Items 69 through 610

A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray; serum albumin, 3.2 mg/dL; serum calcium, 14 mg/dL; serum phosphorus, 2.6 mg/dL; serum chloride, 108 mg/dL; BUN of 32 mg/dL; creatinine of 2.0 mg/dL.

6-9. Appropriate initial management includes a. Intravenous normal saline infusion b. Administration of thiazide diuretics c. Administration of intravenous phosphorus d. Use of mithramycin e. Neck exploration and parathy-roidectomy

6-10. After appropriate immediate management, the patient's symptoms resolve. Diagnostic tests to perform at this point include which of the following?

a. Abdominal angiogram b. Measurement of serum gastrin hormone levels c. Kveim test d. Serum and urine protein electro-phoresis e. Neck exploration

6-11. The parents of an 8-year-old boy with a normal IQ are concerned because he is a very slow reader and does not appear to understand what he reads. When the boy reads aloud, he misses words and changes the sequence of the letters. Choose the correct statement about this disorder.

a. It is diagnosed on the basis of a defect in visual or hearing acuity b. It is often associated with spelling and verbal language difficulties c. It occurs in less than 1% of the population d. It occurs more often in girls than boys e. It is often associated with brain-stem neurologic defects

6-12. A 22-year-old man presents with a 6-mo history of a red, non-pruritic rash over his trunk, scalp, elbows, and knees. These eruptions are more likely to occur during stressful periods and have occurred at sites of skin injury. On exam, sharply demarcated plaques with a thick scale are seen. Which of the following statements is correct?

a. Lesions are contagious, and contact should be carefully avoided b. The patient is allergic to metals c. The clinical description is most consistent with psoriasis d. The rash is unrelated to stress

6-13. The crude death rate in the United States is 150 per 100,000. The crude death rate in a smaller, developing country is 75 per 100,000. Based on these data, which one of the following statements best explains this data?

a. The health care system of the developing country is far better than that of the United States b. More people die in the United States because it has a larger population c. Infant mortality in the first week is higher in developing countries, but it is not included in the crude death rate d. Death rates in the developing country are lower due to the emigration effect e. Crude death rates are usually higher in developed countries because of a higher proportion of older persons in the population

Items 6-14 through 6-15

A 68-year-old hypertensive man undergoes successful repair of a ruptured abdominal aortic aneur-ysm. He receives 9 L of Ringer's lac-tate solution and 4 units of whole blood during the operation. Two hours after the patient is transferred to the surgical intensive care unit, the following hemodynamic parameters are obtained:

Systemic blood pressure (BP): 90/60

mm Hg Pulse rate: 110 beats/min Central venous pressure (CVP): 7 mm Hg

Pulmonary artery pressure: 28/10 mm Hg

Pulmonary capillary wedge pressure (PCWP): 8 mm Hg Cardiac output: 1.9 L/min Systemic vascular resistance: 35 Woods units (normal: 24 to 30 Woods units) PaO2: 140 kPa (Fi02: 0.45 kPa) Urine output: 15 mL/h (specific gravity: 1.029) Hematocrit: 35%

6-14. Proper management now calls for a. Administration of a diuretic to increase urine output b. Administration of a vasopressor agent to increase systemic blood pressure c. Administration of a fluid challenge to increase urine output d. Administration of a vasodiluting agent to decrease the elevated systemic vascular resistance e. A period of observation to obtain more data

6-15. The patient then has an improvement in all hemodynamic parameters. However, 6 h later he develops ST segment depression, and a 12-lead electrocardiogram shows anterolateral ischemia. New hemodynamic parameters are obtained:

Systemic BP: 70/40 mm Hg Pulse rate: 100 beats/min CVP: 18 cm H2O PCWP: 25 mm Hg Cardiac output: 1.5 L/min Systemic vascular resistance: 25 Woods units

The single best pharmacologic intervention is a. Sublingual nitroglycerin b. Intravenous nitroglycerin c. A short-acting beta blocker d. Sodium nitroprusside e. Dobutamine

6-16. A 38-year-old HIV-infected woman presents for follow-up evaluation. She is on antiretroviral therapy. She has no complaints. Her physical examination is normal. Her PPD is reactive at 2 mm. Chest x-ray is normal. The patient has no history of past TB or recent known contact with infectious TB. She lives at home alone. Her CD4 + T cell count is 180/^L. Her previous count was 175/^L. Prophylaxis is most appropriate for which of the following infections?

a. Mycobacterium avium complex (MAC)

b. Cryptococcus neoformans c. M. tuberculosis d. Toxoplasma gondii e. Pneumocystis carinii

6-17. A 4-year-old boy exhibits the onset of episodes of loss of body tone with associated falls as well as generalized tonic-clonic seizures. His cognitive function has been deteriorating. EEG shows 1.5-to 2-Hz spike and wave discharges. The most likely diagnosis is a. Landau-Kleffner syndrome b. Lennox-Gastaut syndrome c. Juvenile myoclonic epilepsy d. Mitochondrial encephalomyopathy e. Febrile seizures

6-18. In a seemingly healthy child, the polymorphonuclear neutrophil shown in the following illustration is most likely to be associated with a. Malignancy b. Iron deficiency c. Folic acid deficiency d. Dohle inclusion bodies e. Pelger-Huët nuclear anomaly

Reproduced, with permission, from Yetman RJ: Pediatrics: PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.

6-19. An emaciated and lethargic 16-year-old girl arrives in the ER. Her BP is 75/50, her HR is 52, her potassium is 2.8, and her bicarbonate is 40 meq/L. The girl's parents report that she has lost 35 lb in 3 mo but is still convinced that she is overweight. She eats only very small amounts of low-calorie food and she runs 2 to 3 h every day. What other activity is the patient likely to have engaged in?

a. Sexual promiscuity b. Ethanol abuse c. Purging d. Wearing tight clothes e. Shoplifting

6-20. A 20-mo-old child presents to your office with a mild viral infection. The results of examination are normal except for a temperature of 37.2°C (99°F) and clear nasal discharge. Review of the patient's vaccination records reveals that she received only two doses of polio vaccine and diphtheria-tetanus-pertussis (DTaP) vaccine, and that she did not receive the measles-mumps-rubella (MMR) vaccine. The mother is 20 wk pregnant. Her brother is undergoing chemotherapy for leukemia. Which of the following is the most appropriate intervention?

a. Schedule a visit in 2 wk for DTaP

b. Administer inactivated polio vaccine (IPV) and DTaP

c. Administer DTaP, oral polio vaccine (OPV), and MMR

d. Administer DTaP, IPV, and MMR

e. Administer DTaP and OPV and schedule a visit in 3 mo for MMR

6-21. You are awakened in the night by your 2-year-old son, who has developed noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough. He has had a mild upper respiratory infection (URI) for 2 days. The most likely diagnosis is a. Asthma b. Epiglottitis c. Bronchiolitis d. Viral croup e. Foreign body in the right main stem bronchus

6-22. A 55-year-old man, as part of a review of systems, describes an inability to achieve erection. The patient has mild diabetes and is on a beta blocker for hypertension. The first step in evaluation is a. Serum testosterone testing b. Serum gonadotropin testing c. Information about libido and morning erections d. Papaverine injection

6-23. A 23-year-old man presents complaining of hematuria for 1 day. He has no other symptoms but states the hematuria started after he played in a fast-paced basketball game. He takes no medications and does not drink alcohol or use illicit drugs. He recalls having a sore throat yesterday but denies cough or fever. He takes no medications and has no family history of renal disease. Physical examination is normal. Rapid streptococcal antigen test is negative. Urinalysis reveals erythrocytes and erythrocyte casts. Which of the following is the most likely diagnosis?

a. Bladder carcinoma b. IgA nephropathy c. Poststreptococcal glomerulonephri-tis d. Alport syndrome e. Minimal change disease

6-24. You are discussing surgical options with a patient with symptomatic pelvic relaxation. Partial colpocleisis (Le Fort procedure) may be more appropriate than vaginal hysterectomy and AV repair for patients who a. Do not desire retained sexual function b. Need periodic endometrial sam-

plmg c. Have had endometrial dysplasia d. Have cervical dysplasia that requires colposcopic evaluation e. Have a history of urinary incontinence

6-25. A 65-year-old retired steel-worker, who has never had any sexual dysfunction, experiences difficulties in obtaining and maintaining an erection shortly after he starts taking a medication prescribed by his primary care physician. What medication is most likely to cause such a side effect?

a. Propranolol b. Amoxicillin c. Lorazepam d. Buproprion e. Thyroid hormone

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