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Exam 1: Medicine

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Question 741

Multiple Choice

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A 35-year-old man comes to the office with a year-long history of fatigue and weakness.  He has had a significant decrease in appetite and interest in day-to-day activities due to lack of energy.  He also reports cold intolerance, a dull constant headache, constipation, erectile dysfunction, and low libido.  The patient has no fever, neck swelling, skin rash, head injury, or excessive urination.  Temperature is 36.6 C (97.9 F) , blood pressure is 98/72 mm Hg, pulse is 50/min, and respirations are 14/min.  The skin is dry and pale.  Neurologic examination shows delayed deep tendon reflexes.  The testes are small and soft on palpation.  Laboratory results are as follows: Further evaluation in this patient would most likely show which of the following?

A) A
B) B
C) C
D) D
E) E

F) B) and D)
G) B) and E)

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Question 742

Multiple Choice

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A 53-year-old woman recently diagnosed with systemic sclerosis comes to the emergency department with headaches, increasing dyspnea, malaise, and nausea.  Her medications include lansoprazole for heartburn and nifedipine for finger discoloration and pain.  Physical examination reveals a distressed and anxious woman.  Her blood pressure is 235/117 mm Hg and pulse is 120/min.  She has visible skin tightening over the face, forearms, chest, and legs.  She has difficulty opening her mouth due to tightening of the skin around the mouth.  Lung examination shows bibasilar inspiratory crackles.  Laboratory studies are as follows: Which of the following red blood cell abnormalities is most likely to be present in the peripheral blood smear?

A) Burr cells
B) Howell-Jolly bodies
C) Schistocytes
D) Spur cells
E) Target cells

F) B) and E)
G) A) and C)

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Question 743

Multiple Choice

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A 56-year-old man comes to the office for a routine preventive visit.  He works as a welder on an oil rig and currently feels well.  The patient has a history of hypertension and hyperlipidemia, which are well controlled with oral medications.  He has smoked a pack of cigarettes daily since age 14 and has been unable to quit despite repeated attempts.  The patient drinks alcohol socially and does not use illicit drugs.  His father died due to complications of Alzheimer disease, and his mother died from ovarian cancer.  Screening colonoscopy at age 52 revealed a 0.5-cm hyperplastic polyp.  Vital signs are within normal limits.  Physical examination shows no abnormalities.  Which of the following screening tests is recommended for this patient?

A 17-year-old white female comes to the office for the evaluation of fatigue which has been present for the past 4 months.  Her past medical history is insignificant.  She denies the use of any drugs.  Her pulse is 74/min, blood pressure is 110/70 mm Hg, and temperature is 36.7° C (98.0° F) .  Physical examination shows scars on the dorsum of her hands and dental erosions.  Laboratory studies show: Urine chloride concentration is 15 mEq/L (Normal = 80-250 mEq/L) .  Based on these findings, what is the most likely diagnosis?

As part of a quality improvement initiative, a hospital implements a new clinical decision support tool in the electronic medical record.  When a provider places a new medication order, the tool prompts the provider to confirm the order if a potentially dangerous multi-drug interaction exists, if a nonstandard dose is entered, or if the drug indication is missing.  A provider is reviewing medication orders on a patient with intractable colon cancer who is about to undergo partial colectomy.  The patient is currently taking oral morphine.  The provider discontinues oral morphine, determines an equivalent dose of intravenous hydromorphone, and enters the order into the electronic medical record.  Which of the following potential errors related to this order would the new clinical decision support tool be most likely to detect?

A 55-year-old man comes to the office due to left-sided facial numbness.  His symptoms began a month ago with tingling over his left mid-face and have progressively worsened to complete numbness on that side.  The patient has also had 2 months of headaches, nasal congestion with intermittent epistaxis, and left ear fullness.  He has had no fever, rhinorrhea, or purulent nasal discharge.  The patient has taken over-the-counter allergy medications, but these have provided no relief.  He has no other medical problems and does not use tobacco, alcohol, or illicit drugs.  He recently immigrated to the United States from southern China to be closer to his son.  Temperature is 37 C (98.6 F) , blood pressure is 126/80 mm Hg, and pulse is 84/min.  Examination reveals sensory loss to touch and pain on the left side of the face.  No facial muscle weakness or other neurological findings are present.  Enlarged, nontender, and mobile cervical lymph nodes are palpable bilaterally.  No oropharyngeal or nasal lesions are visualized.  Otoscopy of the left ear demonstrates clear fluid behind the retracted tympanic membrane, but the right ear is normal.  Nasopharyngoscopy reveals a soft-tissue mass in the nasopharynx.  Which of the following is the most likely diagnosis?

An 87-year-old woman with advanced dementia is brought to the emergency department by her son due to 3 days of fever and foul-smelling, productive cough.  The patient is bed-bound and requires assistance with all activities of daily living.  Her other medical problems include hypertension, hypercholesterolemia, and a hemorrhagic stroke that occurred 8 months ago.  She has been admitted to the hospital twice for pneumonia over the past 6 months, most recently 4 months ago.  The patient has never smoked cigarettes.  Her temperature is 38.3 C (101 F) , blood pressure is 100/70 mm Hg, pulse is 105/min, and respirations are 20/min.  Pulse oxymetry shows oxygen saturation of 90% on room air.  BMI is 20 kg/m².  She is not oriented to name, time, or place.  Physical examination shows dry mucous membranes and decreased skin turgor.  Breath sounds are decreased in the right lung field.  Heart sounds are normal.  The abdomen is soft, nontender, and nondistended.  Chest imaging reveals an infiltrate in the posterior segment of the right upper lobe.  Which of the following is the most important predisposing factor for this condition in this patient?

A 60-year-old man comes to the office due to cough and dyspnea on exertion.  The patient has had a cough for over 2 years, but it has become worse recently and is accompanied by increasing shortness of breath.  The cough is productive with a small volume of mucoid sputum.  He has no hemoptysis, chest pain, or leg swelling.  The patient has a 40-pack-year smoking history and drinks 1 or 2 glasses of wine daily.  He has worked in a shipyard for 10 years.  Other medical conditions include rheumatoid arthritis and hypertension.  Temperature is 37.2 C (99 F) , blood pressure is 140/80 mm Hg, pulse is 80/min, and respirations are 20/min.  Chest x-ray reveals prominent bronchovascular markings and mild diaphragmatic flattening.  Pulmonary function test results are as follows: Diffusion capacity of the lung for carbon monoxide is 100% of predicted value.  Which of the following is the most likely cause of this patient's symptoms?

A 35-year-old woman is brought to the emergency department due to 3 days of progressive nausea, anorexia, malaise, abdominal pain, and lethargy.  The patient is a chronic carrier of hepatitis B virus and has not received any treatment.  She has a history of injection drug use and completed a rehabilitation program 2 years ago, but recently started using drugs again.  She drinks alcohol but does not use tobacco.  Her temperature is 37.8 C (100.2 F) , blood pressure is 106/64 mm Hg, and pulse is 114/min.  Mild tender hepatomegaly is present.  Laboratory testing shows markedly elevated serum aminotransferase levels and a positive serum hepatitis D antigen.  Acute liver failure due to hepatitis D virus superinfection is suspected.  Which of the following is required to make a diagnosis of acute liver failure in this patient?

A 62-year-old woman who works as a high school administrative assistant is brought to the emergency department by her coworker.  She states that 2 hours ago she suddenly felt dizzy while sitting at her desk.  A short time later, the patient tried to stand to go to the bathroom and felt like she was falling to the left.  Her symptoms have been constant and disabling since they started.  The dizziness is exacerbated by any movement of the head, and she has a mild posterior headache.  Medical history is significant for hypertension.  Temperature is 37.2 C (99 F) , blood pressure is 160/85 mm Hg, pulse is 78/min, and respirations are 16/min.  The patient is awake and alert.  Heart and lungs sounds are normal.  Strength is 5/5 in the upper and lower extremities bilaterally.  Finger-to-nose and heel-to-shin testing are abnormal on the left.  Gait is ataxic.  Noncontrast CT scan of the head is normal.  ECG shows normal sinus rhythm.  Which of the following is the best next step in management of this patient?

A 55-year-old woman comes to the office due to right leg swelling and tenderness.  She has a history of ovarian cancer and is currently undergoing chemotherapy.  A duplex venous ultrasound of the right lower extremity shows thrombosis of the right popliteal vein.  The patient is sent home with subcutaneous enoxaparin.  A week later, the patient returns to the office for a follow-up appointment.  Laboratory results are as follows: This patient's current condition predisposes her to which of the following?

A 35-year-old woman comes to her primary care physician complaining of palpitations, weight loss, increased appetite, and diarrhea for the past 2 months.  She does not use alcohol or tobacco.  Her temperature is 37.1° C (98° F) , blood pressure is 135/80 mm Hg, pulse is 100/min, and respirations are 14/min.  Physical examination shows exophthalmos, lid lag, lid retraction, and a diffusely enlarged and nontender thyroid gland.  Laboratory studies show very low serum thyroid-stimulating hormone and increased serum free T4 and T3.  The patient is diagnosed with Graves' disease.  Various treatment options are discussed, and she opts for long-term treatment with methimazole.  Which of the following conditions is this patient at risk for developing from the medication?

A 61-year-old woman comes to the office due to low back pain for the past 2 weeks.  The patient has a constant, dull, aching pain that is more pronounced at night and has awakened her from sleep on several occasions.  She has had no trauma or previous back conditions and attributes the pain to prolonged bending over while gardening.  There is no associated fever, chills, bowel or bladder incontinence, or lower extremity weakness or numbness.  Medical history is notable for hypertension and early-stage breast cancer at age 55, which was treated with lumpectomy, radiation therapy, and hormonal therapy.  The patient does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98.1 F) , blood pressure is 134/86 mm Hg, pulse is 76/min, and respirations are 12/min.  Head and neck, cardiac, lung, breast, and abdominal examinations show no abnormalities.  Spinal examination shows no deformities or focal tenderness.  Lower extremity motor strength and reflexes are normal and symmetric.  Straight-leg raising test is negative.  Which of the following is the most appropriate next step in management of this patient?

A 40-year-old woman comes to the office for follow-up.  The patient has a 4-year history of rheumatoid arthritis and has been taking a disease-modifying therapy.  She reports significant improvement in joint pain and stiffness with treatment and can now perform daily activities without difficulty.  The patient has no other medical conditions and does not use tobacco, alcohol, or illicit drugs.  She consumes a balanced diet and exercises most days of the week.  Vital signs are normal.  Physical examination shows no significant joint swelling, erythema, or tenderness.  Laboratory results are as follows: Laboratory studies were within normal limits 6 months ago.  Which of the following is the most likely additional adverse effect of this patient's pharmacotherapy?

A 31-year-old woman comes to the office with a 3-month history of palpitations and weight loss.  She weighs 110 kg (243 lb) ; 3 months ago, she weighed 118 kg (260 lb) .  There is no associated dysphagia, neck pain, or hoarseness, and her menstrual periods have been regular.  The patient was previously healthy and her family history is unremarkable.  She does not use tobacco or alcohol.  The patient is sexually active with one partner and uses a barrier method for contraception.  Temperature is 36.7 C (98.1 F) , blood pressure is 140/90 mm Hg, pulse is 102/min, and respirations are 20/min.  The thyroid gland cannot be clearly felt on examination due to body habitus.  Ocular examination is unremarkable.  Laboratory tests show an elevated serum free triiodothyronine and thyroxine and low TSH.  A urine pregnancy test is negative.  Radioactive iodine scan reveals uptake of tracer only in the right thyroid lobe, as shown in the image below. Which of the following processes is responsible for this patient's elevated thyroid hormone levels?

A 70-year-old man comes to the office due to pain and stiffness of his neck, shoulders, and hip region for the last 3 months.  His stiffness is worse in the morning and lasts 1-2 hours.  He also has had general malaise and a recent weight loss of 3.17 kg (7 lb) .  The patient has no headache, scalp tenderness, visual symptoms, or jaw claudication.  Examination shows no overt synovitis at the joints, with normal passive range of motion.  The arteries of the scalp, neck, and extremities are normal on palpation without tenderness.  Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

A 34-year-old man comes to the emergency department due to 3 weeks of fever, night sweats, fatigue, cough, and shortness of breath.  He has lost 4.5 kg (10 lb) over this period.  The patient was diagnosed with HIV a year ago but is not taking antiretroviral medication.  His CD4 count was 80/mm³ 3 months ago.  The patient is unemployed and recently moved to Missouri to live with his parents.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.5 C (101.3 F) , blood pressure is 110/66 mm Hg, and pulse is 108/min.  There are small ulcers on the hard palate and multiple enlarged lymph nodes in the cervical and inguinal chains.  Pulmonary examination reveals scattered lung crackles.  The patient's abdomen is soft and nontender, but there is prominent hepatosplenomegaly.  Laboratory studies show pancytopenia and elevated aminotransferase levels.  Chest x-ray reveals bilateral reticulonodular opacities with hilar lymphadenopathy. Which of the following is the best next step in management of this patient?

A 24-year-old woman comes to the office with several months of low back and buttock pain.  Her pain is most severe early in the morning and fades as the day progresses.  There is no recent history of significant illness or trauma.  Vital signs are normal.  On examination, tenderness is present in the lower lumbar spine.  Muscle strength and deep tendon reflexes are normal and equal in all extremities.  Plain x-ray findings are shown in the image below: Which of the following is the most appropriate next step in management?

A 63-year-old man comes to the emergency department due to sudden-onset right-sided weakness that resolved spontaneously within 30 minutes.  Medical history includes hypertension and an early-stage sigmoid colon cancer that was resected 5 years ago; follow-up colonoscopy showed no recurrence.  The patient takes lisinopril.  He has a 20-pack-year history and quit smoking 10 years ago.  Blood pressure is 130/80 mm Hg and pulse is 74/min.  Examination shows a left carotid bruit.  Neurologic examination is normal.  ECG shows normal sinus rhythm.  CT scan of the head is normal.  Lipid panel results are as follows: Echocardiography is unremarkable.  Carotid duplex ultrasonography and follow-up CT angiography show 80% stenosis in the left internal carotid and 40% stenosis in the right internal carotid artery.  Which of the following is the most appropriate next step in preventing a further stroke in this patient?

A 33-year-old man comes to the emergency department due to abdominal discomfort, nausea, and 2 episodes of vomiting containing a small amount of blood over the past several hours.  The symptoms all started this morning.  He has no prior medical problems and has never had similar symptoms.  The patient drank alcohol and used cocaine with his friends late last night.  This morning, he woke up with a "terrible" headache for which he took several aspirin tablets.  The headache improved, but he subsequently developed the gastrointestinal symptoms.  The patient smokes a pack of cigarettes daily and drinks 1 or 2 cans of beer daily.  Vital signs are normal.  Abdominal examination reveals mild epigastric tenderness, but no masses, rebound, or guarding.  Which of the following is the most likely cause of this patient's hematemesis?