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FIGURE I-88

I-89. A 42-year-old man is evaluated for excessive sleepiness that is interfering with his ability to work. He works at a glass factory that requires him to work rotating shifts. He typically cycles across day (7 AM–3 PM), evening (3 PM–11 PM), and night (11 PM–7 AM) shifts over the course of 4 weeks. He notes the problem to be most severe when he is on the night shift. Twice he has fallen asleep on the job. Although no accidents have occurred, he has been threatened with loss of his job if he falls asleep again. His preferred sleep schedule is 10 PM until 6 AM, but even when he is working day shifts, he typically only sleeps from about 10:30 PM until 5:30 AM. However, he feels fully functional at work on day and evening shifts. After his night shifts, he states that he finds it difficult to sleep when he first gets home, frequently not falling asleep until 10 AM or later. He is up by about 3 PM when his children arrive home from school. He drinks about 2 cups of coffee daily but tries to avoid drinking more than this. He does not snore and has a body mass index of 21.3 kg/m². All of the following are reasonable approaches to treatment in this man EXCEPT:

A. Avoidance of bright light in the morning after his shifts

B. Exercise in the early evening before going to work

C. Melatonin 3 mg taken at bedtime on the morning after a night shift

D. Modafinil 200 mg taken 30–60 minutes before starting a shift

E. Strategic napping of no more than 20 minutes during breaks at work

I-90. A 45-year-old woman presents for evaluation of abnormal sensations in her legs that keep her from sleeping at night. She first notices the symptoms around 8 PM when she is sitting quietly watching television. She describes the symptoms as “ants crawling in my veins.” Although the symptoms are not painful, they are very uncomfortable and worsen when she lies down at night. They interfere with her ability to fall asleep about four times weekly. If she gets out of bed to walk or rubs her legs, the symptoms disappear almost immediately only to recur as soon as she is still. She also sometimes takes a very hot bath to alleviate the symptoms. During sleep, her husband complains that she kicks him throughout the night. She has no history of neurologic or renal disease. She currently is perimenopausal and has been experiencing very heavy and prolonged menstrual cycles over the past several months. The physical examination findings, including thorough neurologic examination, are normal. Her hemoglobin is 9.8 g/dL and hematocrit is 30.1%. The mean corpuscular volume is 68 fL. Serum ferritin is 12 ng/mL. Which is the most appropriate initial therapy for this patient?

A. Carbidopa/levodopa

B. Hormone replacement therapy

C. Iron supplementation

D. Oxycodone

E. Pramipexole

I-91. A 20-year-old man presents for evaluation of excessive daytime somnolence. He is finding it increasingly difficult to stay awake during his classes. Recently, his grades have fallen because whenever he tries to read, he finds himself drifting off. He finds that his alertness is best after

exercising or brief naps of 10–30 minutes. Because of this, he states that he takes 5 or 10 “catnaps” daily. The sleepiness persists despite averaging 9 hours of sleep nightly. In addition to excessive somnolence, he reports occasional hallucinations that occur as he is falling asleep. He describes these occurrences as a voice calling his name as he drifts off. Perhaps once weekly, he awakens from sleep but is unable to move for a period of about 30 seconds. He has never had apparent loss of consciousness but states that whenever he is laughing, he feels heaviness in his neck and arms. Once he had to lean against a wall to keep from falling down. He undergoes an overnight sleep study and multiple sleep latency test. There is no sleep apnea. His mean sleep latency on five naps is 2.3 minutes. In three of the five naps, rapid eye movement sleep is present. Which of the following findings of this patient is most specific for the diagnosis of narcolepsy?

A. Cataplexy

B. Excessive daytime somnolence

C. Hypnagogic hallucinations

D. Rapid eye movement sleep in more than two naps on a multiple sleep latency test

E. Sleep paralysis

I-92. Which of the following is the most common sleep disorder in the U.S. population?

A. Delayed sleep phase syndrome

B. Insomnia

C. Obstructive sleep apnea

D. Narcolepsy

E. Restless legs syndrome

I-93. In which stage of sleep are the parasomnias somnambulism and night terrors most likely to occur?

A. Stage 1

B. Stage 2

C. Slow-wave sleep

D. Rapid eye movement sleep

I-94. A 44-year-old man is seen in the emergency department after a motor vehicle accident. The patient says, “I never saw that car coming from the right side.” On physical examination, his pupils are equal and reactive to light. His visual acuity is normal; however, there are visual field defects in both eyes laterally (bitemporal hemianopia). Which of the following is most likely to be found on further evaluation?

A. Retinal detachment

B. Occipital lobe glioma

C. Optic nerve injury

D. Parietal lobe infarction

E. Pituitary adenoma

I-95. A 42-year-old construction worker complains of waking up with a red, painful left eye. She often works without goggles at her construction site. Her history is notable for hypertension, inflammatory

bowel disease, diabetes, and prior IV drug use. Her only current medication is lisinopril. On examination, the left eye is diffusely red and sensitive to light. The eyelids are normal. In dim light, visual acuity is normal in both eyes. All of the following diagnoses will explain her findings EXCEPT:

A. Acute angle-closure glaucoma

B. Anterior uveitis

C. Corneal abrasion

D. Posterior uveitis

E. Transient ischemic attack

I-96. A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

A. Age-related macular degeneration

B. Blepharitis

C. Diabetic retinopathy

D. Episcleritis

E. Retinal detachment

I-97. All of the following statements regarding olfaction are true EXCEPT:

A. Decrements in olfaction may lead to nutritional deficiency.

B. More than 40% of patients with traumatic anosmia will regain normal function over time.

C. Significant decrements in olfaction are present in more than 50% of the population 80 years and
older.

D. The most common identifiable cause of long-lasting or permanent loss of olfaction in outpatients
is severe respiratory infection.

E. Women identify odorants better than men at all ages.

I-98. A 64-year-old man is evaluated for hearing loss that he thinks is worse in his left ear. His wife and children have told him for years that he does not listen to them. Recently, he has failed to hear the chime of the alarm on his digital watch, and he admits to focusing on the lips of individuals speaking to him because he sometimes has difficulties in word recognition. In addition, he reports a continuous buzzing that is louder in his left ear. He denies any sensation of vertigo, headaches, or balance difficulties. He has worked in a factory for many years that makes parts for airplanes, and the machinery that he works with sits to his left primarily. He has no family history of deafness, although his father had hearing loss as he aged. He has a medical history of hypertension, hyperlipidemia, and coronary artery disease. You suspect sensorineural hearing loss related to exposure to the intense noise in the factory for many decades. Which of the following findings would you expect on physical examination?

A. A deep tympanic retraction pocket seen above the pars flaccida on the tympanic membrane.

B. Cerumen impaction in the external auditory canal.

C. Hearing loss that is greater at lower frequencies on pure tone audiometry.

D. Increased intensity of sound when a tuning fork is placed on the mastoid process when compared
with placement near the auditory canal.

E. Increased intensity of sound in the right ear when a tuning fork is placed in the midline of the
forehead.

I-99. A 32-year-old woman presents to her primary care physician complaining of nasal congestion and drainage and headache. Her symptoms originally began about 7 days ago with rhinorrhea and sore throat. For the past 5 days, she has been having increasing feelings of fullness and pressure in the maxillary area that is causing her headaches. The pressure is worse when she bends over, and she also notices it while lying in bed at night. She is otherwise healthy and has not had fevers. On physical examination, there is purulent nasal drainage and pain with palpation over bilateral maxillary sinuses. What is the best approach to ongoing management of this patient?

A. Initiate therapy with amoxicillin 500 mg three times daily for 10 days.

B. Initiate therapy with levofloxacin 500 mg daily for 10 days.

C. Perform a sinus aspirate for culture and sensitivities.

D. Perform a sinus CT.

E. Treat with oral decongestants and nasal saline lavage.

I-100. A 28-year-old man seeks evaluation for sore throat for 2 days. He has not had a cough or rhinorrhea. He has no other medical conditions and works as a daycare provider. On examination, tonsillar hypertrophy with membranous exudate is present. What is the next step in the management of this patient?

A. Empiric treatment with amoxicillin 500 mg twice daily for 10 days

B. Rapid antigen detection test for Streptococcus pyogenes only

C. Rapid antigen detection test for Streptococcus pyogenes plus throat culture if the rapid test
result is negative

D. Rapid antigen detection test for Streptococcus pyogenes plus a throat culture regardless of
result

E. Throat culture only

I-101. A 62-year-old man presents to his physician complaining of shortness of breath. All of the following findings are consistent with left ventricular dysfunction as a cause of the patient’s dyspnea EXCEPT:

A. Feeling of chest tightness

B. Nocturnal dyspnea

C. Orthopnea

D. Pulsus paradoxus greater than 10 mmHg

E. Sensation of air hunger

I-102. A 42-year-old woman seeks evaluation for a cough that has been present for almost 3 months. The cough is mostly dry and non-productive, but occasionally productive of yellow phlegm. She reports that the cough is worse at night and often wakes her from sleep. She denies any recent upper respiratory tract infection, allergic rhinitis, fever, chills or cough. She recalls her mother told her that she had

asthma as a child but she has never felt symptomatic wheezing as an adult. She exercises regularly but continues to smoke 1 pack per day of cigarettes; she’d like to quit. The patient takes no medications. Her physical examination is unremarkable. Which of the following is indicated at this point?

A. Chest PET-CT

B. Chest radiograph

C. Measurement of serum angiotensin-converting enzyme (ACE)

D. Measurement of serum IgE

E. Sinus CT

I-103. In the patient described above, her chest radiograph is normal and further history reveals a long history of symptoms suggestive of GERD. She also admits that her cough is worse on nights after a large or late meal. She often has a bad taste in her mouth as she starts coughing. Based on this information, which of the following would be a reasonable empiric therapeutic trial?

A. Inhaled corticosteroid

B. Inhaled long acting beta agonist

C. Nasal corticosteroid

D. Oral proton pump inhibitor

E. Oral triple antibiotic therapy for H. pylori

I-104. A 48-year-old man is evaluated for hypoxia of unknown etiology. He recently has noticed shortness of breath that is worse with exertion and in the upright position. It is relieved with lying down. On physical examination, he is visibly dyspneic with minimal exertion. He is noted to have a resting oxygen saturation of 89% on room air. When lying down, his oxygen saturation increases to 93%. His pulmonary examination shows no wheezes or crackles. His cardiac examination findings are normal without murmur. His chest radiograph reports a possible 1-cm lung nodule in the right lower lobe. On 100% oxygen and in the upright position, the patient has an oxygen saturation of 90%. What is the most likely cause of the patient’s hypoxia?

A. Circulatory hypoxia

B. Hypoventilation

C. Intracardiac right-to-left shunting

D. Intrapulmonary right-to-left shunting

E. Ventilation–perfusion mismatch

I-105. A patient is evaluated in the emergency department for peripheral cyanosis. All of the following are potential etiologies EXCEPT:

A. Cold exposure

B. Deep venous thrombosis

C. Methemoglobinemia

D. Peripheral vascular disease

E. Raynaud’s phenomenon

I-106. An 18-year-old college freshman is being evaluated for a heart murmur heard at health screening.

She reports an active lifestyle, no past medical history, and no cardiac symptoms. She has a midsystolic murmur that follows a nonejection sound and crescendos with S2. The murmur duration is greater when going from supine to standing and decreases when squatting. The murmur is heard best along the lower left sternal border and apex. Her electrocardiogram is normal. Which of the following is the most likely condition causing the murmur?

A. Aortic stenosis

B. Hypertrophic obstructive cardiomyopathy

C. Mitral valve prolapse

D. Pulmonic stenosis

E. Tricuspid regurgitation

I-107. Which of the following characteristics makes a heart murmur more likely to be caused by tricuspid regurgitation than mitral regurgitation?

A. Decreased intensity with amyl nitrate

B. Inaudible A2 at the apex

C. Prominent c-v wave in jugular pulse

D. Onset signaled by a midsystolic click

E. Wide splitting of S2

I-108. You are examining a 25-year-old patient in clinic who came in for a routine examination. Cardiac auscultation reveals a second heart sound that is split and does not vary with respiration. There is also a grade 2–3 midsystolic murmur at the midsternal border. Which of the following is most likely?

A. Atrial septal defect

B. Hypertrophic obstructive cardiomyopathy

C. Left bundle branch block

D. Normal physiology

E. Pulmonary hypertension

I-109. A 32-year-old woman presents to her physician complaining of hair loss. She is currently 10 weeks postpartum after delivery of a normal healthy baby girl. She admits to having increased stress and sleep loss because her child has colic. She also has not been able to nurse because of poor milk production. On examination, the patient’s hair does not appear to have decreased density. With a gentle tug, more than 10 hairs come out but are not broken and all appear normal. There are no scalp lesions. What do you recommend for this patient?

A. Careful evaluation of the patient’s hair care products for a potential cause

B. Reassurance only

C. Referral for counseling for trichotillomania

D. Treatment with minoxidil

E. Treatment with topical steroids

I-110. A 26-year-old man develops diffuse itching, wheezing, and laryngeal edema within minutes of receiving intravenous radiocontrast media for an intravenous pyelogram. He has not previously

received contrast dye per his recollection. He is treated with supportive care and recovers without further complications. Which of the following best describes the mechanism of the patient’s reaction to the contrast media?

A. Cross-linking of IgE molecules fixed to sensitized cells in the presence of a specific drug-
protein conjugate

B. Deposition of circulating immune complexes

C. Development of drug-specific T-cell immunogenicity

D. Direct mast cell degranulation

E. Hepatic metabolism into toxic intermediate

I-111. A 44-year-old woman is prescribed phenytoin for the development of complex partial seizures. One month after initiating the medication, she is evaluated for a diffuse erythematous eruption with associated fever to 101.3°F. She is noted to have facial edema with diffusely enlarged lymph nodes along the cervical, axillary, and inguinal areas. Her white cell count is 14,500/μL (75% neutrophils, 12% lymphocytes, 5% atypical lymphocytes, and 8% eosinophils). A basic metabolic panel is normal, but elevations in the liver functions tests are noted with an AST of 124 U/L, ALT of 148 U/L, alkaline phosphatase of 114 U/L, and total bilirubin of 2.2 mg/dL. All of the following are indicated in the management of this patient EXCEPT:

A. Administration of carbamazepine 200 mg twice daily

B. Administration of prednisone 1.5–2 mg/kg daily

C. Administration of topical glucocorticoids

D. Discontinuation of phenytoin

E. Evaluation for development of thyroiditis for up to 6 months

I-112. Which of the following drugs is associated with development of both phototoxicity and photoallergy?

A. Amiodarone

B. Diclofenac

C. Doxycycline

D. Hydrochlorothiazide

E. Levofloxacin

I-113. 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 is consistent with the diagnosis of polycythemia vera?

A. Elevated red blood cell mass, high serum erythropoietin levels, and normal oxygen saturation

B. Elevated red blood cell mass, low serum erythropoietin levels, and normal oxygen saturation

C. Normal red blood cell mass, high serum erythropoietin levels, and low arterial oxygen
saturation

D. Normal red blood cell mass, low serum erythropoietin levels, and low arterial oxygen saturation

I-114. All of the following are common manifestations of bleeding caused by von Willebrand disease

EXCEPT:

A. Angiodysplasia of the small bowel

B. Epistaxis

C. Menorrhagia

D. Postpartum hemorrhage

E. Spontaneous hemarthrosis

I-115. A 68-year-old man is admitted to the intensive care unit with spontaneous retroperitoneal bleeding and hypotension. He has a medical history of hypertension, diabetes mellitus, and chronic kidney disease stage III. His medications include lisinopril, amlodipine, sitagliptin, and glimepiride. On initial presentation, he is in pain and has a blood pressure of 70/40 mmHg with a heart rate of 132 beats/min. His hemoglobin on admission is 5.3 g/dL and hematocrit is 16.0%. His coagulation studies demonstrate an aPTT of 64 seconds and a PT of 12.1 seconds (INR 1.0). Mixing studies (1:1) are performed. Immediately, the aPTT decreases to 42 seconds. At 1 hour, the aPTT is 56 seconds, and at 2 hours, it is 68 seconds. Thrombin time and reptilase time are normal. Fibrinogen is also normal. What is the most likely cause of the patient’s coagulopathy?

A. Acquired factor VIII deficiency

B. Acquired factor VIII inhibitor

C. Heparin

D. Lupus anticoagulant

E. Vitamin K deficiency

I-116. A 54-year-old man is seen in the clinic complaining of painless enlargement of lymph nodes in his neck. He has not otherwise been ill and denies fevers, chills, weight loss, and fatigue. His past medical history is remarkable for pulmonary tuberculosis that was treated 10 years previously under directly observed therapy. He currently takes no medications. He is a heterosexual man in a monogamous relationship for 25 years. He denies illicit drug use. He has smoked 1½ packs of cigarettes daily since 16 years of age. He works as a logger. On physical examination, the patient is thin, but not ill-appearing. He is not febrile and has normal vital signs. He has dental caries noted with gingivitis. In the right supraclavicular area, there is a hard and fixed lymph node measuring 2.5 × 2.0 cm in size. Lymph nodes less than 1 cm in size are noted in the anterior cervical chain. There is no axillary or inguinal lymphadenopathy. His liver and spleen are not enlarged. Which of the following factors in history or physical examination increases the likelihood that the lymph node enlargement is caused by malignancy?

A. Age greater than 50 years

B. Location in the supraclavicular area

C. Presence of a lymph node that is hard and fixed

D. Size greater than 2.25 cm² (1.5 × 1.5 cm)

E. All of the above

I-117. 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. She denies fever, malaise, weight loss, and anorexia. She works as a sailing instructor and competes in triathlons. On physical examination, she

is noted to have several palpable 1-cm inguinal lymph nodes that are mobile, non-tender, and discrete. There is no other lymphadenopathy or focal findings on examination. What should be the next step in management?

A. Bone marrow biopsy

B. CT scan of the chest, abdomen, and pelvis

C. Excisional biopsy

D. Fine-needle aspiration for culture and cytopathology

E. Pelvic ultrasonography

F. Reassurance

I-118. All of the following diseases are associated with massive splenomegaly (spleen extends 8 cm below the costal margin or weighs >1000 g) EXCEPT:

A. Autoimmune hemolytic anemia

B. Chronic lymphocytic leukemia

C. Cirrhosis with portal hypertension

D. Marginal zone lymphoma

E. Myelofibrosis with myeloid metaplasia

I-119. The presence of Howell-Jolly bodies, Heinz bodies, basophilic stippling, and nucleated red blood cells in a patient with hairy cell leukemia before any treatment intervention implies which of the following?

A. Diffuse splenic infiltration by tumor

B. Disseminated intravascular coagulation (DIC)

C. Hemolytic anemia

D. Pancytopenia

E. Transformation to acute leukemia

I-120. Which of the following is true regarding infection risk after elective splenectomy?

A. Patients are at no increased risk of viral infection after splenectomy.

B. Patients should be vaccinated 2 weeks after splenectomy.

C. Splenectomy patients over the age of 50 are at greatest risk for postsplenectomy sepsis.

D. Staphylococcus aureus is the most commonly implicated organism in postsplenectomy sepsis.

E. The risk of infection after splenectomy increases with time.

I-121. An 18-year-old man is seen in consultation for a pulmonary abscess caused by infection with Staphylococcus aureus. He had been in his usual state of health until 1 week ago when he developed fevers and a cough. He has no ill contacts and presents in the summer. His medical history is significant for episodes of axillary and perianal abscesses requiring incision and drainage. He cannot specifically recall how often this has occurred, but he does know it has been more than five times that he can recall. In one instance, he recalls a lymph node became enlarged to the point that it “popped” and drained spontaneously. He also reports frequent aphthous ulcers and is treated for eczema. On physical examination, his height is 5′3′′. He appears ill with a temperature of 39.6°C. Eczematous dermatitis is

present in the scalp and periorbital area. There are crackles at the left lung base. Axillary lymphadenopathy is present bilaterally and is tender. The spleen in enlarged. His laboratory studies show a white blood cell count of 12,500/μL (94% neutrophils), hemoglobin of 11.3 g/dL, hematocrit of 34.2%, and platelets of 320,000/μL. Granulomatous inflammation is seen on lymph node biopsy. Which of the following tests are most likely found in this patient?

A. Elevated angiotensin-converting enzyme level

B. Eosinophilia

C. Giant primary granules in neutrophils

D. Mutations of the tumor necrosis factor-alpha receptor

E. Positive nitroblue tetrazolium dye test

I-122. A 72-year-old man with chronic obstructive pulmonary disease and stable coronary disease presents to the emergency department with several days of worsening productive cough, fevers, malaise, and diffuse muscle aches. A chest radiograph 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?

A. 2%

B. 10%

C. 25%

D. 40%

E. 90%

I-123. A patient with longstanding HIV infection, alcoholism, and asthma is seen in the emergency department 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 greater than 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 active antiretroviral 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?

A. Darunavir

B. Efavirenz

C. Ranitidine

D. Prednisone

E. Trimethoprim–sulfamethoxazole

I-124. All of the following statements regarding mercury exposure or poisoning are true EXCEPT:

A. Chronic mercury poisoning is best assessed using hair samples.

B. Ethyl mercury preservative in multiuse vaccines has not been implicated in causing autism.

C. Exposure to as little as a few drops of dimethylmercury may be lethal.

D. Offspring of mothers who ingested mercury-contaminated fish are at higher risk of
neurobehavioral abnormalities.

E. Pregnant women should avoid consumption of sardines and mackerel.

I-125. A 39-year-old man comes to clinic reporting a 4-day illness that began while he was in the Caribbean on vacation. A few hours after attending a large seafood buffet, he developed abdominal pain, chills, nausea, and diarrhea. Soon thereafter, he noticed diffused paresthesias, throat numbness, and fatigue. The symptoms slowly improved over 2 days, and he returned home yesterday. Today he noticed while washing that cold water felt hot and warm water felt cold. He is concerned about this new symptom. All of the following are true regarding his illness EXCEPT:

A. His symptoms should improve over weeks to months.

B. It is likely caused by ingestion of contaminated snapper or grouper.

C. It is likely caused by ingestion of undercooked oysters or clams.

D. Subsequent episodes may be more severe.

E. No diagnostic laboratory test is available.

I-126. Which of the following is the most common cause of death from poisoning?

A. Acetaminophen

B. Carbon monoxide

C. Chlorine gas

D. Insecticide

E. Tricyclic antidepressants

I-127. Which of the following is a distinguishing feature of amphetamine overdose versus other causes of sympathetic overstimulation caused by drug overdose or withdrawal?

A. Hallucination

B. Hot, dry, flushed skin and urinary retention

C. History of benzodiazepine abuse

D. Markedly increased blood pressure, heart rate, and end-organ damage in the absence of
hallucination

E. Nystagmus

I-128. A patient with metabolic acidosis, reduced anion gap, and increased osmolal gap is most likely to have which of the following toxic ingestions?

A. Lithium

B. Methanol

C. Oxycodone

D. Propylene glycol

E. Salicylate

Date: 2016-04-22; view: 673