You examine an 18-year old male college student with a 5-day history of fever, sore throat and fatigue. Physical examination reveals a exudative and bilateral enlarged and slightly tender posterior cervical lymph nodes. The spleen is palpable 3 cm below the rib cage. Which agent is most likely responsible for this patient's illness?

You have just prescribed phenytoin for a 12 year old boy with new onset of epilepsy. Of the following side effects, which is most likely to occur in this patient?

Hydrocephalus, chorioretinitis and diffuse cerebral calcifications are present in a newborn male. Of the following pets, which is most likely to be the source of this zoonotic congenital infection?

Which of the following is considered a risk for prone position?

Vision milestones are being discussed with a group of student nurses. One student asks when babies can begin to visually follow people as they walk across the room. Fixation and tracking through the visual field are well developed by which of the following ages?

A 2-year-old child is being evaluated because the mother notes that her right eye has been turning in. Physical examination documents strabismus with a right esotropia. Attempts to visualize the fundi are unsuccessful, but it is noted that the red reflex. is replaced by a yellow white pupillary reflex in the right eye. This child most likely has which of the following?

Microcytic anemia will result due to deficiency in?

The family of a 2-year-old child with Tay-Sachs disease is interested in having another child. They would like to know the risk of having a second child with Tay-Sachs, What advice would you give?

A 3-month-old infant presents with poor growth and inadequate weight gain. There is no history of vomiting or diarrhea. Except for the appearance of malnutrition and lack of subcutaneous fat, the physical examination is normal. What is the most likely cause of this child's failure to thrive?

A 4-year-old boy has failed to grow and has evidence of exocrine pancreatic insufficiency. What is the most likely cause for this?

newborn infant with stigmata of Down syndrome has a heart murmur. Which of the following cardiac lesions is most likely in this baby?

A 5-year-old girl diagnosed with pauciarticular juvenile idiopathic arthritis has a positive antinuclear antibody test. Which of the following would most likely be found in this patient?

A 7-year-old Caucasian girl is seen in your office for her annual physical. Her physical examination
is remarkable for a palpable goiter. The mother has a positive family history of hypothyroidism, requiring thyroid hormone replacement What is the most likely diagnosis?

The presence of bilateral renal masses and a midline suprapubic mass in a newborn male infant is most suggestive of which of the following?

The feeding of honey to infants less than 6 months of age has been associated with which of the following?

A mother is concerned that her baby might be sharing a room in the hospital with an infant who has RSV. She is asking for a private room. To reas sure her, you counsel her that the most important measure that can be taken to prevent the spread of RSV disease in a hospitalized patient is:

A l O-year-old boy is examined because of recurrent headaches. The headaches started 6 months ago and occur about once a month. He is asymptomatic between episodes. Each headache begins with blurry vision and abdominal pain, followed by rightsided, throbbing pain. It lasts about 60 minutes,
during which he feels better if be takes some ibuprofen and rests in a darkened room. The most likely
diagnosis is:

2 year old boy is seen in your office because of fever, ear pain and postauricular swelling, erytherna and tenderness. The pinna protrudes out on the involved side. The tympanic membrane is red and
bulging, with decreased mobility seen on pneumatic otoscopy. the angle of the jaw is easily palpated and the opening to stensen's duct appear normal. Most likely Dg:

A 3-year old boy is brought to the emergency room with complaint of persistent rhinorrhea for the past 6-weeks. Otherwise the patient has been asymptomatic on examination, you note that the patient has mouth breathing and has dark circles under his eyes. In the nose you find watery discharge and edematous, swollen, bluish mucous membrane
without erythema.
The most likely diagnosis is:

The pubertal growth spurt in males occurs at which of the following ages?

The most common neurological sequela associated with bacterial meningitis, and usually presents at
the time of initial infection is?

A 9 mo-old infant accidentally ingests unknown quantity of digitalis. Which is the most significant noneardiac manifestation of toxicity in this child?

A 4 month old child with vitamin D deficienty rickets would be expected to show all of the following except:

A newborn in the nursery is noted to have frothy secretions from the mouth and nose, and has coughing and cyanosis when given a bottle. The nurse reports that she was unable to pass an NG tube into the stomach. A flat- plate x-ray of the abdomen reveals gaseous dilatation of the stomach. Which of the following is the most likely diagnosis?

which of the following has the highest risk of vascular injury

An obese 9-year-old girl is brought to your office because of a week-long history of persistent headache and blurred vision. She has been alert and has had no constitutional or focal neurologic symptoms. She has had some mild vomiting, but no fever. On physical examination, you find
papilledema, Visual field testing reveals an inferior nasal blind spot. An MRI scan is normal. When you perform a lumbar puncture, the open ing pressure is elevated, but the CSF composition is normal. Laboratory tests, including a CBC, com prehensive metabolic panel, and thyroid tests, are all normal.
The most likely diagnosis is:

An irregular red reflex is noted on the initial examination of an infant. The infant is referred to the opthalmologist for evaluation of a cataract.
Which of the following is most likely to be associated with a cataract in the newborn?

A woman without prenatal care is admitted at 38 weeks by dates for the delivery of her third child. The 8 lb 13 oz infant is born vaginally and APGAR scores are 6 and 9. The pediatrician is called several hours later by the nursery staff to evaluate the left arm. The initial examination reveals an R-sided cephalohematorna. There is asymmetry of the upper limb movements with minimal movement of the left arm. The grasp is preserved. The most likely cause for this paralysis is:

you see a 12 months boy because he is refusing to walk. His mother tells you that he started walking at 10 months and was developing normally until this moment. on examination: 39C, baby looks mildly ill with medially rotated left hip and limitation of active and passive motions. what is the most probable cause?

After being lifted up by one hand, a young toddler refuses to use that arm and holds it against her trunk flexed at the elbow with the forearm
midway between pronation and supination.
The child most likely has which of the following?

full term newborn in font is having episodes of cyanosis and apnea which are worse with attempting to feed but seem better with crying. which of the following is the most important next step to quickly establish the diagnosis?

A 5-year-old boy presents with a history of grossly bloody urine, puffy eyes, and headache for one day. He has been a well developed child, but he did have a fever and sore throat about 10 days ago which resolved without treatment. The most likely diagnosis is:

Because of abnormal spleen functions and high risk of bacterial infections, infants, who have sickle cell anemia get penicillin prophylaxis at age of 4 weeks.To which organisms infants with sickle cell anemia are mostly sensitive?

What is the most likely clinical finding in an
8-year-old with Wilson disease?

newborn infant presents with cyanosis and mild tachypnea at about 6 hours of life. The infant is placed in 95% oxyhood and saturations normalize.Which of the following is the most likely diagnosis in this infant?

A 2 month old boy is seen for nonbilous vomiting after he had been breastfeeding well until 2 weeks ago, when vomiting worsened. on physical ex he has jaudance and gastric peristaltic waves are seen on the abdomen. blood test reveal hypokalernic, hypochlorernic alkalosis. the most likley diagnosis is:

The most common roentgencgraphic abnormality in a child with asthma is which of the following?

Patient 26 years old drink alcohol every day in big amount comes with
hemoglobin 0.5 g I dL, mean corpuscular volume 110 tL, and reticulocyte count 0.5%. The most likely diagnosis:

You are called to delivery of a women with no parenteral care ..Her examination reveal oligohydroamnion. When you get to the newborn at the nursery you should carefully evaluate him for which of the following:

A 16 year old female patient present with short stature and no secondary sexual characteristics. Which diagnosis should be mostly?

An 8-month-old child has vomiting and screaming episodes for 12 hours. Physical examination reveals a sausage-shaped mass in the right upper quadrant. Which of the following would be most useful?

A mother presents for prenatal care with a complicated medical history as listed in the following choices.Which of the conditions most predisposes her fetus to congenital heart disease?

A mentally retarded l-t-year-old boy has long face, large ears, micropenis and large testes. Chromosomal analysis is likely to demonstrates which of the following?

A 38-week infant is born to a mother with gestational diabetes. Birth weight is 4255 g. What would you expect to see most commonly in this infant?

An infant with failure to thrive has rectal prolapse. What test will most likely provide the diagnosis?

A 6-month-old boy is found to have very low levels of lgG, lgM, and lgA. Which of the following organisms is most likely to cause problems in this patient?

A 6-month-old boy is found to have very low levels of lgG, lgM, and lgA. Which of the following organisms is most likely to cause problems in this patient?

Which of the patients are likely to have a low C3 level?

A 65-year-old man undergoes a technically difficult abdorninal-perineal resection for a rectal cancer during which he receives 3 units of packed red blood cells. Four hours later, in the intensive care unit (ICU), he is bleeding heavily from his perineal wound. Emergency coagulation studies reveal normal prothrornbin, partial thrornboplastin, and bleeding times. The fibrin degradation products are not elevated, but the serum fibrinogen content is depressed and the platelet count is 70,000htL. Which of the following is the most likely

which of the following should be the first treatment administered to a patient with a potassium level of 6.3 and flattened p waves on their ecg ?

The initial pathological change that leads to the clinical finding of achalasia is

what is the appropriate treatment for a patient with a type III (mixed) hiatal hernia and iron deficiency anemia?

which of the following procedures has the highest rate of nutritional complications

which of the following procedures has the best treatment for a 1.5 insulinoma located in the mid pf pancreas?

the most common complication of chronic pancreatitis is

the most common adrenal mass incidentally found on ct scan is

A patient with hypertension is diagnosed with hyperaldosteronism. a ct scan shows enlarged adrenals without a mass. the most appropriate next intervention is?

A cirrhotic patient with abnormal coagulation studies due to hepatic synthetic dysfunction requires an urgent cholecystectorny. A transfusion of FFP is planned to minimize the risk of bleeding due to surgery. What is the optimal timing of this transfusion?

A 26-year-old man is resuscitated with packed red blood cells following a motor vehicle collision complicated by a fractured pelvis and resultant hemorrhage. A few hours later the patient becomes hypotensive with a normal central venous pressure (CVP), oliguric, and febrile. Upon examination, the patient is noted to have profuse oozing of blood from his intravenous (IV) sites. Which of the following
is the most likely diagnosis?

man who was in a house fire is transferred to your burn unit He has singed nose hairs and facial burns. Direct laryngoscopy in the emergency room demonstrates pharyngeal edema and mucosa! sloughing. He has 60% total body surface area burns. Which of the following is the next step in the management of this patient?

A 30-year-old man with a history of Crohn disease develops an enterocutaneous fistula and is
placed on total parenteral nutrition through a right subclavian central venous catheter. After 5 days, the patient develops a fever and leukocytosis; CT scan of the abdomen reveals no intra-abdominal abscess. The subclavian catheter insertion site is inspected and noted to be erythematous and painful. Blood cultures are positive. Which of the following organisms is the most likely cause of his fever?

teenage boy falls from his bicycle and is run over by a truck. On arrival in the emergency room
(ER), he is awake and alert and appears frightened but in no distress. The chest radiograph suggests an
air-fluid level in the left lower lung field and the nasogastric tube seems to coil upward into the left chest. Which of the following is the next best step in his management?

A 10-year-old boy was the backseat belted passenger in a high-speed motor vehicle collision. On presentation to the ER, he is awake, alert, and hemodynamically stable. He is complaining of abdominal pain and has an ecchymosis on his anterior abdominal wall where the seatbelt was located. Which of the following is the best next step in his management?

a patient with a solid malignancy is discussing chemotherapy with his oncologist. he is interested in the risks of the treatment. what is the primary toxicity of doxorubicin (adriamycin )?

A 70-year-o!d woman has nausea, vomiting, abdominal distention, and episodic crampy midabdominal pain. She has no history of previous surgery but has a long history of cholelithiasis for which she has refused surgery. Her abdominal radiograph reveals a spherical density in the right lower quadrant. Which of the following is the definitive treatment for this patient's bowel obstruction?

A 4 7-year-old asymptomatic woman is incidentally found to have a 5-mm polyp and no stones in her gallbladder on ultrasound examination. Which of the following is the best management option?

A 55-year-otd man who is extremely obese reports weakness, sweating, tachycardia, confusion, and headache whenever he fasts for more than a few hours. He has prompt relief of symptoms when he eats. Labarotory examination reveals an inappropriately high level of serum insulin during the episodes of fasting.Which of the following is the most appropriate treatment for this condition?

A 57-year-old woman sees blood on the toilet paper. Her doctor notes the presence of an excoriated bleeding 2.8-cm mass at the anus. Biopsy confirms the clinical suspicion of anal cancer. In planning the management of a 2.8-cm epidermoid carcinoma of the anus, which of the following is the best initial management strategy?

During an appendectomy for acute appendicitis, a 4-cm mass is found in the midportion of the appendix. Frozen section reveals this lesion to be a carcinoid tumor. Which of the following is the most appropriate management of this patient?

A newborn infant born from a mother with polyhydramnios presents with excessive salivation along with coughing and choking with the first oral feeding. An x-ray of the abdomen shows gas in stomach and a nasogastric tube coiled in the esophagus. Which of the following is the most likely diagnosis?

4-week-old male infant presents with projectile, nonbilious ernesis. Ultrasound of the abdomen reveals a pyloric muscle thickness of 8 mm (normal 3-4 mm). Which of the following is the best initial management of this patient?

Treatment of toxic megacolon should all the following except:

All of the following are poor prognosis in acute pancreatitis except:

vascular compromise has been associated with all the following except

all of the following are false except

A 19-year-old man sustains severe lower-extremity trauma, including a femur fracture and a crush injury to his foot. He requires vascular reconstruction of the popliteal artery. On the day after surgery, he becomes dyspneic and hypoxernic and requires intubation and mechanical ventilation. Which of the following is the most likely etiology of his decompensation?

A 52-year-old man with a family history of multiple endocrine neoplasia type 1 (MEN l ) has an elevated gastrin level and is suspected to have a gastrinoma. Which of the following is the most likely location for his tumor?

A patient is brought to the ER after a motor vehicle accident. He is unconscious and
has a deep scalp laceration and one dilated pupil. His heart rate is 120 beats per minute blood pressure is 80/40 mm/Hg, and respiratory rate 35 per min. Despite rapid administration of 2 L normal saline, and patients vital signs do not change significantly. Which of the following is the most appropriate next step in the workup of his hypotension?

Which of the following is the most important determinant of survival after treatment of colon cancer?

A 53-year-old man presents with constipation and a 20-lb weight loss over the course of 6 months. Colonoscopy reveals a fungating mass in the sigmoid colon; biopsy is consistent with adenocarcinoma. His metastatic workup is negative, A CEA level is obtained and is 4-fold greater than normal. Which of the following is the appropriate use of this test?

A previously healthy 20-year-old man is admitted to the hospital with acute onset of left-sided chest pain. Electrocardicgraphic findings are normal, but CXR shows a 40% left pneumothorax. Appropriate treatment consists of which of the following procedures?

Indication for operation in Chron's include all except

A 53-year-old man presents to the emergency room with left lower quadrant pain, fever, and
vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with inflamed
diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He returns as an outpatient to clinic
1 month later. He undergoes a colonoscopy, which demonstrates only diverticula in the sigmoid colon. Which of the following is the most appropriate next step in this patient's management?

A 72 years old man status post CABG 5 years ago present with hernatochezia, abdominal pain and fever. colonoscopy reveals dusky appearing mucosa at splenic
flexure without active bleeding. which is the most appropriate management of thispatient?

A 71-year-old man develops dysphagia for both solids and liquids and weight loss of 60 lb over the past 6 months. He undergoes endoscopy, demonstrating a distal esophageal lesion, and biopsies are consistent with squamous cell carcinoma. He is scheduled for neoadjuvant chemoradiation followed by an esophagectomy. Preoperatively he is started on total parenteral nutrition, given his severe malnutrition reflected by an albumin of less than l 6r/dL
Which of the following is most likely to be a concern initially in starting total parenteral nutrition in this
patient?

A 49-year-old obese man has become irritable, his face has changed to a round configuration, he has developedpurplish lines on his flanks, and he is hypertensive. A 24-hour urine collection demonstrates glevated cortisol levels. This is confirmed with bedtime cortisol measurements of 700 ng/mL. Which of the following findings is most consistent with the diagnosis of Cushing disease?

A 23-year-old woman undergoes total thyroidectomy for carcinoma of the thyroid gland. On the second postoperative day, she begins to complain of a tingling sensation in her bands. She appears quite anxious and later complains of muscle cramps.
Which of the following is the most appropriate initial management strategy?

A 72-year-old woman who is planning to undergo ventral hernia repair is on warfarin for atrial fibrillation. She is advised to cease her warfarin several days before her surgery and is hospitalized preoperatively for heparinization. During her hospital stay, she complains of severe abdominal and flank pain. Her prothrornbin time (PT) is normal, but her activated partial thrornboplastin time (aPTT) is elevated. An abdominal CT scan demonstrates a large retroperitoneal bematoma. Which of the
following should be administered to reverse the effects of the heparin?

A 42-year-old man sustains a gunshot wound to the abdomen and is in shock. Multiple units of packed red blood cells are transfused in an effort to resuscitate him. He complains of numbness around his mouth and displays carpopedal spasm. An electrocardiogram demonstrates a prolonged QT interval. Which of the following is the most appropriate treatment?

A 27-year-old m(E) hypoglycemiae gunshot wound to the left thigh. In the ER, he is noted to have a large hematoma of his media I thigh. He complains of paresthesias in his left foot. On examination, there are weak pulses palpable distal to the injury and the patient is unable to move his foot. Which of the following is the most appropriate initial management of this patient?

A 45-year-old man was an unhelmeted motorcyclist involved in a high-speed collision. He was ejected from the motorcycle and was noted to be apneic at the scene. After being intubated, he was brought to the ER, where he is noted to have a left dilated pupil that responds only sluggishly. What is the pathophysiology of his dilated pupil?

A 31-year-old man is brought to the ER following an automobile accident in which his chest struck
the steering wheel, Examination reveals stable vital signs and no evidence of respiratory distress, but the patient exhibits multiple palpable rib fractures and paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of pneumothorax or hemothorax. Which of the following is the most appropriate initial management of this patient?

Following a head-on motor vehicle collision, a 21-year-old unrestrained passenger presents to the ER with dyspnea and respiratory distress. She is intubated and physical examination reveals subcutaneous emphysema and decreased breath sounds. Chest x-ray reveals cervical emphysema, pneumomediastinum, and a right-sided pneumothorax. What is the most likely diagnosis?

A 53-year-old woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. While being evaluated, she becomes somewhat lethargic. Laboratory studies include a normal chest x-ray, serum albumin 3.2 mg/dl., serum calcium 14 mg/dL, serum phosphorus 2.6 mg/dL, serum chloride 108 mg/dL, blood urea nitrogen (BUN) 32 mg/dl., and creatinine 2.0 mg/dl.. Which of the following is the most appropriate initial management?

A 40-year-old woman presents with a rash involving the nipple-areola complex for the last month with associated itching. On physical examination there is crusting and ulceration of the nipple with surrounding erytherna involving the areola and surrounding skin, no palpable breast masses, and no cervical or axillary lymphadenopathy. Which of the following is the most appropriate next step in the management of this patient?

A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding.
Colonoscopy is performed and demonstrates multiple hamartomatous polyps.
The patient is successfully treated by removing as many polyps as possible with the aid of intraoperative endoscopy and polypectomy.
Which of the following is the most likely diagnosis?

A 61-year-old woman with a history of unstable angina complains of hematemesis after retching and vomiting following a night of binge drinking. Endoscopy reveals a longitudinal mucosal tear at the gastroesophageal junction, which is not actively bleeding. Which of the following is the next recommended step in the management of this patient?

a 30 year old female, G5P4, is l 0 weeks pregnant/intrauterine pregnancy) in the presence of an intrauterine device (ID). She is interested in continuing the pregnancy. The IUD wire is visible at the cervical os.
Which of the following is the apropiate management?

which of the following is not absolute contraindication for oral contraceptive administration?

a religious couple is trying to concieve. they are calculating ovulation 14 days after the last day of menstrual cycle.
where is the problem?

A 30 years old male, diagnosed as non obstructive azospermia, small testicle, lack of facial and pubic hair and gynecomastia. Most probable hormonal status :

Which of the following is a test for ovarian reserve?

A 25 year old female is been evaluated for infertility with regular periods. Which of the following confirms the existence of ovulation?

Which of the following potential abnormality or complication in pregnancy is associated with Valproic acid?

A decent looking hungarian milf with prima gravida, uneventful cervix and estimated fetal wight 3800 g which is the most appropriate management at 42+0 week gestation?

Stage lb cervical cancer is diagnosed in a young woman who wishes
to retain her ability to have sexual intercourse. Your consultant has therefore recommended a radical hysterectomy. Assuming that the cancer is
confined to the cervix and that intraoperative biopsies are negative, which
of the following structures would not be removed during the radical hysterectomy?

A patient presents for her routine prenatal visit at 32 weeks' EGA. Her pregnancy up to now has
been uncomplicated. Her BMI is 25. Her laboratory testing is normal including a I-hour glucose screen. An anatomic ultrasound done at 22 weeks was normal and confirmed her dating. Her fundal height is 37 cm today. A brief bedside ultrasound reveals an amniotic fluid index (AFl) of 30 cm. Which of the following situations is most likely to be the etiology of polyhydramnios?

Which can result amenorrhea

Which of the follows doesn't produce hirsutism?

A 29-year-old woman presents with a 6-month history of erythema and edema of the right breast with palpable axillary lymphadenopathy. A punch biopsy of the skin reveals neoplastic cells in the dermal lymphatics.
Which of the following is the best next step in her management?

A patient presents with a positive pregnancy test , the exact date of the start of her last normal menses,
and the date of her luteinizing hormone (LH) surge from a urine kit . Her expected date of delivery can
most correctly be calculated by which of the following?

A 37-year-old obese woman wishes to use OCs for birth control. Her medical history is remarkable only for a 3-y ear history of diabetes that is controlled with diet and an oral agent. She smokes one pack
of cigarettes daily. Her blood pressure is 140/ 90. Physical and pelvic examinations are normal . Total
serum cholesterol is 275 mg/dL (normal <200 mg I dL) . You advise her that combined OCs are primarily contraindicated because of which of the following known factors about her?

24-year -old primigravida at 36 weeks' gestation is exposed to chicken pox. She has no history of varicella. What is the most appropriate next step in the management oft his patient ?

A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

Which is not use for therapy of uterine myoma?

A 67-year-old woman is brought to the ED by paramedics complaining of dyspnea.fatigue, and palpitations. Her BP is 80/50 mm Hg, HR is 139 beats per minute, and RR is 20 breaths per minute. Her skin is cool and she is diaphoretic. Her lung examination reveals bilateral crackles and she is beginning to have chest pain. Her ECG shows a narrow complex irregular rhythm with a rate in the
l 40s. Which of the following is the most appropriate immediate treatment for this patient?

A 55-year-old man presents to the ED at 2:00 a.m. with left-sided chest pain that radiates down his left arm. He takes a b-blocker for hypertension, a proton-pump inhibitor for reflux disease, and an antilipid agent for high cholesterol. He also took sildenafil last night for erectile dysfunction. His blood pressure is 130/70 mm Hg and heart rate is 77. Which of the following medication is contraindicated in
this patient?

A 50-year-old patient with long-standing chronic obstructive lung disease develops the insidious
onset of aching in the distal extremities, particularly the wrists bilaterally. There is a 10 lb weight loss. The skin over the wrists is warm and erythematous. There is bilateral clubbing. Plain film is read as periosteal thickening, possible osteomyelitis.
You should

A 35-year-old woman with systemic lupus erythematosus (SLE) is brought to the ED by her brother after he found her febrile and confused. Physical exam reveals fever, tachycardia, a waxing and waning mental status, petechiae over her oral mucosa, pallor, and mildly heme-positive stool. Her urinalysis is positive for blood, red cell casts, and proteinuria. Laboratory results reveal a blood urea nitrogen
(BUN) of 40 mg/dL, creatinine of 2 mg/dL. Her bilirubin is elevated (unconjugated >conjugated) and her International Normalized Ratio (INR) is 0.98. Her complete blood count reveals WBC 12,000/mL; Hct 29%; and platelet count 17,000/mL with
schistocytes on the peripheral smear. Which of the following is the most appropriate next step in
management?

A 59-year--old man presents to the emergency department (ED) complaining of new-onset chest pain that radiates to his left arm. He has a history of hypertension, hypercholesterolernia, and a 20-pack-year smoking history. His electrocardiogram (ECG) is remarkable for T'-wave inversions in the lateral leads.
Which of the following is the most appropriate next step in management?

A 61-yea.r-old woman with a history of diabetes and hypertension is brought to the ED by her daughter. The patient states that she started feeling short of breath approximately 12 hours ago and then noticed a tingling sensation in the middle of her chest and became diaphoretic. An ECG reveals ST depression in leads JJ, Ill, and aVF. You believe that the patient had a non-STelevation Ml
(NSTEMI). Which of the following cardiac markers begins to rise within 3 to 6 hours of chest pain
onset, peaks at 12 to 24 hours, and returns to baseline in 7 to 10 days?

Which of the fo llowing patients has the lowest clinical probability for the diagnosis of pulmonary embolism (PE)?

A 75-year-old man goes out to shovel snow from his driveway. After 5 minutes of shoveling, he feels short of breath, chest pain, and then passes out. He awakens minutes later to his wife shaking him. In
the ED, he denies chest pain or dyspnea. His blood pressure is 160/85 mm Hg, heart rate 71 beats per minute, and oxygen saturation 97% on room air. On exam, you hear a harsh systolic ejection murmur. ECG reveals a sinus rhythm with left ventricular hypertrophy. Which of the following is the most likely diagnosis?

A 55-year-old man presents to the ED with chest pain and shortness of breath. His BP is 170/80 mm Hg, HR is 89 beats per minute, and oxygen saturation is 90% on room air. Physical examination reveals crackles midway up both lung fields and a new holosystolic murmur that is loudest at the apex and radiates to the left axilla. ECG reveals ST elevations in the inferior leads. Chest radiograph shows pulmonary edema with a normalsized cardiac silhouette. Which of the following is the most likely cause of the cardiac murmur?

A 22-year-old man presents to the ED with a history consistent with an acute MI. His ECG reveals
ST elevations and his cardiac biornarkers are positive. He has been smoking half a pack of cigarettes
per day for the last 3 months. He drinks alcohol when hanging out with his friends. His grandfather died of a heart attack at 80 years of age. The patient does not have hypertension or diabetes mellitus and
takes no prescription medications. A recent cholesterol check revealed normal levels of total
cholesterol, low-density lipoprotein (LDL), and highdensity lipoprotein (HDL). Which of the following is the most likely explanation for his presentation?

A 38 years old man with a history of testicular cancer presents with fatigue, dyspnea on exertion,
and generalized weakness, he underwent chemotherapy 10 years ago. Subsequent serial evaluations
have not revealed any remaining testicular cancer. On physical examination, the patient is found to have pale conjunctivae and nail beds, as well as scattered lower-extremity petechiae. What possible
Jong-term side effects of chemotherapy could be responsible for this patient's symptoms?

A 72-year-old woman with rheumatoid arthritis is brought to the emergency department by her daughter. The patient's daughter reports that her mother has been having more joint pain for the last 2 days, and this morning, she took an extra dose of oxyccdone. She then became confused, prompting
her daughter to bring her to the emergency department. Physical examination reveals an elderly woman who is somnolent and difficult to arouse. Her heart rate and blood pressure are stable, but she is only breathing 8 times per minute. Her pupils are l mm in diameter and symmetric. Of the following,
(original q-what is the best treatment for this patient at this time?) what may have caused her condition?

A 30 years old women present with complains of paresthesias, weakness, leak of coordination and difficulty with gait. Her symptoms are worse after hot shower. Examination of cerebrospinal fluid shows oligoclonal immuncglobulin antibodies IgG. The most likely diagnosis is:

Which of the following is the most likely factor contributing to chronic myeloid leukemia?

A 72 year old woman complains of fatigue, easy bruising, weight loss, and abdominal distention. Her pulse is slightly fast, and she has notable pallor and splenomegaly. Blood counts reveal anemia and thrornbocytosis, you are concerned that she may have myelofibrosis. what would you expect to see on this patient's peripheral blood smear if she did have myelofibrosis?

A 70-year-old man complains of fever and pain in his left knee. Several days previously, he suffered an abrasion of his knee while working in his garage. The knee is red, warm, and swollen. An arthocentesis is performed, which shows 200,000 leukocytes/µL and a glucose of 20 mg/dL. No
crystals are noted. Which of the following is the most important next step?

A22-year-old man develops the insidious onset of low-back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has toss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. A plain film of the spine shows sclerosis of the sacroiliac joints. Calcification is noted in the anterior spinal ligament. Which of the following best characterizes this patient's disease process?

A 60-year-old female complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On exam, the buccal mucosa appears dry and the
salivary glands are enlarged bilaterally. Which of the following is the best next step in evaluation?

A 41-year-old business executive presents to your office and complains of palpitations and shortness of breath. After further questioning, he admits to heavy alcohol consumption the previous evening. On examination, he is found to have an irregular heartbeat of 130 bpm.
The most likely diagnosis is:

Alcoholic 35 year-old male is admitted for nausea, vomiting and abdominal pain that radiates to back, Lab value that suggests a poor prognosis in the patient is:

A 55 year old male with urosepsis started on IV fluid and pipercillin-tazobactam. His symptoms gradually improved until hospital day-5, when he develops a rash and low grade fever. Lab tests reveal an increased creatinine and a urinalysis with blood cells and eosinophils. What is the most likely diagnosis?

A 69-year-old woman with a past medical history of hypertension,hypercholesterolemia, diabetes mellitus type 1, and alcohol abuse is brought to the emergency department (ED) by her daughter who states that her mom has been acting funny over the last hour. She state that the patient did not know where she was despite being in her own house. She also did not recognize her family and was speaking incomprehensibly. Her blood pressure (BP) is 150/80 mm Hg, heart rate (HR) is 90 beats per minute, temperature is 98.9°F, and her respiratory rate (RR) is 16 breaths per minute. On physical examination she is diaphoretic, agitated, and tremulous. Electrocardiogram (ECG) is sinus rhythm with normal ST segments and T waves. Which of the following is the most appropriate course of action for this patient?

A 40-year-old man complains of exquisite pain and tenderness in the left ankle. There is no history of trauma. The patient is taking hydrochlorothiazide for hypertension. On examination, the ankle is very swollen and tender. There are no other physical examination abnormalities.
Which of the following is the best next step in management?

A 70-year-old male complains of the sudden onset of syncope. It occurs without warning and with no sweating, dizziness, or light-headedness. He believes episodes tend to occur when he turns his head too quickly or sometimes when he is shaving.
The best way to make a definitive diagnosis in this patient is:

A 57-year-old man with a past medical history of hypertension and migraines presents to the ED complaining of a headache that started 2 days ago. He states the headache began suddenly with peak intensity while he was defecating. The pain is continuous particularly in the occipital region and is associated with mild nuchal rigidity and mild photophobia. He denies having a recent fever. A noncontrast head CT is obtained and is normal. Which of the following is the most appropriate next step in management?

A 78-year-old man presents to the ED complaining of left arm weakness that started 10 minutes ago in the clinic. The patient states that he has a history of hypertension and diabetes but has never had similar symptoms in the past. He is feeling well otherwise. His BP is 157/85 mm Hg, HR is 87 beats per minute, temperature is 98.8°F, and RR is 14 breaths per minute. His neurologic examination is unremarkable and the patient embarrassingly states that his left arm is no longer weak. Which of the following is the most likely diagnosis?

A 24-year-old woman presents to the ED complaining of dizziness and numbness and tingling in her fingertips with decreased range of motion.
Her initial vitals include a HR of 100 beats per minute, a RR of 30 breaths per minute with an oxygen saturation of l 00% on room air.
The patient denies any other symptoms. Upon physical examination, the patient appears anxious, tachypneic with a clawed
appearance to both hands which are difficult to range. An arterial blood gas is drawn that shows a pH of 7 .55 with a decreased carbon dioxide level and normal bicarbonate level. Which of the following underlying metabolic disturbances is responsible for this patient's symptoms?

A patient with low-grade fever and weight loss has poor excursion on the right side of the chest with decreased fremitus, flatness to percussion, and decreased breath sounds all on the right. The trachea is deviated to the left. Which of the following is the most likely diagnosis?

A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the rnetacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?

A 34 year-old white woman is treated for urinary tract infection with amoxicillin, Initially she improves but 5 days after beginning treatment she develops recurrent fever, abdominal bloating and diarrhea with 6-8 loose stools per day, you suspect Antibiotic-associated colitis, The best diagnosis test is:

A 60 year-old asymptomatic man is found to have leukocytosis when a routine CBC is obtained, Physical exam shows no abnormalities, spleen is normal size, Labratory data:

Hgb: 9 g/dl [Normal : 14-18]
Leukocytes: 40,000 /ul [Normal: 4300-10800]
Peripheral blood smear shows a differential that include 97% small lymphocytes. The most likely diagnosis?

A 27-year-old man complains of chest palpitations and light-headedness for the past hour. He has no past medical history and is not taking any medications. He drinks a beer occasionally on the weekend and does not smoke cigarettes. His HR is 180 beats per minute, BP is l 110/65 mm Hg, and oxygen saturation is 99% on room air. An ECG reveals an HR of 180 beats per minute with a QRS complex of 90 milliseconds with a regular rhythm. There are no discernable P waves.
Which of the following is the most appropriate medication to treat this dysrhythmia?

A 71-year-old man is playing cards with some friends when. he starts to feel a pain in the left side of bis chest. His fingers in the left hand become numb and he feels short of breath. His wife calls the ambulance and he is brought to the hospital. In the ED, an ECG is performed. Which of the following best describes the order of ECG changes seen in an Ml?

A 62-year-old man presents to the ED with gradual dyspnea over the last few weeks. He reports that he is a daily smoker and has not seen a physician in years. Upon physical examination, there are decreased breath sounds on the right as compared to the left. A chest radiograph indicates blunting of the right costophrenic angle with a fluid line. A thoracentesis is performed. Given this patient's history, which of the following most likely describes his effusion?

A 74-year-old lethargic woman is brought to the ED by her family. Her daughter states that the patient has been progressively somnolent over the last week and could not be woken up today. The
patient takes medications for diabetes, hypertension, hypothyroidism, and a recent ankle sprain, which is
treated with a hydrocodone/acetaminophen combination. In the ED, the patient is profoundly lethargic, responsive only to pain, and has periorbital edema and delayed relaxation of the deep tendon reflexes. Her BP is 145/84 mm Hg, HR is 56 beats per minute, temperature is 94.8°F, and RR is 12 breaths per minute. Which of the following is the most likely diagnosis?

A 55-year-old man with a history of diabetes presents with complaints of developed left knee pain several days following a fall from standing height. The patient was brought to the
ED by ambulance after being found on a park bench stating he was unable to walk because of the pain.
On physical examination, there are no rashes or external signs of trauma. His left knee is warm, diffusely tender, and swollen with a large effusion. He has pain on passive range of motion and is refusing to
walk. His BP is 150/85 mm Hg, HR is 105 beats per minute, temperature is l 02.7°F, RR is 16 breaths
per minute, and fingerstick glucose is 89 mg/dl., Which of the following is the most appropriate diagnostic test?

A 75-year-old male complains of unilateral headache. On one occasion he transiently lost his vision. He also complains of aching in the shoulders and neck. There are no focal neurologic findings. Carotid pulses are normal without bruit. There is some tenderness over the left temple. Laboratory data show
a mild anemia. Which of the following tests is most likely to be abnormal?

A 40-year-old alcoholic develops cough and fever. Chest x-ray shows an air-fluid level in the superior segment of the right lower lobe. The most likely etiologic agent is

A 70-year-old patient with chronic obstructive lung disease requires 2 L of nasal O2 to treat his hypoxia, which is sometimes associated with angina. While receiving nasal O2, the patient develops pleuritic chest pain, fever, and purulent sputum. He becomes stuporous and develops a respiratory acidosis with CO2 retention and worsening hypoxia. The treatment of choice is

Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office very concerned about low- grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and heart exam is free of significant murmurs, gallops, or rubs. ECG is unchanged from the last one in the hospital. The most effective therapy is likely

A 72 year-old male comes to the office with intermittent symptoms of dyspnea on exertion, palpitations and cough occasionally productive of blood. On cardiac auscultation, a low-pitched diastolic rumbling murmur is faintly heard toward the apex. The origin of the patient's problem probably relates to

A 52-year-old man complains of impotence. On physical examination, he has an elevated jugular venous pressure, S3 gallop, and hepatomegaly. He also appears tanned, with pigmentation along joint folds. His left knee is swollen and tender. The plasma glucose is 250 mg/dL, and liver enzymes are elevated. Your next study to establish the diagnosis should be

A 30-year-old man is evaluated for a thyroid nodule. The patient reports that his father died from thyroid cancer and that a brother had a history of recurrent renal stones. Blood calcitonin concentration is 2000 pg/ml, (normal is less than 100); serum calcium and phosphate levels are normal. Before referring the patient to a surgeon, the physician should

A 70-year-old male presents with a complaint of fatigue. There is no history of alcohol abuse or liver disease; the patient is on no medication. Scleral icterus is noted on physical exam. There is no evidence for chronic liver disease on physical exam, and the liver and spleen are nonpalpable. The patient is noted to have a normocytic, normochromic anemia. The first step in evaluation of this patient is

A 40-year-old male with long-standing alcohol abuse complains of abdominal swelling, which has been progressive over several months. He has a history of gastrointestinal bleeding. On physical exam, there are spider angiornas and palmar erythem A.Diagnostic paracentesis a. Abdominal collateral vessels are seen around the umbilicus. There is shifting dullness, and bulging flanks are noted. An important first step in the patient's evaluation is