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Question 601

Multiple Choice

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A 23-year-old man is brought to the emergency department by ambulance for a seizure.  According to a witness, he fell on the sidewalk while leaving a pub and had rhythmic movements of the extremities for about 2 minutes.  He has no prior history of seizures.  In the emergency department, the patient is lethargic and confused but follows simple commands.  His temperature is 37.3° C (99.2° F) , blood pressure is 122/70 mm Hg, and pulse is 97/min.  The pupils are equal and reactive to light.  He moves all his extremities, and the deep-tendon reflexes are symmetric.  Complete blood count, serum electrolytes, electrocardiogram, and cervical spine imaging are normal.  A urine toxicology screen is ordered.  What is the most appropriate next step in management of this patient?

A) Brain computed tomography with contrast
B) Brain computed tomography without contrast
C) Electroencephalogram
D) Intravenous phenytoin infusion
E) Lumbar puncture

F) None of the above
G) A) and D)

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Question 602

Multiple Choice

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A 24-year-old woman comes to the office due to pressure-like, substernal chest pain that occurs when she exercises.  The patient began noticing the pain approximately 6 months ago when she started to exercise to lose weight.  Prior to that, her lifestyle was largely sedentary.  She has no associated nausea, vomiting, diaphoresis, dyspnea, palpitations, or syncope.  The patient has no significant past medical history but was told as a child that she has a "murmur."  She has no significant family history of heart disease.  Blood pressure is 130/70 mm Hg on the right and 105/55 mm Hg on the left, and pulse is 72/min and regular.  BMI is 29 kg/m².  A palpable thrill is present in the suprasternal notch.  There is a loud midsystolic murmur best heard at the first right intercostal space.  The lungs are clear to auscultation.  What is the most likely cause of this patient's chest pain?

A) Anomalous origin of the right coronary artery
B) Atherosclerotic narrowing of the coronaries
C) Increased myocardial oxygen demand
D) Stretching of the papillary muscles
E) Systolic anterior motion of the mitral valve

F) A) and C)
G) A) and B)

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Question 603

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A 34-year-old woman comes to the office for a follow-up blood pressure check.  Over the last 12 months, the patient's blood pressure readings have ranged from 145/90 to 150/95 mm Hg.  Her blood pressure was measured during a health fair 2 weeks ago and it was 145/90 mm Hg.  The patient feels well, has no other medical conditions, and has never been pregnant.  Medications include a combination oral contraceptive for the past 5 years and, occasionally, acetaminophen for relief of tension headaches.  She does not use tobacco, alcohol, or illicit drugs.  There is no family history of hypertension, stroke, deep venous thrombosis, or heart attack.  Blood pressure is 150/90 mm Hg and pulse is 80/min.  BMI is 22 kg/m².  Physical examination and ECG are normal.  Six months ago, the patient's total cholesterol level was 170 mg/dL.  Complete blood count, urinalysis, and basic metabolic panel are unremarkable.  Which of the following is the most appropriate next step in management of this patient's hypertension?

A 25-year-old man comes to the emergency department due to 3 weeks of progressive dyspnea on exertion, dry cough, fatigue, intermittent fever, and chills.  He was treated for genital herpes several years ago but otherwise has no significant medical history.  The patient does not use tobacco or illicit drugs but occasionally drinks alcohol.  He has been in a monogamous relationship for the past year and had multiple partners previously.  Temperature is 38.7 C (101.7 F) , blood pressure is 130/80 mm Hg, pulse is 90/min, and respirations are 28/min.  Pulse oximetry is 88% on room air.  Scattered white plaques are present on the oropharyngeal mucosa.  Lung auscultation reveals bilateral, diffuse crackles.  Chest x-ray is shown in the image below. Arterial blood gas shows a PaO₂ of 60 mm Hg and a PaCO₂ of 33 mm Hg.  Induced sputum microscopy shows few leukocytes and no predominant organism.  Which of the following is most likely to be effective for this patient's pulmonary condition?

A 44-year-old man is admitted to the hospital due to severe abdominal pain and vomiting.  The patient reports drinking about 10 shots of whiskey daily for the past 6 months.  He has no other medical conditions.  The patient is diagnosed with acute pancreatitis and receives intravenous fluids, pain control, and NPO.  On the second day, he reports a sensation that he "can't get enough air."  The patient is afebrile.  Physical examination demonstrates bilateral crackles.  Chest x-ray reveals bilateral, diffuse alveolar opacities.  Echocardiography shows normal left and right ventricular function without major valvular disease.  He undergoes endotracheal intubation and mechanical ventilation due to progressive hypoxemia.  Which of the following treatment strategies is most likely to decrease this patient's risk of in-hospital mortality?

A 40-year-old man comes to the office for a medical evaluation.  He has not seen a physician for many years and his wife insisted he get "checked out."  The patient has no prior medical conditions but says that lately he has been feeling fatigued and has had occasional muscle aches.  He has also gained 4.5 kg (9.9 lb) over the past year.  The patient does not smoke but occasionally drinks alcohol.  Family history is significant for coronary artery disease in the patient's father.  Blood pressure is 130/92 mm Hg and pulse is 60/min.  BMI is 26 kg/m².  Physical examination shows no abnormalities.  Fasting serum lipid results are as follows: Which of the following is the best next step in management of this patient's dyslipidemia?

A 32-year-old man arrives at the emergency department with pain, watering, and redness in his left eye for the past 5 days.  He had similar symptoms in the same eye a few months ago that resolved after about a week.  The patient is a construction worker and has been remodeling the attic and roof of an older home for the past few weeks.  Temperature is 36.8 C (98.2 F) , blood pressure is 118/78 mm Hg, heart rate is 82/min.  Clear drainage is visible from the left eye, which is diffusely erythematous around the cornea.  The right eye and bilateral periorbital regions are unremarkable.  There are no oral lesions.  Slit-lamp examination of his left eye is shown below: What is the most likely diagnosis for this patient?

A study evaluated the relationship between the common cold and the number of cigarettes smoked per day.  The research was conducted among fourth-year medical students and sponsored by the public health department of the medical school.  Medical students with symptoms of common cold were asked to fill out a questionnaire about their smoking status, number of packs smoked per day, and duration of smoking.  Which of the following factors would most likely invalidate the findings of this study?

A 65-year-old man is being evaluated for new-onset ptosis.  Earlier in the day, the patient underwent right total knee arthroplasty for advanced osteoarthritis with no operative complications.  While in the postoperative recovery unit, he had difficulty opening his left eye and developed slurred speech.  The patient has never had these symptoms, and his preoperative neurologic examination was unremarkable.  He has no prior history of double vision, difficulty swallowing, or limb weakness.  Medical history includes ischemic stroke with no residual deficits, type 2 diabetes mellitus, hypertension, and a 20-pack-year smoking history.  Temperature is 36.7 C (98.1 F) , blood pressure is 150/90 mm Hg, pulse is 92/min, and respirations are 12/min.  Neurologic examination reveals bilateral ptosis, left greater than right.  Pupils are equal in size and reactive to light.  An ice pack is placed over the closed eyelids for 2 minutes, leading to improvement of the ptosis.  Which of the following is the most likely cause of this patient's current symptoms?

Two studies were conducted on different samples from the same population to assess the relationship between oral contraceptive use and the risk of deep venous thrombosis (DVT) .  Study A showed an increased risk of DVT among oral contraceptive users, with a relative risk of 2.0 and a 95% confidence interval of 1.2-2.8.  Study B showed a relative risk of 2.01 and a 95% confidence interval of 0.8-3.1.  Which of the following statements is most likely to be true regarding these 2 studies?

A 35-year-old woman comes to the office with a 3-day history of sore throat.  A day after the sore throat started, she developed runny nose and cough.  The patient has had difficulty sleeping due to the severity of the cough.  She has smoked a pack of cigarettes daily for the last 10 years.  Temperature is 37.1 C (98.8 F) and blood pressure is 115/65 mm Hg.  Oxygen saturation is 98% on room air.  The tympanic membranes are clear and intact.  The tonsils are red and without exudate.  The uvula is midline.  There is no cervical lymphadenopathy.  The lungs are clear to auscultation, and the abdomen is nontender.  Which of the following is the best next step in management of this patient?

A 26-year-old woman comes to the office due to a skin lesion on her thigh that appeared approximately 3 weeks ago.  The patient does not have a history of similar lesions.  She has mild pruritus but no fever, chills, or pain.  The patient has no chronic medical conditions and takes no medication.  She is sexually active.  Examination of the leg and a close-up of the lesion are shown in the exhibit.  Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to the physician because of a 24-hour history of right flank pain, burning micturition and high-grade fever with chills.  Her temperature is 38.9° C (102° F) , blood pressure is 90/60 mm Hg, pulse is 130/min, and respirations are 20/min.  Physical examination shows costovertebral angle tenderness.  Which of the following is the most likely urine dipstick finding in this patient?

A 65-year-old man comes to the office for evaluation of slowly progressive right-hand weakness for the past 3 months.  The patient has no pain or numbness.  Medical history is significant for degenerative joint disease in both his hips and hypertension.  Vital signs are normal.  Physical examination shows atrophy of right thenar eminence and first and second web spaces.  Muscle strength testing reveals decreased right grip strength and moderate weakness of the finger abduction.  Tendon reflexes are 3+ in the right arm and 1+ in the left arm and lower limbs.  Sensory examination shows no abnormalities.  Electrophysiologic studies reveal widespread fibrillations and positive sharp waves in bilateral upper and lower extremity muscle groups.  The underlying mechanism of this patient's disease most likely involves an abnormality in which of the following?

A 27-year-old man comes to the office to follow up on bipolar disorder.  The patient was hospitalized 6 months ago after disrobing on the subway, shouting at passengers, and attacking the security guards who tried to subdue him.  He was diagnosed with bipolar disorder and started on a psychiatric medication regimen that proved effective.  He has been stable from a psychiatric perspective since discharge, but today he has fatigue, constipation, and myalgias that have steadily worsened over the last month.  His other medical problems include hypertension and hyperlipidemia for which he takes an antihypertensive and a statin.  Temperature is 36.7 C (98 F) , blood pressure is 129/72 mm Hg, pulse is 52/min, and respirations are 12/min.  Examination is within normal limits.  Which of the following is the most likely cause of this patient's symptoms?

A 14-year-old boy is brought to the emergency department by his parents after sustaining a head injury an hour ago.  He was playing hockey and collided with another player, after which he fell and hit his head on the ice.  The patient immediately developed a headache, followed by a single episode of vomiting.  He remained awake, and his symptoms have since resolved.  Vital signs are normal.  The patient is alert and oriented to person, place, and time.  He is unable to cite the months backwards.  Neurologic examination is otherwise normal.  CT scan of the head is normal.  The patient asks whether he may play in a hockey game tomorrow morning.  Which of the following is the best recommendation for return to competitive play in this patient?

A 19-year-old man comes to the emergency department with a daylong history of nausea and abdominal pain.  Temperature is 37.6 C (99.7 F) , blood pressure is 122/86 mm Hg, pulse is 88/min, and respirations are 25/min and deep.  BMI is 18 kg/m².  Pulse oximetry is 98% on room air.  On physical examination, the mucous membranes are dry and skin turgor is decreased.  The lungs are clear to auscultation.  There is diffuse tenderness to palpation over the abdomen without rebound or guarding.  Laboratory results are as follows: Which of the following arterial blood gas findings are most likely to be found in this patient?

A 45-year-old man comes to the emergency department after an episode of syncope.  Medical history is unremarkable except for an upper respiratory infection one week ago.  Temperature is 37.2 C (99 F) , pulse is 90/min, blood pressure is 100/60 mm Hg, and respirations are 13/min.  His neck veins are distended and his heart sounds are distant.  His lungs are clear to auscultation bilaterally.  Chest x-ray reveals small bilateral pleural effusions and an enlarged cardiac silhouette.  Which of the following ECG findings is fairly specific for his condition?

A 36-year-old primigravida at 24 weeks gestation comes to the emergency department due to dry cough and shortness of breath since last night.  The patient has a history of diabetes mellitus type 1 and mild, intermittent asthma.  Six days ago, she went to an urgent care clinic due to urinary frequency and dysuria and was started on nitrofurantoin.  The patient smokes 5 cigarettes daily, down from one pack daily prior to her pregnancy.  Temperature is 38.2 C (100.8 F) , blood pressure is 137/92 mm Hg, pulse is 104/min, and oxygen saturation is 92% on room air.  Lung examination reveals crackles at the bases bilaterally.  On cardiac auscultation, a 2/6 ejection-type murmur is heard at the left upper sternal border.  The extremities are warm to the touch.  There is 1+ edema of the ankles bilaterally.  Laboratory results are as follows: Chest x-ray reveals bilateral parenchymal opacities, predominantly in the mid and lower lung zones.  Which of the following is the most likely diagnosis?

A 78-year-old man comes to the office due to disturbed sleep.  He describes being unable to sleep well for the past few months and says that it is making him feel "slowed down" and without energy.  The patient used to get 7-8 hours of restful sleep each night.  Now his sleep is restless: he describes needing 45-60 minutes to fall asleep and frequently awakening during the night.  On average, he sleeps a total of 5-6 hours each night.  He often gets up at 4:30 AM as he is unable to return to sleep.  The patient has a history of hypertension treated with amlodipine.  He does not drink caffeinated beverages or smoke cigarettes.  He used to drink 2 beers with friends during his weekly golf and card games but has canceled these activities of late as he is too tired and no longer enjoys them.  The patient is retired and has lived alone since his wife died a year ago.  He admits to mild forgetfulness and says that his appetite and concentration "aren't what they used to be."  Height is 180 cm (5 ft 11 in) and weight is 93 kg (205 lb) .  Physical examination is noncontributory apart from a 5.4-kg (12-lb) weight loss since his last visit 6 months ago.  Which of the following is the most likely explanation for this patient's symptoms?