Items 8-1 through 8-2

A 35-year-old man stumbles into the ER. His pulse is 100 beats/ min, his blood pressure is 170/95 mm Hg, and he is diaphoretic. He is tremulous and has difficulty relating a history. He does admit to insomnia the past two nights and states that he sees spiders walking on the walls. He has been a drinker since age 19, but has not had a drink in 3 days.

8-1. The most likely diagnosis is a. Alcohol-induced psychotic disorder b. Wernicke's psychosis c. Alcohol withdrawal delirium d. Alcohol intoxication e. Alcohol idiosyncratic intoxication

8-2. Initial treatment usually includes a.

Haloperidol 10 mg IM Chlorpromazine 50 mg IM Lithium 300 mg PO Chlordiazepoxide 50 mg PO Naloxone 1 mg IV

8-3. A 31-year-old man is brought to the emergency room following an automobile accident in which his chest struck the steering wheel. Examination reveals stable vital signs, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax, but a large pulmonary contusion is developing. Proper treatment consists of which of the following?

a. Tracheostomy, mechanical ventilation, and positive end-expiratory pressure b. Stabilization of the chest wall with sandbags c. Stabilization with towel clips d. Immediate operative stabilization e. No treatment unless signs of respiratory distress develop

8-4. A 25-year-old woman with blonde hair and a fair complexion complains of a "mole." The lesion is on the upper back. The lesion is 6 mm, darkly pigmented, and asymmetric with a very irregular border. The next step in management is to a. Tell the patient to avoid sunlight b. Follow the lesion for any evidence of growth c. Obtain a metastatic workup d. Obtain a full-thickness excisional biopsy e. Obtain a shave biopsy

8-5. A 14-year-old boy is seen in the emergency room because of a 3-wk history of fever between 38.3°C and 38.9°C (101°F and 102°F), lethargy, and a 6-lb weight loss. Physical examination reveals marked cervical and inguinal adenopathy, enlarged tonsils with exudate, small hemorrhages on the soft palate, a WBC differential that has 50% lymphocytes (10% atypical), and a palpable spleen 2 cm below the left costal margin. Which of the following conditions is the likely diagnosis?

a. HIV disease b. Varicella c. Kawasaki's disease d. Streptococcal throat infection e. Infectious mononucleosis

8-6. A 25-year-old woman presents to the delivery room in labor. She has had no prenatal care. The female newborn weighs 4.5 lb and has episodes of seizures shortly after birth. Irritability and hyper-tonicity are also noted. The most likely cause for these findings in the newborn is a. Cocaine b. Alcohol c. HIV

d. Syphilis e. Heroin

8-7. A 16-year-old high school student presents with the sudden onset of sharp right-sided chest pain associated with shortness of breath. He denies any history of trauma. On physical examination, the patient is afebrile with a respiratory rate of 28 breaths/min. His blood pressure is 100/70 mm Hg and his heart rate is 120 beats/min. Neck examination reveals no tracheal deviation. On lung auscultation, the patient has decreased fremitus, hyperresonance, and diminished breath sounds over the right posterior hemithorax. Which of the following is the most likely diagnosis?

a. Tension pneumothorax b. Secondary pneumothorax c. Pulmonary embolus d. Spontaneous pneumothorax e. Pneumonia

8-8. A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. The most common cause of this condition in girls is a. Idiopathic b. Gonadal tumors c. McCune-Albright syndrome d. Hypothyroidism e. Tumors of the central nervous system

8-9. A 42-year-old man presents to your office for a checkup. He has been in excellent health except for a recent diagnosis of mild hypertension and bilateral carpal tunnel syndrome. On physical examination, the patient is tall with large and doughy hands. His facial features are coarse and he has a prominent mandible with wide-spaced teeth. His voice is deep and he has macroglossia. Heart examination reveals the point of maximum impulse (PMI) to be displaced 2 cm laterally. Which of the following is the most likely diagnosis?

a. Acromegaly b. Gigantism c. Hypothyroidism d. Familial prognathism e. Amyloidosis

8-10. Incisional biopsy of a breast mass in a 35-year-old woman demonstrates a hypercellular fibroade-noma (cystosarcoma phylloides) at the time of frozen section. Appropriate management of this lesion could include a. Wide local excision with a rim of normal tissue b. Lumpectomy and axillary lymph-adenectomy c. Modified radical mastectomy d. Excision and postoperative radiotherapy e. Excision, postoperative radiotherapy, and systemic chemotherapy

8-11. Professional organizations recommend that all pregnant women be routinely counseled about HIV infection and be encouraged to be tested. What is the most important reason for early identification of HIV infection in pregnant women?

a. A cesarean section can be planned to reduce HIV transmission to the newborn b. Breast feeding can be discouraged to reduce transmission to the newborn c. Early identification of a newborn at risk of HIV infection will improve survival d. Counseling on pregnancy options, such as termination, can be offered e. Antiretroviral therapy can be offered to reduce the chance of transmission of HIV to the newborn

8-12. A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. The most useful test to make a definitive diagnosis would be a. Rheumatoid factor b. Antinucleolar antibody c. ECG

d. BUN and creatinine

8-13. A 42-year-old woman of Italian descent presents for a pre-employment physical examination. She has no past medical problems and takes no medications. Her physical examination is normal except for pale conjunctiva. FOBT is negative. CBC is remarkable for a hemoglobin of 11.4 g/dL, a MCV of 60 fL, and a reticulocyte count of 0.6%. White blood cell count and plate-lets are normal. Peripheral smear reveals microcytosis, hypo-chromia, acanthocytes (cells with irregularly spaced projections), and occasional target cells. Which of the following is the most likely diagnosis?

a. Iron-deficiency anemia b. Sideroblastic anemia c. Anemia of chronic disease d. Thalassemia trait e. Hemolytic anemia

8-14. A 68-year-old woman with a history of hypertension and diabetes mellitus presents with shortness of breath. She denies chest pain and palpitations. Physical examination reveals a blood pressure of 130/60 mm Hg and a heart rate of 72 beats/min. The patient's lungs are normal. Heart auscultation reveals an S4 gallop. There is no JVD and no peripheral edema. Chest radiograph shows a normal-sized heart and ECG shows left ventricular hypertrophy. Echo-cardiogram reveals concentric left ventricular hypertrophy with a hyperdynamic left ventricle. Which of the following is the most likely diagnosis?

a. Systolic dysfunction b. Diastolic dysfunction c. Left heart failure d. Right heart failure e. Normal heart

8-15. A pregnancy of approximately 10 wk gestation is confirmed in a 30-year-old gravida 5, para 4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the strings of the IUD are protruding from the cervical os. The most appropriate course of action is to a. Leave the IUD in place without any other treatment b. Leave the IUD in place and continue prophylactic antibiotics throughout pregnancy c. Remove the IUD immediately d. Terminate the pregnancy because of the near certain risk of infection, abortion, or both e. Perform laparoscopy to rule out an ectopic pregnancy

8-16. A 6-year-old boy has just been diagnosed with ADHD and started on methylphenidate 5 mg tid. The parents report that the child is able to focus better, is less hyperactive, and seems to have more tolerance for frustration. They are concerned, however, because he is never hungry. The child psychiatrist explains that decreased appetite is a common side effect of methyl-phenidate. Another, more serious side effect of this medication is a. Night terrors b. Choreiform movements c. Tics d. Cardiac arrhythmias e. Leukopenia

8-17. A 43-year-old woman complains of lancinating pains radiating into the right side of her jaw. This discomfort has been present for more than 3 years and has started occurring more than once a week. The pain is paroxysmal and is routinely triggered by cold stimuli, such as ice cream and cold drinks. The patient has sought relief with multiple dental procedures and has already had two teeth extracted. Multiple neuroimaging studies reveal no structural lesions in her head. Assuming there are no contraindications to the treatment, a reasonable next step would be to prescribe a. Clonazepam (Klonopin) 1 mg orally three times daily b. Diazepam (Valium) 5 mg orally two times daily c. Divalproex sodium (Depakote) 250 mg orally three times daily d. Indomethacin (Indocin) 10 mg orally three times daily e. Carbamazepine (Tegretol) 100 mg orally three times daily

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