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

7-26. A 23-year-old student presents to your office for health clearance to play collegiate sports. He is asymptomatic and exercises daily. On physical examination his blood pressure is 160/50 mm Hg and his pulse rate is 60 beats/min. There is pulsus bisferiens. Heart examination reveals an early diastolic rumble at the apex and a blowing diastolic murmur at the left sternal border. Nailbeds reveal a Quincke pulse. Which of the following is the most likely diagnosis?

a. Cardiac tamponade b. Aortic insufficiency (AI)

c. Mitral stenosis (MS)

d. Atrial septal defect (ASD)

e. Tetralogy of Fallot

7-27. A 24-year-old white woman has a maternal serum a fetoprotein (MSAFP) at 17 wk gestation of 6.0 multiples of the median. The next step should be a. A second MSAFP test b. Ultrasound examination c. Amniocentesis d. Amniography e. Recommendation of termination

7-28. A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever, shaking chills with a 15-min episode of rigor, nonproductive cough, and anorexia, as well as the development of right-sided pleuritic chest pain and shortness of breath over the last 12 h. A chest roentgenogram reveals a consolidated right middle lobe infiltrate and a CBC shows an elevated neu-trophil count with many band forms present. Which of the following statements regarding pneumonia in this patient is correct?

a. Sputum culture is more helpful than sputum gram stain in choosing empiric antibiotic therapy b. If the gram stain reveals numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae is the most likely diagnosis c. Although S. pneumoniae is the agent most likely to be the cause of this patient's pneumonia, this diagnosis is very unlikely if blood cultures are negative d. The absence of rigors would rule out a diagnosis of pneumococcal pneumonia e. Penicillin is the drug of choice in all cases of pneumococcal pneumonia

7-29. A 52-year-old patient with chronic cough and shortness of breath is diagnosed with chronic obstructive lung disease. Which of the following factors is the most important contributor to this finding?

a. Tobacco use b. Deficiency of a antitrypsine c. Asthma d. Repeated childhood respiratory tract infections e. Occupation

7-30. A 17-year-old girl presents with a pruritic rash localized to the wrist. Papules and vesicles are noted in a bandlike pattern, with slight oozing from some lesions. The most likely cause of the rash is a. Herpes simplex b. Shingles c. Contact dermatitis d. Seborrheic dermatitis

7-31. A decision analysis is undertaken in an attempt to determine which approach—radiation therapy or surgery—is best for the management of prostate cancer. A sensitivity analysis is plotted on the graph shown below. The x axis represents the probability of death from surgery, and the y axis represents the life expectancy ("expected utility") expressed in quality-adjusted life years (QALYs).


y it




_ R R R R R F






Reproduced, with permission, from Ratelle S: Preventive Medicine and Public Health: PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.


Reproduced, with permission, from Ratelle S: Preventive Medicine and Public Health: PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.

Based on this information, you conclude that a. Radiation therapy is always the best approach b. Surgery is always the best approach c. Radiation therapy is the best approach when mortality from surgery exceeds 11%

d. Mortality from surgery does not affect the choice of approach e. Surgery is the preferred approach when mortality from the procedure exceeds 20%

7-32. An 11-year-old girl presents to your office because of a family history of medullary carcinoma of the thyroid. Physical examination is normal. Which of the following tests would you perform?

a. Urine vanillylmandelic acid (VMA) level b. Serum insulin level c. Serum gastrin level d. Serum glucagon level e. Serum somatostatin level

7-33. A 32-year-old farmer presents to the emergency room with a crushing injury of the index finger and thumb that occurred while he was working with machinery in his barn. Records show that he received three doses of Td in the past, and that his last dose was given when he was 25 years old. In addition to proper wound cleaning and management, which of the following is the most appropriate preventive intervention?

a. No additional prophylaxis b. Administration of tetanus toxoid c. Administration of tetanus immuno-globulin only d. Administration of tetanus toxoid and immunoglobulin e. Administration of tetanus and diphtheria toxoid

7-34. You are helping with school sports physicals and see a 13-year-old boy who has had some trouble keeping up with his peers. He has a cardiac murmur that you correctly diagnose as a ventricular septal defect based on the following auscul-tatory finding a. A systolic crescendo-decrescendo murmur heard best at the upper right sternal border with radiation to the carotids and augmented with transient exercise b. A systolic murmur at the pulmonic area and a diastolic rumble along the left sternal border c. A holosystolic murmur at the mid-left sternal border d. A diastolic decrescendo murmur at the mid-left sternal border e. A continuous murmur through systole and diastole at the upper left sternal border

7-35. A 1-wk-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film shows dilated proximal loops of bowel and stomach. Barium enema reveals the cecum to be in the left lower quadrant. The most likely diagnosis for this patient is a. Jejunal atresia b. Hypertrophic pyloric stenosis c. Malrotation of the intestines with volvulus d. Appendicitis e. Intussusception

Items 7-36 through 7-37

An 18-year-old man complains of fever and transient pain in both knees and elbows. The right knee was red and swollen for 1 day the week prior to presentation. On physical exam, the patient has a low-grade fever but appears generally well. There is an aortic diastolic murmur heard at the base of the heart. A nodule is palpated over the extensor tendon of the hand. There are pink erythematous lesions over the abdomen, some with central clearing. The following laboratory values are obtained:

Hematocrit: 42 WBC: 12,000/^L

Polymorphonuclear leukocytes: 20% Lymphocytes: 80% ESR: 60 mm/h

The patient's ECG is shown below.

Reproduced, with permission, from Berk SL, Davis WR: Medicine: PreTest Self-Assessment and Review, 9th ed. New York, McGraw-Hill, 2001.

7-36. Which of the following tests is most critical to diagnosis?

a. Blood cultures b. Antistreptolysin O antibody c. Echocardiogram d. Antinuclear antibodies e. Creatinine phosphokinase

7-37. Based on the data available, the best approach to therapy is a. Ceftriaxone b. Corticosteroids plus penicillin c. Acetaminophen d. Penicillin plus streptomycin e. Ketoconazole

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