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Question 151

What is the best measure to reduce ihe incidence oiL postoperative pulmonary complications?

(A) Cessation of smoking preoperative^

(B) Incentive spirometry preoperatively

(C) Refusal to give patients narcotics postoperatively

(D) Positive-pressure mechanical ventilation postoperatively

(E) Prophylactic antibiotics perioperatively Question 152

A 32-year-old nonsmoking man with no medical history presents to the office with the chief complaint of hoarseness. He was at a basketball game the night before cheering loudly for his favorite team. When he woke up this morning, he noticed his voice was hoarse. Review of systems and physical examination are within normal limits. Which of the following is the next appropriate step ?

(A) Laryngoscopy

(B) Empirical antibiotics

(C) Reassurance

(D) Throat culture

(E) Full metabolic profile

Question 153

A 22-year-old woman is brought to the emergency department after an automobile accident and is unconscious, not breathing, and bleeding profusely with unstable vital signs. What is the first appropriate step ill tlte management of this patient?

(A) Obtain a full medical history from family members.

(B) Perform a thorough physical examination.

(C) Establish an airway and institute mechanical ventilation.

(D) Blood type and crossmatch, then transfuse 2 U packed red blood cells.

(E) Establish intravenous access, and administer a fluid challenge with Ringer's lactate.

What is the most likely diagnosis in a previously healthy 14-year-old with periumbilical pain associated wiLh nausea and vomiting whose pain subsequently shifts to the right lower quadrant and increases in severity?

(A) Cholecystitis

(B) Appendicitis (Q Crohn's disease

(D) Meckel's diverticulum

(E) Small bowel obstruction

Question 155

In a 45-year-old patient with epigastric pain that radiates through to the back and a markedly elevated amylase and lipase, which of the following is the least likely cause of the probable diagnosis?

(A) Corticosteroid treatment

(B) Hypocalcemia

(C) Alcohol abuse

(D) Gallstones

(F) Trauma

Question 156

In which of the following causes of peritonitis is laparotomy least likely to be one of the appropriate treatment options?

fA) Appendicitis

(B) Cholecystitis

(C) Diverticulitis

[D> Spontaneous bacterial peritonitis

IE) Small bowel obstruction caused by adhesions

Question 157

Which of the following conditions does not have an increased incidence in the setting of a multiple-gestation pregnancy?

(A) Maternal preeclampsia (B; Fetal macrosomia (C) Postpartum uterine atony (D> Vasa previa

(E) Perinatal morbidity

Which of the following treatments is least likely to he helpful in a person with severe, acute liver failure"?

(A) Intravenous fluids

(B) Glucose

(C) Fresh frozen plasma

(E) Addressing the underlying cause of the liver failure Question 159

A woman, gravida 1, para 2, has a routine urinalysis that shows 4+ bacteria at 28 weeks. She is asymptomatic, is afebrile, and has no abnormalities on physical examination. What is the best treatment?

(A) Nothing

(B) Amoxicillin

(C) Ciprofloxacin

(D) Repeat the urinalysis in 6 weeks

(E) Culture of the urine and treatment only if the culture reveals a gram-negative organism

Question 160

A pregnant woman has intractable nausea and vomiting in the first trimester that requires hospitalization for electrolyte abnormalities and inability to keep food down. Which of the following is likely to be true?

(A) The woman is older than age 30,

(B) The woman has several children.

(C) The woman has multiple underlying social stressors.

(D) The woman does not meet the strict criteria for hy-peremesis gravidarum.

(E) The woman has a malignant choriocarcinoma,

Question 161

A 42-year-old executive comes to the office complaining of severe headaches, fatigue, and irritability, Withdrawal from which of the following substances is most likely?

(A) Barbiturates

(B) Marijuana

(D) Benzodiazepines

(E) Caffeine

A 17-year-old girl frequently has injected conjunctiva, locks herself in her room and listens to music for hours on end, and then comes into the family mom looking for food and acting strange. Her parents complain that she has a total lack of motivation. Which of the following is true about the illegal drug she is most likely to be abusing?

(A) It is often used by teenagers for its weight-loss effects,

(B) It may be fatal in overdose,

(C) It has moderate to severe teratogenic effects.

(D) The physical withdrawal symptoms are severely uncomfortable but rarely fatal.

(E) It is the most commonly abused illicit drug,

Question 163

Which of the following is the most likely cause of deaLh in a 16-year-old?

(A) Accident

(B) Homicide

(E) Congenital malformation Question 164

A mother brings in her 2.5-vcar-old child complaining that the child wets her bed two to three times per week. This bedwetting has been going on since birth, although it has decreased in frequency, and it has not resolved with standard behavioral modification techniques that the mother read about, The child has no medical history, Physical examination and urinalysis are normal. Which of the following is true?

(A) Imipramine can be tried.

(B) Uiofeedback is the next treatment of choice.

(C) The child should be spanked whenever bedwetting occurs.

(D) No further treatment for the bedwetting is required at this time.

(E) The child most likely has a congenital urinary tract abnormality.

Questifir 165

A 17-year-old girl comes lo the office for a school physical. She is wearing baggy clothes and seems concerned about her appearance. Physical exam is essentially normal, but you notice some erosion of the skin over the knuckles of the right hand and erosion of some of the enamel on the back of the teeth. The patient has a weight appropriate for height. The patienl has a normal mood and affect and says her only problem is that she is fat. Which of the following is most important to ask about?

(A) Arthritis

(B) Recurrent sore throats and fevers (O Familial bone disorders

(D) Purging behavior tE} Depression

Question 166

A 17-year-old girl broke up with her boyfriend last week and has been moping around the house, crying many times a day since the breakup. She is not interested in talking to her girlfriends when ihey call to console Iter. She has missed a day of school as well Which of the following is the most likely diagnosis?

(A) Major depression

(B) Cyclothymia

(C) Adjuslnient disorder with depressed mood (D> Bipolar 1 disorder, currently depressed

(E) Dysthymic

Question 167

Which of the following is the most likely source of error if an experimenter knows which subjects have been assigned into I he treatment and placebo groups'.'

(A) Recall bias

(B) Unacceptabilitv bias

(C) Interviewer bias

(D) Lead-time bias

(E) Nonresponse bias

An experimenter does a prospective study after placing 50,000 subjects who are equally matched for demographic and lifestyle variables into one of two groups based on the number of pills they take each day (< 3 pills, > 3 pills). He measures only the number of pills subjects lake and ihcir mortalily dala over a 5-year period. He noles that subjects who take more pills are more likely to die and concludes that medications cause an unacceptable number of deaths. Which of the following is the most likely reason for his conclusion Do be invalid?

(A) Nonrandoin bias (R) Lead-time bias (C) Confounding variables (P) Type II error (E) Interviewer bias

Question 169

Which of the following is true regarding commonly used tests that screen for or confirm disease?

(A) Highly specific tests are preferred for screening. IB) Increased specificity can be obtained by increasing sensitivity.

(C) Screening usually is not recommended for chionic, ulitreatable conditions.

(D) Positive predictivc value increases when ihc disease is rare.

(E) The primary goal with screening tests is to have the lowest possible false-positive rate.

Question 170

Which of the following is true regarding indications for ihc measles-mumps-rubella vaccine in adults, assuming that they have not yet been vaccinated?

(A) All immunocompromised patients should be vaccinated. (R) Pregnant women should be vaccinated.

(C) Health care workers should not be vaccinated because of ihc potential risk of giving the diseases lo patients.

(D) Human immunodeficiency virus-positive patients should receive the vaccine,

(E) This vaccine is especially indicated in those with an anaphylactic reaction lo eggs.

Which of the following concerning vaccines is correct?

(A) Patient desire is not a valid indication for the hepatitis B vaccine.

(B) Influenza should be offered to all adults older than age 65. regardless of health status.

(C) The pneumococcal vaccine should rot be given to any patients younger than age 20.

(D) Pediatric patients whet take aspirin should avoid the influenza vaccine because of concerns over Reye's syndrome.

tFl A tetanus booster vaccine should noL be given to adults, unless they sustain a nonclean or nomninor wound, owing to vaccine toxicity concerns.

Question 172

Which of the following is true concerning persons older than age 65?

(A) About 40-50^ suffer from dementia.

(B) Only about live in a nursing home.

(C) Approximately 2% of the population is older than age 65.

(D) Sundmvning is a normal phenomenon in the elderly.

(E) Elderly people are lens likely to commit suicide than younger people are.

Question 173

A 29-y ear-old man presents to the emergency départirent with shortness of breath, faligue, and headache. Medical history is in sign i lie ant, although the patient has noted feeling tired with a nagging dry cough and diarrhea over the past few months. The man is a homosexual with multiple partners and denies alcohol, tobacco, or illicit drug use. He mentions that his pants seem a little loose on him lately, but he is not sure if he has lost weight. On examination, the man is thin and mildly tachypneic with a temperature of 101.2" F. His breath sounds are clear bilaterally, and the heart rate is mildly tachycardie but regular. A radiograph shows diffuse, bilateral interstitial infíltrales, and an arterial blood gas measurement reveals a Pa02 of 5K. Which of the following is most likely to be true?

(A) Pneumococcal pneumonia is likely.

(B) The white blood cell count is probably normal or low.

(C) A broad-spectrum cephalosporin or fluoroquinolone is the preferred treatment.

ÍD) The sexual history is not relevant. (E) The clear breath sounds point toward a noninfectious cause.

Which of the following is true regarding human immunodeficiency virus (HIV) infection?

(A) HIV infection is automatically called acquired immunodeficiency syndrome [AIDS) when the CD4 count drops to less than 400. even withoul symptoms.

(B) Initial infeclion with HIV often clinically resembles infectious mononucleosis.

(C) Initial testing for HIV is done with enzyme-linked immunosorbent assay (ELISA). which also is the confirmatory test.

(D) The HIV Lest is nearly universally positive within 2 weeks of initial infection.

(E) HIV patients should not receive any form of polio vaccine.

Question 175

Which of the following is not considered an example of a cytotoxic or type II hypersensitivity reaction?

(A) Goodpasture's syndrome (Bt Hyperacute transplant rejection

(C) Pemphigus

(D) A u toimmu ne hemolytic anemia caused by methy I-dopa

(E) The tuberculosis skin test (purified protein derivative [PPD|>

Question J76

A 32-year-old man is given oral amoxicillin in the emergency department and 20 minutes later develops shortness [if breath, wheezing, facial Swelling, and decreased blood pressure. He rapidly begins to deteriorate with unstable vital signs, and you attempt intubation. Vou are unable to pass the tube because of laryngeal edema, and the patient loses consciousness. What should you do next?

(A) Start intravenous lluids. (R) Administer diphenhydramine.

(C) Perform cricothyroidoiomy.

(D) Administer subcutaneous epinephrine. Administer corticosteroids.

Question 177

Which of the following is not true regarding muscular dystrophy?

(A) It is an X-linked recessivc disorder.

(B) Creatine phosphokinase levels usually are low at the time of presentation,

(C) It no rim ally affects children before age 7,

(D) Muscle biopsy can be used to confirm the diagnosis.

(E) The condition is thought to be due to a disorder of dystrophin.

Quesliun 17«

A 56-year-old female smoker conies to the office complaining of fatigue and vision problems. She notes in-tenuiLtent double vision, usually toward the end of the day accompanied by muscular fatigue for the last 3 weeks. The fatigue has been gradually getting worse. The woman denies previous problems similar to this and denies any change in visual acuity. Phvsical examination reveals mild ptosis and global, mild muscular weakness that gets worse with continued testing. Reflexes and sensory examination are within normal limits, and there is no muscular tenderness to palpation. The creatine phosphokinase level is normal. Which of the following is true concerning the most likely diagnosis?

(A) Thymectomy usually is advised.

(B) The pathophysiology involves vasculitis as the primary event

(C) The patient needs immediate corticosteroid administration.

(D) The histologic type is most likely to be small cell,

(E) Diagnosis is made by muscle biopsy.

Which of the following is true regarding cancer screening in adults?

(A) Annual stool testing for occult blood should he done starting at age 50, with a baseline sigmoidoscopy or barium enema around this time as well.

(B) In smokers, annual sputum cytology and chest radiograph should be done after age 50.

(C) Annual breast self-examinations for women should begin at the age of 30.

(D) Annual Pap smear for women should begin at the age of 30 whether or not women are sexually active.

(E> Annual prostate-specific antigen (PSA) levels for men should begin at age 30.

Question 181

A 32-y ear-old woman complains of excessive perspiration, palpitations, and fatigue. On questioning, she admits lo anxiety, difficulty sleeping, and diarrhea. She was diagnosed with generalized anxiety disorder by her previous physician and given buspirone, which she is still taking. On examination, you note tachycardia with an irregular rate and shiny, red, indurated skin over both shins. Which of the following is true concerning the most likely diagnosis?

(A) It is mediated by a viral infection.

(B) Alprazolam is more effective lor treatment.

(C) Thymectomy usually is indicated.

(D) Radioactive ablation is used commonly in treatment.

(E) Markedly elevated urinary catecholamine breakdown products are likely.

Question 179

A 67-year-old man has gradual onset of slow^ movement. muscular rigidity, resting hand tremor, and an unstable, shuffling gait. His affect also seems quite flat-Which of'the following is not likely to be true?

(A) He is at an increased risk of suicide.

(B) His symptoms could be caused by medication.

(C) He has an increased risk cf developing dementia.

(D) lie may need medications that block dopamine receptors to treat these symptoms.

ili} He may need medications that block anticholinergic receptors to treat these symptoms.

A 24-year-old patient presents with a chief complaint of an itchy rash. On examination, the patient has vesicles. papules, and wheals on the extensor aspects of the elbows and knees with excoriations. The rest of the examination is within normal limits. The patient also mentions 6 months of diarrhea and some weight loss for which he had a colonoscopy 3 months ago, which was negative. The patient denies any history of abdominal pain. A biopsy of the skin lesions reveals IgA deposits. Stool testing reveals steatorrhea. Which of the following is most likely to be true?

(A) A jejunal biopsy would reveal fingerlike villi with a villus to crypt ratio of roughly 4:1,

(B) A gluten-free diet most likely would reduce symptoms,

(Cj Antibiotics would cure the symptoms.

(D) Serum gastrin level is extremely high.

(E) You would expect to see a small bowel stricture with a barium study.

Question 183

A 32-year-old black woman presents with shortness of breath that has been increasing gradually in severity over the last few months. On examination, breath sounds arc clear, The patient mentions shin pains, and you notice multiple red nodules in the pietibial area bilaterally that are tender to palpation. A chest radiograph reveals hilar adenopathy and ground-glass-appearing, bilateral infiltrates in the lung fields. Which of the following is most likely?

(A) Leukemia

( B ) Goodpasture's syndrome

(C) Paragonimiasis

(D) Tuberculosis

(E) Sarcoidosis

Question 184

Which of the following antibiotics is most likely to cause photosensitivity?

(A) Tetracycline

(B) Ciprofloxacin

(C) Amoxicillin

(D) Ceftriaxone

(El Chloramphenicol

A 10-year-old child is brought to the emergency department after playing with a neighbor's cat and being bitten on the hand by the cat. The bite appears deep. Which of the following is a correct part of the initial management of the wound?

(A) Suture any lacerations present.

(B) Give the rabies vaccine.

(C) Cauterize the wound.

(D) Avoid cleaning the wound with soap.

(E) Give prophylactic antibiotics.

Question 186

A 10-month-old infant is brought to the office in January because of "the flu." The infant had a runny nose and low-grade fever 2 days ago and now is breathing faster than normal. On examination, you hear expiratory wheezing and note some intercostal retractions. Which is true of the most likely diagnosis?

(A) You should not examine the throat because you may precipitate airway obstruction. (B.) Ampicillin and erythromycin are good choices for treatment,

(C) Chest radiograph is most likely to show bilateral, diffuse ground-glass infiltrates.

(D) The best treatment is supportive (e,g. oxygen, intravenous fluids, bronchodilators).

(E) The most likely cause is Staphylococcus aureus.

Question 187

A 27-year-old man presents to the emergency department 2 weeks after a hiking trip in Virginia, complaining of severe headache, fever, and fatigue. He says the symptoms started 3 days ago and have been getting worse. He mentions a rash on his arms and legs that started this morning and is starting to spread. On examination, the patient is ill appearing and has an erythematous macular rash on the distal aspccts of all four extremities ranging from the wrist and ankle to the mid-forearm and shin. His temperature is I04C'F. Which of the following is most likely true?

(A) The patient was bitten by a tick.

(B) The patient was exposed recently to someone with a severe sore throat.

(C) "I'he patient was exposed recently to a sexually transmitted disease.

(D) The patient has not received standard childhood immunizations.

(E) The patient has been exposed recently to Rorrelia burgdorferi.

Question IKS

A 22-year-old woman presents to the office complaining of sore throat, headache, fever, severe fatigue, and "feeling lousy" for the past 6 days. On examination, you note prominent cervical adenopathy, pharyngeal erythema, mild splenomegaly, and a temperature of 99.9° F, The patient has not been sick or sexually active in more than 2 years. She reports no abnormal weight loss or other symptoms. Which of the following would he inconsistent with the most likely diagnosis on the complete blood count and peripheral blood smear'?

(A) Large numbers of atypical, toxic-appearing lymphocytes

(B) Lymphocytosis

(E) Thrombocytopenia

Question 189

A 42-year-old man presents for a routine checkup. He has no complaints, has a medical history significant for seasonal allergies, and takes no medications other than as-needed diphenhydramine, You notice some lesions around the patient's eyes, but the physical examination is otherwise unremarkable.

A 35-year-old woman comes to the office complaining of fatigue, nervousness, and palpitations. Her appearance is shown in the figure:

Which of the following is incorrect regarding the most likely condition?

(A) Thyroid-stimulating hormone level is likely to be low.

(B) Diarrhea or hyperdefecation would not be unusual.

(C) The condition is thoughL to be due to the stimulating effects of an antibody.

(D) The primary treatment is surgical.

(E) Treatment usually can improve or eliminate symptoms.

Which of the following is the most appropriate course of action regarding the lesions?

(A) Observe carefully and see the patient again in 2 months.

(B) Take an excisional biopsy.

(C) Perform laser removal of the Lesions

<D) Check the patient's fasting serum lipid profile. (E) Refer the patient to an ophthalmologist.

191-1% Matching

Match the description with the appropriate personality disorder. Each item can be used as often as needed to answer the questions,

(B) Schizoid

(C) Schizotypal

(D) Avoidant

(E) Histrionic

(F) Narcissistie

(G) Antisocial

(H) Borderline ([> Dependent

(J) Obsessive-compulsive

191 The rules are more important than the objectives

192 Sometimes called an inferiority mm pi ex

193 Wife who continuously slays with an abusive husband

194 The classic loner who does not desire company

195 Splitting and constant crises are common

196 Requires pediatric disorder tu diagnose formally

Decide which cerebrospinal fluid [CSF} profile best fits the clinical description. Each answer can be used only once, if at all.

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