I-1. A physician is deciding whether to use a new test to screen for disease X in his practice. The prevalence of disease X is 5%. The sensitivity of the test is 85%, and the specificity is 75%. In a population of 1000, how many patients will have the diagnosis of disease X missed by this test?
I-2. How many patients will be erroneously told they have diagnosis X on the basis of the results of this test?
I-3. Which type of health care delivery system encourages physicians to see more patients but to provide fewer services?
I-4. The curve that graphically represents the family of cutoff points for a positive vs. negative test is a receiver operating characteristic (ROC) curve. The area under this curve is a quantitative measure of the information content of a test. The ROC axes are
C. sensitivity vs. (1 - specificity)
I-5. A patient is seen in the clinic for evaluation of chest pain. The patient is 35 years old and has no medical illnesses. She reports occasional intermittent chest pain that is unrelated to exercise but is related to eating spicy food. The physician's pretest probability for coronary artery disease causing these symptoms is low; however, the patient is referred for an exercise treadmill test, which shows ST depression after moderate exercise. Using Bayes' theorem, how does one interpret these test results?
A. The pretest probability is low, and the sensitivity
and specificity of exercise treadmill testing in females are poor; therefore, the exercise treadmill test is not helpful in clinical decision making in this case.
I-6. An effective way to measure the accuracy of a diagnostic test is a positive likelihood ratio [sensitivity/(1 - specificity)], which is also defined as the ratio of the probability of a positive test result in a patient with disease to the probability of a positive test result in a patient without disease. What other piece of information is needed along with a positive likelihood ratio to estimate the possibility of a given disease in a certain patient with a positive test result?
D. Pretest probability of the disease in a patient
I-7. Drug X is investigated in a meta-analysis for its effect on mortality after a myocardial infarction. It is found that mortality drops from 10 to 2% when this drug is administered. What is the absolute risk reduction conferred by drug X?
I-9. A healthy 23-year-old female is referred to your clinic after being seen in the emergency department for intermittent severe chest pain. During her visit, she is ruled out for cardiac ischemia, with negative biomarkers for cardiac ischemia and unremarkable electrocardiograms. An exercise single photon emission CT (SPECT) myocardial perfusion test was performed, and a reversible exercise-induced perfusion defect was noted. The test was read as positive. The patient was placed on aspirin. She is quite concerned that she continues to have chest pain intermittently on a daily basis without any consistency in regards to time or antecedent activity.
She is otherwise active and feeling well. She smokes socially on weekends. She has no family history of early coronary disease. What would be the best next course of action?
D. Evaluation for non-cardiac source of her chest pain
I-10. Which of the following statements regarding gender health is true?
C. In a recent placebo-controlled trial, postmenopausal
hormone therapy did not show improvement in disease
progression in women with Alzheimer's disease.
I-11. All of the following statements regarding women's health are true except
D. Women with myocardial infarction (MI) are more
likely to present with ventricular tachycardia, whereas
men are more likely to present with cardiogenic
I-12. When ordering an evaluation of coronary artery
disease in a female patient, all of the following are true except
D. Women undergoing coronary artery bypass surgery
have lower 5- and 10-year survival rates than men.
I-13. Which of the following statements regarding cardiovascular risk is true?
D. Total triglyceride levels are an independent risk factor
for coronary heart disease in women but not in men.
I-14. Which of the following alternative medicines has shown proven benefit compared to placebo in a large randomized clinical trial?
C. Glucosamine/chondroitin sulfate for improving performance and slowing narrowing of the joint space in patients with moderate to severe osteoarthritis
I-15. You prescribe an extended-release antihypertensive agent for your patient at a dosing interval of 24 h. The half-life of the agent is 48 h. Three days later the patient's blood pressure is not controlled. At this point you should
D. recheck the blood pressure in 1 week
I-16. A 56-year-old patient arrives in your clinic with worsening somnolence, per his wife. You have followed him for several years for his long-standing liver disease related to heavy alcohol use in the past and hepatitis C infection, as well as chronic low back pain related to trauma. He has recently developed ascites but has had a good response to
diuretic therapy. He has no history of gastrointestinal
bleeding, he denies fever, chills, abdominal pain, tremor, or any recent change in his medicines, which include furosemide, 40 mg daily; spironolactone, 80 mg daily; and extended-release morphine, 30 mg twice a day. He is afebrile with normal vital signs. His weight is down 5 kg since initiating diuretic therapy. Physical examination is
notable for a somnolent but conversant man with mild jaundice, pinpoint pupils, palmar erythema, spider hemangiomas on his chest, a palpable nodular liver edge at the costal margin, and bilateral 1+ lower extremity edema. He does not have asterixis, abdominal tenderness, or an abdominal fluid wave. Laboratory results compared to 3 months previously reveal an increased INR, from 1.4
to 2.1; elevated total bilirubin, from 1.8 to 3.6 mg/dL; and decreased albumin from 3.4 to 2.9 g/L; as well as baseline elevations of his aspartate and alanine aminotransferases (54 U/L and 78 U/L, respectively). Serum NH4 is 16. What would be a sensible next step for this patient?
A. Decrease his morphine dose by 50% and reevaluate
him in a few days
I-17. A homeless male is evaluated in the emergency department. He has noted that after he slept outside during a particularly cold night his left foot has become clumsy and feels "dead." On examination, the foot has hemorrhagic vesicles distributed throughout the foot distal to the ankle.
The foot is cool and has no sensation to pain or temperature. The right foot is hyperemic but does not have vesicles and has normal sensation. The remainder of the physical examination is normal. Which of the following statements regarding the management of this disorder is true?
B. During the period of rewarming, intense pain can
I-18. A 78-year-old female is seen in the clinic with complaints of urinary incontinence for several months. She finds that she is unable to hold her urine at random times throughout the day; this is not related to coughing or sneezing. The leakage is preceded by an intense need to empty the bladder. She has no pain associated with these episodes, though she finds them very distressing. The patient
is otherwise independent in the activities of daily
living, with continued ability to cook and clean for herself. Which of the following statements is true?
C. Indwelling catheters are rarely indicated for this disorder.
I-19. All of the following statements regarding medications in the geriatric population are true except
B. Fat-soluble drugs have a shorter half-life in geriatric
I-20. Which of the following class of medicines has been linked to the occurrence of hip fractures in the elderly?
I-21. Patients taking which of the following drugs should be advised to avoid drinking grapefruit juice?
I-22. A recent 18-year-old immigrant from Kenya presents to a university clinic with fever, nasal congestion, severe fatigue, and a rash. The rash started with discrete lesions at the hairline that coalesced as the rash spread caudally. There is sparing of the palms and soles. Small white spots
with a surrounding red halo are noted on examination of the palate. The patient is at risk for developing which of the following in the future?
I-23. You are a physician working in an urban emergency department when several patients are brought in after the release of an unknown gas at the performance of a symphony. You are evaluating a 52-year-old female who is not able to talk clearly because of excessive salivation and rhinorrhea, although she is able to tell you that she feels as if she lost her sight immediately upon exposure. At present, she also has nausea, vomiting, diarrhea, and muscle twitching. On physical examination the patient has a blood pressure of 156/92, a heart rate of 92, a respiratory rate of 30, and a temperature of
37.4°C (99.3°F). She has pinpoint pupils with profuse rhinorrhea and salivation. She also is coughing profusely, with production of copious amounts of clear secretions. A lung examination reveals wheezing on expiration in bilateral lung
fields. The patient has a regular rate and rhythm with normal heart sounds. Bowel sounds are hyperactive, but the abdomen is not tender. She is having diffuse fasciculations. At the end of your examination, the patient abruptly develops tonic-clonic seizures. Which of the following agents is most likely to cause this patient's symptoms?
I-25. A 24-year-old male is brought to the emergency department after taking cyanide in a suicide attempt. He is unconscious on presentation. What drug should be used as an antidote?
E. Sodium nitrite with sodium thiosulfate
I-26. A 40-year-old female is exposed to mustard gas during a terrorist bombing of her office building. She presents to the emergency department immediately after exposure without complaint. The physical examination is normal. What is the next step?
A. Admit the patient for observation because symptoms
are delayed 2 h to 2 days after exposure and
treat supportively as needed.
I-27. A 24-year-old healthy man who has just returned from a 1-week summer camping trip to the Ozarks presents to the emergency room with fever, a severe headache, mild abdominal pain, and severe myalgias. He is discharged home but 1 day later feels even worse and therefore returns. Temperature is 38.4°C; heart rate is 113 beats/min; blood pressure is 120/ 70. Physical examination is notable for a well-developed, well-nourished, but diaphoretic and distressed man. He is alert and oriented to time and place. His lungs are clear to
auscultation. He has no heart murmur. His abdomen is mildly tender with normal bowel sounds. Neurologic examination is nonfocal. There is no evidence of a rash. Laboratory evaluation is notable for a platelet count of 84,000/μL. A lumbar puncture is notable for 5 monocytes, no red blood
cells, normal protein levels, and normal glucose levels. What should be the next step in this patient's management?
I-28. A 23-year-old woman with a chronic lower extremity ulcer related to prior trauma presents with rash, hypotension, and fever. She has had no recent travel or outdoor exposure and is up to date on all of her vaccinations. She does not use IV drugs. On examination, the ulcer looks clean with a well-granulated base and no erythema, warmth, or pustular discharge. However, the patient does
have diffuse erythema that is most prominent on her
palms, conjunctiva, and oral mucosa. Other than profound hypotension and tachycardia, the remainder of the examination is nonfocal. Laboratory results are notable for a creatinine of 2.8 mg/dL, aspartate aminotransferase of 250 U/L, alanine aminotransferase of 328 U/L, total
bilirubin of 3.2 mg/dL, direct bilirubin of 0.5 mg/dL, INR of 1.5, activated partial thromboplastin time of 1.6 × control, and platelets at 94,000/μL. Ferritin is 1300 μg/mL. The patient is started on broad-spectrum antibiotics after appropriate blood cultures are drawn and is resuscitated
with IV fluid and vasopressors. Her blood cultures are negative at 72 h: at this point her fingertips start to desquamate. What is the most likely diagnosis?
C. Staphylococcal toxic shock syndrome
I-29. The Centers for Disease Control and Prevention (CDC) has designated several biologic agents as category A in their ability to be used as bioweapons. Category A agents include agents that can be easily disseminated or transmitted, result
in high mortality, can cause public panic, and require
special action for public health preparedness. All the following agents are considered category A except
C. ricin toxin from Ricinus communis
I-30. A 50-year-old alcoholic woman with well-controlled cirrhosis eats raw oysters from the Chesapeake Bay at a cookout. Twelve hours later she presents to the emergency department with fever, hypotension, and altered sensorium. Her extremity examination is notable for diffuse erythema with areas of hemorrhagic bullae on her
shins. What is the most likely diagnosis?
E. Vibrio vulnificus infection
I-31. Hyperthermia is defined as
C. an uncontrolled increase in body temperature despite
a normal hypothalamic temperature setting
I-32. A patient in the intensive care unit develops a temperature of 40.8°C, profoundly rigid tone, and hemodynamic shock 2 min after a succinylcholine infusion is started. Immediate therapy should include
A. intravenous dantrolene sodium
C. external cooling devices
D. A and C
I-33. Which of the following conditions is associated with increased susceptibility to heat stroke in the elderly?
A. A heat wave
B. Antiparkinsonian therapy
C. Bedridden status
D. Diuretic therapy
E. All of the above
I-34. A 68-year-old alcoholic arrives in the emergency department after being found in the snow on a cold winter night in Chicago. His core temperature based on rectal and esophageal probe is 27°C. Pulse is 30 beats/min and blood pressure is 75/40 mmHg. He is immobile and lacks corneal, oculocephalic, and peripheral reflexes. He is immediately intubated and placed on a cardiac monitor. He then converts to ventricular fibrillation: a defibrillation attempt at 2 J/kg is not successful. What should be the next immediate step in management?
A. Active rewarming with forced-air heating blankets,
heated humidified oxygen, heated crystalloid infusion
I-35. In the evaluation of malnutrition, which of the following proteins has the shortest half-life and thus is most predictive of recent nutritional status?
I-36. A 45-year-old man is stranded overnight in the cold after an avalanche. He is airlifted to your medical center and found to have anesthesia and a clumsy sensation in the distal extent of the fingers on his left hand (see Color Atlas, Figure I-36). What is the best initial management of his hand?
C. Rapid rewarming
I-37. Fecal occult blood testing (FOBT) was shown to decrease colon cancer-related mortality from 8.8/1000 persons to 5.9/1000 persons over a 13-year period. What is the approximate absolute risk reduction (ARR) of this intervention in the studied population?
I-38. Which preventative intervention leads to the largest average increase in life expectancy for a target population?
B. Getting a 35-year-old smoker to quit smoking
I-39. All of the following patients should receive a lipid screening profile except
B. a 17-year-old female teen who recently began smoking
I-40. A 46-year-old female presents to her primary care doctor complaining of a feeling of anxiety. She notes that she always had been what she describes as a "worrier," even in grade school. The patient has always avoided speaking in
public and recently is becoming anxious to the extent where she is having difficulty functioning at work and in social situations. She has difficulty falling asleep at night and finds that she is always "fidgety" and has a compulsive urge to move. The patient owns a real estate company that has been in decline since a downturn in the local economy.
She recently has been avoiding showing homes for sale. Instead, she defers to her partners because she finds that she is nervous to the point of being unable to speak to her clients. She has two children, ages 16 and 12, who are very active
in sports. She feels overwhelmed with worry over the possibility of injury to her children and will not attend their sports events. You suspect that the patient has a generalized anxiety disorder. All of the following statements regarding this diagnosis are true except
C. As in panic disorder, shortness of breath, tachycardia,
and palpitations are common.
I-41. For which of the following herbal remedies is there the best evidence for efficacy in treating the symptoms of benign prostatic hypertrophy?
D. Saw palmetto
I-42. Which of the following personality traits is most likely to describe a young female with anorexia nervosa?
I-43. Why is it necessary to coadminister vitamin B6 (pyridoxine) with isoniazid?
C. Isoniazid interacts with pyridoxal phosphate.
I-46. Which of the following is the best indicator of prognosis and longevity in a geriatric patient?
A. Functional status
I-47. Diagnostic criteria for delirium as a cause of a confused state in a hospitalized patient include all of the following except
I-49. A stage 1 decubitus ulcer (nonblanchable erythema of intact skin or edema and induration over a bony pressure point) can progress to a stage 4 decubitus ulcer (full-thickness skin loss with tissue necrosis as well as damage to bone, muscle and tendons) over what period of time?
B. 1-2 days
I-50. A 74-year-old woman complains of leaking urine when she coughs, laughs, or lifts her groceries. She denies polydipsia and polyuria. She delivered four children vaginally and underwent total abdominal hysterectomy for fibroids 20 years earlier. She has mild fasting hyperglycemia that is
controlled with diet. What is likely to be the best management for her problem?
I-51. A 38-year-old man with multiple sclerosis develops acute flaccid weakness in his left arm and left leg. Physical examination reveals normal sensorium, normal cranial nerve function, 1/5 strength in his left upper extremity, 0/5 strength in his left lower extremity, impaired proprioception in his left leg, intact proprioception in his right leg, decreased pain and temperature sensation in his right arm and leg, and normal light touch/pain and temperature sensation in his right leg. Where is his causative lesion most likely to be?
B. High cervical spinal cord
I-52. A 32-year-old man with a history of HIV infection presents to the hospital with nausea, abdominal distention and projectile vomiting that developed over the previous 8-12 h. He denies fevers, chills, diaphoresis,melena, or diarrhea. Over the past 3 months, he has lost 30 lb in the context of advanced HIV infection. He has never had abdominal surgery. On examination, his abdomen
is distended, with high-pitched intermittent bowel
sounds and guarding but no rebound. A periumbilical
bruit is also detected. Abdominal x-ray reveals a smallbowel obstruction with a probable cut-off point in the mid duodenum. What is the diagnostic test of choice for diagnosing the cause of the underlying obstruction?
A. Abdominal CT with abdominal angiogram
I-53. A 64-year-old man with primary light chain amyloidosis develops orthostatic symptoms despite maintaining adequate oral intake. He also notes early satiety, with bloating and vomiting if he eats too rapidly. To combat this, he has decreased the size of his meals but eats twice as frequently during the day, with some positive effect. What is the most likely explanation for his gastrointestinal symptoms?
I-54. A 42-year-old man with a history of end-stage renal disease is on hemodialysis and has been taking a medication chronically for nausea and vomiting. Over the past week he has developed new-onset involuntary lip smacking, grimacing, and tongue protrusion. This side effect is most likely due to which of the following antiemetics?
I-55. Which of the following is not a common cause of persistent cough lasting more than 3 months in a nonsmoker?
D. Mycoplasma infection
I-56. A 64-year-old alcoholic presents to the emergency department with occasional hemoptysis, productive cough, and low-grade fever over the past several weeks. His CT scan shows an abnormality in the right lower lobe. He reports
several contacts with tuberculosis-infected patients
while in prison several years ago. Sputum examination reveals putrid-smelling thick green sputum streaked with blood. The Gram stain shows many polymorphonuclear leukocytes and a mix of gram-positive and -negative organisms. What is the most likely diagnosis?
B. Polymicrobial lung abscess
I-57. A 74-year-old man with known endobronchial carcinoma of his left mainstem bronchus develops massive hemoptysis (1 L of frank hemoptysis productive of bright red blood) while hospitalized. All of the following should be considered in his initial management except
D. placing the patient in the lateral decubitus position
with his right side down
I-58. A patient with proteinuria has a renal biopsy that reveals segmental collapse of the glomerular capillary loops and overlying podocyte hyperplasia. The patient most likely has
B. HIV infection
I-59. A 35-year-old woman comes to your clinic complaining of shortness of breath. It is immediately apparent that she has a bluish tinge of her face, trunk, extremities, and mucusmembranes. Which of the following diagnoses is most likely?
A. Atrial septal defect
I-60. A 43-year-old man with alcoholic liver disease complainsof dyspnea upon sitting up. Physical examination is notable for chest spider angiomas and palmar erythema. His arterial oxygen saturations fall from 96% to 88% upon transition from lying to sitting. His lung fields are clear and heart sounds are crisp. Abdominal examination is notable for a palpable nodular liver edge but no fluid wave or shifting dullness. He has 1+ lower
extremity edema. What is the most likely cause of his dyspnea?
C. Pulmonary arteriovenous fistula
I-61. A 30-year-old woman complains of lower extremity swelling and abdominal distention. It is particularly troublesome after her daily shift as a toll booth operator and is at its worst during hot weather. She denies shortness of breath, orthopnea, dyspnea on exertion, jaundice, foamyurine, or diarrhea. Her symptoms occur independently of her menstrual cycle. Physical examination is notable for 2+ lower extremity edema, flat jugular venous pulsation, no hepatojugular reflex, normal S1 and S2 with no extra
heart sounds, clear lung fields, a benign slightly distended abdomen with no organomegaly, and normal skin. A complete metabolic panel is within normal limits, and a urinalysis shows no proteinuria. What is the most likely diagnosis?
D. Idiopathic edema
I-62. All of the following factors are associated with a greater risk of ventricular arrhythmia versus anxiety/panic attack in a patient complaining of palpitations except
D. palpitations lasting >15 min
I-63. A 25-year-old healthy woman visits your office during the fifth month of pregnancy. Her blood pressure is 142/86 mmHg. What should be your next step in management?
D. Recheck her blood pressure in the seated position in
I-64. A 33-year-old woman with diabetes mellitus and hypertension presents to the hospital with seizures during week 37 of her pregnancy. Her blood pressure is 156/92 mmHg. She has 4+ proteinuria. Management should include all of the following except
D. intravenous phenytoin
I-65. Which cardiac valvular disorder is the most likely to cause death during pregnancy?
D. Mitral stenosis
I-66. A 27-year-old woman develops left leg swelling during week 20 of her pregnancy. Left lower extremity ultrasonogram reveals a left iliac vein deep vein thrombosis (DVT). Proper management includes
I-67. In which of the following categories should women undergo routine screening for gestational diabetes?
A. Age >25 years
B. Body mass index >25 kg/m2
C. Family history of diabetes mellitus in a first-degree relative
D. African American
E. All of the above
I-68. All of the following should be components of the routine evaluation of any patient undergoing medium- or high-risk non-cardiac surgery except
B. chest radiograph
I-69. Noninvasive cardiac imaging/stress testing should be considered in patients with how many of the following six proven risk factors (high-risk surgery, ischemic heart disease, congestive heart failure, cerebrovascular disease, diabetes
mellitus, and renal insufficiency) for perioperative
cardiac events (including pulmonary edema, myocardial infarction, and heart block)?
I-70. A 72-year-old white man with New York Heart Association II ischemic cardiomyopathy, diabetes mellitus, and chronic renal insufficiency (creatinine clearance = 42 mL/ min) undergoes dobutamine echocardiography prior to carotid endarterectomy. He is found to have 7-mm ST depressions
in his lateral leads during the test and develops
dyspnea at 70% maximal expected dosage, requiring early cessation of the stress test. His current medicines include an angiotensin converting enzyme inhibitor, a beta blocker, and aspirin. What would be your advice to the patient?
B. Proceed to cardiac catheterization
I-71. Parkinson's disease can often be differentiated from the atypical Parkinsonian syndromes (multiple system atrophy, progressive supranuclear palsy) by the presence of which of the following?
B. Pill-rolling tremor
I-72. A wide-based gait with irregular lurching and erratic foot placement but no subjective dizziness characterizes which type of gait ataxia?
A. Cerebellar dysfunction
I-73. A patient with a narrow-based gait instability complains that he needs to look at his feet while he walks to prevent falling. He feels wobbly standing with his eyes closed and notes frequent falls. On examination, he has no difficulty initiating gait, his stride is regular, strength is normal, and there is no tremor. Review of routine blood work drawn 3 months prior reveals a hematocrit of 29%
with an elevated mean corpuscular volume. Which of the following is the most likely diagnosis?
E. Pernicious anemia
I-74. Which of the following is an effective method to evaluate for cortical sensory deficits?
A. Graphesthesia (the capacity to recognize letters drawn
by the examiner on the patient's hand)
B. Stereognosis (the ability to recognize common objects, such as coins, by palpation)
C. Touch localization
D. Two-point discrimination testing
E. All of the above
I-75. A 23-year-old female patient complains of visual blurriness. On examination, her pupils are equally round. Shining a flashlight into her right eye causes equal, strong constriction in both of her eyes. When the light is flashed into her left eye, both pupils dilate slightly though not to their previous size prior to light confrontation. Where is
there most likely to be anatomic damage?
B. Left optic nerve or retina
I-76. A patient complains of blurred vision in both eyes particularly in the periphery with the right being worse than the left. Visual field examination with finger confrontation reveal a decreased vision in the left periphery in the left eye and right periphery in the right eye. Where is there most likely to be a lesion?
E. Suprasellar space
I-77. Which of the following methods is most effective for the diagnosis of corneal abrasions?
A. Fluorescein and cobalt-blue light examination
I-78. Which of the following criteria best differentiates episcleritis from conjunctivitis?
B. Lack of discharge
I-79. Which diagnosis can be easily confused with adenoviral conjunctivitis and is a major cause of blindness in the United States?
B. Herpes simplex virus keratitis
I-80. A 34-year-old male patient is referred to your clinic after a new diagnosis of anterior uveitis. All of the following diseases should be screened for by history and physical and/or laboratory examination because they may cause anterior uveitis except
I-81. A 22-year-old female is referred to your clinic after being started on glucocorticoids for a new diagnosis of left optic neuritis seen on examination with disc pallor, and it is confirmed with quantitative visual field mapping. What further evaluation is indicated?
B. Brain MRI
I-82. A 69-year-old male dialysis patient with poorly controlled diabetes, heart failure and chronic indwelling catheters presents with fever and loss of vision in the left eye developing over the past 6 h. Vital signs are notable for a temperature of 101.3°F, heart rate of 105/min, and blood pressure of 125/85. Which test is most likely to confirm the diagnosis?
A. Blood cultures
I-83. Exposure to which of the following types of radiation would result in thermal injury and burns but would not cause damage to internal organs because the particle size is too large to cause internal penetration?
B. Beta radiation
I-84. A "dirty" bomb is detonated in downtown Boston. The bomb was composed of cesium-137 with trinitrotoluene. In the immediate aftermath, an estimated 30 people were killed due to the power of the blast. The fallout area was about 0.5 mile, with radiation exposure of ~1.8 gray (Gy). An estimated 5000 people have been potentially exposed to beta and gamma radiation. Most of these individuals show no sign of any injury, but about 60 people have evidence of thermal injury. What is the most appropriate approach to treating the injured victims?
D. Severely injured individuals should be transported
to the hospital for emergency care after removing
the victims' clothes, as the risk of exposure to health
care workers is low.
I-85. A 54-year-old man is admitted to the hospital with severe nausea, vomiting, and diarrhea. These symptoms began 36 h ago. He briefly improved for a few hours yesterday, but today has progressively worsened. He states he is concerned about possible poisoning because of his role in espionage and counterterrorism for the U.S. government.
He met with an informant 2 days previously at a
hotel bar, where he drank three cups of coffee but did not eat. He does state that he left the table to place a phone call during the meeting and is concerned that his coffee may have been contaminated. He otherwise is quite healthy and takes no medications. On physical examination, he
appears ill. The vital signs are: blood pressure 98/60
mmHg, heart rate 112 beats/min, respiratory rate 24
breaths/min, SaO2 94%, and temperature 37.4°C. Head, ears, eyes, nose, and throat examination shows pale mucous membranes. Cardiovascular examination is tachycardic, but regular. His lungs are clear. The abdomen is slightly distended with hyperactive bowel sounds. There is no tenderness or rebound. Extremities show no edema, but a few scattered petechiae are present. Neurologic examination is normal. A complete blood count is performed. The results are: white blood cell (WBC) count 150/μL, red blood cell count 1.5/μL, hemoglobin 4.5 g/dL, hematocrit 15%, platelet count 11,000/μL. The differential on the WBC count is 98% PMNs, 2% monocytes, and 0% lymphocytes. A blood sample is held for HLA testing. A urine sample is positive for the presence of radioactive isotopes, which are determined to be polonium-210, a strong emitter of alpha radiation. The mode of exposure is presumed to be ingestion. What is the best approach to the
E. Supportive care and dimercaprol
I-86. Several victims are brought to the emergency room after a terrorist attack in the train station. An explosive was detonated that dispersed an unknown substance throughout the station, but several people reported a smell like that of horseradish or burned garlic. Prior to transport to the
emergency room, exposed individuals had their clothing removed and underwent showering and decontamination. On initial presentation, there was no apparent injury except eye irritation. Over the next few hours, most of those exposed complain of nasal congestion, sinus pain, and burning in the nares. Beginning about 2 h after exposure, many
of the exposed individuals began to notice diffuse redness of the skin, particularly in the neck, axillae, antecubital fossae, and external genitalia. In addition, a few people also developed blistering of the skin. Hoarseness, cough, and dyspnea are noted as well. What is the most likely chemical agent that was released in the terrorist attack?
C. Mustard gas
I-87. An unknown chemical agent was released in a terrorist attack in the food court of a shopping mall. Several victims who were close to the site of the release of the gas died prior to arrival of the emergency medical teams. Upon arrival,
the survivors were complaining of difficulty with vision and stated that they felt the world was "going black." The victims were also noted to be drooling and have increased nasal secretions. A few individuals were dyspneic with wheezing. The most severely affected victims fell unconscious
and soon thereafter developed seizures. What
medication(s) should be administered immediately to the survivors?
B. 2-Pralidoxime chloride, 1800 mg IM
C. Diazepam, 5 mg IV
E. B and C
I-88. A 7-month-old child is brought to clinic by his parents. He was the product of a healthy pregnancy, and there were no perinatal complications. The parents are concerned that there is something wrong; he is very hyperactive
and is noted to have a 'mousy' odor. On examination
the child is found to have mild microcephaly,
hypopigmentation and eczema. Laboratory studies are sent and a diagnosis is made. How could this clinical scenario have been prevented?
B. Screening at birth for phenylalanine in blood
I-89. A 35-year-old woman with a history of degenerative joint disease comes to clinic complaining of dark urine over the past several weeks. She has had arthritis in her hips, knees, and shoulders for about 2 years. On examination,
she is noted to have gray-brown pigmentation of the
helices of both ears. Which of the following disorders is most likely?
I-90. A 22-year-old man presents to a local emergency room with severe muscle cramps and exercise intolerance. His symptoms have been worsening over a period of months.
He has noticed that his urine is frequently dark. Examination reveals tenderness over all major muscle groups. A creatine phosphokinase (CK) is markedly elevated. He reports a normal childhood but since age 18 has noticed worsening exercise intolerance. He no longer plays basketball
and recently noticed leg fatigue at two flights of stairs. After intense exercise, he occasionally has red-colored urine. Which of the following is the most likely diagnosis?
C. McArdle disease (type V glycogen storage disease)
I-91. An enzymatic assay of muscle tissue is sent and a diagnosis is made. Which of the following represents a major source of morbidity in this disease which should be explained thoroughly to the patient?
D. Rhabdomyolysis leading to renal failure
I-92. A 21-year-old woman comes to clinic to establish new primary care. She has a history of type III glycogen storage disease (debranching deficiency), for which she takes a high-protein, high-carbohydrate diet. She has a normal
physical examination except for short stature, mild weakness, and a slightly enlarged liver. She works as an administrative assistant and is planning to be married in the next 6 months. She is concerned about her long-term prognosis and the chances of the disease developing in a child. All of the following statements about her prognosis are true except
C. Dementia is a possible complication.
I-93. A 36-year-old man comes to your office asking for genetic testing for Alzheimer's disease. He has no cognitive complaints but notes that all four of his grandparents have had Alzheimer's and his father has mild cognitive impairment at the age of 62. His Mini-Mental Status Examination is 29/30, losing one point on the serial-7's examination. He requests testing for the apolipoprotein E allele (ε4). This request is an example of which of the following?
C. Predisposition testing
I-94. A recently married couple comes to see you in clinic for prenatal counseling. They are both in their mid-thirties and have read extensively on the internet about pregnancy and increasing maternal age. They want to know the risk of miscarriage as well as the risk of having a child with Down
syndrome. Which of the following is true regarding chromosome disorders and increasing maternal age?
E. Women over the age of 42 have a 33% chance of a
I-96. All the following disorders can cause ambiguous sexual differentiation except
C. Klinefelter syndrome
I-97. An 18-year-old female is evaluated in an outpatient clinic for a complaint of amenorrhea. She reports that she feels as if she never developed normally compared with other girls her age. She has never had a menstrual period and complains that she has had only minimal breast growth. Past medical history is significant for a diagnosis
of borderline hypertension. In childhood the patient frequently had otitis media and varicella infections. She received the standard vaccinations. She recently graduated from high school and has no learning difficulties. She is on no medications. On physical examination, the patient is of short stature with a height of 56 in. Blood pressure is 142/88. The posterior hairline is low. The nipples appear
widely spaced, with only breast buds present. The patient has minimal escutcheon consistent with Tanner stage 2 development. Her external genitalia appear normal. Bimanual vaginal examination reveals an anteverted, anteexed uterus. The ovaries are not palpable. What is the most likely diagnosis?
E. Turner syndrome (gonadal dysgenesis)
I-98. A 30-year-old male is seen for a physical examination when obtaining life insurance. The last time he saw a physician was 15 years ago. He has no complaints. Past medical history is notable for scoliosis that was surgically corrected when the patient was a teenager and a recent shoulder dislocation. He takes no medications and does
not smoke, drink, or use illicit drugs. Family history is notable for a father and a brother with colon cancer at ages 45 and 50 years, respectively. Physical examination is notable for normal vital signs, a tall habitus with hypermobile joints, normal skin, and ectopia lentis. Rectal examination is normal, and stool is guaiac-negative. The remainder of the examination is normal. Appropriate
recommendations for follow-up should include which of the following annual studies?
I-99. All the following diseases are caused by errors in DNA repair except
C. fragile X (FX) syndrome
I-100. A 45-year-old male is evaluated for weakness and a progressive change in mental status. After extensive evaluation, he is diagnosed with a mitochondrial disorder. All of the following statements about mitochondrial disorders are true except
C. The proportion of wild-type and mutant mitochondria
in different tissues is identical.
I-101. Prader-Willi syndrome (PWS) is a rare disorder that is characterized by diminished fetal activity, obesity, mental retardation, and short stature. A deletion on the paternal copy of chromosome 15 is the cause. A deletion on the
same site on chromosome 15, but on the maternal copy, results in a different syndrome: Angelman's syndrome. This syndrome is characterized by mental retardation, seizures, ataxia, and hypotonia. What is the name of the genetic mechanism that results in this phenomenon?
B. Genetic imprinting
I-103. A 30-year-old male comes to your office for genetic counseling. His brother died at age 13 years with Tay- Sachs disease. His sister is unaffected. The patient and his wife wish to have children. Which of the following statements
concerning Tay Sachs disease is true?
D. Death occurs as a result of progressive neurologic
I-104. All of the following statements about Gaucher disease are true except
D. Splenomegaly is rare.
I-105. The following pedigree is an example of what pattern of inheritance? (Pedigree figure is attached)
A. X-linked recessive inheritance
I-106. Diseases that are inherited in a multifactorial genetic fashion (i.e., not autosomal dominant, autosomal recessive, or X-linked) and are seen more frequently in persons bearing certain histocompatibility antigens include
A. gluten-sensitive enteropathy
I-107. A 32-year-old man seeks evaluation for ongoing fevers of uncertain cause. He first noted a feeling of malaise about 3 months ago, and for the past 6 weeks, he has been experiencing
daily fevers to as high as 39.4°C (103°F). He awakens with night sweats once weekly and has lost 4.5 kg. He complains of nonspecific myalgias and arthralgias. He has no rashes and reports no ill contacts. He has seen his primary care physician on three separate occasions during this time and has had documented temperatures of 38.7°C
(101.7°F) while in the physician's office. Multiple laboratory studies have been performed that have shown nonspecific findings only. A complete blood count showed a white blood cell count of 15,700/μL with 80% polymorphonuclear polymorphonuclear
cells, 15% lymphocytes, 3% eosinophils, and 2%
monocytes. The peripheral smear is normal. The hematocrit is 34.7%. His erythrocyte sedimentation rate (ESR) is elevated at 57 mm/h. Liver and kidney function are normal. HIV, Epstein-Barr virus (EBV), and cytomegalovirus (CMV) testing are negative. Routine blood cultures for bacteria, chest radiograph, and purified protein derivative
(PPD) testing are negative. In large groups of patients similar to this one with fever of unknown origin, which of the following categories comprises the largest group of diagnoses if one is able to be determined?
I-108. Chronic hypoxia causes biochemical changes whereby oxygen delivery to tissues is not impaired. In comparison to someone living at sea level, which of the following changes would be expected in a healthy person acclimated
to living at high altitude?
C. Increased red blood cell levels of 2,3-diphosphoglycerate
I-109. Independent of insurance status, income, age, and comorbid conditions, African-American patients are less likely to receive equivalent levels of care when compared to white patients for the following scenarios:
A. Prescription of analgesic for pain control
B. Referral to renal transplantation
C. Surgical treatment for lung cancer
D. Utilization of cardiac diagnostic and therapeutic procedures
E. All of the above
I-110. Which of the following would be present in an individual who has lost nondeclarative memory?
B. Inability to recall how to tie one's shoe
I-111. A 24-year-old woman presents for a routine checkup and complains only of small masses in her groin. She states that they have been present for at least 3 years. On physical examination, she is noted to have several palpable 1-cm inguinal
lymph nodes that are mobile, nontender, and discrete. There is no other lymphadenopathy on examination. What should be the next step in management?
I-112. Which of the following findings associated with lymphadenopathy is usually suggestive of metastatic cancer rather than a benign etiology?
A. Hard, matted texture of involved nodes
E. A and B
I-113. All of the following diseases are associated with massive splenomegaly (spleen extends 8 cm below the costal margin or weighs >1000 g) except
C. cirrhosis with portal hypertension
I-114. The presence of Howell-Jolly bodies, Heinz bodies,basophilic stippling, and nucleated red blood cells in a patient with hairy cell leukemia prior to any treatment intervention implies which of the following?
A. Diffuse splenic infiltration by tumor
I-115. Which of the following is true regarding infection risk after elective splenectomy?
A. Patients are at no increased risk of viral infection after
I-116. A 64-year-old man comes to your office complaining of erectile dysfunction. He is not able to generate an erection. His past medical history is significant for coronar artery bypass grafting many years ago, status post-carotid endarterectomy, and a mildly reduced left ventricular ejection fraction. His medications include aspirin, carvedilol,
simvastatin, lisinopril and furosemide. He does not take nitrates. On physical examination, you note normal-sized testes and a normal prostate. There are no fibrotic changes along the penile corpora. His libido is intact. What is the most likely cause of this patient's erectile dysfunction?
A. Disturbance of blood flow
I-117. You perform a nocturnal tumescence study on the patient in the preceding scenario. He does not have any erections during rapid-eye-movement sleep. Which treatment modality do you offer at this time?
I-118. The wife of the patient in the preceding scenario also reports to you that she has experienced a low sexual desire lately. She is not distressed by this and the couple reports no conflict as a result of her low desire. She is 61
years old and also has a history of a coronary artery bypass graft remotely. She experienced menopause at the age of 53. Her medications include an aspirin, metoprolol, simvastatin, verapamil, and a multivitamin. She asks whether an oral agent will assist with her sexual desire.
What is the best answer for this patient?
C. PDE-5 inhibitors have no role in the treatment of female
I-119. A 54-year-old male patient of yours presents to your clinic complaining of unexplained weight loss. On review of his chart, you do notice that he has lost 8% of his total body weight in the past year. He has well-treated hypertension for which he takes a thiazide diuretic. Other than recently being widowed, he has no pertinent social history.
He is a lifelong nonsmoker and worked as a hospital
administrator. An extensive review of systems is unrevealing. Your physical examination reveals no masses or other pathology. A brief psychiatric examination shows no signs of depression. You perform initial testing with a complete blood count; electrolytes, renal function, liver function, urinalysis, thyroid-stimulating hormone, and a chest x-ray, which are unrevealing. He is up to date on his
routine cancer screening. What is the next step in the workup of this patient?
B. Close follow-up
I-120. You are conducting research on a novel nonsteroidal anti-inflammatory drug (NSAID). To ascertain the safety profile of the drug you recruit 100 volunteers who lack the ability to produce IgE. All subjects receive the drug. A minority of participants experience an anaphylactic reaction
within minutes of ingesting the drug. IgE levels are
undetectable in all 100 subjects. What is the most likely explanation for this phenomenon?
A. The drug itself directly triggered the immune system
in a minority of patients.
I-122. Twenty recent attendees at a National Football League game arrive at the emergency department complaining of shortness of breath, fever, and malaise. Chestroentgenograms
show mediastinal widening on several of these patients, prompting a concern for inhalational anthrax as a result of a bioterror attack. Antibiotics are initiated and the Centers for Disease Control and Prevention is notified. What form of isolation should be instituted for these patients?
I-123. Typical Variola major (smallpox) infection can be distinguished from Varicella (chicken pox) infection based on which of the following clinical characteristics?
B. Lesions in the same stage of development at any location
D. Maculopapular rash that begins on the face and extremities and spreads to the trunk (centripetal spread)
F. B and D
I-124. You are working in an urban-based intensive care unit and two cases of severe pneumonia are admitted. Francisella tularensis is cultured from both patients' sputum samples. Neither patient recalls contact with wild or domesticated animals in the past 2 weeks. You should do all of
the following except
C. Institute droplet precaution for the involved patients.
I-125. All of the following are well-documented physical effects of smoking marijuana except
C. delayed gastric emptying
I-126. A young man is brought to the emergency department by his parents. For the past 12 h he has barricaded himself in his room out of fear of being taken away by "the guys in black." He fears he is losing control and fears that he is going
to die. His parents found him trembling and sweating in his room with various pills and plant leaves in his possession. He feels like he is choking and that he is about to die at any minute. On examination, his pupils are dilated and he has a heart rate of 143 beats/min. What substance is
most likely to have caused these symptoms?
B. Lysergic acid diethylamide (LSD)
I-127. A 37-year-old woman arrives at the emergency department after experiencing a transient state of altered mental status on route to the United States as an immigrant from Nigeria. From the reports of the other passengers and flight
attendants on the plane, she was normally interactive throughout most of the flight but was difficult to arouse from sleep upon landing. Upon trying to exit the plane, she fell over and became disarticulate. Her mental status immediately
improved when she received naloxone, thiamine,
and IV glucose via an emergency response team. Upon arrival at the emergency department 1 h later, she appears anxious but is alert, oriented, and appropriate. Temperature is 36.8°C, blood pressure is 162/84 mmHg, heart rate is 108 beats/min, respiratory rate is 22 breaths/min, and oxygen
saturation is 99% on room air. Her pupils are equal and reactive. Cranial nerves are intact. Her oropharynx is slightly dry. There is no lymphadenopathy. Lungs are clear. She has
a regular heart beat with normal S1, S2, and no extra heart sounds. Her abdomen has normal bowel sounds with slight epigastric tenderness. Her skin is normal without any track marks or rash. A complete metabolic panel and complete
blood count are normal. A urine toxicology screen reveals heroin metabolites. Further evaluation should include:
E. orifice examination
I-128. Which of the following is a distinguishing feature of amphetamine overdose versus other causes of sympathetic overstimulation due to drug overdose or withdrawal?
D. Markedly increased blood pressure, heart rate, and
end-organ damage in the absence of hallucination
I-129. Which of the following findings suggests an opiate overdose?
E. Therapeutic response to naloxone
I-130. A patient with metabolic acidosis, reduced anion gap, and increased osmolal gap is most likely to have which of the following toxic ingestions?
I-131. Which of the following is true regarding drug effects after an overdose in comparison to a reference dose?
B. Drug effects begin earlier, peak later, and last longer
I-132. A 28-year-old man with bipolar disorder, who is on lithium, is found in his room 2 days after not showing up to work. He is arousable but dysarthric and has a markedly abnormal gait when trying to walk. Upon arrival at the emergency department, he has a grand mal seizure. The seizure is not sustained but recurs an hour after 6
mg lorazepam is infused IV. In the postictal stage, he is not arousable to sternal rub and lacks a gag reflex. His serum sodium returns at 158 meq/L. In reference to his seizures, all of the following are next steps in his management except
I-133. Which of the following statements regarding gastric decontamination for toxin ingestion is true?
A. Activated charcoal's most common side effect is aspiration.
B. Gastric lavage via nasogastric tube is preferred over
the use of activated charcoal in situations where therapeutic endoscopy may also be warranted.
C. Syrup of ipecac has no role in the hospital setting.
D. There are insufficient data to support or exclude a benefit when gastric decontamination is used more than 1 h after a toxic ingestion.
E. All of the above are true.
I-134. What is the main contributor to the resting energyexpenditure of an individual?
C. Lean body mass
II-1. A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. She develops wound dehiscence on postoperative day 10. Laboratory data show a white blood cell count of 4000/
μL, hematocrit 35%, albumin 2.1 g/dL, total protein 5.8 g/dL, transferrin 54 mg/dL, and iron-binding capacity 88 mg/dL. You are considering initiating nutritional therapy on hospital day 11. Which of the following is true regarding the etiology and treatment of malnutrition in this patient?
C. She has marasmic kwashiorkor, kwashiorkor predominant,and nutritional support should be aggressive.
II-2. You are seeing a patient in follow-up 2 weeks after hospitalization. The patient is recovering from nosocomial pneumonia due to a resistant Pseudomonas spp. His hospital course was complicated by a deep venous thrombosis. The patient is currently on IV piperacillin/ tazobactam and tobramycin via a tunneled catheter, warfarin,
lisinopril, hydrochlorothiazide, and metoprolol.
Laboratory data this morning show an INR of 8.2. At
hospital discharge his INR was stable at 2.5. He has no history of liver disease. What is the most likely cause of the elevated INR?
C. The patient is deficient in vitamin K and needs supplementation.
II-3. A 51-year-old alcoholic man is admitted to the hospital for upper gastrointestinal bleeding. From further history and physical examination, it becomes apparent that his bleeding is from gingival membranes. He is intoxicated and complains of fatigue. Reviewing his chart you find that he had a hemarthrosis evacuated 6 months ago
and has been lost to follow-up since then. He takes no medications. Laboratory data show platelets of 250,000, INR of 0.9. He has a diffuse hemorrhagic eruption on his legs (Figure II-3, Color Atlas).
What is the recommended treatment for this patient's underlying disorder?
D. Vitamin C
II-4. While working in the intensive care unit, you admit a 57-year-old woman with acute pancreatitis and oliguric renal failure. Respiratory rate is 26 breaths/min,heart rate is 125 beats/min, and temperature is 37.2°C. Physical examination shows marked abdominal tenderness with
normoactive bowel sounds. A CT scan shows an inflamed pancreas without hemorrhage. You calculate her APACHE-I score to be 28. When deciding on when to initiate nutritional replacement in this patient, which of the following statements is true?
C. Enteral feeding supports gut function by secretion
of gastrointestinal hormones that stimulate gut
II-5. The resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. Of these two patients with stable weights, which person has the highest resting energy expenditure (REE): Patient A, a 40-year-old
man who weighs 90 kg and is sedentary, or Patient B, a 40- year-old man who weighs 70 kg and is very active?
B. 40-year-old man who weighs 70 kg and is very active
II-6. All of the following clinical features are common in patients with anorexia nervosa except
A. Avoid food-related occupations
II-7. You diagnose anorexia nervosa in one of your newclinic patients. When coordinating a treatment program with the psychiatrist, what characteristics should prompt consideration for inpatient treatment instead of scheduling an outpatient assessment?
E. Weight <75% of expected body weight
II-8. It is hospital day 16 for a 49-year-old homeless patient who is recovering from alcohol withdrawal and delirium tremens. She spent the first 9 days of this hospitalization in the intensive care unit but is now awake, alert, and conversant. She has a healing decubitus ulcer, and herbody mass index is 19 kg/m2. Laboratory data show an albumin of 2.9 g/dL and a prothrombin time of 18 s (normal
range). Is this patient malnourished?
A. Cannot be determined, need more information.
II-9. A 42-year-old male patient wants your opinion about vitamin E supplements. He has read that taking high doses of vitamin E can improve his sexual performance and slow the aging process. He is not vitamin E deficient. You explain to
him that these claims are not based on good evidence. What other potential side effect should he be concerned about?
II-10. Doing rounds in the oncology center, you are see a patient with carcinoid syndrome. Due to the increased conversion of tryptophan to serotonin, this patient has developed niacin deficiency. All of the following are components of the pellagra syndrome except
II-11. An 86-year-old woman with chronic obstructive pulmonary disease (COPD), congestive heart failure, and insulin- requiring type 2 diabetes mellitus is admitted to the intensive care unit with an exacerbation of her COPD.She is intubated and treated with glucocorticoids and
nebulized albuterol. She is also continued on her glargine insulin, aspirin, pravastatin, furosemide, enalapril, and metoprolol. On hospital day 8, parenteral nutrition is begun via catheter in the subclavian vein. Her insulin requirements
increase on hospital day 9 due to episodes of
hyperglycemia. On hospital day 10, she develops rales and an increasing oxygen requirement. A chest radiograph shows bilateral pulmonary edema. Laboratory data show hypokalemia, hypomagnesemia, and hypophosphatemia
and a normal creatinine. Her weight has increased by 3 kg since admission. Urine sodium is <10 meq/dL. All of the following changes in her nutritional regimen will improve her volume status except
C. increasing the protein content of the parenteral nutrition
II-12. A new study has been published showing a benefit of 25 mg/day of vitamin X. The recommended estimated average requirement of vitamin X is 10 mg/day, 2 standard deviations below the amount published in the study. The tolerable upper limit of vitamin X is unknown. Your patient wants to know if it is safe to consume 25 mg/day of vitamin X. Which is the most appropriate answer?
C. 25 mg/day is statistically in a safe range of the estimated
II-13. An elevation in which of the following hormones is consistent with the effects of anorexia nervosa?
II-14. Which of the following statements regarding anorexia nervosa (AN) and bulimia nervosa (BN) is true?
D. The mortality of BN is lower than that of AN.
II-15. You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of symptoms including diarrhea, alopecia, muscle wasting, depression, and a rash involving the face, extremities, and perineum. The child has hypogonadism and dwarfism. You astutely make the diagnosis of zinc deficiency, and
laboratory test confirm this (zinc level <70 μL/dL). What other clinical findings is this patient likely to manifest?
D. Hypopigmented hair
II-16. You are rotating on a medical trip to impoverished areas of China. You are examining an 8-year-old child whose mother complains of him being clumsy and sickly. He has had many episodes of diarrheal illnesses and
pneumonia. His "clumsiness" is most pronounced in the evening when he has to go outside and do his chores. On examination, you notice conjunctival dryness with white patches of keratinized epithelium on the sclera. What is the cause of this child's symptoms?
D. Vitamin A deficiency
II-17. After being stranded alone in the mountains for 8 days, a 26-year-old hiker is brought to the hospital for evaluation of a right femoral neck fracture. He has not had anything to eat or drink for the past 6 days. Vital signs are within normal limits. Weight is 79.5 kg, which is 1.8 kg less than he weighed 6 months ago. Laboratory data show a creatinine of 2.5 mg/dL, blood urea nitrogen
of 52 mg/dL, glucose 96 mg/dL, albumin 4.1 mg/dL,
chloride 105 meq/L, and ferritin on 173 ng/mL. Which of the following statements is true regarding his risk of malnourishment?
C. He is at risk, but a normal individual can tolerate 7
days of starvation.
II-18. You are doing rounds in the intensive care unit on an intubated patient who is recovering from a stroke and has diabetic gastroparesis. When suctioning the patient in the morning, she coughs profusely, with thick green secretions. You are concerned about the possibility of aspiration
pneumonia. All of the following measures are useful
in preventing aspiration pneumonia in an intubated patient except
C. physician-directed methods for formula advancement
II-19. Which of these features represents a critical distinction between anorexia nervosa and bulimia nervosa?
II-20. You are counseling a patient who is recovering from long-standing anorexia nervosa (AN). She is a 22-yearold woman who suffered the effects of AN for 8 years with a nadir body mass index of 17 kg/m2 and many laboratory
abnormalities during that time. Which of the following characteristics of AN is least likely to improve despite successful lasting treatment of the disorder?
D. Low bone mass
III-1. A 73-year-old male presents to the clinic with 3 months of increasing back pain. He localizes the pain to the lumbar spine and states that the pain is worst at night while he is lying in bed. It is improved during the day with mobilization. Past history is notable only for hypertension and remote cigarette
smoking. Physical examination is normal. Laboratory studies are notable for an elevated alkaline phosphatase. A lumbar radiogram shows a lytic lesion in the L3 vertebra. Which of the following malignancies is most likely?
B. Non-small cell lung cancer
III-2. Patients from which of the following regions need not be screened for glucose-6-phosphate dehydrogenase (G6PD) deficiency when starting a drug that carries a risk for G6PD mediated hemolysis?
III-4. A 31-year-old male with hemophilia A is admitted with persistent gross hematuria. He denies recent trauma or any history of genitourinary pathology. The examination is unremarkable. Hematocrit is 28%. All the following are treatments for hemophilia A except
III-5. Which of the following statements regarding incidence of and risk factors for hepatocellular carcinoma is true?
A. A chemical toxin produced by Aspergillus species,
aflatoxin B has a strong association with development
of hepatocellular carcinoma and can be found
in stored grains in hot, humid places.
III-6. You are asked to review the peripheral blood smear from a patient with anemia. Serum lactate dehydrogenase is elevated and there is hemoglobinuria. This patient is likely to have which physical examination finding? (See Figure III-6, Color Atlas.)
C. Mechanical second heart sound
III-7. All of the enzyme deficiencies that lead to porphyrias are inherited either as autosomal dominant (AD) or autosomal recessive (AR) traits with one exception. Which of the following most commonly occurs sporadically?
D. Porphyria cutanea tarda
III-8. A 55-year-old female presents with progressive incoordination. Physical examination is remarkable for nystagmus, mild dysarthria, and past-pointing on finger-to-nose testing. She also has an unsteady gait. MRI reveals atrophy of both lobes of the cerebellum. Serologic evaluation reveals the presence of anti-Yo antibody. Which of the following is the most likely cause of this clinical syndrome?
C. Breast cancer
III-9. A 36-year-old African-American woman with systemic lupus erythematosus presents with the acute onset of lethargy and jaundice. On initial evaluation, she is tachycardic, hypotensive, appears pale, is dyspneic, and is somewhat difficult
to arouse. Physical examination reveals splenomegaly. Her initial hemoglobin is 6 g/dL, white blood cell count is 6300/μL, and platelets are 294,000/μL. Her total bilirubin is 4 g/dL, reticulocyte count is 18%, and haptoglobin is not detectable. Renal function is normal, as is urinalysis. What would you expect on her peripheral blood smear?
III-10. You are investigating the cause for a patient's anemia. He is a 50-year-old man who was found to have a hematocrit of 25% on routine evaluation. His hematocrit was 47% 1 year ago. Mean corpuscular volume is 80, mean corpuscular hemoglobin concentration is 25, mean corpuscular hemoglobin is 25. Reticulocyte count is 5% Review of the peripheral blood smear shows marked numbers of polychromatophilic macrocytes. Ferritin is 340 μg/L. What is the cause of this patient's anemia?
A. Defective erythroid marrow proliferation
III-11. All the following are associated with pure red cell aplasia except
D. low erythropoietin levels
III-12. A 73-year-old man is admitted to the hospital with 3 weeks of malaise and fevers. His past medical history is notable only for hypertension controlled with a thiazide diuretic. He smokes one pack of cigarettes per day and works as an attorney. His physical examination is notable
only for a new systolic heart murmur heard best in the mitral region. His laboratory examination is notable for mild anemia, an elevated white blood cell count, and occasional red blood cells on clean catch urine. Blood cultures grow Streptococcus bovis and echocardiogram shows a <1-cm vegetation on the mitral valve. What additional
evaluation is indicated for this patient?
III-13. A 58-year-old woman presents to the emergency room complaining of jaundice. She first noticed a yellowish discoloration of her skin about 3 days ago. It has become progressively worse since that time. In association with the development of jaundice, she also has noticed clay-colored stools and pruritus. There has been no associated abdominal pain, fever, chills, or night sweats. She has a past medical history of alcohol abuse, but has been abstinent for the past 10 years. She has no known history of cirrhosis. On physical examination, she is afebrile with normal vital signs. She is jaundiced. The bowel sounds are normal. The abdomen is soft and nontender. There is no distention. The liver span is 12 cm to percussion and is palpable at the right costal margin. The spleen tip is not palpable. Liver function testing reveals an AST of 122 IU/L, ALT of 168 IU/L, alkaline
phosphatase of 483 U/L, total bilirubin of 22.1 mg/dL, and direct bilirubin of 19.2 mg/dL. On right upper quadrant ultrasound, the gallbladder cannot be visualized, and there is dilatation of the intrahepatic bile ducts but not the common bile duct. What is the most likely diagnosis?
III-14. An 81-year-old male is admitted to the hospital for altered mental status. He was found at home, confused and lethargic, by his son. His past medical history is significant for metastatic prostate cancer. The patient's medications include periodic intramuscular goserelin injections. On examination he is afebrile. Blood pressure is 110/50 mmHg, and the pulse rate is 110 beats/min. He is lethargic
and minimally responsive to sternal rub. He has bitemporal wasting, and his mucous membranes are dry. On neurologic examination he is obtunded. The patient has an intact gag reflex and withdraws to pain in all four extremities. Rectal tone is normal. Laboratory values are significant for a creatinine of 4.2 mg/dL, a calcium level of 12.4 meq/L, and an albumin of 2.6 g/dL. All the following are appropriate initial management steps except
III-15. Which of the following statements describes the relationship between testicular tumors and serum markers?
C. Both β-hCG and AFP should be measured in following
the progress of a tumor.
III-16. A woman with advanced breast cancer being treated with tamoxifen presents to the emergency department with nausea and vomiting. She has been tolerating her treatment well but in the last 3 days noticed nausea, vomiting, and abdominal pain. Her symptoms are not related to food intake, and she is having normal bowel movements.
She has no fevers or rashes. Her medications include tamoxifen, alendronate, megestrol acetate, and a multivitamin. Abdominal examination reveals very mild tenderness diffusely, and there is no rebound tenderness. Bowel sounds are normal. Plain radiographs and a CT scan of the abdomen are unremarkable. Laboratory analysis reveals a normal white blood cell count. Sodium is 130 meq/L, potassium 4.9 meq/L, chloride 99 meq/L, bicarbonate 29 meq/L, BUN 15 mg/dL, creatinine 0.7 mg/ dL. What is the next most appropriate step in this patient's management?
C. Serum cortisol
III-17. A healthy 62-year-old woman returns to your clinic after undergoing routine colonoscopy. Findings included two 1.3-cm sessile (flat-based), villous adenomas in her ascending colon that were removed during the procedure. What is the next step in management?
B. Colonoscopy in 3 years
III-18. Which of the following statements regarding polycythemia vera is correct?
A. An elevated plasma erythropoietin level excludes the
III-19. A 52-year-old female is evaluated for abdominal swelling with a computed tomogram that shows ascites and likely peritoneal studding of tumor but no other abnormality. Paracentesis shows adenocarcinoma but cannot be further differentiated by the pathologist. A thorough physical examination, including breast and pelvic
examination, shows no abnormality. CA-125 levels
are elevated. Pelvic ultrasound and mammography are normal. Which of the following statements is true?
C. Surgical debulking plus cisplatin and paclitaxel is indicated.
III-20. A 34-year-old female with a past medical history of sickle cell anemia presents with a 5-day history of fatigue, lethargy, and shortness of breath. She denies chest pain or bone pain. She has had no recent travel. Of note, the patient's 4-year-old daughter had a "cold" 2 weeks before the presentation. On examination she has pale conjunctiva, is anicteric, and is mildly tachycardic. Abdominal examination is unremarkable. Laboratories show a hemoglobin of 3 g/dL; her baseline is 8 g/dL. The white blood cell count and platelets are normal. Reticulocyte count is undetectable. Total bilirubin is 1.4 mg/dL. Lactic dehydrogenase is at the upper limits of the normal range. Peripheral blood smear shows a few sickled cells but a total absence of reticulocytes. The patient is given a transfusion of 2 units of packed red blood cells and admitted to the hospital. A bone marrow biopsy shows a normal myeloid series but an absence of erythroid precursors. Cytogenetics
are normal. What is the most appropriate next
C. Check parvovirus titers.
III-21. A 22-year-old pregnant woman of northern European descent presents 3 months into her first pregnancy with extreme fatigue, pallor, and icterus. She reports being previously healthy. On evaluation her hemoglobin is 8 g/dL, reticulocyte count is 9%, indirect bilirubin is 4.9 mg/dL, and serum haptoglobin is not detectable. Her physical examination is notable for splenomegaly and a normal 3-month uterus. Peripheral smear is shown below. What is the most likely diagnosis? (See Figure III-21, Color Atlas.)
C. Hereditary spherocytosis
III-22. A patient with acute lymphoid leukemia (ALL) is admitted with respiratory distress and chest pain. The patient reports 1 day of shortness of breath not associated with cough. There have been no sick contacts, and before the onset of the respiratory symptoms, the patient only recalls fatigue. A chest radiograph shows faint diffuse interstitial infiltrates without pulmonary edema. The cardiac silhouette is normal. An arterial blood gas shows a PaO2 = 54 mmHg, while the pulse oximetry is 97% on room air. A carbon monoxide level is normal. All of the following laboratory abnormalities are expected in this patient except
III-23. A 48-year-old male is referred for evaluation by an acute care center because of a nodule on chest radiography. Three weeks ago he was diagnosed with pneumonia after reporting 3 days of fever, cough, and sputum production. The chest radiogram showed a small right lower lobe alveolar
infiltrate and a left upper lobe 1.5-cm round nodule.
He was treated with antibiotics and is now asymptomatic. A repeat chest radiogram shows that the right lower lobe pneumonia is resolved, but the nodule is still present. He is asymptomatic. He smoked one pack of cigarettes per day for 25 years and quit 3 years ago. He never had a prior chest
radiogram. CT scan shows that the nodule is 1.5 by 1.7 cm and is located centrally in the left upper lobe, has no calcification, and has slightly scalloped edges. There is no mediastinal
adenopathy or pleural effusion. Which of the following is the appropriate next step in his management?
D. 18FDG PET scan
III-24. All the following types of cancer commonly metastasize to the central nervous system (CNS) except
III-25. A 54-year-old woman with atrial fibrillation is anticoagulated with warfarin, 5 mg daily. She developed a urinary tract infection that her primary care physician has treated with ciprofloxacin, 250 mg orally twice daily for 7 days. She presents to the emergency room today complaining of
blood in her urine and easy bruising. Her physical examination shows ecchymoses on her arms. Her urine is bloody in appearance, but no clots are present. After flushing the bladder with 100 mL of sterile saline, the urine returns with a slight pink hue only. A urinalysis shows 3-5 white
blood cells per high power field and many red blood cells per high power field. There are no bacteria present. The international normalized ratio (INR) is 7.0. What is the best approach to treatment of this patient's coagulopathy?
C. Administer vitamin K 1 mg sublingually.
III-26. Which of the following statements about cardiac toxicity from cancer treatment is true?
D. Chronic constrictive pericarditis often manifests
symptomatically up to 10 years after treatment.
III-27. A 23-year-old woman is diagnosed with a lower extremity deep venous thrombosis. Which of the following medical conditions represents a contraindication to therapy with low-molecular-weight heparin (LMWH)?
C. Dialysis-dependent renal failure
III-28. Which of the following pairs of chemotherapy and complication is incorrect?
D. Cisplatin—liver failure
III-29. A 70-year-old man is admitted to the cardiac care unit for complaints of chest pressure occurring at rest radiating to his left arm with associated diaphoresis and presyncope. His admission electrocardiogram (ECG) showed
ST depressions in V4-V6. The chest pain and ECG
changes resolve with sublingual nitroglycerin. He is
treated with IV heparin, aspirin, metoprolol, and lisinopril. His cardiac catheterization shows 90% occlusion of the left anterior descending artery, 80% occlusion of the distal circumflex artery, and 99% occlusion of the right coronary artery. He remains in the cardiac care unit awaiting
coronary artery bypass. He has a history of rheumatic heart disease and underwent mechanical mitral valve replacement at age 58. On admission, his hemoglobin is 12.2 g/dL, hematocrit 37.1%, white blood cell (WBC) count 9800/μL, and platelet count 240,000/μL. His creatinine is 1.7 mg/dL. On the fourth hospital day, his hemoglobin is
10.0, hematocrit 31%, WBC count 7600/μL, and platelet count 112,000/μL. His creatinine has risen to 2.9 mg/dL after the cardiac catheterization. What is the most appropriate treatment of the patient at this time?
B. Discontinue heparin infusion and start argatroban.
III-30. A 24-year-old woman presents to the emergency room complaining of a red, tender rash that has been spreading across her arms and legs over the past 2 days. She also describes severe diffuse muscle pain that has worsened
over a week's time. She woke up feeling as though she could not catch her breath and has developed a dry cough over the past several days. She is without any significant medical history but recalls that she had similar symptoms several years ago, and was told she was having an allergic reaction.
Her symptoms abated with an oral glucocorticoid taper. She takes no prescription medications but takes a number of over-the-counter nutritional supplements daily. She cannot describe any allergic trigger to her previous episode or her current one. Her family history is unremarkable, and
her close contacts are not ill. She works in an office, has no pets, and has not travelled internationally. Her laboratory results are remarkable for a leukocyte count of 12,100 cells/μL and a total eosinophil count of 1100/μL. Which of the following is the most likely cause of her symptoms?
C. Ingestion of L-tryptophan
III-31. A woman wants your advice regarding Papanicolaou smears. She is 36 years old and is monogamous with her husband since they were married 3 years ago. She has had normal Pap smears every year for the past 6 years. She
would like to avoid the yearly test. What is your advice to this patient, based on the current screening guidelines?
B. She may extend the screening interval to once every
III-32. The evaluation in a newly diagnosed case of acute lymphoid leukemia (ALL) should routinely include all of the following except
F. plasma viscosity
III-33. Which of the following statements about lead-time bias occurrence is true?
A. A test does not influence the natural history of the disease;
patients are merely diagnosed at an earlier date.
III-34. Which of the following is sufficient to make a definitive diagnosis of porphyria?
B. Evidence of an enzyme deficiency or gene defect
III-35. All but which of the following statements about the lupus anticoagulant (LA) are true?
C. Bleeding episodes in patients with lupus anticoagulants
may be severe and life-threatening.
III-37. A 34-year-old woman presents for evaluation of left lower extremity swelling and pain. She is obese and 8 weeks postpartum. She recently traveled 6 h by airplane to visit her parents with her infant. She has had no dyspnea, palpitations, or syncope. She is currently on no medications
except iron tablets. She is otherwise healthy. Her
vitals signs are: heart rate 86 beats/min, blood pressure 110/80 mm/Hg, temperature 37.0°C, and respiratory rate 12 breaths/min. Her weight is 98 kg, and height is 170 cm. The left lower extremity is swollen, tender, and warm to touch. A Homan's sign is present, but there are no palpable cords. A lower extremity Doppler shows a thrombosis
in the common and superficial femoral veins of the
left leg. You are considering outpatient treatment with enoxaparin. All of the following statements regarding low-molecular-weight heparins (LMWH) are true except
E. This patient's recent pregnancy is a contraindication
to use of LMWH because there is a greater risk of
bleeding with LWMH compared to IV heparin.
III-38. A 65-year-old man is brought to the emergency room by ambulance after his daughter found him to be incoherent earlier today. She last spoke with him yesterday, and at that time, he was complaining of 2 days of myalgias, headache,
and fever. He had attributed it to an upper respiratory tract infection and did not seek evaluation from his primary care physician. Today, he did not answer when she called his home, and she found him lying in his bed smelling
of urine. He was minimally arousable but appeared to be moving all of his extremities. His past medical history is significant for hypertension, hypercholesterolemia, and chronic obstructive pulmonary disease. He was evaluated 2 weeks previously for a transient ischemic attack after an
episode where he had numbness and weakness of his left arm and leg that resolved over 6 h without intervention. His current medications include aspirin, 81 mg daily, clopidogrel, 75 mg daily, atenolol, 100 mg daily, atorvastatin, 20 mg daily, and tiotropium, once daily. He is allergic to lisinopril,
which caused angioedema. He is a former smoker
and drinks alcohol rarely. On physical examination, he is obtunded and minimally arousable. He is febrile with a temperature of 38.9°C. His blood pressure is 159/96 mmHg, and heart rate is 98 beats/ min. He is breathing at a rate of 24 breaths/min with a room air oxygen saturation of 95%. He has minimal scleral icterus. The oropharynx reveals dry mucous membranes. His
cardiovascular, pulmonary, and abdominal examinations are normal. There are no rashes. His neurologic examination is difficult to obtain. There are no cranial nerve findings. He resists movement of his extremities but has normal strength. Deep tendon reflexes are brisk, 3+ and equal. The laboratory values are as follows: hemoglobin 9.3 g/
dL, hematocrit 29.1%, white blood cell count 14,000/μL, and platelets 42,000/μL. The differential demonstrates 83% neutrophils, 2% band forms, 6% lymphocytes, and 9% monocytes. The sodium is 145 meq/L, potassium 3.8 meq/L, chloride 113 meq/L, bicarbonate 19 meq/L, blood urea nitrogen 68 mg/dL, and creatinine 3.4 mg/dL. The bilirubin is 2.4 mg/dL, and lactate dehydrogenase is 450
U/L. A peripheral blood smear shows diminished platelets and many schistocytes.What is the next most appropriate step in this patient's care?
B. Discontinue clopidogrel and initiate plasmapheresis.
III-39. A primary tumor of which of these organs is the least likely to metastasize to bone?
III-40. The triad of portal vein thrombosis, hemolysis, and pancytopenia suggests which of the following diagnoses?
D. Paroxysmal nocturnal hemoglobinuria (PNH)
III-41. A 68-year-old man seeks evaluation for fatigue, weight loss, and early satiety that have been present for about 4 months. On physical examination, his spleen is noted to be markedly enlarged. It is firm to touch and crosses the midline. The lower edge of the spleen reaches
to the pelvis. His hemoglobin is 11.1 g/dL, and hematocrit is 33.7%. The leukocyte count is 6200/μL, and platelet count is 220,000/μL. The white cell count differential is 75% PMNs, 8% myelocytes, 4% metamyelocytes, 8%
lymphocytes, 3% monocytes, and 2% eosinophils. The peripheral blood smear shows teardrop cells, nucleated red blood cells, and immature granulocytes. Rheumatoid factor is positive. A bone marrow biopsy is attempted, but no cells are able to be aspirated. No evidence of leukemia or lymphoma is found. What is the most likely cause of the splenomegaly?
A. Chronic idiopathic myelofibrosis
III-42. The most common cause of high serum calcium in a patient with a known cancer is
E. production of parathyroid hormone-like substance
III-43. A 72-year-old man with chronic obstructive pulmonary disease and stable coronary disease presents to the emergency room with several days of worsening productive cough, fevers, malaise, and diffuse muscle aches. A chest x-ray demonstrates a new lobar infiltrate. Laboratory
measurements reveal a total white blood cell count of 12,100 cells/μL, with a neutrophilic predominance of 86% and 8% band forms. He is diagnosed with community- acquired pneumonia, and antibiotic treatment is initiated. Under normal, or "nonstress," conditions, what percentage of the total body neutrophils are present in the circulation?
III-44. All of the following laboratory values are consistent with an intravascular hemolytic anemia except
A. increased haptoglobin
III-45. All the following match the anticoagulant with its correct mechanism of action except
B. clopidogrel—inhibition of thromboxane A2 release
III-46. All the following are late complications of bone
marrow transplant preparative regimens except
III-47. Which of the following best describes the mechanism of action of clopidogrel?
E. Irreversibly blocks P2Y12 to prevent adenosine
diphosphate (ADP)-induced platelet aggregation
III-48. A 45-year-old man is evaluated by his primary care physician for complaints of early satiety and weight loss. On physical examination, his spleen is palpable 10 cm below the left costal margin and is mildly tender to palpation.
His laboratory studies show a leukocyte count of
125,000/μL with a differential of 80% neutrophils, 9 bands, 3% myelocytes, 3% metamyelocytes, 1% blasts, 1% lymphocytes, 1% eosinophils, and 1% basophils. Hemoglobin is 8.4 g/dL, hematocrit 26.8%, and platelet count 668,000/μL. A bone marrow biopsy demonstrates increased cellularity with an increased myeloid to eryth-roid ratio. Which of the following cytogenetic abnormalities is most likely to be found in this patient?
C. Reciprocal translocation between chromosomes 9
and 22 (Philadelphia chromosome)
III-49. A 35-year-old patient comes into your office with persistent iron deficiency anemia. His past medical history is significant for end-stage renal disease on hemodialysis, hypertension, and rheumatoid arthritis. His medications include calcium acetate, a multivitamin, nifedipine, aspirin, iron sulfate, and omeprazole. His hemoglobin
6 months ago was 8 mg/dL. One week ago, it
was 7.9 mg/dL. His ferritin is 8 mg/dL. He reports no bright red blood per rectum, and his stool guaiac examinations have been repeatedly negative over the past 6 months. What is the most likely cause of this patient's iron deficiency anemia?
D. Medication effect
III-50. A 32-year-old male presents complaining of a testicular mass. On examination you palpate a 1-by 2-cm painless mass on the surface of the left testicle. A chest x-ray shows no lesions, and a CT scan of the abdomen and pelvis shows
no evidence of retroperitoneal adenopathy. The α fetoprotein (AFP) level is elevated at 400 ng/mL. Beta human chorionic gonadotropin (β-hCG) is normal, as is LDH. You send the patient for an orchiectomy. The pathology comes back as seminoma limited to the testis alone. The
AFP level declines to normal at an appropriate interval. What is the appropriate management at this point?
D. Retroperitoneal lymph node dissection (RPLND)
III-51. All of the following statements regarding tobacco usage and cessation are correct except
C. Smokeless tobacco is associated with gum and dental
disease, not cancer.
III-52. A 29-year-old male is found on routine chest radiography for life insurance to have right hilar adenopathy. He is otherwise healthy. Besides biopsy of the lymph nodes, which of the following is indicated?
III-53. Which of the following is correct regarding small-celllung cancer compared with non-small cell lung cancer?
A. Small-cell lung cancer is more radiosensitive.
III-54. Which of the following statements regarding esophageal cancer is true?
D. Incidence of squamous cell carcinoma has decreased
over the past 30 years while adenocarcinoma continues
III-55. All the following conditions are associated with an increased incidence of cancer except
E. fragile X syndrome
III-56. A 50-year-old female presents to your clinic for evaluation of an elevated platelet count. The latest complete blood count is white blood cells (WBC) 7,000/mm3, hematocrit 34%, and platelets 600,000/mm3. All the following are common causes of thrombocytosis except
E. pernicious anemia
III-57. A 76-year-old man presents to an urgent care
clinic with pain in his left leg for 4 days. He also describes swelling in his left ankle, which has made it difficult for him to ambulate. He is an active smoker and hasa medical history remarkable for gastroesophageal reflux disease, prior deep venous thrombosis (DVT) 9 months ago that resolved, and well-controlled hypertension. Physical examination is revealing for 2+ edema in
his left ankle. A D-dimer is ordered and is elevated.
Which of the following makes D-dimer less predictive of DVT in this patient?
A. Age >70
III-58. A patient with longstanding HIV infection, alcoholism, and asthma is seen in the emergency room for 1-2 days of severe wheezing. He has not been taking any medicines for months. He is admitted to the hospital and treated with nebulized therapy and systemic glucocorticoids. His CD4 count is 8 and viral load is >750,000. His total white blood cell (WBC) count is 3200 cells /μL with
90% neutrophils. He is accepted into an inpatient substance abuse rehabilitation program and before discharge is started on opportunistic infection prophylaxis, bronchodilators, a prednisone taper over 2 weeks, ranitidine,and highly activeantiretroviral therapy. The rehabilitation
center pages you 2 weeks later; a routine laboratory
check reveals a total WBC count of 900 cells/μL with 5% neutrophils. Which of the following new drugs would most likely explain this patient's neutropenia?
III-59. Which of the following symptoms is most suggestive of an esophageal mass?
E. Solid phase dysphagia progressing to liquid phase
III-60. All of the following have been associated with development of a lymphoid malignancy except
C. hepatitis B infection
III-61. A 31-year-old female is referred to your clinic for anevaluation of anemia. She describes a 2-month history of fatigue. She denies abdominal pain but notes that her abdomen has become slightly more distended in recent weeks. Past medical history is otherwise unremarkable.
The patient's parents are alive, and she has three healthy siblings. Physical examination is significant for pale conjunctiva and a palpable spleen 4 cm below the left costal margin. Hematocrit is 31% and bilirubin is normal. The reticulocyte percentage is low. Haptoglobin and lactic dehydrogenase (LDH) are normal. A peripheral blood smear shows numerous teardrop-shaped red cells, nucleated red
cells, and occasional myelocytes. A bone marrow aspirate is unsuccessful, but a biopsy shows a hypercellular marrow with trilineage hyperplasia and findings consistent with the presumed diagnosis of chronic idiopathic myelofibrosis.
You transfuse her to a hematocrit of 40%. What is the most appropriate next management step?
D. Perform HLA matching of her siblings.
III-62. All the following are suggestive of iron deficiency anemia except
D. decreased total iron-binding capacity (TIBC)
III-63. Which source of stem cell is incorrectly paired with the challenge associated with their clinical application?
D. Umbilical cord blood stem cells: Graft-versus-host
III-64. You are seeing a patient in follow-up in whom you have begun an evaluation for an elevated hematocrit. You suspect polycythemia vera based on a history of aquagenic pruritus and splenomegaly. Which set of laboratory tests
are consistent with the diagnosis of polycythemia vera?
B. Elevated red blood cell mass, low serum erythropoietin
levels, normal oxygen saturation
III-65. A 59-year-old man is admitted with a painful, blistering rash on the dorsal aspects of both hands. He has a medical history of alcoholism and admits to a recent relapse and has been drinking heavily over the past week. He is admitted and stabilized. A diagnosis of porphyria cutanea tarda (PCT) is made based on increased circulating porphyrins
in the blood and decreased URO-decarboxylase
activity. He is discharged to a rehabilitation facility and follows up in your clinic 2 weeks later. He has been abstinent from alcohol but his rash has persisted, and now he also has some blistering on the legs and feet. Which of the following treatment modalities is most appropriate?
E. Weekly phlebotomy until ferritin normalizes
III-66. Which of the following hemolytic anemias can be classified as extracorpuscular?
E. Thrombotic thrombocytopenic purpura
III-67. All of the following are obstacles to the more widespread application of stem cells for regenerative medicine except
B. identifying diseases suitable for stem cell based therapies
III-68. You are asked to consult on a 34-year-old male with thrombocytopenia. He sustained a motor vehicle collision 10 days ago, resulting in shock, internal bleeding, and acute renal failure. An exploratory laparotomy was performed that showed a ruptured spleen requiring a splenectomy. He also underwent an open reduction and internal fixation of the left femur. The platelet count was 260,000 cells/μL on admission. Today it is 68,000 cells/μL.
His medications are oxacillin, morphine, and subcutaneous heparin. On examination the vital signs are stable. The examination is significant for an abdominal scar that is clean and healing. The patient's left leg is in a large cast and is elevated. The right leg is swollen from the calf downward. Ultrasound of the right leg shows a deep venous thrombosis. Antiheparin antibodies are positive.
Creatinine is 3.2 mg/dL. What is the most appropriate next management step?
C. Stop heparin and start argatroban.
III-69. A 64-year-old man with chronic lymphoid leukemia (CLL) and chronic hepatitis C presents for his yearly follow- up. His white blood cell count is stable at 83000/μL, but his hematocrit has dropped from 35% to 26% and his platelet count also dropped from 178,000/μL to 69,000/ μL. His initial evaluation should include all of the following
B. bone marrow biopsy
III-70. A 64-year-old man with Child-Pugh class B cirrhosis presents to his gastroenterologist complaining of weight loss and a feeling of abdominal fullness. He was diagnosed with hepatitis C cirrhosis 5 years previously. It is thought that the patient developed with hepatitis C following
a blood transfusion 20 years ago after a car accident. His initial presentation with cirrhosis was volume overload and ascites. He has been successfully managed with sodium restriction, spironolactone, and furosemide. He has no other significant medical history. On examination
today, his liver is enlarged and firm. No ascites is
present. A helical CT of the abdomen shows a single tumor in the right lobe of the liver measuring 4 cm in diameter. The location of the mass is near the main portal pedicles. There is no evidence of vascular invasion or metastatic lesions. The α fetoprotein level is 384 ng/mL. Biopsy of the mass is diagnostic for hepatocellular carcinoma.
What is the best approach for treatment?
A. Liver transplantation
III-71. Which of the following should prompt investigation for hereditary nonpolyposis colon cancer screening in a 32-year-old man?
A. Father, paternal aunt, and paternal cousin with colon
cancer with ages of diagnosis of 54, 68, and 37
III-72. Which of the following carries the best disease prognosiswith appropriate treatment?
E. Nodular sclerosing Hodgkin's disease
III-73. You are asked to consult on a 31-year-old male with prolonged bleeding after an oral surgery procedure. He has no prior history of bleeding diathesis or family history of bleeding disorders. The patient's past medical history is remarkable for infection with the human immunodeficiency virus, with a CD4 count of 51/ mL3. The examination is remarkable only for spotty lymphadenopathy. The platelet count is 230,000 cells/ mL. His international normalized ratio (INR) is 1.5. Activated partial thromboplastin time is 40 s. Peripheral blood smear shows no schistocytes and is otherwise unremarkable. A 1:1 mixing study corrects both conditions immediately and after a 2-h incubation. Fibrinogen level is normal. Thrombin time is prolonged. What is the diagnosis?
III-74. Chemoprevention strategies for cancer have met with varying levels of success. Which of the following pairings correctly identifies an effective chemoprevention strategy with its target effect?
C. Calcium: adenomatous gastrointestinal polyps
III-75. A 48-year-old woman is admitted to the hospital with anemia and thrombocytopenia after complaining of profound fatigue. Her initial hemoglobin is 8.5 g/dL, hematocrit 25.7%, and platelet count 42,000/μL. Her leukocyte count is 9540/μL, but 8% blast forms are noted on peripheral smear. A chromosomal analysis shows a reciprocal translocation of the long arms of chromosomes 15 and 17, t(15;17), and a diagnosis of acute promyelocytic leukemia is made. The induction regimen of this patient should include which of the following drugs:
A. All-trans-retinoic acid (ATRA, or triretinoin)
III-76. The patient above is started on the appropriate induction regimen. Two weeks following initiation of treatment, the patient develops acute onset of shortness of breath, fever, and chest pain. Her chest radiograph shows bilateral alveolar infiltrates and moderate bilateral pleural
effusions. Her leukocyte count is now 22,300/μL, and shehas a neutrophil count of 78%, bands of 15%, and lymphocytes 7%. She undergoes bronchoscopy with lavage that shows no bacterial, fungal, or viral organisms. What is the most likely diagnosis in this patient?
E. Retinoic acid syndrome
III-77. A 76-year-old man is admitted to the hospital with complaints of fatigue for 4 months and fever for the past 1 week. His temperature has been as high as 38.3°C at home. During this time, he intermittently has had a 5.5- kg weight loss, severe bruising with minimal trauma, and an aching sensation in his bones. He last saw his primary
care physician 2 months ago and was diagnosed with anemia of unclear etiology at that time. He has a history of a previous left middle cerebral artery cerebrovascular accident which has left him with decreased functional status. At baseline, he is able to ambulate in his home with the use of a walker and is dependent upon a caregiver for assistance
with his activities of daily living. His vital signs
are: blood pressure 158/86 mmHg, heart rate 98 beats/ min, respiratory rate 18 breaths/min, SaO2 95%, and temperature 38°C. He appears cachectic with temporal muscle wasting. He has petechiae on his hard palate. He has no lymph node enlargement. On cardiovascular examination,
there is a II/VI systolic ejection murmur present.
His lungs are clear. The liver is enlarged and palpable 6 cm below the right costal margin. In addition, the spleen is also enlarged, with a palpable spleen tip felt about 4 cm below the left costal margin. There are multiple hematomas
and petechiae present in the extremities. Laboratory
examination reveals the following: hemoglobin 5.1 g/dL, hematocrit 15%, platelets 12,000/μL, and white blood cell (WBC) count 168,000/μL with 45% blast forms, 30% neutrophils, 20% lymphocytes, and 5% monocytes. Re- view of the peripheral blood smear confirms acute myeloid leukemia (M1 subtype, myeloblastic leukemia without maturation) with complex chromosomal abnormalities
on cytogenetics. All of the following confer a poor prognosis for this patient except
C. hemoglobin <7 g/dL
III-78. A new screening test for thyroid cancer has been introduced into the population. In the first year, 1000 positive tests lead to correct identification of thyroid cancer in the screened population. Over the next year, 250 cases of thyroid cancer are detected among those who initially had a negative test. What is the sensitivity of this new screening test?
III-80. A 65-year-old man seeks evaluation for nasal congestion, headaches, and dysphagia, most notably when he lies supine for sleeping. These symptoms have been slowly worsening for the past month. He has no nasal discharge or fevers. On review of systems, he reports recent hoarseness and dizziness. His past medical history is significant only for mild hypertension. He worked as a roofing contractor and smoked one pack/day of cigarettes since age 16. On physical examination, you note facial edema. His oropharynx is also mildly edematous, and the tonsils are unremarkable. His external and internal jugular
veins are engorged bilaterally, and there are prominent veins on the anterior chest. Chest percussion reveals dullness in the right base with decreased tactile fremitus. A chest radiograph shows a right upper lung mass that on biopsy is consistent with non-small cell lung cancer. All of
the following treatments may help this patient's symptoms except
III-81. All of the following statements regarding the epidemiology of and risk factors for acute myeloid leukemias are true except
D. The incidence of acute myeloid leukemia is greatest
in individuals <20 years.
III-82. A 42-year-old man presented to the hospital with right upper quadrant pain. He was found to have multiple masses in the liver that were found to be malignant on H&E staining of a biopsy sample. Your initial history, physical examination and laboratory tests, including prostate-specific antigen, are unrevealing. Lung, abdominal, and pelvic CT scans are unremarkable. He is an otherwise
healthy individual with no chronic medical
problems. Which immunohistochemical markers should be obtained from the biopsy tissue?
III-83. A 56-year-old woman is diagnosed with chronic myelogenous leukemia, Philadelphia chromosome-positive. Her presenting leukocyte count was 127,000/μL, and her differential shows <2% circulating blasts. Her hematocrit is 21.1% at diagnosis. She is asymptomatic except for fatigue. She has no siblings. What is the best initial therapy for this patient?
C. Imatinib mesylate
III-84. All the following are associated with a reduced lifetime risk of developing breast cancer except
A. absence of a history of maternal nursing
III-85. All the following cause prolongation of the activated partial thromboplastin time (aPTT) that does not correct with a 1:1 mixture with pooled plasma except
D. factor VII inhibitor
III-86. A 53-year-old woman seeks evaluation from her primary care physician regarding primary prevention of cardiovascular disease and stroke. She has a past medical history of type 2 diabetes mellitus for the past 5 years with a known hemoglobin A1C of 7.2%. She does not
have hypertension or known coronary artery disease. She has been obese throughout adulthood, and her BMI is 33.6 kg/m2. She is currently perimenopausal with irregular bleeding that last occurred 3 months ago. She is
taking metformin, 1000 mg twice daily. She has been intolerant of ibuprofen in the past due to gastrointestinal upset. She previously smoked one pack of cigarettes daily from the ages of 18 to 38. She drinks a glass of wine with dinner. Her family history is significant for myocardial infarction in her father at age 58, paternal uncle at age 67, and paternal grandmother at age 62. On
the maternal side, her mother died of a stroke at age 62. She is concerned that she should be taking a daily aspirin as primary prevention of cardiovascular disease and stroke but is also concerned about potential side effects. Which of the following statements regarding aspirin therapy is true?
A. Aspirin is indicated for primary prevention of cardiovascular disease because she has a strong family
history and has a history of diabetes mellitus.
III-87. A 22-year-old man comes into clinic because of a swollen leg. He does not remember any trauma to the leg, but the pain and swelling began 3 weeks ago in the anterior shin area of his left foot. He is a college student and is active in sports
daily. A radiograph of the right leg shows a destructive lesion with a "moth-eaten" appearance extending into the soft tissue and a spiculated periosteal reaction. Codman's triangle (a cuff of periosteal bone formation at the margin of the
bone and soft tissue mass) is present. What is the most likely diagnosis and optimal therapy for this lesion?
C. Osteosarcoma; preoperative chemotherapy followed
by limb-sparing surgery
III-88. Which of the following statements is true?
A. Factor VIII deficiency is characterized clinically by
bleeding into soft tissues, muscles, and weightbearing
III-89. All of the following statements regarding gastric carcinoma are true except
A. Linitis plastica is an infiltrative form of gastric lymphoma
with no defined margins that carries a poorer prognosis than intestinal-type lesions.
III-90. Which of the following statements correctly describes characteristics of stem cells?
A. Ability to differentiate into a variety of mature cells types
B. Capacity for self-renewal
C. Generate, maintain, and repair tissue
D. A and C
E. A and B
F. All of the above
III-91. Which of the following statements regarding malignant spinal cord compression (MSCC) is true?
B. Neurologic abnormalities on physical examination
are sufficient to initiate high-dose glucocorticoids.
III-93. A 22-year-old woman comes to the emergency department complaining of 12 h of shortness of breath. The symptoms began towards the end of a long car ride home from college. She has no past medical history and her only medication is an oral contraceptive. She
smokes occasionally but the frequency has increased recently because of examinations. On physical examination, she is afebrile with respiratory rate of 22 breaths/ min, blood pressure 120/80 mmHg, heart rate 110 beats/min, SaO2 (room air) 92%. The rest of her physical
examination is normal. A chest radiograph and complete blood count are normal. Her serum pregnancy test is negative. Which of the following is the indicated management strategy?
E. Obtain contrast multislice CT of chest.
III-94. The patient described above is found to have a right pulmonary embolus. She is started on low-molecular- weight heparin and warfarin. What is the goal international normalized ratio (INR) and the duration of therapy?
D. INR 2.5; 6 months
III-79. A 56-year-old patient inquires about screening for colon cancer. He has no risk factors for colon cancer, otherthan age. Which of the following statements is true regarding which screening test you recommend for this patient?
B. One-time colonoscopy detects more advanced lesions
than one-time fecal occult blood testing with
III-95. A patient asks you about the utility of performing monthly breast self-examination (BSE). Which of the following statements is correct regarding the utility of and recommendations regarding breast self-examination?
C. Self-examination leads to increased biopsy rate.
III-96. Which of the following tumor characteristics confersa poor prognosis in patients with breast cancer?
D. Overexpression of erbB2 (HER-2/neu)
III-97. Which of the following serum laboratory tests is most useful for predicting return of renal function in a patient with tumor lysis syndrome and acute renal failure?
E. Uric acid
III-98. Fondaparinux may be used to treat all of the following patients except
B. A 46-year-old man with hypertension and focal segmental
glomerulosclerosis with a baseline creatinine of 3.3 mg/dL presents with a left lower extremity deep venous thrombosis. He weighs 82 kg.
III-99. A 26-year-old female who is 4 months pregnant is seen for a standard evaluation. She reports feeling well with decreasing nausea over the last 1 month. The physical examination is normal except for the presence of a 1.5-cm hard nodule in the upper outer quadrant of the right breast. She does not recall the nodule being present previously and has not performed self-examination since be coming pregnant. Which of the following is the next most appropriate action?
A. Aspiration of the nodule
III-100. Aplastic anemia has been associated with all of the following except
D. parvovirus B19 infection
III-101. A 23-year-old man presents with diffuse bruising. He otherwise feels well. He takes no medications, does not use dietary supplements, and does not use illicit drugs. His past medical history is negative for any prior illnesses. He is a college student and works as a barista in
a coffee shop. A blood count reveals an absolute neutrophil count of 780/μL, hematocrit of 18% and platelet count of 21,000/μL. Bone marrow biopsy reveals hypocellularity with a fatty marrow. Chromosome studies of peripheral blood and bone marrow cells are performed which exclude Fanconi's anemia and myelodysplastic syndrome.
The patient has a fully histocompatible brother.
Which of the following is the best therapy?
D. Hematopoietic stem cell transplant
III-102. A 46-year-old woman presents with new onset ascites and severe abdominal pain: a hepatic Doppler examination reveals hepatic vein thrombosis. She also reports tea colored urine on occasion, particularly in the morning, as
well as recurrent worsening abdominal pain. On further evaluation, she is found to have an undetectable serum haptoglobin, elevated serum lactase dehydrogenase, hemoglobinuria
and an elevated reticulocyte count. A peripheral smear shows no schistocytes. What is the most likely diagnosis?
E. Paroxysmal nocturnal hemoglobinuria
III-103. A Sudanese refugee is brought to see you in clinic for abdominal pain. He has had intermittent fevers for months and has lost considerable weight. He was previously a guard for a refugee camp in the Sudan and worked the night shift
exclusively. On examination, he is severely malnourished with temporal wasting. He has massive splenomegaly but no palpable lymphadenopathy. Oropharynx shows no thrush. Laboratory data reveal an anemia, neutropenia, and
thrombocytopenia. Skin examination shows no discrete lesions but you and the patient notice that the skin appears gray throughout. Malaria smears are negative and HIV testing is negative. Chest X-ray is normal. What is the most likely diagnosis?
B. Kala-azar (visceral leishmaniasis)
III-104. A 16-year-old male has recurrent thigh hematomas. He has been active in sports all of his life and has had 3 episodes of limb-threatening bleeding with compartment syndrome. A family history is notable for a maternal grandfather with a similar bleeding history. Paternal family history is not available. Laboratory analysis in clinic reveals
a normal platelet count, a normal activated partial thromboplastin time (22 s) and a prolonged prothrombin time (25 s). He takes no medications. What is the most likely reason for his coagulation disorder?
B. Factor VII deficiency
III-105. A 52-year-old man is admitted with recurrent hemarthroses of his knees. He is an electrician who is still working but over the last year has had recurrent hemarthroses requiring surgical evacuation. Before one year ago, he had no medical problems. He has no other past medical history and seldom sees a physician. He smokes
tobacco regularly. His platelet count is normal, erythrocyte sedimentation rate is 55 mm/hr, hemoglobin is 9 mg/dL and albumin is 3.1 mg/dL. Coagulation studies show a prolonged activated partial thromboplastin time (aPTT) and a normal prothrombin time (PT). Adding plasma from a normal subject does not correct the aPTT. What is the cause of his recurrent hemarthroses?
C. Factor IX deficiency
III-106. During a pre-employment physical and laboratory evaluation, a 20-year-old male is noted to have a prolonged activated prothromblastin time (aPTT). On review of systems, he denies a history of recurrent mucosal bleeding and has never had an issue with other major bleeding. He has never had any major physical trauma. A family history is limited because he does not know his biologic
family history. Mixing studies correct the aPTT
when normal serum is used. You suspect an inherited hemorrhagic disease such as hemophilia. Which other laboratory abnormality would you most likely expect to find if this patient has hemophilia?
A. Low Factor VIII activity
B. Low factor IX activity
III-107. You are evaluating a 45-year-old man with an
acute upper GI bleed in the emergency department. He reports increasing abdominal girth over the past 3 months associated with fatigue and anorexia. He has not noticed any lower extremity edema. His past medical history is significant for hemophilia A diagnosed as a child with recurrent elbow hemarthroses in the past. He has been receiving infusions of factor VIII for most of his life,
and received his last injection earlier that day. His blood pressure is 85/45 mmHg with a heart rate of 115/min. His abdominal examination is tense with a positive fluid wave. Hematocrit is 21%. Renal function and urinalysis is normal. His aPTT is minimally prolonged, his INR is 2.7, platelets are normal. Which of the following is most likely to yield a diagnosis for the cause of his GI bleeding?
E. Mesenteric angiogram
III-108. You are managing a patient with suspected disseminated intravascular coagulopathy (DIC). The patient has end-stage liver disease awaiting liver transplantation and was recently in the intensive care unit with E. coli bacterial peritonitis. You suspect DIC based on a new upper gastrointestinal bleed in the setting of oozing from venipuncture sites. Platelet count is 43000/μL, INR is 2.5, hemoglobin is 6 mg/dL and D-dimer is elevated to 4.5. What is the best way to distinguish
between new-onset DIC and chronic liver disease?
E. Serial laboratory analysis
III-109. A 38-year-old woman is referred for evaluation of an elevated hemoglobin and hematocrit that was discovered during an evaluation of recurrent headaches. Until about 8 months previously, she was in good health, but
developed increasingly persistent headaches with intermittent vertigo and tinnitus. She was originally prescribed sumatriptan for presumed migraine headaches but did not experience relief of her symptoms. A CT scan of the brain showed no evidence of mass lesion. During evaluation of her headaches, she was found to have a hemoglobin
of 17.3 g/dL, and a hematocrit of 52%. Her
only other symptom is diffuse itching after hot showers. She is a non-smoker. She has no history pulmonary or cardiac disease. On physical examination, she appears well. Her BMI is 22.3 kg/m2. Vitals signs are BP 148/84
mmHg, HR 86/min, RR 12/min, SaO2 99% on room air. She is afebrile. The physical examination including full neurologic examination is normal. There are no heart murmurs. There is no splenomegaly. Peripheral pulses are normal. Laboratory studies confirm elevated hemoglobin
and hematocrit. She also has a platelet count of
650,000/μL. Leukocyte count is 12,600/μL with a normal differential. Which of the following tests should be performed next in the evaluation of this patient?
E. Red cell mass and plasma volume determination
IV-1. Which type of bite represents a potential medical emergency in an asplenic patient?
B. Dog bite
IV-2. A 24-year-old man with advanced HIV infection presents to the emergency department with a tan painless nodule on the lower extremity (Figure IV-2, Color Atlas). He is afebrile and has no other lesions. He does not take antiretroviral therapy, and his last CD4+ T cell count was 20/μL. He lives with a friend who has cats and kittens. A biopsy shows lobular proliferation of blood vessels lined
by enlarged endothelial cells and a mixed acute and
chronic inflammatory infiltrate. Tissue stains show gramnegative bacilli. Which of the following is most likely to be effective therapy for the lesion?
IV-3. A 38-year-old homeless man presents to the emergency room with a transient ischemic attack characterized by a facial droop and left arm weakness lasting 20 min, and left upper quadrant pain. He reports intermittent subjective
fevers, diaphoresis, and chills for the past 2 weeks. He has had no recent travel or contact with animals. He has taken no recent antibiotics. Physical examination reveals a slightly distressed man with disheveled appearance. His temperature is 38.2°C; heart rate is 90 beats per minute; blood pressure is 127/74 mmHg. He has poor dentition.
Cardiac examination reveals an early diastolic murmur over the left 3d intercostal space. His spleen is tender and 2 cm descended below the costal margin. He has tender painful red nodules on the tips of the third finger of his right hand and on the fourth finger of his left hand that are
new. He has nits evident on his clothes, consistent with body louse infection. White blood cell count is 14,500, with 5% band forms and 93% polymorphonuclear cells.
Blood cultures are drawn followed by empirical vancomycin therapy. These cultures remain negative for growth 5 days later. He remains febrile but hemodynamically stable but does develop a new lesion on his toe similar to those on his fingers on hospital day 3. A transthoracic echocardiogram
reveals a 1-cm mobile vegetation on the cusp of
his aortic valve and moderate aortic regurgitation. A CT scan of the abdomen shows an enlarged spleen with wedge-shaped splenic and renal infarctions. What test should be sent to confirm the most likely diagnosis?
A. Bartonella serology
IV-4. A 36-year-old man with HIV/AIDS (CD4+ lymphocyte count = 112/μL) develops a scaly, waxy, yellowish, patchy, crusty, pruritic rash on and around his nose. The rest of his skin examination is normal. Which of the following is the most likely diagnosis?
D. Seborrheic dermatitis
IV-5. A 28-year-old woman returns from a 6-week trip to Tanzania in March. She calls your office 2 weeks later complaining of new symptoms of fever, mild abdominal pain, and headache. She feels like she has the flu. What should you do next?
B. Emergently refer her to the emergency department.
IV-6. A 26-year-old woman comes to your clinic complaining of 3-4 weeks of a malodorous white vaginal discharge. She recently began having unprotected sexual intercourse with a new male partner. He is asymptomatic. Her only medication is oral contraceptives. Examination reveals a thin white discharge that evenly coats the vagina.
Further examination of the discharge reveals that it has a pH of 5.0 and has a "fishy" odor when 10% KOH is added to the discharge.Microscopic examination reveals vaginal cells coated with coccobacillary organisms. Which of the following therapies is indicated?
C. Metronidazole, 500 mg PO bid × 7 days
IV-7. A 51-year-old woman is diagnosed with Plasmodium falciparum malaria after returning from a safari in Tanzania. Her parasitemia is 6%, hematocrit is 21%, bilirubin is 7.8 mg/dL, and creatinine is 2.7 mg/dL. She is still making
60 mL of urine per hour. She rapidly becomes obtunded. Intensive care is initiated, with frequent creatinine checks, close monitoring for hypoglycemia, infusion of phenobarbital
for seizure prevention, mechanical ventilation
for airway protection, and exchange transfusion to address her high parasitemia. Which of the following regimens is recommended as first-line treatment for her malarial infection?
B. Intravenous artesunate
IV-8. All of the following infections associated with sexual activity correlate with increased acquisition of HIV infection in women except
A. bacterial vaginosis
D. herpes simplex virus-2
E. Trichomonas vaginalis
F. all of the above are associated with increased acquisition
IV-9. A 9-year-old boy is brought to a pediatric emergency room by his father. He has had 2 days of headache, neck stiffness, and photophobia and this morning had a temperature of 38.9°C (102°F). He has also had several episodes of vomiting and diarrhea overnight. A lumbar puncture is performed, which reveals pleocytosis in the
cerebrospinal fluid (CSF). Which of the following is true regarding enteroviruses as a cause of aseptic meningitis?
B. Enteroviruses are responsible for up to 90% of aseptic
meningitis in children.
IV-10. A 56-year-old man with a history of hypertension and cigarette smoking is admitted to the intensive care unit after 1 week of fever and nonproductive cough. Imaging shows a new pulmonary infiltrate, and urine antigen
test for Legionella is positive. Each of the following is likely to be an effective antibiotic except
IV-11. Which of the following statements regarding HIV epidemiology in the United States is true as of 2005?
C. Minority women aged 13-19 from the southeastern
United States account for a growing proportion of
prevalent HIV cases.
IV-12. A 48-year-old female presents to her physician with a 2-day history of fever, arthralgias, diarrhea, and headache. She recently returned from an ecotour in tropical sub-Saharan Africa, where she went swimming in inland rivers. Notable findings on physical examination include a temperature of 38.7°C (101.7°F); 2-cm tender mobile lymph nodes in the axilla, cervical, and femoral regions; and a palpable spleen. Her white blood cell count is 15,000/μL with 50% eosinophils. She should receive treatments with which of the following medications?
IV-13. A 39-year-old woman received a liver transplant 2 years ago and is maintained on prednisone, 5 mg, and cyclosporine A, 8 mg/kg per day. She has had two episodes of rejection since transplant, as well an episode of cytomegalovirus
syndrome and Nocardia pneumonia. She intends on taking a 2-week gorilla-watching trip to Rwanda
and seeks your advice regarding her health while abroad. Which of the following potential interventions is strictly contraindicated?
E. Yellow fever vaccine
IV-14. A 17-year-old woman presents to the clinic complaining of vaginal itchiness and malodorous discharge. She is sexually active with multiple partners, and she is interested in getting tested for sexually transmitted diseases. A wet-mount microscopic examination is performed, and
trichomonal parasites are identified. Which of the following statements regarding trichomoniasis is true?
D. Trichomoniasis can only be spread sexually.
IV-15. The most common clinical presentation of infection with Babesia microti is
E. self-limited flulike illness
IV-16. When given as a first-line agent for invasive Aspergillus infection, voriconazole commonly causes all of the following side effects except
D. renal toxicity
IV-17. A 42-year-old man with AIDS and a CD4+ lymphocyte count of 23 presents with shortness of breath and fatigue in the absence of fevers. On examination, he appears chronically ill with pale conjunctiva. Hematocrit is 16%. Mean corpuscular volume is 84. Red cell distribution width is normal. Bilirubin, lactose dehydrogenase, and haptoglobin are all within normal limits. Reticulocyte
count is zero. White blood cell count is 4300, with an absolute neutrophil count of 2500. Platelet count is 105,000. Which of the following tests is most likely to produce a diagnosis?
D. Parvovirus B19 polymerase chain reaction (PCR)
IV-18. All of the following are risk factors for the development of Legionella pneumonia except
IV-19. A 38-year-old female pigeon keeper who has no significant past medical history, is taking no medications, has no allergies, and is HIV-negative presents to the emergency room with a fever, headache, and mild nuchal rigidity.
Neurologic examination is normal. Head CT examination is normal. Lumbar puncture is significant for an opening pressure of 20 cmH2O, white blood cell count of 15 cells/ μL (90% monocytes), protein of 0.5 g/L (50 mg/mL), glucose
of 2.8 mmol/L (50 mg/dL), and positive India ink
stain. What is the appropriate therapy for this patient?
D. Amphotericin B for 10 weeks followed by oral fluconazole,
400 mg daily for 6-12 months
IV-20. A 30-year-old female with end-stage renal disease who receives her dialysis through a tunneled catheter in her shoulder presents with fever and severe low back pain. On examination, she is uncomfortable and diaphoretic but hemodynamically stable. She has a soft 2/6 early systolic flow murmur. Her line site is red and warm with no pustular exudates. She is very tender over her lower back. Neurologically, she is completely intact. There is no evidence of Janeway lesions, Osler nodes, or Roth spots. Her white count is 16,700 with 12% bands. Immediate evaluation
should include all of the following except
C. transthoracic echocardiogram
IV-21. While attending the University of Georgia, a group of friends go on a 5-day canoeing and camping trip in rural southern Georgia. A few weeks later, one of the campers develops a serpiginous, raised, pruritic, erythematous
eruption on the buttocks. Strongyloides larvae are found in his stool. Three of his companions, who are asymptomatic, are also found to have strongyloides larvae in their
stool. Which of the following is indicated in the asymptomatic
IV-22. A 79-year-old man has had a diabetic foot ulcer overlying his third metatarsal head for 3 months but has not been compliant with his physician's request to offload the affected foot. He presents with dull, throbbing foot pain and subjective fevers. Examination reveals a
putrid-smelling wound notable also for a pus-filled 2.5 cm wide ulcer. A metal probe is used to probe the wound and it detects bone as well as a 3-cm deep cavity. Gram stain of the pus shows gram-positive cocci in chains, gram-positive rods, gram-negative diplococci, enteric-appearing gram-negative rods, tiny pleomorphic gram-negative rods, and a predominance of neutrophils. Which of the following empirical antibiotic regimens is recommended while blood and drainage cultures are processed?
A. Ampicillin/sulbactam, 1.5 g IV q4h
IV-23. Which of the following scenarios is most likely associated with the lowest risk of HIV transmission to a health care provider after an accidental needle stick from a patient with HIV?
C. The patient whose blood is on the contaminated needle has been on antiretroviral therapy for many years with a history of resistance to many available agents but most recently has had successful viral suppression on current therapy.
IV-24. All of the following regarding herpes simplex virus (HSV)-2 infection are true except
E. Seroprevalence rates of HSV-2 are lower in Africa than in the United States.
IV-25. What is the most common manifestation of Coccidioides infection in an immunocompetent host?
B. Asymptomatic seroconversion
IV-26. You are a physician working on a cruise ship traveling from Miami to the Yucatán Peninsula. In the course of 24 h, 32 people are seen with acute gastrointestinal illness that is marked by vomiting and watery diarrhea. The most likely causative agent of the illness is
IV-27. What is the best method for diagnosis?
E. Polymerase chain reaction (PCR) to identify the
IV-28. A 32-year-old man presents with jaundice and malaise. He is found to have acute hepatitis B with positive hepatitis B virus (HBV) DNA and E antigen. Which of the following antiviral agents are approved as part of a therapeutic regimen for mono-infection with hepatitis B?
IV-29. Which of the following factors is the most important determinant of the rate of disease progression from initial HIV infection to clinical diagnosis of AIDS?
E. HIV viral load set point 6 months after initial infection
IV-30. The standard starting regimen for acid-fast bacilli smear-positive active pulmonary tuberculosis is
D. isoniazid, rifampin, pyrazinamide, ethambutol
IV-31. All of the following are common manifestations of cytomegalovirus (CMV) infection following lung transplantation except
D. CMV retinitis
IV-32. Which of the following statements regarding severe acute respiratory syndrome (SARS) is true?
D. There have been no reported cases of SARS since
IV-33. A 72-year-old woman is admitted to the intensive care unit with respiratory failure. She has fever, obtundation, and bilateral parenchymal consolidation on chest imaging. Which of the following is true regarding the diagnosis of Legionella pneumonia?
D. Legionella urinary antigen maintains utility after antibiotic
IV-34. Which of the following has resulted in a significant decrease in the incidence of trichinellosis in the United States?
D. Laws prohibiting the feeding of uncooked garbage
IV-35. A 23-year-old woman is newly diagnosed with genital herpes simplex virus (HSV)-2 infection. What can you tell her that the chance of reactivation disease will be during the first year after infection?
IV-36. The most common cause of traveler's diarrhea in Mexico is
C. enterotoxigenic Escherichia coli
IV-37. A patient comes to clinic and describes progressive muscle weakness over several weeks. He has also experienced nausea, vomiting, and diarrhea. One month ago he had been completely healthy and describes a bear hunting
trip in Alaska, where they ate some of the game they killed. Soon after he returned, his gastrointestinal (GI) symptoms began, followed by muscle weakness in his jaw and neck that has now spread to his arms and lower back. Examination confirms decreased muscle strength in the
upper extremities and neck. He also has slowed extraocular movements. Laboratory examination shows panic values for elevated eosinophils and serum creatine phosphokinase. Which of the following organisms is most likely the cause of his symptoms?
IV-38. Abacavir is a nucleoside transcription inhibitor that carries which side effect unique for HIV antiretroviral agents?
E. Severe hypersensitivity reaction
IV-39. A 30-year-old healthy woman presents to the hospital with severe dyspnea, confusion, productive cough, and fevers. She had been ill 1 week prior with a flulike illness characterized by fever, myalgias, headache, and malaise.
Her illness almost entirely improved without medical intervention until 36 h ago, when she developed new rigors followed by progression of the respiratory symptoms. On initial examination, her temperature is 39.6°C, pulse is 130 beats per minute, blood pressure is 95/60 mmHg, respiratory
rate is 40, and oxygen saturation is 88% on 100% face mask. On examination she is clammy, confused, and very dyspneic. Lung examination reveals amphoric breath sounds over her left lower lung fields. She is intubated and resuscitated with fluid and antibiotics. Chest CT scan reveals
necrosis of her left lower lobe. Blood and sputum cultures grow Staphylococcus aureus. This isolate is likely to be resistant to which of the following antibiotics?
IV-40. Helicobacter pylori colonization is implicated in all of the following conditions except
D. gastroesophageal reflux disease
IV-41. A 24-year-old woman presents with diffuse arthralgias and morning stiffness in her hands, knees, and wrists. Two weeks earlier she had a self-limited febrile illness notable for a red facial rash and lacy reticular rash on her extremities. On examination, her bilateral wrists, metacarpophalangeal joints, and proximal interphalangeal joints are warm and slightly boggy. What test is most likely to reveal her diagnosis?
D. Parvovirus B19 IgM
IV-42. Candida albicans is isolated from the following patients. Rate the likelihood in order from greatest to least that the positive culture represents true infection rather than contaminant or noninfectious colonization?
Patient X: A 63-year-old man admitted to the intensive care unit (ICU) with pneumonia who has recurrent fevers after receiving 5 days of levofloxacin for pneumonia. A urinalysis drawn from a Foley catheter shows positive leukocyte esterase, negative nitrite, 15 white blood cells/hpf, 10 red blood cells/hpf, and 10 epithelial cells/hpf. Urine culture grows Candida albicans.
Patient Y: A 38-year-old female on hemodialysis presents with low-grade fevers and malaise. Peripheral blood cultures grow Candida albicans in one out of a total of three sets of blood cultures in the aerobic bottle only.
Patient Z: A 68-year-old man presents with a 2-day history of fever, productive cough, and malaise. Chest roentgenogram reveals a left lower lobe infiltrate. A sputum Gram stain shows many PMNs, few epithelial cells, moderate gram-positive cocci in chains, and yeast consistent with Candida.
C. Patient Y > patient X > patient Z
IV-43. Which of the following statements regarding Clostridium difficile-associated disease relapses is true?
D. Recurrent disease is associated with serious complications.
IV-44. A 38-year-old man with HIV/AIDS presents with 4 weeks of diarrhea, fever, and weight loss.Which of the following tests makes the diagnosis of cytomegalovirus (CMV) colitis?
B. Colonoscopy with biopsy
IV-45. In the inpatient setting, extended-spectrum β-lactamase (ESBL)-producing gram-negative infections are most likely to occur after frequent use of which of the following classes of antibiotics?
D. Third-generation cephalosporins
IV-46. A 46-year-old veterinary researcher who frequently operates on rats presents to the emergency room with jaundice and scant hemoptysis. She recalls having a fairly deep cut on
her hand during an operation about 14 days prior. She has had no recent travel or other animal exposures. Her illness started ~9 days prior with fever, chills, severe headache, intense
myalgias, and nausea. She also noted bilateral conjunctival injection. Thinking that she had influenza infection, she stayed home from work and started to feel better 5 days into the illness. However, within a day her symptoms had returned
with worsening headache, and soon thereafter she
developed jaundice. On initial evaluation, her temperature is 38.6°C, pulse is 105 beats per minute, and blood pressure is 156/89 mmHg with O2 saturations of 92% on room air. She appears acutely ill and is both icteric and profoundly jaundiced. Her liver is enlarged and tender, but there are no pal-pable masses and she has no splenomegaly. Laboratory results are notable for a BUN of 64, creatinine of 3.6, total bilirubin of 64.8 (direct 59.2), AST = 84, ALT = 103, alkaline
phosphatase = 384, white blood cell (WBC) count is 11,000 with 13% bands and 80% polymorphonuclear forms, hematocrit of 33%, and platelets = 142. Urinalysis reveals 20
WBCs/hpf, 3+ protein, and granular casts. Coagulation studies are within normal limits. Lumbar puncture reveals a sterile pleocytosis. CT scan of the chest shows diffuse flamelike
infiltrates consistent with pulmonary hemorrhage.
What is the likely diagnosis?
E. Weil's syndrome (Leptospira interrogans infection)
IV-47. A 17-year-old boy in Arkansas presents to a clinic in August with fever, headache, myalgias, nausea, and anorexia 8 days after returning from a 1-week camping trip. Physical examination is remarkable for a temperature of 38.6°C and a generally fatigued but nontoxic appearing,
well-developed young man. He does not have a rash, and orthostatic vital sign measurements are negative. What would be a reasonable course of action?
B. Initiate doxycycline, 100 mg PO bid
IV-48. A 26-year-old woman presents to the emergency department with fever, chills, backache, and malaise. She reports a habit of active IV drug use; last use was 2 days ago. Her vital signs show a temperature of 38.4°C, heart rate of
106/minute, respiratory rate of 22/minute, blood pressure of 114/61 mmHg, and oxygen saturation of 98% on 2 L per nasal cannula. A chest x-ray and subsequent chest CT scan demonstrate multiple peripheral nodular infiltrates with cavitation. Blood cultures are sent to the laboratoryand are pending. At this point in the workup, how many minor criteria are met from the Duke criteria for the clinical diagnosis of infective endocarditis?
IV-49. Which of the following is true regarding influenza prophylaxis?
B. Patients with hypersensitivity to eggs should not receive
the intramuscular vaccine.
IV-50. Which of the following is the most common manifestation of initial (primary) herpes simplex virus (HSV)- 1 infection?
C. Gingivostomatitis and pharyngitis
IV-51. A patient presents to the clinic complaining of nausea, vomiting, crampy abdominal pain, and markedly increased flatus. The patient has not experienced any diarrhea or vomiting but notes that he has been belching more than usual and he describes a "sulfur-like" odor when he does so. He returned from a 3-week trip to Peru and Ecuador several days ago and notes that his symptoms
began about a week ago. Giardiasis is considered in the differential. Which of the following is true regarding Giardia?
D. Ingestion of as few as 10 cysts can cause human disease.
IV-52. An 18-year-old man presents with a firm, nontender lesion around his anal orifice. The lesion is about 1.5 cm in diameter and has a cartilaginous feel on clinical examination. The patient reports that it has progressed to this stage from a small papule. It is not tender. He reports recent unprotected anal intercourse. Bacterial culture of the lesion is negative. A rapid plasmin reagin (RPR) test is also negative. Therapeutic interventions should include
B. IM penicillin G benzathine, 2.4 million U
IV-53. A 17-year-old woman with a medical history of mild intermittent asthma presents to your clinic in February with several days of cough, fever, malaise, and myalgias. She notes that her symptoms started 3 days earlier with a headache and fatigue, and that several students and teachers at her high school have been diagnosed recently with "the flu." She did not receive a flu shot this year. Which of the following medication
treatment plans is the best option for this patient?
D. Symptom-based therapy with over-the-counter agents
IV-54. One month after receiving a 14-day course of omeprazole, clarithromycin, and amoxicillin for Helicobacter pylori-associated gastric ulcer disease, a 44-year-old woman still has mild dyspepsia and pain after meals. What is the appropriate next step in management?
F. Urea breath test
IV-55. Which of the following medications used as antimycobacterial drugs require dose reduction for patients with an estimated glomerular filtration rate <30 mL/min?
IV-56. Which of the following statements regarding the currently licensed human papillomavirus (HPV) vaccine (Gardasil) is true?
E. Vaccinees should continue to receive standard Pap
IV-57. A 25-year-old woman presents with 1 day of fever to 38.3°C (101°F), sore throat, dysphagia, and a number of grayish-white papulovesicular lesions on the soft palate, uvula, and anterior pillars of the tonsils (Figure IV-57, Color Atlas). The patient is most likely infected with which of the following?
IV-58. There is wide concern among many members of the general public regarding which of the following vaccines as a potential cause of autism?
E. Measles-mumps-rubella (MMR) vaccine
IV-59. A 19-year-old female from Guatemala presents to your office for a routine screening physical examination. At age 4 years she was diagnosed with acute rheumatic fever. She does not recall the specifics of her illness and
remembers only that she was required to be on bed rest for 6 months. She has remained on penicillin V orally at a dose of 250 mg bid since that time. She asks if she can safely discontinue this medication. She has had only one other flare of her disease, at age 8, when she stopped taking
penicillin at the time of her emigration to the United
States. She is currently working as a day care provider. Her physical examination is notable for normal point of maximal impulse (PMI) with a grade III/VI holosystolic murmur that is heard best at the apex of the heart and radiates to the axilla. What do you advise the patient to do?
D. She should continue on penicillin indefinitely as she
had a previous recurrence, has presumed rheumatic
heart disease, and is working in a field with high occupational
exposure to group A streptococcus.
IV-60. In a patient with bacterial endocarditis, which of the following echocardiographic lesions is most likely to lead to embolization?
D. 11-mm mitral valve vegetation
IV-61. Testing for latent Mycobacterium tuberculosis infection is indicated in HIV patients at the time of initial diagnosis for all of the following reasons except
A. Active tuberculosis treatment success rates are lower
in HIV-infected patients compared to HIV-uninfected
IV-62. A 19-year-old man presents to the emergency department with 4 days of watery diarrhea, nausea, vomiting, and low-grade fever. He recalls no unusual meals, sick contacts, or travel. He is hydrated with IV fluid, given antiemetics and discharged home after feeling much better. Three days later two out of three blood cultures are
positive for Clostridium perfringens. He is called at home and says that he feels fine and is back to work. What should your next instruction to the patient be?
IV-63. All of the following are clinical manifestations of Ascaris lumbricoides infection except
B. fever, headache, photophobia, nuchal rigidity, and
IV-64. In the developed world, seroprevalence of Helicobacter pylori infection is currently
IV-65. An 87-year-old nursing home resident is brought by ambulance to a local emergency room. He is obtunded and ill-appearing. Per nursing home staff, the patient has experienced low-grade temperatures, poor appetite, and lethargy over several days. A lumbar puncture is performed,
and the Gram stain returns gram-positive rods and many white blood cells. Listeria meningitis is diagnosed and appropriate antibiotics are begun. Which of the following best describes a clinical difference between Listeria and other causes of bacterial meningitis?
D. Presentation is often more subacute.
IV-66. Which of the following antibiotics has the weakest association with the development of Clostridium difficile- associated disease?
IV-67. All of the following statements regarding human T cell lymphotropic virus-I (HTLV-I) infection are true except
C. HTLV-I infection is associated with a gradual decline
in T cell function and immunosuppression.
IV-68. A 33-year-old woman is undergoing consolidation chemotherapy for acute myelocytic leukemia with cytarabine plus daunorubicin. She developed a fever 5 days prior which has persisted despite the addition of cefepime and vancomycin to her prophylactic antibiotic regimen of norfloxacin, fluconazole, and acyclovir. Other than diaphoresis
and chills during her periodic fevers, she remains
largely asymptomatic except for a general sense of
malaise and nausea associated with her chemotherapy, as well as oral pain due to mucositis. She remains neutropenic despite administration of hematopoietic growth factors. Blood, urine, and sputum cultures all remain
negative.What is the next step in her management?
E. High-resolution CT plus serum galactomannan enzyme
IV-69. Which of the following organisms is most likely to cause infection of a shunt implanted for the treatment of hydrocephalus?
E. Staphylococcus epidermidis
IV-70. A 3-year-old boy is brought by his parents to clinic. They state that he has experienced fevers, anorexia, weight loss, and, most recently, has started wheezing at night. He had been completely healthy until these symptoms started
2 months ago. The family had travelled through Europe several months prior and reported no unusual exposures or exotic foods. They have a puppy at home. On examination, the child is ill-appearing and is noted to have hepatosplenomegaly. Laboratory results show a panic value of 82% eosinophils. Total white blood cells are elevated. A complete blood count is repeated to rule out a laboratory error and eosinophils are 78%. Which of the following is the most likely organism or process?
IV-71. An otherwise healthy 5-year-old child presents with low-grade fevers, sore throat, and red, itchy eyes. He attends summer camp, where several other campers were ill. On examination, the patient is noted to have pharyngitis and bilateral conjunctivitis. Which of the following is the most likely etiologic agent?
IV-72. A 35-year-old male is seen 6 months after a cadaveric renal allograft. The patient has been on azathioprine and prednisone since that procedure. He has felt poorly for the past week with fever to 38.6°C (101.5°F), anorexia, and a cough productive of thick sputum. Chest x-ray reveals a left lower lobe (5 cm) nodule with central cavitation. Examination of the sputum reveals long, crooked,
branching, beaded gram-positive filaments. The most appropriate initial therapy would include the administration of which of the following antibiotics?
IV-73. A 53-year-old male with a history of alcoholism presentswith an enlarging mass at the angle of the jaw. The patient describes the mass slowly enlarging over a period of 6 weeks with occasional associated pain. He has also
noted intermittent fevers throughout this period. Recently, he has developed yellowish drainage from the inferior portion of the mass. He takes no medications and has no other past history. He drinks six beers daily. On physical examination, the patient has a temperature of 37.9°C (100.2°F). His dentition is poor. There is diffuse soft tissue
swelling and induration at the angle of the mandible
on the left. It is mildly tender, and no discrete mass is palpable. The area of swelling is ~8 × 8 cm. An aspirate is sent for Gram stain and culture. The culture initially grows Eikenella corrodens. After 7 days you receive a call reporting growth of a gram-positive bacillus branching at acute angles on anaerobic media. What organism is causing this man's clinical presentation?
IV-75. A 40-year-old male smoker with a history of asthma is admitted to the inpatient medical service with fever, cough, brownish-green sputum, and malaise. Physical examination shows a respiratory rate of 15, no use of accessory muscles of breathing, and bilateral polyphonic wheezes throughout the lung fields. There is no clubbing
or skin lesions. You consider a diagnosis of allergic bronchopulmonary aspergillosis. All the following clinical features are consistent with allergic bronchopulmonary aspergillosis except
A. bilateral, peripheral cavitary lung infiltrates
IV-76. All of the following factors increase the risk for Clostridium difficile-associated disease except
C. C. difficile colonization
IV-77. A 19-year-old man presents to an urgent care clinic with urethral discharge. He reports three new female sexual partners over the past 2 months. What should his management be?
D. Nucleic acid amplification test for N. gonorrhoeae
and C. trachomatis plus cefpodoxime, 400 mg PO ×
1, and azithromycin, 1g PO × 1, for the patient and
his recent partners
IV-78. During the first 2 weeks following solid organ transplantation, which family of infection is most common?
E. Typical hospital-acquired infections (e.g., central
line infection, hospital-acquired pneumonia, urinary
IV-79. A 19-year-old college student is brought to the
emergency department by friends from his dormitory for confusion and altered mental status. They state that many colleagues have upper respiratory tract infections. He does not use alcohol or illicit drugs. His physical examination
is notable for confusion, fever, and a rigid neck.
Cerebrospinal fluid (CSF) examination reveals a white blood cell count of 1800 cells/μL with 98% neutrophils, glucose of 1.9 mmol/L (35 mg/dL), and protein of 1.0 g/L (100 mg/dL). Which of the following antibiotic regimens is most appropriate as initial therapy?
E. Cefotaxime plus vancomycin
IV-80. In addition to antibiotics, which of the following adjunctive therapies should be administered to improve the chance of a favorable neurologic outcome?
IV-81. Which of the following viruses is the leading cause of respiratory disease in infants and children?
C. Human respiratory syncytial virus
IV-82. Several family members present to a local emergency room 2 days after a large family summer picnic where deli meats and salads were served. They all complain of profuse diarrhea, headaches, fevers, and myalgias. Their symptoms began ~24 h after the picnic. It appears that everyone who ate Aunt Emma's bologna surprise
was afflicted. Routine cultures of blood and stool
are negative to date. Which of the following is true regarding Listeria gastroenteritis?
A. Antibiotic treatment is not necessary for uncomplicated
IV-83. Which clinical entity is the most difficult to distinguish from osteomyelitis in a diabetic foot on any currently available medical imaging (plain film, CT, MRI, ultrasound, and three-phase bone scan)?
D. Neuropathic osteopathy
IV-84. The human enterovirus family includes poliovirus, coxsackieviruses, enteroviruses, and echovirus. Which of the following statements regarding viral infection with one of the members of this group is true?
B. Enteroviruses cannot be transmitted via blood
transfusions and insect bites.
IV-85. Which of the following sexually transmitted infections (STIs) is the most common in the United States?
D. Human papilloma virus infection
IV-86. A 38-year-old woman presents to the emergency department with severe abdominal pain. She has no past medical or surgical history. She recalls no recent history of abdominal discomfort, diarrhea, melena, bright red blood per rectum, nausea, or vomiting prior to this acute
episode. She ate ceviche (lime-marinated raw fish) at a Peruvian restaurant 3 h prior to presentation. On examination, she is in terrible distress and has dry heaves. Temperature is 37.6°C; heart rate is 128 beats per minute; blood pressure is 174/92 mmHg. Examination is notable for an extremely tender abdomen with guarding and rebound tenderness. Bowel sounds are present and hyperactive. Rectal examination is normal and guaiac test is negative. Pelvic examination is unremarkable. White blood cell count is 6738/μL; hematocrit is 42%. A complete metabolic panel and lipase and amylase levels are all within normal limits. CT of the abdomen shows no abnormality.
What is the next step in her management?
E. Upper endoscopy
IV-87. Which of the following clinical features can be used to rule out malaria in favor of another tropical febrile illness in a returning traveler?
B. Lack of paroxysmal nature of the fevers
C. Lack of splenomegaly
D. Severe myalgias and retroorbital headache
E. None of the above
IV-88. Which of the following serology patterns places a transplant recipient at the lowest risk of developing cytomegalovirus (CMV) infection after renal transplantation?
A. Donor CMV IgG negative, recipient CMV IgG negative
IV-89. Which of the following statements regarding liver abscesses is true?
B. Alkaline phosphatase is the most likely liver function
test to be abnormal in the presence of a liver abscess.
IV-90. All of the following antifungal medications may be used for the treatment of Candida albicans fungemia except
IV-91. A 40-year-old male is admitted to the hospital with 2-3 weeks of fever, tender lymph nodes, and right upper quadrant abdominal pain. He reports progressive weight loss and malaise over a year. On examination, he is found to be febrile and frail with temporal wasting and oral thrush. Matted, tender anterior cervical lymphadenopathy <1 cm and tender hepatomegaly are noted. He is diagnosed with AIDS (CD4+ lymphocyte count =
12/μL and HIV RNA 650,000 copies/mL). Blood cultures grow Mycobacterium avium. He is started on rifabutin and clarithromycin, as well as dapsone for Pneumocystis prophylaxis, and discharged home 2 weeks later after his fevers subside. He follows up with an HIV provider 4 weeks later and is started on tenofovir, emtricitabine and efavirenz. Two weeks later he returns to clinic with fevers, neck pain, and abdominal pain. His temperature is 39.2°C, heart rate is 110 beats per minute, blood pressure is 110/64 mmHg, and oxygen saturations are normal. His cervical nodes are now 2 centimeters in size and extremely tender, and one has fistulized to his skin and is draining yellow pus that is acid-fast bacillus stain-positive. His hepatomegaly is pronounced and tender. What is the most likely explanation for his presentation?
C. Immune reconstitution syndrome to Mycobacterium
IV-92. Which of the following statements regarding prevention of human respiratory syncytial virus (HRSV) infection in children is true?
E. RSV immune globulin should be given monthly to
children <2 years old who were born prematurely.
IV-93. A 52-year-old woman with alcoholic cirrhosis, portal hypertension, esophageal varices, and history of hepatic encephalopathy presents to the hospital with confusion over several days. Her husband remarks that the patient has been
adherent to her medicines. These medicines include labetalol, furosemide, aldactone, and lactulose. Physical examination is notable for temperature of 38.3°C, heart rate of 115 bpm, blood pressure of 105/62 mmHg, respiratory rate
of 12 breaths per minute, and oxygen saturation of 96% on room air. The patient is extremely drowsy, only intermittently able to answer questions, and disoriented. She has slight asterixis. Lungs are clear. Cardiac examination is unremarkable.
Her abdomen is distended and tense but nontender.
She has 3+ lower extremity edema extending to her
thighs. She is guaiac negative. Her cranial nerves and extremity strength are symmetric and normal. Laboratory studies reveal a leukocyte count of 4830/μL, hematocrit = 33% (baseline = 30%), and platelet count of 94,000/μL. Basic metabolic panel is unremarkable. What is an essential component of the diagnostic workup?
IV-94. A 64-year-old female is admitted to the hospital with altered mental status. She recently returned from a summer white-water rafting trip in Colorado. Her husband reports increasing confusion, alternating lethargy and agitation,
and visual hallucinations over the past 3 days. There is no history of drug abuse or psychiatric illness. She takes no medications. Her physical examination is notable for a temperature of 39°C (102.2°F), myoclonic jerks, and hyperreflexia.
She is delirious and oriented to person only when
aroused. There is no nuchal rigidity. Cerebrospinal fluid (CSF) examination reveals clear fluid with a white blood cell count of 15 cells/μL with 100% lymphocytes, protein of 1.0 g/L (100 mg/dL), and glucose of 4.4 mmol/L (80 mg/ dL). Gram stain of the CSF shows no organisms. You suspect
infection with West Nile virus. Which of the following
studies will be most useful in making that diagnosis?
B. CSF IgM antibodies
IV-95. Which of the following represents a rare but serious extrapulmonary complication of influenza infection?
IV-96. You are a physician for an undergraduate university health clinic in Arizona. You have evaluated three students with similar complaints of fever, malaise, diffuse arthralgias, cough without hemoptysis, and chest discomfort, and
one of the patients has a skin rash on her extremities consistent with erythema multiforme. Chest radiography is similar in all three, with hilar adenopathy and small pleural effusions. Upon further questioning you learn that all three
students are in the same archaeology class and participated in an excavation 1 week ago. Your leading diagnosis is
C. primary pulmonary coccidioidomycosis
IV-97. A 34-year-old recent immigrant from Burundi presents with fever, headache, severe myalgias, photophobia, conjunctival injection, and prostration. He lived in a refugee camp for the previous 10 years. In the camp, he was treated for several unknown febrile illnesses. Since arriving
in the United States 7 years ago, he has worked as a computer analyst and lived only in a metropolitan Northwest city with no significant travel. Initial blood cultures are negative. Five days into the illness he develops hypotension pneumonitis, encephalopathy, and gangrene of his distal digits as well as a petechial, hemorrhagic rash
over his entire body except for his face. A biopsy of his rash reveals immunohistochemical changes consistent with a rickettsial infection. Which of the following rickettsial pathogens is most likely in this patient?
D. Rickettsia rickettsii (Rocky Mountain spotted fever)
IV-98. You are the on-call physician practicing in a suburban community. You receive a call from a 28-year-old female with a past medical history significant for sarcoidosis who is currently on no medications. She is complaining of the acute onset of crampy diffuse abdom-inal pain and multiple episodes of emesis that are nonbloody.
She has not had any light-headedness with standing or loss of consciousness. When questioned further, the patient states that her last meal was 5 h previously when she joined her friends for lunch at a local Chinese restaurant. She ate from the buffet, which included multiple poultry dishes and fried rice. What should you do for this patient?
C. Reassure the patient that her illness is self-limited
and no further treatment is necessary if she can
maintain adequate hydration.
IV-99. Borrelia burgdorferi serology testing is indicated for which of the following patients, all of whom reside in Lyme-endemic regions?
A. A 19-year-old female camp counselor who presents
with her second episode of an inflamed, red and
tender left knee and right ankle
IV-100. A 39-year-old injection drug user with a history of right-sided endocarditis and HIV infection notes back pain and fevers over the past week. He had an abscess recently on his right arm that he drained on his own. He is part of a needle-exchange program and always cleans his
arm before shooting heroin into the vein in his antecubital fossa. On physical examination, he has a temperature of 38.1°C, heart rate of 124 beats per minute, and blood pressure of 75/30 mmHg. He is in a great deal of distress and is slightly confused. He has a 4/6 left lower sternal border murmur that varies with the respiratory cycle. His jugular venous pressure is monophasic and to
the jaw when seated at 90 degrees. Lung examination is clear. Abdomen is benign. He is very tender over his lower spine. His extremities are warm. Leg strength is 5/5 on the right, with 4/5 left hip flexion and extension, 3/5 left knee flexion and extension, and 3/5 left foot extension. His
Babinski reflex is upgoing on the left and downgoing on the right.What is the next step in management?
C. Urgent MRI and neurosurgical consultation; vancomycin
plus cefepime after blood cultures are drawn
IV-101. An HIV-positive patient with a CD4 count of 110/ µL who is not taking any medications presents to an urgent care center with complaints of a headache for the past week. He also notes nausea and intermittently blurred vision. Examination is notable for normal vital signs without fever but mild papilledema. Head CT does not show dilated ventricles. The deﬁnitive diagnostic test for this patient is
A. cerebrospinal ﬂuid (CSF) culture
IV-102. Which of the following favors a diagnosis of acute bacterial epididymitis?
C. Concurrent urethral discharge
IV-103. A 19-year-old woman comes to your ofﬁce after being bitten by a bat on the ear while camping in a primitive shelter. She is unable to produce a vaccination record. On physical examination, she is afebrile and appears well. There are two small puncture marks on the pinna of her left ear. What is an appropriate vaccination strategy in this context?
E. Rabies inactivated virus vaccine plus immunoglobulins
IV-104. A 26-year-old woman during a clinic is found to have a positive rapid plasmin reagin test (1:4) and a posi- tive ﬂuorescent treponemal antibody-absorption test (FTA-ABS). She has never been treated for syphilis. She recalls a large painless ulcer on her labia 9 months prior, followed about 2 months later by a diffuse rash and oral lesions that also resolved. She has had ﬁve sexual contacts in the past year. In addition to treating the patient, all of the following additional interventions should be considered except
A. echocardiogram looking at the aortic arch
IV-105. Per-coital rate of HIV acquisition in a man who has unprotected sexual intercourse with an HIV-infected female partner is likely to increase under which of the following circumstances?
A. Acute HIV infection in the female partner B. Female herpes simplex virus (HSV)-2 positive se- rostatus
C. Male nongonococcal urethritis at the time of intercourse
D.Uncircumcised male status
All of the above
IV-106. All of the following are associated with increased risk of pelvic inﬂammatory disease (PID) except
E. symptoms beginning on days 14-21 of the menstrual cycle
IV-107. Current Centers for Disease Control and Preven- tion (CDC) recommendations are that screening for HIV be performed in which of the following?
B. All U.S. adults
IV-108. A 26-year-old woman presents late in the third tri- mester of her pregnancy with high fevers, myalgias, back- ache, and malaise. She is admitted and started on empirical broad-spectrum antibiotics. Blood cultures return positive for Listeria monocytogenes. She delivers a 5-lb infant 24 h after admission. Which of the following statements regard- ing antibiotic treatment for this infection is true?
B. Neonates should receive weight-based ampicillin and gentamicin.
IV-109. Glucocorticoids have been shown to be of beneﬁt for treatment for all of the following infections except
A. Aspergillus fumigatus pneumonia
IV-110. A 23-year-old previously healthy female letter carrier works in a suburb in which the presence of rabid foxes and skunks has been documented. She is bitten by a bat, which then ﬂies away. Initial examination reveals a clean break in the skin in the right upper forearm. She has no history of receiving treatment for rabies and is unsure about vaccination against tetanus. The physician should
D.clean the wound with a 20% soap solution, adminis- ter tetanus toxoid, administer human rabies im- mune globulin IM, and administer human diploid cell vaccine
IV-111. In a patient who has undergone a traumatic sple- nectomy, what test can be ordered to establish lack of splenic function?
D. Peripheral blood smear
IV-112. A patient is admitted with fevers, malaise, and diffuse joint pains. His initial blood cultures reveal methicillin-resis- tant Staphylococcus aureus (MRSA) in all culture bottles. He has no arthritis on examination, and his renal function is normal. Echocardiogram shows a 5-mm vegetation on the aortic valve. He is initiated on IV vancomycin at 15 mg/kg every 12 h. Four days later the patient remains febrile and cultures remain positive for MRSA. In addition to a search for embolic foci of infection, which of the following changes would you make to his treatment regimen?
A. No change
IV-113. A 23-year-old woman develops cytomegalovirus (CMV) pneumonitis 5 months after a lung transplant. She developed severe side effects from ganciclovir while receiving prophylaxis. Foscarnet is prescribed for this epi- sode. Which of the following side effects is most likely?
B. Electrolyte wasting
IV-114. A 38-year-old woman is seen in clinic for a de- crease in cognitive and executive function. Her husband is concerned because she is no longer able to pay bills, keep appointments, or remember important dates. She also seems to derive considerably less pleasure from car- ing for her children and her hobbies. She is unable to concentrate for long enough to enjoy movies. This is a clear change from her functional status 6 months prior. A workup reveals a positive HIV antibody by enzyme im- munoassay and Western blot. Her CD4+ lymphocyte count is 378/µL with a viral load of 78,000/mL. She is afe- brile with normal vital signs. Her affect is blunted, and she seems disinterested in the medical interview. Neuro- logic examination for strength, sensation, cerebellar func- tion and cranial nerve function is nonfocal. Fundoscopic examination is normal. Mini-Mental Status Examination score is 22/30. A serum rapid plasmin reagin (RPR) test is negative. MRI of the brain shows only cerebral atrophy disproportionate to her age but no focal lesions. What is the next step in her management?
A. Antiretroviral therapy
IV-115. A 72-year-old male is admitted to the hospital with bacteremia and pyelonephritis. He is HIV-negative and has no other signiﬁcant past medical history. Two weeks into his treatment with antibiotics a fever evaluation re- veals a blood culture positive for Candida albicans. Exam- ination is unremarkable. White blood cell count is normal. The central venous catheter is removed, and sys- temic antifungal agents are initiated. What further evalu- ation is recommended?
C. Funduscopic examination
IV-116. A 40-year-old man with HIV (CD4+ lymphocyte count = 180, viral load = 1000 copies/mL) was treated for secondary syphilis based on generalized painless lym- phadenopathy, a diffuse maculopapular rash that in- cluded his palms and soles, and a preceding primary genital chancre. He reported no neurologic or ophthal- mic symptoms at the time and received one dose of IM penicillin G benzathine. At the time of diagnosis, his rapid plasmin reagin (RPR) titer was 1:64 and ﬂuorescent treponemal antibody-absorption (FTA-ABS) test was positive. He follows up a year later and is found to have an RPR titer of 1:64 and his FTA-ABS remains positive. What is the appropriate intervention at this time?
C. Lumbar puncture
IV-117. A 26-year-old female college student presents with tender epitrochlear and axillary tender, ﬁrm, 3-cm lymph nodes on her left side. She has a 0.5-cm painless nodule on her left second ﬁnger. She reports low-grade fever and malaise over 2 weeks. She enjoys gardening, exotic ﬁsh collecting, and owns several pets including ﬁsh, kittens, and a puppy. She is sexually active with one partner. She traveled extensively throughout rural Southeast Asia 2 years before her current illness. The differential diagnosis includes all of the following except
C. Sporothrix schenkii infection
IV-118. A person with liver disease caused by Schistosoma mansoni would be most likely to have
B. esophageal varices
IV-119. A previously healthy 28-year-old male describes several episodes of fever, myalgia, and headache that have been followed by abdominal pain and diarrhea. He has experienced up to 10 bowel movements per day. Physical examination is unremarkable. Laboratory ﬁnd- ings are notable only for a slightly elevated leukocyte count and an elevated erythrocyte sedimentation rate. Wright's stain of a fecal sample reveals the presence of neutrophils. Colonoscopy reveals inﬂamed mucosa. Bi- opsy of an affected area discloses mucosal inﬁltration with neutrophils, monocytes, and eosinophils; epithelial damage, including loss of mucus; glandular degenera- tion; and crypt abscesses. The patient notes that several months ago he was at a church barbecue where several people contracted a diarrheal illness. Although this pa- tient could have inﬂammatory bowel disease, which of the following pathogens is most likely to be responsible for his illness?
IV-120. Deﬁcits in the complement membrane attack com- plex (C5-8) are associated with recurrent infections of what variety?
E. Neisseria meningitis
IV-121. A previously healthy 17-year-old woman pre- sents in early October with profound fatigue and mal- aise, as well as fevers, headache, nuchal rigidity, diffuse arthralgias, and a rash. She lives in a small town in Massachusetts and spent her summer as a camp coun- selor at a local day camp. She participated in daily hikes in the woods but did not travel outside of the area dur- ing the course of the summer. Physical examination re- veals a well-developed young woman who appears extremely fatigued but not in extremis. Her tempera- ture is 37.4°C; pulse is 86 beats per minute; blood pressure is 96/54 mmHg; respiratory rate is 12 breaths per minute. Physical examination documents clear breath sounds, no cardiac rub or murmur, normal bowel sounds, a nontender abdomen, no organomeg- aly, and no evidence of synovitis. Several cutaneous le- sions are noted on her lower extremities, bilateral axillae, right thigh, and left groin (Figure IV-121, Color Atlas). All of the following are possible complications of her current disease state except
D. progressive dementia
IV-122. In the patient described above, which of the fol- lowing is appropriate therapy?
D. Doxycycline, 100 mg PO bid
IV-123. Which of the following represents an emergent (same day) indication for cardiac surgery in a patient with infective endocarditis?
D. Sinus of Valsalva abscess ruptured into right heart
IV-124. Which of the following pathogens are cardiac transplant patients at unique risk for acquiring from the donor heart early after transplant when compared to other solid organ transplant patients?
E. Toxoplasma gondii
IV-125. A 68-year-old woman has been in the medical in- tensive care unit for 10 days with a chronic obstructive pulmonary disease ﬂare and pneumonia, including the initial 6 days on a mechanical ventilator. She just ﬁnished a course of moxiﬂoxacin and glucocorticoid taper when she develops abdominal discomfort over 2 days. Vital signs reveal a temperature of 38.2°C, heart rate of 94 beats per minute, blood pressure of 162/94 mmHg, respiratory rate of 18 per minute, and oxygen saturation of 90%. On examination, she is in moderate distress. She is not using accessory muscles but is tachypneic. She has a slight bilat- eral wheeze with good air movement. Heart sounds are distant and unchanged. Her abdomen is moderately dis- tended and tense, with scant bowel sounds present. There is no guarding or rebound, but she is tender throughout. Review of her records reveals no bowel movement over the past 72 h and no stool is palpable in the rectal vault. White blood cell count has increased from 7100/µL to 38,000/µL over the past 2 days. Abdominal plain ﬁlm shows what is read as a probable ileus in the right lower quadrant. Aside from nasogastric (NG) tube placement with suction and NPO status, which of the following should your management also include?
B. Metronidazole, 500 mg IV tid
IV-126. A 25-year-old woman presents to the clinic com- plaining of several days of worsening burning and pain with urination. She describes an increase in urinary frequency and suprapubic tenderness but no fever or back pain. She has no past medical history with the exception of two prior episodes similar to this in the past 2 years. Urine analysis shows moderate white blood cells. Which of the following is the most likely causative agent of her current symptoms?
B. Escherichia coli
IV-127. A 42-year-old man with poorly controlled diabetes (HbA1C = 13.3%) presents with thigh pain and fever over several weeks. Physical examination reveals ery- thema and warmth over the thigh with notable woody, nonpitting edema. There are no cutaneous ulcers. CT of the thigh reveals several abscesses located between the muscle ﬁbers of the thigh. Orthopedics is consulted to drain and culture the abscesses. Which of the following is the most likely pathogen?
D. Staphylococcus aureus
IV-128. Regarding the epidemiology of inﬂuenza viruses, which of the following is true?
C.Avian inﬂuenza outbreaks in humans occur when human inﬂuenza A viruses undergo antigenic shifts with inﬂuenza A from poultry.
IV-129. A 62-year-old man returns from a vacation to Ari- zona with fever, pleurisy, and a nonproductive cough. All of the following factors on history and laboratory exami- nation favor a diagnosis of pulmonary coccidioidomyco- sis rather than community-acquired pneumonia except
E. travel limited to Northern Arizona (Grand Canyon area)
IV-130. A 36-year-old man with a history of hypertension presents complaining of a 3-year history of constant fa- tigue, diffuse myalgias, and memory deﬁcits. He also notes trouble with routine tasks at work. He was diag- nosed with Lyme disease 4 years ago and was brieﬂy ad- mitted to a cardiac care unit for transient third-degree heart block. Symptoms at that time included fever, mal- aise, arthralgias, diffuse erythema migrans, and facial nerve palsy. He received ceftriaxone, 2 g/d for 28 days, and had complete resolution of symptoms for several months but then developed his new constellation of problems that have gradually worsened over time. Physi- cal examination is totally within normal limits. Which is the appropriate next step in management?
E. Symptomatic treatment
IV-131. A sputum culture from a patient with cystic ﬁbro- sis showing which of the following organisms has been associated with a rapid decline in pulmonary function and a poor clinical prognosis?
A. Burkholderia cepacia
IV-132. Empirical antibiotic therapy for continuous ambu- latory peritoneal dialysis (CAPD) patients with peritoni- tis should be directed towards which organisms?
D. Gram-positive cocci plus enteric gram-negative rods
IV-133. Indinavir is a protease inhibitor that carries which side effect unique for HIV antiretroviral agents?
IV-134. A 28-year-old woman presents with fevers, head- ache, diaphoresis, and abdominal pain 2 days after return- ing from an aid mission to the coast of Papua New Guinea. Several of her fellow aid workers developed malaria while abroad, and she stopped her doxycycline prophylaxis due to a photosensitivity reaction 5 days prior. You send blood cultures, routine labs, and a thick and thin smear to evalu- ate the source of her fevers. Which of the following state- ments is accurate in reference to diagnosis of malaria?
A. A thick smear is performed to increase sensitivity in comparison to a thin smear but can only be per- formed in centers with experienced laboratory per- sonnel and has a longer processing time.
B.Careful analysis of the thin blood ﬁlm allows for prognostication based on estimation of parasitemia and morphology of the erythrocytes.
C.In the absence of rapid diagnostic information, empiri- cal treatment for malaria should be strongly considered.
D.Morphology on blood smear is the current criterion used to differentiate the four species of Plasmodium that infect humans.
E.All of the above are true.
IV-135. A 34-year-old injection drug user presents with a 2-day history of slurred speech, blurry vision that is worse with bilateral gaze deviation, dry mouth, and difﬁ- culty swallowing both liquids and solids. He states that his arms feel weak as well but denies any sensory deﬁcits. He has had no recent illness but does describe a chronic ulcer on his left lower leg that has felt slightly warm and tender of late. He frequently injects heroin into the edges of the ulcer. On review of systems, he reports mild short- ness of breath but denies any gastrointestinal symptoms, urinary retention, or loss of bowel or bladder continence. Physical examination reveals a frustrated, nontoxic ap- pearing man who is alert and oriented but noticeably dys- arthric. He is afebrile with stable vital signs. Cranial nerve examination reveals bilateral cranial nerve six deﬁcits and an inability to maintain medial gaze in both eyes. He has mild bilateral ptosis, and both pupils are reactive but sluggish. His strength is 5/5 in all extremities except for his shoulder shrug, which is 4/5. Sensory examination and deep tendon reﬂexes are within normal limits in all four extremities. His oropharynx is dry. Cardiopulmo- nary and abdominal examinations are normal. He has a 4 cm × 5 cm well-granulated lower extremity ulcer with redness, warmth, and erythema noted on the upper mar- gin of the ulcer. What is the treatment of choice?
B. Equine antitoxin to Clostridium botulinum neuro- toxin
IV-136. In an HIV-infected patient, Isospora belli infection is different from Cryptosporidium infection in which of the following ways?
D. Isospora is less challenging to treat and generally responds well to trimethoprim/sulfamethoxazole treatment.
IV-137. In a patient with known HIV infection, all of the following are an AIDS-deﬁning criterion except
F. herpes zoster infection involving more than one dermatome
IV-138. A 27-year-old man presents to your clinic with 2 weeks of sore throat, malaise, myalgias, night sweats, fevers, and chills. He visited an urgent care center and was told that he likely had the flu. He was told that he had a "negative test for mono." The patient is homosexual, states that he is in a monogamous relationship and has unprotected receptive and insertive anal and oral intercourse
with one partner. He had several partners prior to
his current partner 4 years ago but none recently. He reports a negative HIV-1 test 2 years ago and recalls being diagnosed with Chlamydia infection 4 years ago. He is otherwise healthy with no medical problems. You wish to rule out the diagnosis of acute HIV. Which blood test should you order?
D. HIV RNA by polymerase chain reaction (PCR)
IV-139. A 20-year-old female is 36 weeks pregnant and presents for her first evaluation. She is diagnosed with Chlamydia trachomatis infection of the cervix. Upon delivery, what complication is her infant most at risk for?
IV-140. A 29-year-old man is being initiated on HIV antiretroviral therapy (ART) because of a rising viral RNA. He has no significant past medical or psychiatric history and has never received ART. His viral resistance screening shows no likely resistance mutations. Which of the following
is now considered an acceptable first-line regimen
of ART for patients being newly treated for HIV infection who have no viral resistance and no other medical or psychiatric problems?
B. Tenofovir (TDF), emtricitabine (FTC), efavirenz
IV-141. All of the following clinical findings are consistent with the diagnosis of molluscum contagiosum except
B. involvement of the soles of the feet
IV-142. A 45-year-old woman with known HIV infection and medical nonadherence to therapy is admitted to the hospital with 2-3 weeks of increasing dyspnea on exertion and malaise. Chest radiograph shows bilateral alveolar infiltrates and induced sputum is positive for Pneumocystis jiroveci.Which of the following clinical conditions
is an indication for administration of adjunct glucocorticoids?
E. Room air PaO2 <70 mmHg
IV-144. A 19-year-old college student presents to the emergency room with crampy abdominal pain and watery diarrhea that has worsened over 3 days. He recently returned from a volunteer trip to Mexico. He has no past medical history and felt well throughout the trip. Stool examination shows small cysts containing four nuclei, and stool antigen immunoassay is positive for Giardia.
Which of the following is an effective treatment regimen?
IV-145. A 76-year-old woman is brought in to clinic by her son. She complains of a chronic nonproductive cough and fatigue. Her son adds that she has had low-grade fevers, progressive weight loss over months, and "just doesn't seem like herself." A chest CT reveals bronchiectasis
and small (<5 mm) nodules scattered throughout the lung parenchyma. She had a distant history of treated tuberculosis. A sputum sample is obtained, as are blood cultures. Two weeks later, both culture sets grow acid fast bacilli consistent with Mycobacterium avium complex. Which of the following is the best treatment option?
B. Clarithromycin and ethambutol
IV-146. Sensitive and specific serum or urine diagnostic tests exist for all of the following invasive fungal infections except
IV-147. What is the most common side effect of oral ribavirin when used with pegylated interferon for the treatment of hepatitis C?
B. Hemolytic anemia
IV-148. A previously unvaccinated health care worker incurs a needle stick from a patient with known active hepatitis B infection. What is the appropriate management for the health care worker?
C. Hepatitis B vaccine plus hepatitis B immunoglobulins
IV-149. Which of the following is not a common feature of severe Plasmodium falciparum malaria?
C. Hepatic necrosis
IV-150. A 55-year-old male is admitted to the hospital with aspiration pneumonia. Over the past 8 months he has had a relentless neurologic decline characterized by dementia with severe memory loss and decline in intellectual function. These symptoms were preceded by 2-3 months of labile mood, weight loss, and headache. Currently
he is awake but unable to answer questions. Neurologic examination is notable for normal cranial nerves and sensation. He has marked myoclonus provoked by startle or bright lights, but it also occurs spontaneously during sleep. Prior evaluation revealed normal serum chemistries, negative serologic tests for syphilis, and normal
cerebrospinal fluid (CSF) studies. Head CT scan is
normal. The infectious agent that caused his neurologic syndrome is most likely a
C. protein-lacking nucleic acid
IV-151. A previously healthy 19-year-old man presents with several days of headache, cough with scant sputum, and fever of 38.6°C. On examination, pharyngeal erythema is noted and lung fields are clear. Chest radiograph reveals focal bronchopneumonia in the lower lobes. His
hematocrit is 24.7%, down from a baseline measure of 46%. The only other laboratory abnormality is an indirect bilirubin of 3.4. A peripheral smear reveals no abnormalities. A cold agglutinin titer is measured at 1:64.What is the most likely infectious agent?
D. Mycoplasma pneumoniae
IV-152. A 79-year-old Filipino-American man with diabetes mellitus, coronary artery disease, and emphysema develops the acute onset of low back pain and night sweats. Ten days prior, he underwent a prolonged lithotripsy procedure
for septic ureteral stones. He was treated for a positive PPD 23 years ago. He moved to the United States 20 years ago and was a rice farmer in the Philippines prior to moving. Examination reveals tenderness over the lumbar spine. He has 5/5 strength in his lower extremities. MRI
shows findings consistent with osteomyelitis of L3 and L4, with narrowing of the disc space and a small contiguous epidural abscess that is not compressing his spinal cord. A needle culture of the epidural abscess drawn prior to administration of antibiotics will most likely reveal which of the following?
B. Escherichia coli
IV-153. A 64-year-old man in Wisconsin develops a high fever and malaise over 2 days. He has spent his weekends over the past month chopping wood in his backyard. Initial laboratory examination reveals a neutrophil count of 1000/μL, platelet count of 84,000/μL, AST of 140 U/L, and ALT of 183 U/L. A peripheral blood smear reveals prominent morulae in neutrophils. What is the most likely diagnosis?
A. Human granulocytotropic anaplasmosis
IV-154. A 26-year-old asthmatic continues to have coughing fits and dyspnea despite numerous steroid tapers and frequent use of albuterol over the past few months. Persistent infiltrates are seen on chest roentgenogram. A pulmonary
consultation suggests an evaluation for allergic bronchopulmonary aspergillosis.What is the diagnostic test of choice?
E. Serum IgE level
IV-155. A patient who has undergone prosthetic valve surgery 6 weeks ago is readmitted with signs and symptoms consistent with infective endocarditis. Which of the following is the most likely etiologic organism?
B. Coagulase-negative staphylococci
IV-156. A 28-year-old man is diagnosed with HIV infection during a clinic visit. He has no symptoms of opportunistic infection. His CD4+ lymphocyte count is 150/ μL. All of the following are approved regimens for primary prophylaxis against Pneumocystis jiroveci infection except
C. clindamycin, 900 mg PO q8h, plus primaquine, 30
mg PO daily
IV-157. During the late 1990s, there was a resurgence of all of the following bacterial sexually transmitted infections (STIs) among homosexual men except
C. lymphogranuloma venereum
E. all of the above had a resurgence
IV-158. A 47-year-old woman with known HIV/AIDS
(CD4+ lymphocyte = 106/μL and viral load = 35,000/ mL) presents with painful growths on the side of her tongue (Figure IV-158, Color Atlas). What is the most likely diagnosis?
B. Hairy leukoplakia
IV-159. A 45-year-old patient with HIV/AIDS presents to the emergency department. He complains of a rash that has been slowly spreading up his right arm and is now evident on his chest and back. The rash consists of small
nodules that have a reddish-blue appearance. Some of them are ulcerated, but there is minimal fluctuance or drainage. He is unsure when these began. He notes no foreign travel or unusual exposures. He is homeless and unemployed, but occasionally gets work as a day laborer
doing landscaping and digging. A culture of a skin lesion grows a Mycobacterium in 5 days. Which of the following is the most likely organism?
A. M. abscessus
IV-160. A 25-year-old male is seen in the emergency department for symptoms of fevers and abdominal swelling, early satiety, and weight loss. His symptoms began abruptly 2 weeks ago. He was previously healthy and is taking no medications. He denies illicit drug use and
recently immigrated to the United States from Bangladesh. On physical examination, temperature is 39.0°C (102.2°F) and pulse is 120, with normal blood pressure and respiratory rate. The remainder of the exam is notable for cachexia and a distended abdomen with a massively enlarged spleen. The spleen is tender and soft. The liver is not palpable. Mild peripheral adenopathy is present. Which of the following statements is correct regarding this patient with presumed kala azar leishmaniasis?
D. Splenic aspiration offers the highest diagnostic
IV-161. All of the following are examples of an indication for checking an HIV-resistance genotype except
C. A 42-year-old man with HIV/AIDS who was started
on ART [TDF, FTC, and ritonavir-boosted atazanavir
(ATV/r)] 1 year ago was lost to follow-up. Originally
his HIV-1 viral load was 197,000 (5.3 log) and
CD4+ lymphocyte count was 11/μL. He was 100%
compliant with his pills until he ran out of medicines
2 months ago. Viral load on recheck is 184,000
(log 5.3) with CD4+ lymphocyte count of 138/μL.
IV-162. A 41-year-old man with hepatitis C-associated ascites presents with acute abdominal pain. Physical examination
is notable for temperature of 38.3°C, heart rate of
115 beats per minute, blood pressure of 88/48 mmHg, respiratory rate of 16 breaths per minute, and oxygen saturation of 99% on room air. The patient is in moderate discomfort and is lying still. He is alert and oriented. Lungs are clear. Cardiac examination is unremarkable. His abdomen is diffusely tender with distant bowel sounds, mild guarding, and no rebound tenderness. Laboratory
studies reveal a leukocyte count of 11,630/μL
with 94% neutrophils, hematocrit of 29%, and platelet count of 24,000/μL. Paracentesis reveals 658 PMNs/μL, total protein 1.2 g/dL, glucose 24 mg/dL, and gram stain showing gram-negative rods, gram-positive cocci in chains, gram-positive rods, and yeast forms. All of the following are indicated except
C. drotrecogin alfa
IV-163. Patients with which of the following have the lowest risk of invasive pulmonary Aspergillus infection?
B. HIV infection
IV-164. All the following patient characteristics are included in the calculation of the Pneumonia Patient Outcomes Research Team (PORT) score that is used in the evaluation of patients with community-acquired pneumonia except
E. smoking history
IV-166. Which single clinical feature has the most specificity in differentiating Pseudomonas aeruginosa sepsis from other causes of severe sepsis in a hospitalized patient?
A. Ecthyma gangrenosum
IV-167. Which of the following statements regarding varicella- zoster infection after hematopoietic stem cell transplant is true?
C. Multidermatomal and disseminated zoster can occur
in transplant patients who do not receive appropriate
IV-168. All of the following factors influence the likelihood of transmitting active tuberculosis except
C. presence of extrapulmonary tuberculosis
IV-169. Which of the following individuals with a known history of prior latent tuberculosis infection (without therapy) has the greatest likelihood of developing reactivation tuberculosis?
C. A 42-year-old man who is HIV-positive with a CD4
count of 350/μL on highly active antiretroviral therapy
IV-170. A 42-year-old Nigerian man comes to the emergency room because of fevers, fatigue, weight loss, and cough for 3 weeks. He complains of fevers and a 4.5-kg weight loss. He describes his sputum as yellow in color. It has rarely been blood streaked. He emigrated to the United States 1 year ago and is an undocumented alien. He has never been treated for tuberculosis, has never had a purified protein derivative (PPD) skin test placed, and does not recall receiving BCG vaccination. He denies HIV
risk factors. He is married and reports no ill contacts. He smokes a pack of cigarettes daily and drinks a pint of vodka on a daily basis. On physical examination, he appears chronically ill with temporal wasting. His body mass index is 21 kg/m2. Vital signs are: blood pressure 122/68 mmHg, heart rate 89 beats/min, respiratory rate 22 breaths/min, SaO2 95% on room air, and temperature 37.9°C. There are amphoric breath sounds posteriorly in the right upper lung field with a few scattered crackles in
this area. No clubbing is present. The examination is otherwise unremarkable. A portion of the CT scan of his lungs is shown. A stain for acid-fast bacilli is negative.What is the most appropriate approach to the ongoing care of this patient?
A. Admit the patient on airborne isolation until three
expectorated sputums show no evidence of acid-fast
IV-171. A 50-year-old man is admitted to the hospital foractive pulmonary tuberculosis with a positive sputum acid-fast bacilli smear. He is HIV positive with a CD4 count of 85/μL and is not on highly active antiretroviral therapy. In addition to pulmonary disease, he is found tohave disease in the L4 vertebral body. What is the mostappropriate initial therapy?
A. Isoniazid, rifampin, ethambutol, and pyrazinamide
IV-172. All of the following individuals receiving tuberculin skin purified protein derivative (PPD) reactions should be treated for latent tuberculosis except
A. A 23-year-old injection drug user who is HIV negative
has a 12-mm PPD reaction.
IV-173. A 34-year-old man seeks the advice of his primary care physician because of an asymptomatic rash on his chest. There are coalescing light brown to salmon-colored macules present on the chest. A scraping of the lesions is viewed after a wet preparation with 10% potassium hydroxide
solution. There are both hyphal and spore forms
present, giving the slide an appearance of "spaghetti and meatballs." In addition, the lesions fluoresce to a yellowgreen appearance under a Wood's lamp. Tinea versicolor is diagnosed. Which of the following microorganisms is responsible for this skin infection?
B. Malassezia furfur
IV-174. A 68-year-old woman seeks evaluation for an ulcerative lesion on her right hand. She reports the area on the back of her right hand was initially red and not painful. There appeared to be a puncture wound in the center of the area, and she thought she had a simple scratch acquired
while gardening. Over the next several days, the lesion became verrucous and ulcerated. Now, the patient has noticed several nodular areas along the arm, one of which ulcerated and began draining a serous fluid today. She is also noted to have an enlarged and tender epitrochlear lymph node on the right arm. A biopsy of the edge of the lesion shows ovoid and cigar-shaped yeasts. Sporotrichosis is diagnosed. What is the most appropriate
therapy for this patient?
D. Itraconazole orally
IV-175. A 44-year-old man presents to the emergency room for evaluation of a severe sore throat. His symptoms began this morning with mild irritation on swallowing and have gotten progressively severe over the course of 12 h. He has been experiencing a fever to as high as 39°C at home and also reports progressive shortness of breath.He denies antecedent rhinorrhea or tooth or jaw pain. He has had no ill contacts. On physical examination, the patient appears flushed and in
respiratory distress with use of accessory muscles of respiration. Inspiratory stridor is present. He is sitting leaning forward and is drooling with his neck extended. His vital signs are as follows: temperature 39.5°C, blood pressure 116/60
mmHg, heart rate 118 beats/min, respiratory rate 24 breaths/ min, SaO2 95% on room air. Examination of his oropharynx shows erythema of the posterior oropharynx without exudates
or tonsillar enlargement. The uvula is midline. There is no sinus tenderness and no cervical lymphadenopathy. His lung fields are clear to auscultation, and cardiovascular examination
reveals a regular tachycardia with a II/VI systolic
ejection murmur heard at the upper right sternal border. Abdominal, extremity, and neurologic examinations are normal. Laboratory studies reveal a white blood cell count of 17,000 μL with a differential of 87% neutrophil, 8% band
forms, 4% lymphocytes, and 1% monocytes. Hemoglobin is 13.4 g/dL with a hematocrit of 44.2%. An arterial blood gas on room air has a pH of 7.32, a PaCO2 of 48 mmHg, and PaO2
of 92 mmHg. A lateral neck film shows an edematous epiglottis. What is the next most appropriate step in evaluation and treatment of this individual?
D. Endotracheal intubation, ceftriaxone, 1 g IV q24h,
and clindamycin, 600 mg IV q6h
IV-176. A 45-year-old man from western Kentucky presents to the emergency room in September complaining of fevers, headaches, and muscle pains. He recently had been on a camping trip with several friends during which they hunted for their food, including fish, squirrels, and rabbits. He did not recall any tick bites during the trip, but does recall having several mosquito bites. For the past week, he has had an ulceration on his right hand with redness and pain surrounding it. He also has noticed some pain and swelling near his right elbow. None of the friends he camped with have been similarly ill. His vital signs are: blood pressure 106/65 mmHg, heart rate 116 beats/min,
respiratory rate 24 breaths/min, and temperature 38.7°C. His oxygen saturation is 93% on room air. He appears mildly tachypneic and flushed. His conjunctiva are not injected and his mucous membranes are dry. The chest examination
reveals crackles in the right mid-lung field and
left base. His heart rate is tachycardic but regular. There is a II/VI systolic ejection murmur heard best at the lower left sternal border. His abdominal examination is unremarkable. On the right hand, there is an erythematous ulcer with a punched-out center covered by a black eschar. He has no cervical lymphadenopathy, but there are markedly
enlarged and tender lymph nodes in the right axillae and epitrochlear regions. The epitrochlear node has some fluctuance with palpation. A chest x-ray shows fluffy bilateral alveolar infiltrates. Over the first 12 h of his hospitalization, the patient becomes progressively hypotensive and hypoxic, requiring intubation and mechanical ventilation. What is the most appropriate therapy for this patient?
E. Gentamicin, 5 mg/kg twice daily
IV-177. A 24-year-old man seeks evaluation for painless penile ulcerations. He noted the first lesion about 2 weeks ago, and since that time, two adjacent areas have also developed ulceration. He states that there has been blood staining his underwear from slight oozing of the ulcers.
He has no past medical history and takes no medication. He returned 5 weeks ago from a vacation in Brazil where he did have unprotected sexual intercourse with a local woman. He denies other high-risk sexual behaviors and has never had sex with prostitutes. He was last tested for
HIV 2 years ago. He has never had a chlamydial or gonococcal infection. On examination, there are three welldefined red, friable lesions measuring 5 mm or less on the penile shaft. They bleed easily with any manipulation. There is no pain with palpation. There is shotty inguinal lymphadenopathy. On biopsy of one lesion, there is a prominent intracytoplasmic inclusion of bipolar organisms in an enlarged mononuclear cell. Additionally, there is epithelial cell proliferation with an increased number of plasma cells and few neutrophils. A rapid plasma reagin test is negative. Cultures grow no organisms. What is the most likely causative organism?
A. Calymmatobacterium granulomatis (donovanosis)
IV-178. A 75-year-old patient presents with fevers and wasting. He describes fatigue and malaise over the past several months and is concerned that he has been losing weight. On examination, he is noted to have a low-grade fever and a soft diastolic heart murmur is appreciated. Laboratory tests reveal a normocytic, normochromic anemia. Three separate blood cultures grow Cardiobacterium
hominis. Which of the following statements is true
about this patient's clinical condition?
C. He has a form of endocarditis with a high risk of
IV-179. A 38-year-old woman with frequent hospital admissions related to alcoholism comes to the emergency room after being bitten by a dog. There are open wounds on her arms and right hand that are purulent and have necrotic borders. She is hypotensive and is admitted to the intensive care unit. She is found to have disseminated
intravascular coagulation and soon develops multiorgan failure. Which of the following is the most likely organism to have caused her rapid decline?
B. Capnocytophaga spp.
IV-180. A 39-year-old healthy man plans to travel to Malaysia and comes to clinic for appropriate vaccinations. He cannot recall which vaccines he has had in the past, but reports having had "all the usual ones" in childhood. Which of the following represents the most common vaccine- preventable infection in travelers?
IV-181. A 19-year-old man plans on traveling through Central America by bus. He comes to clinic interested in travel advice and any vaccinations he may need. He has
no medical history and takes no medicines. In addition to DEET and mosquito netting, which of the following recommendations would be important for prophylaxis against malaria?
IV-182. Which of the following is the most common source of fever in travelers returning from Southeast Asia?
A. Dengue fever
IV-183. A 54-year-old woman presents to the emergency room complaining of pain and redness of her left face and cheek. The area of redness began abruptly yesterday. At that time, the area was about 5 mm2 near the nasolabial fold. There was rapid progression of the redness to an area
that is now about 5 cm2. In addition, she is complaining of intense pain in this area. On examination, there is a well-demarcated 5 cm2 area of erythema along her left nasolabial
fold. The borders are raised and indurated. The
entire area is very tender to touch. Over the next 24 h, the affected area begins to develop a flaccid bullae. What is the most appropriate treatment for this patient?
IV-184. A 68-year-old man is brought to the emergency room with altered mental status, fever, and leg pain. His wife reports that he first complained of pain in his leg yesterday,
and there was some slight redness in this area. Over the night, he developed a fever to as high as 39.8°C and became obtunded this morning. At that point, his family brought him to the emergency room. Upon arrival, he is unresponsive to voice and withdraws to pain. The vital signs are:
blood pressure 88/40 mmHg, heart rate 126 beats/min, respiratory rate 28 breaths/min, temperature 39.3°C, and SaO2 95% on room air. Examination of the right leg shows diffuse
swelling with brawny edema. The patient grimaces in pain when the area is touched. There are several bullae filled with dark blue to purple fluid. Laboratory studies show: pH 7.22, PaCO2 28 mmHg, PaO2 93 mmHg. The creatinine is 3.2 mg/dL.White blood cell count is elevated at 22,660/μL with a differential of 70% polymorphonuclear cells, 28% band
forms, and 2% lymphocytes. A bulla is aspirated and the Gram stain shows gram-positive cocci in chains.What is the most appropriate therapy for this patient?
C. Clindamycin, penicillin, and surgical debridement
IV-185. In the urgent care clinic, you are evaluating a 47- year-old woman with poorly controlled diabetes who has a chief complaint of "sinusitis." She does not have a history of atopy. She first noticed a headache 2 days ago and now feels very congested in her upper nasal passages. She
has hyperesthesia over her nasal bridge as well and is inquiring about antibiotics to treat her infection. She has a bloody nasal discharge with occasional black specks. On
examination, the sinuses are full and tender. She has a temperature of 38.3°C. Oral examination shows a black eschar on the roof of her mouth surrounded by discolored hyperemic areas on the palate. What is the most appropriate intervention at this time?
C. Immediate biopsy of the involved areas and lipid
IV-186. A 63-year-old man from Mississippi comes to your office for evaluation of a chronic sore on his thigh. He has an open sore on his anterior thigh that has been draining purulent material for many months. The thigh is nontender but is warm to touch. The material is purulent and foul-smelling. He has been given multiple antibiotic courses and recently finished a course of itraconazole
without relief of his symptoms. He has an intact neurovascular examination of his lower extremities. His erythrocyte sedimentation rate is 64, white blood cell count is 15,000/μL and hemoglobin is 8 mg/dL. A plain radiograph of the affected thigh shows a periosteal reaction of the femur with osteopenia. There is suggestion of a sinus tract between the femur and the skin. A Gram
stain of the pus shows broad-based budding yeast and you make a presumptive diagnosis of blastomyces osteomyelitis.
What is the treatment of choice for this patient?
A. Amphotericin B
V-1. A 46-year-old white female presents to your ofﬁce with concerns about her diagnosis of hypertension 1 month previously. She asks you about her likelihood of develop- ing complications of hypertension, including renal failure and stroke. She denies any past medical history other than hypertension and has no symptoms that suggest second- ary causes. She currently is taking hydrochlorothiazide 25 mg/d. She smokes half a pack of cigarettes daily and drinks alcohol no more than once per week. Her family history is signiﬁcant for hypertension in both parents. Her mother died of a cerebrovascular accident. Her father is alive but has coronary artery disease and is on hemodialysis. Her blood pressure is 138/90. Body mass index is 23. She has no retinal exudates or other signs of hypertensive retinop- athy. Her point of maximal cardiac impulse is not dis- placed but is sustained. Her rate and rhythm are regular and without gallops. She has good peripheral pulses. An electrocardiogram reveals an axis of -30 degrees with borderline voltage criteria for left ventricular hypertrophy. Creatinine is 1.0 mg/dL. Which of the following items in her history and physical examination is a risk factor for a poor prognosis in a patient with hypertension?
C. Ongoing tobacco use
V-2. A 68-year-old male presents to your ofﬁce for routine follow-up care. He reports that he is feeling well and has no complaints. His past medical history is signiﬁcant for hypertension and hypercholesterolemia. He continues to smoke a pack of cigarettes daily. He is taking chlorthali- done 25 mg daily, atenolol 25 mg daily, and pravastatin 40 mg nightly. Blood pressure is 133/85, and heart rate is 66. Cardiac and pulmonary examinations are unremarkable. A pulsatile abdominal mass is felt just to the left of the umbilicus and measures approximately 4 cm. You conﬁrm the diagnosis of abdominal aortic aneurysm by CT imag-ing. It is located infrarenally and measures 4.5 cm. All the following are true about the patient's diagnosis except
B. Surgical or endovascular intervention is warranted because of the size of the aneurysm.
V-3. A 45-year-old woman presents to the emergency room complaining of progressive dyspnea on exertion and abrupt onset of painful ulcerations on her toes. She has noted the symptoms for the past 3 months. The dyspnea has progressed such that she is only able to walk about 1 block without stopping. Over this same time, she has no- ticed a cough that occasionally produces thin, pink- tinged sputum. She also has reports that her breathing is worse at night. She sleeps on three pillows but awakens with dyspnea once or twice nightly. Over the past 2 days, she has developed painful ulcerations on toes 1 and 4 on her left foot. She reports that the areas started as reddish painful discoloration that ulcerated over the ensuing days. She denies fevers, chills, or weight loss. She has no history of chest pain, heart disease, or heart murmurs. She has been in good health until the past 3 months. She takes no medications. Her last dental visit was ~8 months ago. On physical examination, she appears in no distress. Vital signs: blood pressure of 145/92 mmHg, heart rate of 95 beats/min, respiratory rate of 24 breaths/min, temper- ature is 37.7°C, and SaO2 is 95% on room air. The cardio- vascular examination reveals a regular rate and rhythm. There is a III/VI mid-diastolic murmur with an occa- sional low-pitched mid-diastolic sound that occurs when the patient is in the upright position. The jugular venous pressure is measured at 10 cm above the sternal angle. A few bibasilar crackles are noted. There is 1+ pitting edema bilaterally to the knees. On her left great toe, there is an area of erythema with central ulceration covered by a black eschar. A similar area is present on her left fourth toe. The peripheral pulses are full and 2+. The patient undergoes an echocardiogram, shown in the ﬁgure. What is the most appropriate plan of care for this patient?
A. Consult cardiac surgery for deﬁnitive therapy.
V-4. Your 57-year-old clinic patient is seeing you in follow- up for chronic stable angina. He is a former heavy to- bacco smoker who maintained an unhealthy diet and ex- ercise routine until recently. Since initiating a healthy diet and commencing an exercise regimen, he has lost weight and improved his blood pressure control. A cardiac cath- eterization 1 month ago showed two nonobstructive cor- onary lesions in the left circumﬂex artery. He still has angina, which is reproducible with moderate exercise that is fully relieved by one sublingual nitroglycerin. Which of the following factors is least likely to be contributing to his angina?
A. Epicardial coronary artery resistance
V-5. In the tracing below, what type of conduction abnor- mality is present and where in the conduction pathway is the block usually found?
B. Second-degree AV block type 1; intranodal
V-6. A 62-year-old male loses consciousness in the street, and resuscitative efforts are undertaken. In the emergency room an electrocardiogram is obtained, part of which is shown below. Which of the following disorders could ac- count for this man's presentation?
C. Intracerebral hemorrhage
V-7. You are seeing an 86-year-old male patient with severe aortic stenosis in follow-up. He has had severe aortic ste- nosis for 4 years without symptoms. Recently, he has scaled back his activities due to light-headedness with ex- ertion. His wife reports one episode a week ago when he passed out brieﬂy while trying to do his gardening. On examination, his blood pressure is 150/85 mmHg, heart rate is 76 beats/min. He has a grade III/VI systolic ejec- tion murmur that extends to S2 with radiation to the ca- rotids. S2 is barely audible, consistent with his prior examinations. Carotid pulses are delayed as they have been in the past. He has femoral and abdominal aortic bruits. Peripheral pulses are 2+ bilaterally. Laboratory data show a creatinine of 0.9 mg/dL, low-density lipopro- tein cholesterol of 75 mg/dL, high-density lipoprotein of 50 mg/dL. What is the next appropriate step in this pa- tient's management?
A. Aortic valve surgery
V-8. A 35-year-old man is evaluated for dyspnea. He ﬁrst noticed shortness of breath with exertion about 12 months ago. It has become progressively worse such that he is only able to walk about 20 ft without stopping. In general, he rates his health as good, although he recalls being told when he was younger that he had a heart mur- mur. He has not seen a physician in 15 years. On exami- nation, he is noted to be hypoxic with an SaO2 of 85% on room air. His cardiac examination reveals a harsh ma- chinery-like murmur that is continuous throughout sys- tole and diastole with a palpable thrill. There is late systolic accentuation of the murmur at the upper left ster-nal angle. He is noted to have cyanosis and clubbing of his toes but not his ﬁngers. What is the most likely cause of the patient's murmur?
C. Patent ductus arteriosus
V-9. In the cardiac care unit, you are caring for a 69-year- old man with an inferior ST-segment elevation myocar- dial infarction (MI). He has undergone successful urgent percutaneous coronary intervention and is recovering. Later that day, he complains of shortness of breath and orthopnea. His vital signs show blood pressure of 118/74 mmHg, heart rate of 63 beats/min, respiratory rate of 20 breaths/min, and oxygen saturation of 91% on room air. Lung examination shows crackles bilaterally. On cardiac examination, the jugular venous pressure is elevated. There is a grade III/VI musical systolic murmur heard at the base of the heart with a crescendo-decrescendo pat- tern. The intensity of the murmur does not change with respiration. The murmur does not radiate to the axilla. A two-dimensional echocardiogram is requested. Which of the following echocardiographic ﬁndings is most likely?
A. Eccentric mitral regurgitant jet
V-10. A 44-year-old man with a history of hypertension that is poorly controlled presents to the emergency room complaining of severe chest pain. The pain began abruptly this afternoon while at rest. He describes the pain as tearing and radiates to the back. He also is com- plaining of feeling lightheaded but does not have nausea or vomiting. He has never had a similar episode of pain and is usually able to exercise at the gym without chest pain. In addition to hypertension, he also has a history of hypercholesterolemia. He has been prescribed felo- dipine, 10 mg once daily, and rosuvastatin, 10 mg once daily, but says that he only takes them intermittently. He smokes 1 pack of cigarettes daily and has done so since the age of 20. His family history is signiﬁcant for coro- nary artery disease in his father, who had a heart attack at the age of 60. On physical examination, the patient ap- pears uncomfortable and diaphoretic. Vital signs: blood pressure is 190/110 mmHg, heart rate is 112 beats/min, respiratory rate is 26 breaths/min, temperature is 36.3°C, and SaO2 is 98% on room air. His carotid pulses are full and bounding. His cardiac examination reveals a hyper- dynamic precordium. The rhythm is tachycardic but reg- ular. An S4 is present. There is a II/VI diastolic murmur heard at the lower left sternal border. An electrocardio- gram (ECG) shows 1 mm of ST elevation in leads II, III, and aVF. A contrast-enhanced chest CT shows a dissec- tion of the ascending aorta with a small amount of peri- cardial ﬂuid. What is the most appropriate management of the patient?
D. Intravenous nitroprusside and esmolol and cardiac surgery emergently
V-11. A 42-year-old male from El Salvador complains of sev- eral months of dyspnea on exertion. Physical examination reveals an elevated jugular venous pressure, clear lungs, a third heart sound, a pulsatile liver, ascites, and dependent edema. Chest radiography reveals no cardiomegaly and clear lung ﬁelds. An echocardiogram demonstrates normal to mildly decreased left ventricular systolic function. The initial diagnostic workup should include all the following except
B. coronary angiogram
V-12. A 29-year-old woman is in the intensive care unit with rhabdomyolysis due to compartment syndrome of the lower extremities after a car accident. Her clinical course has been complicated by acute renal failure and se- vere pain. She has undergone fasciotomies and is admit- ted to the intensive care unit. An electrocardiogram (ECG) is obtained (shown below). What is the most ap- propriate course of action at this point?
D. Intravenous ﬂuids and a loop diuretic
V-13. A 54-year-old male with type 2 diabetes mellitus re- ports 3 months of exertional chest pain. His physical ex- amination is notable for obesity with a body mass index (BMI) of 32 kg/m2, blood pressure of 150/90, an S4, no cardiac murmurs, and no peripheral edema. Fasting glu- cose is 130 mg/dL, and serum triglycerides are 200 mg/ dL. Which of the following is most likely in this patient?
B. Insulin resistance
V-14. A 45-year-old man is admitted to the intensive care unit with symptoms of congestive heart failure. He is addicted to heroin and cocaine and uses both drugs daily via injection. His blood cultures have yielded methicillin-sensitive Staphy- lococcus aureus in four of four bottles within 12 h. His vital signs show a blood pressure of 110/40 mmHg and a heart rate of 132 beats/min. There is a IV/VI diastolic murmur heard along the left sternal border. A schematic representa- tion of the carotid pulsation is shown in the ﬁgure below. What is the most likely cause of the patient's murmur?
A. Aortic regurgitation
V-15. A 30-year-old male is transported to the emergency room after a motor vehicle accident. He is complaining of moderate chest pain. He becomes hypotensive, and his blood pressure pattern reveals a pulsus paradoxus. The heart sounds appear distant. An examination of the neck veins fails to reveal a Kussmaul's sign. An electrocardiogram is un- remarkable, and a chest x-ray reveals an enlarged cardiac sil- houette. A right heart catheter is placed. Which of the following values is consistent with this patient's diagnosis?
B 16 34/16 16
V-16. You are treating a patient with stable angina pectoris. She is a postmenopausal woman with refractory angina despite therapy with metoprolol and isosorbide dinitrate, as well as her other anti-ischemic medications. Past med- ical history is signiﬁcant for coronary artery bypass graft- ing (CABG), chronic obstructive pulmonary disease, ﬁrst-degree atrioventricular block, left bundle branch block, and dyslipidemia. A recent cardiac catheterization showed coronary artery disease not amenable to percuta- neous intervention, and the patient is not interested in redo of the CABG. Renal function is normal. Her left ven- tricular ejection fraction is 15%, and she has New York Heart Association class II heart failure symptoms. Blood pressure and pulse allow for the addition of a calcium channel blocker to her regimen. Which calcium channel- blocking medication is appropriate for this patient?
V-17. A 30-year-old female is seen in the clinic before un- dergoing an esophageal dilation for a stricture. Her past medical history is notable for mitral valve prolapse with mild regurgitation. She takes no medications and is aller- gic to penicillin. Her physician should recommend which of the following?
A. Clarithromycin 500 mg PO 1 h before the procedure
V-18. A 78-year-old male presents to the clinic complaining that every time he shaves with a straight razor, he passes out. His symptoms have been occurring for the last 2 months. Occasionally, when he puts on a tight collar, he passes out as well. The loss of consciousness is brief, he has no associated prodrome, and he feels well afterward. His past medical history is notable for hypertension and hypercholesterolemia. His only medication is hydrochlo- rothiazide. On physical exam his vital signs are normal, and his cardiac exam is normal with the exception of a fourth heart sound. Which of the following is the most appropriate next diagnostic test?
D. Carotid sinus massage
V-19. You are called to the bedside to see a patient with Prinzmetal's angina who is having chest pain. The patient had a cardiac catheterization 2 days prior showing a 60% stenosis of the right coronary artery with associated spasm during coronary angiogram. At the patient's bed- side, which ﬁnding is consistent with the diagnosis of Prinzmetal's angina?
D. ST-segment elevation in II, III, and aVF
V-20. A 32-year-old female is seen in the emergency depart- ment for acute shortness of breath. A helical CT shows no evidence of pulmonary embolus, but incidental note is made of dilatation of the ascending aorta to 4.3 cm. All the following are associated with this ﬁnding except
E. systemic lupus erythematosus
V-21. A 38-year-old Bolivian man is admitted to the car- diac intensive care unit with decompensated heart failure. He has no known past medical history and takes no med- ications. He emigrated from Mexico 10 years ago and currently works in a retail store. On physical examina- tion, he has signs of congestion and poor perfusion. An electrocardiogram shows ﬁrst-degree atrioventricular block and right bundle branch block. An echocardiogram shows dilated and thinned ventricles. He has an apical an- eurysm in the left ventricle with thrombus formation. You treat his heart failure symptomatically and begin an- ticoagulation. A cardiac catheterization shows normal coronaries without atherosclerosis. Which statement is true regarding this patient's prognosis?
C. transplantation offers the only cure for this condition.
V-22. You are evaluating a 43-year-old woman who com- plains of dyspnea on exertion. She was well until 2 months ago when she noticed decreasing exercise tolerance and fa- tigue. She denies chest pain but does have New York Heart Association class II symptoms. She has no orthopnea or paroxysmal nocturnal dyspnea. She has noticed bilateral ankle swelling that improves with recumbency. She has one child and has no other past medical history. On cardiac ex- amination, the jugular venous pressure is slightly elevated. There is a prominent a wave. There is a right-ventricular tap felt along the left sternal border. S1 is prominent and P2 is accentuated. There is a sharp opening sound heard best during expiration just medial to the cardiac apex, which occurs shortly after S2. A diastolic rumble is heard at the apex with the patient in the left lateral decubitus position. Hepatomegaly and ankle edema are present. The pulse is regular and blood pressure is 108/60 mmHg. This patient is at high risk for developing which of the following?
A. Atrial ﬁbrillation
V-24. All of the following are common consequences of congenital heart disease in the adult except
V-25. Acute hyperkalemia is associated with which of the following electrocardiographic changes?
A. QRS widening
V-26. All of the following clinical ﬁndings are consistent with severe mitral stenosis except
B. opening snap late after S2
V-27. All the following patients should be evaluated for sec- ondary causes of hypertension except
A. a 37-year-old male with strong family history of hy- pertension and renal failure who presents to your ofﬁce with a blood pressure of 152/98
V-28. You are seeing a 71-year-old patient with tachycardia- bradycardia syndrome in follow-up. She had a single-lead ventricular pacemaker implanted 2 years ago and has no new complaints. Past medical history also includes an old stroke with mild residual left hand weakness and diabetes. Her last transthoracic echocardiogram showed a left ven- tricular ejection fraction of 35-40% but no valvular ab- normalities. The left atrium is mildly enlarged. Her medical regimen includes aspirin, metformin, metoprolol, lisinopril, lasix, and dipyridamole. What intervention, if any, should be considered for this patient at this time?
V-29. A 64-year-old woman with known stage IV breast cancer presents to the emergency room with severe dysp- nea and hypotension. Her blood pressure is 92/50 mmHg, and heart rate is 112 beats/min. She has dis- tended neck veins that do not collapse with inspiration. Heart sounds are mufﬂed. The systolic blood pressure drops to 70 with inspiration. An echocardiogram shows a large pericardial effusion with right ventricular diastolic collapse consistent with pericardial tamponade. Which of the following values most accurately demonstrate the ex- pected values on right heart catheterization?
C. 17 40/17 45/17 17
V-30. The ECG most likely was obtained from which of the following patients?
C. A 54-year-old female with a long history of smoking and 2 days of increasing shortness of breath and wheezing
V-32. A patient is found to have a holosystolic murmur on physical examination. With deep inspiration, the inten- sity of the murmur increases. This is consistent with which of the following?
C. Carvallo's sign
V-33. A 37-year-old male with Wolff-Parkinson-White syn- drome develops a broad-complex irregular tachycardia at a rate of 200 beats per minute. He appears comfortable and has little hemodynamic impairment. Useful treat- ment at this point might include
E. Direct-current cardioversion
V-34. A 72-year-old man seeks evaluation for leg pain with ambulation. He describes the pain as an aching to crampy pain in the muscles of his thighs. The pain subsides within minutes of resting. On rare occasions, he has noted numb- ness of his right foot at rest and pain in his right leg has woken him at night. He has a history of hypertension and cerebrovascular disease. He previously had a transient is- chemic attack and underwent right carotid endarterectomy 4 years previously. He currently takes aspirin, irbesartan, hydrochlorothiazide, and atenolol on a daily basis. On ex- amination, he is noted to have diminished dorsalis pedis and posterior tibial pulses bilaterally. The right dorsal pedis pulse is faint. There is loss of hair in the distal extremities. Capillary reﬁll is approximately 5 s in the right foot and 3 s in the left foot. Which of the following ﬁndings would be suggestive of critical ischemia of the right foot?
A. Ankle-brachial index <0.3
V-35. A 24-year-old male seeks medical attention for the recent onset of headaches. The headaches are described as "pounding" and occur during the day and night. He has had minimal relief with acetaminophen. Physical exami- nation is notable for a blood pressure of 185/115 mmHg in the right arm, a heart rate of 70/min, arterioventricular (AV) nicking on funduscopic examination, normal jugu- lar veins and carotid arteries, a pressure-loaded PMI with an apical S4, no abdominal bruits, and reduced pulses in both lower extremities. Review of symptoms is positive only for leg fatigue with exertion. Additional measure- ment of blood pressure reveals the following: Right arm Left arm Right thigh Left thigh 185/115 188/113 100/60 102/58 Which of the following diagnostic studies is most likely to demonstrate the cause of the headaches?
C. MRI of the thorax
V-36. The patient described in Question V-35 is most likely to have which of the following associated cardiac abnormalities?
A. Bicuspid aortic valve
V-37. A 30-year-old female with a history of irritable bowel syndrome presents with complaints of palpitations. On further questioning, the symptoms occur randomly throughout the day, perhaps more frequently after caf- feine. The primary sensation is of her heart "ﬂip-ﬂopping" in her chest. The patient has never had syncope. Her vital signs and exam are normal. An electrocardiogram is ob-tained, and it shows normal sinus rhythm with no other abnormality. A Holter monitor is obtained and shows pre- mature ventricular contractions occurring approximately six times per minute. The next most appropriate step in her management is
E. reassurance that this is not pathologic verapamil administration
V-38. All the following ECG ﬁndings are suggestive of left ventricular hypertrophy except
E. R in aVR >8 mm
V-39. A 27-year-old woman is hospitalized in the intensive care unit (ICU) for Lyme disease. Complete heart block is noted and a single-lead pacemaker is implanted. She is discharged on a long course of antibiotics with a perma- nent pacemaker. She returns to see you in clinic complain- ing of inability to concentrate, fatigue, palpitations, and cough. On examination, her blood pressure is 121/72 mmHg; heart rate 60 beats per minute, respiratory rate 18 breaths per minute. She has an elevated jugular venous pressure with cannon a waves. She has rales on lung aus- cultation and an S3 on cardiac auscultation but no periph- eral edema. Electrocardiogram (ECG) shows a ventricular paced rate at 60/min with repolarization abnormalities. These ﬁndings are most consistent with
D. pacemaker syndrome
V-41. All the following disorders may be associated with thoracic aortic aneurysm except
E. Klinefelter's syndrome
V-44. A 44-year-old man with history of HIV infection is brought to the Emergency Department by friends be- cause of an altered mental status. They note that he has been coughing with worsening shortness of breath for the past 2-3 weeks. His antiretroviral therapy includes a pro- tease inhibitor. In triage, his blood pressure is 110/74 mmHg; heart rate 31 beats per minute, respiratory rate 32, temperature 38.7°C, and oxygen saturation 74% on room air. He appears well perfused. Chest radiograph shows bilateral ﬂuffy inﬁltrates. An electrocardiogram shows sinus bradycardia without ST changes. A chest CT scan shows no pulmonary embolus. After initiating oxy- gen and establishing an airway, you direct your attention to his bradycardia. Which is the most appropriate step at this time?
A. Correct the oxygen deﬁcit, check an arterial blood gas, and monitor closely
V-45. A 55-year-old woman is undergoing evaluation of dyspnea on exertion. She has a history of hypertension since age 32 and is also obese with a body mass index (BMI) of 44 kg/m2. Her pulmonary function tests show mild restrictive lung disease. An echocardiogram shows a thickened left-ventricular wall, left-ventricular ejection fraction of 70%, and ﬁndings suggestive of pulmonary hypertension with an estimated right-ventricular systolic pressure of 55 mmHg, but the echocardiogram is techni- cally difﬁcult and of poor quality. She undergoes a right heart catheterization that shows the following results: Mean arterial pressure Left-ventricular end-diastolic pressure Pulmonary artery (PA) systolic pressure PA diastolic pressure PA mean pressure Cardiac output 110 mmHg 25 mmHg 48 mmHg 20 mmHg 34 mmHg 5.9 L/min What is the most likely cause of the patient's dyspnea?
B. Diastolic heart failure
V-46. Which of the following congenital cardiac disorders will lead to a left-to-right shunt, generally with cyanosis?
C. Total anomalous pulmonary venous connection
V-47. You are evaluating a new patient in clinic. On cardiac auscultation, there is a high-pitched, blowing, decre- scendo diastolic murmur heard best in the third intercos- tal space along the left sternal border. A second murmur is heard at the apex, which is a low-pitched rumbling mid-diastolic murmur. Sustained hand-grip increases the intensity of the murmurs. The murmurs are heard best at end-expiration. There are also an S3 and a systolic ejec- tion murmur. The left ventricular impulse is displaced to the left and inferiorly. Radial pulses are brisk with a prominent systolic component. Blood pressure is 170/70 mmHg, heart rate is 98 beats/min, respiratory rate 18 breaths/min. An electrocardiogram (ECG) is obtained in clinic. Which of the following ﬁndings do you expect on the ECG tracing for this patient?
C. Left-ventricular hypertrophy
V-48. A 65-year-old male is seen in the emergency depart- ment with palpitations. His symptoms began 30 min before arrival. He has not had any dizziness, light-headedness, or chest pain. His past medical history is notable for a myocar- dial infarct 2 years ago, chronic atrial ﬁbrillation, and a three-vessel coronary artery bypass graft surgery 1 year ago. Medications include aspirin, metoprolol, warfarin, and li- sinopril. An electrocardiogram shows wide complex tachy- cardia at a rate of 170. Which of the following will prove deﬁnitively that his rhythm is ventricular tachycardia?
B. Cannon a waves
V-49. You have referred your patient for an exercise-electro- cardiography stress test. The report indicates that he walked for 7 min of the Bruce protocol and had no chest pain during or after the test. During the exercise, he had multiple premature ventricular complexes and reached 90% of maximum predicted heart rate. He had 2-mm up- sloping ST-segment response during exercise. At the end of the protocol and during recovery, he had 1-mm ST- segment depressions, which lasted for 6 min. Blood pressure rose from 127/78 to 167/102 mmHg at maximal exertion. Which feature of this report is most suggestive of severe is- chemic heart disease and a high risk of future events?
C. Persistent ST-segment depressions into recovery
V-50. A 45-year-old female who immigrated to the United States 10 years ago from Peru presents with dyspnea on exertion for the last 4 months. She denies chest pain but has noted signiﬁcant accumulation of ﬂuid in her abdo- men and lower extremity edema. She has a history of tu- berculosis, which was treated with a four-drug regimen when she was a child. Electrocardiography shows normal sinus rhythm but no other abnormality. A CT of the chest is obtained and shows pericardial calciﬁcations. In addition to an elevated jugular venous pressure and a third heart sound, which of the following is likely to be found on physical exam?
A. Rapid y descent in jugular venous pulsations
V-51. During a yearly physical, a 55-year-old man is found to have a systolic murmur. The murmur is mid-systolic and begins shortly after S1 and peaks in mid-systole. It is a low- pitched, rough murmur heard best at the base of the heart in the right second intercostal space. There is radiation to the carotids bilaterally. The rest of his physical examination is unremarkable, and you make a presumptive diagnosis of aortic stenosis. Laboratory data show a hemoglobin A1C of 7.2%, high-density lipoprotein cholesterol 45 mg/dL, low- density lipoprotein cholesterol 144 mg/dL, and creatinine 1.2 mg/dL. Blood pressure is 159/85 mmHg, heart rate is 75 beats/min. Body mass index is 33 kg/m2. What is the most likely etiology of this patient's aortic stenosis?
A. Age-related degeneration
V-52. All the following are associated with a high risk of stroke in patients with atrial ﬁbrillation except
V-53. You are asked to evaluate a 66-year-old male for preoper- ative cardiovascular risk before the surgical removal of a 2- cm sigmoid colon cancer. The patient has an 80-pack-year history of cigarette use but quit 6 months before this presen- tation. His past medical history is also signiﬁcant for hyper- tension and hypercholesterolemia. He has no past cardiac history and has never received cardiac imaging or stress test- ing. He currently is taking lisinopril 20 mg/d, hydrochlo- rothiazide 25 mg/d, and pravastatin 20 mg/d. He has not tolerated atenolol in the past because of fatigue and de- creased libido. Functionally, the patient is quite healthy and continues to play golf weekly while carrying his own golf bag. He lives on the fourth ﬂoor of an apartment complex and prefers climbing the stairs to using the elevator. He has no limiting dyspnea or chest pain. On physical examination the patient appears his stated age and has a blood pressure of 136/88. Heart rate is 90. Cardiovascular and pulmonary ex- aminations are normal. The patient has good peripheral pulses and no carotid bruits. His electrocardiogram reveals no evidence of prior ischemia or left ventricular hypertrophy, but he does have a right bundle branch block. What do you advise the patient and his surgeon about his operative risk?
C. Functional status is such that the patient can per- form to greater than four metabolic equivalents, and the patient has only one risk factor for predicting cardiovascular events. Thus, he can proceed to sur- gery without further investigation.
V-54. A 54-year-old man with hypercholesterolemia and poorly controlled hypertension is admitted to the coro- nary care unit after coming to the emergency room with sudden chest pain. A coronary catheterization is per- formed, and complete occlusion of the posterior descend- ing artery is identiﬁed. Percutaneous intervention fails and the patient is medically managed. Two days later he appears to be acutely ill. Physical examination reveals a new murmur. Which of the following would account for an early decrescendo systolic murmur in this case?
A. Acute mitral regurgitation
V-55. A 73-year-old female develops substernal chest pain, severe nausea, and vomiting while mowing the lawn. In the emergency department she has cool extremities, right arm and left arm blood pressure of 85/70 mmHg, heart rate of 65/min, clear lungs, and no murmurs. She has no urine output. A Swan-Ganz catheter is placed and reveals cardiac index of 1.1 L/min per mm2, PA pressure of 20/14 mmHg, PCW pressure of 6 mmHg, and RA pressure of 24 mmHg. The patient most likely has
C. occlusion of the right coronary artery
V-56. Which of the following patients with echocardio- graphic evidence of signiﬁcant mitral regurgitation has the best indication for surgery with the most favorable likelihood of a positive outcome?
D.A 66-year-old man without symptoms, an ejection fraction of 50%, and left-ventricular end-systolic di- mension of 45 mm
V-57. Which of the following patients meets criteria for the diagnosis of the metabolic syndrome?
A. A man with waist circumference of 110 cm, well- controlled diabetes mellitus with fasting plasma glucose of 98 mg/dL, and blood pressure of 140/75 mmHg
V-58. In the maternity ward, 2 days after assisted vaginal delivery of a healthy boy, a 31-year-old African-American woman has developed shortness of breath and wheezing. On examination, blood pressure is 113/78 mmHg, heart rate is 102, and regular and jugular venous pressures are elevated. Chest auscultation shows rales 2/3 bilaterally without evidence of consolidation. Cardiac examination reveals an S3. An echocardiogram shows a dilated left ven- tricle with an ejection fraction of 30%. A diagnosis of peripartum cardiomyopathy is made and she improves with treatment. Which of the following factors is predic- tive of her risk for developing peripartum cardiomyopa- thy or mortality with subsequent pregnancies?
C. Interpartum left ventricular function
V-59. A 55-year-old man complains of 6 months of short- ness of breath. He has new dyspnea on exertion and three- pillow orthopnea. Lung auscultation reveals rales 2/3 bi- laterally. He has 2+ pitting lower extremity edema. Jugular venous pressure is estimated to be 14 cmH20 measured at a 45° angle. Chest radiograph reveals pulmonary inﬁl- trates and an enlarged cardiac silhouette. Electrocardiog- raphy shows low-voltage in the precordial and limb leads. An echocardiogram shows a dilated left ventricle, ejection fraction of 20%, mild mitral regurgitation, and a small pericardial effusion. Which ﬁnding on cardiac examina- tion would be consistent with this patient's diagnosis?
B. Narrow pulse pressure
V-60. A 49-year-old male is found to have persistently elevated total cholesterol and low-density lipoprotein (LDL) despite lifestyle modiﬁcation. You prescribe an HMG-CoA reductase inhibitor to reduce the risk of coronary events. This medica- tion will exert all the following beneﬁcial effects except
D. regression of existing coronary stenosis
V-61. Dipyridamole is often used during nuclear cardiac stress tests. Based on the pathophysiology of myocardial ischemia and the mechanism of action of dipyridamole, in which circumstance might the stress test underestimate the degree of ischemic tissue?
A. Three-vessel high-grade obstruction
V-62. A 62-year-old female with a history of chronic left bundle branch block is admitted to the coronary care unit with 4 hours of substernal chest pain and shortness of breath. She has elevation of serum troponin-T. She receives urgent catheterization with angioplasty and stent place- ment of a left anterior descending (LAD) artery lesion. Three days after admission she develops recurrent chest pain. Which of the following studies is most useful for de- tecting new myocardial damage since the initial infarction?
C. Serum myoglobin
V-63. A 38-year-old woman presents with complaints of fevers and chest pain. She is noted to have a widened mediastinum on chest radiograph, and a diastolic murmur is present at the lower left sternal border. She is hypertensive, with a blood pressure of 180/72 mmHg. All blood cultures are neg- ative on three occasions from separate anatomic sites drawn 6 h apart. Further evaluation of the murmur demonstrates a dilation of the aortic root to 4 cm with subsequent aortic re- gurgitation. She is diagnosed with aortitis. Which of the fol- lowing is the least likely cause of aortitis in this patient?
B. Giant cell arteritis