USMLE_Basic V

A child is brought to your clinic for a routine examination. She can put on a T-shirt but requires a bit of help dressing otherwise. She can copy a circle well but has difficulty in copying a square. Her speech is understandable and she knows four colors. She balances proudly on each foot for 2 seconds but is unable to hold the stance for 5 seconds. Which of the following is the most likely age of this child?

A college student is tackled while playing football and develops severe knee pain. When examined shortly thereafter, the knee is swollen and the patient has pain on direct palpation over the lateral aspect of the knee. With the knee flexed 30 degrees, passive adduction elicits pain on the same area, and the leg can be adducted further than in the normal contralateral leg (varus stress test). The anterior drawer test, posterior drawer test, and Lachman test are negative. Which of the following is the most likely site of injury?

A couple presents to your office to discuss permanent sterilization. They have three children and are sure they do not want any more. You discuss the risk and benefits of surgical sterilization. Which of the following statements is true regarding surgical sterilizations?

A female infant develops cyanosis. She was delivery vaginally at 43 weeks' gestation, and the amniotic fluid had a greenish color. She has dry, peeling skin, emaciated extremities and long fingernails. Tachypnea, nasal flaring, and sub- and intercostal retractions are observed. Auscultation reveals rales and rhonchi. The chest radiograph reveals flattening of the diaphragm, hyperinflation of the lungs, and patchy opacities diffusely distributed over both lung fields. Arterial blood gases reveal hypoxia and hypercarbia. What is most likely impairing the normal respiratory function of this newborn?

A football player is tackled, and he develops severe knee swelling and pain. On physical examination with the knee flexed at 90 degrees, the leg can be pulled anteriorly, like a drawer being opened. A similar finding can be elicited with the knee flexed at 20 degrees by grasping the thigh with one hand, and pulling the leg with the other. Which of the following is the most likely injured structure?

A full-term infant is brought to the office on her 6th day of life because her mother noted that she looked "yellow". The mother states that the infant is strictly breast-fed and has been eating every 2-3 hours. On examination, she is noted to be jaundiced over her trunk and face. There is no scleral icterus. She is otherwise healthy. Both the mother and baby are Rh positive. Which of the following is the most likely cause of this infant's jaundice?

A healthy 29-year-old gravida 2 woman at 39 weeks has been in labor for 3 hours. She had a positive vaginal-anal culture for GBS at 37 weeks’ gestation. Which one of the following statements is correct?

A husband and wife present to the ED with 1 day of subjective fever, vomiting, watery diarrhea, and abdominal cramps. They were at a restaurant a day before for dinner and both ate the seafood special, which consisted of raw shellfish. In the ED, they are both tachycardic with temperatures of 99.8°F and 99.6°F for him and her, respectively. Which of the following is responsible for the majority of acute episodes of diarrhea?

A long-time patient calls your office to speak with you directly. She voices frustration with your receptionist, who has repeatedly refused to allow her to schedule an appointment to see you. The patient says that at her last visit, she had a heated argument with the receptionist about a minor detail regarding her insurance coverage. When she has called since then, the receptionist always responds by saying, "I'm sorry, but there are too many patients waiting ahead of you." Which of the following defense mechanisms is the receptionist demonstrating?

A maternal fetal medicine specialist is consulted and performs an in-depth sonogram on a 30-year-old G1 at 28 weeks with a twin gestation. The sonogram indicates that the fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. Which of the following would be a finding most likely associated with twin A?

A middle-aged man with symptomatic carotid stenosis underwent a carotid endarterectomy on the right side. The area of significant stenosis extended from die carotid bifurcation up into the internal carotid, requiring a very high dissection and clamping of the vessel. The endarterectomy was done with an in situ shunt and closed with a Dacron patch. In the postoperative period, the patient has persistent difficulty swallowing solids and even more difficulty swallowing liquids. Any attempt to do so results in violent coughing and aspiration. His lips look symmetric and move normally, he speaks in a normal tone of voice without tiring, and he has no trouble breathing. When he is asked to stick his tongue out, he does so without deviation to either side. His symptoms are due to intraoperative damage of which of the following nerves?

A mother brings her 3-year-old son to the pediatrician because he has had 7 days of fever and a painful swollen lymph node in his right groin. This is the boy's sixth episode of lymph node swelling; previous episodes resolved after drainage and prolonged antibiotic therapy. The child also has a past medical history significant for pneumonia at 12 months of age that required chest tube placement for drainage. His maternal uncle died in childhood from recurrent infections. On examination, the boy is at the 5th percentile for both height and weight His temperature is 38.5 c (101.3 F). There is an enlarged, tender lymph node in the right inguinal area with erythema and warmth of the overlying skin. There are several healed incisions in the inguinal regions bilaterally, as well as around the neck from old drainage sites. Laboratory analyses reveal the following: Hematocrit 35%, Platelet count 350,000/mm3, Leukocyte count 17000/mm3, Segmented neutrophils 65%, Bands 10%, Lymphocytes 25%. Gram stain of fluid aspirated from the affected lymph node reveals numerous bacteria-filled segmented neutrophils. Cultures grow S. aureus. What is the most likely mechanism underlying these findings?

A mother brings her daughter into the clinic for a routine health-care visit. On examination, you note that she walks alone, knows two words, throws objects, and comes when called. What is the most likely age of this infant?

A mother brings her infant into the clinic for a routine visit. Examination reveals nothing abnormal. Developmental assessment shows that the infant sits well unsupported, enjoys looking around, babbles, and has a raking grasp. What is the most likely age of this infant?

A mother delivers a neonate with meconium staining and Apgar scores of 3 at 1 and 5 minutes of life. She had no prenatal care and the delivery was by emergency cesarean section for what the obstetricians report as “severe fetal bradycardia.”Which of the following sequelae could be expected to develop in this intubated neonate with respiratory distress?

A neonate born at term is found to have webbed neck and swollen hands and feet. Ultrasonogram of the abdomen shows a horseshoe kidney. Which of the following is the most likely cause of edema?

A neonate is found to have an imperforate anus. As the pediatric surgeon you recommend studies to search for other anomalies. Which of the following is an associated abnormality?

A neonate is noted to have many abnormalities, a number of which are located in the midline. The infant has cleft lip and cleft palate. His eyes are very small and have fissures of the iris, shallow supraorbital ridges, and slanted palpebral fissures. He is deaf, and the ears are low set and malformed. Each hand has six fingers and a simian crease. Which of the following congenital abnormalities of the brain is particularly likely to be present in this infant?

A newborn has a midline defect in the anterior abdominal wall. The parents ask what, if anything, should be done. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?

A newborn infant has respiratory distress and trouble feeding in the nursery. The mother has no significant medical history, but the pregnancy was complicated by decreased fetal movement. On physical examination, you note that aside from shallow respirations and some twitching of the fingers and toes, the infant is not moving, and is very hypotonic. In the mouth there is pooled saliva and you note tongue fasciculations. Deep tendon reflexes are absent. Spinal fluid is normal. Appropriate statements about this condition include which of the following statements?

A newborn infant is brought to the nursery for evaluation after delivery. The mother reports that the pregnancy was uncomplicated, but she had only two prenatal visits. The infant was born via normal spontaneous vaginal delivery and required no resuscitation. The infant has hepatosplenomegaly on examination. While in the hospital, the infant requires treatment for anemia and hyperbilirubinemia. On subsequent examinations, the infant has clear rhinorrhea and ulcerative lesions on his feet. Which of the following congenital infections is most likely in this patient?

A newborn is diagnosed with congenital heart disease. You counsel the family that the incidence of heart disease in future children is which of the following?

A newborn is noted to be quite jaundiced at 3 days of life. Laboratory data demonstrate his total bilirubin to be 17.8 mg/dL (direct bilirubin is 0.3 mg/dL). Which of the following factors is associated with an increased risk of neurologic damage in a jaundiced newborn?

A one-month-old infant is brought to the physician for evaluation. His mother reports that for the past two weeks, he has been crying inconsolably for several hours every evening. His mother has tried multiple methods to calm the infant down, but nothing seems to work. The infant was born full term without complications. He takes two ounces of cow's milk-based formula every two hours and is growing well. His mother reports that he is happy and alert the rest of the day. The child's physical examination is unremarkable. Which of the following is a true statement about the child's condition?

A one-year-old girl is brought to the office for the evaluation of sickle cell anemia. Both her parents have sickle cell trait, and her elder sister has sickle cell anemia. Her vital signs are stable. Her height and weight are appropriate for age. On examination, she appears healthy and normal. Her birth and past medical histories are insignificant. Hemoglobin electrophoresis reveals 40% hemoglobin S. What is the most common presentation of this condition?

A patient has the sudden onset of fretfulness and pain. He curls up with his legs drawn in to his abdomen. Over the next few hours he continued to have episodes of pain and cries with tears, but between these times he acts normally. The patient's mother fears something is terribly wrong and brings him to the hospital. His past medical history was unremarkable. The previous week he had had a cold with a runny nose. His stools had been normal that day. On examination he is quiet and his abdomen is surprisingly soft and normal. In the emergency room there is a semi-soft stool with some blood mixed with mucus. This classic presentation of intussusception is most likely to occur in which of the following age groups?

A patient is receiving external beam radiation for treatment of metastatic endometrial cancer. The treatment field includes the entire pelvis. Which of the following tissues within this radiation field is the most radiosensitive?

A patient presents in labor at term. Clinical pelvimetry is performed. She has an oval-shaped pelvis with the anteroposterior diameter at the pelvic inlet greater than the transverse diameter. The baby is occiput posterior. The patient most likely has what kind of pelvis?

A patient requires both cardiac and renal transplantation. Preparation for the procedures has begun. How do cardiac allografts differ from renal allografts?

A patient sustained third-degree burns on both his arms when his shirt caught on fire while he was lighting the backyard barbecue. The burned areas are dry, white, leathery, anesthetic, and circumferential all around the arms and forearms. Which of the following parameters should be very closely monitored?

A patient was induced for being postterm at 42,5 weeks. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical examination: a small amount of cartilage in the earlobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae. Based on this physical examination, what is the approximate gestational age of this male infant?

A patient who has had angina as well as claudication reports feeling light-headed on exertion, especially when lifting and working with his arms. The subclavian steal syndrome is associated with which of the following hemodynamic abnormalities?

A patient with a solid malignancy discusses chemotherapy with his oncologist. He is interested in the risks of the treatment. What is the primary toxicity of doxorubicin (Adriamycin)?

A patient with colon cancer has a mass in the upper lobe of his left lung 2.5 years following resection of his colon cancer and subsequent 12 months of chemotherapy. His CEA level is rising. Which of the following predicts a 5-year survival rate of greater than 20% following resection of pulmonary metastases?

A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

A pregnant woman has premature rupture of membranes. Her baby is born 3 days later, at 37 weeks' gestation. The 5-minute APGAR score is 4. Lung sounds are reduced, and the infant appears to be in respiratory distress. Peripheral blood smear with differential counts demonstrates a neutrophil count of 30,000/mL, with toxic granules evident in many neutrophils. Gram stain of buffy coat demonstrates small gram-positive cocci in chains. Which of the following is the most likely causative organism?

A premature infant has a difficult delivery with episodes of arrhythmia and suspected hypoxiaischemia. After the delivery, the infant is lethargic and has periods of apnea. Intracranial hemorrhage is suspected. No obvious head trauma is noted. Cranial ultrasound identifies blood within the ventricles. Which of the following structures is the most likely source of the hemorrhage?

A premature neonate with respiratory distress syndrome is maintained on mechanical ventilation in a neonatal intensive care unit. Two weeks after delivery, the nurses in the intensive care unit notice that higher ventilation settings are needed and that more secretions are being suctioned from the endotracheal tube. A chest x-ray film shows questionable new infiltrates. Which of the following is the most likely pathogen?

A previously healthy 25-year-old music teacher develops fever and a rash over her face and chest. The rash is itchy and, on examination, involves multiple papules and vesicles in varying stages of development. One week later, she complains of cough and is found to have an infiltrate on x-ray. Which of the following is the most likely etiology of the infection?

A previously healthy 4-year-old child is brought to the physician for a school physical for kindergarten. His mother has brought in his immunization record and reports that received all his immunizations prior to age 2. He has received only a yearly influenza vaccine since age 2. His physical examination is unremarkable. Which of the following immunizations should he be given during this visit?

A previously healthy 5-year-old girl is brought to the emergency room from a camping trip because her parents are concerned about rabies. This morning, they found a bat in the child's tent. There were no obvious bite marks on the child. Afterwards, the girl helped her father clean animals he had brought back from a hunt, including squirrels, rabbits, and chipmunks. Later, while packing up the campsite, the child was bitten on the arm by a rat. Her encounter with which of the following animals most warrants post-exposure rabies prophylaxis?

A previously healthy 6-year-old girl is brought to the office due to a 10-day history of persistent, thick, nasal discharge, nasal congestion, cough, and intermittent low-grade fever. She has had no vomiting, headache, earache, or rash. Her temperature is 37.2 C (98.9 F), blood pressure is 88/50 mmHg, pulse is 90/min, and respirations are 15/min. Physical examination shows clear tympanic membranes, congested posterior nasopharynx with thick, yellow and purulent mucus, and red, swollen nasal turbinates. Transillumination of the sinuses is equivocal. Palpation of the maxillary sinuses shows mild tenderness. Lungs are clearto auscultation. Which of the following organisms is the most common etiologic agent of this condition?

A previously healthy 60-year-old man is referred for urologic evaluation of macroscopic hematuria. Urinary cytology is positive for malignant cells, and cystoscopic examination reveals an exophytic multifocal tumor. A biopsy of die tumor demonstrates papillary fronds lined by ccfls similar to transitional epithelium but showing nuclear atypia, mitoses, and necrosis. Which of the following is the most important risk factor in the U.S. For the development of this type of tumor?

A previously well 28-year-old female has developed gradual onset of fever and malaise over 2–3 weeks. She also complains of arthralgias and myalgias. Repeated measurement of her temperature reveals a low grade fever between 38°C and 39°C. Physical examination reveals an oval retinal hemorrhage with a clear, pale center; a pansystolic cardiac murmur heard best at the apex; and small, tender nodules on her fingertips. Which of the following is the most likely causative organism?

A primiparous woman whose blood type is O positive gives birth at term to an infant who has A-positive blood and a hematocrit of 55%. A total serum bilirubin level obtained at 36 hours of age is 12 mg/dL. Which of the following additional laboratory findings would be characteristic of ABO hemolytic disease in this infant?

A recent outbreak of severe diarrhea is currently being investigated. Several adolescents developed bloody diarrhea, and one remains hospitalized with acute renal failure. A preliminary investigation has determined that all the affected ate at the same restaurant. The food they consumed was most likely to be which of the following?

A small-for-gestational-age infant is born at 30 weeks’ gestation. At 1 hour of age, his serum glucose is noted to be 20 mg/dL (normally greater than 40 mg/dL). Which of the following is the most likely explanation for hypoglycemia in this infant?

A term boy with Apgar scores of 9 and 9 at 1 and 5 minutes has failed to pass meconium at 72 hours. He has had no episodes of emesis, and his abdomen is only mildly distended to palpation. The patient’s mother reports that her older son had the same problem at birth. A plain radiograph of the abdomen shows a small bowel obstruction with numerous air-filled loops of bowel. The patient is treated with a diatrizoate meglumine (Gastrografin) enema, with good results. Which of the following is the most likely mechanism for this infant’s acute intestinal problem?

A term newborn infant from an uncomplicated pregnancy is being examined. He is pink, except for his extremities, which are blue. His heart rate is 150/min, and his respirations are irregular and slow at 40/min. He coughs on nasal stimulation and has some flexion of the extremities. What is his Apgar score?

A term newborn is delivered vaginally following a breech presentation. On physical examination, the Barlow test is positive for bilateral subluxation of the hips. There is decreased abduction of both hips. Besides breech presentation, which of the following infants are most at risk for developmental dysplasia of the hip?

A two-day old infant develops seizures, bulging fontanel, and focal neurologic signs. His temperature is 37 C (98F), pulse is 180/min, and capillary refill is> 2 seconds. The initial work-up reveals a hemoglobin level of 12g/dl. Transfontanel ultrasonography demonstrates a hemorrhage involving the germinal matrix, lateral ventricles, and brain parenchyma. Which of the following is the most significant risk factor for this newborn's condition?

A wealthy American executive donates five million dollars for the prevention of intrauterine growth restriction in the local county. Spending this money on which of the following programs would prevent the greatest number of cases of fetal growth restriction (FGR) in the population?

A wealthy executive donates five million dollars for the prevention of intrauterine growth restriction in the local county. Spending this money on which of the following programs would prevent the greatest number of cases of fetal growth restriction (FGR) in the population?

A woman gives birth to twins at 38 weeks’ gestation. The first twin weighs 2800 g (6 lb, 3 oz) and has a hematocrit of 70%; the second twin weighs 2100 g (4 lb, 10 oz) and has a hematocrit of 40%. Which of the following statements is correct?

A young woman who has received a transplant has posttransplant fever and malaise. Graft-versus-host disease (GVHD) is diagnosed. This has occurred most commonly with the transplantation of which of the following?

After an uneventful labor and delivery, an infant is born at 32 weeks’ gestation weighing 1500 g (3 lb, 5 oz). Respiratory difficulty develops immediately after birth and increases in intensity thereafter. At 6 hours of age, the child’s respiratory rate is 60 breaths per minute. Examination reveals grunting, intercostal retraction, nasal flaring, and marked cyanosis in room air. Auscultation reveals poor air movement. Physiologic abnormalities compatible with these data include which of the following?

After delivery of a term infant with Apgar scores of 2 at 1 minute and 7 at 5 minutes, you ask that umbilical cord blood be collected for pH. The umbilical arteries carry which of the following?

After reading an article titled: ''The Risk of Cancer in Patients with Diethylstilbestrol (DES) Exposed Mothers", a 23-year old female comes to your office with her mother for assessment of possible risks. Her mother had been given DES while pregnant. Which of the following cancers is this patient most at risk of developing?

After reading an article titled: "The Risk of Cancer in Patients with Diethylstilbestrol (DES) Exposed Mothers", a 23-year old female comes to your office with her mother for assessment of possible risks. Her mother had been given DES while pregnant. Which of the following cancers is this patient most at risk of developing?

An 11-year-old girl has her first menses. Both ovaries contain approximately how many oocytes?

An 18-month-old child presents to the emergency center having had a brief, generalized tonic-clonic seizure. He is now postictal and has a temperature of 40C (104F). During the lumbar puncture (which ultimately proves to be normal), he has a large, watery stool that has both blood and mucus in it. Which of the following is the most likely diagnosis in this patient?

An 18-month-old girl is brought to the hospital with a history of 6 days of bloody diarrhea. She has been drinking well but has not been wetting her diaper. She has been irritable. On physical examination, she has periorbital edema. She appears pale and is tachycardic. Her CBC shows a hemoglobin of 6 g/dL and a platelet count of 100,000/mm3. Her blood urea nitrogen (BUN) is 50 mg/dL and creatinine is 5.5 mg/dL. Her urinalysis shows gross hematuria. Which of the following is the most likely causative organism for her clinical problem?

An 18-month-old male infant is brought to the office by his parents for a follow-up visit. He has a congenital condition that started at the age of 6 months with repeated vomiting and hypotonia, and progressively evolved into choreoathetosis, spasticity and dystonia. Over the past month, he has started biting his hands and arms, pinching himself and banging his limbs against the wall. His family history is unremarkable. On examination, he has several scars, cuts and bruises over his arms and hands. His uric acid levels are elevated. What is the most likely deficient enzyme in this patient?

An 18-month-old male is brought to the hospital because of fever, dyspnea, and productive cough of two days duration. His mother reports that he just recovered from prolonged diarrhea due to Giardia infection. His past medical history is also significant for pneumonia and recurrent ear infections since 6 months of age. On physical examination, his temperature is 38.7°C (101.7°F), pulse is 140/min, and respirations are 40/min. Examination reveals a young child in mild respiratory distress and bronchial breath sounds in the right lower lung lobe. Which of the following is the most likely cause of his recurrent infections?

An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient’s estimated date of delivery?

An 18-year-old man develops fever, neck stiff- ness, and headache. On examination, his blood pressure is 110/80 mm Hg, pulse 100/min, temperature 38.7°C, and neck flexion is very painful. The ears, throat, and sinuses are normal; there are no focal neurologic signs; and the remaining examination is normal. There are no reported similar cases in the community. Which of the following is the most likely causative organism?

An 18-year-old man develops fever, neck stiffness, and headache. On examination, his blood pressure is 105/80 mm Hg, pulse 100/min, temperature 38.7°C, and neck flexion is very painful. The ears, throat, and sinuses are normal; there are no focal neurologic signs, and the remaining examination is normal. His is the second case of meningitis in his university dormitory building. Which of the following is the most likely causative organism?

An 18-year-old man is brought to the emergency room by police after he is found wandering in the street, screaming loudly at passersby. In the emergency room he is placed in an examination room, and paces the floor and pounds his fist against the door repeatedly. Which of the following actions should be taken by the psychiatrist first?

An 8-month-old female infant is brought to the clinic for a well-baby examination. She was born prematurely at 35 weeks gestation. She weighs 2.3kg (5 Ib). She cannot sit unsupported. Physical examination reveals mild facial hypoplasia, epicanthal folds, micrognathia, long nasal philtrum, thin upper lip and short palpebral fissures. Auscultation of the heart reveals an III/ IV harsh holosystolic murmur over the precordium. Her karyotype is normal. What is the most likely cause of these findings?

An 8-month-old previously preterm infant with bronchopulmonary dysplasia presents to the emergency department with lethargy. His regular medications include furosemide and spironolactone. His temperature is 37.4 C (99.3 F), blood pressure is 68/32 mm Hg, pulse is 110/min, and respirations are 10/min. He has poor skin turgor and dry mucous membranes. Laboratory chemistry evaluation reveals: sodium, 131 mEq/L; potassium, 3.0 mEq/L; chloride, 84 mEq/L; bicarbonate, 38 mEq/L; blood urea nitrogen, 36 mg/dL; and creatinine, 0.4 mg/dL. An arterial blood gas shows pH, 7.52; PaCO2: 49 mm Hg; and PaO2: 92 mm Hg. Which of the following is the most likely explanation for these findings?

An 8-year-old boy is brought to the office by his mother for a routine check-up. He has fair skin, blond hair and blue eyes. His past medical history is insignificant. His mother wants to know what the best possible photo-protection is for her son, because "his skin has always been sensitive to the sun, and he is almost unable to tan." He had two episodes of sunburn recently. Physical examination reveals several junctional nevi. Which of the following is the best response to this patient's mother?

An 8-year-old boy is seen in the pediatrician's office for a routine health supervision visit. The mother states that he has Duchenne muscular dystrophy. On examination, he is found to have hip waddle and enlargement of both calves. He is ambulatory, but his muscle strength is diminished symmetrically. Which of the following signs is most consistent with Duchenne muscular dystrophy?

An 8-year-old boy with sickle cell disease presents with left leg pain and a high fever. He has been refusing to walk since yesterday. On physical examination, his temperature is 39.8 C (103.6 F), blood pressure is 122/68 mm Hg, pulse is 102/min, and respirations are 20/min. His left femur is tender to palpation 3 cm above the left knee, and there is marked soft tissue swelling. A plain film of his left leg is normal. A bone scan shows increased uptake around the metaphysis of the left femur. Which of the following is the most likely pathogen?

An 8-year-old girl is being evaluated for short stature. She is at 8th percentile for height and 30th percentile for weight. Vital signs are within normal limits. Examination shows a high arched palate and inverted, widely spaced nipples Karyotyping shows 45 XO. Which of the following is she most at risk of developing?

An 8-year-old immigrant from rural Central America presents with complaints of weakness, facial swelling, muscle pain, and fever. A CBC reveals marked eosinophilia. Which of the following parasites is most likely to be responsible?

An 8-year-old sickle-cell patient arrives at the emergency room (ER) in respiratory distress. Over the previous several days, the child has become progressively tired and pale. The child’s hemoglobin concentration in the ER is 3.1 mg/dL. Which of the following viruses commonly causes such a clinical picture?

An 80-year-old Caucasian female is brought to the emergency room by her son with a three-day history of fever and a foul-smelling, productive cough. Her past medical history is significant for advanced dementia, diabetes, and hypertension. She takes aspirin, metformin, insulin, and atenolol. She was admitted two times with pneumonia during the past two months. Her temperature is 38.3°C (101°F), blood pressure is 100/70mmHg, pulse is 105/min, and respirations are 20/min. The patient is not oriented in time and place. Physical examination reveals dry mucus membranes and decreased skin turgor. Breath sounds are decreased to the right. A chest x-ray revealed right, lower lobe infiltrate. Which of the following is the most important predisposing factor for this condition in this patient?

An 80-year-old female is brought from a nursing home with a two day history of poor oral intake and lethargy. Her past medical history is significant for hypertension, diabetes mellitus, coronary artery disease with coronary stenting two years ago and Alzheimer's disease. She was hospitalized six months ago with pneumonia. Her current medications are aspirin, lisinopril, metoprolol, hydrochlorothia zide, metformin and memantine. Her blood pressure is 95/60 mmHg and heart rate is 90/min. Physical examination reveals fine crackles at the right lung base. Her mucous membranes are dry. Her laboratory findings are significant for WBC of 15,000/mm3, creatinine of 2.1 and BUN of 61 mg/dl. Her creatinine was 0.9 mg/dl during the last admission. Which of the following is the best explanation for the abnormal laboratory findings in this patient?

An 80-year-old man comes to the physician because of a slowly growing ulcerated mass on the glans penis. A biopsy is positive for squamous cell carcinoma. Which of the following conditions is usually present in association with this tumor?

An 82-year-old male presents for evaluation of chronic back pain. On physical examination, he is found to have a blood pressure of 160/85 mmHg while supine and 135/70 mmHg while standing. He is otherwise healthy; his only medicine is occasional ibuprofen for back pain. Which of the following age-related changes best explains the observed finding?

An 84-year-old female is hospitalized with right-sided hemiplegia secondary to an ischemic stroke. She has a complex past medical history including hypertension, diabetes mellitus, hypercholesterolemia and mild Alzheimer disease. Her current medications include lisinopril, metoprolol, insulin glargine, simvastatin and aspirin. On physical examination, her blood pressure is 140/60 mm Hg and her heart rate is 62/min. Her neck is supple and without jugular venous distension. Her lungs are clear to auscultation and her abdomen is soft and non-distended. She cannot move her right arm or right leg. There is a partial thickness ulcer on her right heel. Her wound is most likely the result of which of the following?

An 88-year-old female nursing home resident is brought to the hospital with a one-week history of moaning, decreased oral intake and decreased ambulation. Physical examination reveals a very thin female who is moaning and appears to be in pain. She opens her eyes spontaneously but does not respond to questions. Her blood pressure is 75/43 mmHg, pulse is 105/min, temperature is 35.5°C (96°F), and respirations are 22/min. Oxygen saturation (pulse oximetry) is 97% on room air. Her skin and oral mucosa are dry and her neck veins are flat. There is no lymphadenopathy. On chest auscultation, there are crackles in the right upper lung lobe. Abdomen is soft and non-distended. There is 2+ pitting presacral and lower extremity edema, and a deep pressure ulcer in the sacral area. Laboratory analysis reveals the following: Sodium 155mEq/L, Potassium 5.3 mEq/L, Glucose 88mg/dL, Bicarbonate 14mEq/L, BUN 151mg/dL, Creatinine 3.1mg/dl. Which of the following is the most likely cause of her lower extremity edema?

An adolescent with type 1 diabetes returns for a follow-up visit after his annual checkup last week. You note that his serum glucose is elevated, and his glycosylated hemoglobin (hemoglobin A1C) is 16.7%. This finding suggests poor control of his diabetes over at least which of the following time periods?

An awake, alert infant with a 2-day history of diarrhea presents with a depressed fontanelle, tachycardia, sunken eyes, and the loss of skin elasticity. Which of the following is the correct percentage of dehydration?

An infant can regard his parent’s face, follow to the midline, lift his head from the examining table, smile spontaneously, and respond to a bell. He does not yet regard his own hand, follow past the midline, nor lift his head to a 45° angle off the examining table. Which of the following is the most likely age of the infant?

An infant comes to the office for his 1-year check-up. His father states that he is worried that his son is smaller than he should be. The child's weight is 8.6 kg (19 lb), and his length is 71 cm (28 in). He appears to be growing appropriately on his growth curve. Which of the following is the most appropriate explanation about growth to be given to the father?

An infant in brought to the clinic for a routine healthy visit and vaccinations. She is the product of an uncomplicated pregnancy and has been meeting development mileposts. She is feeding well, and her mother reports that the baby seems to be growing well as well. On physical examination, the infant is afebrile with stable vital signs. She can lift her head to 90 degrees, her eyes follow past the midline, she laughs, regards her own hand and has slight awareness of her mother. Which of the following is the most likely age of this infant?

An infant is born to a woman who has received very little prenatal care. The mother is anxious, complains of heat intolerance and fatigue, and reports that she has not gained much weight despite having an increased appetite. On examination the mother is tachycardic, has a tremor, and has fullness in her neck and in her eyes. The infant is most likely at risk for development of which of the following?

An infant is brought to a hospital because her wet diapers turn black when they are exposed to air. Physical examination is normal. Urine is positive both for reducing substance and when tested with ferric chloride. This disorder is caused by a deficiency of which of the following?

An infant is brought to the office for health maintenance visit. On examination, the infant turns when her name is called. She is able to say "mama." Her mother mentions that she also says "dada" at home. She is able to look for her mother when she gets frightened. She also waves bye-bye to the doctor when the doctor steps out of the examination room. What age of this child is most consistent with these developmental milestones?

An infant is due for her first dose of polio vaccine. Her parents have heard that there are two different types of vaccine for polio. They want to know why their daughter needs to get another shot rather than just taking the oral form of the vaccine. You tell the parents the major advantage of the injectable vaccine is which of the following?

An obese 18-year-old woman is brought to the emergency department by her mother, who noted that she had been lethargic all day, and suffered a brief, seizure-like episode. One month earlier, the patient had been started on medication for type 2 DM. Lactic acid levels are normal. Which of the following medications most likely played a role in the patient’s current presentation?

An otherwise healthy 13-year-old boy has seasonal allergic rhinitis. He complains of excessive rhinorrhea, frequent sneezing, and nasal congestion. He has a nasal voice and breathes with his mouth. He derives some relief from keeping windows closed at home and spending as litde time as possible outdoors in periods of high pollen concentration. However, he is excessively bothered by nasal congestion. Which of the following drugs would be most effective in relieving nasal congestion?

An otherwise healthy 7-year-old girl is brought to your office by her father because she has some acne, breast development, and fine pubic hair. Which of the following is the most likely etiology for her condition?

An ovarian mass removed from a 49-year-old female has yellow coloration of its cut surface. The pathologist describes it as a granulosa-theca cell tumor. Based on this pathology report, the tumor is most likely to secrete?

Approximately 19 days after having had a severe sore throat, a 10-year-old girl is taken to a pediatrician because she is complaining that her arms and legs hurt. The mother reports that before the extremity pain began, the child had a rash with irregular boundaries that lasted about a day. Physical examination demonstrates mild fever, as well as swelling and erythema around several large joints. Laboratory studies show an elevated erythrocyte sedimentation rate, and ECG demonstrates a prolonged PR interval. Which of the following is the most likely explanation for these findings?

As part of your anticipatory guidance to new parents of a healthy new-born, you suggest putting the child in which of the following positions for sleep?

At birth, an infant is noted to have an abnormal neurologic examination. Over the next few weeks he develops severe progressive central nervous system (CNS) degeneration, an enlarged liver and spleen, macroglossia, coarse facial features, and a cherry-red spot in the eye. Which of the following laboratory findings most likely explains this child’s problem?

During routine breast examination of a 28-year-old woman with no significant family or past medical history, a firm 2-cm mass is detected in the patient’s right breast. It is freely mobile and non-tender. Ultrasound reveals a solid, well-circumscribed mass, which is later found to be benign by biopsy. Which of the following statements is true?

During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed. Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient?

During the examination of a 2-month-old infant, you note that the infant’s umbilical cord is still firmly attached. This finding prompts you to suspect which of the following?

During the routine examination of the umbilical cord and placenta after a spontaneous vaginal delivery, you notice that the baby had only one umbilical artery. Which of the following is true regarding the finding of a single umbilical artery?

Five patients present for contraceptive counseling, each requesting that an IUD be inserted. Which of the following is a recognized contraindication to the insertion of an IUD?

In a failed suicide gesture, a depressed student severs her radial nerve at the wrist. Which of the following is her expected disability?

In an amenorrheic patient who has had pituitary ablation for a craniopharyngioma, which of the following regimens is most likely to result in an ovulatory cycle?

In the 2nd week of life, a previously healthy newborn develops diarrhea. The stools are watery and voluminous and continue even when the infant is fasting. Which of the following is the most likely pathogen?

Labor and vaginal delivery occur successfully in a 29-year-old woman after administration of oxytocin (Pitocin) for 9 hours. Spontaneous onset of labor at term is the result of which of the following?

On pelvic examination of a patient in labor at 34 weeks, the patient is noted to be 6 cm dilated, completely effaced with the fetal nose and mouth palpable. The chin is pointing toward the maternal left hip. This is an example of which of the following?

One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. A negative antibody titer is obtained. To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?

Otitis media occurring during the first 8 weeks of life deserves special consideration, because the bacteria responsible for infections during this time may be different from those that affect older infants and children. Which of the following organisms is the most likely to cause otitis media in these infants?

Prolonged unopposed estrogen stimulation in an adult woman increases the risk of development of endometrial hyperplasia and subsequent carcinoma. Which of the following is the most common histologic appearance for this type of cancer?

Routine examination of an otherwise healthy kindergarten child with a history of asthma reveals a BP of 140/90 mmHg. Which of the following is the most likely cause of the hypertension?

The mother and father of a newborn come in for the 2-week check-up. The mother complains of “colic” and asks if she can switch to goat’s milk instead of breast milk. Which of the following should be your main concern about using goat’s milk instead of breast milk or cow’s milk?

The mother of a 4-year-old child takes her daughter to a pediatrician because she is "scratching all the time." Physical examination demonstrates multiple areas of excoriation, which are worst on the shoulders, buttocks, and abdomen. In the areas where the scratching has occurred, scattered tiny red punctate lesions are also seen. Careful examination of the clothing reveals small, ovoid, grayish-white structures attached to threads on the seams. Which of the following is the most likely causative agent?

The parents of a 1-month-old infant bring him to the emergency center in your local hospital for emesis and listlessness. Both of his parents wanted a natural birth, so he was born at home and has not yet been to see a physician. On examination, you find a dehydrated, listless, and irritable infant. Although you don’t have a birth weight, the parents do not feel that he has gained much weight. He has significant jaundice. His abdominal examination is significant for both hepatomegaly and splenomegaly. Laboratory values include a total bilirubin of 15.8 mg/dL and a direct bilirubin of 5.5 mg/dL. His liver function tests are elevated and his serum glucose is 38 mg/dL. Serum ammonia is normal. A urinalysis is negative for glucose, but it has a “mouse-like” odor. These findings are consistent with which of the following conditions?

The parents of a 2-year-old bring her to the emergency center after she had a seizure. Although the parents report she was in a good state of health, the vital signs in the emergency center reveal a temperature of 39C (102.2F). She is now running around the room. Which part of the story would suggest the best outcome in this condition?

The recent suicide of a well-known high school cheerleader in your community has generated an enormous amount of community concern and media coverage. A girl who was close friends with the deceased makes an appointment and comes in to your office to discuss the event with you. You ask, and she denies suicidal ideation, but she has many questions about suicide. Correct statements about adolescent suicide include which of the following?

The shortest distance between the sacral promontory and the symphysis pubis is called which of the following?

The signs and symptoms of meningitis in an infant can be different than those in an adult. Which of the following signs and symptoms of meningitis is more helpful in an adult patient than in a 4-month-old?

The state laboratory calls your office telling you that a newborn infant, now 8 days old, has an elevated thyroid stimulating hormone (TSH), and low thyroxin (T4) on his newborn screen. If this condition is left untreated, the infant is likely to demonstrate which of the following in the first few months of life?

Three hours after a church social, eight people develop severe diarrhea. Other symptoms included nausea, vomiting, and abdominal cramps. Food served included chicken salad and cream-filled pastries. All affected individuals had the chicken salad. Which of the fol- lowing is the most likely causative organism?

Two new mothers are discussing their infants outside the neonatal intensive care unit. Both were born at 36 weeks’ gestation. One infant weighs 2600 g (5 lb, 12 oz) while the other infant weighs 1600 g (3 lb, 8 oz). The mother of the second infant should be told that her child is more likely to have which of the following conditions?

Varicella vaccination is a live virus vaccine. It is generally not recommended in immunocompromised patients. Which of the following is an exception to this rule?

Which of the following patients with primary hyperparathyroidism should undergo parathyroidectomy?

Which of the following pubertal events in girls is not estrogen dependent?

Which of the following statements is true regarding contraception?

While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus. You explain that additional testing is necessary because of the woman’s increased risk of congenital anomalies in which organ system?

While palpating the pulse of a patient, you note that the pulse wave has two peaks. You auscultate the heart and are certain that there is only one heartbeat for each two pulse waves. Which of the following best describes this finding?

While playing with his children, a 44-year-old man falls and lands on his right shoulder. There is immediate pain and deformity. In an uncomplicated dislocation of the glenohumeral joint, the humeral head usually dislocates primarily in which of the following directions?

While working at a bookbinding shop, a young man suffers a traumatic amputation of his index finger. The finger was cleanly severed at its base. The patient and the finger are brought to a first-aid station, from which both are to be transported to a highly specialized medical center for replantation to be done. Which of the following is the correct way to prepare and transport the severed finger?

While working in the newborn nursery, you have the chance to counsel a first time mother. She had a healthy pregnancy and good prenatal care. The infant was delivered via normal spontaneous vaginal delivery and is doing well. You are counseling the mother on the benefits of breastfeeding, and she asks you what the differences are between human milk and formula. Which of the following is a true statement?

You are called to the ER to see one of your patients. The father of this 14-year-old mildly retarded child says that he found the child about 20 minutes ago in the neighbor’s garden shed with an unknown substance in his mouth. The child first had a headache, but then became agitated and confused; while you are talking to the father in the ER the child begins to have a seizure and dysrhythmia on the cardiac monitor. The blood gas demonstrates a severe metabolic acidosis. Which of the following agents is most likely the culprit?

You are called to the nursery to evaluate a newborn infant. The mother is a 24-year-old primigravida. Her pregnancy was complicated by preeclampsia. The infant was delivered at 39-weeks’ gestation via emergent cesarean section due to maternal hypertension and non-reassuring fetal heart tones. On examination, the infant's weight is 2.6 kg (5 lb 11 oz) placing him in the 5th percentile, height is 18 inches (46 em) placing him in the 5th percentile, and head circumference is 13 inches (33 cm) placing him in the 1oth percentile. The infant's head seems large for her body. There is a paucity of subcutaneous fat. The remainder of the physical examination is unremarkable. This infant is at risk for developing which of the following?

You are the internist caring for a 26-year-old male who is stricken with alcoholic gastritis. The man has remained absent from his work as a waiter for several days due to his illness. His employer calls you for more information about the illness and the prognosis. He says that he just spoke with his employee on the phone and was granted permission to talk with you. What is the most appropriate response to this request?

You are working in the ED on a Sunday afternoon when four people present with acute-onset vomiting and crampy abdominal pain. They were all at the same picnic and ate most of the same foods. The vomiting began approximately 4 hours into the picnic. They deny having any diarrhea. You believe they may have “food poisoning” so you place IV lines, administer IV fluids, and observe. Over the next few hours, the patients begin to improve, the vomiting stops, and their abdominal pain resolves. Which of the following is the most likely cause of their presentation?

You ask a patient to call your office during her next menstrual cycle to schedule a hysterosalpingogram as part of her infertility evaluation. Which day of the menstrual cycle is best for performing the hysterosalpingogram?

You have a 32-year-old G1P0 patient who has undergone a routine obstetrical ultrasound screening at 20 weeks of gestation. The patient phones you immediately following the ultrasound because during the procedure the ultrasonographer commented that she noted several small fibroid tumors in the patient’s uterus. As this is the patient’s first pregnancy, she is concerned regarding the possible effects that the fibroid tumors may have on the outcome of her pregnancy. As her obstetrician, which of the following should you tell her?

You have been recently named as the medical director of the normal newborn nursery in your community hospital and have been asked to write standardized admission orders for all pediatricians to follow. Which of the following vaccines will you include on these orders?

You have recommended a postcoital test for your patient as part of her evaluation for infertility. She and her spouse should have sexual intercourse on which day of her menstrual cycle as part of postcoital testing?

You have recommended that your infertility patient return to your office during her next menstrual cycle to have her serum progesterone level checked. Which is the best day of the menstrual cycle to check her progesterone level if you are trying to confirm ovulation?

You suspect that your infertility patient has an inadequate luteal phase. She should undergo an endometrial biopsy on which day of her menstrual cycle?

Your hospital is conducting an ongoing research study involving the hormonal response to trauma. Blood is drawn regularly (with Institutional Review Board [IRB] approval) for various studies. Which of the following values are likely to be seen after a healthy 36-year-old man is hit by a bus and sustains a ruptured spleen and a lacerated small bowel?

Your patient delivers a 7-lb 0-oz male infant at term. On physical examination, the baby has normal-appearing male external genitalia. However, the scrotum is empty. No testes are palpable in the inguinal canals. At 6 months of age the boy’s testes still have not descended. A pelvic ultrasound shows the testes in the pelvis, and there appears to be a uterus present as well. The presence of a uterus in an otherwise phenotypically normal male is owing to which of the following?

Your patient is 43 years old and is concerned that she may be too close to menopause to get pregnant. You recommend that her gonadotropin levels be tested. Which is the best day of the menstrual cycle to check gonadotropin levels in this situation?

Your patient is a healthy 28-year-old G2P1001 at 20 weeks gestational age. Two years ago, she vaginally delivered at term a healthy baby boy weighing 6 lb 8 oz. This pregnancy, she had a prepregnancy weight of 130 lb. She is 5ft 4 in tall. She now weighs 140 lb and is extremely nervous that she is gaining too much weight. She is worried that the baby will be too big and require her to have a cesarean section. What is the best counsel for this patient?

Your sister who lives in another state sends via e-mail photographs of her 6-month-old infant. You note the child has a white reflection from one of his eyes. You hastily assist in arranging an urgent pediatric ophthalmologic evaluation. Your sister immediately accesses the Internet and begins to ask questions of you. Which of the following statements found by your sister is correct?