1.A 31-year-old homosexual man presents complaining of pain with defecation. He denies any symptoms of diarrhea, abdominal pain, or fevers. Six months earlier, he developed traveler’s diarrhea while vacationing in Mexico. On physical examination, he is afebrile and has an unremarkable abdominal examination. On examination of the perianal area, there is a group of five clustered ulcers adjacent to the anal orifice and extending into the anal canal. A sigmoidoscopy reveals normal rectosigmoid mucosa. Which of the following is the most likely diagnosis?
E)Ulcerative colitis Normal Labs
2. An elderly diabetic consults a physician because of severe and persistent earache. Otoscopic examination demonstrates foul-smelling purulent otorrhea and a red mass lesion of the external ear canal. Biopsy of the mass demonstrates granulation tissue rather than tumor. Which of the following is the most likely causative organism?
e)Staphylococcus aureus Normal Labs
3.A 74-year-old woman presents complaining of very severe abdominal pain, which began abruptly 8 hours ago. She describes the pain as “the worst I’ve ever had.” On questioning, she is unable to give a precise location but indicates that her entire mid-abdomen is extremely painful. She has been followed for the past 10 years for symptoms of congestive heart failure after she had an anterior wall myocardial infarction. She has remained relatively well controlled with only occasional dyspnea on exertion. Her medications include captopril, furosemide, digoxin, isosorbide dinitrate, and aspirin. She has not had any prior surgery. On physical examination, she appears extremely uncomfortable. Her temperature is 38.9 C (101.9 F), blood pressure is 174/102 mm Hg, and pulse is 118/min and irregularly irregular. On cardiac examination, there is a regular heart rhythm with a II/VI holosystolic murmur heard best at the apex and radiating to the axilla. She has an irregularly irregular S1 and S2, and scattered bibasilar rales. An abdominal examination reveals mild distention and no hepatosplenomegaly. The abdomen is diffusely soft but very tender to palpation. A rectal examination reveals brown, guaiac-positive stool. She has no audible bowel sounds. Which of the following is the most likely diagnosis?
c) Mesenteric ischemia
e)Small bowel obstruction Normal Labs
4. A 22-year-old man comes to the emergency department because of dyspnea, palpitations, and a headache. These symptoms came on soon after he took trimethoprim-sulfamethoxazole for a urinary tract infection. Laboratory studies show a normochromic, normocytic anemia. A peripheral blood smear reveals Heinz bodies. Which of the following is the most likely cause of this patient’s anemia?
a) Lead poisoning
c)Glucose-6-phosphate dehydrogenase deficiency
e) Occult blood loss Normal Labs
5.A 54-year-old obese man presents for a routine physical examination. He was diagnosed with type 2 diabetes 1 year earlier. He has been moderately compliant with dietary precautions and his morning glucose has been persistently between 150 and 200 mg/dL. He is therefore started on glipizide. One month later, metformin is added because of continued poor control. His other medications are propranolol and nifedipine for hypertension, and naproxen, which he began approximately 2 weeks ago for severe knee pain due to osteoarthritis. On physical examination his blood pressure is 154/92 mm Hg, and he has a soft fourth heart sound. The remainder of the physical examination is normal. His routine electrolytes are checked and reveal a BUN of 29 mg/dL and a creatinine of 1.8 mg/dL; both had been normal 1 year earlier. Which of his medications is most likely responsible for the increase in BUN and creatinine?
e) Propranolol Normal Labs
6.A previously healthy 37-year-old woman comes to the physician because of recurrent episodes of double vision and drooping of her eyelids for the last month. Such episodes occur without apparent reason, last for hours, and resolve spontaneously. She also reports occasional hoarseness and difficulty in swallowing, which also come and go. Vital signs and physical examination are normal. Which of the following is the most appropriate next step in diagnosis?
a) Blood, urine, and CSF analysis
b)MRI of the head
d)Electromyography under repetitive stimulation
e) Muscle biopsy Normal Labs
7. During the month of December, a middle-aged patient with chronically dry skin develops widespread coin-shaped lesions. The lesions begin as itchy patches of vesicles and papules. These later ooze serum and crust over. The lesions are most numerous on the extensor surfaces of the extremities and on the buttocks. The patient says that some of the lesions have appeared to heal and then reappear at the same sites. Which of the following is the most likely diagnosis?
a) Nummular dermatitis
e)Stasis dermatitis Normal Labs
8.Which of the following medical interventions is an example of a primary preventive measure?
a)Isolation of disease contacts
d)Screening for visual acuity
e) Testing of stool for occult blood Normal Labs
9. A 17-year-old boy presents with chronic low back pain for the past 8 months. He was the most promising member of the high school swim team but was forced to quit because of his back pain. The pain begins frequently at night, radiates down the thighs, and is accompanied by pronounced stiffness of the lumbar spine. He denies any gastrointestinal or genital infections. His temperature is 37.0 C (98.6 F). Examination reveals moderate limitation of back motion and tenderness of the lower spine. A diastolic murmur along the left sternal border is heard on chest examination. Laboratory investigation shows an elevated erythrocyte sedimentation rate (ESR) and negative rheumatoid factor. X-ray films of the vertebral column and pelvic region show flattening of the lumbar curve and subchondral bone erosion involving the sacroiliac joints. Which of the following is the most likely diagnosis?
a) Ankylosing spondylitis
b)Degenerative join disease
c) Reiter syndrome
d)Seronegative rheumatoid arthritis e) Still disease Normal Labs
10. A 56-year-old man has been admitted to the medical intensive care unit in respiratory distress. An endotracheal tube is placed for mechanical ventilation at a tidal volume of 900 mL, a rate of 12 breaths/min, and a fraction of inspired oxygen of 50%. The positive end expiratory pressure is 10 cm of water. Medications include subcutaneous heparin and aspirin. He now develops tachycardia and a blood pressure of 70/palpation mm Hg. Cardiac examination reveals multiple premature contractions. His arterial blood gas reveals a PO2 of 40 mm Hg. Which of the following is the most likely cause of this condition?
a) Cardiac arrhythmia
e) Pulmonary embolus Normal Labs
11. A 45-year-old alcoholic man with cirrhosis is transferred to the intensive care unit after developing esophageal varices complicated by shock. A screening battery of tests is ordered, revealing a total thyroxine (T4) of 3.8 mg/dL. Physical examination of the thyroid gland is unremarkable. Follow-up studies showed a total triiodothyronine (T3) of 30 ng/dL and TSH (third-generation test) of 0.7 mIU/mL. Which of the following is the most likely diagnosis in this patient?
a) Euthyroid sick syndrome
c) Hashimoto disease
d)Medullary carcinoma of the thyroid
e) Silent lymphocytic thyroiditis Normal Labs
12.A 29-year-old man presents to the clinic complaining of generalized fatigue. The patient is new to the clinic and reports that, over the past few weeks, he has been feeling much more tired than usual. He also reports that this happens to him just about every year, and that other physicians have told him that he is “overworked.” His review of symptoms is notable for frequent sneezing, post-nasal drip, eye watering, and a itch of his posterior pharynx. These symptoms tend to be worse in the spring and summer and have been bothering him since mid-April, about 1 month ago. His past medical history is remarkable only for mild asthma induced by being outdoors. He takes no regular medications but does take diphenhydramine on occasion. He denies tobacco, ethanol, or illicit substance use. Which of the following is the most appropriate diagnostic test at this time?
a) Blood radioallergosorbent test
b)None, the diagnosis is based solely on the history and physical examination
d)Serum protein electrophoresis
e)Skin-prick testing Normal Labs
13.A 58-year-old man with known hepatitis C and cirrhosis complains of worsening fatigue and confusion over the past 5 days. He has been admitted three times in the past 4 months for variceal bleeding and has had ascites that has been refractory to high-dose oral diuretic use. He also reports that over the past 48 hours he has had a declining urinary output. On physical examination, he is gaunt and jaundiced. He has tense ascites and a liver span of 7 cm in the midclavicular line. Laboratory results reveal a white blood cell count of 4600/mm3, a hemoglobin of 9.4 g/dL, and a hematocrit of 29%. His electrolytes reveal a BUN of 34 mg/dL and a creatinine of 3.1 mg/dL. A urinary sodium is less than 10 mEq/L. Which of the following is the most appropriate treatment for his elevated BUN and creatinine? a)Large volume paracentesis b)Hemodialysis c)Mesocaval shunt d)Kidney transplantation e)Liver transplantation Normal Labs 14. A 54-year-old, malnourished man is admitted for evaluation of jaundice, ascites, and tenderness in the right upper abdomen. His temperature is 38 C (100.4 F). Physical examination reveals mild hepatomegaly and splenomegaly, as well as generalized muscle wasting. Ultrasound examination confirms the presence of an enlarged liver and a small amount of ascitic fluid. Laboratory studies show: Serum albumin………………………2.5 g/dL Globulin……………………………….3.8 g/dL Bilirubin: Total………………………………….3.5 mg/dL Direct………………………………..1.7 mg/dL AST…………………………………..300 U/L ALT…………………………………..120 U/L Amylase……………………………..100 U/L Alkaline phosphatase…………….100 U/L Hematologic hemoglobin………..10 g/dL Mean corpuscular volume………100 µm Leukocyte count…………………..4000/mm3 Segmented neutrophils…………..66% Bands………………………………..7% Prothrombin time………………….18 sec Which of the following is the most likely diagnosis? a) Acute pancreatitis b)Alcoholic hepatitis c)Cholecystitis d)Duodenal peptic ulcer e)Viral hepatitis Normal Labs 15. A 28-year-old man who recently emigrated from Italy returns to the physician’s office for a follow up visit to evaluate his anemia. Four days ago, he presented with fatigue and dyspnea on exertion, and was found to have a hematocrit of 22%. At that time he was admitted to the local hospital for evaluation. Laboratory analysis shows: Hematocrit………………………………….23% Mean corpuscular volume (MCV)……59 µm3 Reticulocyte count………………………..4.3% Serum iron………………………………….160 µg/dL Total iron binding capacity (TIBC)…..230 µg/mL Serum ferritin……………………………..80 ng/mL Hemoglobin electrophoresis:…………..Absent beta bands Which of the following is the most likely diagnosis? a) Alpha-thalassemia b)Beta-thalassemia c)Iron deficiency anemia d)Megaloblastic anemia e)Sickle cell disease Normal Labs 16. A 25-year-old man has had type 1 diabetes mellitus for 5 years. His physician is concerned about the possibility of permanent renal damage. Which of the following is the best early indicator for diabetic nephropathy? a)Albuminuria b)Hypertension c)Rising blood urea nitrogen d)Rising creatinine e) Urinary tract infection Normal Labs 17. A 40-year-old woman presents with complaints of burning and tingling sensations in the left hand for several months. She relates that she has been frequently awakened at night by aching pain in the same hand. She is otherwise in good health. Examination fails to detect any impairment in sensation, but pain is elicited by extreme dorsiflexion of the wrist. The patient is unable to correctly identify different clothes by rubbing between the left thumb and index finger. Which of the following is the most likely diagnosis? a)Angina pectoris b)Carpal tunnel syndrome c)Dupuytren contracture d)Fibrositis e)Reflex sympathetic dystrophy Normal Labs 18.A 50-year-old man develops a mass on the back of his hand. The lesion somewhat resembles a “volcano” and consists of a round, firm, flesh colored, 1-cm nodule with sharply rising edges and a central crater. Keratotic debris can be expressed from the central crater. The lesion has developed very rapidly over about a three-month period. Which of the following is the most likely diagnosis? a)Keratoacanthoma b)Lipoma c)Malignant melanoma d)Pyogenic granuloma e) Seborrheic keratosis Normal Labs 19. A physician is called to see a 69-year-old woman who underwent cardiac catheterization via the right femoral artery earlier in the morning. She is now complaining of a cool right foot. Upon examination she has a pulsatile mass over her right groin with loss of her distal pulses, and auscultation reveals a bruit over the point at which the right femoral artery was entered. Which of the following is the most likely diagnosis? a)Cholesterol emboli syndrome b)Femoral aneurysm c)Femoral hernia d)Femoral pseudoaneurysm e)Retroperitoneal hematoma Normal Labs 20. A patient complains to a physician of chronic pain and tingling of the buttocks. The pain is exacerbated when the buttocks are compressed by sitting on a toilet seat or chair for long periods. No lumbar pain is noted. Pain is elicited when the physician performs Freiberg’s maneuver, in which there is a forceful internal rotation of the extended thigh. Which of the following is the most likely diagnosis? a)Disk compression of the sciatic nerve b)Fibromyalgia c)Piriformis syndrome d)Popliteus tendinitis e)Posterior femoral muscle strain Normal Labs 21. A 74-year-old woman, who has been followed for the past 25 years for chronic obstructive pulmonary disease (COPD) presents complaining of 48 hours of temperatures to 38.6 C (101.4 F) and worsening shortness of breath. She has a chronic productive cough, which has become more copious. On physical examination, she has rhonchi and increased fremitus in the posterior mid-lung field. A Gram’s stain reveals many epithelial cells and multiple gram-positive and gram-negative organisms; no neutrophils are seen. Which of the following is the most likely organism causing the symptoms? a)Escherichia coli b)Haemophilus influenzae c)Klebsiella pneumoniae d)Mycobacterium tuberculosis e)Mycoplasma pneumonia Normal Labs 22. A 53-year-old man comes to the physician because of progressive weakness and weight loss over the past 2 months. He says that he also began noticing areas of his skin getting darker even though it is winter and he is never in the sun. He takes no medications and has no other medical conditions. Physical examination shows no abnormalities except for orthostatic hypotension and hyperpigmentation of his skin. Laboratory studies show: Sodium……………………130 mEq/L Chloride ………………….95 mEq/L Potassium……………….6.5 mEq/L Bicarbonate…………….20 mEq/L Leukocyte count…………..5000/mm3 Segmented neutrophils……40% Band forms ………………….4% Lymphocytes……………….40% Monocytes …………………6% Eosinophils………………….9.5% Basophils……………………0.5% Which of the following is the most likely diagnosis? a)Addison’s disease b) Conn’s syndrome c)Cushing’s disease d)Cushing’s syndrome e) Syndrome of inappropriate antidiuretic hormone secretion Normal Labs 23. A 35-year-old HIV-positive man comes to medical attention with a 6-month history of progressive memory loss and incontinence. He is taking zidovudine and a protease inhibitor. He first noticed difficulties with handwriting. Neurologic examination demonstrates deficits in cognitive and fine motor control functions. Laboratory investigations show a CD4 cell count of 25/mm3. MRI studies reveal moderate brain atrophy but no focal lesions. A lumbar puncture shows no CSF abnormalities. Which of the following is the most likely diagnosis? a) CMV encephalitis b)Cryptococcal meningoencephalitis c)HIV encephalitis d) HIV myelopathy e)Primary brain lymphoma f)Progressive multifocal leukoencephalopathy g)Toxoplasmosis Normal Labs 24. A 57-year-old woman presents with progressive shortness of breath over the past 2 days. The woman was admitted to the medical service 6 days ago after a fall and has been on bed rest for a nondisplaced pubic ramus fracture. She has been on deep vein thrombosis prophylaxis with subcutaneous heparin. Her past medical history is significant for type 2 diabetes and dialysis-dependent renal failure secondary to diabetic nephropathy. She makes no urine at baseline. Her last dialysis run was 4 days ago, though she usually undergoes dialysis 3 times per week. She has no chest pain. On physical examination, she appears anxious. Her blood pressure is 160/105 mm Hg, pulse is 110/min, and respirations are 22/min. Her oxygen saturation is 80% on room air, and she appears cyanotic. She has a jugular venous pressure of 10 cm and inspiratory crackles half way up from the bases on auscultation of the lungs. An ECG reveals a rate-related right bundle branch block but no ischemic changes. A chest xray film obtained yesterday revealed interstitial edema and vascular redistribution to the apices. Which of the following is the most appropriate initial therapy? a) An anti-hypertensive agent to decrease her blood pressure to normal b)A beta blocker to better control her pulse c)IV morphine to decrease her respirations to normal d)Oxygen by endotracheal intubation to maximize the oxygen concentration e) Oxygen by face mask to increase her oxygen saturation Normal Labs 25. A 37-year-old accountant presents to ask for advice regarding the future management of his ulcerative colitis. He has had pancolitis for the past 19 years and has been told that he is at an increased risk for developing colorectal cancer. He asks for the physician’s recommendation regarding appropriate surveillance. Which of the following is the most appropriate response? a)Annual stool guaiac testing b)Barium enema c)Colonoscopy d)Colonoscopy and multiple biopsies e)Flexible sigmoidoscopy with multiple biopsies Normal Labs 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 d)Serum ferritin e)Serum iron Normal Labs 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? a)Erythropoietin b)Ferrous sulfate c)Vancomycin d)Vitamin D e) Uremia Normal Labs 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? a)Acetaminophen b)Alcohol c)Benzodiazepines d)Clonidine e) Monoamine oxidase (MAO) inhibitors f)Tricyclic antidepressants Normal Labs 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 Normal Labs 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) c)17-ketosteroids d)Vanillylmandelic acid VMA e) Zinc protoporphyrin Normal Labs 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 d)Insulin resistance e)Systemic lupus erythematosus Normal Labs 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? a) Amoxicillin b)Ampicillin-sulbactam c)Ceftriaxone d)Erythromycin e) Erythromycin plus ceftriaxone Normal Labs 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 b)11 mEq/L c)13 mEq/L d)15 mEq/L e) 20 mEq/L Normal Labs 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: Hematocrit 39.0% 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 Normal Labs 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 c)Oral aspirin d)Oral Coumadin e) Subcutaneous unfractionated heparin Normal Labs 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 Normal Labs 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 b)Myelofibrosis c)Polycythemia vera d)Primary thrombocythemia e) Secondary thrombocythemia Normal Labs 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? a) Bicarbonate b)Calcium c)Magnesium d) Potassium e) Sodium Normal Labs 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? a)Electroencephalogram (EEG) 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) Normal Labs 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 b)Invasive melanoma c)Keratoacanthoma d)Pyogenic granuloma e)Squamous cell carcinoma Normal Labs 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 Normal Labs 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 Normal Labs 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 d)Ventilation-perfusion scan e)X-ray films of the chest, posterior-anterior (PA) and lateral views Normal Labs 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? a)Bisphosphonates b) Calcitonin c)Calcium and vitamin D d) Conjugated estrogens e)Sodium fluoride Normal Labs 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: Hemoglobin……………………………..11 g/dL Hematocrit………………………………39% Erythrocyte sedimentation rate…….39 mm/hr Which of the following is the most likely pathogen? a)Candida albicans b)Pseudomonas aeruginosa c)Serratia marcescens d)Staphylococcus aureus e)Streptococcus viridans Normal Labs 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 Normal Labs 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 c)Bacterial cholangitis d)Primary biliary cirrhosis e)Primary sclerosing cholangitis Normal Labs 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? a) Folate b)Iron c)Vitamin B12 d)Vitamin C e)Vitamin K Normal Labs 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? a)Bilateral hydronephrosis b)Bladder dilation c)Bladder dyskinesis d)Unilateral hydronephrosis e)Ureteral dilation Normal Labs 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 c)Hemorrhagic infarction d)Pituitary apoplexy e)Ruptured berry aneurysm