26. A 70-year-old woman has been in long-standing poor health, with severe diabetes mellitus and rheumatoid arthritis. Her physician notes that she appears pale and orders a hematocrit, which shows a result of 35%. Examination of the blood smear reveals a microcytic anemia. The physician is considering a differential diagnosis of iron deficiency anemia versus anemia of chronic disease. Which of the following laboratory determinations would be most helpful in distinguishing these conditions?
a)Erythrocyte:granulocyte ratio in bone marrow
b) Presence or absence of polychromatophilic target cells
c)Presence or absence of stippled erythrocytes
27. A 45-year-old patient on hemodialysis for one week has noted that his blood pressure is more difficult to control. He reports good compliance with his medications, which include erythropoietin, ferrous sulfate, vancomycin, and vitamin D. His blood pressure is 180/99 mm Hg. Which of the following is the most likely cause for the worsening control of his blood pressure?
28. A 40-year-old man is brought to the emergency room by his friends. Apparently, he has ingested some unknown medication in a suicide attempt. The patient is disoriented to time. His temperature is 39.3 C (103 F), blood pressure is 120/85 mm Hg, pulse is 100/min and irregular, and respirations are 22/min. The skin is flushed and dry. Dilated pupils and muscle twitching are also noted on physical examination. ECG reveals prolonged QRS complexes. Hepatic transaminases are normal, and blood gas analysis shows a normal pH. These findings are most likely due to intoxication by which of the following substances?
e) Monoamine oxidase (MAO) inhibitors
29.A 72-year-old man comes to the physician because of a 3-day history of right-sided chest pain. He denies any shortness of breath, nausea or vomiting. Physical examination shows a unilateral, erythematous, maculopapular rash extending from the anterior chest wall around to the back in a dermatomal pattern. The remainder of the examination is normal. In conversation, he states that is he is going to visit his grandchildren next week and that their mother "doesn't believe in immunizations". His grandchildren are at increased risk for which of the following rashes?
a) Discrete maculopapular lesions that become confluent as they spread from "head to toe"
b)Dome-shaped papules with central umbilication
c)Expanding annular lesion with central clearing
d) "Slapped-cheek" appearance and a lacy reticular rash
e) Vesicles at various stages of evolution
30. A 50-year-old man consults a physician because he has been having transient periods of rapid heart beat accompanied by sweating, flushing, and a sense of impending doom. Physical examination is unrevealing, with no evidence of arrhythmia at the time of the exam. However, the man's wife is a nurse, so the physician asks that she take vital signs the next time one of the episodes occurs. She does, and demonstrates a blood pressure of 195/140 mm Hg with heart rate 160/min during the episode. She promptly takes her husband to the emergency room, but the spell is over by the time that he is seen. Urinary measurement of which of the following would most likely be diagnostic in this case?
a) Dehydroepiandrosterone (DHEA)
b)Human chorionic gonadotropin (hCG)
d)Vanillylmandelic acid VMA
e) Zinc protoporphyrin
31. A 35-year-old woman consults an ophthalmologist because of double vision and droopy eyelids. She also has complaints of generalized muscle weakness. IV injection of edrophonium dramatically, but only briefly, reverses her symptoms. This patient's probable disease has a pathophysiologic basis that is closest to that of which of the following conditions?
a) Bullous pemphigoid
b)Diabetes mellitus type 1 (some cases)
c)Idiopathic Addison disease
e)Systemic lupus erythematosus
32.A 34-year-old woman who is healthy without underlying medical problems presents to clinic with complaints of temperature up to 101 F and cough with greenish sputum production for 2 days without any dyspnea. Her heart rate is 88/min, and her respiratory rate is 18/min. There is no accessory muscle use or conversational dyspnea, nor are there wheezes, bronchial breath sounds, rales, or egophony over the right lower lung fields. Chest x-ray film reveals a right lower lobe consolidation. A CBC shows a leukocyte count of 13,000/mm3. Which of the following is the most appropriate pharmacotherapy?
e) Erythromycin plus ceftriaxone
33. A 23-year-old type 1 diabetic is brought to the emergency department after being found in a coma. The scent of acetone is present on the patient's breath. Urinary catheterization with subsequent dipstick analysis demonstrates marked positivity for glucose and ketones. Stat blood chemistries would most likely show which of the following values for the anion gap?
a) 6 mEq/L
e) 20 mEq/L
34. A 70-year-old man presents to the emergency department with a 3-day history of right temporal headache, fever, and profound malaise. He appears acutely ill. His temperature is 39.5 C (103.1 F), blood pressure is 130/80 mm Hg, pulse is 98/min, and respirations are 24/min. Tenderness over the right temporal region is appreciated on palpation. The right temporal artery is tender and slightly nodular. Neurologic examination is normal, including funduscopic examination. However, visual acuity is reduced. Laboratory studies show:
Hemoglobin 10.9 g/dL
Leukocytes 8800/µL (neutrophils 68%)
Erythrocyte sedimentation rate 80 mm/hr
Which of the following is the most appropriate next step in management?
a)Measurement of intraocular pressure
b)Visual field assessment
c)Low-dose (10 mg/day) prednisone treatment
d)High-dose (60 mg/day) prednisone treatment
e) Temporal artery biopsy
35.A 74-year-old woman presents to her physician for a postoperative medical visit. Three days ago, she underwent a left total knee replacement for severe osteoarthritis. She has a past medical history significant for type 1 diabetes mellitus and glaucoma. Her hospital course was uneventful. She continues to take daily NPH insulin and has good control of her blood glucose. She also takes oxycodone, which was given to her in the hospital for pain. She is involved in a physical therapy rehabilitation program at the local hospital. On review of her medications, which of the following is most acutely indicated at this time?
a) An ACE inhibitor
b)A nonsteroidal anti-inflammatory agent
e) Subcutaneous unfractionated heparin
36. A 37-year-old woman presents with complaints of severe heartburn with or without meals. She has a history of hypertension, which has been treated with captopril. She also has a history of Raynaud disease, multiple facial telangiectasias, and very taut skin on the dorsum of both hands. She has failed to obtain relief for her heartburn with large doses of antacids, ranitidine, or omeprazole. Esophageal manometry is ordered. Which of the following would be the most likely results of this test?
a) Decreased esophageal peristalsis and decreased LES pressure
b)Decreased esophageal peristalsis and increased LES pressure
c)Increased esophageal peristalsis and decreased LES pressure
d)Increased esophageal peristalsis and increased LES pressure
e) Normal esophageal peristalsis and normal LES pressure
37. A 60-year-old woman consults a physician because of weakness, headaches, dizziness, and tingling in her hands and feet. Physical examination demonstrates multiple areas of bruising on the back of her forearms and shins. On specific questioning, she reports having had five nosebleeds in the past two months, which she had attributed to "dry air". Blood studies are drawn which show a platelet count of 1.2 × 106/µL, a red cell count of 5.1 ×106/µL, and a white count of 10,500/µL with a normal differential count. Review of the peripheral smear demonstrates many abnormally large platelets, platelet aggregates, and megakaryocyte fragments. No abnormal red or white blood cells are seen. Philadelphia chromosome studies are negative. Which of the following is the most likely diagnosis?
a)Chronic myelogenous leukemia
e) Secondary thrombocythemia
38. A 23-year old-dancer presents with a chief complaint of weakness. She denies any other symptoms, including nausea or vomiting. She denies diarrhea. Her blood pressure is 80/40 mm Hg. There is no edema and the lungs are clear. Laboratory analysis of serum shows:
Sodium 126 mEq/L
Potassium 2.2 mEq/L
Bicarbonate 29 mEq/L
Magnesium 2.0 mg/dL
Calcium 9.0 mg/dL
The most likely cause of the patient's weakness is an abnormality in which of the following?
39. A 43-year-old woman is admitted for new-onset of seizures in the setting of hyponatremia. At baseline, she is well educated and works as a computer marketer. Her medical history is remarkable for a long history of depression and alcoholism, with multiple visits to the Emergency Department for trauma. She was initially found in her hot apartment by paramedics. At that time, she was postictal, incontinent of urine, and oriented only to name. She was last seen at work 3 days ago. In the Emergency Department her systolic blood pressure is 70 mm Hg and her pulse is 130/min. Upon 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. She proceeds to have two addition seizures in the Emergency Department that are controlled with intravenous lorazepam. Laboratory studies reveal a serum sodium of 115 mEq/L, potassium of 2.8 mEq/L, and bicarbonate of 32 mEq/L. Which of the following is the most appropriate next test to obtain?
b)Magnetic resonance imaging (MRI) of the head
c) Non-contrast computed tomography (CT) of the head
d)X-ray films of the skull
e)Lumbar puncture (LP)
40.A 65-year-old West Texas farmer of Swedish ancestry has an indolent, pale, raised, waxy, 1.2-cm skin mass over the bridge of the nose. The mass has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the neck. Other than a "weather-beaten" appearance for the rest of his exposed skin, the remainder of the physical examination is unremarkable. Which of the following is the most likely diagnosis?
a)Basal cell carcinoma
e)Squamous cell carcinoma
41.A 22-year-old woman goes to the emergency department because she feels very weak and is having muscle cramping and fasciculations. Blood chemistry studies demonstrate a plasma potassium of 1.5 mEq/L. On questioning, she admits to chronic use of laxatives and diuretics to control her weight. Which of the following ECG changes would be most characteristic of changes related to her K+ level?
a)Increased U wave amplitude
b)Prolongation of the P wave
c)Shortening of the QT interval
d)Tall, symmetric, peaked T waves
e)Widening of the QRS complex
42. A 34-year-old man presents with a swollen left knee of 2 days' duration. He denies any known trauma to that region and has no prior history of any musculoskeletal complaints. He is in otherwise excellent health. He is homosexual and practices safe sex with a single partner. On physical examination, his knee is swollen, tender to palpation, and erythematous and has a limited range of motion. An arthrocentesis is performed. Which of the following is most suggestive of a septic arthritis in this patient?
a)A complete blood cell count with 14,300 white blood cells per mL
b)A joint fluid aspirate with a white blood cell count of 28,000 per mL
c)A joint fluid aspirate with a white blood cell count of 36,000 per mL
d)A joint fluid aspirate with a white blood cell count of 48,000 per mL
e) A joint fluid aspirate with a white blood cell count of 93,000 per mL
43. A 59-year-old man presents to the hospital complaining of cough. The patient describes a cough that has progressively worsened over the past 3 days, becoming more productive of yellowish sputum. He also reports one episode of shaking chills 2 days ago. His past medical history is remarkable for rheumatoid arthritis, for which he takes a nonsteroidal agent for pain control. On examination, his blood pressure is 140/90 mm Hg, and his pulse is 100/min. He has coarse breath sounds over his right base and a normal cardiac examination. Which of the following is the most appropriate diagnostic test for this patient?
a)High-resolution chest CT
b)Positron emission tomography (PET) scan of the lungs
c)MRI of the chest
e)X-ray films of the chest, posterior-anterior (PA) and lateral views
44. A 52-year-old woman is seen by in clinic for advice on osteoporosis. She has been a patient there for a number of years. She has a past medical history significant for hypertension and diet-controlled diabetes mellitus. She smokes 1 pack of cigarettes per day. She was documented by previous LH and FSH levels to be in menopause within the last year. She is concerned about "breaking her hip when I'm old" and she is seeking advice on osteoporosis prevention. She should be told that independent of side effects, the best therapy currently available for prevention is which of the following?
c)Calcium and vitamin D
d) Conjugated estrogens
45.A 22-year-old man comes to the emergency department with a 3-day history of fever, chills, a cough, pleuritic chest pain, and low-back pain. He says that the symptoms came on "out of the blue". He is the son of a wealthy local businesswoman and still lives at home, which he says "is cool because my parents are never around". His temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, pulse is 70/min, and respirations are 16/min. Physical examination shows oval, retinal hemorrhages with a clear, pale center and pinpoint lesions between his toes. Blood cultures are drawn. A chest x-ray film shows multiple patchy infiltrates. Laboratory studies show:
Erythrocyte sedimentation rate.......39 mm/hr
Which of the following is the most likely pathogen?
46. A 57-year-old man comes to his physician for his semi-annual visit. He has a medical history significant for long-standing chronic obstructive pulmonary disease (COPD). He has had a two to three pack per day smoking history for the past 40 years. He also has hypertension and diet-controlled type 2 diabetes mellitus. His medications include lisinopril once daily and thiazide. He has no allergies. He reports that he continues to smoke one to two packs of cigarettes per day and drinks one glass of whisky each night. He seems to be compliant with his medications. He walks one half mile per day at a fairly brisk pace but is limited by fatigue and shortness of breath.
His home blood glucose log shows a range of values from 108 to 201 mg/dL. On physical examination, he is a fairly obese man with a large barrel chest. He is breathing comfortably. His blood pressure is 152/88 mm Hg, and pulse is 82/min and regular.
His lungs are hyperresonant to percussion with scant bibasilar crackles. He has an S4 gallop and a grade one systolic ejection murmur radiating to the carotids bilaterally. His extremities are without edema or clubbing.
Which of the following is the most appropriate preventative measure in this patient?
a)Add an oral glucose control agent
b)Encourage additional exercise
c)Encourage rapid cessation of alcohol use
d)Encourage rapid cessation of tobacco use
e)Increase his dose of thiazide
47. A 53-year-old woman presents complaining of fatigue over the past 6 months. During this time, she has also developed pruritus and lost 4 pounds. She is not sexually active, and her past medical history is significant only for Sjögren syndrome.
On physical examination, she is afebrile and has mildly icteric sclera. There are excoriations noted on all four extremities and trunk and back. The liver edge is smooth and non-tender and measures 9 cm at the midclavicular line. There is no ascites, splenomegaly, or peripheral edema.
Laboratory results reveal a normal complete blood count, normal electrolytes, and liver function tests with an alkaline phosphatase of 260 U/L (normal, <110 U/L), total bilirubin of 3.1 mg/dL, and normal transaminase levels. Which of the following is the most likely diagnosis?
a) Acute cholecystitis
b)Acute hepatitis A infection
d)Primary biliary cirrhosis
e)Primary sclerosing cholangitis
48. An elderly woman consults a physician because she is "feeling so tired all the time". Intraoffice hematocrit is 35%. Peripheral blood smear shows many macrocytic red cells. On questioning, the woman, whose finances are limited, admits that has been living on a "tea and toast" type diet. She has been drinking a powdered orange juice substitute (Tang). She has not been taking vitamin pills because she feels she can't afford them. A nutritional deficiency of which of the following is the most likely cause of this patient's anemia?
49. A 65-year-old woman is admitted to the hospital for constant, severe abdominal pain that has worsened over the prior week. She has no other associated symptoms, such as nausea or vomiting, but has noticed that her daily urine output has sharply decreased. She has had a constant desire to urinate, but, when she tries, only a small amount of bloody urine is discharged. The patient is a long-time smoker, having smoked three packs per day for more than 45 years, although she claims to have quit 2 days ago. A bladder ultrasound in the emergency department reveals a mass consistent with bladder cancer, as well as significant urinary retention. Which of the following is most likely to be detected upon imaging the patient's genitourinary system?
50. A 29-year-old man is brought to the emergency department in a comatose state a few hours after complaining of sudden onset of excruciating headache. Neurologic examination reveals dilated pupils poorly responsive to light. A CT scan of the head without contrast demonstrates hyperdensity within the suprasellar cistern, while MRI is unremarkable. Lumbar puncture shows hemorrhagic cerebrospinal fluid. Which of the following is the most likely diagnosis?
a)Amyloid angiopathy-related hemorrhage
b)Cavernous sinus thrombosis
e)Ruptured berry aneurysm