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Cultura Documentos
collision. He has a seatbelt sign across his neck and chest with an
ecchymosis over his left neck. He is hemodynamically stable and
neurologically intact. A CT angiogram shows a left carotid
dissection. In the absence of other significant injuries, what is the
next step in his management?
a. Antiplatelet therapy
b. Systemic anticoagulation with heparin
c. Neck exploration and left carotid artery repair
d. Neck exploration and left intra-extracranial bypass
e. Angiography and left carotid artery stenting
in a blunt carotid artery injury :
One of the greatest concerns after BCVIs is stroke secondary to
thromboembolism developing from the disrupted vessel wall. , so if there are
no contraindication , must give systemic anticoagulation
radical orchiectomy for a mixed germ cell tumor. His chest x-ray is
normal. Serum beta- human chorionic gonadotropin (-hCG) and
alpha-fetoprotein (AFP) are markedly elevated. Liver enzymes are
slightly elevated, and the patient relates a history of ethanol
excess. He receives three cycles of chemotherapy. Restaging
reveals a 3- cm retroperitoneal mass, a normal chest x-ray, and
normal serum -hCG. However, the serum AFP is 20 IU/mL
(normal = 0 to 9 IU/mL). What is the next step in the management
of this patient?
a. Computed tomography (CT)guided needle biopsy
b. External-beam radiotherapy
c. Retroperitoneal lymph node dissection
d. Salvage chemotherapy
e. Serial markers and CT scans
This patient presents with a residual bulky mass after three courses of
platinum-based chemotherapy. Although the chest x-ray and -hCG are
normal, the serum AFP remains slightly elevated. AFP production is usually
attributed to yolk sac elements in a mixed germ cell tumor. It is also seen with
a number of other conditions, such as hepatocellular carcinomas and benign
hepatic disease, including alcohol hepatitis, as is probable in this case.
Patients with persistent marker elevations after chemotherapy are usually
considered very likely to harbor residual carcinoma and probably best
managed by further chemotherapy. However, the AFP elevation seen in this
case is more likely due to benign liver disease. Consequently, this patient
would be best managed by retroperitoneal lymph node dissection instead.
The most likely finding at retroperitoneal lymph node dissection would be
either fibrosis or residual teratoma. CT scandirected percutaneous needle
biopsy would have considerable sampling error, and external-beam
radiotherapy has no efficacy, particularly in the management of teratoma
16. A 40-year-old woman presents with a rash involving the nippleareola complex for the last month with associated itching. On
physical examination there is crusting and ulceration of the nipple
with surrounding erythema involving the areola and surrounding
skin, no palpable breast masses, and no cervical or axillary
lymphadenopathy. Which of the following is the most appropriate
next step in the management of this patient?
a. Reexamine the patient in 1 month
b. Corticosteroid cream to the affected area
c. Administration of oral antibiotics
d. Mammogram and biopsy of the affected area
e. Modified radical mastectomy
17. A 29-year-old woman with a history of difficulty becoming
pregnant presents to her primary care physician and is diagnosed
with Grave disease on iodine uptake scan; her thyrotropin (TSH)
level is markedly suppressed and her free thyroxine (T4) level is
elevated. She desires to conceive as soon as possible and elects
to undergo thyroidectomy. After she is rendered euthyroid with
medications preoperatively, which of the following management
strategies should also be employed to reduce the risk of
developing thyroid storm in the operating room?
!
!
!
31. A 19-year-old man is brought to the physician by his parents
after he called them from college, terrified that the Mafia was after
him. He reports that he has eaten nothing for the past 6 weeks
other than canned beans because they are into everythingI
cant be too careful. He is convinced that the Mafia has put
cameras in his dormitory room and that they are watching his
every move. He occasionally hears the voices of two men talking
about him when no one is around. His roommate states that for the
past 2 months the patient has been increasingly withdrawn and
suspicious. Which of the following is the most likely diagnosis?
a. Delusional disorder
b. Schizoaffective disorder
c. Schizophreniform disorder
d. Schizophrenia
e. Phencyclidine (PCP) intoxication
32. Amnestic disorders :
A. are secondary syndromes caused by primary etiologies.
B. are most often caused by nutritional deficiencies related to
chronic alcohol dependence.
C. may be diagnosed in the context of delirium.
D. may be diagnosed in the context of dementia.E. none of the
above!
35. A 22-year-old college student calls his psychiatrist because for the
past week, after cramming hard for finals, his thoughts have been racing
and he is irritable. The psychiatrist notes that the patients speech is
pressured as well. The patient has been stable for the past 6 months on
500 mg of valproate twice a day, and a blood level is in the therapeutic
range. Which of the following is the most appropriate first step in the
management of this patients symptoms?
a. Hospitalize the patient
.!b. Increase the valproate by 500 mg/day
.!c. Prescribe clonazepam 1 mg qhs.!
d. Start haloperidol 5 mg qd.!
e. Tell the patient to begin psychotherapy one time per week.
Sleep deprivation has an antidepressant effect in depressed patients and may
trigger a manic episode in bipolar patients. The patient is not ill enough to
require hospitalization. The use of a long-acting benzodiazepine will allow the
patient to return to a normal sleep pattern and generally will abort the manic
episode.
41.. A 6 month old boy is found to have very low levels of IgG, IgM,
55.!What!is!the!most!common!complication!of!Para!cervical!block?!
a.!Maternal!hypotension!!
b.!CNS!toxicity!!
c.!Fetal!bradycardia!!
d.!Bleeding!
e.!arrest!of!dilation!!
!
!
!
10.10!
!
1. A 74-year-old man is brought to the hospital because of urinary
10. Aplastic anemia has been associated with all of the following
EXCEPT:
A. Carbamazepine therapy
B. Methimazole therapy
C. Nonsteroidal anti-inflammatory drugs
D. Parvovirus B19 infection
E. Seronegative hepatitis
Parvovirus B19 infection most commonly causes pure red blood cell
(RBC) aplasia, particularly in patients with chronic hemolytic states and
high RBC turnover (e.g., sickle cell anemia).
23. A 4-month-old male infant has been seen on three occasions with febrile
illnesses without localizing signs. He is breast fed, and his growth and
development have been normal. During weekdays he is in a daycare setting
while the mother works, and there are at least five other infants being cared
for in that daycare center. The mother is concerned about some sort of
immune deficiency that is making her infant susceptible to infections. Which
one of the following statements is true?
A. Hypogammaglobulinemia is a normal occurrence at 4 months
B. Infants are born with IgG, IgM, and IgA levels near normal adult values
C. Boys born with X-linked (Bruton) agammaglobulinemia usually develop
serious infections before 6 months of age
D. Infants with hypogammaglobulinemia will generally do poorly with ordinary
viral infections
E. Patients with hypogammaglobulinemia can usually handle infections with
encapsulated organisms normally
24. A mother has brought in her 8-year-old daughter because of the development of
breasts over the past year. They are now to the size that she is requiring a bra and is
being teased by the other children. Premature thelarche differs from true precocious
puberty in that premature thelarche is associated with which of the following? !
(A) axillary hair development
(B) isolated breast development
(C) pubic hair development
(D) spontaneous ovulations
(E) voice changes !
25. A 20-month-old male presents to your office with 5 days of fever to 104C that reduces
minimally with antipyretics. On exam he has a strawberry tongue, edema of the hands and
feet, and an erythematous maculopapular rash on his trunk. Which of the following is
required to make the diagnosis of Kawasaki disease?
A. Inguinal lymphadenopathy greater than 2 cm!
B. Nonexudative bulbar conjunctival injection!
C. Oral ulcerations
D. Mitral valve regurgitation on ECHO
E. Scrotal edema
27. A 32-year-old man with a 3-year history of ulcerative colitis (UC) presents for
discussion for surgical intervention. The patient is otherwise healthy and does not
have evidence of rectal dysplasia. Which of the following is the most appropriate
elective operation for this patient?
a. Total proctocolectomy with end ileostomy
b. Total proctocolectomy with ileal pouch-anal anastomosis and diverting ileostomy
c. Total proctocolectomy with ileal pouch-anal anastomosis, anal mucosectomy, and
diverting ileostomy
d. Total abdominal colectomy with ileal-rectal anastomosis
e. Total abdominal colectomy with end ileostomy and very low Hartmann
29. A 60-year-old male patient with hepatitis C with a previous history of variceal
bleeding is admitted to the hospital with hematemesis. His blood pressure is 80/60
mm Hg, physical examination reveals splenomegaly and ascites, and initial
hematocrit is 25%. Prior to endoscopy, which of the following is the best initial
management of the patient?
a. Administration of intravenous octreotide
b. Administration of a -blocker (eg, propranolol)
31. A 53-year-old man presents to the emergency room with left lower quadrant
pain, fever, and vomiting. CT scan of the abdomen and pelvis reveals a thickened
sigmoid colon with inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid
collection in the pelvis. After percutaneous drainage and treatment with antibiotics,
the pain and fluid collection resolve. He returns as an outpatient to clinic 1 month
later. He undergoes a colonoscopy, which demonstrates only diverticula in the
sigmoid colon. Which of the following is the most appropriate next step in this
patients management?
a. Expectant management with sigmoid resection if symptoms recur
b. Cystoscopy to evaluate for a fistula
c. Sigmoid resection with end colostomy and rectal pouch (Hartmann procedure)
d. Sigmoid resection with primary anastomosis
e. Long-term suppressive antibiotic therapy
Diverticular abscesses are treated with percutaneous drainage initially followed by definitive
resectional therapy. Initial percutaneous drainage allows for a 1-stage procedure that consists of
resection of the affected colon with primary anastomosis. Perforated diverticulitis is typically treated
with either the Hartmann procedure (sigmoid resection with end colostomy and rectal stump) or
sigmoid resection, anastomosis, and diverting loop ileostomy.
32. A 52-year-old man with gastric outlet obstruction secondary to a duodenal ulcer
presents with hypochloremic, hypokalemic metabolic alkalosis. Which of the
following is the most appropriate therapy for this patient?
a. Infusion of 0.9% NaCl with supplemental KCl until clinical signs of volume
depletion are eliminated
b. Infusion of isotonic (0.15 N) HCl via a central venous catheter
c. Clamping the nasogastric tube to prevent further acid losses
d. Administration of acetazolamide to promote renal excretion of bicarbonate
e. Intubation and controlled hypoventilation on a volume-cycled ventilator to further
increase PCO2
33. A 68-year-old man presents to the ED complaining of a daily
34. A 70-year-old woman presents to the ED with dark stool for 3 weeks.
She occasionally notes bright red blood mixed with the stool. Review of
systems is positive for decreased appetite, constipation, and a 10-lb
weight loss over 2 months. She denies abdominal pain, nausea, vomiting,
and fever, but feels increased weakness and fatigue. She also describes a
raspy cough with white sputum production over the previous 2 weeks.
Examination reveals she is pale, with a supine BP of 115/60 mm Hg and
HR of 90 beats per minute. Standing BP is 100/50 mm Hg, with a pulse
of 105 beats per minute. Which of the following is the most likely
diagnosis?
a. Hemorrhoids!
b. Diverticulitis!
c. Mallory-Weiss tear
d. Diverticulosis!
e. Adenocarcinoma
11.2
1. A 60-year-old woman complains of fever and constant left lower quadrant
pain of 2-day duration. She has not had vomiting or rectal bleeding. She has a
history of hypertension but is otherwise healthy. She has never had similar
abdominal pain, and has had no previous surgeries. Her only regular
medication is lisinopril. On examination blood pressure is 150/80, pulse 110,
and temperature 38.9C (102F). She has normal bowel sounds and left lower
quadrant abdominal tenderness with rebound. A complete blood count reveals
WBC = 28,000. Serum electrolytes, BUN, creatinine, and liver function tests
are normal. What is the next best step in evaluating this patients problem?
a. Colonoscopy
b. Barium enema
c. Exploratory laparotomy
d. Ultrasound of the abdomen
e. CT scan of the abdomen and pelvis
The most likely diagnosis in this patient is acute diverticulitis.
2. a child suffer a provoked bite from a stray dog that was captured
by animal control and appears healthy. the most appropriate action
would be:
a-confine and observe the dog for 10 days for sings suggestive of
rabies
b-submit the dog's heads for examination for rabies
3. A 48-year-old man with a past medical history of hepatitis C and cirrhosis presents
to the ED complaining of acute-onset abdominal pain and chills. His BP is 118/75
mm Hg, HR is 105 beats per minute, RR is 16 breaths per minute, temperature is
101.2F rectally, and oxygen saturation is 97% on room air. His abdomen is
distended, and diffusely tender. You decide to perform a paracentesis and retrieve 1 L
of cloudy fluid. Laboratory analysis of the fluid shows a neutrophil count of 550
3
cells/mm . Which of the following is the most appropriate choice of
treatment?!
a. Metronidazole!
b. Vancomycin!
c. Sulfamethoxazole/trimethoprim (SMX/TMP)
d. Neomycin and lactulose!
e. Cefotaxime
a. Send a urethral swab for culture and administer 125 mg ceftriaxone intramuscularly
and 1 g azithromycin orally.
b. Send urine for culture and administer SMX/TMP orally.!
c. Discharge the patient with strict instructions to return if his symptoms worsen.
d. Order a CT scan to evaluate for a kidney stone.
e. Have him follow-up immediately with a urologist to evaluate for testicular cancer.
5. An 81-year-old woman presents to the ED after tripping over the sidewalk curb
and landing on her chin causing a hyperextension of her neck. She was placed in a
cervical collar by paramedics. On examination, she has no sensorimotor function of
her upper extremities. She cannot wiggle her toes, has 1/5 motor function of her
quadriceps, and only patchy lower extremity sensation. Rectal examination reveals
decreased rectal tone. Which of the following is the most likely diagnosis?
a. Central cord syndrome!
b. Anterior cord syndrome!
c. Brown-Squard syndrome!
d. Transverse myelitis!
e. Exacerbation of Parkinson disease
6. A 22-year-old man presents to the ED after being ejected from his vehicle
following a high-speed motor vehicle collision. Upon arrival, his BP is 85/55 mm Hg
and HR is 141 beats per minute. Two large-bore IVs are placed in the antecubital
veins and lactated Ringer solution is being administered. After 3 L of crystalloid fluid,
the patients BP is 83/57 mm Hg. Which of the following statements is most
appropriate regarding management of a hypotensive trauma patient who fails to
respond to initial volume resuscitation?
a. It is important to wait for fully cross-matched blood prior to transfusion.
b. Whole blood should be used rather than packed red blood cells (RBCs).
c. Blood transfusion should begin after 4 L of crystalloid infusion.!
d. Type O blood that is Rh-negative should be transfused.
sidewalk yesterday. He states that the pain started on the left side of his lower back
and now involves the right and radiates down both legs. He also noticed difficulty
urinating since last night. On neurologic examination, he cannot plantar flex his feet.
Rectal examination reveals diminished rectal tone. He has a medical history of
chronic hypertension and underwent a vessel surgery many years earlier. Which of
the following is the best diagnosis?
a. Abdominal aortic aneurysm (AAA)
b. Disk herniation!
c. Spinal stenosis!
d. Cauda equina syndrome
e. Osteomyelitis
leg pain, saddle anesthesia, and impaired bowel and bladder function (retention or
incontinence).
9. You have just prescribed phenytoin for a 12- year-old boy with new onset
of epilepsy. Of the following side effects, which is most likely to occur in this
patient?
(A) lymphoma syndrome !
(B) Raynaudphenomenon !
(C) acute hepatic failure !
10. A previously well 12-year-old girl presents to clinic because of painful swellings on the
front of the legs of about 3 days duration. Examination reveals tender erythematous nodules,
12 cm in diameter, on the extensor surfaces of the lower legs. The remainder of the physical
examination is unremarkable. Which of the following is most likely to confirm the cause of
this condition?
(A) stool smear and culture !
(B) urine analysis and BUN !
(C) throat culture !
(D) slit-lamp examination of the eye !
(E) echocardiogram !
To answer this question you must not only identify the rash as erythema nodosum (an
uncommon but not rare disease) but you must also know that group A -hemolytic
streptococcal infection is a common cause. Erythema nodosum is a reactive phenomenon
characterized by tender, erythematous nodules 12 cm in diameter. The lesions usually are on
the extensor surfaces of the extremities and are more common on the legs.
11.A 6-year-old girl presents with unilateral nonpainful, nonsuppurative conjunctivitis and
preauricular lymphadenitis. What is the most likely
causative organism?
(A) Mycobacterium avium !
(B) Bartonella henselae !
(C) Adenovirus !
(D) Staphylococcus aureus !
(E) Chlamydia trachomatis !
12. Causes of macrocephaly include all of the following EXCEPT:
A. Klinefelter syndrome
B. Chronic subdural effusions
C. Hydrocephalus
D. Familial factors
E. Congenital CMV infection
14. You suspect the diagnosis of a brain tumor in a 2-year-old girl with a recent
history of ataxia, slurred speech, and early morning vomiting. Which statement
about childhood brain tumors is true?
(A) Most are located in the midline and/or below the tentorium cerebri. !
(B) Brain tumors are a rare type of cancer in childhood. !
(C) Signs of increased intracranial pressure are rare on presentation. !
(D) Seizures are the presenting complaint in most cases. !
(E) Most cases occur in the first year of life. !
17. A 3-year-old boy presents with acute right leg pain and a limp. There is
no history of trauma. He holds his right hip in external rotation and flexion
and he has mild restriction of range of motion. He appears otherwise well
and is afebrile. His WBC is normal and ESR is 25 mm/h. What is the best
treatment option at this time?
(A) intravenous antibiotics !
(B) surgical drainage of the right hip joint !
(C) anti-inflammatory drugs and bed rest !
(D) oral antibiotics !
(E) intra-articular corticosteroids !
(C) Transient synovitis is the most common cause for limping in a healthy
child at this age. Transient synovitis classically occurs 12 weeks after a
nonspecific upper respiratory tract infec- tion. Transient synovitis is a
diagnosis of exclusion. Treatment of this disorder is symptomatic with
nonsteroidal anti-inflammatory medications.
18. You counsel the new parents of a baby boy with hypospadias
19. All of the following clinical findings are consistent with the
diagnosis of molluscum contagiosum EXCEPT:
A. Involvement of the genitals
B. Involvement of the soles of the feet
C. Lack of inflammation or necrosis at the site of the
rash
D. Rash associated with an eczematous eruption
E. Rash spontaneously resolving over 3 to 4 months
20. An 8-year-old boy is referred for new-onset seizures. Which of the following
would mostly support a diagnosis of complex partial (psychomotor) seizures?
(A) normal mental state, consciousness, and responsiveness during seizure
(B) a brief tonic-clonic phase
(C) automatisms
(D) three-persecond spike-and-wave pattern on EEG
(E) normal mental state, consciousness, and responsiveness after seizure
21. The parents of a 3-yr-old girl with a history of several previous coughing
b. Gastric carcinoma
c. Emphysema
d. Lung cancer
e. Nephrotic syndrome
33. A 64-year-old woman who is receiving chemotherapy for metastatic breast cancer has
been treating midthoracic pain with acetaminophen. Over the past few days she has become
weak and unsteady on her feet. On the day of admission she develops urinary incontinence.
Physical examination reveals fist percussion tenderness over T8 and moderate symmetric
muscle weakness in the legs. Anal sphincter tone is reduced. Which of the following
diagnostic studies is most important to order?
a. Serum calcium!
b. Bone scan!
c. Plain radiographs of the thoracic spine
d. MRI scan of the spine!
e. Electromyogram with nerve conduction studies
Spinal cord compression is an oncologic emergency. Major neurological deficit is often
irreversible and severely compromises the patients remaining quality of life. Vertebral and
then epidural involvement precede the neurological findings; the thoracic cord is involved
70% of the time. The patient is often given high-dose dexamethasone before being sent for
MRI. In the presence of neurological compromise, the definitive test, MRI scan, should be
performed as quickly as possible.
35. An 18-year-old boy presents with acute severe chest pain. EKG and enzyme studies
radiographs in 1 week.
c. Order a CT scan of the finger to confirm that there is no occult fracture before
discharging the patient home.
d. Place the hand in a radial gutter splint, prescribe a 10-day course of antibiotics,
and have the patient follow up with an orthopedic surgeon in 1 week.
e. Place the hand in a radial gutter splint, administer broad-spectrum antibiotics, and
admit the orthopedic service for operative debridement.
41.A 8 year old child referred to the clinic because of bed wetting,
several behavioral interventions have been attempted, including
eliminated fluid intake in the evening, scheduled awakenings at
nights to use the bathroom and urine alarm (bell and pad). These
techniques were unsuccessful and the child continued to urinate
every night. Which medication is the most appropriate to prescribe
to treat the enuresis:
A. retalin
B. paroxetin
C. trazodone
D. imepramin (primonil)
E. benztropine (cogentin)
43. A teenage boy falls from his bicycle and is run over by a truck.On arrival in the emergency
room(ER),he is awake and alert and appears frightened but in no distress. The chest
radiograph suggests an air-fluid level in the left lower lung field and the
nasogastric tube seems to coil upward into the next best step in his management?
a)Placement of a left chest tube
b)Thoracotomy
c)Laparotomy
d)Esofagogastroscopy
e)Diagnostic peritoneal lavage
12.2
3. Of the following steps taken prior to the induction of general anesthesia, which
has been the key factor in decreasing maternal mortality rates from general
anesthesia?
a. Antacids!
b. Preoxygenation!
c. Uterine displacement
!d. Aggressive IV hydration
When you perform Anesthesia there is a risk of pulmonary aspiration. So you
give antacids to increase the stomach PH.
4. Which of the following is the LEAST important to the normal progress of labor?
a. Cervical position
b. Uterine contractions
!c. Resistance of maternal tissues
a. Cornua
b. Fimbria
c. Isthmus
d. Ampulla
6. Which of the following is NOT a sonographic fetal finding of congenital syphilis?
a. Hepatomegaly
b. Lymphadenopathy
c. Placentomegaly
d. Ascites/hydrops
14. A teenage boy falls from his bicycle and is run over by a truck.On arrival in
the emergency room(ER),he is awake and alert and appears frightened but in
no distress. The chest radiograph suggests an air-fluid level in the left lower
lung field and the nasogastric tube seems to coil upward into the next best
step in his management?
a)Placement of a left chest tube
b)Thoracotomy
c)Laparotomy
d)Esofagogastroscopy
e)Diagnostic peritoneal lavage
The patient has an acute diaphragmatic rupture, which occurs in about 4% of
patients who sustain either blunt abdominal or chest trauma, and should be
treated with immediate laparotomy, which allows both for examination of the
intra-abdominal solid and hollow viscera for associated injuries and for
adequate exposure of the diaphragm to allow secure repair. Because of the
risk of vascular compromise of the contents of the hernia, exacerbated by the
negative thoracic pressure, acute diaphragmatic rupture should be repaired
immediately. Diagnosis may be difficult. The finding of an air-fluid level in the
left lower chest, with a nasogastric tube entering it after blunt trauma to the
abdomen, is diagnostic of diaphragmatic rupture with gastric herniation into
the chest. Esophagogastroscopy is of limited value. CT scanning and MRI
may be useful adjuncts, but neither can definitively rule out diaphragmatic
rupture. Diagnostic peritoneal lavage is neither sensitive nor specific for
diaphragmatic injuries, particularly in the absence of significant hemorrhage.
Diaphragmatic repair can be accomplished via the left chest, but laparotomy
is the procedure of choice for acute traumatic rupture for the stated reasons.
c. Placenta accreta!
d. Ectopic implantation
2 weeks prior to this admission. She did well and was dismissed 5
days after the procedure. Pain and swelling of the right leg began
2 days before this admission; she has noticed mild dyspnea but no
chest pain. The clinical suspicion of deep vein thrombosis (DVT) is
confirmed by a venous Doppler, and the patient is started on
unfractionated heparin. Her initial laboratory studies, including
CBC, are normal.The next day her pain has improved, and helical
CT scan of the chest reveals no evidence of pulmonary embolism.
She is instructed in the use of low-molecular-weight heparin and
warfarin; she is eager to go home. Her serum creatinine is normal.
Her predischarge CBC shows no anemia, but the platelet count
has dropped to 74,000. An assay for antibodies to heparin-platelet
factor 4 complexes is ordered. What is the best next step in her
management?
a. Dismiss the patient on low-molecular heparin, warfarin, and
close outpatient follow-up.
b. Obtain a liver-spleen scan to look for platelet sequestration.
c. Discontinue all forms heparin, continue warfarin, and add aspirin
162 mg daily until INR becomes therapeutic.
d. Keep the patient in the hospital, discontinue unfractionated
heparin, add low-molecular-weight heparin, and monitor the
platelet count daily.
. Keep the patient in the hospital, discontinue all forms of
e
heparin, and start the patient on lepirudin by intravenous infusion.
Hemoglobin: 7 g/dL
MCV: 89 fL (normal 86-98) WBC: 12,000/mL
BUN: 44 mg/dLCreatinine: 3.2 mg/dL
Ca: 11.5 mg/dLChest x-ray: LLL infiltrate Reticulocyte count: 1%
The definitive diagnosis is best made by which of the following?
a. 24-hour urine protein
b. Bone scan
c. Renal biopsy
d. Rouleaux formation on blood smear
e. Greater than 30% plasma cells in the bone marrow
Multiple myeloma would best explain this patients presentation. The onset of myeloma is
often insidious. Pain caused by bone involvement, anemia, renal insufficiency, and bacterial
pneumonia often follow. This patient presented with fatigue and bone pain, then developed
bacterial pneumonia probably secondary to Streptococcus pneumoniae, an encapsulated
organism for which antibody to the polysaccharide capsule is not adequately produced by the
myeloma patient. There is also evidence for renal insufficiency. Hypercalcemia is frequently
seen in patients with multiple myeloma and may be life threatening. Definitive diagnosis of
multiple myeloma is made by demonstrating greater than 30% plasma cells in the bone
marrow
18. The operation most appropriate for severe stress ulcer bleeding is
19. the most appropriate operation of a 30-year old patient with a history of
peptic ulcer disease who presents with a perforated duodenal ulcer is
a) Patch closure with a highly selective vagotomy
b) Gastrectomy with a Billroth I reconstruction
polyps.:
a. Polyps less than 1 cm in diameter are unlikely to be malignant
b. Villous adenomas most commonly occur in the cecum
c. FAP (familial adenomatous polyposis; is an autosomal recessive
condition
d. Hamartomatous polyps have a high incidence of malignant
transformatione. Fecal occult blood testing has not changed the
mortality from colon cancer.
23. During a routine prenatal visit a mother states she has been
reading about kernicterus. She is very concerned that her infant
will develop kernicterus if she provides breast milk for the infant
since she has also read that some breastfed infants have high
bilirubin levels. Which of the following is most predictive for the
development of kernicterus?
(A) hyperbilirubinemia within the first 24 hours of life
(B) peak conjugated bilirubin level
(C) peak unconjugated bilirubin level
(D) duration of hyperbilirubinemia
(E) hemoglobin level immediately after birth
24. Prevention of bilirubin encephalopathy or kernicterus is one of
the goals for the appropriate diagnosis and treatment of
hyperbilirubinemia. Which of the following mechanisms has a role
in preventing these adverse outcomes?
(A) Unconjugated bilirubin is not lipid soluble.
(B) Unconjugated bilirubin is tightly bound to albumin.
indicated?
(A) vertex delivery of the first twin and breech presentation of the
second twin
(B) term transverse lie with cervix completely dilated and
membranes intact
13.2
3. Even after menopause, most women have circulating estrogen. In high enough levels, this
can promote the development of endometrial cancer. It mainly originates from the
aromatization of which of the following?
(A) androstenedione to estradiol by ovarian granulosa cells
(B) androstenedione to estrone by ovarian thecal cells
(C) androstenedione to estrone by adipose tissue
(D) estradiol to estrone by adipose tissue
(E) testosterone to estradiol by adipose tissue
4. Women perceive the menstrual flow as an indication that the reproductive system
is functioning well. In fact the actual menstrual flow is associated with which of the
following?
(A) prolonged maintenance of estrogen
(B) prolonged maintenance of progesterone
(C) withdrawal of FSH
(D) withdrawal of LH
(E) withdrawal of progesterone
menstruation?
(A) FSH increases its own receptor numbers on theca cells.
(B) FSH induces granulosa cell LH receptors within the dominant follicle.
(C) FSH induces theca cell aromatase.
(D) FSH stimulates follicular growth only in the early preantral stage.
(E) FSH stimulates granulosa cell androgen production.
7. A 24-year-old patient presents with amenorrhea for more than 6 months. Prior to
the amenorrhea she had had oligomenorrhea for a number of months. She is not
pregnant, her weight has been stable with body mass index (BMI) of 23, and there is
no evidence of hirsutism or galactorrhea. On the basis of clinical evaluation, it
appears that she has GnRH suppression. A detailed history needs to be considered
regarding medication use since the inhibitory action of sex steroids on GnRH
secretion is primarily mediated by which of the following?
(A) dopamine
(B) melatonin
(C) norepinephrine
(D) opioid peptides
(E) serotonin
8. A 7-year-old girl is brought in for evaluation. On examination, she has welldeveloped pubic hair and breasts and she is 99% of height for her age. Her mother
recently noted some bloodstains on her underwear. Which of the following conditions
is most likely the cause of these findings?
(A) estrogen-producing ovarian cyst
(B) hepatoma
10. A mother brings her 2-month-old daughter to the pediatrician because she
feels a lump in her abdomen. On pelvic ultrasound the infant has an ovarian
mass. When counseling the mother, you inform her that the most common
ovarian lesion associated with the transient elevated gonadotropins in a
female newborn during the first 6 to 12 months of life is which of the
following?
(A) granulosa cell tumor
(B) leiomyoma
(C) serous cystadenoma
(D) single large follicular cyst
(E) theca cell tumor
13. All the following are true about cardiac valve replacement EXCEPT:
A. Bioprosthetic valve replacement is preferred to mechanical valve
replacement in younger patients because of the superior durability of the
valve.
B. Bioprosthetic valves have a low incidence of thromboembolic
complications.
C. The risk of thrombosis with mechanical valve replacement is higher in the
mitral position than in the aortic position.
D. Mechanical valves are relatively contraindicated in patients who wish to
become pregnant.
E. Double-disk tilting mechanical prosthetic valves offer superior
hemodynamic characteristics over single-disk tilting valves.
14.
Labor is induced at 38 weeks due to severe oligo-hydramnios. The infant is born with a
congenital absence of the left hand. This is likely due to which of the following?
(A) They are first capable of producing highly concentrated urine at 3 months.
(B) They are first capable of producing highly concentrated urine at 6 months.
(C) They are not affected by urinary tract obstruction in utero.
(D) If absent, they are associated with pulmonary hypoplasia.
(E) They produce only normotonic urine.
the fetus.
20. A patient presents with a positive pregnancy test, the exact date of the
start of her last normal menses, and the date of her luteinizing hormone (LH)
surge from a urine kit. Her expected date of delivery can most correctly be
calculated by which of the following?
(A) adding 254 to the date of the start of the last menstrual period (LMP)
(B) counting 10 lunar months from the time of ovulation
(C) counting 280 from the first day of the LMP
(D) counting 40 weeks from the last day of the LMP
(E) adding 256 to the date of the elevated urinary LH when detected by home
testing
21. A patient develops a fever and tachycardia during a blood
with an artificial porcine valve placed 6 months ago for CHD. She
is 10 weeks pregnant, tired, and does not sleep particularly well.
The fetus is size-date appropriate. Of the following choices, which
is the best first step in management?
(A) evaluate for valve replacement due to assumed cardiac
enlargement
(B) anticoagulate with aspirin and a platelet inhibitor
(C) recommend termination of the pregnancy as she had not
postponed conception for the mandatory24 months after valve
replacement
(D) anticoagulate with heparin
(E) keep on low-dose oral antibiotics
that for the past 2 months he has been increasingly irritable, withdrawn, and
apathetic. He has been refusing to do his homework, and his grades have
dropped. Which of the following is the best next step in management?
a. The child should be hospitalized.
b. The child should be started in supportive psychotherapy.
c. The mother should be warned that the child will likely turn out to be bipolar
(67% chance).
d. The child should receive an antidepressant medication.
e. The child should receive lithium and an antidepressant.
2. A 32-year-old man is being treated for a severe major depression. Which of the
following symptoms, if present, is one of the most accurate indicators of long-term
suicidal risk?
a. Revenge fantasies
b. Presence of rage in the patient
c. Hopelessness
d. Presence of guilte. Presence of a need for punishment in patient
3. A 30-year-old man comes to the psychiatrist for the evaluation of a depressed mood. He
states that at least since his mid-20s he has felt depressed. He notes poor self-esteem and low
energy, and feels hopeless about his situation, though he denies suicidal ideation. He states he
does not use drugs or alcohol, and has no medical problems. His last physical examination by
his physician 1 month ago was entirely normal. Which of the following treatment options
should be tried first?
a. ECT
!b. Hospitalization
c. Psychoanalysis
d. Venlafaxine!
e. Amoxapine
This patient has a dysthymic disorder.
A succussion splash describes the sound obtained by shaking an individual who has free flu
gas in a hollow organ or body cavity.
It is usually elicited to confirm intestinal or pyloric obstruction due to pyloric stenosis or gas
carcinoma, but may also be heard with hydropneumothorax, a large hiatal hernia, or over a
stomach.
To examine for this sign, gently shake the abdomen by holding either side of the pelvis. A p
occurs when a splashing noise is heard, either with the naked ear, or with the aid of a steth
test is not valid if the patient has eaten or drunk fluid within the last three hours.
(A) SLE
(B) scleroderma
16. A
e. Her age
Major predictors include unstable angina, recent myocardial infarction,
decompensated congestive heart failure, significant arrhythmias, and severe valvular
disease.
A 28-year-old medical student seeks your attention because of a testicular mass. Biopsy
is consistent with pure seminoma. There is no evidence of enlarged retroperitoneal lymph
nodes on CT scan. Which of the following is the best treatment strategy for this patient?
a. Orchiectomy alone
b. Orchiectomy followed by chemotherapy
c. Orchiectomy with retroperitoneal lymph node dissection
d. Orchiectomy with retroperitoneal lymph node dissection followed by external beam
radiation
e. Orchiectomy followed by external beam radiation to the retroperitoneal lymph nodes
26.
A 52-year-old woman sees her physician with complaints of fatigue, headache, flank
pain, hematuria, and abdominal pain. She undergoes a sestamibi scan that demonstrates
persistent uptake in the right superior parathyroid gland at 2 hours. Which of the following
laboratory values is most suggestive of her diagnosis?
a. Serum acid phosphatase above 120 IU/L
b. Serum alkaline phosphatase above 120 IU/L
c. Serum calcium above 11 mg/dL
d. Urinary calcium below 100 mg/day
e. Parathyroid hormone levels below 5 pmol/L
27 !A!38!year!old!woman!visits!her!family!physician!because!of!her!concern!about!a!
lump!in!her!left!breast!which!she!noticed!after!a!fall!approximately!one!week!
previously.!She!doesnt!smoke,!drinks!wine!on!social!occasions,!and!takes!birth!
control!pills.!There!is!no!family!history!of!breast!cancer.!Physical!examination!reveals!
a!rather!stocky!women!with!pendulous!breasts.!She!has!a!moderated!sized,!
nontender,!irregular!lump!in!the!lower!outer!quadrant!of!her!left!breast.!The!
overlying!skin!appears!thickened.!No!nipple!discharge!is!present,!and!she!has!no!
axillary!lymphadenopathy.!The!right!breast!and!axilla!are!normal.!Mammography!
reveals!increased!density!in!the!affected!region.!Ultrasound!guided!fine!needle!
aspiration!(FNAB)!was!performed.!The!pathology!report!was!consistent!with!a!
diagnoses!of!fat!necrosis.!Which!of!the!following!is!the!most!appropriate!next!step!in!
the!management!of!this!patient?!
a.!Excise!the!mass.!!
b.!Repeat!fine!needle!aspiration!biopsy!after!one!month.!!
c.!Repeat!mammography!in!a!month.!!
d.!Reassure!the!patient!and!follow!up!in!a!few!weeks.!!
29.!A!24!year!old!male!playing!football!fell!on!his!outstretched!hand!hoping!to!make!
a!touchdown.!The!patient!complains!on!severe!pain!in!his!right!arm.!His!vital!signs!
are:!BP!140/80,!PR!98!regular,!Temp!37C!and!RR!22/min!regular.!The!right!arm!is!
swollen!and!angulated!in!the!mid!arm!area,!it's!tender!to!touch!and!movement!is!
painful.!The!humeral!appear!to!be!fractured,!capillary!circulation!in!the!nail!bed!is!
normal.!However,!there!is!a!clinical!evidence!of!nerve!damage.!X[ray!imaging!
confirms!fracture!of!the!humeral!shaft!with!some!angulated!displacement.!Which!of!
the!following!is!the!nerve!injury!associated!with!this!fracture:!
a.!Axiliary!nerve!!
b.!Median!nerve!
!c.!Ulnar!nerve!!
d.!Radial!nerve!!
e.!Brachial!nerve!Correct!
the following?
(A) Increased breath sounds on the left
(B) Egophony on the left
(C) Increased timbre
(D) Increased width of intercostals on the left
(E) Mediastinal structures shifted to the left
This patient has sustained a pneumothorax in the left hemithorax secondary to
trauma. A pneumothorax can occur spontaneously or secondary to trauma
resulting from a blunt or penetrating injury. A pneumothorax is the presence of
air trapped in the pleural space that is unavailable for gaseous exchange.
Physical findings include hyperresonance to percussion (also known increased
timbre) on the side of the problem (choice C).
31.!While riding his bicycle, a 9-year-old boy loses control and falls.
During the process, his abdomen strikes the handlebar. His
parents bring him to the emergency department because he has
vague midabdominal pain and some bruising of the
anteriorabdominal wall. His vital signs are stable, and he has no
other visible injuries. Which of the following is the most likely
diagnosis?
(A) Ruptured spleen
(B) Ruptured liver
(C) Ruptured pancreas
(D) Hematoma in the rectus muscle
(E) Ruptured duodenum
The presentation of this patient is classic for rupture of the duodenum (choice
E). Patients have vague symptoms because the duodenum is retroperitoneal. If
left untreated, mortality is almost 100%. The best way to diagnose it is to
maintain a high index of suspicion and conduct repeated physical
examinations. Serum amylase is often elevated but is not diagnostic. X-ray
films of the abdomen reveal retroperitoneal air, which is the sine qua non of
duodenal rupture. Duodenal rupture in children could also result from the use
of the lap belt without shoulder support in motor vehicles. This results from
acute hyperflexion of the thoracolumbar spine, which crushes the duodenum.
Drivers of motor vehicles can also sustain duodenal rupture as a result of compression against the steering wheel. This possibility is greatly reduced by an air
bag.
34. A 52-year-old woman is brought to the emergency room after her husband finds her
unresponsive at home. The patient left behind a suicide note, and two empty bottles of pills
(sertraline and lorazepam) plus an empty bottle of vodka were found next to the patient. In the
emergency room the patients vital signs are: blood pressure 90/60 mm Hg, pulse 60
beats/minute, respirations 6 breaths/minute. Which of the following medications is most
likely to be helpful in the emergency
a. Ramelteon
b. Trazodone
c. Zolpidem
d. Triazolam
e. Zaleplon
C. Rape
D. All of the above
E. None of the above
45. A 23-year-old G2P1 develops chorioamnionitis during labor
and is started on ampicillin and gentamicin. She requires a
cesarean delivery for arrest of active phase labor and the same
antibiotics are continued after surgery. On postoperative day 3, the
patient remains febrile and symptomatic with uterine fundal
tenderness. No masses are appreciated by pelvic examination.
She is successfully breast-feeding and her breast examination is
normal. Which antibiotic should be initiated to provide better
coverage?
a. Cefazolin
b. Clindamycin
c. Moxifloxacin
d. Piperacillin with tazobactam
e. Vancomycin
46. A 23-year-old G2P1 develops chorioamnionitis during labor
and is started on ampicillin and gentamicin. She requires a
cesarean delivery for arrest of active phase labor and the same
antibiotics are continued after surgery. On postoperative day 3, the
patient remains febrile and symptomatic with uterine fundal
tenderness. No masses are appreciated by pelvic examination.
She is successfully breast-feeding and her breast examination is
normal. Which antibiotic should be initiated to provide better
coverage?
a. Cefazolin
b. Clindamycin
c. Moxifloxacin
d. Piperacillin with tazobactam
e. Vancomycin
Following vaginal delivery the antibiotic treatment of choice is ampicillin and
gentamicin, the same as the treatment for chorioamnionitis. After cesarean
delivery, broad- spectrum coverage with clindamycin and gentamicin is the
standard of care, and ampicillin is added to cover enterococcus if fever
persists after 48 to 72 hours. Clindamycin should be used for the treatment of
infections after cesarean delivery to provide anaerobic coverage.
47. You are asked to assist in the well-born nursery with neonatal care. Which of the
following is a part of routine care in a healthy infant?!
a. Administration of ceftriaxone cream to the eyes for prophylaxis for gonorrhea and
chlamydia!
b. Administration of vitamin A to prevent bleeding problems
c. Administration of hepatitis B vaccination for routine immunization!
d. Cool-water bath to remove vernix!
e. Placement of a computer chip in left buttock for identification purposes
e. Septic shock
50. Certain patients are more likely than others to have uterine
51.
52. You are checking a 22-year-old primigravida in active labor. Labor has lasted 14
hours. She is 8-cm dilated and at 0 station. As the fetal head has descended, the shape
has changed. Which of the following is the most likely etiology?
(A) cephalohematoma
(B) molding
(C) subdural hematomas
(D) hydrocephalus
(E) caput succedaneum
55.
Which of the following indications most likely predict a classic cesarean section as
opposed to a traditional transverse lower uterine segment cesarean section?
(A) maternal Crohns disease
(B) vertical skin incision, unknown previous uterine incision
(C) 26-week gestation with a breech presentation
(D) fundal myoma
(E) twins, with the first baby in a breech presentation
53.!Term labors lasting less than 3 hours are associated with which of the following
conditions?
(A) decreased fetal morbidity
(B) less maternal morbidity
(C) increased fetal morbidity
(D) primiparous labors
(E) twins
16.2
You are a passenger aboard an airplane and a 78-year-old
woman is complaining of chest pain and difficulty breathing. You
are the only medical professional available and volunteer to help.
Fortunately, the aircraft is well-equipped with basic medical
equipment, as well as with ACLS medications and a cardiac
monitor. On examination, the passengers BP is 75/40 mm Hg, HR
is 180 beats per minute, and RR is 24 breaths per minute. On
examination, the patient is in obvious distress but able to answer
basic questions. Her heart is tachycardic, regular, and without
murmurs, rubs, or gallops. Physical examination is remarkable for
a bounding carotid pulse. You attach the cardiac monitor and see a
regular rhythm at 180 beats per minute with wide QRS complexes
and no obvious P waves. After asking the pilot to make an
emergency landing, what do you do next?
a. Amiodarone IV
b. Synchronized cardioversion
c. Verapamil IV
d. Lidocaine IV
e. Procainamide IV
1.
a. Atropine
a. Atropine!
b. Naloxone!
c. Lidocaine!
d. Epinephrine!
e. Sodium bicarbonate
a. Administer terbutaline.
b. Initiate amnioinfusion.
c. Initiate Pitocin augmentation.
d. Perform cesarean delivery for arrest of descent.
e. Perform cesarean delivery of early decelerations.
6. Eight minutes after a normal delivery under pudendal anesthesia, the patient has
not completed the third stage of labor. The uterus is discoid and firm; no bleeding is
evident. What should you do?
(A) pull steadily but with greater traction on the cord
(B) perform Credes maneuver
(C) augment the contractions with intramuscular
(IM) methergine
(D) manually remove the placenta
(E) gently massage the uterus and wait
11. Term labors lasting less than 3 hours are associated with
which of the following conditions?
(A) decreased fetal morbidity
(B) less maternal morbidity
(C) increased fetal morbidity
(D) primiparous labors
(E) twins
14. A 6-year-old girl has a history of 2 weeks of abdominal pain. She is significantly
taller than her peers. Physical examination shows early breast development and
abdominal distention. Blood is present at the introitus, and pelvic examination is
attempted but cannot be accomplished. Serum gonadotropin levels are in the
prepubertal range and do not change after gonadotropin-releasing hormone (GnRH)
administration. Abdominal sonography shows a 6-cm solid right adnexal mass. Which
of the following is the most likely diagnosis?
!(A) epophoron
(B) granulosa cell tumor
(C) corpus luteum cyst !
(D) endometrioma
(E) fibroma
17. A 28-year-old G2P2 presents to the hospital 2 weeks after vaginal delivery with
the complaint of heavy vaginal bleeding that soaks a sanitary napkin every hour. Her
pulse is 89 beats per minute, blood pressure 120/76 mm Hg, and temperature 37.1C
(98.9F). Her abdomen is nontender and her fundus is located above the symphysis
pubis. On pelvic examination, her vagina contained small blood clots and no active
bleeding is noted from the cervix. Her uterus is about 12 to 14 weeks size and
nontender. Her cervix is closed. An ultrasound reveals an 8-mm endometrial stripe.
Her hemoglobin is 10.9, unchanged from the one at her vaginal delivery. -hCG is
negative. Which of the following potential treatments would be contraindicated?
a. Methylergonovine maleate (Methergine)
b. Oxytocin injection (Pitocin)!
c. Ergonovine maleate (Ergotrate)!
d. Prostaglandins
e. Dilation and curettage
b. surgery alone.
c. surgery followed by chemotherapy.
d. surgery followed by radiation therapy.
d. chemoradiation alone.
19. A 50-year-old woman is diagnosed with cervical cancer. Which
20. Your next patient is returning to see you to get her pelvic
22. Which of the following aneuploidies would be most common in the setting of otherwise
normal screening?
Trisomy 21 !
Trisomy 18 !
Trisomy 13 !
Sex chromosomal aneuploidy !
None of the above !
23.
examination. Her right leg is swollen from the mid-thigh down and
is tender. Doppler studies demonstrate a large deep venous
thrombosis in the femoral and ileac veins extending into the pelvis.
Laboratory studies on admission prior to therapy show normal
electrolytes, normal white blood cell (WBC) and platelet counts,
normal prothrombin time, and an activated partial thromboplastin
time 3 normal. Her pregnancy test is negative. Low- molecularweight heparin therapy is initiated in the emergency department.
Subsequent therapy should include:
A. Rituximab 375 mg/m2 per week for 4 weeks
B. Warfarin with INR goal of 2.03.0 for 3 months
C. Warfarin with INR goal of 2.03.0 for 12 months
D. Warfarin with INR goal of 2.53.5 for life
E. Warfarin with an INR goal of 2.53.5 for 12 monthsfollowed by
daily aspirin for life
Anti phospholipid syndrome : After diagnosis of a thrombotic event due to APS,
patients should receive warfarin for life with a goal INR of 2.53.5 alone or in combination
with daily aspirin.
25. Your patient presents for her first prenatal visit. She is 27-year-
30. A 3-year-old girl has a mild febrile illness with mild URI
symptoms. She has an erythematous rash on both cheeks. Her
pregnant mother had arthralgias of the hands wrists, knees, and
ankles a week ago. What should be the next action?
(
A) Closely monitor the childs sibling who has spherocytosis.
(B) Exclude the child from daycare until rash has resolved.
(C) Exclude the pregnant daycare providers until no further cases
are diagnosed for 2 weeks.
(D) Give the mother IVIG.
(E) Give the sibling with spherocytosis IVIG.
31. Two weeks after the birth of her infant, a new mother brings the
child in to see you. The childs eyes are edematous, with
conjunctival erythema and a mucopurulent discharge. Your
evaluation and treatment should include which of the following?
(A) a pelvic examination (using a small scope) of the infant
(B) culture maternal genital tract for GC and chlamydia
(C) anaerobic cultures of the infants and mothers eyes
(D) immunoglobulin M (IgM) titers of the infant
(E) penicillin VK for both the mother and the infant
42. The hospital is reviewing its protocols to decrease the iatrogenic infection
rate within the hospital. For which of the following procedures would
prophylactic antibiotics be appropriate?
(A) amniocentesis
(B) laparoscopy
(C) tubal sterilization
(D) vaginal hysterectomy
(E) episiotomy repair
43. Regarding immunization during pregnancy, which of the following
vaccines would be the safest to receive during pregnancy?
(A) mumps
(B) polio
(C) rabies
(D) rubella
(E) rubeola (measles)