Mock 13

Calculate the anion gap.

Na = 135 , Cl = 95, Hco3 =15, K+=4.0, Ca++= 8.9

An 88-year-old man has exertional dyspnea. Blood pressure 90/70 mm Hg, pulse 86/min, respirations 18/min. Carotid upstroke is slow. A 3/6 ejection murmur is heard loudest in the 2nd intercostal space along the right sternal border. An apical S4 gallop is heard. Which of the following is the most likely etiology of the cardiac disorder?

A 71-year-old man takes dabigatran in therapy of non-valvular atrial fibrillation. Which of the following is the mechanism of action of this drug?

Intravenous adenosine is administered to a 23-year-old healthy man who has the acute onset of paroxysmal supraventricular tachycardia. Which of the following is the most likely transient adverse effect?

A 20-year-old woman who chronically abuses cocaine has a 2 month history of progressive weakness. For the past week swelling of both ankles has been present. Blood pressure 80/54 mm Hg, pulse 118/min/regular, respirations 18. Examination shows normal jugular venous pressure and lungs clear to auscultation. The cardiac apical impulse is in the 6th intercostal space in the anterior axillary line. An apical S3 gallop is heard. Which of the following is the most likely diagnosis?

An 84-year-old man has an acute ST segment elevation myocardial infarction complicated by cardiogenic shock. Blood pressure 76/40 mm Hg, pulse 110/min/regular. Bibasilar crackles and an apical S4 gallop are heard. Which of the following is the preferred medication to be administered?

The common causes of pulseless electrical activity (PEA) include all of the following except:

A 68-year-old man who has known chronic bronchitis now has a 6-day history of increasing dyspnea and weight gain. Vital signs are: BP = 110/70 mmHg (left arm, supine), pulse = 120 beats/minute (regular), respirations = 34 breaths/minute. Physical exam reveals scleral icterus and cyanosis of the lips and nailbeds. Jugular veins are distended to the angle of the jaw with the patient at 30 degrees elevation. A grade II/VI holosystolic murmur is heard in the 4th intercostal space along the left sternal border. Peripheral edema is present in both lower extremities. Which of the following is the most likely diagnosis?

A 55-year-old man has a 2 week history of exertional dyspnea. Blood pressure 90/74 mm Hg, pulse 98/min/regular. Carotid upstroke is slow. Bibasilar rales are heard. An apical lift and 3/6 aortic ejection murmur are noted. Which of the following is the most likely diagnosis associated with the dyspnea?

A 2-week-old male infant is in right heart failure related to congenital heart disease. Which of the following is the most likely sign of the heart failure to be present upon examination?

A 27-year-old woman who has type 1 diabetes mellitus gives birth to a 12 pound infant. Which of the following is most likely to be noted in the newborn infant?

A 24-year-old woman with type 1 diabetes mellitus seeks counseling concerning pregnancy. She should be advised that her baby is at increased risk of having which of the following congenital abnormalities?

Propylthiouracil therapy is initiated in a 32-year-old woman in treatment of Graves’ disease. Which of the following is the most likely adverse effect?

Which of the following descriptions is most typical of a patient with acromegaly?

Immediately after a diagnostic thoracentesis in the right chest, a 56-year-old man has acute dyspnea. Examination shows reduced thoracic expansion, hyperresonance, and decreased breath sounds on the affected side. Which of the following is the most likely diagnosis?

Upon auscultation of a patient’s lungs, there are harsh, hollow breath sounds which have a long inspiratory component in the region of the suprasternal notch. Throughout the periphery of the lung fields, softer breath sounds are heard. Which of the following best describes these findings?

A 3-month-old infant has suspected bacterial community acquired pneumonia. Which of the following is the preferred management?

Patients with long-term exposure to silica, coal dust, and asbestos may develop which of the following as complications?

A 25-year-old pregnant female has sudden onset of sharp pleuritic chest pain, and becomes apprehensive, tachypneic, and diaphoretic. Which of the following studies is the most useful diagnostic modality for this patient?

A 58-year-old male returns from a business convention with anorexia, malaise, and a minimal cough that is nonproductive. He has a fever of 103.7 F, respirations are 22/min, and pulse rate 55 bpm. Exam reveals dry oral membranes and rales over the right base. Chest x-ray shows bilateral pulmonary infiltrates. Serum sodium is 129 mEq/L. The most probable diagnosis is:

A 66-year-old woman with long standing history of CAD has a 1 week history of dyspnea without cough. Examination reveals bilateral rales and a right pleural effusion, the remainder of the exam is benign. Thoracentesis demonstrates a transudate. Which of the following is the most likely diagnosis?

An 18-year-old woman has profuse diarrhea starting 4 days after a camping trip. Stool microscopy confirms giardiasis. Which of the following is the preferred initial therapy?

Which of the following are the minimum criteria in millimeter diameter of induration for a positive tuberculosis skin-test screening result in an HIV-positive patient?

A 6-year-old presents with a cat bite to the left hand. Which of the following antibiotics is the best choice for treating this wound and preventing infection?

A 21-year-old female returns from a two-week camping trip along the Appalachian Trail in New York State. She comes to your office complaining of a low-grade fever, fatigue, joint pains, and a non-pruritic rash on her back and buttocks. Physical exam reveals two large 5 cm erythematous lesions with central clearing on her low back and buttocks. There is no lymphadenopathy. CBC with differential and sedimentation rate are normal. Which of the following vectors transmitted this patient’s disease?

An 86-year-old woman has a 5 month history of cognitive dysfunction. Presence of which of the following symptoms is most suggestive of normal pressure hydrocephalus?

A 37-year-old man has newly diagnosed cluster headaches. Administration of which of the following is the preferred initial therapy?

A 55-year-old man with no history of mental illness presents with recent onset of disorientation, fluctuating mental status, abnormal autonomic signs, poor coordination, tremor, and seeing “little men” in his bedroom. He has no known history of substance abuse. What is the most likely diagnosis?

Lithium therapy is to be initiated in a 33-year-old woman in treatment of bipolar disorder. Which of the following is proper counseling for the patient?

A 45-year-old male stumbles in to the office. He has difficulty relating a history and is agitated. He does admit to insomnia the past two nights because he thinks a ghost is in his bedroom. He has a history of alcohol abuse since 15 years of age, but had not consumed any alcohol in 3 days according to his girlfriend. His blood pressure is 174/96 mmHg, pulse is 110/bpm, and he is diaphoretic. Which of the following is the most likely diagnosis?

A 27-year-old man has sudden, recurrent episodes of falling asleep during the day. Narcolepsy is diagnosed. The patient is most likely to have which of the following associated symptoms?

A 30-year-old male surfer presents for concern about a rash across his shoulders and down his back. He states the rash has slowly spread and is occasionally itchy. He is concerned about the numerous light pigmented spots which are occurring on his back. Which of the following would be the most appropriate diagnostic exam?

What personality disorder is associated with patients who were overly emotional and attention seeking?

A 40-year-old man has recently diagnosed cluster headaches. During a headache, which of the following is least likely to be noted on examination?

A 22-year-old man has chronic allergic rhinitis with nasal congestion and rhinorrhea. Which of the following is proper counseling for the patient when he is planning a commercial airline flight?

A 67-year-old man has a 2 week history of increasing facial swelling with onset of facial cyanosis. Examination shows elevated jugular venous pressure and dilation of the veins of the anterior chest and both arms. Cardiac examination is normal. Which of the following is the most likely underlying cause?

A 65-year-old woman has a 3 month history of profuse, clear rhinorrhea without nasal congestion that occurs immediately after eating. Symptoms are worse when eating spicy foods. Examination of the nasal turbinates shows pale mucosa. Which of the following is the most likely diagnosis?

Which of the following is the preferred initial treatment of choice for epistaxis?

A mother presents with her seven-year-old concerned about a mass which is arisen on his neck. She is gravely concerned about thyroid disorder. She states the mass occurred approximately 2 weeks after a mild upper respiratory infection and has persisted since. Examination finds a small, soft, round midline mass just below the hyoid. You note the mass to be mildly fluctuant. The mass moves upward with protrusion of the patient’s tongue. Which of the following is the most likely diagnosis?

A 21-year-old male overdoses on aspirin, what renal function changes are expected?

A patient with CAD and systolic heart failure is taking captopril, spironolactone, aspirin, carvedilol, clopidogrel and simvastatin.  He presents to the ED with syncope and is found to have hyperkalemia and peaked T waves on EKG.  What is the recommended initial therapy for the hyperkalemia to prevent further arrhythmia?

A 55-year-old male presents with hyperkalemia to the ED, he has been given calcium chloride, albuterol treatments, D50 + Insulin and remains hyperkalemic and despite treatment continues to have ventricular tachycardia.  What is definitive treatment for the hyperkalemia?

A 77-year-old man has recurrent bloody diarrhea without associated fever or vomiting. The gastrointestinal condition is most likely an adverse reaction to which of the following?

A 34-year-old woman has Crohn’s disease manifest by chronic diarrhea, weight loss, and abdominal discomfort. Which of the following is the expected radiographic abnormality on upper gastrointestinal series with small bowel follow-through?

A 77-year-old man has gram negative bacteremia manifest by fever, hypotension, azotemia, and disseminated intravascular coagulation. Which of the following is the most likely underlying cause?

Ten days after having completed a course of quinolone therapy, a 41-year-old woman has abdominal cramps, low grade fever, and watery diarrhea. Pseudomembranous colitis is diagnosed. Which of the following is the preferred therapy?

A 32-year-old man has tendinous xanthomas on his elbows. He is most likely to have which of the following conditions?

The emergency department clinician suspects child abuse after examination of a 2-year-old girl. Which of the following is the most likely injury sustained by the child?

A 34-year-old woman tests positive for mutations of BRCA1 and BRCA2 genes. Which of the following cancers is she at high risk for developing?

A 26-year-old newly pregnant woman presents with body mass index greater than 30 and family history of diabetes in a first-degree relative. She was screened for gestational diabetes but it was negative. What would be your next step in caring for this pregnant patient?

A 20-year-old man who does not drink alcohol has had 4 attacks of acute pancreatitis in the past 7 months. Which of the following is the most likely underlying cause of the pancreatitis?

A 9-year-old male presents to the ER with right wrist pain after falling while skateboarding approximately 30 minutes ago. The patient states his skateboard hit a rock and as he tried to maintain his balance, he fell on his outstretched hand. PE reveals a swollen, ecchymotic right wrist with no break in the skin. X-ray of the right wrist demonstrates dorsal displacement and shortening of the distal radius. What is the most likely diagnosis?

A 23-year-old patient presents with complaints of right wrist, hand and forearm pain, occurring over the past two months but now becoming more severe. She wakes up at night with numbness and tingling in her right hand. She has normal sensation to all digits, a positive Tinel’s sign and a negative Phalen’s sign. The most likely diagnosis is:

A 12-month-old who just started walking presents with significant genu varum. The parents are concerned that the child’s legs are deformed and require immediate surgical intervention. Which of the following is the best clinical approach to managing this patient?

A 21-year-old female with multiple sex partners presents for the results of her Pap smear. Her results are reported as a low grade squamous intraepithelial lesion (LSIL) and she is HPV negative. Which of the following would be the next appropriate step in her management?

A 26-year-old female presents with complaints of milky nipple discharge for the last four months and she has not had her menstruation for the last five months. She is sexually active, is not using oral contraception and pregnancy tests have been negative. She is also noted visual changes which are reported by her ophthalmologist as by temporal hemianopsia. Which hormone level is most likely to be elevated in this patient?

A 32-year-old woman has primary Raynaud’s phenomenon not associated with any underlying disorder. Which of the following is the preferred medication to prevent future attacks?

What vitamin deficiency can cause night blindness, Bitot’s spots and keratomalacia?

A 42 year old male presents for a routine physical exam. He has no past medical history, does not take any medications and has no complaints. He is an avid runner and is specifically requesting a medical clearance for an upcoming marathon. His BP is 124/72 mmHg. An EKG is obtained and is shown below. Which of the following would be the most appropriate EKG interpretation?

A 17-year-old female patient presents for a follow-up after recurrent epistaxis and persistent and prolonged gingival bleeding after dental procedures. Laboratory evaluation finds platelet number and morphology to be normal however bleeding time is increased. Further testing shows that factor VIII levels are reduced. Which of the following is the most likely diagnosis?