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Exam 1: Medicine

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Question 801

Multiple Choice

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A 42-year-old woman is evaluated for chronic abdominal pain and fatigue.  Her pain is epigastric, burning, and sometimes awakens her from sleep.  She has no recent weight loss, nausea, or vomiting.  Her diet consists primarily of fruits and vegetables.  The patient also complains of a "strange appetite" for paper and ice that she has never had before.  Upper gastrointestinal endoscopy shows duodenal erythema and an ulcer on the anterior wall of the duodenal bulb but is otherwise normal.  Her unusual appetite is most directly related to which of the following?

A) Chronic bleeding
B) Helicobacter pylori infection
C) Lactose intolerance
D) Oral leukoplakia
E) Reflux esophagitis
F) Vitamin B12 deficiency

G) A) and B)
H) All of the above

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Question 802

Multiple Choice

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A 44-year-old-man comes to the emergency department due to a day of fever, chills, and productive cough.  Over the past several weeks, the patient has also had progressive fatigue and dyspnea to the point that he was unable to mow the lawn last weekend.  The patient has no prior medical conditions and takes no medications.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.8 C (102 F) , blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 24/min.  Examination shows mucosal pallor and scattered ecchymoses.  Lung auscultation reveals left-sided crackles and bronchial breath sounds.  There is no lymphadenopathy or splenomegaly.  Laboratory results are as follows: Left lower lobe consolidation is seen on chest x-ray.  Peripheral blood smear reveals decreased leukocytes, erythrocytes, and platelets but is otherwise unremarkable.  Which of the following is the most likely mechanism of this patient's hematologic abnormalities?

A) Acquired deficiency of hematopoietic stem cells
B) Excessive collagen deposition in the bone marrow
C) Impaired DNA synthesis in precursor cells
D) Malignant proliferation of mature lymphocytes
E) Replacement of bone marrow by plasma cells

F) B) and D)
G) C) and D)

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Question 803

Multiple Choice

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A 27-year-old woman, gravida 1 para 0 at 30 weeks gestation, comes to the office due to increasing difficulty hearing, especially on the right side.  She has had no ear pain or discharge.  The patient has no prior medical conditions; the pregnancy has been uncomplicated other than an episode of acute cystitis 8 weeks ago, which was treated with antibiotics.  She takes no medications aside from a multivitamin.  The patient eats a balanced diet and does not use tobacco or alcohol.  Vital signs are within normal limits.  Bilateral tympanic membranes are normal with no middle ear effusion.  A tuning fork held over the middle of the forehead sounds louder in the right ear.  Tuning fork sounds are better heard with bone conduction on the right side and with air conduction on the left.  The remainder of the neurologic examination shows no abnormalities.  Which of the following is the most likely cause of this patient's current symptoms?

A 5-year-old boy is brought to the emergency department by his parents due to sudden-onset difficulty breathing.  The patient developed a mild cough and sore throat yesterday; his parents gave him acetaminophen, which improved his throat pain.  However, this morning the patient had difficulty breathing and was sitting in bed and leaning forward, refusing to lie down.  He takes no medications and has no known allergies.  The patient has had no vaccinations.  Temperature is 39.1 C (102.4 F) , blood pressure is 100/65 mm Hg, pulse is 130/min, and respirations are 46/min.  Oxygen saturation is 92% on room air.  The patient appears anxious, is drooling, and has inspiratory stridor.  The uvula is midline, and there is no oropharyngeal or tonsillar erythema.  Lung examination shows transmitted upper airway noises without wheezing or crackles.  Which of the following is the most likely diagnosis?

A 54-year-old man is brought to the emergency department after an episode of hematemesis and lightheadedness.  He has a history of anemia, intravenous drug use, hepatitis C infection with cirrhosis, and alcohol use.  The patient says he has had no alcohol in about 5 days.  He takes no medications.  His temperature is 36.7 C (98 F) , blood pressure is 105/60 mm Hg, pulse is 110/min, and respirations are 16/min.  He has scleral icterus.  Examination shows blood in the oropharynx.  The lungs are clear to auscultation.  The abdomen is distended with a fluid wave.  Laboratory results are as follows: The patient receives normal saline through 2 large-bore intravenous lines and is started on ceftriaxone.  Which of the following is the most appropriate next step in management of this patient?

A 34-year-old man is admitted to the hospital due to recurrent pancreatitis following a 2-week period of heavy alcohol consumption.  He has a long history of alcohol abuse and has been through inpatient alcohol treatment programs on multiple occasions.  The patient realizes he needs to stop, but says he drinks when he is home alone and feels stressed.  Medical history is notable for hypertension and type 2 diabetes mellitus, treated with lisinopril and metformin.  Blood pressure is 146/85 mm Hg and pulse is 72/min.  BMI is 46 kg/m².  On examination, the patient appears comfortable.  Fasting glucose is 183 mg/dL and hemoglobin A1c is 8.2%.  The patient says he is not willing to return to an inpatient alcohol treatment program after hospital discharge but might consider outpatient counseling.  Which of the following is the most appropriate response to this patient?

A 25-year-old medical volunteer comes to the occupational health office after accidentally pricking his finger while disposing of sharps from a procedure on a 36-year-old patient.  The patient had been admitted to the hospital for anorexia, abdominal pain, and jaundice.  Laboratory results on the source patient 's blood are as follows: The volunteer admits that he is not vaccinated against hepatitis B.  Which of the following is the most appropriate next step in his management?

A 55-year-old man is admitted to the hospital due to fever and altered mental status.  He was seen in an urgent care clinic 2 days ago for cellulitis of the left leg, for which he received a prescription for oral doxycycline.  The patient has no other medical conditions and takes no medications.  Temperature is 39 C (102.2 F) , blood pressure is 80/60 mm Hg, and pulse is 112/min.  Oxygen saturation is 94% on 2 L/min of oxygen via nasal cannula.  The patient is drowsy but moves all the extremities on verbal command.  Examination of the left leg reveals significant tenderness with erythema, swelling, and warmth.  Laboratory results are as follows: Finger-stick blood glucose is 46 mg/dL.  Blood pressure improves to 100/70 mm Hg with a fluid bolus.  Which of the following is the most likely cause of the low glucose levels in this patient?

A 68-year-old woman comes to the office due to a 4-year history of pain and stiffness in the fingers of both hands.  The pain is worse after she does housework and improves with rest.  She also has morning stiffness lasting 10-15 minutes after awakening.  The patient has no other joint pains, weight loss, rash, or shortness of breath.  Medical history is notable for type 2 diabetes mellitus and Graves disease treated with radioiodine therapy.  She smoked cigarettes for 10 years and quit at age 40.  Vital signs are normal.  The image below shows examination findings in the hands, and the remainder of the physical examination is normal. Which of the following is the most appropriate next step in management?

A 23-year-old man comes to the office due to frequent, foul-smelling, bulky stools and weight loss over the last 6 months.  He has lost about 4.5 kg (10 lb) over the past 3 months.  He also has poor energy and occasional joint pains.  The patient has no previous medical problems and takes no medication.  He does not use tobacco, alcohol, or illicit drugs.  Vital signs are normal.  Examination shows mild pallor.  There is no hepatosplenomegaly or lymphadenopathy.  Hemoglobin is 10.2 g/dL and serum ferritin is 10 ng/mL.  Immunoglobulin A anti-tissue transglutaminase antibody screening is negative.  Small-bowel biopsy shows villous atrophy.  Which of the following is the most likely cause of this patient's symptoms?

A 35-year-old woman established primary care at a clinic 3 months ago.  Last month, she arrived unannounced, urgently requesting to see the same physician.  Due to a cancellation, she was seen later that day for the complaint of a rash on her chest.  The male physician completed a thorough but unremarkable physical examination in the presence of a female nurse practitioner.  Two weeks later, the patient comes to the same physician's office at closing time and without an appointment.  She complains of "needing to talk to the doctor immediately about a private matter."  She informs the receptionist that it is "absolutely critical" for her to be seen and examined for similar skin complaints that seem to "come and go" and "itch frequently."  The patient is calm but insists that an appointment with the female nurse practitioner is not acceptable and instead requests to see the physician privately, without the presence of another staff member.  Which of the following would be the most appropriate initial response by the physician?

An 8-month-old boy is brought to the emergency department due to fever and decreased appetite.  For the past 3 days, he has had fever despite receiving acetaminophen and ibuprofen.  Today, the patient has been refusing solid foods.  He is still breastfeeding, but the mother notes that his latch feels weak and he falls asleep within 1-2 minutes of feeding.  The patient has been awake only 2 hours today; most of that time, he was crying.  Immunizations are up to date.  He attends day care twice a week but has stayed home with his mother since becoming sick.  Temperature is 40 C (104 F) .  Blood pressure, pulse, and respirations are normal for age.  On examination, the patient appears sleepy and has a high-pitched cry when roused.  The anterior fontanelle is bulging.  The pupils are equal, round, and reactive to light.  Extraocular movements are normal.  There are no focal neurologic deficits.  Complete blood count and blood culture are pending.  Which of the following is the most appropriate next step in management of this patient?

A 45-year-old man comes to the office for routine follow-up.  The patient was diagnosed with hypertension and hypercholesterolemia a year ago and is taking hydrochlorothiazide and amiloride daily.  He currently feels well.  He does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 135/85 mm Hg.  Physical examination is unremarkable.  Laboratory results are as follows: There was no evidence of hemolysis when the blood sample was checked by the laboratory technician.  ECG demonstrates normal sinus rhythm with no other abnormalities.  Which of the following is the most appropriate next step in management of this patient?

A 27-year-old man comes to the office due to 2 weeks of malaise, anorexia, and fatigue.  The patient has had no cough, chest pain, arthralgias, or diarrhea.  He underwent an uncomplicated dental root canal procedure 4 weeks ago.  Medical history is otherwise unremarkable.  Temperature is 38.5 C (101.3 F) , blood pressure is 135/76 mm Hg, pulse is 90/min, and respirations are 18/min.  His fingernail is shown in the image below: An early diastolic murmur is heard at the left sternal border.  Chest x-ray is unremarkable.  ECG reveals normal sinus rhythm.  Urinalysis shows microscopic hematuria.  Which of the following is the best next step in management of this patient?

A 7-year-old girl is brought to the office for a routine physical examination.  She and her parents have no concerns.  The girl is in the second grade and has several friends at school.  She is doing well academically, can tie her shoes independently, and is an adept soccer player.  The patient is up to date on vaccinations and takes no daily medications.  Weight is at the 50th percentile and height is at the 5th percentile for age.  Examination shows a short, webbed neck and a broad chest with widely spaced nipples.  Cardiovascular evaluation of this patient would most likely reveal which of the following anomalies?

A 42-year-old man comes to the emergency department with sudden-onset severe abdominal pain and 2 episodes of vomiting.  He rates his pain as 9/10 in severity with radiation to the back.  He has never experienced these symptoms before and has no other medical problems.  The patient admits to binge drinking last night while watching a football game on television.  His temperature is 37.7 C (99.9 F) , blood pressure is 112/70 mm Hg, pulse is 102/min, and respirations are 16/min.  There is epigastric tenderness on palpation of the abdomen but no rigidity.  There is no evidence of hematemesis, and a guaiac smear is negative.  Initial laboratory findings include a normal hemoglobin and leukocytosis.  A chest radiograph and electrocardiogram are normal.  Which of the following is the best next step in management of this patient?

A 50-year-old man comes to the office with a 2-day history of malaise, fever, fatigue, and pain in the front of his neck.  He recovered from an upper respiratory illness a week prior to the onset of his current symptoms, but he previously had felt well.  The patient was seen in the clinic occasionally in the remote past for sexually transmitted infections, but his medical history is otherwise unremarkable.  He lives alone and is sexually active with both men and women.  Temperature is 38.5 C (101.3 F) , blood pressure is 150/70 mm Hg, and pulse is 110/min.  The thyroid gland is diffusely enlarged and tender.  Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

A 43-year-old woman with congestive heart failure, rheumatoid arthritis, and chronic hepatitis C with early liver cirrhosis complains of difficulty breathing.  Her temperature is 37.8 C (100 F) , blood pressure is 126/72 mm Hg, pulse is 97/min, and respirations are 28/min.  Pulse oximetry is 94% on room air.  Physical examination shows dullness to percussion at the right lung base.  Chest x-ray shows moderate-size right pleural effusion and cannot rule out underlying infiltrates.  Thoracentesis shows pleural fluid with glucose of 28 mg/dL and lactate dehydrogenase of 252 U/L.  Which of the following explains the low pleural fluid glucose concentration?

A 24-year-old man undergoes pulmonary function testing to evaluate dyspnea on exertion.  He has no other symptoms except chronic low back pain.  The pain is worse at night and improves upon arising and with exercise.  He only takes naproxen as needed for back discomfort.  He smokes 1 pack of cigarettes per day and drinks a 6-pack of beer each weekend.  His erythrocyte sedimentation rate is 77 mm/hr.  The following values are obtained: (FEV₁: Forced expiratory volume in 1 second; FVC: Forced vital capacity; FRC: Functional residual capacity) Which of the following best explains the pulmonary function test findings in this patient?

A 54-year-old man comes to the physician because of edema of his right ankle.  He reports heaviness and cramping in the same leg that is worse after a long day at work.  The swelling is usually reduced significantly when he wakes up in the morning and worsens progressively throughout the day.  He denies any other symptoms.  He has no significant medical problems except hypertension, for which he takes atenolol.  His temperature is 36.7° C (98° F) , blood pressure is 120/76 mm Hg, pulse is 80/min and respirations are 16/min.  JVP is normal. Lungs are clear to auscultation.  There are no murmurs.  There is no hepatosplenomegaly. Examination shows edema of the right ankle.  Doppler examination of the leg shows no evidence of thrombosis.  Which of the following is the most likely cause of his edema?