smergency depariment ater an apparent selzure. Over the past 2 days, she has vomited si mes and has been feeding poorly Tothargie and afebrile, The antere fortanel ls tonse. Thore ae Batra renal homorages. Which of ta folowing is tne most Troy diagnosis? A) Bactorial meningitis 8) Brain tumor (©) Child abuse 1) Goarctaton of he sorta ) Renal fare45. A,7yearcd woman is brought tothe emergency department 30 minutes after being involved in a motor vehicle collsion. She was the unrestrained diver ofa car traveling at 85 mon that rita bidge abutment On arival, she Nas severe neck pan and mid chest and abdominal pain. Hor puso is SS/in oepratone are 20min, and blood pressure 120/60 mm Hg. Examination showe severe tondenose ofthe covvieal spine al C8, Thore fa bruise ané mid onder overt lower sornum fd upper abdomen. Neurologic examination snows no abrormaliien. An xray ofthe eres! shows no abnoematies except fox a sigh widened mediasnum. AN xa ho cervical sine shows a CS face! facture, An ray ef the abdomen shows no abnermalies, Which a the flowing i the most Ika) location af the ife-nreatning cardiovaccular ur? A) Abdominal sorts (6) Juguiar vein 8B) Carotid artery Hy Pulmonary artery O)Heart |) Puimonary vein ) Invi vona cava 4) Subelavian atory ) Innominate artery ) Superior vona cava, F)lorominate won © L) Thoracic aorta 0 ~ @ ra44, A@month-ald boy is brought to the physician because ofa dlaper rash fr 3 days. Hels otherwise healthy. He breas-eeds si ies daly. His tomporature Is 37 4°C (@3.3°F, pulses 100i, and respratons aro 28min. Examination shows 22-0, rus, paula, noney-colorod lesion with a clear scharge in holt gtln. Thore {xno olor lesions. Tho most aporopriato management is lopieal application of which ofthe folowing? (©) Muprecin iniment B) Nystatin cam (©) Petroleum lly 0) Tramelnaione 0.1% cream E) inc oxide ointment 0 ~ @ ra48. An 18-year-old woman comes to the physician because ofa 3-day history of fatigue and yelow eyes. She has a history of mid ‘anemia but otnerwsa noah, Her 18-year-old brother also has mil enema, Her temperature & 367°C (96°F), pul 8 62min, ‘espraton Homogiin sega Mean corpuscuar horogibin concontaton 38% Hbicoll Relievocyte count 8% ‘Serum total biruin 3 mold ‘Adlrect antlebuln (Coombs) tests negative, A bioas smears shown, Which of he flowing fs mest ikely tohave prevented this patients curent symptoms? {A rravenous 19 thorapy B) Monthly transfusions of packed re blood cals (C} Prednisone therapy 1) Bone marrow ranspiant (© E) Splenectomy F) No preventive measures are efficacious42. AAT-year-ld woman comes io th physician because of fever, nausee, vomiting, and severe headache for 24 hours. Her temperature is 30°C (102 2°). Examination ‘hows woaknose of ho ight upper extramity and nyslagmus; opt fund cannot be veualzed. Kerig signs present. Which ofthe follwing is tho most approprate xt stop in diagnosis? A) ee-water caloric testing BEES ©0)CT scan of he head 1) Lumbar puncture E) Cerebeal rerography41, Apreviusly heathy 62-year-old woman comes tothe physician because of a month history of diffaityswalloning soli Fogurgtates undignsted food. Examination shows no abnoralises excopt for fou-smoling breath Which of a flowing is dagnoss? 1 igus. Sho states that she occasionally most approprata nal top in '8)24-Hour pH monitoring (0B) Barium swallow (©) CT scan ofthe chest ) Esophageal manometry E) Esophagogastodvodenoscopy 0 ~ @ ra40, A 22-year-old primigravd woman at terms admitted to the hospital n labor. Her pregnancy has been complicated by three wary trac infections; last episode ‘ocurred at 22 wants geetaton. She te now taking daly iofurastcin. Shes therwise haelny, Which of he folowing the mest ikaly cause oF this patios recurent ‘inary tract infections? |A) Decreased urinary pH during pregnancy 8) Hypotonic ervrenment in renal medulla (Increased sodium excration 0) Increased urnary bladder tone © E) Usnary siasis38, Acounty heath offcer investigates an cutbreak of iness among persons atoning a church plcic. The less Is characterized by the onst of nausea and voting 3 to ¢noute after standing the pene. Al afeced persons recover wihout spelncthoapy. Tha invtigaton impleates gg sand ae tro vehicle o! ranemission Which fo folowing isthe factor most commonly contbuing to an outbreak ofthis yp0? 'A) Contamination of equipment used to prepare the implicated food £8) An implicated food that's inherany dangerous (Inadequate cooking of te implieted food (©D) Inadequate refrigeration ofthe impcated food ) Poor personal hygiene by the person serving the implicated food28, 47-year-old woman comes tothe physician because of fatigue for‘ week. She has a 10-year history of type 2dlabetas malitus curent trated wih short-acting Insulin beter each mal as neodod and 12 U of infermoxiato-acting inulin at bedtime. Ovar the past week, Ror blood glucose concortatons have Been over 260 !maldL and have boon gator than 350 moidL on several occasions, Hor previous blood glucose concontraons hag ranged betwoon 99 mgidL and {10 mgidh. She ‘pears trea She is 760 em (5 3 n) al and weighs 68 kp (1600), BM 827 kgm Her temperature 98.5°C (10% °F), pulse 90min whie supine and 120/min ‘hie standing, and blood preseure 170/70 mm Ha while supine and G00 mm Hg while eanding. The ramainder ofthe examination shows no ebrormatie. Her fingrstick bicod glucose cancenratin s 350 mgidL.Usne dipstick postive fr gluense and negative for proain and ketones. Urinalysis shows 6-10 WECInpt and ‘ho RBCs or eats Which a the folowing the mos! Bxely causo of tis pallet postural hypotension? A) Adrenal nsuteney 8) Autonome insuficiency (©.0) Inravascular volume depletion 0) Renal sat wasting ) Vonous pooting 0 ~ @ ra37. Duting examination prior to patcipation in schoal sports, 2 heathy 14-year-old boy has a blood pressure of 180/90 mm Hg. His bod pressure at previous routine ‘examinations has boon normal. Ho is 183 cm (612i) tll and walghs 62 Ig (180); Bld 6.24 kgm Examination shows ra other abnormalities. Which of ho following isthe most aporoprate next sop in management? (©-A) Repeat bood pressure measurement in 4 weeks 8) Calorie-recuced diet ©) Sodumrestrcted dit 0) Renal uirasonography ) Antnypertensive terapy 0 ~ @ raamenarrhele for” years. She hasan @-year history of ancrexa nervosa, Compares to other 28, A24-yearold woman comes tothe physician because she has be ‘woman in her age group who manstuaio regu. this patant has an incoased rik for which of ho folowing? 'A Breast cancer ) Endometral cancer (0.0) Osteoporosis ) Ovarian cancer E) Thyroid eisoaso 0 ~ @ ra235. previously healthy 6-yer-ld boy is bought to the emergency department because of cramping abdominal paln and right-sided scrotal paln for 4 hours. He voted ‘eco on tha way to te Moet Examination shows a distended abdomen. Bowel sounde are decreased, and tharos diftuse tenderness to palpation with involuntary ‘uarding. The ight homiscrotums sighly discolored wih swoling and toncemess superior, The lf homigerlum is normal, tre let's normal. Which othe ‘ollowing Is the most appropriate nest step n management? A) Trarsiumination of srotam 8) Valealva maneuver ) Urinalysis 1) Doppler utrasonography E)cT scan F) Antbote therapy (06) Operative procedure134. A52.yearcld man comes tothe physician because of excruciating pa and sweling of hs ight great oe since undergoing appendectomy 10 days ago. The pains so Severe that he cana foerate Fes bedeheel touching i oe. Treatment wits ealacoka ha provided no reise temperature e 376°C (09.6°F], Examination ofthe too shows sweling, enema, and marked tendemess of te mealarsophalangeal joint. Which of te folowing is tne most appropiate nex step in pharmacotherapy? |) Aestarinophen 8) Alopurinol ©) Aspirin (0D) Dexamethasone ) Indomethacin 0 ~ @ ra‘The tem has associated media that may reque the use of headphones 33. Aproviously heathy 4-yoar-old boy i brought tothe physician bocause of a 3-day history of over, cough, and runny nasa. He has not had wheezing, vomiting, oF Garrea. Ho eat the 750, heght and 10 pereuntle for meght His tomporaure is 7-5°C (98 5°F), Tho skin e warm and pink. Capa refi mo fs 2 secands. Examination shows clear rhinos, Breath sounds are normal. To view the cardiac examination, cick he “Meda Player" tab. The remainder of the ‘examination shows no abnormales. Which ofthe folowing iste most ikl agnosis? A) Congestive heat fue 2) lsopathic pulmonary hypertension ©) Percarcits (©D) Upper respiratory tract infection ) Ventricular septal defect 0 ~ @ ra22, An 82,yar-od woman is brought othe emergency department because of visual loss inthe left aye sina awakening this maming, Sha has hypertension treated with Tinoprl Sha also takes dally sepiin. Tho pup a 2 mm blstraly and reactive to ight. Veualscuty fs 2070 on tha right and 20400 on the lft. Funuscopic ‘examination of tho loft eye shows diated retinal veins and widespread retinal hamecthagosintorixod wih patches of white exudate, Th ight optic fundus i normal. ‘Ocular movement are ful, Which othe folowing ' the most kel agnosis? A) Cental retinal artery occlusion F)kidooycitis (© B) Contal retinal vein acctusion G) Optic nee glioma (©) Comeal abrasion H) Optic neuritis D) Glaucoma 1 Retrobubar hemonhage ) Herpes simplex coniunctvis 4) Vitreous hemerthage 0 ~ @ raom. ‘A 18-year-old git is brought tothe physician by her mother who requests contraception fr her daughter. The mather asks to speak othe physician alone and explains that she persuaded her daughto to come bocause Te gr has Begun to stay out lo, rcoive many cal rom several fant boys, and wear ight cothing ana ‘excessive makaup, She eave hor daughler confides mary deals of hor dales to het, Sho ade tal he gif father's rious and Boral nor about tvs behavior even though he does not know about mest of whats going on. To protect her daughter, she does not want to tel him about all the daughters activites. On incl Intervow, the gl saye sho does not undarstand why she does these things, bul she wou Ike lo understand, Physical examination shows no abnormaitie. Which of the folowing isthe most appropriate nox step in management? A) Tal tho mothor that her daughters just gong through 2 phase (© B) Benavor therapy forthe patient ©) Famiy therapy ) Maral terapy forthe parents ) Peycrodynamic paychetherapy forthe pationt F) Thazolam therapy fr tho patent20, AGT-yearold man comes tthe physician because ofa {-month history of aca bleeding. He says he passas bight ec blood wth bowel movements. He has nat had ‘any other symptoms He hae hyparteneon and osteoarthrla. Curent madioatons Include losartan, metosal, amlopne, and naproxen, Hi faterraceved na ‘Fagnoss of colon cancer al he age of 70 years ans id at tro age of 74 your. His 89-year-old mother recived the diagnosis of breast cancer 20 years ago and has ‘survives: He is 183 em (6) tl and weighs 9 kg (200 Io): BM is 27 Kgl Viel signs are within normal lms. Amass a papated inthe rectum. The remainder ofthe ‘@aminaicn shows ne abrecralies. Caloroscopy shows a large ucerating rectal masa. A blopsy specimen ofthe mass shows rectal canca. Rovow cf which ofthe folowing types of chica studios is tka to bo most usetuln developing a Waatment ertogy for bis patent? ‘A Gase-contoled observational study 8) Case reports (©) Conon study ) Ptiont satstaction suvoys (© E) Randomizod, controled ceical tl28, Aprevcusly healthy 42-year-old woman has had generalized weakness, ltharsy, and double vision for 2 weaks. Examination shows no other abnormaliles.X-ays of the cheat shaw an upper anteror mecsasinal mage. Which of he foloning isthe meat kely clogneels? A Lymphoma 8) Nevrogenie tumor (©) Parathyroid tumor ) Teratoma OE) Tymmoma 0 ~ @ © ©Fr each patient wih muscle weakness, select the most Ikaly cause, A) Decreased aceyholine receptors 8) Decreased release of acetycholne from motor nerve terminals (©) Degeneration of muscle fbes © D) Demyoinaton of axons ) Loss of motor neurons 28, A3T-yearold man comes tothe physician becauee of progresee weakness over the past § cays, The weaknees started atthe ankles and spread othe proximal ‘muscles ofthe lower exits, bands, forearms, and faco. He has had mid tingling of tho foot and fingors. Two wooks apo, he had an uppor respiratory act ifection that has resolved: Examination shows moderate weakness of the facil muscles and proximal muscles a the extremes and marked weakness ofthe data muscles of the extremes. Deep tendon reflexes are absent. There Is hypotonia ofthe knees and ankles. Sensation tight touch and vibration Is mily decreased ove he fet.The response options forthe next 2 lems re the same, Sloct one anewer foreach Kor In he sot Fr each patient wih muscle weakness, select the most aly cause, (OA) Decreased acetychaline receptors 8B) Decreased release of actycholine fam motor nerve terminals (©) Degeneration of muscle fives 1D) Demyeinaton of axons E) Loss of motor neurons ‘Apreviouely heathy 4-year old woman comes tothe physician because of intermittent double vision and drooping of the eyelics for 3 weeks and eitfeuty chewing and ‘sullowin fort week. Her symptoms are worse latin the day. Examination shows variable eels ptosis that's worse on he rght Tere ls weakness of abduction ot the gt eye, adduction ofthe lt eve, and eye closure. There a mild Weakress of he forehead and mauth. Speech fs nasa. Deep tendon reflexos and sensation re28. A2T-yearold man comes tothe physician with his 27-year-old wife because thay have boon unable o conceive forthe past 10 months. The wife concelved her 4-year- ‘1 daughter fem anciner manage without dieu. and the husband nae ro chire, The wife's menses occur at regu 23-cay nara: her let Sarina 1 ‘month ago showed no abnormalites. Examination othe husband shows ill defined soft massos palpated blatoraly, high inthe serum. Which ofthe folowing is tho ‘most ikely cause ofthese masses? (©) Batra doc inguinal horias 2) Batra epcicyite (©) Bilateral hyarocelos ) Batra veeoosies ) Previous sports-related inury 0 ~ @ ra25. Ad-year-ld gis brought to the physician because of cough and @ 23-49 (Sb) weight oss curing the past 2 months. Thre ls no histor of serious lines, and she taxes na mecicaone,Immunzatons ae uptodate. She tat he SUth persone for hlght and 25m parsantio fer weight Oosasionaleracles aro heard Over te right idle lun fel. nadormalekintostng wth PPO, tetanus taxi, and angons for Candida abicans and Tichootyon fonsurans is noreoacive a 72 hours. Hor leukocyte counts St 00mm’. Nucet acd hybrlzaton testing of gastric aspates shows Mycobacterium tubercubsis. Which othe following iste mast key ‘explanation fortis patents fedings? A) Antbogy detcency 8B) Comploment dofcioney (©) Impaired chometaxis ) Impaired respiratory burst E) Neutropenia F) Splenic dysfunction (©) THymphooyt dystuncton 0 ~ @ ra24, previously healthy 26-yeerold man comas tthe emergency department because of shorinass of breath for 3 waaks and palful bumps onthe lag fort waak. His tomporaturo i 382°C (100.8), pulsa is 60min and blood pressuro is 40/85 mm Hg. Examination shows 2-0 Sam tender, od nodules onthe aarr shins. AN X- ray of the chest shows bialral ilar floss. Which of tho folowing serum abnormallis is most kal in tis patont? ‘A) Decreased caitonin 8B) Decreased cakium (Increased caictonin (©) Increased calcium ) Increased magnesium F) Incroasod parathyroid hormone G) Incroasod tyrie-stmuating hormone H) Increased thyrxine (T.) I) Increased triosayronine (.) 0 ~ @ ra22, A.32-yearold woman Is brought ta the amargency department because of abominal pain and nausea and vorting for 6 hours. She underwent a cholecystectomy 2 Yyoars ago. Mensos occur at regular 28-say intervals; par last monsiual period was 2 weeks ago. Sno doos not smoke or dank alcoho). She appsars acutely I. Hor tomporaturo i 374°C (98.3°F), and respirations ao imi. Hor pul is 10/min and blood pressure is 130/70 mm Hg while supino, and puso is 136/rin and blood Prosar is 90/60 mm Hg wile standing. Abdominal examination shows guarding with rebound over the epigastum: bowel sounds are decease, The remainder of {he examination shows no abnermaliee. Serum studios show. Nav 148 mEo Ke 33 meq, Ca Soma “ola brn tng ‘Akalive phosphatase oun ast eeun ‘Amylase 022 un. ‘The most appropriate nxt stp in determining the undaryng cause is measurement of which ofthe follwing serum concentrations? 1A) Apolipoprotein A 8B) Apotpoprtoin 8 )HOL-8. An asymptomatic 22-year-od man comes tothe physician for a preamployment evaluation Examination shows normal fdings. APD skin tat shows 16 mm of induration and eythara. He has nad no previous PPO si tests and a his Koawedge has not boon exposed to anyone wih active tubercuoas. An ay ofthe chost ‘shows no abnormalties, Sodum eamples show no act fast act. Which ol ho Yolowing the most propa nen slop h management? AyRes 8B) Repeat xrays of he chest in 6 months (0.6) Treatment of active tuberculosis now o) 5) 0 ~ @ ra18. A {4-mant>-old boy Is brought fora wel-child examination. His mathar fs concerned because he snot yet walking on his own. Ha wl stand alone for several seconds bofore fling tothe Toor He can empty risns fam a cup and isto eat with a spoon. Ho sa the 25% porate fr length and Soh percono for woight. Examination ‘shows no abnormalities. Which ofthe folowing i tho most appropriate next stp in management? (OA) Reassurance 18) Chromosomal analysis (C) Measurement of serum creatine kinase activity 0) X-ay of he lower extremities E)X-y ofthe apne F)MR ofthe brain 0 ~ @ ra7. A17-yea-oa git cores tothe physician because ofa 4-month histor of @ persistent rash over her faco and upper back. Aphotograph of he rachis shown. Which ofthe folowing structures is primary involved in the dovelopmant of tis rash? 1) Apocrine glands 8) Dermis ©) Epidermal-dermalunetion D) Pennicutss (© E) Piosebaceous fliies Fas) 76. A62:year-old woman is admitted othe hospital caus of shorinees of brash for 12 hours. She has a 15-year history of type 2 labetes malts and a year history of ‘Gronie ranalnsufiseney. Medieaions inl insulin and captopri. Her fomporature is 38.2°C(100.8°F), pulse is alm, aepitions are T6/min, ana blood prossure is |iaarrommg. Examination sows ro adenopathy. Inspiratory erachlas are hear thal are greater on tho ght than on the lft Cardac examination ehows a ducrote point of maximal impulse, @ normal S, and S;, ang an intemitentsy Thee is race pedal edema, Pulse oxmelry on room air shows an oxjgen sattation of €O%, Het Toukosyte counts 13,000/mm and serum cfeatnine concentra f 22 mala. X-rays of th chest shou a pate infra nthe right midurg ld. Treatment with intravenous catraxone and neparnis bogun. Sha has pocr ora taka. Hr tomporature ranges For 37°C (98.8°F to 384°C (101.1), and blood proseue ranges ‘om 112160 mm Ho 148184 mn Fg, Hor serum lucove concentration is morlored four times daly and despite adjustment of neu doeago, hr serum qucoso ‘onceniraions range between 140 and 320 mglal; One day ater admision, vertlaon-pertslon lung seans snow no abnormalves Two eays ater acmisson, pulmonary anglogapry shows no evidence of a pulmonary emboli. Four dave ster admission, er Serum creatine concentration is 36 mM, Which o the flowing Sal ly Pave end A GTS OE fSIORESTERSIMNESS A) Low-protein det 8) Better control of serum glucose concentration nthe hospital (©) Anthypertensve nerapy D) Dosage adjustment of cotviaxone (©) Intravenous fu therapy 0 ~ @ ra5. Overthe past month, 272.yearcld woman has had indigestion while walking uphill or briskly I's rlleved aftr a fow minutes of vest. Her symptoms are rot elated to ‘eating and ae no aleved by antacise, Examination shows co abnormates, Which oft flowing he moet appropriate net step in dagnosie?™ ©A) Bxarcioe siross test ) Upper gastrointestinal sores (G) Eehocarcography 1) Utrasonography ofthe ver and bile ducts ) CT sean of tre chest 0 ~ @ ra4. AST.yearold woman has had malaise, muscle aches, Blfifllwuivarbstrs, vaginal discharge, and dysria for 3 days. She lasthad sexual ntrcourse 7 days ago wit now partner. Her tomperatur is 38°C (100.4°F). Examination shows Biateal paint ingual adenopathy and numorous 1-9 3mm vesicles and lca nvaling the laba maja and minora, pneu, vulva, mons pubs, priurotval, and perianal arcas, Which of tho flowing isthe most appropriato nox slop in dagnosis of tose lesion? 'A) Darko examination of lsion seraping 1) Gram stain eflesion seraping (0) Serologic test or syphis 1) Teating for Chlamydia trachomatis (© E) Culture for herpes simplex 0 ~ @ ra3. A2T-year-old woman comes othe physician becauss of afd history of headache, sever, cite abdominal pain, and nausea and vomiting, The pln is exacerbated by eating and level byVamting. Tho vomitus tally consisted ofa largo amount of sms mataral mod with clear groon liquid but now consist of oar yolow gui ony. Sho nas not had any cher symptoms. She has Crofn disease read wih prednisone; she was istuciod to taper hor dosage 2 wooks ago. Adltonal medications ineude mesalamine and azathoprine. He las mensrual period was 7 weeks ago. She s sexually active wih one male parr, ane they vse condoms Ineonaltanty She appear Hand in moderata dress, Hor oriperature s 384°C (101 2F), pulse is 120fmi, respirators are 22m, and bid pressure 1 0050 rmm'ig. Examination show cry oral micosa ang pale conjunetvae. The abdomen ls eended, diusely tender ane fympans. Bowel sounds ara decreased, Pvc ‘Gxaminalon shows no abnormalities, Laboratory suses show: Hemator 31% oukosyte count 15,000%mm® ‘Serum ‘Amylase 00 un, Lipase SUL (Ne14-280) Which of he folowing is the most ikely agnosis? A) Acie pancreatis (©B) Gastric out! obstruction ©) Gastoparosis D) Migraine ) Pelviciflammatary disease F)Prognancy 6G) Smal-bowel obstruction H) Wal gastroontertis2. Six hours ater coronary atry bypass grating, @62-yser-old man has @ decrease in systalcbcod pressure rom 120/90 mm Hg to 00V85 mm Hg, Urine output ‘Secroaees trom 60 mL to 10 mL/, ad eardac ouput decrases fom & Linn to 3 Limin. Pulmonary artery castle preeauraMaelN@@ABa” An ray ofthe chest ‘shows a widened modiastnum. Which of the flowing is the most appropriate nxt stp in managornon? 8) - (0.0) Placoment ofan inva-sorte balloon 10) Revision ofthe coronary grat ) Surges explorton of the mediastinum 0 ~ @ ra1. Adz.year-od man comes tothe emergency department at michight, 6 hous ater the onset of severe flank pain. His temperatures 37°C (88.6°F), pulses 110i, reepiraons are 12min, and blood pressure 120190 mm Hg, Ther is tenderness over he ght lower Quadrant ofthe abdoran and cosiovertebra ang. Urinalyese ‘shows 80-100 RBCMnot and 3-6 WBCIhpt. Two houts afer administration of morphine, th symptoms subside. In addon to providing anagosies, whch ofthe folowing Is the most appropriate nex step in management?” (©) Discharge and encourage fd ntako 8B) Discharge and schedule cytography (©) Discharge with oalantitictes 1) Admit the ganeral medical unit ) Admit tothe intensive care unit FF) Admit for an emergency operation 2