Items 434 through 437

A 35-year-old man complains of stumbling and slurred speech. His problem started several months earlier and has progressed slowly but consistently. On neurologic examination he is found to have scanning speech, nystagmus, limb dysmetria, and kinetic tremor. His intellectual function is normal.

4-34. The most appropriate investigation to request initially is a. Lumbar puncture b. Serum drug screen c. Routine urinalysis d. Posterior fossa myelogram e. Precontrast CT scan

4-36. A postcontrast CT scan reveals a cyst and two smaller masses in the left cerebellar hemisphere. Your recommendation is that the patient a. Submit to surgical resection of the cerebellar lesions as soon as possible b. Submit to radiation therapy of the cerebellar lesions immediately c. Have follow-up magnetic resonance imaging (MRI) to look for involution of the lesions d. Have a diagnostic lumbar puncture to look for evidence of parasitic infestation of the brain e. Have a needle biopsy of the cerebellum to establish the histology of the cystic lesion

4-35. Admission studies include a hematocrit of 55% and a routine urinalysis, which reveals excess protein and some red blood cells in the urine. Urine culture is negative. The initial physical examination reveals an enlarged liver and spleen. Additional physical findings will most likely include a. A Kayser-Fleischer ring around the cornea b. Hypopigmented (ash leaf) spots on the patient's trunk c. Telangiectasias in the fundi on retinal examination d. Bilateral hearing loss e. Generalized hyporeflexia

4-37. Within 6 years of the patient's initial visit, he returns with a pathologic fracture of his spine. Biopsy reveals metastatic cancer. The source of the tumor is most likely the a. Cerebral hemisphere b. Cerebellar hemisphere c. Liver d. Kidney e. Spleen

4-38. A 48-year-old man presents with peripheral edema. He has been healthy and physically active all of his life. His family history is unremarkable. His blood pressure is normal. On physical examination, the patient is noted to have anasarca. Kidneys are not palpable. Urinalysis reveals a moderate amount of pro-teinuria and "grape clusters" are seen under light microscopy. Which of the following is the most likely diagnosis?

a. Glomerulonephritis b. Rhabdomyolysis c. Nephrotic syndrome d. Acute interstitial nephritis e. Acute tubular necrosis

4-39. Your 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she should anticipate resumption of normal menses. You counsel her that by 3 mo after discontinuation of birth control pills, the following proportion of patients will resume normal menses a. 99%

4-40. A 55-year-old woman without a previous psychiatric history becomes depressed, withdrawn, and despondent. One month later the patient is diagnosed with cancer. Which type of carcinoma is most likely manifest with depressive symptoms?

a. Prostatic b. Renal c. Gastric d. Pancreatic e. Ovarian

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