DES C_ParaClinic (6) Prepared : CHILLY

A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. Which of the following is the most appropriate initial diagnostic evaluation of this patient?
Voiding cystourethrogram
Cystourethroscopy
Plain abdominal radiographs and an intravenous pyelogram (IVP)
Abdominal ultrasound
Urine for cytology
A 70-year-old man with a 50 pack-year history of smoking presents with a 6-week history of intermittent, painless, gross hematuria and urinary frequency. There are no masses palpable on abdominal examination, and rectal examination is normal. Urinalysis confirms the presence of hematuria, and urine culture is negative. The initial diagnostic evaluation does not reveal any abnormalities. Which of the following is the best next step in the diagnostic workup?
A transrectal ultrasound
Re-evaluation in 2–4 weeks, with repeat urinalysis and urine culture
An abdominal CT scan
Cystourethroscopy and urinary cytology
Exploratory laparoscopy
A 70-year-old patient presents to the ER with a 3-hour history of intensive retrosternal chest pain that radiates to the interscapular area. He states that he has never experienced this pain before. His past medical history is significant for a 20-year history of hypertension and a 10-year history of diabetes mellitus, type 2. His current medications include enalapril and hydrochlorothiazide. He does not smoke or consume alcohol. His vital signs are BP 180/110 mmHg in the right arm and 178/110 mmHg in the left arm, PR 85/min and RR 18/min. The physical examination revealed an early decrescendo-type diastolic murmur at the left sternal border. The EKG is normal. Which of the following is the best next step in the management of this patient?
Magnetic resonance imaging
Aortography
Transesophageal echocardiography
CK MB and troponin T levels
Ventilation/perfusion scanning
A 70-year-old woman with a history of hypertension, congestive heart failure, and atrial fibrillation presents to the ED with several hours of acute onset diffuse abdominal pain. She denies any nausea or vomiting. The pain is constant, but she is unable to localize it. She was diagnosed with a renal artery thrombosis several years ago. Vital signs include HR of 95 beats per minute, BP of 110/70 mm Hg, and temperature of 98°F. Her abdomen is soft and mildly tender, despite her reported severe abdominal pain. Her WBC count is 12,000/μL, hematocrit 38%, platelets 250/μL, and lactate 8 mg/dL. The stool is traced heme-positive. You are concerned for acute mesenteric ischemia. What is the best way to diagnose this condition?
Serum lactate levels
CT scan
Abdominal radiograph (supine and upright)
Angiography
Barium contrast study
A 71-year-old man is playing cards with some friends when he starts to feel a pain in the left side of his chest. His fingers in the left hand become numb and he feels short of breath. His wife calls the ambulance and he is brought to the hospital. In the ED, an ECG is performed. Which of the following best describes the order of ECG changes seen in an MI?
ST-segment elevation, Q wave, hyperacute T wave
ST-segment elevation, hyperacute T wave, Q wave
Hyperacute T wave, Q wave, ST-segment elevation
Q wave, ST-segment elevation, hyperacute T wave
Hyperacute T wave, ST-segment elevation, Q wave
A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management?
Full thickness biopsy of the center of the lesion
Full thickness biopsy of the edge of the lesion
Pathologic studies after the entire lesion is resected with a margin of 1 cm of normal skin all around
Scrapings and culture of the ulcer base
Response to a trial of radiation therapy
A 72-year-old male comes to the emergency department (ED) due to a sudden onset of right-sided weakness, aphasia and incontinence. He did not lose consciousness. All his symptoms started suddenly, 1 hour ago. He was previously diagnosed with hyperlipidemia, and is on simvastatin. He is a known smoker and alcoholic. He is taking aspirin as prophylaxis for heart attacks and strokes. His family history is not significant. His blood pressure is 160/88 mm Hg, pulse is 78/min, respirations are 18/min, and temperature is 37.8°C (100°F). He is admitted to the ED, and a patent airway is secured. The cardiac examination and EKG findings are normal. CT of the brain shows no acute hemorrhage. Which of the following interventions will result in the best outcome in this patient?
Nimodipine
Streptokinase and heparin combination
IV nitroprusside to reduce blood pressure
IV high dose corticosteroids
Tissue plasminogen activator within 3 hours
A 72-year-old man undergoes an aortobifemoral graft for symptomatic aortoiliac occlusive disease. The inferior mesenteric artery (IMA) is ligated at its aortic attachment. Twenty-four hours after surgery the patient has abdominal distention, fever, and bloody diarrhea. Which of the following is the most appropriate diagnostic study for this patient?
Aortogram
Computed tomographic (CT) scan
Magnetic resonance imaging (MRI)
Sigmoidoscopy
Barium enema
A 72-year-old man with end stage renal disease secondary to hypertension presents with several months of back pain. He denies fever, weight loss, difficulty walking, altered sensation in his legs, or incontinence. He was diagnosed with renal disease 20 years ago and was managed medically for many years. However, 2 years ago he began hemodialysis because of a progressive decline in renal function. There is no family history of renal disease or malignancy. Physical examination is unremarkable. X-ray of the chest shows ill-defined bands of increased bone density adjacent to the vertebral endplates. What laboratory abnormalities is most likely in this patient?
Bence-Jones protein in urine
Elevated bone-specific alkaline phosphatase
Decreased phosphate
Elevated parathyroid hormone
Decreased parathyroid hormone
A 72-year-old woman presents with pruritus for the past 6 weeks. She is careful to moisturize her skin after her daily shower and uses soap sparingly. She has never had this symptom before. The itching is diffuse and keeps her awake at night. Over this time she has lost 15 lb of weight and has noticed diminished appetite. She has previously been healthy and takes no medications. Physical examination shows no evidence of rash; a few excoriations are present. She appears fatigued and shows mild temporal muscle wasting. The general examination is otherwise unremarkable. What is the best next step in her management?
Oral antihistamines
Skin biopsy at the edge of one of the excoriations
Topical corticosteroids
Psychiatric referral for management of depression
Laboratory testing including CBC, comprehensive metabolic panel, and thyroid studies
A 73-year-old female presents to your office with lower abdominal discomfort. Physical examination reveals an adnexal mass on the right side. This patient is most likely to have elevated levels of which of the following?
CEA
CA 19-9
CA-125
Alpha-fetoprotein
HCG
A 73-year-old man comes to his primary care physician for his yearly check-up. His medical history is significant for obesity, new onset diabetes mellitus, and a remote history of tobacco use. The patient has noticed that his stool has been darker for the past 3 months, although he has only seen gross blood in his stool once, a week ago. He also complains of recent fatigue and occasional light-headedness when standing up from sitting. On examination the patient has fecal occult blood and a hematocrit of 32%. Colonoscopy and upper gastrointestinal endoscopy reveal no obvious pathology. Which of the following is the best diagnostic test to locate this patient’s hemorrhage?
Angiography
Barium enema
Colonoscopy
CT scan with contrast
Tagged RBC scan
A 73-year-old man comes to the physician because of a one-year history of progressively worsening urinary urgency, hesitancy, nocturia, and weak urinary stream. He has no fever, abdominal pain, hematuria, malaise or weight loss. He takes atenolol for essential hypertension. He has no history of diabetes mellitus or ischemic heart disease. He does not use tobacco, alcohol, or drugs. Rectal examination shows a smooth, firm enlargement of the prostate with no induration or asymmetry. Neurological examination shows no abnormalities. Urinalysis shows no abnormalities. Laboratory studies show serum creatinine of 2.1 mg/dl. Which of the following is the most appropriate next step in management?
Ultrasound of kidneys, ureters, and bladder
Treatment with finasteride
Treatment with prazosin
Watchful waiting
Transurethral resection of prostate
A 74-year -old Caucasian man is evaluated for occasional palpitations and poor exercise tolerance. He has been living alone since his wife died two years ago. His diet consists mainly of precooked food that he heats up in the microwave oven. He has a history of degenerative joint disease and hypertension. He takes a daily aspirin, hydrochlorothiazide, and glucosamine. He quit smoking 20 years ago and occasionally drinks alcohol. His peripheral blood smear is shown below. Which of the following substances is most likely elevated in this patient's blood?
Ferritin
Methionine
Haptoglobin
Homocysteine
Cobalamin
A 74-year-old man is brought to hospital because of urinary retention. He has a Foley catheter inserted to relieve the obstruction, and 1500 cc of urine is emptied from his bladder. Over the next few hours, he has 200cc/h of urine output. Which of the following urine electrolyte values is most likely in keeping with his diagnosis?
High sodium
Low potassium
High specific gravity
Low pH
Osmolality > 500 mOsm/kg
A 74-year-old man presents with sudden onset of extremely severe, tearing precordial chest pain that radiates to the back and migrates downward shortly after its onset. As far as the man can tell, there was no precipitating event. He is seen within an hour and is in obvious distress. He is afebrile, but his blood pressure is 220/110 mm Hg and his pulses in the upper extremities are unequal at 102/min. Chest x-ray shows a wide mediastinum. Which of the following could best establish the diagnosis?
ECG and cardiac enzymes
Spiral CT scan or MRI angiogram
Gastrografin swallow, followed by barium if negative
Ventilation-perfusion scan
Pulmonary angiogram
A 74-year-old woman presents to your office complaining of diarrhea and decreased appetite over the past week as well as increasing fatigue and occasional palpitations over the last few days. Her past medical history is significant for chronic atrial fibrillation for which she takes metoprolol, digoxin and warfarin. She smokes cigarettes and has for the past several years. On physical examination, her blood pressure is 140/90 mmHg and her heart rate is 70/min and irregular. Lung auscultation reveals scattered wheezes. Her abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. There is no ankle edema. Her last measured INR was 2.3 two weeks ago. Which of the following is the best initial test in this patient?
Echocardiography
Chest x-ray
Pulmonary function tests
Thyroid function tests
Blood drug level
A 75-year-old G2P2 presents to your gynecology office for a routine examination. She tells you that she does not have an internist and does not remember the last time she had a physical examination. She says she is very healthy and denies taking any medication, including hormone replacement therapy. She has no history of abnormal Pap smears. She is a nonsmoker and has an occasional cocktail with her dinner. She does not have any complaints. In addition, she denies any family history of cancer. The patient tells you that she is a widow and lives alone in an apartment in town. Her grown children have families of their own and live far away. She states that she is self-sufficient and spends her time visiting friends and volunteering at a local museum. Her blood pressure is 140/70 mm Hg. Her height is 5ft 4 in and she weighs 130 lb. Her physical examination is completely normal. Which of the following are the most appropriate screening tests to order for this patient?
Mammogram, colonoscopy, and bone densitometry
Mammogram, colonoscopy, bone densitometry, and TB skin test
Pap smear and mammogram
Pap smear, mammogram, and colonoscopy
Mammogram, colonoscopy, bone densitometry, TB skin test, and auditory testing
A 75-year-old male comes to the office for the evaluation of a two-month history of intermittent right eye visual loss. Each episode is "painless, lasts a few seconds, and feels like a curtain coming over the eye." He denies any other symptoms. He has never had any trauma to his eye, and does not use any medications. His past medical history is significant for hypertension. He quit smoking 20 years ago, but had smoked for 25 years. On examination, the patient is alert and without neurologic findings. His blood work and chest x-ray are normal. What is the best next step in the management of this patient?
CT head
Echocardiography
Duplex study of neck
Lumbar puncture
MRI brain
A 75-year-old man is brought to the emergency department for severe pain in the left flank and back of 1 hour duration. He has a prior history of a myocardial infarction and coronary artery bypass grafting 8 years ago. On examination, he is found to have a BP of 80/50 mmHg, pulse rate of 110/min, respiratory rate of 15/min, and a pulsatile, tenderabdominal mass. He has had two large-bore IV lines placed by the paramedics. He is alert and oriented, and gives consent for surgery. On postoperative day 3, the patient develops dark-colored diarrhea but remains normotensive, on full mechanical ventilation, and is awake. Laboratory analysis reveals normal electrolytes, blood urea nitrogen (BUN), and creatinine; hematocrit of 30; and WBC of 15,000. Which is the most appropriate next step in management?
Stool for C difficile toxin test and institution of metronidazole
Sigmoidoscopy
Air contrast barium enema
CT scan
Abdominal x-rays
A 75-year-old man is found by his internist to have an asymptomatic carotid bruit. Which of the following is the most appropriate next test?
Spiral CT angiography
Magnetic resonance arteriogram (MRA)
Transcranial Doppler studies
Doppler ultrasonography (duplex)
Arch aortogram with selective carotid artery injections
A 75-year-old man with a history of myocardial infarction 2 years ago, peripheral vascular disease with symptoms of claudication after walking half a block, hypertension, and diabetes presents with a large ventral hernia. He wishes to have the hernia repaired. Which of the following is the most appropriate next step in his preoperative workup?
He should undergo an electrocardiogram (ECG)
He should undergo an exercise stress test
He should undergo coronary artery bypass prior to operative repair of his ventral hernia
He should undergo a persantine thallium stress test and echocardiography
His history of a myocardial infarction within 3 years is prohibitive for elective surgery. No further testing is necessary
A 75-year-old woman comes to the emergency department with complaints of nausea and nonbilious, nonbloody vomiting over the past 4 days. The patient reports that both the nausea and vomiting come in “waves”; that is, several hours will pass during which she feels well before the vomiting suddenly recurs. A detailed history reveals that the woman was told several months ago that she “has stones in her gall-bladder,” but she has been too frightened to undergo surgery. She has not had a bowel movement for 7 days. Her temperature is 38.4°C (101.1°F) and the abdomen is distended with high-pitched bowel sounds. Which of the following is the most appropriate initial test for a patient with suspected gallstone ileus?
Diagnostic laparoscopy
Hepatic iminodiacetic acid scan
Abdominal ultrasound
Plain X-ray of the abdomen
Endoscopic retrograde cholangiopancreatography
A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?
Hormone replacement therapy
Oral contraceptive pill
Hysteroscopy
Laparoscopy
Hysterectomy
A 75-year-old woman comes to the physician complaining of vulvar itch that has been worsening for the past 2 years. She has had no bleeding from the vagina since she underwent menopause at the age of 52. She smokes five cigarettes per day. On physical examination she has a raised, pigmented lesion on the right labia majora. The rest of her physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?
Prescribe an antibiotic
Prescribe an antifungal
Prescribe steroid cream
Refer to psychiatry
Biopsy the lesion
A 75-year-old woman is brought to the emergency department from a nursing home for abdominal pain, distention, and obstipation over the last 2 days. Past history is pertinent for stroke, diabetes, atrial fibrillation, and chronic constipation. Examination reveals a temperature of 98.6°F, pulse rate 90/min and irregularly irregular, and BP 160/90 mmHg. Heart examination reveals irregularly irregular rhythm with no murmurs; lung examination reveals few bibasilar rales; and abdominal examination reveals a distended, tympanic abdomen with mild tenderness and no rebound tenderness. Plain abdominal x-rays reveal dilated loops of bowel, and a barium enema is obtained and shown in Figure 6-9. Which of the following is the most appropriate next step in management following NG tube decompression and resuscitation?
Urgent sigmoid resection
Nonoperative reduction by passage of well-lubricated rectal tube
Proximal colostomy
Nonoperative reduction by proctoscopy and rectal tube
Urgent operative detorsion
A 76-year-old Caucasian female is brought to the hospital with a one-hour history of confusion. Her husband says that she started to complain of occipital headaches two hours ago and took some acetaminophen; an hour later, he found her confused on the couch and called an ambulance. She has no recent history of fever, chills, ear pain, or upper respiratory infection. Her past medical history is significant for coronary artery disease, diabetes mellitus, hypertension and atrial fibrillation. She had triple vessel coronary artery bypass five years ago. Her current medications include warfarin, metoprolol, diltiazem and lisinopril, plus 25 units of long-acting insulin at bedtime. She lives with her husband and is independent in her activities of daily living. On examination, her blood pressure is 160/90 mmHg and her heart rate is 80/min and irregular. She is unable to follow simple commands or speak. She moves all four extremities. Deep tendon reflexes are symmetric and Babinski reflexes are downgoing bilaterally. Which of the following is the best next step in evaluating this patient?
Brain MRI
Electroencephalogram
CT scan of the head without contrast
Nerve conduction studies
Lumbar puncture
A 76-year-old male with a history of mild dementia, hypertension and diabetes mellitus is brought to the emergency department by his daughter because of two days of confusion, disorientation and decreased oral intake. She says that he has been talking to people who are not there and wandering around the house in the middle of the night. His current medications are metoprolol, valsartan and metformin. On physical examination, his blood pressure is 100/60 mmHg and his heart rate is 70/min. Which of the following initial evaluations is most important for this patient?
Complete blood count and iron studies
Serum electrolytes and urinalysis
CT scan of the head
Brain MRI
EKG and serum troponin T level
A 76-year-old man is admitted to the coronary care unit after an episode of substernal chest pain. His other medical problems include hypertension, hyperlipidemia, and type 2 diabetes mellitus. He has a history of a diverticular bleed 2 years ago. After initial workup, cardiac catheterization is performed and shows 50% left main coronary artery stenosis, 90% proximal left anterior descending artery stenosis, and 65% right coronary artery stenosis. Antiplatelet agents are stopped, and the patient is continued on a heparin drip in preparation for coronary artery bypass surgery the next day. Five hours after the catheterization, his blood pressure is 75/60 mm Hg and pulse is 120/min and regular. He complains of some generalized weakness and back pain but denies chest pain, shortness of breath, nausea, and abdominal discomfort. He appears to be diaphoretic and clammy. Neck veins are flat. Heart sounds are normal, and the chest is clear to auscultation. The groin site for arterial puncture is mildly tender, without subcutaneous hematoma. He receives 1000 ml of normal saline, with symptomatic improvement. His blood pressure is 96/60 mm Hg and pulse is 85/min. His ECG seems to be unchanged. Which of the following is the most appropriate next step in managing this patient?
Obtain a CT scan of the chest with contrast
Proceed to immediate coronary artery bypass surgery
Obtain a CT scan of the abdomen and pelvis without contrast
Place a nasogastric tube
Resume antiplatelet agents
A 76-year-old man with multi-infarct dementia is brought to the emergency department because of lethargy. For the past 6 months, he has had difficulties with feeding and occasionally regurgitates undigested food. In recent days, his condition has deteriorated, and he has become lethargic. He has a history of hypertension for 15 years, chronic atrial fibrillation for 7 years, dementia for 5 years, and frequent respiratory tract infections for the past year. His temperature is 37.8°C (101.5°F), blood pressure is 150/95 mm Hg, pulse is 120/min, and respirations are 26/min. Physical examination shows foul-smelling breath; there is a fluctuating mass in the left side of his neck. Auscultation shows crackles in the right lung base. An x-ray film of the chest shows multiple infiltrates without cavitation in the right lower lung field. The patient is admitted, sputum and blood cultures are sent, and antibiotics are started. Which of the following is the most appropriate next step in management?
Puncture of the neck mass
Esophagoscopy
Esophagography
Bronchoscopy
CT of the neck
A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize. Which of the following is the most appropriate next step in management?
Vaginal Pap smear
Vulvar punch biopsy
Radical vulvectomy
Estrogen cream
Wet mount smear
A 77-year-old man becomes "senile" over a period of 3 or 4 weeks. He used to be active and managed all of his financial affairs. Now, he stares at the wall, barely talks, and sleeps most of the day. His daughter recalls that he fell from a horse about a week before the mental changes began. Which of the following would a CT scan of his head most likely show?
Chronic epidural hematoma
Frontal lobe infarction
Chronic subdural hematoma
Diffuse intracerebral bleeding
Generalized, severe brain atrophy
A 77-year-old woman comes to the emergency department because of feeling “light-headed and dizzy.” Except for the irregular pulse, her physical examination is normal. What is the rhythm in the lead tracing shown in Fig.?
First-degree heart block
Third-degree heart block
Premature ventricular beats
Premature atrial beats
Second-degree heart block
A 78-year-old man is seen in the doctor’s office for a nonproductive cough, 9-kg (20-lb) unintentional weight loss, and bilateral breast enlargement, all occurring within the past 6 months. He has smoked two packs per day for the past 40 years. His past medical history is otherwise unremarkable, and he takes no medications. His temperature is 36.7°C (98.1°F), blood pressure is 125/85 mm Hg, pulse is 68/ min and regular, respiratory rate is 15/min, and oxygen saturation is 99% on room air. There are crackles at the left lower lung field and a ridge of symmetric glandular tissue (1 cm in diameter) around the nipple-areolar complexes of both breasts. Complete blood cell count shows a WBC count of 6000/mm³ hemoglobin of 14.7 g/dL, and platelet count of 210,000/ mm³. All other laboratory results are normal. X-ray of the chest shows a focal 5-cm mass lesion in the left lower lung corroborated by CT scan. Which of the following is most likely histologic type of lung cancer present in this patient?
Adenocarcinoma
Large cell carcinoma
Small cell carcinoma
Squamous cell carcinoma
Bronchoalveolar cell carcinoma
A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6°C (97.9°F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min, and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents and bile but no blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again from the rectum. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?
Upper gastrointestinal endoscopy
Capsule endoscopy
Barium enema
Labeled erythrocyte scintigraphy
Laparotomy
A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6C (97.9F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents without blood. His bleeding stopped a few hours after dmission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again, and he is now hypotensive with a BP of 100/70 mm Hg. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?
Upper gastrointestinal endoscopy
Capsule endoscopy
Barium enema
Labeled .erythrocyte scintigraphy
Laparotomy
A 9-month-old child comes in for a routine visit. She has had several episodes of otitis media in the past, but no major illnesses or hospitalizations. Her mother is concerned because the child was previously happy and social around other people, but now cries if her mother is not in the room. The child constantly wants to be held by her mother and becomes upset if her mother walks into the next room. Her grandmother keeps her during the day, and she now cries when her mother leaves her in the morning. Developmentally, she is crawling and waves bye-bye. She does not yet respond to her name or say words. She previously babbled but stopped several months ago. When you hide a toy with your hand, she lifts your hand to look for the toy. Which of the following is the best next step in the management of this child?
Psychological evaluation
Audiology evaluation
Reassure the mother that the child's development is normal
Physical therapy evaluation
Social services referral
A 9-month-old infant is brought to the pediatrician's office because his weight is persistently below the 10th percentile. His mother states that the infant seems to be hungry all the time and usually consumes 8-12 oz of formula every 2-3 hours in addition to some table food. He also has frequent, bulky, and malodorous stools. A malabsorption syndrome is suspected. The results of which of the following tests will most likely be abnormal?
Abdominal radiography
Stool culture for Clostridium difficile toxins
Fecal fat quantification
Serum albumin
Stool smear for leukocytes and eosinophils
A 9-year-old girl is brought to the clinic with complaints of fatigue, abdominal pain and low grade fever. Four days ago her mother noticed a red rash on the tops of her daughter's feet, which has now spread to her thighs and buttocks. The rash was initially small red dots, but has now become patches. Her daughter subsequently developed periumbilical, cramping, abdominal pain. Review of systems is positive only for a respiratory viral illness three weeks ago. Her temperature is 37.7 C (99.8 F), pulse is 96/min, and respirations are 18/min. Abdominal examination is remarkable for tenderness to palpation near the umbilicus, but the abdomen is otherwise soft, with no rebound or guarding, and no organomegaly. Raised, palpable purpuric lesions are present on the buttocks and thighs. The ankles are tender and edematous bilaterally. Complete blood count reveals a leukocyte count of 9,000/mm3. Her hemoglobin 12. 6 g/dL, and platelets are 325,000/mm3. Serum electrolytes are normal. Which of the following is her urinalysis most likely to reveal?
Elevated levels of copper
Glucosuria
Red blood cells
White blood cell casts
Yeast
A car is involved in a head-on collision. The driver, who is sober and wearing his seat belt, explains that he clearly saw his drunk, unrestrained front seat passenger hit the windshield with his face and the dashboard with his knees. Examination of the passenger indeed shows multiple facial lacerations, but because of his intoxication he cannot explain where else he might be hurting. He is neurologically intact, and his cervical spine x-ray films are normal. Additional injury, representing a potential orthopedic emergency, is not obvious but is suspected. Therefore, an x-ray film of which of the following areas should most likely be obtained?
Both patellas
Both hips
The jaw
The lumbar spine
The skull
A Caucasian couple presents to your office for infertility evaluation. They are unable to conceive after 14 months of unprotected sex. The woman is 23 years of age. Her menstrual periods are regular, occurring every 26 days. She denies perimenstrual pain or pelvic discomfort. Her last menstrual period was six days ago. Her past medical history is insignificant, and bimanual examination is normal. The man is 27 years old. He is not taking any medications. Physical examination, including external genitals, is normal. What is the best next step in the management of this couple?
Serum progesterone level
Semen analysis
Hysterosalpingography
Serum prolactin level of the woman
Laparoscopy
A concerned mother brings her 2-month-old daughter to the clinic because of constipation. The mother had appropriate prenatal care but decided to deliver her child at home with the help of a midwife. The child has not received any medical attention since birth. Examination reveals jaundice, an umbilical hernia, and poor muscle tone. Which of the following is the most appropriate diagnostic study?
Alpha-1-antitrypsin genotyping
Measurements of T4 and TSH
Liver and spleen scan
Barium swallow
RPR and FTA for syphilis
A couple presents for evaluation of primary infertility. The evaluation of the woman is completely normal. The husband is found to have a left varicocele. If the husband’s varicocele is the cause of the couple’s infertility, what would you expect to see when evaluating the husband’s semen analysis?
Increased sperm count with an increase in the number of abnormal forms
Increased sperm count with absent motility
Decreased sperm count with an increase in motility
Azoospermia
Decreased sperm count with an increase in the number of abnormal forms
A father brings his 3-year-old daughter to the emergency center after noting her to be pale and tired and with a subjective fever for several days. Her past history is significant for an upper respiratory infection 4 weeks prior, but she had been otherwise healthy. The father denies emesis or diarrhea, but does report his daughter has had leg pain over the previous week, waking her from sleep. He also reports that she has been bleeding from her gums after brushing her teeth. Examination reveals a listless pale child. She has diffuse lymphadenopathy with splenomegaly but no hepatomegaly. She has a few petechiae scattered across her face and abdomen and is mildly tender over her shins, but does not have associated erythema or joint swelling. A CBC reveals a leukocyte count of 8,000/µL with a hemoglobin of 4 g/dL and a platelet count of 7,000/µL. The automated differential reports an elevated number of atypical lymphocytes. Which of the following diagnostic studies is the most appropriate next step in the management of this child?
Epstein-Barr virus titers
Antiplatelet antibody assay
Serum haptoglobin
Reticulocyte count
Bone marrow biopsy
A father brings his 7-year-old boy to the office because "his eyes are getting yellow". The boy has no other complaints. However, he is feeling tired and does not feel like going to the next Steelers game. There is a history of diabetes and lung cancer in the family. His vitals are stable, but he has pallor, jaundice, and splenomegaly. His labs revel: WBC 10,000/cmm, Hemoglobin 10 gm/dl, Hematocrit 28%, RBC count 3.5 million, Platelets 240,000/cmm, Reticulocyte count 4%. RBC indices were as follows:MCV 90 fl, MCHC 38%, MCH 28 pg. Peripheral smear revealed anisocytosis, some spherocytosis, and polychromatophilia. Coomb's test was negative. LFTs showed: Albumin 5.2 g/dl, AST 47U/L, ALT 52U/L, Alkaline phosphatase 120 U/L, Total bilirubin 3.0 mg/dl, Direct bilirubin 0.2 mg/dl. What is the next step?
Bone marrow biopsy
Osmotic fragility test
Sugar water test
Hemoglobin electrophoresis
Serum B 12 level
A four-week-old male infant is brought to the emergency department because of persistent vomiting immediately after feeding for the past several days. Examination shows an emaciated infant with dry mucus membranes. An olive-shaped mass is palpated in the right upper quadrant of the abdomen. Which of the following acid-base abnormalities is most likely in this patient? pH, PaCO2 (mm Hg), HCO3-(mEq/L)
7.10, 80, 24
740, 40, 24
7.55, 46, 42
7.62, 21, 21
7.62, 30, 30
A full-term infant is born after a normal pregnancy; delivery, however, is complicated by marginal placental separation. At 12 hours of age, the child, although appearing to be in good health, passes a bloody meconium stool. For determining the cause of the bleeding, which of the following diagnostic procedures should be performed first?
A barium enema
An Apt test
A platelet count, prothrombin time, and partial thromboplastin time
Gastric lavage with normal saline
An upper gastrointestinal series
A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?
Ultrasound of the hips
Ultrasound of the spinal cord
Reassurance
X-ray of the hips
X-ray of the lumbosacral regio
A healthy 20-year-old G1P0 presents for her first OB visit at 10 weeks gestational age. She denies any significant medical history both personally and in her family. Which of the following tests is not part of the recommended first trimester blood testing for this patient?
Complete blood count (CBC)
Hepatitis B surface antigen
Screening for human immunodeficiency virus (HIV)
Blood type and screen
One-hour glucose challenge testing
A healthy, 32-year-old, primigravid woman at 12 weeks of gestation comes to the physician for a routine prenatal visit. She has no complaints. She does not use tobacco or alcohol. She has blood group O, Rh(O)+, and her husband has blood group AB, Rh(O)+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. Although the child will have a different blood group from the patient, alloimmunization is of little concern due to which of the following?
Antibodies to ABO antigens cause mild disease in most newborns
Antibodies to ABO antigens are not hemolytic
The mother is tolerant to the child's ABO antigens
Immune response is depressed in pregnancy
ABO antigens are weakly antigenic
A hypertensive 47-year-old man is proposed for kidney transplantation. He is anemic but is otherwise functional. Which of the following would preclude renal transplantation?
Positive cross-match
Blood pressure of 180/100 mm Hg
Donor blood type O
Two-antigen HLA match with donor
Hemoglobin level of 8.2 g/dL
A male infant born at term is found to have bilateral colobomas, choanal atresia, ear anomalies, and cryptorchidism. There is no history maternal drug or alcohol abuse during pregnancy. There is no family history of similar congenital defects. Which of the following is the most appropriate initial test to exclude any associated abnormalities?
Barium swallow
Echocardiography
Fiberoptic bronchoscopy
Renal ultrasonography
Skeletal survey
A middle-aged homeless man is brought to the ER by EMS for altered mental status, seizures, and vomiting. On physical examination he has no fever, neck stiffness, or evidence of head trauma. He does, however, have multiple dental caries and a focal neurologic deficit. Which of the following is the best next step in the patient’s workup?
Placement of ventriculoperitoneal shunt
Placement of ICP monitor
Contrast-enhanced head CT
Noncontrast head CT
Lumbar puncture
A middle-aged woman presents with a variety of cognitive and somatic symptoms, fatigue, and memory loss. She denies feeling sad, but her family physician is aware of this patient’s lifelong inability to identify and express feelings. He suspects she is depressed. Which of the following results is most likely to confirm a diagnosis of depression?
Diffuse cortical atrophy on CAT scan
Prolonged REM sleep latency in a sleep study
Reduced metabolic activity and blood flow in both frontal lobes on PET scan
Atrophy of the caudate on MRI
Subcortical infarcts on MRI
A neonate is markedly edematous and dies 1 hour after birth. A diagnosis of hydrops fetalis is made after the hematocrit on cord blood is demonstrated to be 5%. The erythrocytes in a smear from the cord blood are markedly hypochromatic. The mother is Rh positive and is known to have alpha-thalassemia trait. The thalassemia status of the father is unknown. Alpha-thalassemia is the suspected cause of the infant's hydrops. Which of the following hemoglobins would most likely be markedly elevated in this infant's blood if this diagnosis were correct?
HbBarts
HbC
HbGlower2
HbH
HbS
A neonate is noted to have aniridia of the right eye on physical examination. He was born by spontaneous vaginal delivery after an uncomplicated full-term pregnancy. The remainder of the physical examination is normal. Which of the following is the most appropriate next step before the infant is released from the hospital?
An abdominal ultrasound
A neurology consult
An echocardiogram
A rapid plasmin reagin (RPR) test
TV antibiotics
A nurse notices that a 1-week-old, premature infant in the neonatal unit is experiencing migratory jerks of the extremities. She picks the infant up and can feel that the muscle jerks are continuing to happen, even when she holds an involved extremity still. After about 5 minutes, the jerking movements stop. Which of the following is the most appropriate first step in diagnosis?
CT scan of head
EEG
Serum chemistries
Skull x-rays
Ultrasound of head
A one-month-old infant is born with craniofacial anomalies. Further evaluation reveals a cognitive impairment, a 22q 11 microdeletion in his chromosomes, and a heart condition with a right-to-left shunt. The infant subsequently undergoes heart surgery. The surgeon notes that the patient's thymus is absent. The anesthesiologist observes prolonged QT intervals in the patient's ECG. What is the most important parameter that should be monitored throughout this surgery?
Lymphocyte count
Platelet count
Calcium levels
Potassium levels
Coagulation parameters
A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time?
No action is needed because the patient is asymptomatic, has not missed her period, and cannot be pregnant
Perform a bimanual pelvic examination to assess uterine size
Perform an abdominal ultrasound
Listen for fetal heart tones by Doppler equipment
Order a serum quantitative pregnancy test
A patient in your practice calls you in a panic because her 14-year-old daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5ft 4in tall and weighs 95 lb. Which of the following blood tests is not indicated in the evaluation of this patient?
BHCG
Bleeding time
CBC
Type and screen
Estradiol level
A patient is brought to the ER after a motor vehicle accident. He is unconscious and has a deep scalp laceration and one dilated pupil. His heart rate is 120 beats per minute, blood pressure is 80/40 mm Hg, and respiratory rate is 35 breaths per minute. Despite rapid administration of 2 L normal saline, the patient’s vital signs do not change significantly. Which of the following is the most appropriate next step in the workup of his hypotension?
Neurosurgical consultation for emergent craniotomy for suspected subdural hematoma
Emergent burr hole drainage at the bedside for suspected epidural hematoma
Neurosurgical consultation for emergent ventriculostomy to manage his intracranial pressure
Administration of mannitol and hyperventilation to treat his elevated intracranial pressure
Abdominal ultrasound (focused assessment with sonography in trauma [FAST])
A patient is seen on the first postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. Her estimated blood loss was 500 mL. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are temperature 38.2C (100.8F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 to 9.8, her white blood cell count is 9.5, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL. What is next best step in the management of this patient?
Order chest x-ray
Start intravenous antibiotics
Order intravenous pyelogram
Order renal ultrasound
Transfuse two units of packed red blood cells
A patient presents for her first initial OB visit after performing a home pregnancy test and gives a last menstrual period of about 8 weeks ago. She says she is not entirely sure of her dates, however, because she has a long history of irregular menses. Which of the following is the most accurate way of dating the pregnancy?
Determination of progesterone level along with serum HCG level
Quantification of a serum estradiol level
Crown-rump length on abdominal or vaginal ultrasound
Quantitative serum human chorionic gonadotropin (HCG) level
Determination of uterine size on pelvic examination
A patient presents to you for evaluation of infertility. She is 26 years old and has never been pregnant. She and her husband have been trying to get pregnant for 2 years. Her husband had a semen analysis and was told that everything was normal. The patient has a history of endometriosis diagnosed by laparoscopy at age 17. At the time she was having severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few small implants of endometriosis on her ovaries and fallopian tubes and several others in the posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several subcentimeter serosal fibroids. You have recommended that she have a hysterosalpingogram as part of her evaluation for infertility. Which of the patient’s following conditions can be diagnosed with a hysterosalpingogram?
Endometriosis
Hydrosalpinx
Subserous fibroids
Minimal pelvic adhesions
Ovarian cyst
A patient with benign prostatic hyperplasia has moderately severe symptoms and is started on finasteride. After six months of treatment with finasteride, his symptoms improve remarkably and his prostate has regressed in size. Which of the following histological patterns was most likely present at the time of initiation of treatment?
Hyperplasia of prostate with predominance of muscular element
Hyperplasia of prostate with predominance of collagen
Hyperplasia of prostate with predominance of epithelial components
Hyperplasia of prostate with predominance of both collagen and smooth muscles
Hyperplasia of prostate with predominance of glandular tissue
A patient with severe neurological devastation after head trauma has a prolonged course in the intensive care unit. He has been mechanically ventilated for his entire hospital stay. Which of the following clinical findings is diagnostic of a ventilator-associated pneumonia?
White blood cell count of greater than 12,000/mL
Greater than 1000 colony-forming U/mL of an organism on bronchoalveolar lavage
Greater than 10,000 colony-forming U/mL of an organism on bronchoalveolar lavage
Purulent tracheal secretions
Right lower lobe infiltrate on chest x-ray
A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management?
Otoscopic examination and laboratory studies of the fluid
Emergency ear surgery to stop the leak of cerebrospinal fluid
CT scan of the head, extended to include the cervical spine
Antibiotics and high dose corticosteroids
Cervical spine and skull x-ray films
A pedestrian is hit by a car. The paramedics report that he was unconscious at the site, and he arrives at the emergency department in coma, strapped to a head board with sandbags on either side of his head. Initial survey shows stable vital signs, and his pupils are of equal size and reactive to light. He is rapidly intubated by the nasotracheal route over a flexible bronchoscope and then sent for CT scans of the head. As he is being positioned on the table, it is noted that there is a sizable hematoma behind his right ear and that clear fluid is dripping from the ear canal. Which of the following is most advisable, considering this new finding?
Extend the CT scan to include his neck
Start antibiotics
Do an MRI instead of a CT scan
Inject high-dose corticosteroids
Plan an emergency craniotomy
A postoperative patient with swelling and pain in his right calf is suspected of having a deep venous thrombosis. Prior to initiating treatment with anticoagulants, he requires a confirmatory examination. Which of the following is a limitation of the duplex ultrasound in evaluating a DVT?
It is invasive
It is expensive
It is not very sensitive for detecting calf thrombi in symptomatic patients
It cannot image the proximal veins (iliac veins, IVC)
It cannot differentiate between acute and chronic venous thrombi
A pregnant patient of yours goes to the emergency room at 20 weeks gestational age with complaints of hematuria and back pain. The emergency room physician orders an intravenous pyelogram (IVP) as part of a workup for a possible kidney stone. The radiologist indicates the absence of nephrolithiasis but reports the presence of bilateral hydronephrosis and hydroureter, which is greater on the right side than on the left. Which of the following statements is true regarding this IVP finding?
The bilateral hydronephrosis is of concern, and renal function tests, including BUN and creatinine, should be run and closely monitored
These findings are consistent with normal pregnancy and are not of concern
The bilateral hydronephrosis is of concern, and a renal sonogram should be ordered emergently
The findings indicate that a urology consult is needed to obtain recommendations for further workup and evaluation
The findings are consistent with ureteral obstruction, and the patient should be referred for stent placement
A pregnant woman is being followed by a nephrologist for chronic glomerulonephritis. Which of the following findings is normal at 28 weeks’ gestation?
Serum creatinine of 1.1 mg/100 mL
Glycosuria with a plasma glucose of 130 mg/100 mL
Blood pressure of 132/86 mmHg
Blood urea nitrogen (BUN) of 21 mg/100 mL
Glomerular filtration rate (GFR) of 130 mL/min
A pregnant woman who is 7 weeks from her LMP comes in to the office for her first prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The patient therefore is very anxious about the well being of this pregnancy. Which of the following modalities will allow you to best document fetal heart action?
Regular stethoscope
Transvaginal sonogram
Fetoscope
Special fetal Doppler equipment
Transabdominal pelvic sonogram
A premenopausal, 48-year-old woman undergoes a routine mammographic screening. Physical examination is normal. Mammography identifies a suspicious focus with clustered micro-calcifications located deeply in the lateral upper quadrant of the right breast. No abnormality can be detected in this area on breast examination. Which of the following is the most appropriate next step in diagnosis?
Ultrasonography
Fine-needle aspiration cytology
Mammographic reexamination in 1 year
Large needle (core needle) biopsy
Biopsy guided by mammographic localization
A previously healthy 15-month-old girl is brought to the emergency department after she had several episodes in which she lost consciousness after crying. Her parents state that the episodes always occur when the child gets frustrated or upset. She has no cyanosis or incontinence. The episodes last about 45 seconds each. After the episode, she is alert and appropriate. Physical examination is unremarkable. What is the next best step in the management of this patient?
Reassure the parents
Computed tomography of the head
Obtain an electroencephalogram
Obtain an electrocardiogram
Magnetic resonance imaging of the brain
A previously healthy 19-year-old female university student develops myalgia, headache, fever, and malaise. Blood tests reveal lymphocytosis, with 20% of the lymphocytes being atypical. She remains tired and unwell for 6 weeks, but repeated tests for heterophil antibody are negative. Which of the following is the most likely diagnosis?
Epstein-Barr virus (EBV) infection
Primary HIV infection
Human herpes virus type 7 (HHV-7)
CMV infection
Toxoplasmosis
A recovering premature infant who weighs 950 g (2 lb, 1 oz) is fed breast milk to provide 120 cal/kg/d. Over the ensuing weeks, the baby is most apt to develop which of the following?
Hypernatremia
Hypocalcemia
Blood in the stool
Hyperphosphatemia
Vitamin D toxicity
A very upset mother brings her 8-month-old child to the emergency room because he will not move his leg. She reports that when she was carrying him to the car about half an hour ago, she slipped on some ice and fell on top of him. The mother, an 18-year-old African American woman, has been exclusively breast-feeding her child. She has only recently started him on cereals, and has not supplemented his diet with vitamins. A radiograph of the child’s leg is shown below. Which of the following laboratory findings would be expected?
Hypocalcemia
Reduced serum alkaline phosphatase
Hypocalciuria
Hyperphosphatemia
Hypophosphaturia
A window cleaner falls from a third-story scaffold and lands on his feet. Physical examination and x-rays show comminuted fractures of both calcaneus. He is tender to palpation over multiple bruises and abrasions in other parts of his trunk and extremities, but he has normal vital signs and a normal neurologic exam. Given the mechanism of injury, which of the following is the most appropriate next step in diagnosis?
Abdominal CT scan
Appropriate arteriograms
X-ray films of thoracic and lumbar spine
Retrograde urethrogram medical
Cervical spine x-ray films
A young Hispanic couple brings their first child to their physician for a well-child examination. The child is a 3-month-old healthy-appearing infant, whose weight is at the 45th percentile of the normal growth curve. During examination, the physician observes an area of blue-black pigmentation over the buttocks. The parents say that it was present from the time of birth. Which of the following is the most appropriate next step in management?
Order CT/MRI scans to rule out dysraphism
Tell parents that this is a severe condition finding
Tell parents that this is a bruise caused by trauma
Tell parents that this is a normal finding
File a report of suspected child abuse
A young man is brought to the emergency department following a head-on collision at 30 miles per hour. He is awake and alert. Other than a forehead laceration, physical examination is normal and laboratory values are within normal limits. Chest x-ray films are unremarkable. Which of the following is the most appropriate next step in diagnosis?
Echocardiogram
CT scan of the abdomen
Lateral cervical spine x-ray
CT scan of the head
Peritoneal lavage
An 11-month-old boy is brought to the emergency department by his parents. The child has a fracture of the right femur. The father reports this was sustained as a result of falling out of the crib. The child is also noted to have bruises on his shoulders and back. The rest of his examination is unremarkable. Which of the following is the most appropriate next step in diagnosis?
Social services consult
Chest x-ray
CT of the head
Funduscopic exam
Lumbar puncture
An 11-month-old girl is brought by her mother to the office due to fever, fussiness, and irritability. The girl has a tendency to hold and pull on her left ear. For the past few days, she has had rhinorrhea and nasal congestion. Her medical history reveals nothing particular. Her temperature is 38.9C (102F). Otoscopic examination reveals a bulging, erythematous tympanic membrane with decreased mobility on air compression. What is the most likely organism responsible for the patient's condition?
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pneumoniae
Pseudomonas aeruginosa
Group A Streptococcus
An 18-month-old boy is brought to the clinic for a checkup. As part of his routine care, a serum lead level is obtained. It is 25 g/mL. Which of the following is the most appropriate next step in his management?
Chelation with succimer
Reassurance that this level is not a problem
Chelation with CaEDTA
Repeating the level in 6 months
Investigation of his home for lead hazards
An 18-year-old girl comes to the office due to a three-week history of headaches that has been disturbing her daily activities, including her sleep. She describes these headaches as pulsatile, diffuse, and occasionally results in vomiting. Her school grades have deteriorated over the past 3 months. She complains of double vision when she looks sideways. Her family history is significant for migraine. She is afebrile. Her neurologic examination is significant for sixth cranial nerve palsy. The pupils are equal, and reactive to light and accommodation. There is no sinus tenderness. Fundoscopy reveals bilateral papilledema. MRI of the brain reveals an empty sella. What is the most appropriate next step in the management of this patient?
Lumbar puncture
Sinus imaging
Refractive testing of the eye
Trial of prednisone
Start sumatriptan
An 18-year-old male complains of fever and transient pain in both knees and elbows. The right knee was red and swollen for 1 day during the week prior to presentation. On physical examination, the patient has a low-grade fever. He has a III/VI, high pitched, apical systolic murmur with radiation to the axilla, as well as a soft, mid-diastolic murmur heard at the base. A tender nodule is palpated over an extensor tendon of the hand. There are pink erythematous lesions over the abdomen, some with central clearing. The following laboratory values are obtained: Hct: 42, WBC: 12,000/µL with 80% polymorphonuclear leukocytes, 20% lymphocytes, ESR: 60 mm/h. The patient’s ECG is shown below. Which of the following tests is most critical to diagnosis?
Blood cultures
Echocardiogram
Antinuclear antibodies
Creatine kinase
Antistreptolysin O antibody
An 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have?
Colonoscopy
Mammogram
Pap smear
Pelvic ultrasound
Sigmoidoscopy
An 18-year-old woman comes to your office because of abdominal pain. She states that the pain started yesterday afternoon and has been worsening. The pain is in the right lower quadrant and does not radiate. She rates it a 7 on a scale of 1 to 10. She has had some nausea but no vomiting. Nothing seems to improve or worsen the pain. She has a history of hypothyroidism for which she takes thyroid hormone replacement, and no other medical problems. She has never had surgery. She is allergic to penicillin. Physical examination is significant for right lower quadrant tenderness. Bimanual examination reveals right adnexal tenderness. Which of the following is the most appropriate next step in the diagnostic workup of this patient?
Abdominal computed tomography (CT)
Pelvic ultrasound
Abdominal x-ray
Appendiceal ultrasound
Urine human chorionic gonadotropin (hCG)
An 8-year-old boy is brought to the emergency department by his mother. Two weeks ago, he developed a low-grade fever followed by a persistent cough. He occasionally has severe paroxysms of cough that are precipitated by eating and do not resolve with antitussive medications. On physical examination, extensive subcutaneous emphysema over the anterior chest is noted. What is the most appropriate next step in the management of this patient?
Chest x-ray
Throat culture
Ear examination
CT scan of head
Blood cultures
An 8-year-old boy presents to the pediatrician's office with a headache for the past 3 weeks. His mother also states that he has been more tired and has had frequent nose bleeding for the past month. On physical examination, his height and weight are both below the 5th percentile for his age. His blood pressure is 152/86 mm Hg in all four extremities. His pulse is 74/min, and respirations are 16/min. His heart examination is normal with no murmur. His peripheral pulses are strong and symmetric. Urinalysis and serum electrolytes are ordered. Which of the following is the most appropriate next step in diagnosis?
Blood urea nitrogen and creatinine concentration
Plasma and urine catecholamine levels
24-hour urine creatinine and protein
Serum aldosterone level
Serum Cortisol level
An 8-year-old girl is brought to the pediatrician's office for evaluation of new onset swelling around the eyes. Physical examination reveals periorbital, sacral, and pretibial edema; her blood pressure is 96/64 mm Hg. The rest other physical examination is normal. Which of the following is the most appropriate initial diagnostic study?
Levels of liver enzymes
Transthoracic echocardiography
Radiography of the chest
Ultrasonography of the kidneys
Urinalysis
An 8-year-old is accidentally hit in the abdomen by a baseball bat. After several minutes of discomfort, he seems to be fine. Over the ensuing 24 hours, however, he develops a fever, abdominal pain radiating to the back, and persistent vomiting. On examination, the child appears quite uncomfortable. The abdomen is tender, with decreased bowel sounds throughout, but especially painful in the midepigastric region with guarding. Which of the following tests is most likely to confirm the diagnosis?
Serum amylase levels
Serum total and direct bilirubin levels
CBC with differential and platelets
Abdominal radiograph
Electrolyte panel
An 81-year-old man is hospitalized for acute onset of shortness of breath and lower extremity edema. Although he lives by himself, it is very difficult for him to move around his apartment without experiencing fatigue. He has not seen his physician in years but was told in the past that he had high blood pressure. On physical examination his jugular venous pulse is palpated 9 cm above his sternal notch, inspiratory crackles are heard at his lung bases, and there is 3+ lower extremity edema. Which of the following will confirm the most likely diagnosis?
Cardiac angiography
Echocardiography
Electrocardiogram
Endomyocardial biopsy
X-ray of the chest
An 82-year-old woman is in the surgical intensive care unit after a carotid endarterectomy. She has been taking clindamycin and ciprofloxacin for the past 13 days. On postoperative day 2 the patient is febrile and tachycardic with a high WBC count and a low RBC count. She is also noted to be dehydrated and hypotensive. On physical examination she is distended and has abdominal tenderness with rebound and guarding. Barium enema reveals colonic dilatation of 8 cm. Stool is sent for Gram stain and analysis for fecal leukocytes, fecal occult blood, and Clostridium difficile toxin. Which of the following is most likely present in the stool sample?
Clostridium difficile toxin
Gram-negative rods
Gram-positive cocci
No fecal occult blood
Spores and hyphae
An 82-year-old woman presents 1-hour after the sudden onset of moderate-to-severe epigastric pain. The pain radiates to her back, both scapulae, and both arms. She has been nauseated and vomited three times in the past hour. Her past medical history is remarkable for peptic ulcer disease 10-years ago, cholelithiasis for the past 6-years, and stable angina pectoris for the past 3-years. She has had occasional episodes of biliary colic and two bouts of acute cholecystitis which were treated conservatively. Her temperature is 36.8°C (98.2°F), blood pressure is 120/70 mmHg, pulse is 90/min, and respirations are 14/min. The lungs are clear to auscultation. Abdominal examination shows a soft abdomen with mild tenderness to palpation in the epigastrium. Murphy's sign is negative. Which of the following studies should be done first?
Abdominal ultrasound
Electrocardiogram
Upper GI endoscopy
Upright abdominal x-ray
Serum amylase and lipase
An 83-year-old man with Parkinson’s disease presents with low-grade fever and cough for several weeks. Lately, he has been experiencing more rigidity and difficulty with his walking. He is on a levodopa/carbidopa combination for treatment for the past 5 years. On examination, his gait is shuffling and slow. He has a tremor in his left hand at rest, and there is cogwheel rigidity of the forearm. There are crackles in the left lower lung field. CXR reveals a lung abscess in the left lower lobe. Which of the following is the most likely bacteriologic diagnosis for the lung abscess?
Oropharyngeal flora
Staphylococcus aureus
Pseudomonas aeruginosa
Candida albicans
Tuberculosis
An 84-year-old Caucasian male is brought to the ER with severe chest pain, dyspnea and diaphoresis. His past medical history is significant for a long history of hypertension and diabetes mellitus, type 2. He experienced a severe myocardial infarction 6 months ago. His current medications are enalapril, metoprolol, aspirin, furosemide, potassium, glyburide and pravastatin, but he says that he has not been taking some of his medications recently. Physical examination reveals acrocyanosis and symmetric 3+ lower extremity edema. Point of maximal apical impulse is displaced to the left, and a holosystolic II/VI apical murmur is heard at the apex. Non-specific ST segment and T wave changes are present on ECG. The initial set of cardiac enzymes are positive. The patient continues to deteriorate, despite aggressive diuretic and vasodilator therapy. You perform an echocardiographic evaluation of left ventricular function and decide to proceed with pulmonary artery catheterization. Cardiac index (CI), total peripheral resistance (TPR) and left ventricular enddiastolic volume (LVEDV) are determined. Which of the following is most likely to present in this patient?
Cl decreased, TPR increased, LVEDV normal
Cl normal, TPR decreased, LVEDV increased
Cl decreased, TPR increased, LVEDV increased
Cl decreased, TPR increased, LVEDV decreased
Cl decreased, TPR decreased, LVEDV decreased
An 85-year-old man who resides in a nursing home presents with a 3-day history of lower abdominal pain and increasing fatigue and lethargy. He is afebrile, his BP is 160/92 mm Hg, and RR 16/min. His lungs are clear and his heart examination normal. There is diffuse abdominal tenderness on palpation and a large area of fullness and dullness to percussion starting just below the umbilicus and extending to the suprapubic area. His serum sodium is 130 mEq/L, potassium 4.9 mEq/L, BUN 75 mg/dL, and creatinine is 3.5 mg/dL. His baseline BUN and creatinine were 25 and 1.3 respectively as recently as 1 month ago. A Foley catheter is placed and 1200 cc of urine is obtained. What will be the likely clinical course for this patient with regard to his renal function?
He will require dialysis within 24 hours
He will produce minimal urinary output for at least 3 days
His creatinine will return to 1.3 over the next week
His creatinine will continue to rise slowly for 2 to 3 more days
His renal function is unlikely to show any improvement in the future and 3.5 will be his new baseline
An 87-year-old female is brought to the emergency department for evaluation of altered mental status. Her medical history is significant for multi-infarct dementia, hypertension, stroke, coronary artery disease, severe degenerative joint disease, chronic atrial fibrillation, constipation and urinary incontinence. Her medications include aspirin, acetaminophen, atenolol, nitroglycerin, multivitamins, pravastatin, docusate, senna, digoxin and glucosamine. She lives in a local nursing home, and the people who brought her to the ED deny any history of new symptoms. Her blood pressure is 110/70 mmHg, pulse is 98/min, respirations are 16/min and temperature is 36.1°C (97°F). Physical examination reveals dry mucus membranes and decreased skin turgor. There are no new focal neurologic deficits. Which of the following is most likely to be present in this patient?
Hyponatremia
Hypokalemia
Hypernatremia
Hyperkalemia
Hypocalcemia
An edentulous 72-year-old man with a 50-year history of cigarette smoking presents with a nontender, hard mass in the lateral neck. Which of the following is the best diagnostic test for establishing a diagnosis of malignancy?
Fine-needle aspiration cytology
Computed tomography (CT) scan of the head and neck
Bone marrow biopsy
Nasopharyngoscopy
Sinus x-ray
An elderly man presents to the emergency department with chest pain. He has a history of stable angina and recent onset diabetes mellitus, but now the chest pain comes on with less exertion and takes longer to go away. An ECG and cardiac enzymes are ordered. If this man has unstable angina, what are the expected findings on ECG and cardiac enzyme testing?
ST-segment depressions on ECG and normal cardiac enzyme levels
ST-segment elevations with Q waves and normal cardiac enzyme levels
No changes on ECG and elevated cardiac enzyme levels
Low voltage ECG and elevated cardiac enzyme levels
Delta waves on the ECG and elevated cardiac enzyme levels
An elderly woman is brought to the emergency department (ED) by her husband in a semiconscious state. According to her husband, she had complained of feeling unwell "over the past day or so”, but he only became very concerned when he returned from work today and found her very drowsy and difficult to arouse. Her past medical history is significant for diabetes with diabetic nephropathy and hypothyroidism. Her medications include thyroxine, metformin, gliclazide and lisinopril. Her temperature is 37.3°C (99°F), blood pressure is 110/65 mmHg, and pulse is 90/min. GCS = 13/15 (Motor 6, Verbal4, Eye3). She is confused and not oriented to time or place, but is able to follow commands. Physical examination reveals dry mucous membranes and decreased skin turgor. Neurological examination reveals weakness in the left arm. The rest of the examination is unremarkable. Urinalysis shows: Blood negative, Glucose +++, Ketones negative, Protein +, Leukocyte esterase negative, Nitrites negative, WBC 10-20/HPF. Which of the following is the most appropriate next investigation to perform?
MRI of head
Head CT
Blood glucose
Echocardiogram
Blood cultures
An infant has had repeated pneumonias and middle ear infections that began at about 5 months of age. At 1 year of age, serum electrophoresis demonstrated hypogammaglobulinemia. T cell function was normal. By 2 years of age, the child's infection rate has decreased, and repeat serum electrophoresis is normal. Which of the following immunoglobulins was likely decreased in this child during the period of increased susceptibility to infection?
IgA
IgD
IgE
IgG
IgM
An intoxicated 22-year-old man is a restrained driver in a high-speed motor vehicle collision. Examination reveals normal vital signs, but the rest of the examination is unreliable secondary to the patient’s intoxicated state from alcohol. Which of the following sole findings on a CT scan of the abdomen and pelvis mandates an exploratory laparotomy?
Free fluid in the pelvis
Pelvic fracture
Liver hematoma
Splenic hematoma
Renal hematoma
An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?
Microinvasive stage
I
II
III
IIa
An obese Caucasian father brings his 1 0-year-old obese son to your office. The father states that he was recently diagnosed with high cholesterol levels and coronary artery disease. Even though his son is asymptomatic, he is worried about the obesity. Which of the following best explains the next best step in management?
Evaluate him for coronary artery disease
Advise parents to start him on a regular physical exercise schedule
Advise parents to start him on a low cholesterol diet
Get a fasting lipid profile
Get a screening test for total cholesterol level
An otherwise healthy 17-year-old complains of swollen glands in his neck and groin for the past 6 months and an increasing cough over the previous 2 weeks. He also reports some fevers, especially at night, and possibly some weight loss. On examination, you notice that he has nontender cervical, supraclavicular, axillary, and inguinal nodes, no hepatosplenomegaly, and otherwise looks to be fairly healthy. Which of the following would be the appropriate next step?
Biopsy of a node
Trial of antituberculosis drugs
CBC and differential
Chest radiograph
Cat-scratchtiters
An otherwise healthy 28-year-old man comes to his physician because of painless enlargement of the right testis. He began to feel a sensation of heaviness in the right hemiscrotum approximately 6 months ago. Physical examination reveals diffuse enlargement of the right testis, but it is difficult to determine whether this is due to an intratesticular or extratesticular lesion. Which of the following is the most appropriate next step in diagnosis?
CT scanning
Scrotal ultrasonography
Serum levels of hCG, alpha-fetoprotein, and LDH
Needle biopsy
Inguinal orchiectomy
An otherwise healthy, 65-year-old woman comes to the physician because of bloody discharge from the right nipple for 2 weeks. On examination, no retraction, erosion, or other abnormal change is present. Palpation reveals an ill-defined, 1-cm nodule located deep in the right areola. Which of the following is the most appropriate next step in diagnosis?
Mammography alone
Mammography followed by fine-needle cytology
Cytologic examination of nipple discharge
Ultrasonography
Biopsy under mammographic localization
As a city public health officer, you have been charged with the task of screening high-risk children for lead poisoning. Which of the following is the best screen for this purpose?
Careful physical examination of each infant and child
Erythrocyte protoporphyrin levels (EP, FEP, or ZPP)
CBC and blood smear
Blood lead level
Environmental history
As you are walking across the hospital lobby, you stumble upon the arterial blood gas (ABG) results of a patient. The ABG (on room air) results are shown below: Blood pH 7.43, PaO2 100 mm Hg, PaCO2 25 mm Hg, HCO3- 16 mEq/L. Which of the following patients is most likely to have these laboratory values?
36-year-old patient with pulmonary embolism
64-year-old male with excessive diuresis
42-year-old patient with severe asthma exacerbation
42-year-old female with aspirin toxicity
52-year-old female with persistent vomiting
As you palpate the right upper quadrant (RUQ) of a 38-year-old woman’s abdomen, you notice that she stops her inspiration for a brief moment. During the history, the patient states that over the last 2 days she gets pain in her RUQ that radiates to her back shortly after eating. Her vitals include a temperature of 100.4°F, HR of 95 beats per minute, BP of 130/75 mm Hg, and RR of 16 breaths per minute. What is the initial diagnostic modality of choice for this disorder?
Computed tomography (CT) scan
Radioisotope cholescintigraphy (HIDA scan)
Plain film radiograph
Ultrasonography
Magnetic resonance imaging (MRI)
During a routine breast self-examination, a 35-year-old woman is concerned because her breasts feel “lumpy.” She consults you as her primary care physician. After performing an examination, you reassure her that no masses are present and that the “lumpiness” is due to fibrocystic changes. Which of the following pathologic findings is a type of nonproliferative fibrocystic change?
A blue-domed cyst
A radial scar
Atypical ductal hyperplasia
Papillomatosis
Sclerosing adenosis
During a routine office visit, a 62-year-old male is found to have a pulsatile non-tender mass above his umbilicus. His medical history is significant for hypertension, chronic renal insufficiency, myocardial infarction, and peripheral vascular disease. He quit smoking 10 years ago. On physical examination, his blood pressure is 160/90 mmHg and pulse is 76/min. Laboratory analyses reveal a serum creatinine of 2.0 mg/dl. Which of the following is the most appropriate next step in evaluating this patient's abdominal mass?
Plain abdominal x-ray
CT scan with contrast
Abdominal ultrasound
Abdominal MRI
No testing require
During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks gestational age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other parameters of the urine test are normal. Which of the following is the most likely etiology of the increased sugar detected in the urine?
The patient’s urinalysis is consistent with normal pregnancy
The patient’s urine sample is contaminated
The patient has diabetes
The patient has a urine infection
The patient has kidney disease
During a routine yearly checkup, a 10-year-old boy is found to have 2+ proteinuria on urinalysis. Which of the following would be the most appropriate diagnostic test?
Electrolytes, BUN, and serum creatinine
A repeat urinalysis
Antistreptococcal antibodies
IVP
Renal ultrasound
During routine ultrasound surveillance of a twin pregnancy, twin A weighs 1200 g and twin B weighs 750g. Hydramnios is noted around twin A, while twin B has oligohydramnios. Which statement concerning the ultrasound findings in this twin pregnancy is true?
The donor twin develops hydramnios more often than does the recipient twin
Gross differences may be observed between donor and recipient placentas
The donor twin often develops polycythemia
The donor twin is more likely to develop widespread thromboses
The donor twin usually suffers from a hemolytic anemia
Eight hours after undergoing a transnasal, transsphenoidal resection of a prolactinoma, a young lady becomes lethargic, confused, and eventually comatose. Review of the record shows that her urinary output since surgery has averaged 600 mL/hr, while her intake of IV fluids (5% dextrose in 0.45% saline) has been 100 mL/hr. Her blood pressure is 110/75 mm Hg, and her pulse is 88/min. Which of the following would most likely yield the correct diagnosis?
Blood glucose determination
Creatinine clearance
CT scan of the head
Serum levels of ACTH
Serum sodium determination
Following surgery a patient develops oliguria. You believe the oliguria is due to hypovolemia, but you seek corroborative data before increasing intravenous fluids. Which of the following values supports the diagnosis of hypovolemia?
Urine chloride of 15 mEq/L
Urine/serum creatinine ratio of 20
Urine sodium of 28 mEq/L
Urine osmolality of 350 mOsm/kg
Fractional excretion of sodium less than 1
For the first 6 hours following a long and difficult surgical repair of a 7-cm abdominal aortic aneurysm, a 70-year-old man has a total urinary output of 25 mL since the operation. Which of the following is the most appropriate diagnostic test to evaluate the cause of his oliguria?
Renal scan
Left heart preload pressures
Aortogram
Urinary sodium concentration
Creatinine clearance
For which of the following patients is an abdominal CT scan contraindicated?
A 52-year-old man with abdominal pain after blunt trauma, negative focused assessment with sonography for trauma (FAST) examination, BP 125/78 mm Hg, and HR 109 beats per minute
A 22-year-old woman with RLQ pain, negative β-hCG, temperature 100.6 F
A 45-year-old man with abdominal pain, temperature 100.5 F, WBC 11,200/μL, BP 110/70 mm Hg, HR 110 beats per minute, and lipase 250 IU
A 70-year-old man with abdominal pain, an 11-cm pulsatile mass in the epigastrium, BP of 70/50 mm Hg, and HR of 110 beats per minute
A 65-year-old woman with right flank pain that radiates to her groin, microhematuria, BP 165/85 mm Hg, and HR 105 beats per minute
Her son brings a 50-year-old female to the emergency room because she is confused and sweating a lot. She does not have any medical problems, except hypertension for which she takes hydrochlorothiazide. She is not taking any other medication. He tells you that his mother complained of profound weakness, and inability to stand, because of lightheadedness 3 hours ago. On examination, the patient is drowsy, confused, and appears sick. Her temperature 36.8°C (98.2° F) BP 153/83mm Hg PR 128/min. Her clothes are damp from perspiration. No other abnormalities are noted on physical examination. Initial laboratory studies show: Sodium 144 mEq/L, Potassium 3.6 mEq/L, Bicarbonate 26 mEq/L, Blood urea nitrogen: 12 mg/dl, Creatinine 0.6 mg/dl. You order a few more tests and on the basis of which you diagnose insulinoma. What set of following results leads to this diagnosis? (Serum Glucose, Insulin, C-Protein)
Increased, Decreased, Increased
Decreased, Increased, Increased
Increased, Increased, Increased
Decreased, Increased, Decreased
Normal,Normal,Normal
In an adolescent presenting with pityriasis rosea, which of the following would be an appropriate blood test to order?
Venereal Disease Research Laboratory (VDRL)
Fluorescent antinuclear antibody (FANA)
Complete blood count (CBC)
Hepatitis A immunoglobulin M (IgM)
Glucose
In the first postoperative day after an open abdominal procedure, a patient develops a temperature of 38.9 C (102 F). He is encouraged to ambulate, cough, and breathe deeply, but he is noncompliant. On the second day, he is still febrile. Incentive spirometry and postural drainage are instituted, but his participation is less than enthusiastic. He lies in bed all day and hardly moves. By the third day, he is still spiking fevers in the same range, although efforts to improve his ventilation continue, resolution of his problem will most likely require which of the following?
Cultures of his wound and wound opening if needed
Chest x-ray, sputum cultures, and appropriate antibiotics
Urinalysis, urinary cultures, and appropriate antibiotics
Doppler studies of deep leg and pelvic veins
CT scan of the abdomen and percutaneous drainage of abscess
On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6C (99.8F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?
Arterial blood gas
Chest x-ray
CT angiography
Lower extremity Dopplers
Ventilation-perfusion scan
On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?
Retinal examination looking for fat droplets
Ventilation-perfusion lung scan, or spiral CT scan of the chest
ECG and cardiac enzymes
Intubation and respirator, with hyperventilation and PEEP
Aortogram and emergency surgical repair
On the second postoperative day after an abdomino-perineal resection for cancer of the rectum, a 72-year-old man complains of severe retrosternal pain. The pain is crushing in nature and radiates to the left arm. He also becomes short of breath and tachycardic. Except for his fresh surgical wounds and postoperative discomfort, physical examination is unremarkable. He does not have distended neck veins. Which of the following is the most appropriate next step in diagnosis?
Blood gases
CPK-MB isoenzyme
Chest x-ray film
Pulmonary angiogram
Transaminase levels (ALT, AST)
One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?
MRI
Venography
Computed tomographic scanning
Real-time ultrasonography
X-ray of lower extremity
Over the last six weeks a 45-year-old nurse has developed progressive difficulty getting out of chairs and climbing stairs. She can no longer get in and out of the bathtub. She has no muscle pain and takes no regular medications. She does not use alcohol and does not smoke cigarettes. On examination she has a purplish rash that involves both eyelids (see figure). There is weakness of the proximal leg muscles. What is the best next diagnostic test?
Vitamin B12 level
Chest x-ray
HLAB27
MRI scan of the lumbar spine
CPK
Physical examination of a baby boy shortly after birth reveals a large bladder and palpable kidneys. The nurses note that he produces a weak urinary stream. A voiding cystourethrogram is shown below. He appears to be otherwise normal. Which of the following is the most likely diagnosis?
Ureteropelvic junction obstruction
Duplication of the collecting system
Horse shoe kidney
Posterior urethral valve
Prune belly syndrome
Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?
Liver biopsy and determination of portal pressures
Liver biopsy and more detailed liver function tests
Ultrasound of biliary tract and Doppler studies of the anastomosed vessels
Liver biopsy and trial of steroid boluses
Measurement of preformed antibody levels
The 1-year-old brother of a child with known abetalipoproteinemia is evaluated by a pediatrician for the disease. The 1 -year-old has been exhibiting steatorrhea and ataxia. Which of the following would most strongly support the suspected diagnosis?
Globoid cells on brain biopsy
"Sea-blue" histiocytes on bone marrow biopsy
Acanthocytes on peripheral smear
"Crumpled silk" histiocytes on bone marrow biopsy
Metachromatic deposits on sural nerve biopsy
The ECG shown in Fig. Was obtained during the initial stages of an acute MI. The patient had just received thrombolytic therapy. What is the rhythm?
Atrial fibrillation
Nonsustained ventricular tachycardia
Atrial flutter
Second-degree heart block
Wenckebach phenomenon
The parents of a 2-month-old baby boy are concerned about his risk of coronary artery disease because of the recent death of his 40-year-old maternal uncle from a myocardial infarction. Which of the following is the most appropriate management in this situation?
Screen the parents for total cholesterol
Counsel the parents regarding appropriate dietary practices for a 2-month-old infant and test him for total cholesterol at 6 months of age
Recommend yearly ECGs for the patient
Initiate lipid-lowering agents
Reduce the infant’s dietary fat to less than 30% of his calories by giving him skim milk
The parents of a 3-year-old patient followed in your clinic recently took their child on quickly planned 5-day trip to Africa to visit an ill grandparent. Everyone did well on the trip, but since their return about 10 days ago the boy has been having intermittent, spiking fevers associated with headache, sweating, and nausea. The parents had not been too concerned since he was relatively well, except for being tired, between the fevers. Today, however, they feel that he looks a bit pale and his eyes appear “yellow.” Which of the following is likely to reveal the source of his problem?
Hepatitis A IgG and IgM titers
Hemoglobin electrophoresis
Complete blood count (CBC) with smear
Tuberculosis skin test
Hepatitis B IgG and IgM titers
The photomicrograph below is of a urine specimen from a 15-year-old girl. She has had intermittent fever, malaise, and weight loss over the previous several months. Recently she has developed swollen hands, wrists, and ankles, the pain of which seems out of proportion to the clinical findings. She also complains of cold extremities and has some ulceration of her distal digits. Which of the following laboratory tests is most likely to assist in the diagnosis of this condition?
Antibodies to nDNA and Sm nuclear antigens
A urine culture
Erythrocyte sedimentation rate
Simultaneously acquired urine and serum bicarbonate levels
Throat culture for group A β-hemolytic streptococcus
The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?
Extension of the CT to include the entire cervical spine
Separate CT scan of the abdomen
Base of the skull x-ray films
Special views of the maxillary sinuses
Radiographs of all the teeth
Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?
Number of nodules
Presence of epithelial hyperplasia
Serous nipple discharge
Size of the dominant mass
Presence of a palpable axillary node
Which of the following is the most appropriate evaluative procedure for an otherwise normal 7-day-old boy with perineal hypospadias?
Renal ultrasonography
Serum creatinine determination
Cystography
Circumcision
Intravenous pyelography (IVP)
While playing a match of tennis, a 56-year-old man with a medical history significant only for acid reflux disease starts to feel substernal chest pain that radiates into his left arm and shortness of breath. His pain feels better after drinking antacid, but since it is not completely resolved, his partner calls 911. Upon arrival, EMS administers aspirin and sublingual nitroglycerin. After 20 minutes, the man’s symptoms resolve. He is brought to the ED for further evaluation where his ECG shows sinus rhythm without any ischemic abnormalities. You order a chest radiograph and send his blood work to the laboratory for analysis. Which of the following statements regarding the diagnosis of acute MI is most accurate?
A normal ECG rules out the diagnosis of acute MI
One set of negative cardiac enzymes is sufficient to exclude the diagnosis of MI in this patient
Troponin may not reach peak levels for at least 12 hours
Relief of symptoms by antacids essentially rules out a cardiac cause of his chest pain
Epigastric discomfort and indigestion is a rare presentation of ACS
Within 8 hours after birth, an infant has "excessive salivation." Physical examination reveals that she has an imperforate anus, with a small fistula to the vagina. A small, soft nasogastric tube is inserted, and the infant is taken to x-ray. The film shows the tube coiled back on itself in the upper chest, and a normal gas pattern in the gastrointestinal tract. There are no apparent abnormalities of the radius or the vertebral bodies. Which of the following is the most appropriate next step in management?
Renal sonogram and echocardiogram
Diverting colostomy
Barium swallow
Placement of a gastrostomy tube
Surgical repair of esophageal atresia
Yesterday you admitted a 55-year-old white male to the hospital for an episode of chest pain, and you are seeking to rule out MI plus assess for any underlying coronary artery disease. The patient tends to be anxious about his health. On admission, his lungs were clear, but his heart revealed a grade 1/6 early systolic murmur at the upper left sternal border without radiation. Blood pressure readings have consistently been in the 140/90 mmHg to 150/100 mmHg range. Cardiac enzymes are normal. A resting ECG shows only left ventricular hypertrophy with secondary ST-T changes (“LVH with strain”). Why would a treadmill ECG stress test not be an appropriate test in this patient?
Anticipated difficulty with the patient’s anxiety (ie, he might falsely claim chest pain during the test)
The presence of LVH with ST-T changes on baseline ECG
Concern about the heart murmur, a relative contraindication to stress testing
Concern that this represents the onset of unstable angina with unacceptable risk of MI with stress testing
Increased risk associated with high blood pressure readings
You are asked by a colleague to evaluate a 5-year-old boy as a second opinion. He has a history of chronic and recurrent upper respiratory tract infections, several admissions to the hospital for pneumonia, and three surgeries for PE tubes for chronic otitis media. Of note is a right-sided heart on repeated radiographs. Convinced you know the diagnosis based on history alone, you confirm your diagnosis with a biopsy of the nasal mucosa. You expect to find which of the following?
Eosinophilic infiltrate
Absence of nasal mucous glands
Bordetella pertussis
Random orientation of cilia
Nasal polyps
You are asked to evaluate an infant born vaginally 3 hours previously to a mother whose only pregnancy complication was poorly controlled gestational diabetes. The nursing staff noticed that the infant was breathing abnormally. On examination, you find that the infant is cyanotic, has irregular, labored breathing, and has decreased breath sounds on the right side. You also note decreased tone in the right arm. You provide oxygen and order a stat portable chest radiograph, which is normal. Which of the following studies is most likely to confirm your diagnosis?
Nasal wash for viral culture
Fiberoptic bronchoscopy
Chest CT
Chest ultrasound
Induced sputum culture
You are called by a surgical colleague to evaluate a 54-year-old woman with ECG abnormalities one day after a subtotal thyroidectomy for a toxic multinodular goiter. Her only medication is fentanyl for postoperative pain control. The patient denies any history of syncope, and has no family history of sudden cardiac death. Physical examination is unremarkable except for a clean postoperative incision at the base of the neck. Her ECG is reproduced below. What is the best next step in evaluation and management of this patient?
Administration of intravenous magnesium sulfate
Reassure the patient that her ECG is normal for a woman her age
Stat noncontrast CT scan of the brain
Measurement of serum ionized calcium
Formal auditory testing
You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was normal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?
Colposcopy
No further treatment/evaluation is necessary if the patient is asymptomatic
Endometrial biopsy
Renal sonogram
Urine culture
Your patient complains of decreased fetal movement at term. You recommend a modified BPP test. Nonstress testing (NST) in your office was reactive. The next part of the modified BPP is which of the following?
Ultrasound assessment of fetal breathing movements
Ultrasound assessment of fetal tone
Amniotic fluid index evaluation
Ultrasound assessment of fetal movement
Contraction stress testing
Your patient is a 23-year-old woman with primary infertility. She is 5 ft 4 in tall and weighs 210 lb. She has had periods every 2 to 3 months since starting her period at age 12. She has a problem with acne and hair growth on her chin. Her mother had the same problem at her age and now has adult-onset diabetes. On physical examination of the patient, you notice a few coarse, dark hairs on her chin and around her nipples. She has a normal appearing clitoris. Her ovaries and uterus are normal to palpation. Which of the following blood tests has no role in the evaluation of this patient?
TSH
Total testosterone
17 α-hydroxyprogesterone
DHEAS
Estrone
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