USMLE_ParaClinic I

A pediatrician discussing a clinical case with a group of medical students, featuring anatomical charts and a bright classroom setting.

USMLE Pediatric Quiz

Test your knowledge with our engaging USMLE Pediatric Quiz designed for medical students and professionals! This quiz contains a plethora of clinical scenarios that reflect real-life challenges faced in pediatric practice. Enhance your understanding and retention of vital pediatric concepts while having fun!

  • Multiple-choice questions
  • Focus on pediatrics and clinical practices
  • Learn while you play!
250 Questions62 MinutesCreated by CaringDoctor452
A 1-day-old normal-appearing infant develops tetany and convulsions. He was born at 34 weeks’ gestation with Apgar scores of 2 and 4 (at 1 and 5 minutes, respectively) to a woman whose pregnancy was complicated by diabetes mellitus and pregnancy-induced hypertension. Which of the following serum chemistry values is likely to be the explanation for his condition?
. Serum bicarbonate level of 22 mEq/dL
. Serum calcium of 6.2 mg/dL
. Serum glucose of 45 mg/dL
. Serum magnesium level of 5.0 mg/dL
. Intracranial hemorrhage
A 1-month-old male infant is brought to the emergency department by his mother due to a 3-day history of projectile vomiting. He has been formula- fed since birth, and his bowel movements are normal. He has never been ill before. His parents and 4-year-old sister are all healthy. One of his maternal uncles is mentally retarded. He weighs 3.1 kg (7 Ib). Physical examination reveals fair hair and skin, blue eyes, eczematous rash, and mild signs of dehydration. His urine has a mousy odor. What is the most appropriate screening test for this patient's early diagnosis and treatment?
Aminolevulinic acid and porphobilinogen in the urine
SerumTSH
Blood level of alfa 1-antiprotease
Guthrie test in urine
Serum LDH
A 1-year-old boy is brought to the pediatrician for a routine visit. While talking to his mother, she reports that they moved into an old house several months ago and are in the process of renovating. The child eats table food and drinks whole milk. His height, weight, and head circumference are all at the 50th percentile for his age. Physical examination is normal. The results of a fingerstick blood test are shown below: Hemoglobin 10.5 g/dL, Hematocrit 30.0%, Lead level 12 μg/dL (Normal < 10 μg/dL). Which of the following is the most appropriate next step in management?
Remove the child from the house
Check a serum lead level
Initiate chelation therapy with dimercaprol
Initiate chelation therapy with dimercaptosuccinic acid (DMSA, succimer)
Recheck lead level in one month
A 10-month-old baby boy, recently adopted from Guyana, has a 5-hour history of crying, with intermittent drawing up of his knees to his chest. On the way to the emergency room he passes a loose, bloody stool. He has had no vomiting and has refused his bottle since the crying began. Physical examination is noteworthy for an irritable infant whose abdomen is very difficult to examine because of constant crying. His temperature is 38.8C (101.8F). The rectal ampulla is empty, but there is some gross blood on the examining finger. Which of the following studies would be most helpful in the immediate management of this patient?
. Stool culture
. Examination of the stool for ova and parasites
. Air contrast enema
. Examination of the blood smear
. Coagulation studies
A 10-month-old infant has poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul-smelling stools for months. Which of the following diagnostic maneuvers is likely to result in the correct diagnosis of this child?
CT of the chest
Serum immunoglobulins
TB skin test
Inspiratory and expiratory chest x-ray
Sweat chloride test
A 10-year-old boy has a long history of recurrent infections. These have included pneumonia, suppurative lymphadenitis, persistent rhinitis, dermatitis, diarrhea, and perianal abscesses. Involved organisms have included Staphylococcus aureus, Serratia, Escherichia coli, and Pseudomonas. Biopsy of skin and lymph nodes have demonstrated granulomatous lesions, even though the only species isolated were those noted above. Immunoglobulin levels are higher than normal. Which of the following findings would be most helpful in establishing the diagnosis?
. Absent B cells and normal numbers of T cells
. Deficient nitroblue tetrazolium dye reduction in neutrophils
. High serum IgM and very low serum IgG
. Very low CD11 on the surface of white blood cells
. Very low serum calcium levels
A 10-year-old child arrives with the complaint of new-onset bed-wetting. He has had no fever, his urine culture is negative, and he has had no new stresses in his life. He is well above the 95th percentile for weight as is much of his family. Which of the following is most helpful in making a diagnosis?
. Fasting plasma glucose of 135 mg/dL
. Random plasma glucose of 170 mg/dL
. Two-hour glucose during glucose tolerance test of 165 mg/dL
. Acanthosis nigricans on the neck
. Symptoms alone are enough to make the diagnosis
A 10-year-old patient with sickle cell disease comes to the physician for a routine visit. The patient has a history of multiple pain crises and pneumonias. He was started on hydroxyurea one year ago and has not had any further pain crises since then. He has had no recent illnesses or hospitalizations. His physical examination is unremarkable. The patient's laboratory results are shown below. Complete blood count: Hemoglobin 9.0 g/L, Erythrocyte count 2.2 mln/mm3, MCHC 32%, MCV 105 fl, Reticulocytes 2.0%, Platelets 212,000/mm3, Leukocyte count 9500/mm3, Neutrophils 56%, Eosinophils 3%, Lymphocytes 36%, Monocytes 5%. Which of the following best describes the role of hydroxyurea in the treatment of patients with sickle cell disease?
Removes sickled red blood cells from the circulation
Lyses microthrombi in the circulation
Protects against encapsulated bacterial infections
Increases fetal hemoglobin
Chelates iron to prevent iron toxicity
A 12-year-old boy is in a motor vehicle collision in which the car caught fire. He sustains significant inhalation injury and a circumferential burn without fractures or other soft tissue trauma to his left lower extremity during extrication from the burning vehicle. He is intubated and aggressively resuscitated in the intensive care unit. Which of the following is the most appropriate method of assessing for compartment syndrome of the left lower extremity?
. X-ray of the left lower extremity
. Doppler signals of the left lower extremity
. Computed tomography (CT) scan of the left lower extremity
. Magnetic resonance imaging (MRI) of the left lower extremity
. Left lower extremity angiogram
A 12-year-old girl has a solitary thyroid nodule found on routine examination; she has no symptoms. Which of the following is the most appropriate next step for this patient?
. Fine needle aspirate
. CT scan of the neck
. Serum thyroid function tests
. Trial of suppressive T4 treatment to look for nodule shrinkage
. Excisional biopsy
A 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problem at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perceptioin. Which of the following can confirm the patient’s diagnosis?
. CT scan of the head
. EMG studies
. EEG studies
. Psychiatric evaluation
. Lumbar puncture
A 12-year-old male child comes to the office after being referred for a medical evaluation. His schoolteacher says that he has a problem concentrating during class. He stares in space for a few seconds several times a day, and appears totally absorbed in his thoughts. He is not disruptive in class, but appears forgetful. There is no history of trauma, infection or problems at birth. On examination, the child is alert with stable vital signs. There is no loss of motor or sensory perception. Which of the following can confirm the patient's diagnosis?
. CT scan of the head
. EMG studies
. EEG studies
. Psychiatric evaluation
. Lumbar puncture
A 12-year-old, previously healthy girl presents to her physician with a chief complaint of early morning headaches. She states that these headaches wake her up from sleep 2-3 days a week. She also complains of some vomiting associated with the headaches. The headaches have been getting progressively worse for the past 2 months. She denies any photophobia, dizziness, or blurred vision. There is no history of a recent respiratory infection, runny nose, or cough. There is no history of recent trauma. In the office, her vital signs are within normal limits. Her examination shows pupils that are equal, round, and reactive, with no maxillary or frontal sinus tenderness. Her tympanic membranes are clear and intact. Her neck is supple with full range of motion. Neurologic examination shows a positive Romberg sign. Which of the following tests would most likely confirm the diagnosis?
CT of the brain
MRI of the brain
Plain film of the skull
Sinus x-ray film
Spinal tap
A 13-year-old patient with sickle-cell anemia presents with respiratory distress; she has an infiltrate on chest radiograph. The laboratory workup of the patient reveals the following: hemoglobin 5 g/dL; hematocrit 16%; white blood cell count 30,000/μL; and arterial blood (room air) pH 7.1, PO2: 35 mm Hg, and PaCO2: 28 mm Hg. These values indicate which of the following?
Acidemia, metabolic acidosis, respiratory alkalosis, and hypoxia
Alkalemia, respiratory acidosis, metabolic alkalosis, and hypoxia
Acidosis with compensatory hypoventilation
Long-term metabolic compensation for respiratory alkalosis
Primary respiratory alkalosis
A 14-year-old African-American girl presents to the ER with a mild fever and severe right-sided thigh pain. She is agitated and requests quick pain relief. Her heart rate is 120/min and blood pressure is 120/70 mmHg. She says that she had a similar episode one year ago and was placed in the hospital for intravenous pain management. Her brother had similar episodes and died of an infection at 10 years of age. Which of the following would you most expect to see on this patient's peripheral blood smear?
Burr cells
Polycythemia
Reticulocytosis
Iron deficiency
Hypersegmented neutrophils
A 14-year-old boy comes to the office because he has been feeling a mass under his right nipple for the last three weeks. The physical examination reveals clinical findings suggestive of right gynecomastia with very mild tenderness. The left breast and the rest of the physical exam is unremarkable. His testis is 2 cm in length and has 3 ml volume. What is the most appropriate next step in the management of this patient?
Biopsy of breast mass
Reassurance
Karyotyping
MRI brain
Serum prolactin levels
A 14-year-old boy comes to the physician because of a 2-day history of fever and nasal discharge. He has also had malaise, fatigue and myalgia. His temperature is 38.8°C (101.9°F), blood pressure is 130/70mm Hg, pulse is 90/min, and respirations are 15/min. Examination shows no abnormalities. Urine dipstick testing shows proteinuria but there is no hematuria or pyuria; urinalysis otherwise shows no abnormalities. Which of the following is the most appropriate next step in management?
. Repeat dipstick testing
. BUN and serum creatinine
. 24-hour urinary collection for protein
. Renal ultrasound
. Reassurance
A 14-year-old boy is brought to your office by his mother because of a two-week history of generalized edema, fatigue, and abdominal pain. His past medical history is insignificant, and the boy is not taking any medications. His BP is 110/70 mmHg and heart rate is 80/min. Urinalysis reveals proteinuria 4+, but urine sediment findings are within normal limits. Which of the following light microscopy finding would you expect in this patient's kidney biopsy?
Diffuse thickening of glomerular basement membrane
Subepithelial spikes
Mesangial hypercellularity
Crescent formation
Normal findings
A 14-year-old boy presents at the pediatric clinic for a routine check-up. The patient had developed end-stage renal disease over the previous 2 years, and was successfully treated with a renal transplant 6 months prior. Since his operation, he has developed purple striae on his back and arms, central obesity, and an increasingly round face. During the subsequent blood analysis, which of the following results would be most likely?
A
B
C
D
E
A 14-year-old boy slides down a banister and crashes into a large ornamental knob at its base, thereby injuring his scrotal contents. He presents in the emergency department with acute testicular pain and a scrotal hematoma the size of a grapefruit. He is able to void normally, and his urine does not contain blood. A rectal examination is unremarkable. Findings from which of the following tests will most likely determine further therapy?
. Aspiration of scrotal contents
. Retrograde cystogram
. Retrograde urethrogram
. Scrotal sonogram
. Scrotal surgical exploration
A 14-year-old girl comes to the physician for an annual examination. She has no complaints. She became sexually active during the past year and uses condoms occasionally for contraception. She has asthma, for which she occasionally takes an albuterol inhaler. She had an appendectomy at age 9. Physical examination is unremarkable including a normal pelvic examination. When should this patient begin having Pap testing?
. Immediately
. Age 16
. Age 18
. Age 20
. Age 21
A 14-year-old girl is being evaluated for short stature. She has not yet had any menstrual periods. She is not sexually active. She is at 6th percentile for height and 20th percentile for weight. Blood pressure is elevated in the upper extremities and low in the lower extremities. Lungs are clear to auscultation. If measured, which of the following is most likely to be present in this patient?
. High inhibin
. Low growth hormone
. High estrogen
. High FSH
. High testosterone
A 14-year-old girl is brought to the office by her mother for the evaluation of leg muscle fatigability while climbing the stairs. She has occasional headaches. She was diagnosed (via karyotyping) with Turner's syndrome two years ago. Her blood pressure is 165/95 mm Hg on the right arm, and 161/95 mm Hg on the left arm. Her heart rate is 85/min. The physical examination reveals no secondary sexual characteristics. Her chest is broad. The point of maximal apical impulse is displaced to the left and increased in intensity. A mild, continuous murmur is heard all over the chest. The lungs are clear. What is the most probable finding on her chest radiograph?
Prominent right ventricular contour
Diffuse increase in pulmonary vascular markings
Pulmonary congestion signs
Rib notching
Pericardial calcification
A 14-year-old male presents with a complaint of soreness, and weakness in his legs for the past day that has slowly spread from his calves to his thighs. He now complains of weakness in his trunk and arms. On examination he appears tired and lays on the examining table. His temperature is 37 C (98.6 F), pulse is 48/min, and respirations are 22/min. Both of his legs are diffusely tender. Deep tendon reflexes are absent in the lower extremities, and sensation is greatly diminished. Which of the following studies is essential for this patient's diagnosis?
. Creatinine phosphokinase levels
. Stool culture for Campylobacter jejuni
. Motor nerve conduction test
. Cerebrospinal fluid studies
. Muscle biopsy
A 15-year-old African-American girl has a facial rash and vague joint pains. Her temperature is 37.2C (99F). On examination, a malar erythematous rash is noted. Her laboratory evaluation is significant for anemia, leukopenia, and a normal platelet count. Her antinuclear antibody and Rapid Plasma Reagin (RPR) tests are positive. Which of the following tests is confirmatory for this patient's condition?
VDRL (Veneral Disease Research Laboratory) test
FTA (Fluorescent T reponemal Antibody) test
Anti-Smith antibody test
Coomb's test
Bone marrow examination
A 15-year-old boy has been immobilized in a double hip spica cast for 6 weeks after having fractured his femur in a skiing accident. He has become depressed and listless during the past few days and has complained of nausea and constipation. He is found to have microscopic hematuria and a blood pressure of 150/100 mm Hg. Which of the following is the most appropriate course of action?
. Request a psychiatric evaluation
. Check blood pressure every 2 hours for 2 days
. Collect urine for measurement of the calcium to creatinine ratio
. Order a renal sonogram and intravenous pyelogram (IVP)
. Measure 24-hour urinary protein
A 15-year-old boy with tall stature presents with decreased exercise tolerance over the past 2 months. He states that he used to play two games of basketball with no problem, but he now can play only one game. On physical examination, his weight is at the 25th percentile, and his height higher than the 95th percentile. He is thin and has a gangly body habitus. His fingers are long and thin. There is pectus deformity in his chest. His joints are hyperextensible. An ophthalmologic examination reveals mild subluxation of the lens. Which of the following is the most likely finding on an echocardiogram?
. Aortic root dilatation
. Aortic stenosis
. Bicuspid aortic valve
. Dextrocardia
. Pulmonary stenosis
A 15-year-old Caucasian female comes to your office because her menses have not yet started. Her breast development is Tanner stage 2 and there is scant pubic hair. Physical examination is also significant for decreased femoral pulses. Which of the following is the best next step in evaluating her condition?
Abdominal CT scan
Progesterone challenge
Serum prolactin level
Karyotype analysis
Urine 17 -hydroxyprogesterone level
A 15-year-old girl is being evaluated for primary amenorrhea. Her previous medical history is unremarkable and she denies taking any medications. Examination reveals absent breasts as well as pubic and axillary hair. Vaginal examination could not be performed. Olfactory exam reveals an inability to identify different odors. Ultrasound shows a uterus and two ovaries; serum FSH level is 2 U/L (Normal is 4-30). Which of the following is the most likely karyotype to be found in this patient?
. 45 XO
. 45 YO
. 46 XX
. 46 XY
. 47 XXY
A 15-year-old girl is brought to the physician by her mother because she has not begun menstruating. She is otherwise healthy and has no medical problems. Vitals signs are within normal limits. Physical examination shows absence of breast development and no pubic hair is seen. Examination shows no other abnormalities. Ultrasound confirms the presence of a uterus. Which of the following is the most appropriate next step in management?
. Estrogen level
. MRI of pituitary
. Serum FSH level
. Karyotyping
. GnRH stimulation test
A 15-year-old girl presents with diplopia after prolonged reading and ptosis that worsens in the afternoon. On examination, she is noted to have bilateral ptosis, impaired extraocular muscle movements, facial weakness, and generalized hypotonia and weakness increasing with repetition. Which of the following is the best diagnostic test for this disorder?
. CT of the brain
. Electromyography
. Lumbar puncture
. Muscle biopsy
. Nerve conduction velocity
A 15-year-old male presents to your office on the advice of his football coach. The patient started playing football this year and suffered a syncopal episode at practice yesterday. He reports that he was sprinting with the rest of the team and became lightheaded. He lost consciousness and fell to the ground, regaining consciousness within one or two minutes. He suffered no trauma during the event. He has no prior history of head injury or recent illness. He has had no prior episodes of syncope. The patient is adopted and family history unavailable. Physical examination is unremarkable. What is the best course of action regarding this patient’s syncopal episode?
. Perform an ECG and echocardiogram. The patient may not return to competitive sports until results are available
. Perform an ECG. The patient may not return to competitive sports until results are available
. Perform an ECG. The patient may return to competitive sports pending the results
. Reassurance. The patient may return to competitive sports provided he increases his water consumption during practice times
. Reassurance. The patient may return to competitive sports with no restrictions
A 15-year-old otherwise healthy boy presents with a complaint of intermittent abdominal distention, crampy abdominal pain, and excessive flatulence. He first started noticing these symptoms when he moved into his father’s house, and his stepmother insisted on milk at dinner every night. He has normal growth, has not lost weight, and has no travel history. Which of the following is the most appropriate study to diagnose his condition?
. Barium swallow and upper GI
. Hydrogen excretion in breath after oral administration of lactose
. Esophageal manometry
. Stool pH after one to 2 weeks of a lactose-free diet
. Fasting serum lactose levels
A 15-year-old woman presents to your office for her first well-woman examination. She has a history of asthma, for which she uses an inhaler as needed. She denies any prior surgeries. Her menses started at the age of 13 and are regular. She has recently become sexually active with her 17-year-old boyfriend. She states that they use condoms for contraception, but she is interested in something more effective. Which of the following is the most appropriate instrument to use when performing the Pap smear test in this patient?
. Graves speculum
. Pederson speculum
. Pediatric speculum
. Vaginoscope
. Nasal speculum
A 16-month-old girl is brought to medical attention because of irritability, poor feeding, and temperatures up to 39.4 C (103 F). Careful history and physical examination fail to disclose any identifiable cause of her fever. There is some degree of abdominal tenderness on palpation. Which of the following is the most appropriate next step in diagnosis?
Microscopic examination and culture of stool
Renal ultrasound
Chest x-ray films
Voiding cystourethrogram
Culture of urine obtained by transurethral catheterization
A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?
. CT chest for pneumothorax
. Nerve conduction studies
. Angiogram
. Open reduction of the clavicle
. Closed reduction with figure of eight brace
A 16-year-old female presents to the office with her mother and complains of changes in her physical appearance over the past year. She first noted the appearance of dark hair on the cheeks, upper lips, around the nipples and umbilicus. Her menstrual cycles have always been irregular since her menarche at age 14. Her medical history is otherwise unremarkable. She denies taking any medications. She has a boyfriend, but claims that she is still not sexually active. Her blood pressure is 115/65 mmHg, pulse is 80/min, respirations are 16/min, and temperature is 37°C (98°F). Pelvic examination could not be performed, and abdominal examination is normal. Ultrasound is normal. Results of the initial work-up are as follows: Serum Na+ 140mEq/L, Serum K+ 4.0mEq/L, Serum Cl- 98 mEq/L, Bicarbonate 25 mEq/L, 1,7-alpha-hydroxyprogesterone elevated. According to these findings, which of the following hormone deficiencies does this patient most likely have?
. 17 -alpha-hydroxylase-deficiency
. 21-hydroxylase-deficiency
. 11-beta-hydroxylase-deficiency
. 3-beta-hydroxysteroid-dehydrogenase deficiency
. Cystathionine synthase deficiency
A 16-year-old girl comes to the emergency department because of abdominal pain and vaginal bleeding. She has been sexually active with her boyfriend for the past year; they occasionally use condoms. This is their only means of contraception. Her last menstrual period was eight weeks ago. Previous menses occurred at regular 28-day intervals. She has had two episodes of pelvic inflammatory disease in the past year. Which of the following is the most appropriate next step in management?
. Prescribe antibiotics and see her back in three days
. Call her parents to discuss the problem and obtain their consent for treatment
. Admit the patient and start high dose estrogen therapy
. Obtain a pregnancy test and an abdominal ultrasonogram
. Obtain a urinalysis and CT scan of the abdomen
A 16-year-old girl is brought to your office by her mother for evaluation of primary amenorrhea. Her older sister had her first period at age 13. Vitals signs are within normal limits. Physical examination shows absence of breast development and external genitalia at Tanner stage 1. Examination shows no other abnormalities. Which of the following is the most appropriate next step in management?
. Estrogen levels
. Serum LH levels
. Serum FSH levels
. Karyotyping
. GnRH stimulation test
A 16-year-old obese Hispanic girl presents to her physician’s office complaining of ugly skin around my neck and having to wear turtlenecks. On examination the physician notes darkening and thickening of the skin, which has a velvety appearance. Which of the following is the most appropriate course of action?
Obtain a CT scan of the abdomen
Obtain a punch biopsy of the affected skin
Obtain a serum glucose test
Obtain a shave biopsy of the affected skin
Obtain liver function tests
A 17-year-old adolescent female is 6 weeks postpartum. She presents to the emergency room with the complaints of increased jaundice, abdominal pain, nausea, vomiting, and fever. Her examination is remarkable for jaundice, pain of the right upper quadrant with guarding, and a clear chest. Chest radiographs appear normal. Which of the following tests is most likely to reveal the cause of this pain?
. Serum chemistries
. Complete blood count (CBC) with platelets and differential
. Ultrasound of the right upper quadrant
. Upper GI series
. Hepatitis panel
A 17-year-old G1P1 presents to your office for her yearly wellwoman examination. She had an uncomplicated vaginal delivery last year. She has been sexually active for the past 4 years and has had six different sexual partners. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal discharge. She denies tobacco, alcohol, or illicit drug use. Which of the following are appropriate screening tests for this patient?
. Pap test
. Pap test and gonorrhea and chlamydia cervical cultures
. Pap test and herpes simplex cultures
. Pap test and hemoglobin level assessment
. Pap test and hepatitis C antibody
A 17-year-old girl has never had a menstrual period. On physical examination, she has minimal breast development and no axillary or pubic hair. She is color blind and has had a diminished sense of smell since birth. Laboratory evaluation would most likely reveal which of the following?
 
2
A
B
C
D
E
A 17-year-old girl is brought to the office by her mother due to weakness of her hands and legs. The weakness has been progressively worsening over the past 24 hours, and she now feels that the weakness is affecting her hips. Her mother says she was a bit unwell a couple of weeks ago, but otherwise her past medical history is unremarkable. The physical examination reveals 1/5 power in ankle and knee flexion/extension and 2/5 power in hip flexion. Reflexes are absent in her lower extremities bilaterally. She is admitted to the hospital. Spinal fluid analysis shows albumino-cytologic dissociation. Which of the following tests is the most appropriate for monitoring her respiratory function?
. Arterial blood gas
. Vital capacity
. FEV1/FVC ratio
. Peak expiratory flow rate
. Chest x-ray
A 17-year-old man presents with new symptoms of fatigue, malaise, fever, and a sore throat. He has no significant past medical history and is not on any medications. Physical examination is entirely normal except for enlarged, palpable cervical, lymph nodes. He reports no weight loss or night sweats. Laboratory investigations include a normal chest x-ray, negative throat swab, but abnormal blood film with atypical lymphocytes. The hemoglobin is 15.5 g/dL; hematocrit 42%; platelets 290,000/mL; WBC 10500/mL, with 45% segmented neutrophils, 1% eosinophils, and 54% lymphocytes, of which 36% were atypical. Which of the following is the most appropriate initial diagnostic test?
Lymph node biopsy
Bone marrow
Erythrocyte sedimentation rate (ESR)
Heterophil antibody (sheep cell agglutination) test
Hepatic biopsy
A 17-year-old primipara at 41 weeks wants an immediate cesarean section. She is being followed with biophysical profile (BPP) testing. Which of the following is correct information to share with the patient?
. BPP testing includes amniotic fluid volume, fetal breathing, fetal body movements, fetal body tone, and contraction stress testing
. The false-negative rate of the BPP is 10%
. False-positive results on BPP are rare
. Spontaneous decelerations during BPP testing are associated with significant fetal morbidity
. A normal BPP should be repeated in 1 week to 10 days in a post-term pregnancy
A 17-year-old teenage girl presents to your office with a 10-month history of lower abdominal pain that radiates to the upper thighs and back. The pain is colicky in nature and usually starts a few hours prior to menses, lasting 3-4 days. Menses have occurred at regular 28-day intervals over the past 2 years. She has no inter-menstrual bleeding. She became sexually active 6-months ago and does not use contraception. Physical examination shows healthy genitalia and well-developed secondary sexual characteristics; the uterus is normal in size and freely mobile. Examination shows no other abnormalities. Which of the following is the most likely cause of her pelvic pathology?
. Ureteric stone
. Pelvic infection
. Abnormal myometrial growth
. Increased prostaglandins
. Ectopic endometrial implants
A 17-year-old woman presents with peripheral and periorbital edema. She has previously been healthy and takes no medications. Her blood pressure is 146/92 mm Hg; she is afebrile. The patient has mild basilar dullness on lung examination; her cardiac examination is normal. She has periorbital edema and soft, doughy 3+ edema in her legs. Her serum creatinine is 0.6 mg/dL and her serum albumin is 2.1 g/L. Urinalysis shows 3+ protein, no RBC or WBC, and some oval fat bodies. What is the next best step to take in evaluating this patient?
. Order serum and urine protein electrophoresis
. Request a nuclear medicine renal scan
. Measure plasma aldosterone and renin activity
. Order a 24-hour urine collection to quantitate the degree of proteinuria
. Ask a nephrologist or radiologist to perform a renal biopsy
A 19-year-old G1P0 presents to her obstetrician’s office for a routine OB visit at 32 weeks gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompliant with diet and insulin therapy. She has had two prior normal ultrasounds at 20 and 28 weeks gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm. Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age?
. Fetal hydrocephaly
. Uterine fibroids
. Polyhydramnios
. Breech presentation
. Undiagnosed twin gestation
A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat. On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver span is 12 cm and the spleen is palpable. Throat culture: negative for group A streptococci, Hgb: 12.5, Hct: 38%, Reticulocytes: 4%, WBC: 14, 000/μL, Segmented: 30%, Lymphocytes: 60%, Monocytes: 10%, Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2), Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220), Aspartate aminotransferase (AST): 40 U/L (normal 8 to 20 U/L), Alanine aminotransferase (ALT): 35 U/L (normal 8 to 20 U/L), Alkaline phosphatase: 40 IU/L (normal 35 to 125). Which of the following is the most important initial test combination to order?
. Liver biopsy and hepatitis antibody
. Streptococcal screen and antistreptolysin O (ASO) titer
. Peripheral blood smear and heterophile antibody
. Toxoplasma IgG and stool sample
. Lymph node biopsy and cytomegalovirus serology
A 19-year-old man is involved in a motorcycle accident in which he sustains a closed fracture of his right femur and a pelvic fracture. In addition to the obvious deformity in his leg, physical examination is remarkable for the presence of a scrotal hematoma and blood at the meatus. There is no blood in the rectal exam, but the prostate cannot be felt. The patient states that he feels the need to void, but cannot do it. Which of the following is the most appropriate next step in diagnosis?
CT scan of the pelvis
Scrotal sonogram
IV pyelogram (IVP)
Retrograde cystogram via Foley catheter
Retrograde urethrogram
A 19-year-old man presents to your office with a one-week history of fever, fatigue, and sore throat. He denies diarrhea or rash. He has no significant past medical history. His brother died of cystic fibrosis at 14 years of age. He admits to occasional cigarette use and alcohol consumption. He has smoked marijuana several times but has never used injectable drugs. He is sexually active with one partner and uses condoms occasionally. Physical examination reveals enlarged tonsils with a whitish exudate and enlarged, slightly tender lymph nodes deep to the sternocleidomastoid muscle bilaterally. The exam is otherwise unremarkable. Which of the following is the best initial test in this patient?
. Rapid plasma reagin (RPR)
. Heterophile antibody test
. HIV antibody determination
. Lymph node biopsy
. Purified protein derivative
A 19-year-old man presents with malaise, nausea, and decreased urine output. He was previously well, and his physical examination is normal except for an elevated jugular venous pressure (JVP) and a pericardial rub. His electrolytes reveal acute renal failure (ARF). Which of the following findings on the urinalysis is most likely in keeping with acute glomerulonephritis (GN)?
Proteinuria
White blood cell casts
Granular casts
Erythrocyte casts
Hyaline casts
A 19-year-old man with insulin-dependent diabetes mellitus is taking 30 units of NPH insulin each morning and 15 units at night. Because of persistent morning glycosuria with some ketonuria, the evening dose is increased to 20 units. This worsens the morning glycosuria, and now moderate ketones are noted in urine. The patient complains of sweats and headaches at night. Which of the following is the most appropriate next step in management?
. Measure blood glucose levels at bedtime
. Increase the evening dose of NPH insulin further
. Add regular insulin to NPH at a ratio of 2/3 NPH to 1/3 regular
. Obtain blood sugar levels between 2:00 and 5:00 AM
. Add lispro via a calculated scale to each meal; continue NPH
A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?
. Absence of ganglion cells on full-thickness rectal biopsy 2 cm above the dentate line
. Absence of ganglion cells on full-thickness rectal biopsy 1 cm above the dentate line
. Absence of ganglion cells on suction rectal biopsy 1 cm above the dentate line
. Identification of a transition zone between the sigmoid colon and the distal rectum on barium enema
. Inhibition of the resting anal inhibitory reflex on anorectal manometry
A 2-month-old infant is brought to the emergency department with irritability and lethargy. The parents state that he was well until he rolled off the couch on to the floor yesterday. On examination, he is inconsolable and afebrile. The fontanels are full and tense. He has a generalized tonic-clonic seizure. Which of the following is the most important initial diagnostic study to order?
Serum calcium, phosphorus, and magnesium levels
Analysis of cerebrospinal fluid (CSF)
Cranial computed tomography (CT) scan
Serum ammonia level
Serum acetaminophen level
A 2-month-old infant is brought to the physician for evaluation of fever. The infant was born at 37 weeks gestation via normal spontaneous vaginal delivery. His mother had an uncomplicated pregnancy and delivery. He has been doing well until this morning when he developed a temperature of 101.5 F (38.6 C). His mother reports that he is still taking his formula well. He has some clear rhinorrhea and intermittent sneezing. His 3-year-old brother had an upper respiratory tract infection one week ago. The patient's chest radiograph is shown below. Which of the following best describes the findings on this patient's chest radiograph?
. Right upper lobe infiltrate
. Right middle lobe infiltrate
. Hilar lymphadenopathy
. Cardiomegaly
. Normal cardiothymic silhouette
A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?
. Administration of indomethacin if there is a patent ductus arteriosus
. Ligation of a patent ductus arteriosus
. Echocardiography
. Aortogram with bilateral lower extremity runoffs
. Cardiac catheterization
A 2-year-old boy has been doing well despite his diagnosis of tetralogy of Fallot. He presented to an outside ER a few days ago with a complaint of an acute febrile illness for which he was started on a “pink antibiotic.” His mother reports that for the past 12 hours or so he has had a headache and is more lethargic than normal. On your examination he seems to have a severe headache, nystagmus, and ataxia. Which of the following would be the most appropriate first test to order?
. Urine drug screen
. Blood culture
. Lumbar puncture
. CT or MRI of the brain
. Stat echocardiogram
A 2-year-old boy is brought to the clinic because of a swelling at the base of his neck on the left side. The family indicates that since he was born, they suspected he had some kind of a mass in his left supraclavicular area and behind the sternomastoid on that same side, but the area felt soft and mushy, was not always evident, and seemed to be painless, so they did nothing about it. Two weeks ago the child had an upper respiratory infection, and within a day or two the mass became larger and quite obvious. On physical examination he indeed has a soft, mushy, ill-defined mass occupying the entire left supraclavicular area and extending into the posterior triangle of the neck. He has no enlarged lymph nodes anywhere, and his spleen and liver are not palpable. Which of the following is the most appropriate next step in the evaluation?
Bone marrow biopsy
MRI of the neck and chest
Multiple percutaneous needle biopsies
Open surgical excisional biopsy
Panendoscopy under general anesthesia
A 2-year-old boy is brought to the emergency department (ED) in acute respiratory distress. He is afebrile, and has a heart rate of 100/min, respiratory rate of 80/min, and Sa02 of 84% on room air. He is sitting upright, and has significant nasal flaring and intercostal retractions. He is given supplemental oxygen in the ED. Chest x-ray reveal hyperinflation of the right lung, mediastinal shift to the left, and a severely hypoinflated left lung Which of the following is the most appropriate next step in management?
Bronchodilator therapy
Direct laryngoscopy and rigid bronchoscopy
Direct laryngoscopy and flexible bronchoscopy
Segmental lung resection
CT scan of the chest
A 2-year-old boy who emigrated from Eastern Europe 1 year ago is brought to the physician because of fever, cough, and night sweats for 3 weeks. The child's grandmother, who lives with him, has similar symptoms. The child's temperature is 39.2 C (102.6 F), Wood pressure is 110/65 mm Hg, pulse is 90/min, and respirations are 28/min. A Mantoux test is reactive, and a chest x-ray film shows a right middle lobe infiltrate and hilar lymphadenopathy. Which of the following is the most appropriate next step in diagnosis?
Cervical lymph node biopsy
Gastric aspiration
Pleurocentesis
Sputum induction
Gastroscopy
A 2-year-old boy with cough and difficulty breathing is brought to the emergency department by his mother. She says that he was well and playing with his toys until 2 hours prior to presentation. He is healthy, but his 6-year old brother has a peanut allergy. The patient's temperature is 36.7 C (98 F), blood pressure is 92/48 mmHg, pulse is 114/min, and respirations are 48/min. The patient's pulse oximetry shows 91 % on room air. Physical examination shows nasal flaring and grunting with both subcostal and intercostal retractions. Wheezing is heard in the right lung field; the left field is clear to auscultation. No rales or rhonchi are noted. The remainder of the physical examination is within normal limits. Supplementary oxygen is applied. Chest x-ray reveals mild hyperinflation of the right lung. Which of the following is the most appropriate next step in management of this child?
. Bronchoscopy
. Chest computed tomography scan
. Chest physiotherapy
. Chest tube placement
. Intramuscular epinephrine
A 2-year-old child is brought to the physician for a routine visit. He is growing and developing appropriately. He drinks 3-4 glasses of whole milk each day. He is starting to put words together into short sentences. His mother has no concerns. Physical examination shows mild pallor. Laboratory studies show the following: Hemoglobin 9.5 g/dL, RDW 21%, MCV 70 fl, Platelet count 284,000/mm3, Leukocyte count 6,500/mm3. Which of the following additional findings is most likely in this patient?
. Abnormal hemoglobin electrophoresis
. Low reticulocyte count
. Low serum total iron binding capacity
. High indirect bilirubin
. Positive fecal occult blood test
A 2-year-old girl is brought to the emergency department with a fever, chills, poor appetite, and vomiting. On examination, she is irritable and diaphoretic. Her temperature is 39.2 C (102.5 F), blood pressure is 80/48 mm Hg, pulse is 88/min, and respirations are 17/min. She is tender at the left costovertebral angle. Initial laboratory tests show the following: Leukocyte count 16,300/mm3, Hemoglobin 12.5 g/dL, Platelet count 245,000/mm3, Blood urea nitrogen 6 mg/dL, Creatinine 0.5 mg/dl. Urinalysis is positive for leukocyte esterase and nitrite, with 150 white blood cells/hpf. After TV antibiotic administration and stabilization, what is the most appropriate diagnostic study?
CT of the abdomen and pelvis
IV pyelography
Plain abdominal radiography
Radionuclide imaging of the kidneys
Voiding cystourethrography
A 2-year-old presents to the emergency center with several days of rectal bleeding. The mother first noticed reddish-colored stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile, alert, and playful, and is eating well without emesis. He is slightly tachycardic, and his abdominal examination is normal. Which of the following is the best diagnostic study to order to confirm the diagnosis?
. Exploratory laparotomy
. Barium enema
. Ultrasound of the abdomen
. Radionucleotide scan
. Stool culture
A 20-month-old male is brought to the emergency department for evaluation of rectal bleeding after his parents discovered a substantial amount of maroon colored stool when changing his diaper. He has no history of hematochezia. The patient has been otherwise healthy and has not appeared to be in any pain. He has been eating and drinking well. His temperature is 37 C (98.6 F), blood pressure is 85/50 mmHg, pulse is 130/min, and respiratory rate is 20/min. On examination, the abdomen is soft, nondistended, and nontender. On rectal examination, there are no fissures or masses present. A fecal occult blood test is positive. The remainder of the physical examination is normal. Which of the following is the best test to confirm the diagnosis?
Abdominal radiography
Superior mesenteric arteriography
Barium enema
Technetium-99m pertechnetate scan
Abdominal CT scan
A 20-year old GOPO woman presents to the emergency room with complaints of vaginal bleeding and right lower quadrant pain. Her last menstrual period was approximately 5 weeks ago. She is sexually active and uses condoms occasionally. Her temperature is 37.2 C (98.9 F), blood pressure is 120/74 mm Hg, pulse is 80/min and respirations are 14/min. Examination shows mild right lower quadrant tenderness, but no rebound or guarding. There is no active vaginal bleeding and the cervical os is closed. Her initial hemoglobin is 11.0 g/dl. She is Rh positive and a quantitative β-HCG is 1000 mIU/mL. A vaginal ultrasound is done and no intrauterine or extrauterine pregnancy can be seen. Which of the following is next best step in management?
. Consent for laparoscopy
. Methotrexate administration
. Repeat β-HCG in 48 hours
. Administration of anti-D immune globulin
. Consent for dilatation and curettage
A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 37.8°C [100°F]), sore throat, and coryza. On examination, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest examination shows a few basilar rales. Sputum Gram stain shows white blood cells without organisms. Laboratory findings are as follows: Hct: 31, WBC: 12,000/μL, Lymphocytes: 50%, Mean corpuscular volume (MCV): 94 nL, Reticulocytes: 9% of red cells, CXR: bilateral patchy lower lobe infiltrates. Which of the following is the best method for confirmation of the diagnosis?
. High titers of antibody to adenovirus
. High titers of IgM cold agglutinins or complement fixation test
. Methenamine silver stain
. Blood culture
. Culture of sputum on chocolate media
A 20-year-old female presents to your office for a routine. She has no complaints and her past medical history is insignificant. She is not taking any medications and denies drug abuse. Her blood pressure is 125/65 mmHg and heat rate is 80/min. Cardiac auscultation reveals early diastolic murmur at the left sternal border. What is the next best step in the management of this patient?
. Electrocardiogram
. Chest x ray
. Coronary angiography
. Echocardiography
. No further work-up
A 20-year-old man presents with obtundation. Past medical history is unobtainable. Blood pressure is 120/70 mm Hg without orthostatic change, and he is well perfused peripherally. The neurological examination is nonfocal. His laboratory values are as follows: Na: 138 mEq/L, K: 4.2 mEq/L, HCO3: 5 mEq/L, Cl: 104 mEq/L, Creatinine: 1.0 mg/dL, BUN: 14 mg/dL, Ca: 10 mg/dL. Arterial blood gas on room air: PO2 96, PCO2 15, pH 7.02 Blood glucose: 90 mg/dL. Urinalysis: normal, without blood, protein, or crystals. Which of the following is the most likely acid-base disorder?
. Pure normal anion-gap metabolic acidosis
. Respiratory acidosis
. Pure high anion-gap metabolic acidosis
. Combined high anion-gap metabolic acidosis and respiratory alkalosis
. Combined high anion-gap metabolic acidosis and respiratory acidosis
A 20-year-old white male is found to have an elevated calcium level on routine pre-employment screening blood tests. He denies any polyuria, polydipsia or constipation. He has no significant past medical history and does not take any medication. He does not use tobacco, alcohol or drugs. His pulse rate is 82/min, blood pressure is 110/70 mmHg, temperature is 37.0°C (99°F) and respirations are 14/min. Complete physical examination is unremarkable. Laboratory studies show the following: Serum sodium 140 mEq/L, Serum potassium 4.0 mEq/L, Chloride 103 mEq/L, Bicarbonate 24 mEq/L, Blood urea nitrogen (BUN) 18 mg/dl, Serum creatinine 0.8 mg/dl, Calcium 11.2 mg/dl, Blood glucose 98 mg/dl, Serum PTH level 55 pg/ml (normal 10-65 pg/ml), Urine calcium/creatinine clearance ratio < 0.01. Which of the following conditions is most consistent with this patient's findings?
. Primary hyperparathyroidism
. Vitamin D overproduction
. Multiple myeloma
. Sarcoidosis
. Familial hypocalciuric hypercalcemia
A 20-year-old white man notes an uneven tan on his upper back and chest. On examination, he has many circular, lighter macules with a barely visible scale that coalesce into larger areas. Which test is most likely to establish the diagnosis?
. Punch biopsy
. Potassium hydroxide (KOH) microscopic examination
. Dermatophyte test medium (DTM) culture for fungus
. Serological test for syphilis
. Tzanck smear
A 20-year-old woman complains of headache and discomfort in both sides of her jaw. Physical examination reveals enlarged parotid glands that are slightly tender on palpation. There is reddening of the orifice of Stensen’s duct on intra oral examination; her temperature is 38.3°C, and the pulse rate is 80/min. Laboratory data show hemoglobin 14 g/dL; hematocrit 40%; WBC 11000/mL, with 33% segmented neutrophils, 7% monocytes, and 60% lymphocytes. Which of the following diagnostic tests will help to confirm the diagnosis of epidemic parotitis?
Single blood sample for a specific immunoglobulin G (IgG)
Blood cell count
Blood culture
Single blood test for a specific immunoglobulin M (IgM)
Serum amylase
A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is done. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?
. HPV type 11
. HPV type 16
. HPV type 18
. HPV type 45
. HPV type 56
A 21-year-old female has a several month history of easy fatigability and palpitations. She also complains of excessive sweating. She follows a strict, low calorie diet in order to lose weight. Her blood pressure is 120/70 mmHg and her heart rate is 100/min. Her BMI is 19kg/m2 Thyroid function testing reveals the following findings: TSH decreased, Total T4 high, Total T3 high. Radioiodine uptake is diffusely decreased over the thyroid gland. Which of the following is the most likely pathologic finding on biopsy of this woman's thyroid gland?
. Dense lymphocytic infiltrate
. Diffuse follicular hyperplasia
. Orphan Annie nuclei
. Follicular atrophy
. Papillary neoplastic growth
A 21-year-old man has a nonproductive cough, shortness of breath, and chest pain, which changes with breathing. He also has pain in the left arm. On examination, there is tenderness over the left shoulder, heart sounds are normal, and the lungs are clear. CXR reveals a lytic lesion in the left humerus and reticulonodular opacities in the upper and middles lobes. The eosinophil count is normal. Which of the following is the most appropriate initial diagnostic test?
Lung biopsy
Humerus bone biopsy
CT scan of chest
Bronchoscopy
Pulmonary function tests
A 21-year-old man presents to the clinic feeling tired and generally unwell. He has fallen several times over the past month and has developed a slight tremor in both hands. Physical examination is significant for scleral icterus, ankle edema, and a distended and tense abdomen. Laboratory studies show: Hemoglobin: 7 g/dL, Reticulocyte count: 7% Total bilirubin: 3.1 mg/dL, Aspartate aminotransferase: 84 U/L Alanine aminotransferase: 92 U/L Ceruloplasmin: 5 mg/dL (normal: 20–45 mg/dL). Results of a Coombs’ test are negative. Which of the following is an appropriate preventive management step after chelation therapy?
Blood protein electrophoresis
Colonoscopy
ECG
Schilling test
Upper endoscopy
A 21-year-old woman G1P0 with an intrauterine pregnancy (IUP) at 8 weeks' gestation presents for her first prenatal visit. The patient states that she would like to have a termination of the pregnancy. She denies any medical history, surgical history, allergies, and taking any medications. Vital sign: BP, 115/75 mm Hg; P, 78 beats/min; R, 20 breaths/min; T, 98.6°F. Fetal movement: Negative, contractions: Negative, vaginal bleeding: Negative, leakage of fluid: Negative. What laboratory studies need to be done before consideration of this request?
. CMP
. Blood type and screen
. UA
. HIV
. Rapid plasma reagin (RPR)
A 21-year-old woman has just delivered a term infant. She has had only one visit to her obstetrician, and that was at about 6 weeks of pregnancy. She provides her laboratory results from that visit. The delivered infant is microcephalic, has cataracts, a heart murmur, and hepatosplenomegaly. Your further evaluation of the child demonstrates thrombocytopenia, mild hemolytic anemia, and, on the echocardiogram, patent ductus arteriosus and peripheral pulmonary artery stenosis. Which of the following maternal laboratory tests done at 6 weeks gestation is likely to explain the findings in this child?
. Positive hepatitis B surface antibody
. Positive rapid plasma reagin (RPR) with negative Micro hemagglutination Treponema pallidum test(MHATP)
. Negative rubella titer
. Negative triple screen
. Positive varicella titer
A 21-year-old woman presents to the emergency room in active labor. She has had no prenatal care, but her last menstrual period was approximately 9 months prior. Her membranes are artificially ruptured, yielding no amniotic fluid. She delivers an 1800-g (4-lb) term infant who develops significant respiratory distress immediately at birth. The first chest radiograph on this infant demonstrates hypoplastic lungs. After this infant is stabilized, which of the following is the most appropriate next step for this infant?
. Cardiac catheterization
. Renal ultrasound
. MRI of the brain
. Liver and spleen scan
. Upper GI
A 22-year-old football player comes to the physician because of difficulty in extending his right knee. This started one month ago after he twisted his knee while playing. There was mild swelling immediately; he took pain relievers which relieved both the pain and swelling. However, now the knee motion is limited and this is significantly restricting his physical activities. Physical examination shows no swelling of the knee. While passively flexed and extended, a popping sensation is noted under the examiner's finger (which is placed at the right knee). Which of the following is the most appropriate next step in management?
. Bone scan
. Intraarticular steroid injection
. Arthroscopy
. Active exercise
. Rest and NSAIDs
A 22-year-old G1P0 presents to your clinic for follow-up of evacuation of a complete hydatidiform mole. She is asymptomatic and her examination is normal. Which of the following would be an indication to start single-agent chemotherapy?
. A rise in hCG titers
. A plateau of hCG titers for 1 week
. Return of hCG titer to normal at 6 weeks after evacuation
. Appearance of liver metastasis
. Appearance of brain metastasis
A 22-year-old man with inflammatory bowel disease is noted to have a “string sign” in the ileal area on barium enema. In which of the following conditions is this sign most often seen?
. In the stenotic or nonstenotic phase of the disease
. In the stenotic phase only
. As a rigid, nondistensible phenomenon
. With gastric involvement
. With rectal involvement
A 22-year-old white male comes to the office and complains of a noise in his right ear. The noise has been intermittently present for several months, but recently became "very annoying." He also complains of decreased hearing on his right side while using the telephone. His past medical history is insignificant. The physical examination reveals numerous cafe-au-lait spots. What is the best next step in the management of this patient?
. Plain radiographs of the skull
. MRI with gadolinium
. CT with contrast
. Electroencephalogram
. Surgery
A 22-year-old woman (G2POA1) is being followed by her family physician for pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse during her pregnancy. Her first prenatal exam at 12 weeks' gestation showed a negative HIV, Chlamydia, gonorrhea, and urine cultures. Her blood type is A negative and Rh (D) negative. She has not communicated with the father of the child during the pregnancy but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?
. MMR vaccination
. Urine culture
. Rh(D) antibody test
. HIV antibody test
. Pneumococcal vaccine
A 22-year-old woman comes to the physician for an annual examination. She has normal periods every month and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day. She has intercourse with more than one partner. Examination is unremarkable, including a normal pelvic examination. A Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management?
. Repeat Pap smear in 1 year
. Repeat Pap smear in 6 months
. Perform colposcopy
. Perform a cone biopsy
. Perform a hysterectomy
A 22-year-old woman comes to your office at 10 weeks gestation for her first prenatal visit. Her obstetrical history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her mother has hypothyroidism, and she asks you to order thyroid function tests for her. She denies any symptoms, and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?
. Normal total T4, normal TSH
. Decreased free T4, decreased TSH
. Increased total T4, normal TSH
. Increased free T4, decreased TSH
. Decreased total T4, increased TSH
A 22-year-old woman is being followed by her family physician during her first pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse for the past 15 weeks. Her first prenatal exam was at 12 weeks' gestation, at which time her HIV, chlamydia, gonorrhea, Rh(D)-antibody, and urine cultures were negative. Her blood type is A negative. She does not know who the father of the child is but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?
. MMR vaccination
. Urine culture
. Rh(D) antibody test
. HIV antibody test
. Pneumococcal vaccine
A 22-year-old woman presents for her first Pap smear. She has been sexually active with only one boyfriend since age 19. Her physical examination is completely normal. However, 2 weeks later her Pap smear results return showing HGSIL. There were no endocervical cells seen on the smear. Which of the following is the most appropriate next step in the management of this patient?
. Perform a cone biopsy of the cervix
. Repeat the Pap smear to obtain endocervical cells
. Order HPV typing on the initial Pap smear
. Perform random cervical biopsies
. Perform colposcopy and directed cervical biopsies
A 22-year-old woman presents with complaints of vaginal discharge and severe vulvar pruritus. She is otherwise healthy. Physical examination reveals a thin, malodorous vaginal discharge and marked vulvar and vaginal erythema. The pH of the vaginal discharge is 5.5. Microscopic examination of the discharge is most likely to reveal which of the following?
. Pseudohyphae
. Flagellated motile organisms
. Clue cells
. Multinucleated giant cells
. Numerous eosinophils
A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?
. 10 weeks
. 16 weeks
. 22 weeks
. 28 weeks
. 37 weeks
A 23-year-old female comes to the physician complaining of a 3-day history of intermittent lower abdominal pain and vaginal spotting. The pain is of mild to moderate intensity. Her last menstrual period was 6 weeks ago. A pregnancy test is performed, and the result is positive. Her temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows unilateral adnexal tenderness. Transabdominal ultrasonogram does not reveal an intrauterine gestation. Quantitative beta-HCG is 1500 IU/L. Which of the following is the most appropriate next step in management?
. Culdocentesis
. Laparoscopy
. Gram stain and culture of endocervical secretions
. Transvaginal ultrasonogram
. Laparotomy
A 23-year-old G1PO female presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepitheliallesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is?
. Loop electrosurgical excision procedure (LEEP)
. Repeat pap smear 12 months
. Termination of pregnancy
. Repeat colposcopy after delivery
. Endocervical curettage
A 23-year-old G1POfemale presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepithelial lesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is?
. Loop electrosurgical excision procedure (LEEP)
. Repeat pap smear 12 months
. Termination of pregnancy
. Repeat colposcopy and biopsy after delivery
. Endocervical curettage
A 23-year-old man arrives in the ER after a motor vehicle collision. Examination reveals an unstable pelvis and blood at the urethral meatus. Which of the following studies would most accurately identify a urethral injury?
. CT scan of the pelvis
. Intravenous pyelogram
. Stress cystogram
. Antegrade urethrogram
. Retrograde urethrogram
A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?
. CT scan of the knee joint
. Joint fluid aspiration
. Arthroscopy
. MRI of the knee joint
. Plain radiographs of the knee joint
A 23-year-old man complains of progressive low back pain for the past several months. He has morning stiffness that lasts for one hour. He has no history of trauma to his back and denies any recent illness. He had an episode of pain, blurring, and photophobia of his right eye two years ago that required ophthalmology evaluation. His vital signs are within normal limits. Examination shows tenderness in both sacroiliac joints and reduced range of motion of the lower back. If measured, which of the following is most likely to be present in this patient?
. Rheumatoid factor
. Anti-cyclic citrullinated peptide (CCP) antibodies
. Anti dsDNA antibodies
. HLA B 27 positivity
. Glutamic acid decarboxylase antibodies
A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen's disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normotensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?
. CT scan of the head looking for meningiomas
. MRI of his adrenal glands
. MRI of the acoustic nerves
. Radionuclide scans from the neck to the pelvis looking for extra-adrenal pheochromocytomas
. Radiation therapy to the left lower quadrant abdominal mass
A 23-year-old man presents to the emergency room with the history of a fever up to 38°C (100.5°F) intermittently over the past 2 weeks, a persistent cough, and a 10-lb weight loss in the past month. He notes that he has also been becoming increasingly forgetful for the past month and that his thinking is “not always clear.” He has gotten lost twice recently while driving. Which of the following diagnostic tests will be most helpful with this patient?
. EEG
. Liver function tests
. Thyroid function tests
. HIV antibody test
. Skull x-ray
A 23-year-old man presents to your office complaining of occasional headaches, muscle weakness and fatigue. He also describes periodic numbness of his extremities. The symptoms started 6 months ago and have gradually progressed. His past medical history is insignificant. He is not taking any medication. His blood pressure is 165/104 mmHg and heart rate is 80/min. His physical examination is within normal limits. Which of the following laboratory findings is the most specific for the patient's condition?
. Low serum potassium level
. High serum sodium level
. Metabolic alkalosis
. Low plasma renin activity
. High aldosterone/renin ratio
A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 %, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mg/dl, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?
. Upper GI endoscopy
. Pelvic ultrasonogram
. CT scan of the head
. Right upper quadrant ultrasonogram
. Quantitative beta HCG levels
A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?
. Evaluation in one year
. Follow beta-hCG levels to 0
. Dactinomycin
. Methotrexate
. Hysterectomy
A 23-year-old white man is brought to the emergency department (ED) by an ambulance due to an epileptic seizure. He fell on the sidewalk while going home from a pub, where he had two beers. A witness noted tonic-clonic movements of all four extremities for about one minute. This seizure was his first episode, and lasted 30 minutes. In the ED, he is in a state of partial confusion and disoriented to time, place and person. The physical examination does not reveal any focal neurologic pathology. His eye exam does not show any papilledema. His airway is secured, and his breathing is normal. CBC, serum electrolytes, EKG and chest x-ray are normal. Urine toxicology screen is ordered, and lorazepam is given. What is the most appropriate next step in the management of this patient?
. Psychiatric consultation
. Brain computed tomography without contrast
. Brain computed tomography with contrast
. Lumbar puncture
. Electroencephalogram
A 23-year-old white woman presents complaining of 6 months of progressive low back pain. She complains of morning stiffness that lasts one hour, and says her symptoms improve with physical activity. She denies rash, eye pain, urinary problems, and diarrhea. Her past medical history is significant only for an appendectomy at the age of 16 years. She has been taking birth control pills for the past two years. She is afebrile with normal weight and height. Examination reveals reduced forward flexion of the lumbar spine and tenderness over the sacroiliac joints. The remainder of the physical examination is normal. Which of the following is the most appropriate next step in the management of this patient?
. HLA-B27 testing
. ANA and rheumatoid factor levels
. Bone scan
. MRI of the spine
. X-ray of the sacro-iliac joints
A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?
. 0%
. 1%
. 20%
. 80%
. 100%
A 23-year-old woman presents to the ED complaining of lower abdominal pain and vaginal spotting for 2 days. Her menstrual cycle is irregular. She has a history of ovarian cysts and is sexually active but always uses condoms. Her BP is 115/75 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Which of the following tests should be obtained next?
. Chlamydia antigen test
. β-Human chorionic gonadotropin (β-hCG)
. Transvaginal ultrasound
. Abdominal radiograph
. Observe her abdominal pain, if it resolves discharge her with a diagnosis of menstruation
A 23-year-old woman presents to the ED in moderate pain in her left lower quadrant (LLQ). She states that the pain began suddenly and is associated with nausea and vomiting. She had a bout of diarrhea yesterday. This is the second time this month that she experienced pain in this location, however, never with this severity. Her BP is 120/75 mm Hg, HR is 101 beats per minute, temperature is 99.5°F, and RR is 18 breaths per minute. She has a tender LLQ on abdominal examination and a tender adnexa on pelvic examination. Which of the following is the most appropriate diagnostic test for the patient?
. CT scan
. MRI
. X-ray
. Doppler ultrasound
. Laparoscopy
A 23-year-old woman presents with a rubbery, freely movable 2-cm mass in the upper outer quadrant of the left breast. Which of the following histologic features is most likely to be seen when examining a biopsy specimen from this mass?
. Large numbers of neutrophils
. Large numbers of plasma cells
. Duct ectasia with inspissation of breast secretions
. Necrotic fat surrounded by lipid-laden macrophages
. A mixture of fibrous tissue and ducts
A 23-year-old woman presents with weight loss and chronic diarrhea. She appears unwell and cachectic. Routine laboratory tests reveal a low hemoglobin level and an increased international normalized ratio (INR) even though she is not taking any anticoagulants. The liver enzymes are normal, but the albumin and calcium levels are low, suggesting generalized malnutrition. Which of the following is the most appropriate initial diagnostic test for malabsorption?
. Xylose absorption
. Schilling test
. x-ray studies
. Stool fat quantitation
. Small intestinal biopsy
A 23-year-old woman, gravida 1, para 0, at 25 weeks’ gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows: Leukocyte count 10,500/mm3, Platelet count 62,000/mm3, Hematocrit: 26%, Sodium: 140 mEq/L, Chloride: 100 mEq/L, Potassium: 4.5 mEq/L, Bicarbonate: 26 mEq/L. A peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?
Decreased fibrin split products
Decreased lactate dehydrogenase
Elevated AST
Elevated fibrinogen
Elevated glucose
A 24-month-old pale child is brought to the office by his mother, who says, "Doc, I think he is under some weird spell. He acts bizarre and always seems tired. He likes to eat wooden, painted toys." The child and her mother live in a relatively poor neighborhood. CBC reveals:WBC 8,600 /mm3, Hemoglobin 7.1 g/dl, Hematocrit 25%, Platelets 166,000 /mm3. His blood lead levels are elevated. Which of the following is most likely seen in this child's peripheral blood smear?
. Megaloblastic anemia and basophilic stippling
. Tear-drop RBCs and hypochromic, microcytic anemia
. Loss of concavity of the RBC and basophilic stippling
. Basophilic stippling and microcytic, hypochromic anemia
. Normochromic, normocytic anemia and basophilic stippling
A 24-year-old Caucasian male undergoes pulmonary function testing. The following values are obtained: FEV 80% of predicted, FEV1/FVC 85%, FRC 110% of predicted. He has no current complaints except for occasional low back pain treated with naproxen. He smokes one pack per day and drinks a six-pack of beer each weekend. His ESR is 47 mm/hr. Which of the following best explains the pulmonary function test findings in this patient?
. Emphysema
. Small airway obstruction
. Pulmonary fibrosis
. Chest wall motion restriction
. Pulmonary vascular disease
A 24-year-old Caucasian man is brought to the emergency room with acute asthma exacerbation. His current medications include inhaled fluticasone and salmeterol. The attack started 10 hours ago and did not respond to numerous albuterol inhalations and systemic steroids. His blood pressure is 120/70 mmHg and heart rate is 110/min. The patient is tachypneic and speaks with difficulty. Lung auscultation reveals decreased breath sounds, prolonged expiration, and bilateral wheezing. Pulse oximetry showed 86% at room air. ABG at room air are: pH 7.43, Po2 68 mmHg, PCO2 40mmHg. The chest x-ray demonstrates hyperinflated lungs. Which of the following findings indicates that the patient is getting worse?
. Lung hyperinflation
. Tachypnea
. Tachycardia
. Hypoxia
. Normal PCO2
A 24-year-old man woke up from sleep 1 hour ago with severe pain in his right testicle. He states that he is sexually active with multiple partners. On examination, the right scrotum is swollen, tender, and firm. You cannot elicit a cremasteric reflex. His BP is 145/75 mm Hg, HR is 103 beats per minute, RR is 14 breaths per minute, temperature is 98.9°F, and oxygen saturation is 99% on room air. Which of the following is the most appropriate next step in management?
. Administer one dose of ceftriaxone and doxycycline for 10 days and have him follow-up with a urologist
. Swab his urethra, send a culture for gonorrhea and Chlamydia, and treat if positive
. Send a urinalysis and treat for a urinary tract infection (UTI) if positive
. Treat the patient for epididymitis and have him return if symptoms persist
. Order a statim (STAT) color Doppler ultrasound and urologic consultation
A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?
. Staining for Donovan bodies
. The presence of serum antibodies to Chlamydia trachomatis
. Positive Frei skin test
. Culturing Haemophilus ducreyi
. Culturing Calymmatobacterium granulomatis
A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?
. Fasting and random urine sugar
. One time fasting blood sugar
. 75gram oral glucose tolerance test
. One hour 50gram oral glucose tolerance test
. Three hour 100gram oral glucose tolerance test
A 24-year-old white female is brought to the emergency department (ED) by her mother due to altered mental status. According to her mother, she suffered from viral gastroenteritis 4 days ago. Since then, she has been on oral fluids. Over the past 2 days, her condition had been deteriorating, but she kept refusing admission to the hospital. Her past history is not significant, except for excessive thirst, water intake and weight loss over the past two months. Her blood pressure is 100/56 mmHg, pulse is 120/min (regular and weak), temperature is 37.2°C (99°F), and respirations are 28/min (rapid and deep). Pulse oximetry is 94% on room air. She is arousable and moves all her extremities. Her mucous membranes are very dry. Her neck is supple. The chest is clear on auscultation. Which of the following is the most appropriate next step in management?
. Obtain electrocardiogram
. Obtain arterial blood gases
. Fingerstick glucose
. Intubate the patient
. Obtain CT scan of head
A 24-year-old woman comes to the physician because of a 24-hour history of right flank pain, burning micturition and high-grade fever with chills. Her temperature is 102°F (38.9°C), blood pressure is 90/60 mm Hg, pulse is 130/min, and respirations are 20/min. Physical examination shows costovertebral angle tenderness. Which of the following is the most likely urine dipstick finding in this patient?
. Positive for nitrites and esterase
. Positive for nitrites only
. Positive for esterase only
. Negative for both esterase and nitrites
. Negative for esterase and positive nitrites
A 24-year-old woman comes to your office complaining of an 8-week history of amenorrhea. She is sexually active and uses OCPs for contraception. Her medical history is unremarkable. She does not have any particular complaints except moderate fatigue and a decline in mood. She denies headaches, visual disturbances, or any gastrointestinal symptoms. She denies cigarette smoking or any drug use, and drinks alcohol socially. Breast examination reveals a white, milky secretion upon expression of both nipples. A pelvic examination reveals a uterus of normal size. BMI is 28 kg/m2. Initial investigations reveal a negative serum beta-hCG level. According to these findings, which of the following is the most appropriate next step in the management of this patient?
. Determine serum TSH level
. Determine serum TRH level
. Perform visual field study
. Order sellar MRI
. Order sellar CT scan
A 24-year-old woman presents to the emergency department complaining of right lower quadrant pain and vaginal spotting. Her last menstrual period was 5 weeks ago. Her temperature is 37 C (98.6 F), blood pressure is 112/70 mm Hg, pulse is 74/min, and respirations are 14/min. The abdomen is soft and non-tender. Pelvic examination reveals scant blood in the vagina, a closed cervical os, no pelvic masses, and right pelvic tenderness. Her leukocyte count is 8000/mm3, hematocrit is 38%, and a platelet count is 250,000/mm3. Which of the following is the most appropriate step next in diagnosis?
Serum hCG
Serum TSH
Abdominal x-ray
Abdominal/pelvic CT
Laparoscopy
A 24-year-old woman presents with nausea, vomiting, anorexia, and gross hematuria. She had a sore throat 2 weeks ago that resolved on its own. On examination, her blood pressure is 160/90 mm Hg, pulse 90/min, JVP is 7 cm, heart sounds are normal, there is 1+ pedal edema, and the lungs are clear. She has a renal biopsy. Which of the following electron microscopy findings on the renal biopsy is most likely in keeping with poststreptococcal GN?
Diffuse mesangial deposits
No deposits
Electron-dense endothelial deposits
Closed capillary lumen
Subepithelial humps
A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?
. Lack of ascites
. Unilocularity
. Papillary vegetation
. Diameter of 5 cm
. Demonstration of arterial and venous flow by Doppler imaging
A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. Which of the following would be the best way to evaluate her urologic injury?
. Sonogram of the bladder
. Intravenous pyelogram
. Cystoscopy
. Retrograde cystogram including post-void films
. Retrograde cystogram including views of the ureters
A 24-year-old woman, G1 P1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?
. Discontinue OCP and recommend intrauterine contraceptive device
. Measure serum FSH and LH
. Measure serum beta-HCG
. Advise her to stop taking oral contraceptives temporarily and advise condom use until symptoms resolve
. Tell her this is normal with patients who have recently begun taking oral contraceptives, and that her symptoms will resolve eventually
A 25-year-old female presents to her physician with a painful ulcerative lesion on her labia for the past 2 days. She also complains of dysuria. She admits to having sexual intercourse with multiple partners for the last 6 years. Tzanck preparations of one of her lesions reveal multi-nucleated giant cells. She is encouraged to undergo testing for HIV and other STDs. Which of the following is the most appropriate screening test for HIV infection?
. HIV serology by ELISA
. HIV serology by western blot
. HIV viral load
. Absolute CD4 count
. P 24 antigen assay
A 25-year-old female presents to the emergency department with sudden-onset severe shortness of breath and wheezing. She has a history of asthma. On examination, she is unable to speak in full sentences and is using accessory muscles of respiration. She is intubated, mechanically ventilated and treated with continuous albuterol nebulization and intravenous methylprednisolone. Within six hours, her condition is improved. She is extubated and treated with hourly nebulizer treatments. The next morning, she complains of muscle weakness. On physical examination, she has difficulty lifting her arms over her head and mild hand tremors. Her vital signs are stable. What should be the immediate next step in her management?
. Check peak expiratory flow rate
. Check chest x-ray, PA view
. Check serum TSH level
. Check serum electrolyte panel
. Obtain electromyography (EMG)
A 25-year-old female presents to the physician's office complaining of fatigue, joint pains, and frequent mouth ulcers over the past three months. She has no medical problems and does not take any medications. She does not use tobacco, alcohol or drugs. Her temperature is 37.5°C (99.5°F), blood pressure is 150/100 mmHg and pulse is 78/min. Examination shows erythema over the cheeks and nose. Labs reveal a serum creatinine of 2.8 mg/dl and her urinalysis shows 2+ protein and 20 RBC/HPF. Anti-double stranded antibodies (anti-dsDNA) are positive. Which of the following is the most appropriate next step in management of this patient?
. Kidney biopsy
. Methotrexate
. Methylprednisolone
. Cyclophosphamide
. Cyclophosphamide and methylprednisolone
A 25-year-old female presents to your office complaining of exertional dyspnea and fatigue. Her past medical history is insignificant. She does not smoke or consume alcohol. Her blood pressure is 110/70 mmHg and heart rate is 90/min. Physical examination reveals pale conjunctiva. The laboratory values are: ESR 15 mm/hr, Hemoglobin 7.5 g/dL, MCV 70 fl, MCHC 29%, Leukocyte count 7,000/cmm, Segmented Neutrophils 55%, Bands 3%, Eosinophils 3%, Basophils 0%, Lymphocytes 32%, Monocytes 7%. What is the best next step in the management of this patient?
. Bone marrow sampling
. Iron studies
. Serum folate level
. Schilling test
. HbA2 measurement
A 25-year-old female with blonde hair and fair complexion complains of a mole on her upper back. The lesion is 8 mm in diameter, darkly pigmented, and asymmetric, with an irregular border (see illustration below). Which of the following is the best next step in management?
. Tell the patient to avoid sunlight
. Follow the lesion for any evidence of growth
. Obtain metastatic workup
. Obtain full-thickness excisional biopsy
. Obtain shave biopsy
A 25-year-old G2, PI at 28 weeks gestation is brought to the emergency department by her boyfriend, who found her lying on her bed in a pool of blood. She is very drowsy, but denies any pain or uterine contraction. Her temperature is 38°C (100.4°F) and respirations are 18/min. Physical examination is suggestive of a transverse lie. Inspection of the perineum reveals gross blood and active bleeding per vagina. Which of the following set of parameters would most likely be seen in this patient?
. Set A
. set B
. Set C
. set D
. set E
A 25-year-old G3P1011 presents to the ED with a 6-hour history of worsening lower abdominal pain, mostly in the RLQ. She also noticed some vaginal spotting this morning. She is nauseated, but did not vomit. Her last menstrual period was 2 months ago, but her cycles are irregular. She is sexually active and has a history of pelvic inflammatory disease. Her BP is 120/75 mm Hg, HR is 95 beats per minute, temperature is 99.2°F, and RR is 16 breaths per minute. Her abdomen is tender in the RLQ. Pelvic examination reveals right adnexal tenderness. Her WBC count is slightly elevated and her β-hCG is positive. After establishing IV access, which of the following is the most appropriate next step in management?
. Call the OR to prepare for laparoscopy
. Order an emergent CT scan of the abdomen
. Perform a transvaginal ultrasound
. Order a urinalysis
. Swab her cervix and treat for gonorrhea and Chlamydia
A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered 2 liters of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left upper quadrant. Ultrasound shows fluid in the spleno-renal angle. The most appropriate next step is?
. Perform exploratory laparotomy
. Perform a CT scan
. Admit to the surgical ICU
. Admit to the ward
. Laparoscopy
A 25-year-old male presents with progressive shortness of breath over the past 6 months. His past medical history is significant only for neonatal hepatitis that resolved spontaneously when he was 6 months of age. The man has never smoked. On lung auscultation today, there are decreased breath sounds over both lower lobes. Chest x-ray demonstrates emphysematous changes in the bilateral lower lobes. Routine blood work is normal. Which of the following analyses would be most helpful in establishing this patient's diagnosis?
. Open lung biopsy
. Serum alpha-1 antitrypsin level
. Video-assisted lung biopsy
. High resolution CT scan of chest
. Pulmonary function testing
A 25-year-old male student presents with the chief complaint of rash. He denies headache, fever, or myalgia. A slightly pruritic maculopapular rash is noted over the abdomen, trunk, palms of the hands, and soles of the feet. Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic, flat, wartlike lesions are noted around the anal area. Laboratory studies show the following: Hct: 40%, Hgb: 14 g/dL, WBC: 13,000/μL, Diff: 50% segmented neutrophils, 50% lymphocytes. Which of the following is the most useful laboratory test in this patient?
. Weil-Felix titer
. Venereal Disease Research Laboratory (VDRL) test
. Chlamydia titer
. Blood cultures
. Biopsy of perianal lesions
A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, 5 cm below the groin crease. The exit wound is in the posterolateral aspect of the thigh, half way between the greater trochanter and the knee. He has palpable pulses in the dorsum of his foot and in the posterior tibial artery behind the malleolus. The popliteal pulse is reported normal by one examiner, but cannot be felt by another. There is no hematoma under the entrance wound, and blood is oozing from both wounds but not at an alarming rate. He is hemodynamically stable. Neurologic examination of the leg is normal. X-ray films show the femur to be intact. In addition to local wound care and the appropriate tetanus prophylaxis, which of the following is the most appropriate next step in management?
Discharge home
Digital exploration of the wounds in the emergency department
Hospitalization to observe for development of complications
Arteriogram
Formal surgical exploration of the area in the operating room
A 25-year-old nulligravid woman comes to the physician because of chronic pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2 C (98.9 F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Urine pregnancy test is negative. Which of the following is most appropriate diagnostic test in her management?
. Endometrial biopsy
. Laparoscopy
. CA-125 levels
. Hysterosalpingogram
. CT scan of the pelvis
A 25-year-old nulligravid woman comes to the physician because of constant pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2 C (98.9 F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Which of the following is most appropriate diagnostic test in her management?
. Endometrial biopsy
. Laparoscopy
. CA- 125 levels
. Hysterosalpingogram
. Serial beta-hCG
A 25-year-old postal worker presents with a pruritic, nonpainful skin lesion on the dorsum of his hand. It began like an insect bite but expanded over several days. On examination, the lesion has a black, necrotic center associated with severe local swelling. The patient does not appear to be systemically ill, and vital signs are normal. Which of the following is correct?
. The lesion is ecthyma gangrenosum, and blood cultures will be positive for Pseudomonas aeruginosa
. A skin biopsy should be performed and Gram stain examined for gram-positive rods
. The patient has been bitten by Loxosceles reclusa, the brown recluse spider
. The patient has the bubo of plague
. The patient has necrotizing fasciitis and needs immediate surgical debridement
A 25-year-old who has been living in Washington, DC, presents with a diffuse vesicular rash over his face and trunk. He also has fever. He has no history of chickenpox and has not received the varicella vaccine. Which of the following information obtained from history and physical examination suggests that the patient has chickenpox and not smallpox?
. There are vesicular lesions on the palms and soles
. Vesicular lesions are concentrated on the trunk
. The rash is most prominent over the face
. All lesions are at the same stage of development
. The patient experienced high fever several days prior to the rash
A 25-year-old woman presents to your office for evaluation of primary infertility. She has regular periods every 28 days. She has done testing at home with an ovulation kit, which suggests she is ovulating. A hysterosalpingogram demonstrates patency of both fallopian tubes. A progesterone level drawn in the mid–luteal phase is lower than expected. A luteal phase defect is suspected to be the cause of this patient’s infertility. Which of the following studies performed in the second half of the menstrual cycle is helpful in making this diagnosis?
. Serum estradiol levels
. Urinary pregnanetriol levels
. Endometrial biopsy
. Serum follicle-stimulating hormone (FSH) levels
. Serum luteinizing hormone (LH) levels
A 25-year-old woman who is “about 5 months” pregnant with her first child presents for the first time to an obstetrician. She has had no prenatal care. When asked about her medical history, she states she sometimes takes medicine for “depression,” and she produces a prescription bottle with lithium tablets in it. She is otherwise healthy and her pregnancy has been uncomplicated to date. The fundus of her uterus is 22 cm from the pubic symphysis, fetal movement is felt, and fetal heart tones are present at 130/min. Which of the following tests should be advised given the patient’s lithium ingestion?
Chorionic villus sampling
Fetal echocardiography
Fetal renal ultrasound
Maternal oral glucose tolerance test
Measurement of α-fetoprotein, β-human chorionic gonadotropin, and estriol levels
A 25-year-old woman with end-stage renal disease is exploring the benefits of renal transplantation. Which of the following is an advantage of dialysis over renal transplantation?
. Better patient survival
. More cost-effective longterm
. Improved quality of life
. No need for lifelong immunosuppression
. More cost-effective if the renal transplant functions for more than 2 years
A 25-year-old woman, 8 weeks pregnant, is found to have a 1-cm mass in the upper outer quadrant of the right breast. Core biopsy diagnoses infiltrating ductal carcinoma. Technically, the tumor is amenable to a lumpectomy. Palpation of the axilla is negative. When confronted with her therapeutic options, the patient indicates that her first consideration is the welfare of her unborn child, the second consideration is her own chance of cure, and the last consideration is the cosmetic outcome of the treatment. To help her achieve those ends, which of the following is the most appropriate first step of her treatment?
. Lumpectomy and sentinel node biopsy
. Lumpectomy and axillary dissection
. Modified radical mastectomy
. Radiation treatment to the affected breast
. Systemic chemotherapy
A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. She is known to be 0 (-) while her husband is 0 (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-0 immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-0 antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?
. No prophylaxis early in this pregnancy
. Too early administration of anti-0 immune globulin postpartum
. Low dose of anti-D immune globulin at 28 weeks of her first pregnancy
. Low dose of anti-D immune globulin postpartum
. No prophylaxis between the pregnancies
A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. This pregnancy has been uncomplicated thus far. She is known to be D (-) while her husband is D (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-D immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-D antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?
. No prophylaxis early in this pregnancy
. Too early administration of anti-D immune globulin postpartum
. Low dose of anti-D immune globulin at 28 weeks of her first pregnancy
. Low dose of anti-D immune globulin postpartum
. No prophylaxis between the pregnancies
A 26-year-old Caucasian male comes to the physician because of severe productive cough for the past two months. He also complains of occasional blood in sputum, and dyspnea for the last three weeks. His past medical history is significant for otitis media, two episodes of pneumonia, and sinusitis. He and his wife were recently worked up for infertility. Physical examination shows crackles in the left upper lobe. Chest x-ray shows dilated and thickened airways and irregular peripheral opacities in the left upper lobe. Which of the following is the most appropriate test to make the diagnosis of his condition?
. Sweat chloride test
. DNA studies
. Pulmonary function tests
. Semen analysis
. Bronchoscopy
A 26-year-old G1P0 patient at 34 weeks gestation is being evaluated with Doppler ultrasound studies of the fetal umbilical arteries. The patient is a healthy smoker. Her fetus has shown evidence of intrauterine growth restriction (IUGR) on previous ultrasound examinations. The Doppler studies currently show that the systolic to diastolic ratio (S/D) in the umbilical arteries is much higher than it was on her last ultrasound 3 weeks ago and there is now reverse diastolic flow. Which of the following is correct information to share with the patient?
. The Doppler studies indicate that the fetus is doing well
. With advancing gestational age the S/D ratio is supposed to rise
. These Doppler findings are normal in someone who smokes
. Reverse diastolic flow is normal as a patient approaches full term
. The Doppler studies are worrisome and indicate that the fetal status is deteriorating
A 26-year-old man presents with a 1-week history of intermittent, crampy, lower abdominal pain accompanied by rectal urgency, bloody diarrhea, nausea and vomiting. His symptoms have become more severe over the past 24 hours. His past medical history is unremarkable. He denies any recent travel or antibiotic use. His temperature is 38.5°C (102.0°F), blood pressure is 120/80 mmHg, pulse is 95/min, and respirations are 15/min. Abdominal examination reveals distension and tenderness to palpation without rebound or guarding. The bowel sounds are decreased. Rectal examination shows marked rectal tenderness and mucus mixed with blood in the vault. An x-ray film of the abdomen shows distended colon filled with gas. Laboratory studies show: Hb 10.8 g/dl, WBC 19,600/cmm, Platelet count 459,000/cmm, ESR 54/hr. Which of the following is the most appropriate next step in management?
. Stool for ova, parasites and culture
. Barium enema
. Proctosigmoidoscopy and biopsy
. Serology for Entamoeba histolytica
. CT scan of the abdomen
A 26-year-old nulligravid patient presents to her physician seeking preconceptional advice. She plans to conceive in about 1 year. Her past medical history is significant for chickenpox as a child. She had an appendectomy 2 years ago. She takes no medications and is allergic to penicillin. Her complete physical examination, including a pelvic examination, is unremarkable. Which of the following is the most appropriate next step in diagnosis to prevent morbidity in this patient's offspring?
Blood cultures
Group B Streptococcus culture
Pelvic ultrasound
Rubella titer
Urine culture
A 26-year-old white female presents with worsening weakness of her right upper extremity, left lower extremity and ataxia. She also complains of unilateral eye pain and visual loss. The eye pain is worsened by ocular movements. On eye examination, there is a central visual field defect in her right eye. Fundoscopy is normal. Neurological examination shows spastic paraparesis in the right upper extremity and the left lower extremity. What is the most appropriate next step in this patient's management?
. CT scan with contrast
. MRI of the brain
. Lumbar puncture
. Brain biopsy
. PET scan
A 26-year-old woman presents for evaluation of infertility. She describes her menstrual cycles as irregular stating that they occur anywhere between 32 to 35 days. She has no galactorrhea. She eats a balanced diet and exercises regularly. She has no other medical problems. Her BMI is 22 Kg/m2. Physical examination is unremarkable. Which of the following is the most appropriate initial test to evaluate her infertility?
. Endometrial biopsy
. Hysterosalpingogram
. Mid luteal serum progesterone level
. Serum testosterone
. Karyotyping
A 26-year-old woman, gravida 3, para 2, comes to the physician for the first time for a prenatal checkup. She changed her physician and in the interim has missed two prenatal checkups. She states that she is at 7months gestation. According to her prenatal records and an ultrasound performed at 16 weeks gestation, she is now at 30 weeks, but her fundal height is only 26 cm (10.2 inches). Fetal heart tones are heard by Doppler. Blood pressure is 140/90 mm Hg. You suspect fetal growth restriction (FGR) and order a repeat ultrasonogram. Which of the following is the single most useful parameter for predicting fetal weight by ultrasonogram in suspected FGR?
. Biparietal diameter
. Abdominal circumference
. Femur length
. Head to abdomen circumference ratio
. Calculated fetal weight
A 27 year-old African-American woman presents to the emergency room complaining of unilateral leg swelling, pleuritic chest pain and shortness of breath. She reports a rash on her face that worsens in the sun, two previous miscarriages, and complains of recent painful swelling in both knees. A CT angiogram confirms a pulmonary embolus. Which of the following is the most likely laboratory abnormality?
. Decreased prothrombin time (PT)
. Absent Von Willebrand's factor
. Prolonged partial thromboplastin time (PTT)
. Increased bleeding time
. Thrombocytosis
A 27-year old woman comes to the physician for evaluation of infertility. She and her 31-year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. She has regular 28-day menstrual cycles and during the menstrual cycles she develops mild pelvic pain and bilateral breast tenderness. She has no pain during sexual intercourse. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination is completely unremarkable. Which of the following could most likely be abnormal in this patient?
. Serum prolactin level
. Hysterosalpingogram
. Mid luteal serum progesterone level
. Serum testosterone level
. Serum inhibin B level
A 27-year-old Caucasian male is diagnosed with medullary thyroid carcinoma that is non-resectable. His past medical history is insignificant. He does not smoke or consume alcohol. His family history is significant for thyroid cancer and pheochromocytoma in his father. Which of the following tests could have been most effective in preventing this patient's non-resectable cancer?
. Annual physical examination
. Frequent self-examination of the neck
. Periodic serum calcium measurement
. Periodic stimulated serum calcitonin measurement
. DNA testing
A 27-year-old G2P1 at 29 weeks gestational age, who is being followed for Rh isoimmunization presents for her OB visit. The fundal height is noted to be 33 cm. An ultrasound reveals fetal ascites and a pericardial effusion. Which of the following can be another finding in fetal hydrops?
. Oligohydramnios
. Hydrocephalus
. Hydronephrosis
. Subcutaneous edema
. Over-distended fetal bladder
A 27-year-old healthy woman comes to the office for evaluation of infertility. She and her 31 -year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. Her husband is healthy and takes no medications. He has a normal semen analysis. She has regular 28-day menstrual cycles. The patient has mid-cycle pelvic pain and an egg white like consistency to her discharge mid-cycle. She has no pain during sexual intercourse. The patient does report having been hospitalized with a pelvic infection in her late teens, during which time she had pain with intercourse, discharge, and fever. Her sister was diagnosed with polycystic ovarian disease. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is most likely to be abnormal in this patient?
. Serum prolactin level
. Hysterosalpingogram
. Mid-luteal phase progesterone
. Serum testosterone level
. Serum inhibin B level
A 27-year-old man complains of difficulty in walking. He noticed leg weakness several days ago, and now he is barely able to walk. He also complains of mild back pain and foot numbness. Two weeks ago, he had an upper respiratory tract infection. Physical examination reveals lower extremity muscle weakness, absent knee and ankle reflexes, and minimal sensory loss. Spinal MRI shows no abnormalities. Which of the following findings would you expect on CSF analysis in this patient? (Protein, WBC, count RBC, count Glucose)
. high, increased, normal, normal
. high, increased, increased, low
. high, increased, normal, low
. high, normal, normal, normal
. normal, increased, increased, normal
A 27-year-old man complains of poor appetite, loss of interest in his daily activities, and impaired sleep. He has lost 10 pounds over the last two months. He says that he feels regretful about IV drug abuse in his past, but denies having suicidal or homicidal thoughts. He drinks alcohol occasionally but denies regular alcohol consumption or early morning drinking. He is sexually active with one partner and she uses oral contraceptives. On physical examination, his pulse is 76/min and his blood pressure is 110/70 mm Hg. His heart and lung exams are unremarkable and his abdomen is soft and non-tender. The liver span is 9 cm and the spleen is not palpable. He is fully oriented to person, place and time but performs poorly on memory tests. Which of the following is the best next step in managing this patient?
. Selective serotonin reuptake inhibitors
. Benzodiazepines
. HIV testing
. Thyroid function testing
. Serum iron studies
A 27-year-old man is seen in the ED for a leak around a surgical G-tube that was placed 2 weeks ago and has been used for enteral feeding for 1 week. Inspection reveals the tube is pulled out from the stoma, but is still in the cutaneous tissue. The abdomen is soft and nondistended and there are no signs of skin infection. Which of the following is the most appropriate next step in management?
. Insert a Foley catheter into the tract and aspirate. If gastric contents are aspirated the tube can be used for feeding
. Insert a Foley catheter into the tract, instill water-soluble contrast, and obtain an abdominal radiograph prior to using for feeding
. Remove the tube and admit the patient for observation
. Remove the tube and immediately obtain a CT scan of the abdomen
. Return to the OR for closure of gastrotomy and placement of a new tube
A 27-year-old man presents with diarrhea. He returned 3 weeks ago from a trip to rural South America. Over the past few days, he has gradually developed lower abdominal pain and diarrhea. Now the symptoms are much worse with eight stools a day consisting mostly of mucus and blood. He is afebrile, the abdomen is tender in left lower quadrant, and the remaining examination is normal. His stool is mostly comprised of blood and mucus. Which of the following is the most appropriate initial diagnostic test?
Stool culture
Stool toxin assay
Examination of a dried stool specimen
Immunofluorescence of stool specimen
Examination of a wet stool specimen
A 27-year-old man was assaulted and stabbed on the left side of the chest between the areola and the sternum. He is hemodynamically unstable with jugular venous distention, distant heart sounds, and hypotension. Which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade?
. More than a 10 mm Hg decrease in systolic blood pressure at the end of the expiratory phase of respiration
. Decreased right atrial pressures on Swan-Ganz monitoring
. Equalization of pressures across the 4 chambers on Swan-Ganz monitoring
. Compression of the left ventricle on echocardiography
. Overfilling of the right atrium
A 27-year-old woman comes to the physician for preconception counseling. She takes no medication. Her menses are regular, are moderate in amount, and last 5-6 days. Her diet is well balanced. Her grandparents are from Greece. Her husband's family is also of Mediterranean ancestry. Her mother and sister have been diagnosed with anemia, but she does not know the types. The presence of thalassemia anemia in her family is suspected. Which of the following is the most appropriate initial screening test?
. Complete blood count in the patient
. Hemoglobin electrophoresis testing in the patient
. Hemoglobin electrophoresis testing in the patient and her husband
. Iron level, total iron-binding capacity, and ferritin level in the patient
. Solubility testing in the patient
A 27-year-old woman complains of fatigue, low-grade fevers, anorexia, headaches and skin rash over the past several weeks. She also notes new exertional dyspnea and an unintentional 5-pound weight gain over the past two weeks. On physical examination, her blood pressure is 190/110 mmHg and her heart rate is 90/min. Which of the following is the most likely finding on this patient's urinary tests?
. High VMA excretion
. High daily cortisol excretion
. Red blood cells
. Glucosuria
. Uric acid crystals
A 27-year-old woman is 7 months pregnant with her first child. Her pregnancy has been uncomplicated to date. She presents to the emergency department complaining of sudden-onset, right-sided chest pain that is exacerbated with deep breathing and shortness of breath, which began 1 hour ago. She denies leg pain and notes that her legs began swelling during the sixth month of her pregnancy but the swelling has not worsened. Her temperature is 37.9°C (100.3°F), blood pressure is 130/87 mm Hg, pulse is 107/min and regular, respiratory rate is 24/min, and oxygen saturation is 90% on room air, increasing to 98% with 4 L oxygen via nasal cannula. Physical examination is significant for crackles at the lower right lung field and a negative Homans’ sign bilaterally. X-ray of the chest appears normal. The D-dimer level is elevated. ECG shows sinus tachycardia, right-axis deviation, S wave in lead I, Q wave in lead III, and an inverted T wave in lead III. Which of the following is the most appropriate next step in diagnosis?
Arterial blood gas analysis
Doppler ultrasound of the lower extremity
MRI of the lower extremity
Pulmonary angiography
Ventilation/perfusion scans
A 27-year-old woman presents to the office due to a significant amount of hair on her cheeks, chin and upper lips. This symptom developed over the past two months. Her last menstrual period was 12 weeks ago, but she did not seek medical help because her home pregnancy test was negative. Her medical history is unremarkable. She denies taking any medications other than oral contraceptive pills. Physical examination reveals acne on the forehead and cheeks; there is terminal hair on the upper lip, cheeks, chin, upper chest and lower abdomen. Examination of the genitals shows clitoromegaly. The abdominal exam is normal; the uterus is normal in size. Ultrasound reveals a normal uterus and ovaries, but there is a left adrenal mass. Which of the following measurements is most specific for this patient's condition?
. Luteinizing hormone (LH)
. Adrenocorticotropic hormone (ACTH)
. Testosterone
. Dehydroepiandrosterone-sulfate
. Dihydrotestosterone
A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?
. Quantitative beta-HCG measurement
. Pelvic ultrasonography
. Chorionic villous sampling
. Check PT/INR and PTT
. Reassurance and routine follow-up
A 27-year-old, HIV-positive man comes to his physician with a two-day history of fever, profuse watery diarrhea, and abdominal cramps. He has been taking zidovudine, didanosine, and indinavir for the past eight months. His temperature is 37.9°C (100.2°F), pulse is 102/min, respirations are 14/min, and blood pressure is 105/70 mm Hg. He is started on fluid and electrolyte support. What is the most appropriate next step in the management of this patient?
. Stop antiretroviral therapy and send stool for Clostridium difficile toxin assay
. Colonoscopy with biopsy of the colonic mucosa
. Stool examination for ova and parasites
. Start empiric treatment for cytomegalovirus
. Loperamide and lactose-free diet until diarrhea subsides
A 28-year-old African American woman presents with mild dyspnea on exertion. She reports no coughing, sputum production, or wheezing symptoms, but has noticed a red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Her pulmonary function tests reveal a mild restrictive pattern. Which of the following tests will most likely make a definitive diagnosis?
Tuberculin skin test
Bronchoscopy with transbronchial biopsy
Elevated ACE level
Serum hypercalcemia
Increased uptake on gallium scan
A 28-year-old Caucasian female presents to the emergency department (ED) appearing very anxious. She is accompanied by her boyfriend. She woke up this morning with severe weakness over the right side of her body. The weakness came on all of a sudden, but gradually resolved during the day. She denies any sensory symptoms. Her boyfriend reports that her speech was "weird, almost as if she was stuttering or struggling to get her words out." This too has resolved. The patient denies any other symptoms. The only other history of note is that she returned from a holiday in Italy 2 days ago. Vitals signs are unremarkable. The neurological examination is normal. Her chest x-ray is within normal limits. EKG shows normal sinus rhythm with a rate of 82/min. An urgent head CT scan is within normal limits. Which of the following investigations is most likely to reveal the underlying cause of this episode?
. Carotid Doppler ultrasonography
. MRI head
. Psychiatric referral
. Transthoracic echocardiogram
. Cerebral angiography
A 28-year-old G1P0 woman at 12 weeks’ gestation presents for routine follow-up with her obstetrician. She complains of mild nausea and occasional vomiting, but otherwise is doing well and reports no other symptoms or complications. Her physical examination is unremarkable and fetal ultrasound is normal for gestational age. Laboratory tests show: Free triiodothyronine: 180 ng/dL, Free thyroxine: 2.2 ng/dL, Total thyroxine: 12 μg/dL, Thyroid-stimulating hormone: 0.1 μU/mL(normal: 0.4 – 4 μU/mL). Results of a thyroid-stimulating hormone receptor antibody test are negative. Which of the following best explains these findings?
Acute infectious thyroiditis
Graves’ disease
Hashimoto’s thyroiditis
High serum estrogen concentration
High serum β-human chorionic gonadotropin level
A 28-year-old G2, P 1woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020, Blood: ++, Glucose: negative, Ketones: negative, Protein: negative, Leukocyte esterase: negative, Nitrites: negative. What is the best next step in the management of this patient?
. Cervical cultures
. Shockwave lithotripsy
. Intravenous pyelogram
. Ultrasound of the abdomen
. CT scan of the abdomen and pelvis
A 28-year-old G3P2 woman at 32 weeks gestation comes to the physician because she has felt only 2 or 3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard by Doppler. Which of the following is the most appropriate next step in management of this patient?
. Amniotic fluid index
. Contraction stress test
. Deliver the fetus immediately
. Non-stress test
. Ultrasound for fetal heart tones
A 28-year-old Glo with an IUP at 26 weeks' gestation presents to the emergency department for shortness of breath. She receives regular prenatal care, and her pregnancy has been uncomplicated thus far. She developed shortness of breath suddenly after a long drive in traffic. She has chest pain when she takes a deep breath. Vital sign: BP, 120/80 mm Hg; P, 120 beats/min; R, 24 breaths/min; T, 98.9°F; pulse ox, 89% on room air. Physical examination: general: awake, alert, oriented x3, mild respiratory distress, cardiovascular: S1S2+RRR no m/r/g, lungs: clear to auscultation bilaterally. Abdomen: gravid; fundal height 25 cm; no tenderness, extrimies: 1+ edema bilaterally; no erythema, chest radiography with an abdominal shield is within normal limits. What is the next best step?
. CBC
. CMP
. n-Dimer
. Doppler ultrasonography of the legs
. MRI
A 28-year-old man presents to the ED complaining of constant vague, diffuse epigastric pain. He describes having a poor appetite and feeling nauseated ever since eating sushi last night. His BP is 125/75 mm Hg, HR is 96 beats per minute, temperature is 100.5°F, and his RR is 16 breaths per minute. On examination, his abdomen is soft and moderately tender in the right lower quadrant (RLQ). Laboratory results reveal a WBC of 12,000/ μL. Urinalysis shows 1+ leukocyte esterase. The patient is convinced that this is food poisoning from the sushi and asks for some antacid. Which of the following is the most appropriate next step in management?
. Order a plain radiograph to look for dilated bowel loops
. Administer 40 cc of Maalox and observe for 1 hour
. Send the patient for an abdominal ultrasound
. Order an abdominal CT scan
. Discharge the patient home with ciprofloxacin
A 28-year-old man presents with coughing up blood and sputum. He gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. He has no other past medical history and is a lifetime nonsmoker. On physical examination, there are no oral lesions, heart sounds are normal, and wet inspiratory crackles are heard at the lung bases posteriorly. He also has clubbing of his fingers, but there is no hepatosplenomegaly or any palpable lymph nodes. CXR show fibrosis and pulmonary infiltrates in the right lower lung. Which of the following is the most appropriate initial diagnostic test?
Chest CT scan
Bronchoscopy
Bronchography
Open thoracotomy
Bronchoalveolar lavage
A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, she has had two dilation and curettages (D&Cs), which have failed to resolve her symptoms, and oral contraceptives and antiprostaglandins have not decreased the abnormal bleeding. Which of the following options is most appropriate at this time?
. Perform a hysterectomy
. Perform hysteroscopy
. Perform endometrial ablation
. Treat with a GnRH agonist
. Start the patient on a high-dose progestational agent
A 28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?
. There is nothing to offer this couple
. Offer testing of the parents
. Offer MRI of the fetus
. Offer 2nd trimester amniocentesis
. Offer termination of the pregnancy
A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?
. Complete blood count
. Kleihauer-Betke
. Liver function tests
. Prothrombin time
. Serum potassium
A 28-year-old primigravid woman comes to the physician for a follow-up prenatal visit. According to prenatal records, ultrasound at 16 weeks gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She is now at 40 weeks gestation. Examination shows a fundal height consistent with dates and the cervix is not favorable. Fetal heart tracing is reassuring. She wishes to continue the pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which of the following?
. Polyhydramnios
. Oligohydramnios
. Abruptio placenta
. Placenta previa
. Preeclampsia
A 28-year-old white female presents to the office for the evaluation of goiter. She denies any recent change in appetite or weight, diarrhea, constipation, heat or cold intolerance, dyspnea and hoarseness. Her menses are normal and regular. Examination shows a symmetrically enlarged, non-tender, firm and rubbery thyroid gland. There is no lymphadenopathy. The rest of the physical examination is normal. Laboratory studies reveal an elevated serum TSH level with normal T4 and T3 levels. Serological testing for Hashimoto's thyroiditis is ordered. Which of the following are the most prevalent antibodies in patients with Hashimoto's thyroiditis?
. Anti-thyroid peroxidase antibodies
. Anti-smooth muscle antibodies
. TSH-receptor blocking antibodies
. Thyroid-stimulating immunoglobulins
. Anti-mitochondrial antibodies
A 28-year-old woman comes to the physician for routine physical examination and a Pap smear. She has had multiple sexual partners and uses barrier methods for contraception. She was treated for chlamydial cervicitis four months ago. She has no other medical problems. Pelvic examination is unremarkable and a Pap smear was performed. A week later the result came as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepitheliallesion). Which of the following is the most appropriate next step in management?
. Repeat Pap smear in 2 weeks
. Repeat Pap smear in 12 months
. Reflex HPV testing
. Cone biopsy
. Colposcopy
A 28-year-old woman is admitted for delivery. She began experiencing regular, painful uterine contractions three hours ago and her water broke en route to the hospital. The cervix is 5 cm dilated and 80% effaced. The fetal presentation is vertex and the baby's head is at -1 station. After placing a fetal heart monitor and external tocometer, repetitive decreases in fetal heart rate are noted which begin at the same time as the contractions and end before the contractions have ceased. Which of the following is most likely responsible for the fetal heart pattern?
. Periods of fetal sleep
. Umbilical cord compression
. Fetal head compression
. Uteroplacental insufficiency
. Intrauterine infection
A 28-year-old woman presents 4 weeks after delivering her first child with a low-grade fever and pain in her right breast. She states that she has been breast feeding her newborn infant. Physical examination finds this breast to be tender, swollen, and erythematous. Microscopic examination of nipple smears from this woman would most likely reveal large numbers of which of the following types of cells?
. Adipocytes
. Eosinophils
. Giant cells
. Mast cells
. Neutrophils
A 28-year-old woman presents to your office with symptoms of a urinary tract infection. This is her second infection in 2 months. You treated the last infection with Bactrim DS for 3 days. Her symptoms never really improved. Now she has worsening lower abdominal discomfort, dysuria, and frequency. She has had no fever or flank pain. Physical examination shows only mild suprapubic tenderness. Which of the following is the best next step in the evaluation of this patient?
. Urine culture
. Intravenous pyelogram
. Cystoscopy
. Wet smear
. CT scan of the abdomen with contrast
A 28-year-old woman presents with hematochezia. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. Which of the following is the test of choice in this patient?
. Angiography
. Small-bowel enteroclysis
. CT scan of the abdomen
. Technetium 99m (99mTc) pertechnetate scan
. Small-bowel endoscopy
A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. She does not use tobacco, alcohol or drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard. Which of the following is the next most appropriate step in management?
. Non-stress test
. Biophysical profile
. Contraction stress test
. Ultrasonography
. Deliver the baby immediately
A 29-year-old female is brought to the emergency department due to paraplegia, urinary incontinence and urgency. She denies any trauma. She has a history of trigeminal neuralgia. The neurological examination shows spasticity and hyperreflexia in the lower extremities, and impaired vibration and proprioception in her left forearm. Which of the following is the most likely finding in this patient's cerebrospinal fluid (CSF) examination?
. Oligoclonal bands
. Albumino-cytologic dissociation
. Increased pressure
. Increased cell count
. Increased total protein concentration
A 29-year-old G2P1001 with an IUP at 35 weeks' gestation presents to the ED for vaginal bleeding. The patient states that she woke up in a puddle of blood. She denies abdominal pain. She also denies other medical history, surgical history, and allergies. The patient is taking prenatal vitamins. Fetal movement: Present, Contractions: Absent, Vaginal bleeding: Present, Leakage of fluid: Absent. Physical examination: CVS: Normal, Lungs: Clear bilaterally, Abd: Gravid, nontender, nondistended, +BS, Ext: No edema bilaterally. What is the next step in the management of this patient?
. Transvaginal US
. Abdominal US
. Digital vaginal examination
. Fetal fibronectin level
. CT
A 29-year-old G2P1001 with an IUP at 7 weeks' gestation presents to the emergency department (ED) for vaginal bleeding. She started to have abdominal pain and vaginal bleeding overnight. No clots were expressed per the vagina. She denies any other medical history, surgical history, and allergies. The patient is takingprenatal vitamins. The bleeding started after sexual relations. Vital sign: BP, 120/80 mm Hg; P, 76 beats/min; R, 12 breaths/min; T, 98.6°F. Fetal movement: Negative, contractions: Unsure what the abdominal pain is, vaginal bleeding: Positive, leakage of fluid: Negative. Physical examination: CVS: Normal, Lungs: Normal, abdomen: Soft, nontender, nondistended, +BS, Extrimities: No edema, sterile speculum exam: Cervix closed; blood in vaginal vault. What is the next step?
. Abdominal US
. Beta-human chorionic gonadotropin (BHCG)
. Computed tomography (CT) scan
. RhoGAM
. Discharge home with follow-up as an outpatient
A 29-year-old man is brought to the hospital because he was found running around on the streets with no shoes on in the middle of winter, screaming to everyone that he was going to be elected president. Upon admission to the hospital, he was stabilized on olanzapine and lithium and then discharged home. Assuming the patient is maintained on the olanzapine and the lithium, which of the following tests should be performed at least once per year?
. MRI of the brain
. Liver function tests
. Creatinine level
. Rectal exam to look for the presence of blood in the stool
. ECG
A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?
. Mammography in 1 year
. Ultrasound in 1 year
. Tamoxifen therapy
. Open biopsy
. Mastectomy
A 29-year-old woman presents for her first prenatal visit. She is 10 weeks pregnant as determined by her last menstrual period. She does not have any medical problems and does not take any medications. She is devoutly religious and has been in a monogamous relationship with her husband since getting married 5 years ago. They live in a house built in 1983 where she works as a homemaker. Her husband is an accountant. She does not smoke cigarettes or drink alcohol. Her physical exam is within normal limits. Which of the following screening tests is indicated at this time?
. Rapid plasma reagin test
. Hepatitis C antibody
. Serum lead level
. Red blood cell folic acid level
. Chlamydia PCR
A 29-year-old woman presents with chest pain and exertional dyspnea of 10days duration. Her medical history is significant for a normal spontaneous vaginal delivery three months ago, after which she has had frequent episodes of dark bloody vaginal discharge. The most recent bleeding episode was 6 days ago. The patient denies fever, chills, hemoptysis, orthopnea, or leg pain. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her temperature is 37.7°C (98.9°F), pulse is 80/min, blood pressure is 110/68 mmHg and respirations are 16/min. Examination shows clear lungs. Pelvic examination shows an enlarged uterus. Complete blood count and serum electrolytes are within normal limits. Chest radiographs reveal multiple bilateral infiltrates of various shapes. Which of the following investigations will be most helpful in establishing the diagnosis?
. Ventilation perfusion scan
. Echocardiogram
. Quantitative beta HCG
. Pulmonary function tests
. CT scan of the chest
A 29-year-old woman presents with severe pain during menstruation (dysmenorrhea). During workup, an endometrial biopsy is obtained. The pathology report from this specimen makes the diagnosis of chronic endometritis. Based on this pathology report, which of the following was present in the biopsy sample of the endometrium?
. Neutrophils
. Lymphocytes
. Lymphoid follicles
. Plasma cells
. Decidualized stromal cells
A 3-day-old, full-term baby boy is brought into the emergency department because of feeding intolerance and bilious vomiting. X-rays films show multiple dilated loops of small bowel and a "ground glass" appearance in the lower abdomen. The mother has cystic fibrosis. Which of the following diagnostic tests would also have therapeutic value?
Barium enema
Gastrografin enema
Colonoscopy
Endoscopic retrograde chokngiopancreatogram (ERCP)
Full thickness rectal biopsy
A 3-month old infant is brought to a pediatrician's office because of increased lethargy and irritability. The parents state that the child rolled off the couch and fell on the floor one day prior to presentation. His parents report that the child has been previously healthy and is up to date on his vaccinations. He has been meeting his development milestones. His fontanelles are full. While in office the patient develops a tonic-clonic seizure. Which of the following is the next appropriate step?
. Obtain a head computerized tomography scan
. Perform a retinoscopic examination
. Check serum levels of ammonia
. Administer intravenous benzodiazepines
. Perform a lumbar puncture
A 3-year-old African American boy is brought to the emergency department with sudden onset of difficulty walking. His mother reports that his right hand also seems "clumsy." The boy's past medical history is significant for a hospitalization one year ago for severe upper extremity pain and hand swelling. On physical examination, he has a blood pressure of 90/60 mmHg, heart rate of 120/min, temperature of 36.7°C (98°F), and respiratory rate of 22/min. Which of the following would be most helpful in diagnosing his condition?
Carotid ultrasonography
CBC and reticulocyte count
Antineutrophil cytoplasmic antibodies
Temporal artery biopsy
Lumbar puncture
A 3-year-old boy is admitted for seizure-like activity. He has been a healthy child and has been meeting all development milestones. His immunization schedule is up-to-date. Examination is notable for an erythematous throat and fever. His convulsions require IV administration of a benzodiazepine. Serum analysis reveals a normal white cell count with mild basophilic stippling. The lumbar puncture reveals elevated CSF pressure. Head CT scan is notable for cerebral edema. Which of the following is the next diagnostic step?
Antistreptolysin O titer
Electroencephalography
Protoporphyrin level
Rapid slide (Monospot) test
Spinal fluid culture
A 3-year-old boy is brought to the ER with a two-day history of decreased appetite, neck swelling, and irritability. He keeps his head rotated slightly to the right side. He resists passive flexion of the neck and rotation to the left side. Which of the following is the best next step in managing this patient?
. Direct laryngoscopy
. Soft neck collar
. X-ray of the neck
. Lumbar puncture
. Botulinum toxin injection
A 3-year-old boy of African descent is brought to your office by his stepfather because of easy bruising. He says that the child bruises easily even without trauma. The child started playing games by himself recently. He has a past history of clavicular fracture, which the stepfather attributes to a fall down a set of stairs. The history of the biological father is unknown. On examination, there is a right knee effusion with decreased range of motion, and multiple soft tissue hematomas on the thigh. What is the most appropriate diagnostic step in management?
Contact child protective services
Obtain type 1 collagen assay
Obtain prothrombin time and liver function tests
Obtain factor VIII level
Obtain bleeding time
A 3-year-old child presents to your office for an evaluation of constipation. The mother notes that since birth, and despite frequent use of stool softeners, the child has only about one stool per week. He does not have fecal soiling or diarrhea. He was born at term and without pregnancy complications. The child stayed an extra day in the hospital at birth because he did not pass stool for 48 hours, but has not been in the hospital since. Initial evaluation of this child should include which of the following?
. A child psychiatry evaluation for stool retention and parenting assistance
. A barium enema and rectal manometry
. Plain films of the abdomen
. Dietary log and observation
. Beginning oral antispasmodic medication
A 3-year-old girl is brought to the pediatrician with complaints of abdominal pain and fever. Her mother states that the fever started 2 days ago, with the highest temperature being 39.0 C (102.2 F). She has had no vomiting or diarrhea. The mother states that her daughter has been complaining of pain on urination. On examination, she is tender in her lower abdomen, and there is some right-sided costovertebral angle tenderness. A urinalysis confirms the suspicion of a urinary tract infection. Which of the following would be the most appropriate diagnostic procedure?
Cystoscopy
Dimercaptosuccinic acid (DMSA) scan in 1-2 months
Intravenous pyelogram
Voiding cystourethrogram (VCUG) now
VCUG in 1-2 months
A 3-year-old girl with a ventricular septal defect (VSD) presents to the emergency department after a 15-minute focal seizure of her left arm and leg. A brief history reveals that the child has no known seizure disorder and has been having a low-grade fever at home for about 4 days. She also has been less active and has had poor appetite. On physical examination, her temperature is 40.2 C (104.3 F), and her pulse is 82/min. She is not responsive to her name, but she is responsive to painful stimuli with withdrawal of her extremities. Cardiac examination is significant for a grade 3 systolic murmur best heard at the left lower sternal border. Neurologic examination reveals anisocoria with a dilated right pupil. After stabilization, which of the following is the most appropriate next step in diagnosis?
CT of the brain
ECG
Electroencephalography
MRI of the brain
Complete blood count and blood culture
A 30-hour-old infant has not passed meconium since birth. He was full term with a birth weight of 3856 g (8 lb 8 oz). The pregnancy was uncomplicated. The baby appears well with no respiratory distress. Slight abdominal distention is noted. Rectal examination reveals a slightly tight rectum and results in a greenish gush of stool. Which of the following tests will probably confirm the likely diagnosis?
. A stool culture
. A rectal biopsy
. A barium enema
. An alpha1-antitrypsin level
. A serum TSH level
A 30-year old woman has irregular menses. She reports that her last menstrual period (LMP) was 8 weeks ago. She has been experiencing vaginal spotting and left lower quadrant pain. She is afebrile. She has a normal size uterus and mild tenderness in the right lower quadrant with no rebound tenderness. A human chorionic gonadotropin (hCG) beta-subunit level of 1400 mIU/ml is reported in her records from an obstetrics visit 2 days ago. Which of the following is the appropriate management?
. Perform a pelvis ultrasound
. Perform a culdocentesis
. Repeat hCG measurement in 1 week
. Repeat hCG measurement in 24 hours
. Refer for diagnostic laparoscopy
A 30-year-old black female has a 2-month history of non-productive cough and a painful skin eruption in the lower extremities. She denies fever or weight loss. Physical examination shows several non-tenders raised plaques around the nares and scattered similar plaques around the base of the neck. In the lower extremities she has several erythematous tender non-ulcerated nodules, measuring up to 4 cm in diameter. Chest x-ray reveals bilateral hilar adenopathy and a streaky interstitial density in the right upper lobe. What is the best way to establish a histological diagnosis?
. Punch biopsy of one of the plaques on the neck
. Incisional biopsy of one of the lower extremity nodules
. Sputum studies for AFB and fungi
. Mediastinoscopy and biopsy of one of the hilar or mediastinal nodes
. Serum angiotensin-converting enzyme assay
A 30-year-old female complains of palpitations, fatigue, and insomnia. On physical examination, her extremities are warm and she is tachycardic. There is diffuse thyroid gland enlargement and proptosis. There is thickening of the skin in the pretibial area. Mild clubbing of digits is present. Which of the following laboratory values would you expect in this patient?
. Increased free thyroxine (free T4), increased TSH
. Increased free thyroxine, decreased TSH
. Increased free thyroxine, normal TSH
. Normal free thyroxine, elevated triiodothyronine (T3), normal TSH
. Normal free thyroxine, decreased TSH
A 30-year-old G1P0 with a twin gestation at 25 weeks presents to labor and delivery complaining of irregular uterine contractions and back pain. She reports an increase in the amount of her vaginal discharge, but denies any rupture of membranes. She reports that earlier in the day she had some very light vaginal bleeding, which has now resolved. On arrival to labor and delivery, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 minutes. She is afebrile and her vital signs are all normal. Her gravid uterus is non tender. The nurses call you to evaluate the patient. Which of the following is the most appropriate first step in the valuation of vaginal bleeding in this patient?
. Vaginal examination to determine cervical dilation
. Ultrasound to check placental location
. Urine culture to check for urinary tract infection
. Labs to evaluate for disseminated intravascular coagulopathy
. Apt test to determine if blood is from the fetus
A 30-year-old male comes to the emergency department screaming, "Something blew into my right eye while I was drilling !' He complains of a foreign body sensation in the right eye, photophobia, and excessive lacrimation. Gross examination of the right eye with a penlight after the application of a topical anesthetic is insignificant. What is the best next step in the management of this patient?
. Tonometry
. Fluorescein examination
. Topical antibiotic
. Ultrasonography
. MRI of the orbits
A 30-year-old male presents with right upper quadrant pain. He has been well except for an episode of diarrhea that occurred 4 months ago, just after he returned from a missionary trip to Mexico. He has lost 7 pounds. He is not having diarrhea. His blood pressure is 140/70, pulse 80, and temperature 37.5°C (99.5°F). On physical examination there is right upper-quadrant tenderness without rebound. There is some radiation of the pain to the shoulder. The liver is percussed at 14 cm. There is no lower-quadrant tenderness. Bowel sounds are normal and active. Which of the following is the most appropriate next step in evaluation of the patient?
. Serology and ultrasound
. Stool for ova and parasite
. Blood cultures
. Diagnostic aspirate
. Empiric broad-spectrum antibiotic therapy
A 30-year-old male with sickle cell anemia is admitted with cough, rusty sputum, and a single shaking chill. Physical examination reveals increased tactile fremitus and bronchial breath sounds in the left posterior chest. The patient is able to expectorate a purulent sample. Which of the following best describes the role of sputum Gram stain and culture?
. Sputum Gram stain and culture lack the sensitivity and specificity to be of value in this setting
. If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae
. Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary
. There is no characteristic Gram stain in a patient with pneumococcal pneumonia
. Gram-positive cocci in clusters suggest pneumococcal infection
A 30-year-old man presents to the emergency department with sudden onset of severe epigastric pain and vomiting 3 hours ago. He reports a 6-month history of chronic epigastric pain occurring nearly every day and relieved by antacids. On examination, he appears sweaty and avoids movement. Vital signs reveal a temperature of 100°F, BP of 100/60 mmHg, pulse rate of 110/min, and respiratory rate of 12/min. The remainder of his examination reveals diminished bowel sounds and a markedly tender and rigid abdomen. A chest x-ray and abdominal films reveal pneumoperitoneum. Which of the following is the most appropriate next diagnostic test?
. CT scan
. UGI water-soluble contrast study
. lower GI water-soluble contrast study
. Abdominal ultrasound
. None of the above
A 30-year-old obese woman comes to the physician with a six-month history of oligomenorrhea. She has never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 21; none of which have shown any abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is indicated in the initial workup of this patient?
. Screening mammogram
. Oral glucose tolerance test
. CA-125 levels, annually
. Diagnostic laparoscopy
. Iron studies
A 30-year-old patient with a history of mild persistent asthma (baseline peak expiratory flow rate of 85%) presents to the emergency department with shortness of breath and wheezing that has not relieved by her albuterol inhaler for the past 12 hours. She was able to tolerate pulmonary function tests and a set was performed. Which of the following is the most likely test result?
Decreased FEV1, normal/increased FVC, decreased FEV1: FVC ratio, with post- bronchodilator FEV1 increased by 13%
Decreased residual volume and total lung capacity
Increased FEV1, increased FVC, normal FEV1: FVC ratio
Increased residual volume, increased total lung capacity, increased FEV1
Normal FEV1, decreased FVC, increased FEV1: FVC ratio
A 30-year-old white female presents with an attack of common migraine. This is her fourth attack of migraine over the last 4 months. Her attacks previously responded well to aspirin and ibuprofen; however, her current headache is very severe and not relieved by NSAIDs. She has been trying to conceive for the past 2 months. Six years ago, she was treated with isoniazid due to a positive PPD test. Her father died at the age of 45 from an acute myocardial infarction. Before starting therapy with serotonin agonists (e.g., sumatriptan), which of the following tests should be performed in this patient?
. Liver function tests
. Stress echocardiogram
. PPD and chest x-ray
. Pregnancy test
. Visual field testing
A 30-year-old woman comes to the office due to the recent onset of fever, chills, and dysuria. Her temperature is 38.3°C (101.0°F), blood pressure is 110/70mm Hg, pulse is 68/min, and respirations are 15/min. Examination shows tenderness at the right costovertebral angle. Laboratory studies show WBC count of 16,000/microl with left shift. Urinalysis shows bacteriuria and pyuria. Her urine and blood is collected for culture and sensitivity. She is prescribed oral ciprofloxacin and sent home. After three days, she returns for a follow-up visit. She is still febrile, and the physical examination is unchanged. The blood cultures have no growth after 72 hours of incubation. Results of the urine culture show. Which of the following is the most appropriate next step in management?
. Start intravenous ampicillin and gentamicin
. Start intravenous ciprofloxacin
. Continue oral ciprofloxacin for another 10 days
. Perform renal ultrasound
. Renal CT scan
A 30-year-old woman presents for a physical examination for work. She denies any medical problems or surgeries in the past. She has had no pregnancies. She is sexually active and has been using oral contraceptive pills for the past 6 years. She denies any allergies to medications. On examination, her weight is 62 kg, blood pressure 120/78 mm Hg, pulse 76 beats per minute, respiratory rate 15 breaths per minute, temperature 36.8C (98.4F). Her physical examination is normal. Laboratory evaluation is also done. Which direct effect of birth control pills could be noted in the laboratory results?
. Decreased glucose tolerance
. Decreased binding globulins
. Decreased high-density lipoprotein (HDL) cholesterol
. Decreased triglycerides
. Decreased hemoglobin concentration
A 30-year-old woman presents with a 5-month history of episodic retrosternal pain that radiates to the interscapular region. The pain episodes typically last 15 minutes, and are precipitated by emotional stress and hot or cold food. Her relative gave her sublingual nitroglycerine tablets, which alleviated the pain. Her past medical history is unremarkable, and she does not take any other medications. There is no family history of coronary artery disease. Her vital signs are within normal limits. Physical examination shows no abnormalities. A lipid profile is within normal limits. An EKG shows a normal sinus rhythm. A stress test fails to reproduce the symptoms or to induce ST/T wave changes. Chest x-ray, upper GI endoscopy, and echocardiography show no abnormalities. Which of the following is the most appropriate next step in diagnosis?
. CT scan of the chest with contrast
. Esophageal motility studies (manometric recordings)
. Coronary angiogram
. Acid perfusion (Bernstein) test
. Pulmonary perfusion/ventilation scintigraphy
A 30-year-old woman, gravida 3, para 2, at 26 weeks gestation comes to the physician because of a decrease in fetal movements. She has felt few fetal kicks the past 20 hours. Her prenatal course, prenatal tests and fetal growth have been normal. She has chronic hypertension and is now taking methyldopa and labetalol. Her previous pregnancies were uncomplicated and both delivered vaginally. She does not use tobacco, alcohol or drugs. Fetal heart tones are heard by Doppler. Non-stress test is reactive. Which of the following is the most appropriate next step in management?
. Repeat non-stress test weekly
. Perform contraction stress test
. Biophysical profile
. Give vibroacoustic stimulation
. Deliver the baby immediately
A 3010-g (6.6-lb) boy was born to a 37-year-old primagravida by spontaneous vaginal delivery after an uncomplicated pregnancy. On examination he has cyanotic extremities and a significant right precordial heave, a single S2, and a harsh systolic ejection murmur along the sternal border. He also has a prominent squared nose and cleft palate. An echocardiogram is subsequently performed and demonstrates tetralogy of Fallot. Corrective surgery is performed without complications. At 2 months of age the infant is diagnosed with Pneumocystis jiroveci pneumonia, and at 3 months he is diagnosed with fungal septicemia. Additional work-up of this child should include which of the following tests?
Hemoglobin electrophoresis
Nitroblue tetrazolium
Quantitative immunoglobulin levels
Renal ultrasound
Serum calcium
A 31-year-old man is brought by helicopter to the trauma center after a motor vehicle accident in which he sustained massive lower extremity crush injury. The patient is alert and awake but in tremendous pain. His blood pressure is 140/80 mm Hg, and his pulse is 110/min. There is copious ongoing blood loss from the sites of injury. Urgent laboratory data will most likely show which of the following electrolyte abnormalities?
Hyperkalemia
Hypernatremia
Hypocalcemia
Hypoglycemia
Hypophosphatemia
A 31-year-old man with severe kyphoscoliosis due to cerebral palsy is experiencing worsening shortness of breath with exertion. On examination, he has a severe scoliosis to the left and decreased air entry to that side. His right lung is clear, JVP is 3 cm, and heart sounds are normal. Pulmonary function tests are performed. Which of the following is the most likely abnormality to be seen on the pulmonary function tests?
Increased total lung capacity (TLC)
Increased functional residual capacity (FRC)
Decreased TLC
Increased compliance
Increased vital capacity (VC)
A 31-year-old pregnant woman 6–7 weeks from her last menses comes to the emergency department of your hospital complaining of lower abdominal pain for 3 hours. The pain is diffused in the lower abdomen but worse on the right side. Her serum human chorionic gonadotropin (hCG) concentration is 9600 mIU/mL. Which of the following is the strongest evidence that she has a tubal ectopic pregnancy?
Absence of an extrauterine sac on ultrasonography
Absence of blood on culdocentesis
Absence of a mass on bimanual examination
Absence of an intrauterine sac on ultrasonography
Her hCG concentration
A 31-year-old woman comes to the clinic for a preoperative evaluation. She is undergoing an infertility workup and a laparoscopy is planned. She and her husband have been trying to have a child for the last 5 years, but have not had any success. Over that time period, this woman has suffered three miscarriages. Her past medical history is remarkable for anemia, a history of depression, and a deep venous thrombus suffered during her first pregnancy. Her review of systems reveals diffuse arthralgias, but is otherwise unremarkable. She is currently not taking any medications, though she does report having a drug reaction to prenatal vitamins. Early in pregnancy, she had a red facial rash across her face that spared her nasolabial folds. Physical examination today is unremarkable. Laboratory studies, with the exception of a prothrombin time elevated to two times greater than normal, are unremarkable. Which of the following studies will most likely explain this patient’s laboratory abnormality?
. Assay for cardiolipin antibody
. Blood smear with manual review
. Screening for Factor V Leiden mutation
. Ristocetin cofactor analysis
. Serologic test for syphilis
A 31-year-old woman presents to the emergency department complaining of shortness of breath. She denies associated chest pain or palpitations. She tells you that she recently returned from a trip to Thailand. She smokes one pack of cigarettes per day and drinks alcohol occasionally. She is married and uses oral contraceptives. She has no significant past medical history. On physical examination, her blood pressure is 110/70 mmHg and her heart rate is 120/min. A negative result on which of the following tests would best exclude pulmonary venous thromboembolism in this patient?
. Echocardiography
. Chest x-ray
. Venous ultrasound
. Plasma D-dimer
. Electrocardiogram
A 32-year-old Caucasian female comes to the physician because of a one-week history of fatigue, progressive worsening of shortness of breath and swelling of feet. She denies any chest pain. She has no other medical problems except a recent cold two weeks ago. She is not taking any medication. Her temperature is 36.7°C (98°F), blood pressure is 110/65 mmHg, pulse is 90/min, and respirations are 20/min. Bilateral basal crackles, elevated jugular venous pressure, and 2+ bilateral pitting edema of the ankles are noted. Complete blood count is unremarkable. Transthoracic echocardiogram of her heat will most likely show?
. Concentric hypertrophy of the heart
. Eccentric hypertrophy of the heart
. Mitral stenosis
. Hypokinesia of the inferior wall
. Dilated ventricles with diffuse hypokinesia
A 32-year-old Caucasian female presents to your office with persistent cough and shortness of breath. She has had three episodes of pneumonia over the last year. She had severe sinusitis one year ago, and an episode of bloody diarrhea that required hospitalization and IV antibiotic therapy six months ago. She does not smoke or consume alcohol. She denies any illicit drug use. She is currently not taking any medications. All her immunizations are up-to-date. Her blood pressure is 130/80 mmHg and heart rate is 90/min. Physical examination reveals fine crackles over the right lower lung lobe. No lower extremity edema is present. Neck palpation does not reveal any lymph node enlargement. The chest x-ray shows right lower lobe infiltrates and left upper lobe fibrosis. The ECG reveals non-specific ST segment and T wave changes. What is the best next step in the management of this patient?
. Measurement of serum alpha-1-antitrypsin level
. Methacholine challenge test
. Quantitative measurement of serum lg levels
. Sweat chloride test
. Ventilation/perfusion lung scan
A 32-year-old Caucasian primigravida presents to your office in her 30'" week of pregnancy. On review of systems, she complains of leg swelling and occasional heartburn. She denies abdominal pain or vaginal discharge. She eats a balanced diet and takes folic acid supplements. Her blood pressure is 165/100 mmHg and her heart rate is 90/min. Which of the following additional findings is most likely in this patient?
. Proteinuria
. Ketonuria
. Thrombocytosis
. Splenomegaly
. Fasting hyperglycemia
A 32-year-old female from South America presents with a 3-month history of progressive difficulty with swallowing for both liquids and solids. At night she has a bitter taste in her mouth. Over the past two months, she has had a 10 lb (4.54 kg) weight loss. She has not had any previous illnesses, and does not take any medication. Physical examination is unremarkable. A lateral x-ray film of the chest shows extreme dilatation of the esophagus with an air fluid level. Which of the following is the diagnostic test for this patient's condition?
. Barium swallow
. Endoscopy
. PH monitoring
. Manometry
. CTscan
A 32-year-old female is being evaluated for abnormal uterine bleeding. A urine pregnancy test is negative. Pelvic ultrasound reveals endometrial hyperplasia and a right-sided adnexal mass. In this patient, the adnexal mass is most likely to be a?
. Mucinous cystadenocarcinoma
. Dysgerminoma
. Teratoma
. Granulosa cell tumor
. Fallopian tube cancer
A 32-year-old female is brought to the clinic by her husband because he believes she is a malingerer and is "just being difficult." Sometimes, she appears confused and disoriented. Over the past year, she has complained of visual loss, eye pain and inability to do any household chores. Two months ago, she claimed to have lost control of her bladder. Interestingly, she is "her normal self" when it is time to go for summer trips. The wife insists that she does not understand what is happening to her, and adds that she occasionally loses the ability to move her right hand. The physical examination is basically normal. The patient appears, alert, oriented, and is in no distress. Which of the following is the most appropriate next step in management?
. MRI of the brain
. Lumbar puncture
. Tonometry
. Serum immunoglobulins
. Nerve conduction studies
A 32-year-old male presents to your office with concern about progressive fatigue and lower extremity edema. He has experienced decreased exercise tolerance over the past few months, and occasionally awakens coughing at night. Past medical history is significant for sickle cell anemia and diabetes mellitus. He has had multiple admissions to the hospital secondary to vasoocclusive crises since the age of three. Physical examination reveals a displaced PMI, but is otherwise unremarkable. ECG shows a first degree AV block and low voltage. Chest x-ray shows an enlarged cardiac silhouette with clear lung fields. Which of the following would be the best initial diagnostic approach?
. Order serum iron, iron-binding capacity, and ferritin level
. Order brain-natriuretic peptide (BNP)
. Order CT scan of the chest
. Arrange for placement of a 24-hour ambulatory cardiac monitor
. Arrange for cardiac catheterization
A 32-year-old man is in a high-speed motorcycle collision and presents with an obvious pelvic fracture. On examination, he has a scrotal hematoma and blood at his urethral meatus. Which of the following is the most appropriate next step in his management?
. Placement of a Foley catheter
. Cystoscopy
. CT of the pelvis
. Retrograde urethrogram
. Nephrostomy tube placement
A 32-year-old man is intubated and mechanically ventilated after an opioid drug overdose. The ventilator triggers 12 breaths per minute, each delivering 500 ml of tidal volume at a flow rate of 60 L/min. You perform an inspiratory hold for 2 seconds following delivery of the tidal volume, and the airway pressure is measured to be 30 cm H2O. The measured pressure reflects which of the following?
. Upper airway resistance
. Total airway resistance
. Pulmonary compliance
. Expiratory muscle strength
. End-expiratory pressure
A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?
. Suction evacuation of uterus
. Exploratory laparotomy
. Ultrasound guided aspiration of the mass
. Diagnostic laparoscopy
. Reassurance and follow-up with ultrasonogram
A 32-year-old woman comes to the emergency department complaining of sudden onset shortness of breath accompanied by a non-productive cough and left-sided chest discomfort that increases on inspiration. She denies subjective fever, coughing up blood, wheezing, palpitations, leg pain, and swelling of the lower extremities or any recent travel. Past medical history is significant for an appendectomy at age 15. Her medications include birth control pills and over- the-counter vitamins. She is a known carrier of sickle cell trait. Her father, age 65, has had diabetes for 20 years; mother, age 58, has coronary artery disease. She has never been pregnant, drinks alcohol socially and does not smoke. Her temperature is 99°F (38°C), blood pressure is 110/70 mmHg, pulse 130/min and respirations are 33/min. Pulse oximetry shows an oxygen saturation of 85% on 6 liters of oxygen. Her BMI is 30 kg/m2. She is alert and cooperative without cyanosis or jaundice. Her lungs are clear to auscultation. Her abdomen is soft, nondistended and non-tender. Which of the following is the best test to confirm this patient's diagnosis?
. EKG and cardiac enzymes
. Echocardiogram
. Doppler ultrasound of lower extremities
. Spiral CT-Scan of the chest
. Chest-x ray and sputum cultures
A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your colposcopic impression is of acetowhite changes suggestive of human papilloma virus infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which of the following is the most appropriate next step in the management of this patient?
. Cryotherapy of the cervix
. Laser ablation of the cervix
. Conization of the cervix
. Hysterectomy
. Repeat the Pap smear in 3 to 6 months
A 32-year-old woman presents to the ED with a persistent fever of 101°F over the last 3 days. The patient states that she used to work as a convenience store clerk but was fired 2 weeks ago. Since then, she has been using drugs intravenously daily. Cardiac examination reveals a heart murmur. Her abdomen is soft and nontender with an enlarged spleen. Chest radiograph reveals multiple patchy infiltrates in both lung fields. Laboratory results reveal white blood cells (WBC) 14,000/μL with 91% neutrophils, hematocrit 33%, and platelets 250/μL. An ECG reveals sinus rhythm with first-degree heart block. Which of the following is the most appropriate next step in management?
. Obtain four sets of blood cultures, order a TTE, and start antibiotic treatment
. Order a monospot test and recommend that the patient refrain from vigorous activities for 1 month
. Administer a nonsteroidal anti-inflammatory drug (NSAID) and inform the patient she has pericarditis
. Administer isoniazid (INH) and report the patient to the Department of Health
. Order a Lyme antibody and begin antibiotic therapy
A 33-year-old African-American woman presents with one week of painful skin lesions on her legs. She has no cough, shortness of breath or bowel symptoms, and denies any recent illness or travel. She has no other significant past medical history and does not take any medication. She smokes one pack of cigarettes and drinks one glass of wine daily. She denies a history of sexually transmitted diseases and has been married to a monogamous partner for the past eight years. Her mother was diagnosed with ovarian cancer at age 65. Her temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. On examination, she has multiple tender pink to reddish nodules noted below the knee on the extensor surface, as shown below. Which of the following is the most appropriate next step in her management?
. CT scan of the abdomen
. HIV testing
. Chest x-ray
. Rectal swab for culture
. Colonoscopy
A 33-year-old male was involved in a motor vehicle accident with numerous rib fractures. His course in the hospital was complicated by difficulty with deep breathing and later developed pneumonia. The chest x-ray later confirmed that the patient had developed a parapneumonic effusion. Which one of the following laboratory tests on the pleural fluid is currently thought to be most helpful in determining the need for chest tube placement in parapneumonic effusion?
. Lactate dehydrogenase
. WBC count
. Pleural fluid pH
. Total protein
. Color of the pleural fluid
A 33-year-old woman comes to the emergency department due to a 4-day history of left-sided flank pain, nausea, vomiting, fevers and chills. Her temperature is 39°C (102°F) and blood pressure is 100/60 mm Hg. Examination shows significant left costovertebral angle tenderness. Urinalysis shows positive nitrites, many WBC and bacteria. Laboratory studies show a WBC count of 17,000/cmm with 8% bands. Which of the following is the most appropriate next step in management?
. Intravenous pyelogram
. Intravenous antibiotics
. Blood cultures
. CT scan of the abdomen
. Ultrasound of the abdomen
A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit, for the first time. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?
. Amniocentesis
. Chorionic villus sampling
. Ultrasonogram
. Cordocentesis
. Urinary estradiol levels
A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?
. Chest x-ray every 3 years
. Coronary angiography every 3 years
. Fasting glucose testing every 3 years
. Mammography every 3 years
. Pap testing every 3 years
A 33-year-old woman, otherwise perfectly well, presents with recurrent episodes of hemoptysis. She has no fever, weight loss, cough, or sputum production. Her physical examination is entirely normal. Her CXR, biochemisty, CBC, and coagulation profile are also normal. Which of the following is the most appropriate initial diagnostic test?
Echocardiogram
Gallium scan
CT scan of chest
Bronchoscopy
Pulmonary function tests
A 34-year-old African American man presents with mild dyspnea on exertion and joint discomfort in his knees, wrists, and ankles. He also has a fever and red tender rash on his shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on his legs. CXR shows bilateral symmetric hilar adenopathy. Which of the following laboratory findings is not characteristic of this condition?
Hyperglobulinemia
Elevated ACE level
Elevated sedimentation rate (ESR)
Elevated serum calcium
Normal gallium scan
A 34-year-old Caucasian man presents to your office with a several day history of difficulty walking. He also describes some "funny" sensations in his feet. He denies any recent skin rash, diarrhea, or joint pain. His past medical history is significant only for a recent mild respiratory infection. He visited his friends in Connecticut one month ago. He smokes one pack of cigarettes a day and admits to occasional IV drug use. He is not sexually active. His temperature is 36°C (98°F), heart rate is 90/min, respirations are 20/min, and blood pressure is 160/100 mmHg. Chest examination is unremarkable. Abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Cranial nerves II-XII are intact. Muscle strength is reduced in the lower extremities but well preserved in the upper extremities. Lower extremity sensation is decreased. Stroking the soles of the feet elicits extension of the great toe. Which of the following is most likely to diagnose this patient's condition?
. Electromyography
. CT scan of the brain
. MRI of the spine
. Serologic tests for B. burgdorferi
. Lumbar puncture
A 34-year-old female comes to your office for an infertility evaluation. She has been having irregular menstrual cycles for the past five years, stating that her menstrual periods come on average once every two to three months. Her past medical history is not significant. She is not taking any medications currently. Her blood pressure is 145/96 mmHg and heart rate is 72/min. Her BMI is 33 kg/m2. Physical examination reveals facial acne and excessive hair growth over the upper lip and chin. Which of the following is the most likely pathologic finding in this patient?
. Polycystic kidneys
. Enlarged ovaries
. Pituitary adenoma
. Atrophic adrenals
. Atrophic endometrium
A 34-year-old G2P1 at 31 weeks gestation presents to labor and delivery with complaints of vaginal bleeding earlier in the day that resolved on its own. She denies any leakage of fluid or uterine contractions. She reports good fetal movement. In her last pregnancy, she had a low transverse cesarean delivery for breech presentation at term. She denies any medical problems. Her vital signs are normal and electronic external monitoring reveals a reactive fetal heart rate tracing and no uterine contractions. Which of the following is the most appropriate next step in the management of this patient?
. Send her home, since the bleeding has completely resolved and she is experiencing good fetal movements
. Perform a sterile digital examination
. Perform an amniocentesis to rule out infection
. Perform a sterile speculum examination
. Perform an ultrasound examination
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