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

Items 6-26 through 6-28

An 80-year-old man has a history of 2 years of progressive gait disturbance and incontinence that has been attributed to old age and prostatism. Within the past 3 mo, the patient has been forgetful, confused, and withdrawn. His gait is short-stepped, and he turns very slowly, almost toppling over. He has a history of head trauma 30 years ago. His CT scan is shown on the following page.

Reproduced, with permission, from Elkind MSV: Neurology:PreTest Self-Assessment and Review, 4th ed. New York, McGraw-Hill, 2001.

6-26. The most likely diagnosis is a. Alzheimer's disease b. Creutzfeldt-Jakob disease c. Progressive multifocal leukoencephalopathy (PML)

d. Normal pressure hydrocephalus e. Chiari malformation

6-27. The patient undergoes lumbar puncture. Forty cc of fluid are removed. Three hours later the patient is able to walk unassisted, and turns well. Spinal fluid would be expected to show a. No abnormalities b. Elevated protein c. Low protein d. Atypical lymphocytes e. Low glucose

6-28. The patient undergoes ven-triculoperitoneal shunt placement. He is discharged 2 days later, his gait and cognition much improved. The following morning his wife finds him lying in bed, very confused, and complaining of a headache. He is unable to walk. The surgeon who performed the procedure is concerned that his new symptoms are due to a. Chemical meningitis b. Subdural hematoma c. Epidural hematoma d. Seizures e. Bacterial ventriculitis

6-29. A 28-year-old woman presents with nausea, vomiting, and diarrhea. She has no fever. Her history reveals that she attended a reception about 6 h ago. She ate roast beef with gravy, salad, and cream-filled pastries. Prevention of this foodborne illness could have been achieved by a. Freezing the food b. Heating the food to 140°F

c. Proper hand washing by food handlers d. Proper cleaning of contaminated surfaces e. Control of flies

6-30. Following blunt abdominal trauma, a 12-year-old girl develops upper abdominal pain, nausea, and vomiting. An upper gastrointestinal series reveals a total obstruction of the duodenum with a "coiled spring" appearance in the second and third portions. Appropriate management is a. Gastrojejunostomy b. Nasogastric suction and observation c. Duodenal resection d. TPN to increase size of retroperi-toneal fat pad e. Duodenojejunostomy

6-31. A 50-year-old woman complains of leakage of urine when she laughs, coughs, or sneezes. After stress incontinence, the most common cause of this urinary leakage is a. Detrusor dyssynergia b. Unstable bladder c. Unstable urethra d. Urethral diverticulum e. Overflow incontinence

6-32. A 30-year-old woman presents with the chief complaint of shortness of breath with minimal activity. In retrospect, she feels she has been dyspneic for at least 1 year but has now progressed to the point where she has difficulty climbing stairs or walking short distances. She denies fever, cough, or chest pain. On physical examination, the patient has JVD and a palpable right ventricular lift. On heart auscultation, there is a loud S2 and a systolic murmur that increases with inspiration. Lungs are clear. There is no clubbing. Which of the following is the most likely diagnosis?

a. Sarcoidosis b. Coronary heart disease c. Idiopathic pulmonary fibrosis d. Primary pulmonary hypertension e. Systemic lupus erythematosus

6-33. An active 78-year-old woman has been followed for hypertension but presents with new onset of mild left hemiparesis and the finding of atrial fibrillation on ECG. She was in sinus rhythm 6 mo earlier. Optimal treatment by hospital discharge includes antihyperten-sives plus a. Close observation b. Permanent pacemaker c. Aspirin d. Warfarin (Coumadin)

e. Subcutaneous heparin

6-34. A 73-year-old man presents complaining of right lateral hip pain that worsens when he lies on his right side or when he is standing. He has no other complaints. Physical examination is normal. He has a negative Faber test. Which of the following is the most likely diagnosis?

a. Ischial bursitis b. Osteoarthritis of the hip c. Avascular necrosis of the hip d. Trochanteric bursitis e. Fracture of the proximal femur

6-35. A 62-year-old woman presents for her annual examination. Her last spontaneous menstrual period was 9 years ago, and she has been reluctant to use postmenopausal hormone replacement because of a strong family history of breast cancer. She complains of diminished interest in sexual activity. Which of the following is the most likely cause of her complaint?

a. Decreased vaginal length b. Decreased ovarian function c. Increased alienation from partner d. Untreatable sexual dysfunction e. Physiologic anorgasmia

6-36. A 57-year-old woman presents to your office because of vaginal bleeding. She had her menopause at age 50. She does not use hormonal replacement therapy. Her last periodic health examination was 1 year ago. Physical and pelvic examinations are normal. Which of the following is the most likely diagnosis?

a. Atrophic vaginitis b. Blood coagulation disorder c. Endometrial carcinoma d. Cervical carcinoma e. Ovarian cancer

6-37. A 27-year-old man who is in excellent health presents for a routine physical examination. Family history reveals that the patient's mother died of colon cancer at the age of 40 years and that a brother, who is 36 years old, was recently diagnosed with colon cancer. The patient also has two maternal aunts with ovarian cancer. Physical examination is normal and fecal occult blood test (FOBT) is negative. Laboratory data is normal. Which of the following statements is true in this patient?

a. He most likely has the BRCA2 mutation b. He needs an annual colonoscopy beginning at age 36

c. He should have a prophylactic colec-tomy d. If he develops colon cancer, it will most likely be in the proximal colon e. If he develops colon cancer, it will most likely be in the distal colon

6-38. A 70-year-old man with unresectable carcinoma of the lung metastatic to liver and bone has developed progressive weight loss, anorexia, and shortness of breath. The patient has executed a valid living will that prohibits the use of a feeding tube in the setting of terminal illness. The patient becomes lethargic and stops eating altogether. The patient's wife of 30 years insists on enteral feeding for her husband. Since he has become unable to take in adequate nutrition, you would a. Respect the wife's wishes as a reliable surrogate decision maker b. Resist the placement of a feeding tube in accordance with the living will c. Call a family conference to get broad input from others d. Place a feeding tube until such time as the matter can be discussed with the patient

6-39. An infant weighing 1400 g (3 lb) is born at 32 wk gestation in a delivery room that has an ambient temperature of 24°C (75°F). If left in an open crib for a few minutes, this child is likely to demonstrate a. Ruddy complexion b. Shivering c. Hypertension d. Increased respiratory rate e. Metabolic alkalosis

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