Items 415 through 416

4-15. A 1-day-old infant who was born by a difficult forceps delivery is alert and active. She does not move her left arm, however, but keeps it internally rotated by her side with the forearm extended and pronated; she also does not move it during a Moro reflex. The rest of her physical examination is normal. This clinical picture most likely indicates a. Fracture of the left clavicle b. Fracture of the left humerus c. Left-sided Erb-Duchenne paralysis d. Left-sided Klumpke paralysis e. Spinal injury with left hemiparesis

4-16. The infant in the previous question immediately develops tachypnea with cyanosis. She improves somewhat on oxygen but has predominantly thoracic breathing movements, and the chest x-ray, which appears to have been taken inadvertently at expiration, seems normal. The procedure most likely to provide a specific etiologic diagnosis is a. Venous blood gas b. CT scan of the head c. Ultrasound or fluoroscopy of the chest d. Bronchoalveolar lavage e. Blood culture

4-17. A 30-year-old woman complains of fatigue, constipation, and weight gain. There is no prior history of neck surgery or radiation. The patient's voice is hoarse and her skin is dry. Serum TSH is elevated and T4 is low. The most likely cause of these findings is a. Autoimmune disease b. Postablative hypothyroidism c. Pituitary hypofunction d. Thyroid carcinoma

4-18. A 42-year-old man with no history of use of nonsteroidal anti-inflammatory drugs (NSAIDs) presents with recurrent gastritis. Infection with Helicobacter pylori is suspected. Which of the following statements is true?

a. Morphologically, the bacteria is a gram-positive, tennis-racket-shaped organism b. Diagnosis can be made by serologic testing or urea breath tests c. Diagnosis is most routinely achieved via culturing endoscopic scrapings d. The most effective way to treat and prevent recurrence of this patient's gastritis is through the use of single-drug therapy aimed at eradicating H. pylori e. The organism is easily eradicated

4-19. A 23-year-old woman presents to your office for a prenatal visit. She has not received any previous prenatal care and does not know the date of her last menstrual period. On physical examination, the fundal height is palpated to be at the level of the umbilicus. Which of the following is the estimated number of weeks of gestation?

4-20. A 19-year-old college student presents to the university student health center complaining of severe coughing spells for the last 4 days, following initial symptoms of coryza and malaise. She is afebrile. Her medical history is uneventful, and immunizations are up to date. She is a member of the basketball team. During weekends, she babysits a 10-mo-old and a 2-year-old. In terms of management of contacts, which eti-ological agent is the most important to include in the differential diagnosis?

a. Streptococcus pneumoniae b. Mycoplasma pneumoniae c. Bordetella pertussis d. Influenza virus e. Legionella pneumophila

4-21. A 61-year-old man develops progressive cramping of his legs and pins and needles sensations in his feet over the course of a year. He consulted a physician when he noticed the paresthesias in his hands and unsteadiness of his gait. The patient's family reports that he has had some urinary incontinence, but was too embarrassed to report it. On examination, the patient has a spastic paraparesis with severe disturbance of position and vibration sense in his legs. Despite obvious spasticity in the legs, the deep tendon reflexes are absent at the knees and ankles. Peripheral blood smear reveals hypersegmented polymor-phonuclear leukocytes. Select the nutritional deficiency that is most likely responsible.

a. Deficiency amblyopia b. Vitamin B12 deficiency c. Pyridoxine (vitamin B6) deficiency d. Vitamin E (a tocopherol) deficiency e. Vitamin D deficiency f. Thiamine (vitamin B1) deficiency g. Nicotinic acid deficiency h. Kwashiorkor i. Vitamin C deficiency

4-22. Two weeks after hospital discharge for documented myocardial infarction, 65-year-old Mr. Chang returns to your office very concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and heart exam is free of significant murmurs, gallops, or rubs. ECG is unchanged from the last ECG in the hospital. The most effective therapy is likely a. Antibiotics b. Anticoagulation with warfarin (Cou-madin)

c. An anti-inflammatory agent d. An increase in antianginal medication e. An antianxiety agent

4-23. An adolescent presents to the emergency room with his distraught parents. His neck is bent to one side, his eyes are rolled upward, and his tongue is hanging out of his mouth. These symptoms disappear after he is given 50 mg of Benadryl intravenously. When he is able to talk, the boy admits that, earlier that evening, he had taken "a few pills" at a party. Which of the following is most likely to cause these symptoms?

a. Methamphetamine b. Demerol c. Alprazolam d. Methylphenidate e. Haloperidol

4-24. A 28-year-old patient, GoPoAo, comes for her first prenatal visit at 6 wk of pregnancy. Her examination is normal for gesta-tional age. Her history reveals that she does not smoke. She drinks one glass of wine about 2 days a week. She has been married for 3 years and her husband is her only sexual partner. She is employed as a paralegal. Her family history is negative. She is very concerned about preserving the mental and physical health of her baby. Which of the following interventions is most likely to reduce the risk of neurological defect in the infant?

a. Eliminating alcohol use b. Folic acid supplements c. Ultrasound d. Amniocentesis e. a fetoprotein testing

4-25. On a routine well-child examination, a 1-year-old boy is noted to be pale. He is in the 75th percentile for weight and the 25th percentile for length. Results of physical examination are otherwise normal. Having performed a complete history and physical examination on the patient, you proceed with a diagnostic workup. Initial laboratory results are as follows:

Hemoglobin: 8 g/dL Hematocrit: 24%

Leukocyte count: 11,000/|L with 38% neutrophils, 7% bands, 55% lymphocytes Hypochromia on smear

Free erythrocyte protoporphyrin (FEP): 110 |g/dL

Lead level: 7 |g/dL, whole blood

Platelet count: adequate

Reticulocyte count: 0.5%

Sickle cell preparation: negative

Stool guaiac: negative

Mean corpuscular volume (MCV): 65 fL

You would most appropriately recommend a. Blood transfusion b. Oral ferrous sulfate c. Intramuscular iron dextran d. An iron-fortified cereal e. Calcium EDTA

You Should Have Completed Approximately 25 Questions and Have 30 Minutes Remaining.

4-26. A 60-year-old man with a history of appendectomy 30 years ago presents to the emergency room complaining of abdominal pain. He describes the pain as colicky and crampy and feels it builds up and then improves on its own. He has vomited at least 10 times since the pain started this morning. He states that he has not had a bowel movement for 2 days and cannot recall the last time he passed flatus. The abdomen is slightly distended. Abdominal auscultation reveals high-pitched bowel sounds and peristaltic rushes. Percussion reveals a tympanic abdomen. The patient is diffusely tender on palpation but has no rebound tenderness. Rectal examination reveals the absence of stool. Which of the following is the most likely diagnosis?

a. Cholecystitis b. Diverticulitis c. Pancreatitis d. Gastroenteritis e. Intestinal obstruction

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