Question bank

A 68-year-old White male, with a history of hypertension, an 80 pack-year history of tobacco use and emphysema, is brought into the ER because of 4 days of progressive confusion and lethargy. His wife notes that he takes amlodipine for his hypertension. He does not use over-the-counter (OTC) medications, alcohol, or drugs. Furthermore, she indicates that he has unintentionally lost approximately 30 lbs in the last 6 months. His physical examination shows that he is afebrile with a blood pressure of 142/85, heart rate of 92 (no orthostatic changes), and a room-air O2 saturation of 91%. He is 70 kg. The patient appears cachectic. He is arousable but lethargic and unable to follow any commands. His mucous membranes are moist, heart rate regular without murmurs or a S3/S4 gallop, and extremities without any edema. His pulmonary examination shows mildly diminished breath sounds in the right lower lobe with wheezing bilaterally. The patient is unable to follow commands during neurologic examination but moves all his extremities spontaneously. Laboratory results are as follows: Blood Sodium: 109 Potassium: 3.8 Chloride: 103 CO2: 33 BUN: 17 Creatinine: 1.1 Glucose: 95 Urine osmolality: 600 Plasma osmolality: 229 White blood cell (WBC): 8000 Hgb: 15.8 Hematocrit (HCT): 45.3 Platelets: 410 Arterial blood gas: pH 7.36/pCO2 60/pO2 285 A chest x-ray (CXR) reveals a large right hilar mass. Which of the following provides the best explanation for this patient's hyponatremia?

A 53-year-old Black male, with a history of hypertension, hepatitis C, and newly diagnosed nonsmall cell lung cancer, undergoes his first round of chemotherapy, which includes cisplatin. You are called to see this patient 5 days into his hospitalization for oliguria and laboratory abnormalities. Other than the chemotherapy, he is receiving lansoprazole, acetaminophen, and an infusion of D5-- 0.9% normal saline at 50 mL/h. On examination, his BP is 98/60 and heart rate is irregular, between 40 and 50 bpm. His physical examination shows a middle-aged male in no acute distress. His cardiac examination is unremarkable, his lungs show bibasilar crackles, and the abdominal examination is positive for a palpable spleen tip without any hepatomegaly or abdominal tenderness. He has trace bilateral ankle edema. His distal pulses are irregular. The neurologic examination was unremarkable. His laboratory (serum sample) results are as follows What is the mechanism that best explains this patient's hyperkalemia?

A 53-year-old White female, with a history of systemic lupus erythematosus (SLE), hypertension, and peripheral vascular disease, is admitted to the hospital for chest pain and dyspnea. Her cardiac enzymes were positive for acute MI. She subsequently undergoes a cardiac catheterization and stenting of the right coronary artery. Her postcardiac catheterization course is unremarkable, and she is discharged home 3 days later with adequate blood pressure control. Five days later, she is brought to the ER by her husband for abdominal pain and nausea. Her medications consist of aspirin, metoprolol, and prednisone. On physical examination, her blood pressure is 190/95 and her heart rate is 85 bpm. In general, she appears nauseated but is in no acute distress. Her cardiac examination reveals a regular rate and rhythm without murmur or rub. Her lung fields are clear bilaterally. The abdominal examination is positive for diffuse discomfort, without guarding or rebound, and normoactive bowel sounds; her stool is positive for occult blood. Her lower extremities have trace edema bilaterally with 2+ distal pulses; moreover, she has a reddish-blue discoloration on both her lower extremities. You retrieve her records from prior hospitalization. The patient's laboratory results are as follows: Which of the following laboratory findings would be most suggestive of active lupus nephritis?

You are evaluating a journal article describing a test for the diagnosis of congestive heart failure (CHF). In the study described, 250 consecutive patients were given the test. Of the 250 subjects, 106 tested positive for CHF and 144 tested negative. All 250 subjects were then evaluated by expert cardiologists who were blinded to the results of the experimental test. These cardiologists determined that of the 106 persons who tested positive, 95 actually had CHF. Further, the cardiologists found that of the 144 who tested negative, 2 truly had CHF. What is the negative predictive value (NPV) of this test for the diagnosis of CHF?

A 60-year-old male presents to the office with a growth on the inside of his lower lip. It has been present for several months and is slowly growing. He is a nonsmoker but has a long history of chewing tobacco. Which of the following is the most likely to be found on biopsy of the lesion?

A 67-year-old female was admitted to the hospital because of chronic fatigue and low back pain. An x- ray of the vertebral column showed diffuse osteoporosis and compression fractures of L1 and L2 vertebral bodies. The complete blood count (CBC) was within normal limits. The peripheral blood smear showed rouleaux formation. The immunoelectrophoresis showed a monoclonal spike of more than 3 g. A bone marrow biopsy was performed and showed an increase of more than 20% in plasma cells see Figure below Radiographs of the bone and skeletal system in multiple myeloma will more characteristically show which of the following?

A 52-year-old woman has biopsy of a breast lesion which confirms the mass as malignant. She is also found to clinically have a palpable ipsilateral axillary lymph node. Which of the following would be the most likely pathologic finding in this node?

A 32-year-old female was seen by her family physician because of an enlarged and pigmented lesion of her back. On examination, the lesion measures 2 × 1.5 cm and it is variegated by hues of brown, black, and pink areas. The central area appears to ulcerate. A biopsy of the area was performed. What would be the most likely diagnosis?

A 55-year-old male who is a former IV drug user presents with jaundice, ascites, and leg edema. A CT scan of the abdomen reveals a malignant-appearing mass in the liver. According to the above findings of patient having hepatitis virus, select the most likely type of viral hepatitis.

You are evaluating a journal article describing a test for the diagnosis of congestive heart failure (CHF). In the study described, 250 consecutive patients were given the test. Of the 250 subjects, 106 tested positive for CHF and 144 tested negative. All 250 subjects were then evaluated by expert cardiologists who were blinded to the results of the experimental test. These cardiologists determined that of the 106 persons who tested positive, 95 actually had CHF. Further, the cardiologists found that of the 144 who tested negative, 2 truly had CHF What is the positive predictive value (PPV) of this test for the diagnosis of CHF?

A14-year-old male is evaluated for thigh pain. He has no history of injury. An x-ray of the leg shows a mass in the distal femur that extends into the soft tissue. Abiopsy is performed and cytogenetic studies show translocation of chromosomes 11 and 22. What is this patient's diagnosis?

Routine screening is advocated by numerous authorities for many different types of cancer. These screening programs have resulted in various degrees of success in terms of reduction in mortality. Cytologic screening for cancer of which of the following organs has successfully produced a marked reduction in mortality?

A 42-year-old man presents to your clinic with a 1-week history of pain and inflammation involving his right first metatarsophalangeal (MTP) joint. He describes the pain as sudden in onset and worse at night. He denies experiencing any fever or traumatic injury to the joint and states that he has never had this type of pain before. He denies any chronic medical conditions, any prior surgery, and any current medication use. Besides an erythematous and exquisitely tender right first MTP joint, the remainder of his physical examination is unremarkable. Which of the following interventions is most appropriate at this time for your patient's condition?

A 23-year-old female graduate student with acne and asthma presents to you with a chief complaint of headaches. She has noted a gradual increase in the intensity and frequency of the headaches to the point where they are interfering with her daily activities and studies. Your examination shows an obese young lady with papilledema. The remainder of your physical examination is normal Which of the following is most commonly associated with this condition?

You are about to see a 52-year-old man in your office who presented with a 30-lb weight loss over the past 3 months and jaundice. He also has begun to develop early satiety and frequent vomiting. You had obtained a CT scan, which is shown in Figure 2-11. After reviewing the results of the scan, you discuss the diagnosis with him. He becomes angry and he demands that you operate immediately to remove the tumor. In response you do which of the following? Schedule the patient for an urgent Whipple procedure.

In your role as a physician in a community health center, you agree to perform sports preparticipation examinations on students from the local high school. You have several scheduled for today. Your first appointment is with a 16-year-old male who is planning to run on the cross-country team in the Fall and play baseball in the Spring. He reports that one time he "blacked out" while running, but he has never had chest pain while exercising and he is one of the top runners on the team. He has no known medical history, denies alcohol, tobacco, recreational drug, or performance-enhancing drug use. He has a cousin who died at the age of 21 of "some kind of heart disease," although your patient is not sure of any details. On examination, he is healthy appearing and has normal vital signs, with a pulse rate of 72 and a blood pressure of 100/65. Auscultation of his heart reveals no cardiac murmur while he is lying down, a soft systolic murmur when he stands which increases on having the patient perform a Valsalva maneuver. The remainder of his examination is normal Your next appointment is with a 15-year-old female who plans to play basketball and volleyball. She has no significant medical history, denies a family history of premature cardiac deaths, and denies tobacco, alcohol, recreational drug, or performance-enhancing drug use. She reports having regular menstrual cycles. On examination, she is 72 in. tall, weighs 150 lbs, and has an arm-span of 77 in. Her vital signs are normal. She has a high-arched palate, pectus excavatum, and long, slender fingers. Her cardiac, pulmonary, abdominal, and dermatologic examinations are normal. Your management at this point should include further evaluation for the possible diagnosis of which of the following?

A meta-analysis of randomized-controlled trials was published comparing two methods of managing postterm pregnancies. The question studied was whether the routine induction of labor at 41 weeks' gestation would result in improved maternal or fetal outcomes compared with expectant management. The authors reported that the odds ratio for caesarian delivery rate in the induction group compared to the expectant management group was 0.88 with a 95% confidence interval (CI) of 0.780.99. A second outcome studied was perinatal mortality. For this outcome, the odds ratio for the induction group compared to the expectant management group was 0.41 with a 95% CI of 0.141.18. The authors assessed the study as being underpowered for the outcome of perinatal mortality. Possible ways to increase the statistical power of a study include which of the following?

On the second day after an appendectomy, a 33-year-old man complains of chest pain. Vital signs are: temperature 102°F, BP 130/70 mmHg, pulse rate 100/m in, and respiration rate 22/min. Room air ABG reveals a pH of 7.50, PCO2 of 29, and PO2 of 49. His WBC count is elevated and CXR shows a right lower lobe infiltrate. Which of the following is the most likely diagnosis? pulmonary embolism

You are evaluating a journal article describing a test for the diagnosis of congestive heart failure (CHF). In the study described, 250 consecutive patients were given the test. Of the 250 subjects, 106 tested positive for CHF and 144 tested negative. All 250 subjects were then evaluated by expert cardiologists who were blinded to the results of the experimental test. These cardiologists determined that of the 106 persons who tested positive, 95 actually had CHF. Further, the cardiologists found that of the 144 who tested negative, 2 truly had CHF What is the specificity of this test for the diagnosis of CHF?

A62-year-old woman with a long-standing history of diabetes and hypertension presents for evaluation of hyperkalemia. Her room air arterial blood gas (ABG) and electrolytes are the following: pH 7.38/PCO2 34/PO2 89 Na 140 Cl 106 BUN 51 K 5.9 CO2 20 Cr 2.8 Which of the following is the underlying renal abnormality?