Figure 109.1. Rash on chest wall of patient in Question 3.

QUESTION 4. A 46-year-old salesman presents with recurrent nosebleeds and easy bruisability. He has no prior episodes of bleeding and takes a daily aspirin. He has oral mucosal hemorrhages, multiple bruises, guaiac-positive stool, and no petechiae. His laboratory evaluation reveals Hct 42%, prothrombin time (PT) of 39 seconds and platelets 339,000/µL. His PT is 85 seconds, and partial thromboplastin time (PTT) is 150 seconds. His parameters improve with three doses of vitamin K, 5 mg given subcutaneously, but after 1 week he is back to similar laboratory values. What is the most likely diagnosis?

    A. Lack of green vegetables in the diet

    B. Congenital factor VII deficiency

    C. Occult liver disease

    D. Superwarfarin poisoning

    E. Factor XI inhibitor

QUESTION 5. A 27-year-old woman is brought to the emergency room after being found unresponsive by her boyfriend who last spoke to her about 12 hours earlier. She was found with a suicide note and an empty bottle of Tylenol. On arrival to the ED, she is unarousable with a heart rate of 120 beats per minute and a blood pressure of 100/50 mm Hg.

    Which of the following is the most reasonable next step?

    A. Begin ipecac and gastric lavage immediately

    B. Administer activated charcoal and then administer N-acetylcysteine (NAC)

    C. Administer NAC immediately

    D. Send an acetaminophen level and then begin NAC based on the level

    E. Send liver function tests (LFTs), an arterial blood gases (ABG), and coagulation studies before initiating any therapy

QUESTION 6. A 26-year-old student presents to urgent care with an episode of palpitations accompanied by lightheadedness. He reports that the episode lasted approximately 5 minutes. He has an examination tomorrow and is quite anxious. He has had two similar episodes over the last 2 years. He takes no illicit or prescribed drugs, does not drink alcohol, and has no family history of heart disease. His electrocardiogram (EKG) is shown in Figure 109.2.

    What is the diagnosis?

    A. Right bundle branch block

    B. Inferior myocardial infarction

    C. Paroxysmal atrial fibrillation

    D. Left ventricular hypertrophy

    E. Wolff-Parkinson-White syndrome

QUESTION 7. A 32-year-old pharmacist is found to have a 3 × 3 cm nodule in the left lobe of her thyroid gland on routine examination. She has no symptoms. Her serum thyroid stimulating hormone (TSH) concentration is normal. The next step in her evaluation should be:

    A. Computed tomogram (CT) of the neck

    B. Fine-needle aspiration (FNA)

    C. Empiric thyroxine therapy

    D. Surgical neck exploration

    E. Nuclear medicine scan of her thyroid

QUESTION 8. A 31-year-old nanny presents with fevers, bone pain, and anemia and is diagnosed with acute myelogenous leukemia (AML). She undergoes induction chemotherapy with daunorubicin/cytarabine and achieves remission. Twelve days after her first cycle of high-dose cytarabine consolidation chemotherapy, she calls the office with a temperature of 102.5ºF. She comes in, has no focal findings on examination, her catheter site is without erythema, and she has a clear chest x-ray. Her white blood cell (WBC) count is 0.6 × 10³/µL with 12% polymorphonuclear cells. What do you do?

    A. Admit to hospital for observation

    B. Admit to hospital for bone marrow transplant

    C. Admit to hospital for intravenous cefepime

    D. Administer granulocyte colony-stimulating factor

    E. Prescribe oral amoxicillin/clavulanic acid and close outpatient follow-up

QUESTION 9. A 45-year-old female teacher presents complaining of severe left knee pain. She has a long history of rheumatoid arthritis, which has been well controlled for several years on a multidrug regimen of methotrexate, hydroxychloroquine, and nonsteroidal antiinflammatory drugs (NSAIDs). Which of the following symptoms suggests secondary degenerative joint disease (rather than rheumatoid arthritis) as a cause of her knee pain?

    A. Prolonged morning stiffness

    B. Pain that is exacerbated by activity

    C. Increased fatigue

    D. Multiple joint complaints

    E. Weight loss

QUESTION 10. A 36-year-old photographer comes to your office with one week of malaise and fatigue and two days of scleral icterus. He has also lost his appetite, has persistent nausea, and noted his urine to be very dark. He has no other medical problems and takes no medications. He does not drink any alcohol and recently returned from a trip to Central America, where he was taking pictures for a magazine article. On physical examination, his sclerae are icteric, his abdomen is soft with a liver span percussed to 13 cm. No spleen tip is palpable. He has no skin changes. His alanine aminotransferase (ALT) is 3650 U/L, aspartate aminotransferase (AST) is 2893 U/L, alkaline phosphatase is 322 U/L, and total bilirubin is 6.3 mg/dL, with a direct fraction of 5.2 mg/dL. His PT is 12.2 seconds. What is the most likely diagnosis?

    A. Acute hepatitis A

    B. Alcoholic hepatitis

    C. Acute cholecystitis

    D. Acute hepatitis C

    E. Acetaminophen overdose

QUESTION 11. A 30-year-old lawyer presents to her primary care physician (PCP) after her 65-year-old father died of a heart attack. She asks what can be done to reduce her risk of also having a heart attack. Her blood pressure is 118/62 mm Hg. Her fasting glucose is 72 mg/dL, her high-density lipoprotein (HDL) is 52 mg/dL and her low-density lipoprotein (LDL) is 134 mg/dL. She is a nonsmoker. You advise her to:

    A. Begin aspirin 325 mg daily

    B. Begin aspirin 81 mg daily

    C. Maintain a healthy diet and exercise four or five times a week

    D. Begin simvastatin 10 mg daily

    E. Begin beta-carotene supplements

QUESTION 12. A 29-year-old nurse comes to see his primary care physician because colleagues noted facial asymmetry. His facial symptoms began yesterday with a progressive left facial droop. He has some malaise and fatigue and achiness in the knees. However, he has no headaches, fevers, or pain. On examination, he cannot furrow his left eyebrow and has dysgeusia. His sensation to light touch is normal, muscle strength in the extremities is 5/5, and deep tendon reflexes are intact. Skin examination reveals an erythematous rash that he first noticed a week ago. His head computed tomography (CT) is normal. What is the most likely diagnosis?

    A. Bell’s palsy

    B. Lyme disease facial palsy

    C. Fibromyalgia

    D. Herpes zoster infection

    E. Zoster sine herpete

QUESTION 13. A comatose 30-year-old male with type I diabetes mellitus is found down. He is afebrile, tachypneic, and his blood pressure decreases from 115/75 to 95/70 mm Hg with elevation of his head. Physical examination reveals a 70-kg acutely ill male with signs of extracellular volume contraction and nonfocal neurological findings. Venous blood is drawn and then 50% dextrose is given by intravenous push followed by 50 mL/hour of D5NS. The patient remains unconscious with progressive hypotension and tachycardia. The EKG shows a widened QRS, peaked T waves, absent P waves, and multiple PVCs. Laboratory values show Na = 130 mEq/L, K = 7.1 mEq/L, Cl = 95 mEq/L, HCO₃ = 10 mEq/L, blood urea nitrogen (BUN) = 63 mg/dL, Cr = 2.3 mg/dL, Glu = 450 mg/dL. His urinalysis has 3+ ketones. WBC = 17,000/mm³, Hct = 44%. Which of the following should be the next step in treatment?

    A. Give 2 ampules of sodium bicarbonate

    B. Give calcium gluconate 10 mmol immediately via intravenous infusion

    C. Initiate hemodialysis

    D. Give 10 units intravenous insulin immediately

    E. Place a temporary wire

QUESTION 14. A 38-year-old sanitation worker is bitten by a skunk. The skunk escapes capture. The patient is at high risk for what infection?

    A. Rabies virus

    B. Borrelia burgdorferi

    C. Pasteurella

    D. Aeromonas hydrophila

    E. Capnocytophaga cynodegmi

QUESTION 15. A 52-year-old carpenter is sent to his primary care doctor after a chest x-ray performed in the emergency room revealed a pulmonary nodule. He is a never-smoker, has no family history of lung cancer, and has lived his entire life in New Hampshire. He has a follow-up CT scan, which is shown in Figure 109.3. The pattern of calcifications is described by the radiologist as “popcorn.”

    The most likely diagnosis is:

    A. Carcinoid

    B. Small cell lung cancer

    C. Metastatic thyroid cancer

    D. Bronchial cyst

    E. Hamartoma

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