Mock 3

A 52-year-old woman with known systemic sclerosis has a 3 week history of increasing dyspnea, bilateral peripheral edema, anorexia, and nausea. Blood pressure 110/72 mm Hg, pulse 122/min/regular, and respirations 32/min. Examination reveals clear lungs, elevated jugular venous pressure, bilateral peripheral edema, and tender smooth hepatomegaly. Upon palpation of the chest for the PMI (point of maximal impulse) what is the expected finding?

A 68-year-old man with a 40-year history of smoking two packs of cigarettes per day presents with a two-week history of cough and new onset hemoptysis. Physical examination is unremarkable, but a chest x-ray reveals a 5-cm solid lesion in the left upper lung field. Which of the following is the most likely diagnosis?

An 81-year-old man has an acute inferior wall myocardial infarction. Blood pressure 140/90 mm Hg, pulse 66/min. Examination shows lungs clear to auscultation. An apical S4 gallop is heard. Electrocardiography shows normal sinus rhythm and PR interval 0.57 sec. Which of the following medications should not be administered?

A 57-year-old smoker presents with “chest pain that awakens me at night”. He has had recurrent episodes of this non-exertional chest pain but he presents today as it is worsening in intensity and frequency. His EKG in the office is unremarkable. You decide to place a Holter monitor for night-time monitoring and give him Nitroglycerin SL to have at the bedside. Which one of the following would be an initial, classic finding of variant angina during his chest pain event?

A patient diagnosed with rheumatic heart disease is at a highest risk for which of the following valvular abnormalities?

A 76 year old patient presents to the ER with a complaint of generalized weakness, fever and dysuria. Her BP is 84/62, heart rate is 130 and her EKG is shown below. Which of the following most accurately describes her EKG?

A 26-year-old female comes to see you 10 days after returning home from an Asian tour that included visits to India, Thailand and China. About three days ago, she began experiencing fatigue and general malaise followed over the next two days by low-grade fever, nausea and vomiting and right upper quadrant abdominal pain. This morning her roommate said that her eyes looked yellow and told her to see you. The patient does not smoke or drink alcohol, is on no medication and does not use illicit drugs. On exam, her temperature is 100.4 F; she has scleral icterus and a tender enlarged liver. Which of the following would you consider most likely?

A 67-year-old male presents to the clinic with a 3 month history of a persistent cough which worsens when he lies down. He is concerned because he is barely able to walk from his bedroom to the kitchen without “getting winded” and having to rest. He denies chest pain. Past history is significant for asthma and GERD. Current medications are albuterol and pantoprazole. Vital signs are notable for a blood pressure of 172/104 mmHg, heart rate is 98 beats/min, and respirations are 24 breaths/min at rest. Pulse oximetry is 92% on room air. Exam reveals mild JVD and diminished peripheral pulses. The heart has a regular rate and rhythm. Crackles are heard in both lung bases. Which of the following treatments will provide the greatest long-term benefit?

A 66-year-old African male with untreated HTN, presents to your office for follow up. He is noticing that he gets fatigued easily and that he cannot walk around the block without feeling tired and short of breath. His physical exam is remarkable for blood pressure of 172/98 in the right arm seated and 180/100 in the left arm seated. Of the following medications, which combination should be your initial treatment?

Acute myocardial infarction in an elderly person commonly presents with:

A healthy 6-month-old infant has a widely split and fixed S2, a grade II/VI systolic ejection murmur at the pulmonic area and a heaving impulse palpated at the lower sternal border. Which of the following is the most likely diagnosis?

A 15-year-old boy has left anterior chest pressure radiating down his left arm while playing basketball. This discomfort ends with 5 minutes of rest. While asymptomatic, blood pressure is 110/70 mm Hg with pulse of 70/min/regular. Cardiac exam is normal. Electrocardiography shows normal sinus rhythm with ST segment elevations in the inferior leads. Which of the following is the most likely diagnosis?

A 74 year old male is in cardiac arrest, EKG monitoring is initiated. You find the rhythm shown below. Which of the following is the most appropriate initial step?

A previously healthy 12-year-old boy presents to the emergency department with a three week history of a progressively worsening cough. He does not appear extremely ill. Oral temperature is 99.4 degrees F. Pulse oximetry results are 99% on room air. Physical exam is significant for a injected, bulging left eardrum, injection of the pharyngeal mucosa without exudates, and rales at the left posterior lung base. CXR shows a small area of patchy infiltrate but no evidence of effusion. Which of the following is the most appropriate therapy?

Which of the following is the most common sign/symptom of an acute pulmonary emboli with infarction?

A 59-year-old man has bronchogenic squamous cell carcinoma in the apex of his left lung. Which of the following is the most likely complication to occur in this patient?

A tall, thin 28-year-old male presents to the ED with SOB, tachypnea, and right-side chest pain. An x-ray of his chest is significant for a small pneumothorax in the right upper lung field. He is asymptomatic and is 100% O2 sat on room air. Which of the following is the recommended treatment?

Which of the following drugs should not be used to manage hypertension in a symptomatic asthmatic?

A 57-year-old man has bilateral painless gynecomastia. The patient is most likely taking which of the following medications?

A 63-year-old woman has hypertension and type 2 diabetes mellitus. Blood urea nitrogen is 30 mg/dL and serum creatinine is 1.7 mg/dL. Which of the following medicines is contraindicated in her therapy?

A 61-year-old woman has newly diagnosed hypothyroidism caused by Hashimoto’s thyroiditis. Which of the following is the most likely sign to be noted upon examination?

Over a period of 3 months, a 56-year-old woman has developed bilateral carpal tunnel syndrome. Which of the following laboratory diagnostic tests should be ordered?

A 7-year-old boy has a 1 day history of fever, headache, photophobia, and vomiting. Vital signs are normal except that axillary temperature is 102.8 degrees F. The patient is alert and oriented. Examination shows nuchal rigidity without localizing neurologic signs. Examination of the cerebrospinal fluid shows 32 mononuclear cells/micro, normal glucose, and slightly elevated protein. Which of the following is the most likely diagnosis?

An 83-year-old man has a 5 month history of cognitive dysfunction manifest by inability to balance his checkbook and memory loss. Presence of which of the following signs upon examination is most suggestive of normal pressure hydrocephalus?

The presence of which of the following differentiates central vertigo caused by brainstem Infarction from peripheral vertigo caused by benign positional vertigo?

An 18-year-old man has headaches. Evaluation shows an unruptured cerebral aneurysm. The patient most likely has which of the following disorders?

A 59-year-old man has acute low back pain that radiates into the left buttocks and perineum. The presence of which of the following symptoms is most suggestive of S2/S3/S4 radiculopathy?

Which of the following diseases is caused by infection by anaerobic or microaerophilic bacteria?

A 63-year-old woman has intense itching in the vaginal area without discharge. Examination shows the vulva to be thin, wrinkled, and white. The anterior portions of the labia minora have agglutinated. Which of the following is the most likely diagnosis?

A 77-year-old man has Parkinson’s disease. He is most likely to have which of the following skin disorders?

A 63-year-old retired engineer presents with one month of difficulty sleeping. He has a hard time staying asleep and says he is just restless. He also states that he has been more forgetful and can’t pay attention very well. He lives with his wife. He denies fever, chills, recent trauma, or difficulty walking. When asked about the specifics of his symptoms, he repeatedly replies, “I don’t know,” without really trying. He states his wife thinks he just sits around the house all day since he retired. His neurological exam is unremarkable, except for some mild psychomotor retardation. Which of the following is the most likely diagnosis?

A 68-year-old woman has bipolar disorder. Which of the following is clinically associated with this disorder?

A 54-year-old male complains of burning pain and itching on his right side for the past four days. He has now noticed the eruption of a rash. Upon exam you find vesicular lesions within erythematous base which follow the T5 dermatome and do not cross the midline. Which of the following is the most likely infective agent?

A mother has brought her 17-year-old daughter in and has given the following description of her behavior, “She is constantly perceiving herself as being overweight, when in fact she isn’t. She cannot go a day without an extensive exercise session. At dinner time she has to have her plate filled with what is generally double portions but after dinner disappears to the bathroom. Her mother noted left over laxative wrapper in her trash and her last dental appointment the dentist was concerned about eroded enamel. What is the most likely diagnosis?

A 60-year-old woman has nearsightedness (myopia). She is at greatest risk of developing which of the following?

When performing a Weber test on a patient with impacted cerumen in the right canal, the sound should be:

A patient presents with a nontender, painless, nodule involving a meibomian gland. Which of the following is the most likely diagnosis?

An 8-year-old boy has painful crises caused by sickle cell disease. Which of the following is the preferred treatment in order to reduce the frequency of the crises?

The presence of which of the following differentiates chronic myelogenous leukemia from chronic lymphocytic leukemia?

A 22-year-old woman has had repeated episodes of epistaxis and also notes slight bleeding when she brushes her teeth. She has other family members with similar symptoms. Initial laboratory work up reveals a normal platelet count. A bleeding time is obtained and is noted to be increased and a platelet function assay shows decreased platelet function. Which of the following laboratory test results would most likely be expected in this patient?

A 64-year-old male presents to the office with concern related to hearing loss and otorrhea which have been occurring over the last three months. The patient describes a progressive loss of hearing in his right ear and states she has had transient yellowish discharge which he finds on his pillow. Otoscopic exam finds no erythema and the retraction of the skin in the upper posterior quadrant of the tympanic membrane. Which of the following is the most likely diagnosis?

A 60-year-old man has type 2 diabetes mellitus. Presence of which of the following is the first indication of diabetic nephropathy?

A 60-year-old woman has a 2 day history of fever, dysuria, and right low back pain. Blood pressure 90/64 mm Hg, pulse 136/min, respirations 26/min. The patient appears acutely ill. Examination shows generalized flushing and right costovertebral tenderness. Urinalysis shows pyuria with white cell casts. After appropriate cultures are taken, which of the following is the preferred first line therapy?

Which of the following signs and symptoms is typically found in patients with acute cystitis?

Which of the following signs and symptoms is typically found in patients with acute cystitis?

A 21-year-old male presents to the clinic complaining of “a painful lump on the tailbone” that has gotten worse over the past few days. He relates that he has had symptoms on and off over the past year, but now it is “the worse than ever” and ibuprofen is not helping with the pain. He is noted to have a red, tender area in the region of the gluteal cleft with dimpling. Which of the following is the most likely diagnosis?

Upon metabolic analysis, a 56-year-old man has a deficiency in both magnesium and folate. He most likely has which of the following conditions?

You are asked to examine a 42-year-old patient who is found to have a week history of persistent abdominal pain that localizes to the left lower quadrant, low-grade fever, general malaise, and diarrhea recently started. He denies hematochezia. Vital signs are stable. On physical examination, the patient has tenderness to palpation that is localized to the left lower quadrant. Rectal exam reveals generalized tenderness and hemoccult positive stool but no frank bleeding. Based on your findings, which of the following is the most likely diagnosis?

A 45-year-old male was playing tennis and fell on his right shoulder. He presents with complaints of moderate anterior shoulder pain. There is no deformity on inspection. Physical examination reveals diffuse tenderness over the deltoid. Apprehension sign and drop-arm test are positive. X-ray is negative for fracture and malalignment. Which of the following is the most likely diagnosis?

A 21-year-old male presents with left-sided chest pain over the past 48 hours. He denies any trauma. It is aggravated with deep respirations and rotation at the trunk. Vital signs are stable. No swelling or lesions are noted to the chest wall, but localized tenderness to the mid-upper left anterior chest wall and left sternal border with light to moderate palpation. Vital signs are stable. Cardiac exam is unremarkable. Lungs are clear to auscultation. Which of the following is the most likely diagnosis?

A 65-year-old female fell out of her bed. She presents with pain and swelling in her right wrist and a limited range of motion. A ‘dinner fork ‘ deformity is noted on X-ray. Which of the following is the most likely diagnosis?

A 38-year-old healthy woman has had a white, curd-like vaginal discharge for the past week. There is no bleeding. A Pap smear demonstrates normal appearing squamous epithelial cells along with scattered neutrophils and budding cells with pseudohyphae. Which of the following drugs is most likely to cure this woman’s condition?

A 39-year-old woman presents with irregular vaginal bleeding. She has been infertile, and describes the bleeding as heavy. She also reports frequent urinary urgency and significant menstrual cramping with her menses. Which of the following is the most likely diagnosis?

Which of the following neurological exam finding would be found in a woman diagnosed with preeclampsia?

Two weeks after completing a course of clindamycin therapy a 55-year-old man has watery diarrhea. Antibiotic associated diarrhea is diagnosed but does not respond to oral metronidazole. Which of the following is the preferred next step?

A 34-year-old male who is treated five months ago by his primary care for cholelithiasis, however refused surgical treatment, presents to the emergency room with severe epigastric pain. The patient states the pain radiates to his left upper quadrant and to his left scapula. The pain increases and worsens when he lies supine and becomes severe when he tries to eat. The patient has been unable to eat for the last three days. Physical exam finds hyperactive bowel sounds and epigastric and left upper quadrant tenderness and guarding. The patient’s stool guaiac test is negative for blood and he is afebrile. Which of the following is the most likely diagnosis?

A 55-year-old man has an acute fracture of the left femur due to an automobile accident. Thirty-six hours later he has acute dyspnea. Examination shows central cyanosis, tachypnea, and mental confusion. Which of the following is the most likely diagnosis?

For several months, a 50 year old man has complained of generalized weakness, weight loss, fever, and malaise. He is referred to a rheumatologist who performs angiography and diagnoses him with a multisystem, necrotizing vasculitis of the small and medium-sized muscular arteries in which involvement of the renal and visceral arteries is characteristic. This finding best coincides with which of the following?

A 62-year-old female presents the office with vaginal bleeding for the past three days. The patient has been menopausal for the last eight years and has had no bleeding since. She reports dark red brown bleeding and spotting. Bimanual exam finds no abnormalities. What is your next step in the treatment of this patient?

Hydroxychloroquine therapy is to be initiated in a 32-year-old woman in treatment of rheumatoid arthritis. She should be counseled to have which of the following periodic examinations?