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An 84-year-old female is diagnosed with a third recurrence of breast cancer that has now metastasized to the brain and lungs. She does not wish to pursue further treatment at this time despite being advised that this is a terminal condition. Her family insists on trying both radiation and chemotherapy in hopes that the cancer will again be successfully treated. It is the duty of the physician to

professional_medicine

3D

A cohort study is conducted to compare the incidence of adverse effects of a recently approved antihypertensive pharmacotherapy with that of conventional therapy. A total of 20,000 patients are enrolled. Twelve thousand are prescribed the recently approved therapy, and 8,000 are prescribed conventional therapy. Patients in the study and control groups are matched for baseline blood pressure, age, and gender. Data are collected from the records of the patients' ongoing clinical care. Results show that those receiving the newly approved treatment have twice the incidence of fatigue compared with those receiving the conventional treatment. The results are statistically significant (p=0.01). Which of the following potential flaws is most likely to invalidate this study?

professional_medicine

1B

A 55-year-old man is brought to the emergency department by his wife because he told her he did not want to live anymore. During the past 6 weeks, he has experienced fatigue, loss of interest in usual activities, a 7-kg (15-lb) weight loss, and insomnia. He has no history of serious medical or psychiatric illness. Vital signs are temperature 37.0°C (98.6°F), pulse 80/min, respirations 16/min, and blood pressure 140/82 mm Hg. Physical examination discloses no abnormalities. Beck Depression Inventory score is 35 (severely depressed). He says he feels guilty that his investments have not done well and that he has ruined his family finances. He reports he hears voices at night telling him he has sinned. In addition to olanzapine, which of the following is the best treatment option for this patient?

professional_medicine

1B

A 14-year-old girl with a 9-year history of type 1 diabetes mellitus is brought to the physician by her mother for a follow-up examination. She has been admitted to the hospital twice in the past 3 months because of diabetic ketoacidosis. She previously had been compliant with monitoring her blood glucose concentration and with her diet and insulin regimen. She acknowledges that, when she is with her peers, she eats whatever she wants and does not check her blood glucose concentration. She adds, "I'm embarrassed to inject myself in front of them." The physician is having a great deal of difficulty with her 15-year-old son who has been truant from school and sneaking out of the house. She says to the patient, "You should be ashamed for not taking care of yourself. We've all worked so hard to keep you healthy." Which of the following terms best describes the physician's reaction to the patient?

professional_medicine

0A

A 70-year-old woman comes to the office for an annual health maintenance examination. She describes a 1-year history of slowly progressive fatigue, diffuse muscle aches, and generalized pain. Medical history is significant for osteoporosis diagnosed 5 years ago. Medications include alendronate and calcium supplementation. Vital signs are normal. Physical examination is unremarkable for her age, with no point tenderness on palpation. Results of complete blood count, serum electrolyte and thyroid-stimulating hormone concentrations, liver function tests, and erythrocyte sedimentation rate are all within the reference ranges. Screening mammography and colonoscopy done 1 year ago disclosed no abnormalities. Which of the following is the most appropriate next step in evaluation?

professional_medicine

3D

A 6-day-old breast-fed boy is brought to the emergency department by his mother because of poor weight gain and irritability since delivery, and a 2-hour history of vomiting. Physical examination shows jaundice and hepatomegaly. A reducing substance test result of the urine is positive, and a glucose oxidase test result is negative. The concentration of which of the following metabolites in liver is most likely increased in this patient?

professional_medicine

1B

For 8 weeks, a 52-year-old man with a 5-year history of type 2 diabetes mellitus has had deep burning pain in the ball of his right foot and big toe when the foot is raised above chest concentration. He also has cramping in his right calf when he walks more than 50 feet. He has smoked two packs of cigarettes daily for 30 years. Femoral pulses are palpable; pedal pulses are absent. Which of the following is the most likely diagnosis?

professional_medicine

1B

A 56-year-old man comes to the emergency department because of a 4-day history of colicky right flank pain that radiates to the groin and hematuria. Ultrasound examination of the kidneys shows right-sided hydronephrosis and a dilated ureter. Which of the following is most likely to be found on urinalysis?

professional_medicine

3D

A 45-year-old man with AIDS comes to the community health center because of a 1-week history of fever, chills, sweating, mild shortness of breath, and nonproductive cough. Medical history is also remarkable for pneumonia 3 years ago that required hospitalization. Today, he says that he lost his job 6 months ago, is now homeless, and cannot afford to buy his antiretroviral medications. Vital signs are temperature 38.6°C (101.5°F), pulse 82/min, respirations 20/min, and blood pressure 116/72 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 97%. The health center is very busy with several patients waiting to be evaluated. Which of the following is the most appropriate next step?

professional_medicine

2C

A 19-year-old woman noticed a mass in her left breast 2 weeks ago while doing monthly breast self-examination. Her mother died of metastatic breast cancer at the age of 40 years. Examination shows large dense breasts; a 2-cm, firm, mobile mass is palpated in the upper outer quadrant of the left breast. There are no changes in the skin or nipple, and there is no palpable axillary adenopathy. Which of the following is the most likely diagnosis?

professional_medicine

0A

A 2-week-old newborn is brought to the physician because his lips have turned blue on three occasions during feeding; he also sweats during feeding. He was born at 38 weeks' gestation and weighed 2466 g (5 lb 7 oz); he currently weighs 2778 g (6 lb 2 oz). His temperature is 37.8°C (100°F), pulse is 170/min, respirations are 44/min, and blood pressure is 75/45 mm Hg. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. An x-ray of the chest shows a small boot-shaped heart and decreased pulmonary vascular markings. Which of the following is the most likely diagnosis?

professional_medicine

3D

A 72-year-old woman comes to the physician because of a 3-day history of fever, shortness of breath, difficulty swallowing, chest pain, and cough. She is frail. Physical examination shows tachypnea and equal pulses bilaterally. Percussion of the chest shows dullness over the right lower lung field. Laboratory studies show arterial hypoxemia and decreased PCO2. A chest x-ray shows an area of opacification in the lower region of the right lung. Which of the following is the most likely cause of this patient's condition?

professional_medicine

1B

A 24-year-old woman comes to the office for a routine health maintenance examination. She has been generally healthy for the past year. She is 155 cm (5 ft 1 in) tall and weighs 68 kg (150 lb); BMI is 28 kg/m2 . Vital signs are temperature 37.0°C (98.6°F), pulse 60/min, respirations 18/min, and blood pressure 118/54 mm Hg. Physical examination shows several small (<1 cm), smooth, slightly irregular, mobile, mildly tender lymph nodes palpable in her left groin just below the inguinal ligament. The most likely source of this lymphadenopathy will be found in which of the following?

professional_medicine

3D

An obese 33-year-old woman has had four 12-hour episodes of severe, sharp, penetrating pain in the right upper quadrant of the abdomen associated with vomiting but no fever. She has no diarrhea, dysuria, or jaundice and is asymptomatic between episodes. There is slight tenderness to deep palpation in the right upper quadrant. Which of the following is the most appropriate next step in diagnosis?

professional_medicine

2C

A 25-year-old man with Down syndrome and mild mental retardation is brought to the office by his parents. He is their only child, and they are concerned that his current lifestyle is increasing his risk for coronary artery disease and stroke. The patient has a systolic murmur and also underwent surgical repair of an atrial septal defect at 1 year of age. He has smoked one pack of cigarettes daily for 5 years. He lives in a group home and works about 25 hours each week in a fast-food restaurant. He has a few friends and is romantically involved with a woman from his church group. The patient is 157 cm (5 ft 2 in) tall and weighs 91 kg (200 lb); BMI is 36 kg/m2 . Vital signs are normal. A grade 2/6 systolic murmur is heard best at the apex. The parents would like him to stop smoking and follow a healthier diet, and they feel the only way to monitor and control his behavior is for him to move back into their home. They request your assistance in obtaining legal guardianship of their son. Which of the following is the most appropriate initial recommendation?

professional_medicine

3D

A 21-year-old woman comes to the physician for preconceptional advice. She is recently married and would like to conceive within the next year. She does not eat meat, fish, or dairy products and wishes to decrease the risks of her diet on her baby. Menses occur at regular 28-day intervals and last 5 days. She does not smoke or drink alcohol. She takes no medications. She is 157 cm (5 ft 2 in) tall and weighs 50 kg (110 lb); BMI is 20 kg/m2 . Physical examination shows no abnormalities. Pelvic examination shows a normal appearing vagina, cervix, uterus, and adnexa. Which of the following is most likely to decrease the risk of fetal anomalies in this patient?

professional_medicine

1B

A grossly obese 65-year-old male presents to the office with tingling and painful itching in the anterolateral region of the thigh. The patient loses weight, and the symptoms disappear. This paresthesia is most consistent with compression of the

professional_medicine

3D

A 12-year-old girl is brought to the physician because of a 2-month history of intermittent yellowing of the eyes and skin. Physical examination shows no abnormalities except for jaundice. Her serum total bilirubin concentration is 3 mg/dL, with a direct component of 1 mg/dL. Serum studies show a haptoglobin concentration and AST and ALT activities that are within the reference ranges. There is no evidence of injury or exposure to toxins. Which of the following additional findings is most likely in this patient?

professional_medicine

0A

A 63-year-old man is brought to the emergency department because of a 4-day history of increasingly severe left leg pain and swelling of his left calf. He also has a 1-month history of increasingly severe upper midthoracic back pain. During this time, he has had a 9-kg (20-lb) weight loss despite no change in appetite. He has no history of major medical illness. His only medication is ibuprofen. He is 180 cm (5 ft 11 in) tall and weighs 82 kg (180 lb); BMI is 25 kg/m2 . His vital signs are within normal limits. On examination, lower extremity pulses are palpable bilaterally. The remainder of the physical examination shows no abnormalities. An x-ray of the thoracic spine shows no abnormalities. A CT scan of the abdomen shows a 3-cm mass in the body of the pancreas; there are liver metastases and encasement of the superior mesenteric artery. Ultrasonography of the left lower extremity shows a femoropopliteal venous clot. Which of the following is the most likely cause of this patient’s symptoms?

professional_medicine

1B

A 63-year-old woman with hypertension has her son call your office to make an appointment for evaluation of vaginal bleeding. Her general physician recently retired. The son tells you that his mother has been deaf since infancy and that he uses sign language to communicate with her. Which of the following is the most appropriate course of action to ensure good communication?

professional_medicine

1B

A 4-year-old boy with cystic fibrosis is brought to the emergency department 20 minutes after being found unconscious in his yard by his parents. He had been playing outside all afternoon; the outside temperature was 95°F. He had been feeling well lately with no recent acute exacerbations of cystic fibrosis. On arrival, he responds to pain but speech is incoherent. His temperature is 41.2°C (106.2°F), pulse is 148/min, respirations are 36/min and shallow, and blood pressure is 88/46 mm Hg. His skin is hot and dry. The lungs are clear to auscultation. Muscle tone is poor; deep tendon reflexes are diminished throughout. Neurologic examination shows no focal abnormalities. Which of the following is the most likely underlying mechanism for these findings?

professional_medicine

1B

A 37-year-old woman, gravida 5, para 4, at 34 weeks' gestation comes to the emergency department because of vaginal bleeding for 2 hours. She has had no prenatal care. Her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate; her other three children were delivered vaginally. Her pulse is 92/min, respirations are 18/min, and blood pressure is 134/76 mm Hg. The abdomen is nontender, and no contractions are felt. There is blood on the vulva, the introitus, and on the medial aspect of each thigh. The fetus is in a transverse lie presentation. The fetal heart rate is 144/min. Which of the following is the most likely diagnosis?

professional_medicine

3D

A previously healthy 32-year-old man is brought to the emergency department after being found unconscious on the floor at his workplace. On arrival, he is obtunded. He is intubated and mechanical ventilation is begun. Examination shows flaccid paralysis on the right. A CT scan of the head shows a large evolving cerebral infarction on the left. Carotid duplex ultrasonography shows dissection of the left carotid artery. After receiving intensive medical care for 6 hours, the patient develops decerebrate posturing and becomes hemodynamically unstable. Vasopressor therapy is begun. A second CT scan of the head shows a massive left hemispheric cerebral infarction with severe edema and herniation. The physician determines that surgical intervention is not indicated because of the patient's poor prognosis. The patient's driver's license indicates that he wishes to be an organ donor. The physician meets with the patient's family and informs them about the patient's prognosis, and they are devastated. During the meeting, they say that they were unaware of his willingness to be an organ donor and agree that he should not receive cardiopulmonary resuscitation. Which of the following is the most appropriate next step with respect to organ donation?

professional_medicine

0A

A 52-year-old woman begins pharmacotherapy after being diagnosed with type 2 diabetes mellitus. Four weeks later, her hepatic glucose output is decreased, and target tissue glucose uptake and utilization are increased. Which of the following drugs was most likely prescribed for this patient?

professional_medicine

2C

A 64-year-old male presents to the emergency room with a bloody nose that has been dripping out his nares for the past 2 hours. He denies any trauma, recent upper respiratory illness, or history of prior bloody nose. Past medical history is unremarkable, and he takes no medications. He has a blood pressure of 180/90 mmHg. Examination of the nasal passages reveals that the site of the bleeding is on the septal mucosa of the right naris. The most likely site of origin of this patient's epistaxis is

professional_medicine

2C

A 25-year-old female is admitted to the hospital for the evaluation of fainting spells, which have been occurring several times a day for 10 days. These occur without warning and are not associated with any injury. The patient is evaluated during one of these falls, manifesting no change in heart rate, blood pressure, or color. Neurologic examination findings are normal. The most likely diagnosis is

professional_medicine

2C

A 31-year-old woman comes to the office for initial prenatal care. She is 12 weeks pregnant by date of her last menstrual period. This is her fourth pregnancy; she has three healthy children. Her last pregnancy resulted in cesarean delivery because of fetal distress during labor. Her history includes heavy use of alcohol and cigarettes, and multiple sexual partners. In addition to routine prenatal laboratory work-up, the patient consents to an HIV antibody test, which is later reported as positive. At a follow-up visit this patient should be counseled regarding which of the following?

professional_medicine

1B

A 60-year-old man has had painful skin with exfoliation of the skin and mucous membranes for 1 day. He has been taking allopurinol and probenecid for 2 weeks because of gouty arthritis. There is diffuse exfoliation of the skin with oozing of serous fluid. The mucous membranes of the mouth are erythematous and exfoliated. There are no target lesions. Which of the following is the most likely diagnosis?

professional_medicine

3D

A 27-year-old man comes to the office with his wife because of a recent episode of loss of muscle control. He says, "I was at a reception, someone told a joke, and when I laughed, my legs collapsed!" His wife tells you that he recovered in a few seconds and he did not lose consciousness. He has a long history of sleepiness and he is able to go to sleep quickly. He usually awakens feeling refreshed after a short nap. He has no history of similar episodes or hallucinations. There is no family history of similar problems. Vital signs are normal. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

professional_medicine

0A

A 47-year-old man comes to the emergency department because of a 3-day history of increasing pain, tenderness, and swelling near the fingernail of his right index finger. He rates the pain as an 8 on a 10-point scale. He has not had fever or chills, and he has not sustained any trauma to the finger. Medical history is unremarkable and the patient takes no medications. He appears generally well and is not in distress. Vital signs are temperature 37.1°C (98.8°F), pulse 72/min, respirations 14/min, and blood pressure 120/80 mm Hg. Physical examination of the right hand discloses swelling, erythema, warmth, and tenderness of the periungual region of the right index finger. There is a mildly fluctuant area near the nail edge. The remainder of the physical examination discloses no abnormalities. Which of the following is the most appropriate next step in management?

professional_medicine

0A

A randomized controlled trial is conducted to assess the risk for development of gastrointestinal adverse effects using azithromycin compared with erythromycin in the treatment of pertussis in children. Of the 100 children with pertussis enrolled, 50 receive azithromycin, and 50 receive erythromycin. Results show vomiting among 5 patients in the azithromycin group, compared with 15 patients in the erythromycin group. Which of the following best represents the absolute risk reduction for vomiting among patients in the azithromycin group?

professional_medicine

1B

A 42-year-old man comes to the office for preoperative evaluation prior to undergoing adrenalectomy scheduled in 2 weeks. One month ago, he received care in the emergency department for pain over his right flank following a motor vehicle collision. At that time, blood pressure was 160/100 mm Hg and CT scan of the abdomen showed an incidental 10-cm left adrenal mass. Results of laboratory studies, including complete blood count, serum electrolyte concentrations, and liver function tests, were within the reference ranges. The patient otherwise had been healthy and had never been told that he had elevated blood pressure. He takes no medications. A follow-up visit in the office 2 weeks ago disclosed elevated urinary normetanephrine and metanephrine and plasma aldosterone concentrations. The patient was referred to a surgeon, who recommended the adrenalectomy. Today, vital signs are temperature 36.6°C (97.9°F), pulse 100/min, respirations 14/min, and blood pressure 170/95 mm Hg. Physical examination discloses no significant findings. Initial preoperative preparation should include treatment with which of the following?

professional_medicine

3D

A 36-year-old male presents to the office with a 3-week history of low back pain. He denies any recent trauma but says that he climbs in and out of his truck numerous times a day for his job. Examination of the patient in the prone position reveals a deep sacral sulcus on the left, a posterior inferior lateral angle on the right, and a lumbosacral junction that springs freely on compression. The most likely diagnosis is

professional_medicine

3D

A previously healthy 32-year-old woman comes to the physician 8 months after her husband was killed in a car crash. Since that time, she has had a decreased appetite and difficulty falling asleep. She states that she is often sad and cries frequently. She has been rechecking the door lock five times before leaving her house and has to count exactly five pieces of toilet paper before she uses it. She says that she has always been a perfectionist but these urges and rituals are new. Pharmacotherapy should be targeted to which of the following neurotransmitters?

professional_medicine

3D

A 44-year-old man comes to the office because of a 3-day history of sore throat, nonproductive cough, runny nose, and frontal headache. He says the headache is worse in the morning and ibuprofen does provide some relief. He has not had shortness of breath. Medical history is unremarkable. He takes no medications other than the ibuprofen for pain. Vital signs are temperature 37.4°C (99.4°F), pulse 88/min, respirations 18/min, and blood pressure 120/84 mm Hg. Examination of the nares shows erythematous mucous membranes. Examination of the throat shows erythema and follicular lymphoid hyperplasia on the posterior oropharynx. There is no palpable cervical adenopathy. Lungs are clear to auscultation. Which of the following is the most likely cause of this patient's symptoms?

professional_medicine

3D

A 22-year-old male marathon runner presents to the office with the complaint of right-sided rib pain when he runs long distances. Physical examination reveals normal heart and lung findings and an exhalation dysfunction at ribs 4-5 on the right. Which of the following muscles or muscle groups will be most useful in correcting this dysfunction utilizing a direct method?

professional_medicine

2C