old woman presents to her physician of 3 years with progressive shortness of breath. The dyspnea was initially limited to exertion but has progressed to shortness of breath at rest. She has had intermittent cough but no fever. Her past medical history is significant for mild hypertension and seropositive rheumatoid arthritis. Which of the following aspect of her social history is the most important consideration to review at this point?
    A. Alcohol history
    B. Drugs of abuse history
    C. Marital status
    D. Occupation
    E. Tobacco history

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    36) A 42-year-old man presents for his annual physical examination. He was last seen 2 years ago for a periodic health examination and was in good health. He is on no medications. His past medical history is significant for a cholecystectomy 2 years ago and rheumatic fever at age 15. He has been smoking approximately ten cigarettes daily for the past 23 years. On physical examination, his blood pressure is 154/56 mm Hg, pulse is 68/min, and respirations are 14/min. He is afebrile. A head and neck examination is normal. His lungs are clear. He has a regular heart rhythm, with a II/IV blowing decrescendo diastolic murmur heard at the aortic area. His abdominal and rectal examinations are normal. Complete blood count, electrolytes, and thyroid function tests are normal. Which of the following is the most appropriate advice for this man regarding future preventive health maintenance?
    A. Antibiotic prophylaxis before dental work
    B. Annual chest x-ray film
    C. Annual echocardiogram
    D. Annual flexible sigmoidoscopy
    E. Annual prostate specific antigen testing

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    37) A 30-year-old man consults a physician at his wife's insistence because "his eyes are a little yellow all the time now". Screening chemistry studies show modest elevations of liver transaminases and total bilirubin 2.0 mg/dL, almost all of which is conjugated. The patient denies ever using alcohol. Viral hepatitis studies are negative. Liver biopsy shows hepatic fibrosis with normal iron levels and no evidence for alpha-1-antitrypsin deficiency. On further questioning about his general health, the patient reveals that he has had an unusually large number of bacterial pneumonias in his life. He has even had Pneumocystis pneumonia at one point. HIV testing at that time and repeated twice since has always been negative. A doctor at the time had commented that he seemed to have some trouble making neutrophils. T and B cell numbers are within normal limits. Antibody studies reveal the following: IgG total 200 mg/dL [normal 723-1685 mg/dL]
    IgA 40 mg/dL [normal 81-463 mg/dL]
    IgM 450 mg/dL [normal 48-271 mg/dL]
    Which of the following is the most likely diagnosis?
    A. Adenosine deaminase deficiency
    B. Bruton's agammaglobulinemia
    C. IgG subclass deficiency
    D. Hyper IgM immunodeficiency
    E. Selective IgA deficiency

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    38) A 42-year-old man consults a physician because he has a "lump" on his forearm. Examination of the arm demonstrates a 3-cm diameter nodule protruding above the forearm surface. The lesion is covered with apparently normal skin and is soft and freely movable. It location appears to be subcutaneous. The lesion has been slowly growing over the past 2 years, and the patient has experienced no discomfort. He has consulted a physician at this time because his wife keeps pestering him to get something done about it. Which of the following is the most likely diagnosis?
    A. Capillary hemangioma
    B. Dermatofibroma
    C. Intradermal nevus
    D. Lipoma
    E. Seborrheic keratosis

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    39) A 45-year-old man undergoes a routine examination. While the physical examination is unrevealing, a hematocrit performed in the physician's office gives a value of 25%. Review of the peripheral smear reveals smaller-than-normal erythrocytes. The cells vary in size, and some have abnormal shapes. The cells do not appear paler than normal. Reticulocytes are decreased. Assuming that this patient has only a single cause for his anemia, which of the following is most likely to be seen on further evaluation?
    A. Low iron
    B. Low iron binding capacity
    C. Low folate
    D. Low mean corpuscular hemoglobin concentration (MCHC)
    E. Low vitamin B12

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    40) A 23-year-old African American man with AIDS is sent for work up of the nephrotic syndrome. His blood pressure is 140/82 mm Hg. He has 3+ edema in both legs. His risk factor for AIDS is IV heroin use. His creatinine is 2.0 mg/dL, and his urine reveals +3 protein, no blood. A kidney biopsy would most likely reveal which of the following?
    A. Diabetic nephropathy
    B. Focal glomerular sclerosis
    C. IgA nephropathy
    D. Membranous nephropathy
    E. Nil disease

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    41) A 57-year-old woman presents to her physician for follow-up of a fasting serum cholesterol level of 236 mg/dL. She is post-menopausal since age 52, and has been not been on hormone replacement therapy. She has a positive family history for coronary artery disease and she has smoked one-half pack of cigarettes per day for the past 20 years. During her last physical examination, a lipid profile was ordered, and she presents today for evaluation of those results. Which of the following lipid panels would most strongly suggest the need for pharmacologic therapy in this patient?
    A. Total cholesterol 180 mg/dL, LDL cholesterol 140 mg/dL
    B. Total cholesterol 184 mg/dL, LDL cholesterol 100 mg/dL
    C. Total cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL
    D. Total cholesterol 245 mg/dL, LDL cholesterol 165 mg/dL
    E. Total cholesterol 285 mg/dL, LDL cholesterol 100 mg/dL

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    42) A 47-year-old man presents for follow up of his previous visit 2 weeks ago, when he was seen for evaluation of his duodenal ulcer. At that time, a test for Helicobacter pylori was performed. The patient was otherwise well but had been complaining of epigastric pain that was exacerbated by eating. An esophageal-gastroduodenoscopy revealed the presence of a duodenal ulcer, and biopsies were taken at that time. In addition, the patient was told that he needed to modify his diet, such as decreasing his coffee intake, and cutting his tobacco use. The patient returns today to discuss his test results, which were positive for the H. pylori organism. Which of the following is the most appropriate therapy at this time?
    A. Amoxicillin orally
    B. Bismuth, metronidazole, tetracycline, and omeprazole orally
    C. Metronidazole orally
    D. Omeprazole orally
    E. Sucralfate orally

    ________________________________________

    43) A 33-year-old woman comes to the physician because of palpitations, restlessness, sweating, weight loss, and a tremor for the past 3 weeks. She does not drink coffee, tea, soda, or alcohol, and she does not smoke cigarettes. Her temperature is 37 C (98.6 F), blood pressure is 130/80 mm Hg, and pulse is 90/min. Examination shows a fine tremor, lid lag and stare, and pretibial myxedema. The thyroid gland is diffusely enlarged, asymmetric, and lobular. A bruit is present over the gland. Laboratory studies show an undetectable level of thyroid-stimulating hormone, an increased level of thyroid hormones, and an increased radioactive iodine uptake (RAIU). The diagnosis of Graves' disease is made and the treatment options are discussed. The patient selects radioactive iodine therapy. This patient is at greatest risk for which of the following conditions?
    A. Cholestasis
    B. Granulocytopenia
    C. Hypothyroidism
    D. Recurrent laryngeal nerve damage
    E. Thyroid carcinoma

    ________________________________________

    44) A 65-year-old man complains of increasing urinary frequency and dribbling at night. He has no past medical history and is on no medications. On physical examination, a digital rectal exam reveals a normal-sized prostate. The prostate-specific antigen (PSA) level is elevated at 15.4 ng/mL. Ultrasonography reveals a small hypoechoic area on the prostate measuring 6 × 8 mm in the right lobe. Which of the following is the most appropriate next step?
    A. Administer leuprolide
    B. Biopsy prostate lesion
    C. Perform bone scan
    D. Repeat PSA in 3 months
    E. Scan pelvis and retroperitoneum

    ________________________________________

    45) The day after hunting and skinning wild rabbits, a hunter develops an inflamed papule on one finger. The papule rapidly enlarges and then bursts, releasing pus and forming a clean ulcer cavity productive of thin, colorless exudate. Several days later, the patient develops severe illness with atypical pneumonia and delirium. It is at this point that the patient seeks medical care. The regional lymph nodes of the axilla of the affected arm are enlarged. Reduced breath sounds and occasional rales are heard. Splenomegaly is noted. Blood studies show a mild leukocytosis. Which of the following is the most likely diagnosis?
    A. Actinomycosis
    B. Brucellosis
    C. Melioidosis
    D. Plague
    E. Tularemia

    ________________________________________

    46) A 72-year-old man with a 25-year history of emphysema presents to his physician after he develops the acute onset of fevers, rigors, and a cough productive of green sputum. The symptoms gradually worsen over 36 hours and he presents to the emergency department. He has been taking a beclomethasone inhaler twice daily, an albuterol nebulizer treatment at home four times daily, and has been taking erythromycin for a recent bronchitis. On physical examination he is 183 cm (6 feet) tall and weighs 85 kg. His temperature is 38.3 C (100.9 F), blood pressure is 162/92 mm Hg, pulse is 94/min, and respirations are 32/min. His lung examination reveals diffuse bilateral coarse rhonchi. He uses his sternocleidomastoid muscles with each inspiration. An arterial blood gas reveals a pH of 7.20, a pCO2 of 60 mm Hg, and a pO2 of 52 mm Hg. Over the next 2 hours, he becomes increasingly tachypneic, and his pCO2 rises to 74 mm Hg. The decision is made to intubate him at that point. Which of the following settings would be most appropriate for his tidal volume on the respirator?
    A. 500 mL/breath
    B. 600 mL/breath
    C. 700 mL/breath
    D. 850 mL/breath
    E. 1000 mL/breath

    ________________________________________

    47) A 41-year-old man presents to his physician for a routine physical examination. He is a new to this office and brings his previous medical record with him. He has no significant past medical history but he does have a strong family history of cancer and heart disease. His father and his brother both had myocardial infarctions before age of 55, and his sister, mother, and aunt had breast cancer. He exercises regularly and eats well, with most of his diet being low in saturated fat and cholesterol. He smokes one pack of cigarettes per week. His review of systems is unremarkable. He is very anxious and would like only minimal interventions done because of his good health. Which of the following is an age-appropriate screening test in this patient?
    A. Fasting lipid profile
    B. Non-fasting total cholesterol level
    C. Oral glucose tolerance test
    D. Prostate examination
    E. Sigmoidoscopy

    ________________________________________

    48) Two weeks after receiving an allogeneic bone marrow transplant for treatment of acute myelogenous leukemia, a 45-year-old man develops fever, intractable diarrhea, generalized rash, and non-productive cough. Chest x-ray films show bilateral interstitial infiltrates in the lung. The patient dies of overwhelming sepsis and multiorgan failure. Autopsy investigations reveal cytomegalovirus pneumonia, and extensive single cell necrosis in the intestinal epithelium and skin. This complication of bone marrow transplantation is principally mediated by which of the following cells?
    A. B-lymphocytes of bone marrow graft
    B. Leukemic cells
    C. Natural killer cells of recipient
    D. T-lymphocytes of bone marrow graft
    E. T-lymphocytes of recipient

    ________________________________________

    49) A 25-year-old woman consults a dermatologist because of scaling skin since childhood. Physical examination demonstrates fine scaling of the back and extensor surfaces of the extremities. Involved areas also show horny plugs in the orifices of hair follicles. The flexor surfaces are uninvolved. Cracking of the skin is prominent on the palms and soles. The patient also has a history of atopy. Which of the following is the most likely diagnosis?
    A. Epidermolytic hyperkeratosis
    B. Ichthyosis vulgaris
    C. Lamellar ichthyosis
    D. X-linked ichthyosis
    E. Xeroderma

    ________________________________________

    50) A 32-year-old woman has had a 15-year history of heartburn. Over the past 4 months, she has had difficulty swallowing large bites of solid food. She has no difficulty with soft foods or liquids, and she has not lost weight. Which of the following is the most likely ) Explanation for her symptoms?
    A. Adenocarcinoma in the lower third of the esophagus
    B. Barrett's esophagus in the distal esophagus
    C. Fibrosis and narrowing at the distal esophagus
    D. Schatzki ring in the distal esophagus
    E. Squamous carcinoma in the mid-third of the esophagus

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    Default Answers to questions above

    1-30 answers and detailed explanations:

    [HIDE]
    1) Explanation ---------------------------------------------------
    The correct answer is
    D. The immediate step is to screen the family for TB exposure. The most effective manner in which to accomplish this is by placing PPDs on all members and working up those with a positive test. The white cell count may be elevated for a variety of reasons and would not necessarily help in diagnosis or management (choice A).

    Sputum cultures will take 6 months to grow and may be too cumbersome to obtain (choice B).

    Chest CT scans may show the tuberculosis lesion but a more effective method would be to place the PPD and perhaps then scan those with a positive test (choice C).

    A bronchoscopy would be too invasive an option at this point (choice E).

    2) Explanation ---------------------------------------------------
    The correct answer is
    C. This patient has the classic presentation of a patient with acute gouty arthritis with the sudden onset of severe pain (typically in the middle of the night), swelling, erythema and warmth of a single joint. Low-grade fever and leukocytosis may be seen. It is more common in men and it is associated with hyperuricemia, usually due to decreased renal excretion of uric acid. Common causes are thiazides and alcohol. Diagnosis is made by examination of joint fluid under polarizing light. Negatively birefringent, needle-shaped crystals within polymorphonuclear leukocytes, hyperuricemia, and acute monoarticular arthritis make the definitive diagnosis of gout. Indomethacin or colchicine is the treatment during an acute attack. Allopurinol, probenecid, and sulfinpyrazone are used for prophylaxis against further attacks.

    Allopurinol (choice A) is a xanthine oxidase inhibitor that is used as an antihyperuricemic agent by individuals with recurrent gouty attacks. Common side effects include rash, headache, and gastrointestinal upset.

    Ceftriaxone (choice B) is the treatment of acute gonococcal arthritis. It has no role in the treatment of gout.

    Probenecid (choice D) is a uricosuric agent that increases the rate of urate excretion. It is used to prevent gouty attacks. It may precipitate nephrolithiasis.

    Sulfinpyrazone (choice E) is another uricosuric agent that increases urate excretion. It is used to prevent gouty attacks. It, too, may precipitate nephrolithiasis.

    3) Explanation ---------------------------------------------------
    The correct answer is
    C. The most likely diagnosis is a dystonic reaction to the droperidol. Droperidol causes its antiemetic effect by antagonizing dopaminergic receptors in the vomiting center (central chemoreceptor zone) of the brain. This antidopaminergic action can produce torticollis or other dystonias.

    A cerebral vascular accident (choice A) is unlikely given that the patient is alert and oriented, has no detectable language deficit, and has an otherwise nonfocal neurologic examination.

    A conversion disorder (choice B) is unlikely since the patient has no prior history of a psychiatric disorder and has a viable medical reason (dystonia from droperidol) for her neuromuscular deficit.

    Munchausen syndrome (choice D) is also unlikely since the patient had valid medical reasons for her initial admission and your current visit. We are also not informed of any prior history of hospitalizations or seeking of medical attention without appropriate cause.

    A seizure (choice E) is similarly unlikely since the patient has no history of a seizure disorder and is alert, oriented, and conversant.

    4) Explanation ---------------------------------------------------
    The correct answer is
    E. This is stasis dermatitis, which is a persistent inflammation of the skin of the lower legs. The condition is often related to varicose veins, although it has been postulated that the true cause may instead be perivascular fibrin deposition and abnormal small vessel vasoconstrictive reflexes. The presentation illustrated is typical. Most patients are relatively asymptomatic and may not seek medical attention until the edema becomes severe or the lesions become complicated by secondary bacterial infection or ulceration. It is important to increase the venous return to the heart by elevating the ankles while resting and use of properly fitted support hose. Local topical tap water compresses can be helpful. Purulent lesions can be treated with hydrocolloid dressings. Ulcers are treated with compresses and bland dressings, such as zinc oxide paste.

    Atopic dermatitis (choice A) typically involves the antecubital and popliteal fossas, eyelids, neck, and wrists.

    Cellulitis (choice B) is a bacterial infection of the subcutaneous tissues, and causes local erythema, tenderness, and often lymphangitis.

    Lichen simplex chronicus (choice C) is a skin rash caused by chronic scratching characterized by dry, scaling, well-demarcated, hyperpigmented plaques.

    Nummular dermatitis (choice D) causes widespread coin-shaped, crusted skin lesions.

    5) Explanation ---------------------------------------------------
    The correct answer is
    E.Nocardia asteroides is an aerobic soil saprophyte that can cause acute or chronic infectious disease often characterized by granulomatous-suppurative lesions that may become widely disseminated. Many, but not all, patients have underlying causes for immunodeficiency, including advanced age, lymphoreticular malignancies, organ transplantation, high dose corticosteroid therapy, or (increasingly commonly) AIDS. Disseminated nocardiosis usually starts as a pulmonary infection that can resemble either a severe pneumonia or tuberculosis. Once dissemination occurs, metastatic brain abscesses are particularly common, occurring in as many as 1/3 of patients with nocardiosis. Nocardiosis is treated with sulfa drugs, such as sulfadiazine or trimethoprim-sulfamethoxazole, for periods of months.

    Actinomyces (choice A) is very similar to Nocardia, but is not acid-fast.

    Aspergillus(choice B) is a fungus.

    Burkholderia(choice C)pseudomallei is a gram-negative bacillus that causes melioidosis, which is characterized by lung involvement or disseminated infection.

    Francisella(choice D)tularensis causes tularemia, which is usually acquired by contact with infected wild rabbits.

    6) Explanation ---------------------------------------------------
    The correct answer is
    C. Peritonitis in a patient on CAPD is usually due to gram-positive pathogens such as Staphylococcus aureus or epidermidis. It is usually characterized by abdominal pain and over 100 white blood cells (typically polymorphonuclear leukocytes) in a sample of peritoneal dialysis fluid. Intravenous vancomycin would be a reasonable treatment to cover gram-positive pathogens.

    Fluconazole (choice A) would be indicated for a fungal infection. Fungal peritonitis is not usually seen until patients have been treated with multiple antibiotics or are further immunosuppressed.

    Immediate removal of the dialysis catheter (choice B) is usually not needed unless the patient has a peritonitis that has not improved with a trial of antibiotics.

    Intravenous gentamicin (choice D) has good gram-negative coverage but would not be an ideal drug to cover Staphylococcus.

    Ciprofloxacin (choice E) would be a very broad spectrum antibiotic that would not be a first choice as a single antibiotic to treat staphylococcal peritonitis. Further, the oral route may not be adequate as patients with peritonitis may have nausea and vomiting.

    7) Explanation ---------------------------------------------------
    The correct answer is
    D. Any patient with a first-degree relative who has developed an adenoma or colorectal cancer should undergo colonoscopy for screening at age 50, or 10 years before the relative developed the adenoma or carcinoma, whichever comes first. This patient has a brother who has a colon cancer at age 60; therefore, a full colonoscopy is warranted. Although there are various opinions regarding appropriate screening in the "average risk individual," there is a consensus that full colonoscopy is required in patients who have an increased risk, e.g., first-degree relative with a positive history.

    Annual digital rectal examination and fecal occult blood testing (choice A) are no longer considered a reliable method of screening for colon cancer, since a shift in the demographics of colon cancer has lead to more than half being identified in the first half of the colon. Digital rectal examination also often fails to identify premalignant colonic polyps.

    Flexible sigmoidoscopy (choice B) is a good initial screening technique for patients older than 50 with no specific known risk factors. If polyps are identified, they can be biopsied, their type established, and subsequent complete colonoscopy performed if adenomas were identified microscopically.

    Flexible sigmoidoscopy and barium enema (choice C) offers an alternative way of screening the entire colon in patients in whom a complete colonoscopy cannot be performed.

    Genetic testing for the p53 gene (choice E) is not currently used for colon cancer screening.

    8) Explanation ---------------------------------------------------
    The correct answer is
    D. This is one of the most common neurologic complications of AIDS. Its pathologic substrate is degeneration of the spinal tracts in the posterior and lateral columns, which have a vacuolated microscopic appearance. Although the morphologic changes and clinical manifestations are similar to those associated with vitamin B12 deficiency, the pathogenetic mechanism is probably not related to dietary deficiencies. Since there is no specific clinical or laboratory test available for the diagnosis of this syndrome, vacuolar myelopathy in AIDS patients remains a diagnosis of exclusion. This implies that other HIV-related neurologic complications must be ruled out (see below).

    AIDS dementia complex (choice A) manifests with progressive memory loss, alterations in fine motor control, urinary incontinence, and altered mental status.

    CMV polyradiculopathy (choice B) may simulate HIV myelopathy and is a relatively frequent complication of AIDS. It can be excluded by the results of CSF analysis. CMV infection leads to neutrophilic pleocytosis in the CS
    F.

    Cryptococcal meningoencephalitis (choice C) would lead to signs and symptoms of meningitis. The CSF would show the fungal organism, which can be detected by special stains and culture studies.

    Zidovudine-related toxicity (choice E) would lead to proximal muscle weakness and tenderness due mainly to a myopathic process.

    9) Explanation ---------------------------------------------------
    The correct answer is
    B. The usual cause of hyperphosphatemia is advanced renal insufficiency that destroys the kidneys' ability to excrete phosphate, thereby leading to hyperphosphatemia. Other causes include hypoparathyroidism, pseudohypoparathyroidism, and excessive oral phosphate administration. Acute transcellular shifts of phosphate into the extracellular space can also occur in the settings of diabetic ketoacidosis, crush injuries, rhabdomyolysis, systemic infections, and tumor lysis syndrome.

    Failure of the heart (choice A), liver (choice C), or lungs (choice D) has no direct effect on phosphate metabolism.

    Pancreatic failure (choice E) has no direct effect on phosphate metabolism. Diabetic ketoacidosis can cause a transcellular shift of phosphate into the extracellular space.

    10) Explanation ---------------------------------------------------
    The correct answer is
    E. The most effective treatment for aggressive systemic lupus erythematosus with nephritis is pulse cyclophosphamide. This has been shown to be the best agent to treat type IV lupus nephritis.

    Oral cyclophosphamide (choice B) is effective but not as effective as the pulse IV form.

    Oral gold (choice C) is used to treat rheumatoid arthritis.

    Oral prednisone (choice D) and oral azathioprine (choice A) are other commonly used agents but are not as effective as cyclophosphamide.

    11) Explanation ---------------------------------------------------
    The correct answer is
    A. This is Paget disease of the breast, which actually corresponds microscopically to the presence of individual adenocarcinoma cells in the epidermis. When it involves the nipple area, it usually overlies an area of breast cancer. (Paget disease can also involve the vulva and vagina, where it may be unrelated to bulk cancer.) It is important to recognize the presentation, since focusing on treating the skin lesion empirically can lead to a delay in recognizing the cancer. The clinical description given in the question stem is typical. Mastectomy is a common form of treatment in these cases because of the nipple involvement.

    Crohn disease (choice B) can cause erythema nodosum (deep subcutaneous nodules on lower legs).

    Gastric cancer (choice C) can cause supraclavicular node enlargement due to metastasis.

    Rheumatoid arthritis (choice D) can cause subcutaneous rheumatoid nodules.

    Systemic lupus erythematosus (choice E) can cause a rash, most commonly seen on the face.

    12) Explanation ---------------------------------------------------
    The correct answer is E. Attitudes of physicians has been shown to have a significant effect on the delivery of health care. Health providers believe men to be more likely to have cardiac disease than women and this has guided practice, leading to a larger amount of cardiac procedures for men, compared with women.

    Fewer outcome studies have studied women because of the belief that cardiac disease is more common in men (choice A).

    The incidence of cardiovascular disease in women is similar to that in men (choice B) across the entire life-span.

    There is a significant disparity between men and women in the use of cardiovascular interventions in the absence of financial (i.e., insurance) barriers (choice C).

    One study has reported that women receive more appropriate cardiac services than men and that major interventions in men are over-utilized (choice D), but this does not explain the overall disparity.

    13) Explanation ---------------------------------------------------
    The correct answer is C. Nail pitting and dystrophy associated with distal destructive asymmetric arthritis are virtually diagnostic of psoriatic arthritis. Skin disease may or may not be severe and obvious. Nail changes occur in 85% of those with psoriatic arthritis, and in only 20% of those with uncomplicated psoriasis. The clinical categories of psoriatic arthritis include distal interphalangeal, asymmetric, symmetric, mutilating, and spinal. Antimalarials should be avoided if disease-modifying therapy is indicated, as they can exacerbate psoriasis.

    Primary generalized osteoarthritis (choice A) can involve the distal interphalangeal joints; joint erosions do not occur, and osteophytes are seen radiologically. Nail dystrophy does not occur.

    A variant of pseudogout (choice B) can closely mimic rheumatoid arthritis or a mutilating arthropathy, but nail changes are absent, and there is radiologic evidence of chondrocalcinosis (calcification of articular cartilage).

    Rheumatoid arthritis (choice D) does not cause distal erosive disease and is generally (but not invariably) symmetric.

    14) Explanation ---------------------------------------------------
    The correct answer is
    A. While there is some variation in the usage of the term, Addison disease is usually taken to mean adrenocortical insufficiency related to disease that destroys the adrenal gland. Most authors separate out secondary adrenocortical insufficiency due to pituitary failure and recent or current exogenous steroid therapy. True Addison disease, which is not related to inadequate pituitary secretion of ACTH, frequently has stigmata of hyperpigmentation relating to a melanocyte-stimulating hormone (MSH) effect seen with high ACTH levels. The biochemical basis of this is a homology between part of the ACTH molecule and the MSH molecule. Typical hyperpigmentation features include black freckles of the shoulders, head, and neck; bluish-black discoloration of areolas and mucous membranes (both oral and anogenital); and diffuse tanning, specifically including non-sun-exposed skin. The pattern of laboratory screening studies illustrated in the question stem is also very suggestive, with very low serum sodium, high potassium, low bicarbonate, and high serum urea nitrogen.

    A large, furrowed tongue (choice B) suggests acromegaly.

    Many spider angiomas (choice C) suggest chronic liver disease.

    Protruding eyeballs (choice D) suggest Grave's disease.

    Small glistening bumps on the lips (choice E) suggests the mucosal neuromas of MEN IIb.

    15) Explanation ---------------------------------------------------
    The correct answer is
    E. This patient clearly has pneumonia. The absolute requirement to diagnose pneumonia is an infiltrate on chest radiograph, coupled with clinical findings suggestive of a pneumonia, which this patient has. The next relevant issue is, what is the likely organism? If this man were living at home, the most common organism is the pneumococcus. However, given his recent hemicolectomy, the possibility of a more virulent organism emerges. This is the most critical factor in dictating his course of therapy.

    Whether the patient received the annual influenza vaccine (choice A) is important given his age and the morbidity associated with an influenza infection, however, it has no bearing on the course of this pneumonia or its therapy.

    His lipid status (choice B) is not relevant to therapy of his pneumonia.

    The stage of his colon cancer (choice C) is important, but not for the treatment of his pneumonia. There is no clinical relationship between pneumonia severity and colon cancer progression until late stage metastases occur and there is a possibility of post-obstructive pneumonia developing.

    The patients social support structure for home therapy (choice D) is an issue only at the time of discharge when the issue of continued home therapy is important. At this time his ability to have assistance with possible intravenous medications is an issue.

    16) Explanation ---------------------------------------------------
    The correct answer is
    A. This patient has pernicious anemia, as demonstrated by correction of her deficiency in intrinsic factor production by her parietal cells. This is an autoimmune disease directed against the parietal cells of the stomach, which are the normal producers of the intrinsic factor needed for absorption of vitamin B12. The lack of B12 then causes development of a megaloblastic (with high mean corpuscular volume) anemia. Biopsy of the gastric mucosa in these cases reveals atrophic gastritis. The Schilling test examines the absorption of radioactively labeled vitamin B12 before and after administration of intrinsic factor. A result of poor absorption of B12 before administration of intrinsic factor and good absorption after strongly suggests pernicious anemia as the diagnosis. Patients with pernicious anemia require long-term (probably life-long) parenteral replacement of vitamin B12 and may also have other significant autoantibodies, notably those directed against thyroid antigens.

    Choices B, C, and D may all produce a B12 deficiency, but they do not correct with intrinsic factor. In patients with bacterial overgrowth (choice B), the excess bacteria will preferentially absorb intraluminal B12.

    Chronic pancreatitis (choice C) may predispose to a B12 deficiency by failing to secrete the enzymes that are necessary to cleave the salivary R factor from the B12, making it unavailable for binding to intrinsic factor.

    Crohn disease (choice D) may cause a B12 deficiency if the terminal ileum is severely inflamed or has been resected.

    Gastric ulcer (choice E) can cause anemia secondary to bleeding, but it would be a normocytic anemia (unless there had been enough blood loss to cause iron deficiency, in which case it would microcytic) and would not be expected to respond to B12.

    17) Explanation ---------------------------------------------------
    The correct answer is
    C. This patient has pernicious anemia, in which autoimmune gastritis causes a lack of the intrinsic factor needed to absorb vitamin B12. Autoantibodies that are often present include those directed against the microsomal fraction of parietal cells and those capable of neutralizing intrinsic factor. The result is that vitamin B12 can no longer be absorbed by the terminal ileum. Since some vitamin B12 is stored in the liver, deficiency tends to develop slowly. Vitamin B12 deficiency can cause megaloblastic anemia; neurologic abnormalities that tend to begin with loss of position and vibration sense; and GI manifestations including anorexia, intermittent constipation or diarrhea, and abdominal pain.

    Antibodies to basement membrane (choice A) are associated with Goodpasture syndrome.

    Antibodies to insulin receptors (choice B) are associated with insulin resistance.

    Antibodies to SS-B (choice D) occur in association with Sjögren syndrome.

    Antibodies to TSH receptor (choice E) are associated with Graves disease.

    18) Explanation ---------------------------------------------------
    The correct answer is
    A. This patient displays signs of oculomotor palsy, with restriction of the eye movements in all directions (except laterally, due to preservation of the sixth cranial nerve, the abducens), and ptosis. Dilatation of the pupil, which fails to react to light, is a sign of intracranial compression of the third, or oculomotor cranial nerve. This should prompt search for an underlying surgical cause of oculomotor palsy. Uncal herniation and aneurysm of the posterior communicating artery are the two most common surgical conditions leading to oculomotor palsy. In the absence of clinical evidence of increased intracranial pressure, it may be assumed that the patient has an aneurysm of the posterior communicating artery until proven otherwise. Cerebral angiography is the investigation of choice to confirm the diagnosis.

    All of the most common medical causes of oculomotor nerve palsy result in paresis of extraocular movements and ptosis, but the pupillary light reflex is preserved. These conditions include diabetes mellitus (choice C), giant cell arteritis (choice D), syphilis (choice E) and systemic hypertension (choice F).

    Carcinoma of the right pulmonary apex (choice B) may result in Horner syndrome (miosis, ptosis, enophthalmos, and loss of sweating on the affected hemiface) due to infiltration of the cervical autonomic ganglia.

    19) Explanation ---------------------------------------------------
    The correct answer is
    B. This is the way that cavernous sinus thrombosis presents. This condition is due to a septic thrombosis that can complicate chronic bacterial sinusitis. Meningitis is another significant possibility. Lumbar puncture is dangerous in a patient with increased intracranial pressure, as indicated by the papilledema. Emergency CT scan of the cavernous sinus, air sinuses, orbit, and brain is warranted. Additionally, cultures of blood and any nasal discharge are warranted; Gram's stain of the nasal discharge may give a preliminary indication of the causative organism. High dose intravenous antibiotics are started, and then altered, if necessary, when culture results are reported. Cavernous sinus thrombosis has a 30% mortality rate, even when prompt, appropriate medical care is given.

    Simply monitoring (choices A and E) a patient like this would be very dangerous. Ultrasound (choice D) would probably not adequately visualize the complex structures of the sinuses, orbits, and brain.

    Surgery (choice C) is not indicated in this setting.

    20) Explanation ---------------------------------------------------
    The correct answer is
    D. Before initiating pharmacologic therapy, it is worthwhile to consider lifestyle modifications that may reduce symptoms in patients with gastroesophageal reflux disease (GERD). In this regard, elevating the head of his bed is an important step, since it will reduce the degree of nocturnal acid reflux while the patient is in the supine position. Other nonpharmacologic measures that may be helpful include avoidance of strong stimulants of acid secretion (coffee, alcohol), avoidance of certain drugs (anticholinergics) and foods (fats, chocolates), and cessation of smoking.

    Although fatty foods may exacerbate GERD by reducing the pressure on the lower esophageal sphincter (LES), high-protein diets (choice A) and carbohydrates (choice E) have no particular effect on the mechanism or symptoms or GER
    D.

    Although aspirin (choice B) may be injurious to the gastric and duodenal mucosa, it is not implicated in exacerbations of GER
    D.

    Acetaminophen (choice C) has no effect on the symptoms or cause of GER
    D.

    21) Explanation ---------------------------------------------------
    The correct answer is
    B. A prolongation of the QRS interval is highly predictive of both cardiac and CNS toxicities from tricyclic antidepressant ingestion.

    Left deviation of the QRS axis (choice A), which can be seen with conditions such as left ventricular hypertrophy and left bundle branch block, is not typically associated with tricyclic cardiac toxicity. Conversely, right deviation of the QRS axis (greater than 120 degrees) is very predictive of cardiac toxicity from tricyclics.

    Shortening of the QT interval (choice C) is not seen with tricyclic toxicity, but can be seen with metabolic derangements such as hypercalcemia.

    Neither ST segment depression (choice D) nor T wave inversion (choice E) is directly associated with cardiac toxicity from tricyclic overdose. These changes may be seen, however, in conjunction with the more classic ECG manifestations of tricyclic toxicity (prolonged QRS interval, right axis deviation) if the resulting cardiac toxicity leads to diminished coronary perfusion and ischemia.

    22) Explanation ---------------------------------------------------
    The correct answer is
    B. Although this patient has rarely been aware of symptoms of gastroesophageal reflux disease (GERD), the development of a peptic stricture clearly indicates longstanding acid reflux into the distal esophagus. This will be a persistent process and, if not treated, will lead to recurrent strictures. He therefore requires chronic treatment with a proton pump inhibitor to suppress acid secretions.

    Famotidine and antacids, such as magnesium hydroxide (choices A and C), are adjuncts to the mainstay of therapy, which is proton pump inhibition.

    Even though the patient is not symptomatic, he does require continued acid suppression. Metoclopramide (choice D) reduces the lower esophageal sphincter pressure and is an adjunct to acid suppression in the management of patients with reflux. It is not used as first-line therapy, however. It is nowhere near as effective as proton pump inhibitors and frequently leads to side effects of sedation because of its ability to cross the blood-brain barrier and inhibit dopamine, producing Parkinson-like symptoms.

    As stated above, this patient will have recurrent strictures if he does not receive treatment. Therefore, choice E is incorrect.

    23) Explanation ---------------------------------------------------
    The correct answer is
    A. Acute appendicitis is the second most common cause in the U.S., behind hernia, of severe acute abdominal pain that requires abdominal operation. Although it can occur at all ages, many patients, like this man, are teenagers or young adults. This patient's presentation is typical for acute appendicitis, with initially poorly localized pain that is followed by nausea and vomiting. In classic appendicitis, the pain shifts to the right lower quadrant, where it becomes more localized. In most patients, acute obstruction of the appendiceal orifice by a fecalith initiates the acute appendicitis.

    The acute onset of ileocolitis (choice B) will produce diarrhea or bloody stools.

    There is no evidence to suggest an etiology for ischemic colitis (choice C), which will typically present with bloody diarrhea and often with left-sided abdominal pain.

    Acute Yersinia infection (choice D) will produce acute right lower quadrant findings similar to those of acute appendicitis. However, it is accompanied by diarrhea, which is not described in this case.

    There is no reason to suspect obstruction of the ileocecal area by any mass (choice E) in a 23-year-old man. Such an obstruction, should it occur, would typically present with abdominal distention as a result of bowel obstruction.

    24) Explanation ---------------------------------------------------
    The correct answer is
    A. Administering glucose to a patient who is deficient in thiamin may precipitate Wernicke-Korsakoff syndrome, which is a combination of confusion, ataxia, ophthalmoplegia, anterograde and retrograde amnesia, and confabulation. It is therefore imperative to administer IV thiamin prior to glucose-containing IV fluids.

    Niacin (choice B) is an essential component of the coenzymes involved in oxidation-reduction reactions. Profound deficiency in niacin causes the classic triad of pellagra: dermatitis, diarrhea, and dementia.

    Vitamin B12 deficiency (choice C) may lead to megaloblastic anemia, neurologic complications, and dementia.

    Vitamin C deficiency (choice D) may lead to difficulty with wound healing and scurvy.

    Vitamin K (choice E) is essential for the production of selected clotting factors. Although alcoholics may be deficient in all the vitamins mentioned in the answer choices, only deficits in thiamin are associated with harmful effects if glucose is administered without replenishment.

    25) Explanation ---------------------------------------------------
    The correct answer is
    B. The clinical manifestations are consistent with fat embolism. This complication is frequent, following fractures of long bones, but is usually asymptomatic. Fat embolism mainly affects the lungs and the brain, and the clinical picture consists of dyspnea, tachycardia, and mental status changes. Only rarely, does this condition lead to death. In the lungs, fat emboli can be visualized histologically. In the brain, multifocal petechiae in the white matter represent the most common pathologic change.

    Diffuse axonal injury (choice A) is one of the most common forms of traumatic brain injury. It involves the central white matter, especially the corpus callosum and cerebral peduncles. It is sometimes associated with small petechiae in these areas. The patient may develop coma a few hours to days after head trauma.

    Septic embolism (choice C) results from septic emboli lodging in the terminal intraparenchymal arteries of the brain. It leads to multiple cortical infarcts, usually of the hemorrhagic type. The white matter is spared.

    Systemic thromboembolism (choice D) is usually of cardiac origin—for example, in patients with cardiac arrhythmias with thrombi in the right atrium or ventricle. Thromboemboli in the brain cause hemorrhagic infarction in the cortex.

    Watershed infarction (choice E) is often seen in patients suffering from acute hypotensive episodes, especially if the circle of Willis is already compromised by atherosclerotic change. The cortical regions at the border zone between different vascular territories (e.g., between the distribution of the anterior and middle cerebral arteries) undergo ischemic necrosis.

    26) Explanation ---------------------------------------------------
    The correct answer is
    D. The patient has a prostatic abscess. The typical age is 40 to 60 years, and is consequently somewhat younger than the ages at which benign prostatic hyperplasia and prostate cancer become major problems. Infecting organisms include aerobic gram-negative bacilli and Staphylococcus aureus. Prostatic abscess should be suspected when a man develops repeated urinary tract infections that seem to get better with antibiotic therapy, only to recur later. The most important diagnostic clue, if detectable, is the presence of a fluctuant mass in the prostate on rectal exam. Some patients have only prostatic enlargement, or even no positive findings on physical examination. Patients may have normal urine, although it is more usual for an organism to be cultured at some point. Prostatic ultrasound may be helpful if the diagnosis is suspected. A few cases are even picked up at the time of prostatic resection for benign prostatic hyperplasia or other disease. Treatment is with evacuation of the abscess by a transurethral or perineal route followed by appropriate antibiotics.

    Benign prostatic hyperplasia (choice A) can cause urinary obstruction predisposing for bladder infection, but the prostate would not be fluctuant.

    Chronic nonbacterial prostatitis (choice B) can cause symptoms resembling urinary tract infection, but would not cause a fluctuant prostate.

    Prostadynia (choice C) is a noninfectious, noninflammatory condition of younger men that can mimic prostatitis, but would not cause a fluctuant prostate.

    Prostatic carcinoma (choice E) is usually asymptomatic, and can cause a firm prostatic mass.

    27) Explanation ---------------------------------------------------
    The correct answer is
    D. Patients who receive the hepatitis vaccine will develop only surface antibodies, since the vaccine contains only epitopes of the surface antigen and NOT of the intact viral particle, which contains the core antibody. These patients will therefore have a negative surface antigen, negative core antibody, and positive surface antibody.

    Choice A describes a patient who has recent hepatitis B infection and has not yet developed surface antibody
    B.

    Choice B describes a patient that has had a past hepatitis B infection and has developed immunity.

    Choice C refers to a patient who has developed acute hepatitis B and has not yet developed immunity.

    Choice E describes a patient who has never been exposed to surface antigen and has no immunity.

    28) Explanation ---------------------------------------------------
    The correct answer is
    C. There is an extensive body of literature indicating that beta blockers given to non-cardiac surgical patients who are at risk of cardiac events are associated with a more favorable outcome in terms of postoperative cardiovascular morbidity and mortality. This patient has somewhat poorly controlled hypertension, as well as at least three cardiovascular risk factors (hypertension, tobacco, age). Ideally, one would like to have better control of the blood pressure and to reduce any risk for adverse perioperative events. Beta blockers can achieve both of these endpoints.

    Captopril (choice A) is an ACE inhibitor that has good efficacy in the treatment of hypertension. This class of drugs has also been shown to prolong survival in patients with congestive heart failure.

    Clonidine (choice B) is a central alpha-2 receptor agonist that works to attenuate sympathetic outflow and thus lower blood pressure. Although it is a reasonably efficacious drug, it is associated with rebound hypertension if abruptly discontinued. It has no role in the perioperative management of blood pressure.

    Nifedipine (choice D) is a calcium channel blocker that has reasonable efficacy in treating hypertension. There is no benefit to giving this agent in the perioperative period.

    Prazosin (choice E) is a alpha-1 receptor antagonist that is very efficacious in the treatment of hypertension. This class of drugs is also useful in the treatment of benign prostatic hypertrophy (BPH).

    29) Explanation ---------------------------------------------------
    The correct answer is
    D. This patient's occupational history of working in the mining industry should always prompt the consideration of the diagnosis of silicosis. There is usually bilateral upper lobe involvement associated with hilar lymphadenopathy and "eggshell" calcification of the visualized lymph nodes.

    There is no description of asbestos exposure (choice A), making this diagnosis unlikely.

    Bronchopulmonary aspergillosis (choice B) is often seen in farm workers who have been working in silos.

    Cystic fibrosis (choice C) presents during childhood, and these patients do not survive to this age.

    There is no evidence of tuberculosis exposure (choice E) by the patient's history.

    30) Explanation ---------------------------------------------------
    The correct answer is
    A. The symptoms and signs that she is describing, particularly in the context of atrial fibrillation (AF), suggest peripheral embolization, which is a surgical emergency. The treatment of choice involves immediate embolectomy, which is usually performed by a vascular surgeon, followed by anticoagulation. Her subtherapeutic prothrombin time and persistent AF on examination are supportive of this diagnosis.

    All the other choices (choices B through E) represent actions that would delay surgical care and likely lead to the loss of her limb. Even if the physician has not seen this patient before, it is incumbent on him to direct her to and facilitate immediate surgical intervention.

    [/HIDE]

  3. #3
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    31-50 answers and detailed explanations:

    [HIDE]
    31) Explanation ---------------------------------------------------
    The correct answer is
    D. This patient is in pericardial tamponade, most probably as a result of his malignancy. Lung cancer is particularly likely to cause pericardial effusions. Furthermore, since this patient has metastases to the pericardium, he might be bleeding into the pericardial space. This tamponade may be the cause of his significant hypotension and the soft cardiac sounds. Electrical alternans, a phenomenon in which the QRS changes axis, is indicative of pericardial effusion, since the heart is moving freely in the fluid, causing a change in axis noted on the ECG. Emergently, this patient needs decompression of the pericardial space with the aid of pericardiocentesis, whereby a catheter directly drains the fluid in the pericardial sac.

    Beta-blockers (choice A) would be of no benefit in treating cardiac tamponade.

    Nonsteroidal anti-inflammatory drugs (NSAIDs) (choice B) can be useful in treating pericarditis, which may cause pericardial effusions. However, this is a longer term option and will have little utility emergently.

    Steroids (choice C) may similarly be used in pericarditis, after NSAIDs have failed. However, this is an option to be explored after the pericardial fluid has been drained.

    Cardiac catheterization is often used to confirm the diagnosis of tamponade (choice E). Typically the pressure equalizes across the right atrium and ventricle. However, emergently, this patient should have pericardiocentesis.

    32) Explanation ---------------------------------------------------
    The correct answer is
    C. This is a patient who has 3 clear risk factors for coronary artery disease (tobacco, family history and age) and based on his physical examination, likely has severe peripheral vascular disease. He has, by definition, typical chest pain, so called "new onset angina". He is a prime patient to have significant coronary disease, and thus we suspect ischemia as a cause for his pain. As a surrogate for coronary angiography, which actually shows anatomy, an exercise treadmill test allows us to detect ECG changes of ischemia with activity and thus stratify this patient as requiring intervention (such as percutaneous transluminal coronary angioplasty, or coronary artery bypass grafts), or perhaps angiography to better evaluate his anatomy.

    A resting ECG (choice A) is appropriate, but not the most appropriate, given that he is pain-free at present and one would not expect to see any ECG changes associated with ischemia.

    A cardiac echocardiogram (choice B) will likely be performed, given his dyspnea on exertion, but is not an appropriate test in the triaging of suspected ischemic chest pain. In some centers a "stress-echo", specifically a dobutamine echocardiogram, is used to evaluate ischemic potential.

    A non-urgent coronary angiography (choice D) is also inappropriate since angiography is an invasive procedure reserved for people that have had equivocal results from less invasive diagnostic procedures, or are having signs of crescendo angina. This patient has new angina, but it is "typical" angina in that it is exertional.

    An immediate coronary angiogram (choice E) is clearly not indicated as the patient is not having active ischemia or a myocardial infarction requiring reperfusion.

    33) Explanation ---------------------------------------------------
    The correct answer is
    E. The acute infection due to hepatitis C virus (HCV) is most commonly asymptomatic, but 80% of these cases progress to chronic hepatitis. Of the 80%, 20% will eventually evolve to cirrhosis. The source of infection remains unknown in a substantial number of cases, but 50% are related to IV drug abuse and 4% are attributable to blood transfusion. HCV, on the other hand, is now the most common cause of transfusion-associated hepatitis. The mode of presentation of chronic hepatitis C is often insidious, and patients might well be in good health when elevated aminotransferases are discovered. This laboratory finding prompts additional investigations, usually including a percutaneous liver biopsy. This will demonstrate the typical histologic changes of chronic hepatitis, namely chronic portal inflammation eroding, to varying extents, into the hepatic lobule. The degree of lobular "invasion" by the portal inflammatory infiltrate is the main indicator of the propensity for evolution to cirrhosis. Male sex, infection after age 40, and alcohol consumption are risk factors for evolution of chronic hepatitis C to cirrhosis. Nowadays, HCV is considered the most common cause of chronic hepatitis and one of the most common causes of cirrhosis in industrialized countries.

    34) Explanation ---------------------------------------------------
    The correct answer is
    D. The etiology of pneumonia is related to both the age of the patient and the particular risk factors that he or she may exhibit. For patients with no specific risk factors, pneumonia is referred to as community-acquired pneumonia (CAP). CAP has a variable etiology depending on the age of the patient. In patients aged 29-55, the pneumococcus (Streptococcus pneumoniae), a gram-positive organism, is the most frequent agent causing so-called typical or bacterial pneumonia.

    Bordetella pertussis(choice A) causes whooping cough in children. Most adults in the U. S. have been vaccinated against this organism. However, 20 years after the last booster, immunity begins to fade, and it is reasonably common to see patients aged 55 and older presenting with upper and lower respiratory tract infections caused by this organism.

    Klebsiella pneumoniae(choice B) is a reasonably frequent source of pneumonia in both hospitalized patients and those with chronic aspiration problems, such as post-stroke patients.

    Mycoplasma pneumoniae(choice C) is the primary agent responsible for so-called atypical pneumonia in the same age bracket.

    Staphylococcus aureus(choice E) is a gram-positive organism that causes severe cavitating pneumonia. It is most often responsible for pneumonia in diabetic patients.

    35) Explanation ---------------------------------------------------
    The correct answer is
    E. In the U.S., lung damage from smoking is by far the most important contributor to lung disease, from an epidemiologic standpoint. In addition, smoking can significantly exacerbate the clinical course of other diseases that affect the lungs, such as asthma or cystic fibrosis. Fortunately, smoking behavior can be potentially altered by new pharmacologic approaches. Although the physician may have asked this patient about smoking before, it is now time to review her smoking history in detail.

    Asking about alcohol (choice A) and drugs of abuse (choice B) is always important, even in the elderly, but reviewing the smoking history should take precedence here. Alcohol use typically does not directly lead to lung pathology or cause dyspnea. Some drugs of abuse, such as marijuana, crack cocaine, and heroin, have deleterious effects when introduced into the lungs. That said, the age of this patient makes it much more likely that she would be using tobacco.

    Although exploring the marital status (choice C) and key relationships in a patient's life is very important in terms of the patient's overall health, this process has little additional role during this visit.

    Reviewing the occupational history (choice D) is also an important part in the evaluation of dyspnea. Although smoking usually overshadows occupational-related lung injuries, the occupational history should take a close second to the smoking history. Occupational exposures can exacerbate diseases such as asthma and can cause diseases such asbestosis and silicosis. If the patient had been a 50-year-old brake mechanic or shipyard worker, the occupational history may have been a more important component of the social history on which to concentrate.

    36) Explanation ---------------------------------------------------
    The correct answer is
    A. This patient should have antibiotic prophylaxis before undergoing dental work. The patient's physical examination is consistent with asymptomatic aortic insufficiency, as indicated by his lack of symptoms combined with a characteristic diastolic murmur. This has occurred as a result of his childhood rheumatic fever. Patients with any significant cardiac valvular disease should be instructed to have antibiotic prophylaxis before dental work to reduce the risk of subacute bacterial endocarditis.

    Although this man is at increased risk for lung cancer given his long history of smoking, chest x-ray films (choice B) have never been proven effective as early detection.

    Although he does have underlying valvular heart disease, there is no indication for an annual echocardiogram (choice C) unless specific symptoms develop and warrant evaluation.

    A sigmoidoscopy (choice D) is one of several choices that are appropriate colorectal cancer screening examinations beginning at age 50.

    Prostate specific antigen testing (choice E) remains controversial in asymptomatic adults and is certainly not recommended in asymptomatic men younger than 50.

    37) Explanation ---------------------------------------------------
    The correct answer is
    D. Hyper IgM immunodeficiency is a congenital, often X-linked, form of immunodeficiency which is characterized by low IgG and IgA and compensatory high IgM. The immunodeficiency causes increased susceptibility to major gram-positive pathogens and opportunistic infections (such as the patient's Pneumocystis infection). The biochemical basis of the condition appears to be a defect in a receptor on the T cell membrane that helps to trigger B cell switching from IgM to IgA, IgG, and Ig
    E. Cases, such as in this question, in which the problem is not picked up because of the immunodeficiency may come to medical attention with other features of the syndrome, including lymphadenopathy, autoimmunity (notably Coombs positive hemolytic anemia), or chronic liver disease.

    Adenosine deaminase deficiency (choice A) is a cause of a form of severe combined immunodeficiency that usually presents (often with thrush) in the first three months of life.

    Bruton's agammaglobulinemia (choice B), also known as x-linked agammaglobulinemia, is characterized by markedly decreased B cell numbers, and low values of all of the immunoglobulins, particularly IgG.

    IgG subclass deficiency (choice C) is characterized by markedly decreased levels of a single IgG subclass in the setting of normal total IgG levels.

    Selective IgA deficiency (choice E) is very mild, and is usually clinically significant only because of a tendency to anaphylaxis if given IgA-containing blood products.

    38) Explanation ---------------------------------------------------
    The correct answer is
    D. This is probably a lipoma, which is a benign mass lesion composed of mature adipose tissue bound by a limiting membrane. (Another possibility is an epidermoid cyst, which can be indistinguishable clinically from lipoma.) Lipomas are very common, and patients may have more than one lipoma. Common sites include the trunk, nape of the neck, and forearms. The lesions are only rarely malignant, although a rapidly growing lesion should be biopsied to make sure of the diagnosis. They are usually asymptomatic; a small percentage are painful. They can be treated with surgical excision or liposuction.

    Capillary hemangioma (choice A), also known as strawberry mark, is a bright red, vascular lesion that usually develops shortly after birth and then often involutes by late childhood.

    Dermatofibroma (choice B) causes a firm, red to brown, small papule or nodule that is most frequently found on the legs.

    Intradermal nevus (choice C) causes a flesh colored to black, elevated, lesion that is usually 3 to 6 mm in size.

    Seborrheic keratosis (choice E) causes a pigmented, superficial, usually warty, epithelial lesion.

    39) Explanation ---------------------------------------------------
    The correct choice is
    A. This patient has a microcytic, normochromic anemia and is not obviously ill on physical examination. The overwhelmingly most likely diagnosis is iron-deficiency anemia, which is, in turn, almost always due to bleeding in adults on a typical American diet. Occult GI bleeding is a common source in both men and women. Menstrual disorders are also important causes of iron deficiency in women.

    Low iron binding capacity (choice B) is seen in the anemia of chronic disease.

    Low folate (choice C) produces a megaloblastic anemia.

    Low mean corpuscular hemoglobin concentration (MCHC; choice D) is seen in hypochromic anemias.

    Low vitamin B12 (choice E) produces a megaloblastic anemia.

    40) Explanation ---------------------------------------------------
    The correct answer is
    B. Focal glomerular sclerosis is the type of nephropathy most commonly seen in African American IV drug users with AIDS. It is likely to lead to a very rapid loss of renal function.

    There is no clinical evidence to indicate that this person has diabetes, making diabetic nephropathy (choice A) unlikely.

    Nil disease (choice E), IgA nephropathy (choice C) and membranous nephropathy (choice D) are only very rarely associated with AIDS.

    41) Explanation ---------------------------------------------------
    The correct answer is
    D. For those patients in whom a fasting panel has been obtained, a stepwise approach to intervention based on the patient's LDL and risk factors may be used. A patient with 2+ risk factors (this patient) and an LDL of greater than 160 mg/dL warrants medical therapy.

    A total cholesterol of 180 mg/dL, LDL cholesterol of 140 mg/dL (choice A) or a total cholesterol of 184 mg/dL with an LDL cholesterol 100 mg/dL (choice B) in this patient could be managed with a trial of dietary modification and education.

    For marginally high total cholesterol: total cholesterol 230 mg/dL, LDL cholesterol 100 mg/dL (choice C), there is no indication for drug therapy because the LDL is still not above 130.

    A total cholesterol of 285 mg/dL with an LDL cholesterol of 100 mg/dL (choice E), although disconcerting, does not require drug therapy. The total cholesterol is elevated, but the LDL is not, suggesting either increased triglycerides or an equally high HDL level.

    42) Explanation ---------------------------------------------------
    The correct answer is
    B.Helicobacter pylori plays a major role in the pathogenesis of peptic ulcer disease. The organism is present in 95% to 100% of patients with duodenal ulcers and in 75% to 85% of those with gastric ulcers. Eradicating the organism generally results in a cure for the disease. Therapy varies, but one of the more common regimens consists of antibiotics and a proton-pump inhibitor.

    Oral amoxicillin (choice A) and oral metronidazole (choice C) are possible antibiotics used in combination therapy. They are not efficacious when given without the other agents in the combination.

    The same is true for oral omeprazole (choice D). This proton-pump inhibitor is not efficacious in eradicating the organism when it is given without antibiotics.

    Oral sucralfate (choice E) has no role in therapy of H. pylori infection. This drug coats pre-existing gastric erosions to prevent worsening of ulcers, not to prevent acid secretion.

    43) Explanation ---------------------------------------------------
    The correct answer is
    C. Hypothyroidism is the main complication of radioactive iodine therapy, affecting up to 70% of patients in 10 years. Radioactive iodine therapy is a safe and effective treatment for Graves' disease because it can provide the same ablative effects of surgery without the surgical complications. There is no evidence that this treatment increases the risk for carcinoma (choice E).

    Cholestasis (choice A) and granulocytopenia (choice B) are side effects of long-term antithyroid therapy (propylthiouracil).

    Recurrent laryngeal nerve damage (choice D) is a complication of subtotal thyroidectomy. Subtotal thyroidectomies provide rapid control of the disease but can lead to nerve damage, hemorrhage, hypothyroidism, and hypoparathyroidism.

    44) Explanation ---------------------------------------------------
    The correct answer is
    B. Measurement of serum levels of prostate-specific antigen (PSA) can be used to screen for prostate cancer. However, this substance can also be elevated in prostate hypertrophy. A transrectal ultrasound can identify lesions not palpable on rectal examination, and the area can be biopsied under ultrasound guidance.

    Metastatic prostate cancer can be treated with leuprolide (choice A). This is a luteinizing hormone releasing hormone (LH-RH) agonist that suppresses testicular testosterone production. This is equivalent to orchiectomy or estrogen therapy.

    Patients with prostate cancer will undergo a metastatic work-up as well, including a bone scan (choice C) to rule out bony metastases. However, the diagnosis of cancer must first be made.

    Repeat PSA analysis would be helpful in following response to therapy (choice D). However, the PSA is high enough to warrant immediate work-up.

    Imaging of the pelvis and retroperitoneum (choice E) would be part of the standard metastatic work-up as well.

    45) Explanation ---------------------------------------------------
    The correct answer is
    E. This is tularemia, the causative organism of which is Francisella tularensis. The classic clue in test questions is exposure to wild rabbits, although wild rodents and their arthropod vectors may also carry the disease. You should also be aware that this highly infectious organism should not be isolated except in special protective hoods. The description in the question stem is typical of the ulceroglandular form; less common forms include disease resembling typhoid fever, an oculoglandular form secondary to eye inoculation, and a glandular form in which the initial site of infection is not obvious. Very severe cases may develop disseminated necrotic lesions of various sizes throughout the body. Agglutination tests can confirm the diagnosis after about the 10th day of illness. Untreated cases tend to last 3 to 4 weeks before resolving. Streptomycin is the antibiotic of choice; gentamicin and chloramphenicol can alternatively be used. Deaths occur in about 6% of untreated cases and are very rare in treated cases.

    Actinomycosis (choice A) causes multiple draining sinuses.

    Brucellosis (choice B) causes recurrent fevers.

    Melioidosis (choice C) causes lung and disseminated infection, usually following contamination of wounds by infected soil or water.

    Plague (choice D) causes lymph node and lung involvement after exposure to infected rodents and their parasites.

    46) Explanation ---------------------------------------------------
    The correct answer is
    D. The tidal volume for a patient is generally estimated as 10 mL/kg of weight, which for this patient would be 850 mL/breath. Giving a lower tidal volume will yield hypoventilation and be insufficient to eliminate pCO2. Providing a tidal volume greater than 10 mL/kg increases the risk of pneumothorax, particularly in a patient with longstanding emphysema who may have thin-walled alveoli.

    A low tidal volume with risk of hypoventilation would be produced by choice A (500 mL/breath), choice B (600 mL/breath), and choice C (700 mL/breath).

    A high tidal volume with risk of pneumothorax would be produced by choice D (1000 mL/breath).

    47) Explanation ---------------------------------------------------
    The correct answer is
    B. The current recommendations for routine, age-appropriate screening are based, in some measure, on data from clinical trials. Depending on the source of the recommendations, there is considerable variability in these recommendations. One of the more agreed on recommendations is that, at least every 5 years, a random cholesterol level should be checked.

    A fasting lipid profile (choice A) is usually obtained only after a screening cholesterol is shown to be greater than 240 mg/dL.

    An oral glucose tolerance test (OGTT) (choice C) is given to pregnant women to screen for gestational diabetes. There is no current recommendation for using OGTT in routine screening practice in any age group.

    The incidence of prostate cancer is age-related and becomes reasonably prevalent after age 50. Therefore, prostate examinations (choice D) are recommended annually after age 50. Like prostate cancer, colon cancer is also age-related and begins to have significant incidence after the 5th decade.

    Sigmoidoscopy (choice E) is indicated every 3-5 years after age 50 to monitor for lesions up to the splenic flexure. Colonoscopy is necessary to survey the entire colon.

    48) Explanation ---------------------------------------------------
    The correct answer is
    D. Allogeneic bone marrow transplantation has become a frequent therapeutic approach to a variety of conditions, including leukemic diseases. The patient undergoing bone marrow transplantation is profoundly immunosuppressed and prone to developing opportunistic infections. The clinical picture described in this case is consistent with graft versus host disease (GVHD), in which T cells (both helper and suppressor cells) of the engrafted marrow react against the recipient's antigens, thus triggering inflammation and injury to the host tissues. The most severely affected organs include the immune system, gastrointestinal tract, liver, skin, and lungs. This complication may be acute (this case) or chronic. CMV pneumonia is a frequent fatal complication in the acute stage. The chronic stage is characterized by progressive fibrosis of affected organs.

    B-lymphocytes of a bone marrow graft (choice A) do not play a significant role in GVH
    D.

    Leukemic cells (choice B) may give rise to recurrence of the original disease, which must be distinguished from GVH
    D. The combination of skin rash and opportunistic infections strongly favor GVH
    D. In addition, single cell necrosis in the epithelia of skin, GI tract, and liver is highly characteristic of GVH
    D.

    Natural killer cells of the recipient (choice C) and T-lymphocytes of the recipient (choice E) play a crucial role in mediating rejection of allogeneic marrow transplants.

    49) Explanation ---------------------------------------------------
    The correct answer is
    B. This is ichthyosis vulgaris, which is the most frequent form of inherited ichthyosis. Ichthyosis vulgaris has autosomal dominant inheritance with a frequency of 1:300 in the general population. The condition usually begins in childhood and has the features illustrated in the question stem. Skin care should involve minimizing bathing with use of soaps only in the intertriginous areas. Bathing limited to 10-minute periods (to hydrate the stratum corneum), followed by immediate application of an emollient such as petrolatum, can help to control the scaling. In addition, 50% propylene glycol in water under occlusion by thin plastic film or bags during the night is helpful in adults, but is not usually used in children.

    Epidermolytic hyperkeratosis (choice A) is a rare, autosomal dominant form of ichthyosis that is present from birth and is characterized by thick, warty skin all over the body, most prominently in flexural creases.

    Lamellar ichthyosis (choice C) is a rare, autosomal recessive form of ichthyosis that is present from birth and causes large, coarse scale over most of the body.

    X-linked ichthyosis (choice D) is a relatively common form of ichthyosis that can present at birth or in childhood and usually causes large, dark scales with a predilection for the neck and trunk; the palms and soles are normal.

    Xeroderma (choice E) is a mild, acquired form of dry skin, sometimes with cracking or mild scaling.

    50) Explanation ---------------------------------------------------
    The correct answer is
    C. This patient has classic symptoms of mechanical dysphagia, as she has difficulty with large solid food but not softer foods or liquids. Mechanical dysphagia frequently follows many years of heartburn and is often indicative of a peptic stricture that has developed as a result of fibrosis after a long period of chronic inflammation due to gastroesophageal reflux disease (GERD). These benign strictures can usually be dilated endoscopically. An intensive regimen of proton-pump inhibitors should then be instituted to reduce the frequency of recurrence.

    Although chronic acid reflux can predispose for Barrett's esophagus (choice B) and then subsequently adenocarcinoma (choice A), Barrett's esophagus is a mucosal change only that would not cause lumenal narrowing. Furthermore, adenocarcinoma would be very unusual in a patient this young.

    Schatzki ring (choice D) is unlikely, since it typically produces episodic mechanical dysphagia rather than the progressive mechanical dysphagia described in this question.

    Squamous carcinoma (choice E) in the mid-third of the esophagus can produce mechanical dysphagia. However, this patient is far younger than the usual patient with squamous carcinoma, and she has no risk factors, such as smoking, drinking, lye ingestion, or upper esophageal web (Plummer-Vinson syndrome).
    [/HIDE]

  4. #4
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    thank u ,very good questions
    can i ask u where did u take them from??

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    Thank u very very much again!!!!!

  6. #6
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    really nice one .can u most questions of these kind.plz

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    thanks for ans.

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    Thanks very much. Great quesions

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    thanks but where is the answers ?

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    thanks so much

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