Questions 300301

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300. A patient presents to the ED and has the following laboratory values: sodium 139 mEq/L, potassium 4.1 mEq/L, chloride 112 mEq/L, bicarbonate 15 mEq/L, blood urea nitrogen (BUN) 22, creatinine 1.5, and glucose 180. All of the following could be the etiology of these laboratory findings EXCEPT

(A) salicylates

(B) renal tubular acidosis, type II

(C) acute diarrhea

(D) ureterosigmoidostomy

(E) pancreatic fistula

301. What is the calculated osmolarity for the patient in question 300?

302. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion can be caused by each of the following EXCEPT

(A) meningitis

(B) pneumonia

(C) hyperthryoidism

(D) thiazide diuretics

(E) monoamine oxidase inhibitors

303. A patient is sent to the ED from his doctor's office because of hypocalcemia. One would expect all of the following EXCEPT

(A) Chvostek's sign

(B) muscle spasms

(C) prolonged QT interval

(E) weakness

304. A patient presents to the ED complaining of sudden onset of shortness of breath 1 day after a 5-h plane ride. Arterial blood gas on room air at sea level is: pH = 7.32, PaO2 = 74 mm Hg, PCO2 = 30 mm Hg. What is the alveolar-arterial (A-a) gradient for this patient?

305. A young male presents to the ED unable to give a history. As part of the work-up, you find an anion gap (AG) of 38. All of the following are possible etiologies of this patient's problem EXCEPT

(A) lactic acidosis

(B) ethylene glycol

(C) hyperglycemic hyperosmolar state

(D) renal failure

(E) isopropanol

306. All of the following statements are true of hyper-kalemia EXCEPT

(A) leukocytosis may cause a pseudohyperkalemia

(B) calcium chloride should be given for severe cases of hyperkalemia

(C) kayexalate will not work for patients who have had a colon resection

(D) inhaled albuterol can be used to treat hyperkalemia

(E) the effects of hyperkalemia are decreased in patients with hyperglycemia

307. Which of the following statements regarding hypo-glycemia is FALSE?

(A) Counterregulatory hormones are released in a hypoglycemic state

(B) Hypoglycemia causes both autonomic and neu-roglycopenic symptoms

(C) Hypoglycemic patients commonly present with altered levels of consciousness, lethargy, confusion, or agitation

(D) Hypoglycemia is diagnosed when the blood glucose is less than 60 mg/dL

(E) Glucagon is ineffective in the treatment of alcohol-induced hypoglycemia

308. All of the following are important in quickly mediating and correcting states of hypoglycemia EXCEPT

(A) glucagon

(B) epinephrine

(C) glucocorticoid

(D) decrease in insulin secretion

(E) glycogenolysis

309. What is the MOST common cause of hypoglycemia in patients presenting to the ED?

(A) First time presentation of diabetes

(B) Alcohol related

(C) Oral hypoglycemics

(D) Insulinoma

(E) Liver failure

310. Which scenario is MOST typical of alcoholic ketoacidosis?

Glucose

Alcohol

Ketones

AG

(A)

Normal

High

Large

Present

(B)

High

Low

Large

Present

(C)

High

High

Small

Absent

(D)

Mild

Low

Large

Present

elevation

(E)

Mild

High

Small

Absent

elevation elevation

311. Which of the following statements about alcoholic ketoacidosis (AKA) is FALSE?

(A) Therapy includes intravenous administration of glucose and saline solutions

(B) As AKA is treated, the nipride test becomes more positive

(C) The development of Wernicke's encephalopathy can be prevented by administration of thiamine before glucose infusion

(D) Most patients fully recover

(E) AKA occurs only in chronic alcoholics

312. All of the following statements about hypothyroidism are TRUE EXCEPT

(A) prevalence is greater in women than in men

(B) amiodarone and lithium may mask the presentation secondary to elevation of thyroid hormone levels

(C) in secondary hypothyroidism, thyroid-stimulating hormone (TSH) levels are usually low

(D) although hypothyroidism is common in those older than 60 years, a paucity of symptoms may make the diagnosis difficult

(E) postablation hypothyroidism is a cause of primary hypothyroidism

313. All the following abnormalities are common in a patient with myxedema EXCEPT

(A) respiratory: hypoventilation, hypoxia

(B) central nervous system: confusion, lethargy, coma

(C) electrolyte: hypernatremia, water retention

(D) cardiovascular: bradycardia

(E) thermoregulatory: hypothermia

314. All of the following pathways occur as diabetic ketoacidosis develops EXCEPT

(A) hyperglycemia ^ glycosuria ^ dehydration and loss of electrolytes

(B) hyperglycemia ^ cell dehydration ^ altered level of consciousness

(C) insulin and glucagon deficiency ^ increased hepatic gluconeogenesis

(D) lipolysis ^ ketosis ^ acidosis

(E) muscle breakdown ^ azotemia ^ loss of sodium

315. Which of the following statements is TRUE regarding administration of sodium bicarbonate solution during the management of diabetic ketoacidosis (DKA)?

(A) It prevents paradoxical spinal fluid acidosis and cerebral edema

(B) It shifts potassium ions extracellularly and corrects the hypokalemia

(C) It shifts the oxyhemoglobin dissociation curve to the right, facilitating off-loading of oxygen at the tissue level

(D) Complications include rebound alkalosis and sodium overload

(E) It is recommended in all DKA patients with severely altered levels of consciousness

316. All of the following are appropriate treatments for DKA EXCEPT

(A) administering 3 to 5 L normal saline in the first 4 to 6 h

(B) replacing the 3 to 5 mEq KCl/kg deficit gradually over the first 2 to 3 days

(C) infusing insulin at 0.1 U/kg/h after the initial bolus is given

(D) stopping insulin administration when glucose levels fall to 250 mg/dL

(E) administering phosphate if levels fall below 1.0 mg/dL

317. Which of the following statements concerning hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is TRUE?

(A) The mortality rate of HHNS is less than that of DKA

(B) HHNS and DKA are easily distinguishable

(C) A majority of HHNS patients present with coma

(D) Metabolic acidosis excludes the diagnosis

(E) Seizures occur in up to 15 percent of patients with HHNS

318. Precipitating factors for HHNS include all of the following EXCEPT

(A) infections

(B) extensive burns

(C) thiazide diuretics

(D) ingestion of large quantities of sugar-containing fluids

(E) salicylic acid

319. Which of the following statements regarding lactic acidosis is FALSE?

(A) It is an uncommon cause of metabolic acidosis

(B) The source of elevated lactic acid comes from the conversion of pyruvate to lactate

(C) In anoxic states, the cellular lack of NAD prevents mitochondrial reduction of lactate to pyruvate

(D) Lactic acidosis caused by tissue hypoxia is classified as type A lactic acidosis

(E) Liver and kidney gluconeogenesis contribute significantly to lactate utilization

320. An ill-appearing 48-year-old European female presents to the ED with nonspecific complaints. Laboratory tests show an elevated AG, lactate level of 5.0, pH 7.34, and a normal glucose level. Detailed history reveals that she is taking oral phenformin. All of the following apply to this patient's lactic acidosis EXCEPT

(A) the patient most likely has type B lactic acidosis

(B) sodium bicarbonate should be administered

(C) myocardial contractility and hypotension may occur at pH levels below 7.1

(D) phenformin has been withdrawn from the U.S. market

(E) ethanol use can cause a similar presentation

321. Which of the following statements regarding hyper-thyroidism is FALSE?

(A) Free T3 is more biologically active than T4 but has a shorter half-life

(B) Hyperthyroidism during pregnancy is almost always due to Graves' disease

(C) Lithium, iodine, and amiodarone have all been associated with hyperthyroidism

(D) Normal T4 levels eliminate the possibility of hyperthyroidism

(E) Mortality rates from thyroid storm range from 20 to 50 percent

322. Assuming no allergies, which of the following is TRUE for all patients with thyroid storm?

(A) Give aspirin to control fever

(B) Administer propranolol to block the adrenergic drive

(C) Give propylthiouracil (PTU) 1 h before iodide therapy

(D) Draw free T4/TSH levels before and 1 h after administering antithyroxine

(E) Avoid steroids because these increase conversion of T4 to T3

323. Which of the following is TRUE regarding hormones produced in the adrenal glands?

(A) Corticotropin-releasing factor emanates from the pituitary and stimulates cortisol release

(B) Cortisol is a potent hormone that increases glucose uptake into cells

(C) Aldosterone is an important mineralocorticoid that increases sodium resorption and potassium excretion

(D) Adrenally produced androgens are an important source of androgens in men

(E) Adrenal insufficiency occurs primarily because of decreased epinephrine and norepinephrine production in the medulla

324. An 18-year-old, ill-appearing female presents to the ED with low blood pressure. She has a 1 day history of headache and fever. Examination is significant for petechial skin lesions. Waterhouse-Friderichsen syndrome is suspected. All of the following statements are TRUE EXCEPT

(A) bilateral adrenal gland hemorrhage frequently occurs with this disorder

(B) the bacterial organism implicated in this severe infection is Neisseria meningitidis

(C) although controversial, administration of glucocorticoids is indicated in most cases

(D) abdominal CT is not sensitive in determining adrenal hemorrhages

(E) pregnancy is a risk factor for developing adrenal hemorrhage

325. A 48-year-old female with a history of sarcoidosis comes to the ED with a chief complaint of syncope. She admits to anorexia, nausea, vomiting, and abdominal pain. She stopped going to work because she is too tired. Physical examination is significant for hyperpig-mented lesions and alopecia. Initial laboratory findings show a glucose level of 50 mg/dL and a potassium level of 5.4 mEq/L. What is the MOST likely diagnosis?

(A) Conn's syndrome

(B) Nephrogenic diabetes insipidus

(C) Hyperthyroidism

(D) Adrenal insufficiency

(E) Depression

326. A 24-year-old male comes to the ED in adrenal crisis. His wife reports that he has been feeling poorly for about 48 h. He is mumbling incoherently, blood pressure is 80/60, and temperature is 103°F. Which of the following actions is LEAST likely to benefit this patient initially?

(A) Starting mineralocorticoid therapy

(B) Infusing isotonic saline

(C) Administering dextrose

(D) Administering 100 to 200 mg hydrocortisone

(E) Administering appropriate intravenous antibiotics

327. Each of the following cardiac conditions is associated with systemic lupus erythematosus (SLE) EXCEPT

(A) pericarditis

(B) aortic stenosis

(C) angina

(D) costochondritis

(E) myocarditis

328. A 10-year-old female comes to the ED with bilateral knee and ankle joint pain and subcutaneous nodules over the extensor surfaces. Which of the following additional criteria is needed to confirm the diagnosis of acute rheumatic fever (ARF)?

(B) Arthralgia

(C) Petechial rash

(D) Evidence of preceding streptococcal infection

(E) Chorea

329. A 58-year-old female presents to the ED with headache, tender temples, and flashes of blindness consistent with temporal arteritis. Which of the following actions is MOST appropriate?

(A) Consulting surgery for an immediate temporal artery biopsy

(B) Confirming the diagnosis with an elevated erythrocyte sedimentation rate and then consulting surgery

(C) Referring the patient back to her primary medical doctor (PMD) in the morning for extensive rheumatologic evaluation

(D) Initiating high doses of indomethacin

(E) Initiating prednisone therapy

330. A 56-year-old male with no medical history presents to the ED with a 1 to 2 day history of a painful elbow. He denies trauma. Examination demonstrates a warm, tender, erythematous joint. Range of motion is limited secondary to pain. All of the following are TRUE EXCEPT

(A) a diagnostic arthrocentesis should be performed

(B) uric acid crystals may be seen upon examination of joint fluid with a polarizing microscope

(C) serum urate levels are often normal in gout patients

(D) administration of intravenous colchicine is the first line of treatment for this patient

(E) during an acute flare, other medications used to prevent recurrences of gouty arthritis should not be adjusted

331. A 21-year-old male complains of new-onset left knee pain without antecedent trauma. He last had sex 1 week before and does not use condoms. Which of the following statements is TRUE?

(A) Cultures for gonorrhea should be obtained from the oropharynx, urethra, and rectum

(B) Synovial fluid from joints infected with gonoccocus often does not show the organism

(C) Intravenous antibiotics should be considered when gonorrhea infection is present in weight-bearing joints

(D) In some patients with gonorrhea, vesiculopustular lesions are found on the fingers

(E) All of the above

332. A 33-year-old intravenous drug user presents to the ED with complaints of fever and arthralgias. On visual inspection, there is no obvious swelling of the extremities. Which of the following joints are at greatest risk for infection in this patient?

(A) Atlanto-axial-occipital joint

(B) Metacarpal and interphalangeal joints

(C) Sternoclavicular, sacroiliac, and intervertebral joints

(D) Elbow and shoulder joints

(E) None of the above; all joints are equally affected

333. All of the following support the diagnosis of a ruptured Baker's cyst rather than a deep venous thrombosis (DVT) EXCEPT

(A) swelling that spares the foot

(B) a "crescent sign"

(C) rapid diminution of popliteal fullness

(D) sudden onset calf pain and swelling

(E) arthrogram showing no thrombus

334. Which one of the following is the causative agent in Lyme disease?

(A) Borrelia burgdorferi

(B) Ehrlichia chaffeensis

(C) Isolated neurotoxin from a tick

(D) Rickettsia rickettsii

(E) Babesia species

335. All of the following are consistent with a diagnosis of Kawasaki's syndrome EXCEPT

(A) 80 percent of cases occur in patients younger than 4 years

(B) conjunctivitis is common

(C) cervical lymphadenopathy is present in the majority of children

(D) sterile pyuria is an associated feature

(E) only 15 percent of patients treated with intravenous immunoglobulin within the first 10 days of illness develop coronary artery aneurysms

336. All of the following are criteria for admitting patients with Henoch-Schonlein purpura (HSP) EXCEPT

(A) age younger than 2 years

(B) renal function monitoring

(C) rehydration for recurrent emesis

(E) control of abdominal pain

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