drsandep
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06.30.06 (2 years ago)
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a life insurance A 55-year-old male smoker undergoes a physical examination and laboratory workup for application. History and physical examination, including rectal examination, are normal. Blood count is also normal, but urinalysis reveals the presence of blood in the urine (> 20 RBC/HPF). Cystoscopy is negative. Abdominal ultrasound reveals a 5-cm solid mass in the upper pole of the left kidney, confirmed by computerized tomography scan. Which one of the following is the most appropriate management?
1) computerized tomography scan guided percutaneous biopsy *
2) retrograde pyelogram
3) repeat computerized tomography scan in 6 months
4) intravenous pyelogram
5) surgical resection
62-year-old male is brought to the Emergency Department by family members after having experienced a seizure. They report his recent complaints of headache and weakness of his left hand. The most likely diagnosis is
1) idiopathic epilepsy.
2) brain neoplasm. *
3) migraine.
4) temporal arteritis.
5) cluster headache.
A 40-year-old woman mother of four children and whose last child had problems at birth with hemolytic disease of the newborn has just been rushed to the emergency room following a motor vehicle accident. She has lost a lot of blood and needs immediate transfusion but there is no time to cross and type her blood. She should receive blood that is
1) O, Rh positive.
2) AB, Rh positive.
3) O, Rh negative. *
4) AB, Rh negative.
5) B, Rh positive.
A 75-year-old man with chronic bronchitis develops a bulge in his left groin. On examination, an elongated swelling is seen above the medial end of the inguinal ligament. When the patient coughs, the swelling enlarges, but does not descend into the scrotum. Which one of the following is the most likely diagnosis?
1) femoral hernia
2) acquired hydrocele
3) inguinal lymphadenopathy
4) direct inguinal hernia *
5) incomplete descent of left testis
A 54-year-old woman complains of "pins and needles" in her hand and difficulty in buttoning her clothes when dressing. She complains of discomfort in the thumb, index and middle fingers. On examination there was no impairment of sensation and no loss of power or wasting of the thenar eminence. Which one of the following nerves is most likely affected?
1) ulnar nerve
2) radial nerve
3) median nerve *
4) musculocutaneous nerve
5) axillary nerve
An elderly man with a history of unresected lung cancer and new onset decreased level of consciousness is found to have a large cerebral metastasis with some edema and midline shift on an magnetic resonance imaging MRI of the brain. Which one of the following would be consistent with the diagnosis?
1) unilateral headache
2) increased heart rate
3) increased respiratory rate
4) reduced blood pressure
5) reduced heart rate *
An 18-year-old university student is brought to your office by her mother who is concerned about her daughter's 6-month history of weight loss and anorexia. The girl states that she feels perfectly well. She is able to maintain her normal activities, including a rigorous exercise program at the university. She measures 162 cm and weighs 38 kg. Her skin is dry, and there is bilateral, painless swelling in both parotid regions. Investigations are most likely to show
1) low basal levels of luteinizing hormone. *
2) a low thyroid-stimulating hormone level.
3) an elevated serum glucose.
4) a mediastinal mass on chest x-ray.
5) an abnormal small bowel biopsy.
A 42-year-old woman presents with her second episode of shingles. Which one of the following is characteristic of recurrent herpes zoster infections?
1) The virus is confined to the initial site of infection.
2) The recurrences are preceded by acute clinical disease.
3) They elicit a poor antibody response.
4) They involve infected carrier individuals. *
5) The principal reservoir is zoonotic.
A 28-year-old lawyer woman presents to you with a three-month history of fatigue, weight gain, menstrual irregularity and declining memory. Which of the following laboratory results is helpful in diagnosing the underlying problem?
1) TSH increased, free T4 increased
2) TSH decreased, free T4 increased
3) TSH increased, free T4 decreased *
4) TSH decreased, free T4 decreased
5) TSH within normal range, free T4 within normal range
A 52-year-old woman, recently diagnosed with hypertension, presents to her family physician complaining of hirsutism and acne. Laboratory examination (normal range shown within brackets) reveals: cortisol 1500 nmol/L (200 - 660 nmol/L) aldosterone 200 pmol/L (140 - 415 pmol/L) ACTH 4 pmol/L (4 - 22 pmol/L) Which one of the following is the most likely diagnosis?
1) Addison's Disease
2) Cushing's Syndrome *
3) Bartter's Syndrome
4) Renal artery stenosis
5) Conn's Syndrome
A 35-year-old businessman has come to the Emergency Room complaining of fever and headache for the last six days. He travels extensively for his company. In the last year alone, he has been to Bangkok, New Delhi, Jeddah, and Dar es Salaam He returned from Africa only three weeks ago. Which of the following diagnosis is most likely?
1) dengue fever
2) meningococcal meningitis
3) tuberculosis
4) malaria *
5) acute retroviral (HIV) syndrome
A 20-year-old man is referred for assessment of proteinuria found on an insurance examination. The history is unrevealing. Physical examination is normal. Urinalysis (urine microscopy) shows 1-2 proteinuria by "dipstick" and is otherwise unremarkable. Urea nitrogen is 5.4 mmol/L and serum creatinine is 88.4 µmol/L. Which one of the following would be the correct management?
1) Reassurance and reassessment in 6 months.
2) Admission to hospital for percutaneous renal biopsy.
3) Determination of urine protein electrophoretic pattern.
4) Intravenous pyelogram and cystoscopic examination.
5) Determination of 24-hour urine protein excretion, fractionated into supine and upright samples. *
A 55-year-old woman presents with ptosis and diplopia. On examination of the eye, the pupil is widely dilated and non-reactive to light. Which one of the following is likely injured?
1) oculomotor nerve *
2) trochlear nerve
3) trigeminal nerve
4) abducent nerve
5) optic nerve
In the emergency room you are asked to assess a man with alcoholic cirrhosis and recent alcohol cessation. He is agitated, confused and hallucinating. You make a presumptive diagnosis of delirium tremens. What is the best treatment for his condition?
1) diazepam (Valium®) *
2) nitrazepam (Nitrazedon®)
3) chlordiazepoxide (Librium®)
4) lorazepam (Ativan®)
5) clonazepam (Rivotril®)
A 35-year-old woman who was born in Vietnam has had her dyspepsia diagnosed by endoscopy as a duodenal ulcer. Her Pathology
is positive for Helicobacter pylori. She has not previously been diagnosed with peptic ulcer disease. What would be the preferred treatment option?
1) combination antibiotics plus omeprazole *
2) omeprazole alone
3) surgical vagotomy and pyloroplasty
4) octreotide
5) ranitidine
A 25-year-old woman with depression repeatedly talks about irrelevant topics when being interviewed by a psychiatrist. Which one of the following symptoms is the patient demonstrating?
1) suppression
2) denial
3) introjection *
4) resistance
5) repression
32-year-old female with a history of depression presents with restlessness, nausea and unstable vital signs. She was recently switched from citalopram (SSRI) to phenelzine (MAOI). On examination her blood pressure is 140/90 mmHg and she is tachycardic and tachypneic. Her neurological examination is normal aside from hyperreflexia and myoclonous. What is the most likely diagnosis?
1) neuroleptic malignant syndrome
2) serotonin syndrome *
3) akathisia
4) hypertensive crisis
5) SSRI withdrawal
A 5-year-old boy is seen because of torticollis, clumsiness and gait difficulties for the past month. Which one on the following is the most likely diagnosis?
1) behavior disorder
2) problems with vision
3) cerebellar damage *
4) atlantoaxial subluxation
5) myopathy
A 12-month-old infant boy presents for routine vaccination in your office. His mother tells you that 2 weeks ago, he tried a small amount of scrambled eggs and developed hives, wheezing and swelling. He was treated in the emergency room. Which of the following would you be particularly concerned that he may react to?
1) diphtheria toxoid
2) tetanus toxoid
3) MMR vaccine *
4) polio vaccine
5) pertussis vaccine
A 10-year-old is referred to you for evaluation of hypertension. He has a history of recurrent urinary tract infections. Which one of the following is the most likely diagnosis?
1) vesico-ureteral reflux *
2) horseshoe kidney
3) dominant polycystic disease
4) juvenile diabetes mellitus
5) post-streptococcal glomerulonephritis
An 8-year-old boy is admitted with a diagnosis of acute renal failure. The serum potassium level is 7.0 mmol/L. Which one of the following is most likely to be observed on the electrocardiogram?
1) increased P wave amplitude
2) ST segment elevation
3) increased T wave amplitude *
4) increased R wave
5) absent Q waves
A 9-year old boy who had been suffering from a gait disturbance for several weeks was found to have a posterior fossa mass on CT scan. Which of the following is the most likely cause for these findings?
1) a berry aneurysm
2) astrocytoma
3) medulloblastoma *
4) oligodendroglioma
5) pseudotumor cerebri
A 23-year-old woman regularly has episodes of pain associated with menstrual periods. Following investigations, you diagnose endometriosis. Which one of the following is the commonest site of this disease outside of the pelvis?
1) gastrointestinal tract *
2) lung
3) pleura
4) kidney
5) spleen
A 17-year-old high school student has just returned from Costa Rica. She presents with a 10-day history of crampy abdominal pain, bloody diarrhea and weight loss of about 2,5 kg over a two-week period. She is anorexic but denies having nausea or vomiting. Examination reveals tenderness in both right and left iliac fossa. Which one of the following conditions is the most likely cause of this patient's weight loss and diarrhea?
1) Salmonellae enterocolitis *
2) Campylobacter species
3) Entamoeba hystolytica colitis
4) Giardia Lamblia infection
5) Cryptosporidium parvum infection
Section 2
A first-born male child develops vomiting at the age of five weeks. The vomit is free of bile. The child remains hungry and vomits after taking feedings. Examination reveals visible peristalsis in the upper abdomen. Which one of the following is the most likely diagnosis?
1) esophageal atresia
2) hypertrophic pyloric stenosis *
3) duodenal web
4) midgut volvulus
5) incarcerated inguinal hernia
A 45-year-old obese female patient presents to the emergency room with a history of right upper quadrant pain lasting two hours. She states this is the third attack of similar pain in the past two months. The pain started suddenly and is described as sharp, constant and radiates to her right shoulder. On examination, she is afebrile and has mild right upper quadrant tenderness. Which diagnostic test would be most appropriate for this patient?
1) abdominal ultrasound *
2) upper GI contrast study
3) upper GI endoscopy
4) electrocardiogram (ECG)
5) lung scan
A 32-year-old male is admitted to the Emergency Department 1 hour after he sustained major burns to the thorax, the neck and the face. Aside from hypovolemic shock, the most immediate life-threatening complication to anticipate is
1) acute renal failure.
2) hemorrhage secondary to a stress ulcer.
3) acute gastric dilation.
4) Gram-negative sepsis.
5) secondary inhalation airway injury. *
You are asked to harvest the organs from an asystolic organ donor. Which one of the following organs has the greatest probably of survival?
1) bone *
2) cornea
3) kidney
4) heart
5) lung
A 32-year-old-male presents with history of trauma to the right shoulder. On examination the outer aspect of the right shoulder is flattened and the shoulder cannot be moved. Skin sensation is absent over the lower part of the right deltoid muscle. X-ray shows anterior dislocation of the right shoulder. Which one of the following nerves is most likely injured?
1) radial nerve
2) musculocutaneous nerve
3) ulnar nerve
4) long thoracic nerve
5) axillary nerve *
A 75-year-old man comes to the emergency room (ER) with a history of pain in the abdomen and back. He is found to be hypotensive, with a pulsatile, tender abdominal mass. The correct immediate management of this patient consists of which one of the following?
1) transfer to the operating room
2) transfer to the x-ray department for abdominal ultrasound
3) transfer to the x-ray department for CT scan
4) resuscitation in the ER with intravenous fluids *
5) workup in the ER to rule out myocardial infarction
Following a myocardial infarction, a 65-year-old man is noted to have a wide physiological splitting of S2 on cardiac auscultation. Which one of the following conditions is most likely to be causing this finding?
1) left bundle-branch block
2) right bundle-branch block
3) right ventricular ectopic beats
4) atrial septal defect
5) aortic stenosis *
A 17-year-old girl has a diffuse, red skin rash, a fever of 39.4°C, and mild, watery diarrhea. She had a sore throat recently for which sulfamethoxazole was administered. She began her menses 3 days ago. Physical examination shows diffuse erythematous changes of the skin with early desquamation. The mouth and conjunctivae are red. Which one of the following conditions best explains the process?
1) salmonella bacteremia
2) toxic shock syndrome (TSS) *
3) tuberculosis
4) Epstein-Barr virus mononucleosis
5) sulfa allergy
A patient with chronic renal failure is being treated with furosemide for edema on a long term basis. Which one of the following is the most common adverse effect?
1) depression
2) hypokalemia *
3) metabolic acidosis
4) hypervolemia
5) bradycardia
Hemochromatosis has a prevalence of 0.5% in the general population. The treatment of choice is regular phlebotomy. You have decided to initiate a new test for this disease. The literature indicates a sensitivity of 80.5% and a specificity of 89.5% for this test. You decide to screen 1000 people and institute treatment solely on the results of the test. Which one of the following is correct?
1) you will treat 40 people with phlebotomy
2) 995 people will not be treated
3) 100 people who do not have the disease will be treated with phlebotomy
4) 80% of the subjects will be correctly diagnosed
5) 200 people who have the disease will be denied treatment
A 48-year-old alcoholic man has had a deep venous thrombosis (DVT) and the INR is well-controlled on warfarin. He is noted to have an INR of 6.0 following a weekend binge. Which one of the following is the most likely pharmacological explanation of this finding?
1) alcohol intake decreases the volume of distribution of warfarin
2) alcohol intake increases the absorption of warfarin from the gut
3) alcohol competes for and reduces the hepatic metabolism of warfarin*
4) alcohol reduces the plasma protein binding of warfarin
5) alcohol reduces the renal execution of warfarin
A 68-year-old man presents to the emergency room with a four day history of worsening headaches and confusion. He is on no medications. Physical examination confirms the confusion, but is otherwise normal. His plasma sodium is found to be 117 mmol/L (normal 135 - 145 mmol/L) and plasma osmolality is 248 mmol/kg H20 (normal 285 - 295mmol/kg H20). Which one of the following is the most likely diagnosis?
1) hypoadrenalism
2) syndrome of inappropriate antidiuretic hormone secretion *
3) congestive heart failure
4) pseudohyponatremia
5) hyperthyroidism
An 18-year-old male presents with a 2-week history of cough, headache, malaise, and fever. Physical examination shows a patient in good general condition with no abnormal findings on auscultation. Gram stain of the sputum is negative and the white blood cell count is normal. Chest x-ray shows bilateral pneumonia in the lower lobes without pleural effusion. Which one of the following is the most likely cause?
1) Haemophilus influenzae
2) Staphylococcus aureus
3) Mycoplasma pneumoniae *
4) Klebsiella pneumoniae
5) Streptococcus pneumoniae
A 66-year-old diabetic man presents with constriction of the pupil, drooping of the upper lid and enophthalmos on the left. Which one of the following nerves is most likely involved?
1) oculomotor
2) sympathetic *
3) trochlear
4) trigeminal
5) abducent
A 45-year-old woman smoker, on steroids for seropositive rheumatoid arthritis, presents with cough, hemoptysis, and a perihilar lung nodule on chest x-ray. The best way to establish the diagnosis is
1) tomography.
2) computed tomography scan of chest.
3) tuberculin skin test. *
4) pulmonary function test.
5) bronchoscopy.
A 35-year-old man suddenly develops a generalized pruritic macular erythematous rash and fever. Four days ago he saw his physician because of a sore throat that started the day before and was started on penicillin after a throat culture grew beta-hemolytic streptococci. Laboratory studies now reveal a urea of 14 mmol/L Urinalysis shows no casts, 2 protein, 50 RBC/high power field, and 50 WBC/high power field. Complete blood cell count is normal except for eosinophilia (12%). Urine protein concentration is 650 mg/24 h. Which one of the following is the most likely diagnosis?
1) acute poststreptococcal glomerulonephritis
2) membranous glomerulonephritis
3) polyarteritis nodosa
4) Schonlein-Henoch purpura
5) drug-induced interstitial nephritis *
A 40-year-old man presents with sporadically occurring behaviour automatisms and olfactory hallucinations. Which one of the following is the most likely diagnosis?
1) schizophrenia
2) schizophreniform psychosis
3) hysterical personality disorder
4) nondominant parietal lobe lesion
5) temporal lobe lesion *
You are considering treating a 21-year-old female with a history of anorexia nervosa and depression with an antidepressant. Which one of the following should you avoid?
1) desipramine
2) citalopram
3) venlafaxine
4) bupropion
5) phenelzine *
A 3-year-old boy presents to the emergency room following a 40 second generalized tonic-clonic seizure. The infant has been ill with a high fever for 24 hours. His history is unremarkable, and physical examination is normal, CBC and urinalysis are normal. Which one of the following would be the best initial step?
1) Arrange to have an EEG performed urgently.
2) Admit to hospital for an immediate CT scan of the head.
3) Carry out blood cultures.
4) Reassure the mother and recommend close observation. *
5) Perform a lumbar puncture.
A 10-year-old boy develops an itchy, red rash on his legs after walking in the forest. He has had this before during the summer months. The rash is composed of blisters arranged in lines. In this condition, which one of the following is TRUE?
1) antibodies have been formed
2) a cell mediated response is responsible *
3) this is a type I allergic response
4) antibodies are directed against skin basement membrane
5) the antigen is bound to a cell surface protein.
A 7-year-old girl has a blood pressure of 130/90 mmHg. She has had recurrent urinary tract infections in the past. She has proteinuria. Which one of the following would be the most appropriate investigation?
1) renal ultrasound *
2) renal scan
3) plasma renin activity
4) computerized tomography of abdomen
5) digital substraction angiography of renal vessels
A 2-year old child, who was previously well, presents with a sudden onset of cough, respiratory distress and wheeze. Examination reveals that he is afebrile with diminished air entry and wheezing on the right side. Which one of the following is the most likely diagnosis?
1) acute asthma
2) acute pneumothorax
3) congenital lung cyst
4) foreign body inhalation*
5) bronchitis
A female patient is a newcomer to the country. She is single and in labor. She has had no prenatal care. You decide to give her anti-Rh Ig (RhoGam) to prevent which one of the following in subsequent pregnancies.
1) immunodeficiency
2) neonatal lupus
3) hemolytic disease of the newborn *
4) T cell immune deficiency syndrome
5) transient hypogammaglobulinemia
A 28-year-old mother has delivered a full-term healthy newborn baby. Mother has tested positive for hepatitis HBe antigen and HBs antigen two weeks before delivery. Which one of the following would you recommend for managing the newborn?
1) Check mother's serum for anti-HBsAg before giving the infant any immunizations
2) Advise not to breast-feed to prevent hepatitis B virus transmission to the infant
3) hepatitis B vaccine and intravenous IgG *
4) hepatitis B vaccine and hepatitis B hyper immune globulin
5) hepatitis B hyper immune globulin in the first 12 hours after delivery
Section 3
A 55 year old male known to have cirrhosis comes to the hospital because he has been vomiting blood. Which one of the following is the diagnostic study most useful in identifying the source of bleeding?
1) esophagogastroduodenoscopy *
2) upper gastrointestinal series
3) abdominal ultrasound
4) CT scan of the abdomen
5) celiac angiography
A 24-year-old male arrives at your office complaining of pain in his rectum. Examination reveals a perianal abscess. All of the following signs are characteristic, EXCEPT
1) external swelling.
2) redness.
3) induration.
4) rectal ulcer. *
5) tenderness on rectal examination.
A 24-year-old male presents to the Emergency Department with fever and mild diarrhea of 1 day's duration. Ten days ago, he had a perforated appendix removed. The present diagnosis probably is
1) subphrenic abscess.
2) regional enteritis (Crohn disease).
3) pseudomembranous enterocolitis.
4) pelvic abscess. *
5) bacterial enterocolitis (e.g., Salmonella, Shigella).
A 65-year-old man presents with a discoloured skin lesion which has been diagnosed as basal cell carcinoma. Which one of the following is the best treatment option?
1) radiotherapy
2) cryotherapy
3) curettage
4) chemotherapy
5) surgical excision *
A 45-year-old female presents with a history of a direct blow over the shaft of her left humerus. Her x-ray shows a spiral fracture of the distal third of the humerus. On examination of her hand, sensation is intact on the palmar side but absent on the dorsum of her hand. Which one of the following nerves is most likely injured?
1) axillary nerve
2) musculocutaneous nerve
3) median nerve
4) radial nerve *
5) ulnar nerve
An 80-year-old man who is taking warfarin because of a history of atrial fibrillation, is found on routine blood work to have an INR of 7.2. Which one of the following is the best immediate management of this problem?
1) hold the warfarin for 3 days
2) vitamin K 1 mg orally *
3) vitamin K 10 mg intravenously
4) fresh frozen plasma intravenously
5) desmopressin (DDAVP)
A 25-year-old male, who lived all his life in Southern Ontario and Central Canada
, developed fever, night sweats and a chronic progressive cough resistant to antibiotic treatment. An x-ray shows a coin-like lesion in the upper lobe of the right lung. The TB skin test was negative twice. Which one of the following is the most likely cause?
1) legionellosis
2) tuberculosis
3) silicosis *
4) dimorphic mycosis
5) atypical mycobacteria
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