03.2011 internal

A 48 year old woman is being evaluated for cough that persist for 3 month. She describe that it occur daily, Nonproductive, with no hemoptysis. She have no dyspnea, wheezing, fever, weight los , no night sweats or recent illness. So travels recently. She wasn`t exposed no anyone who have been ill. She never smoke. She was diagnosed with essential hypertension 6 months ago and take lisinopril daily. Physical examination is unremarkable. No oral /pharyngeal exudate or drainage. Chest x ray is normal. Which is the most appropriate management option for this patient this time?

A 32 year old female physician is beginning a post graduate fellowship at a university hospital and must undergo tuberculin skin testing. She is healthy, she grew up in Africa and completed medical school and residency training in London. She received BCG vaccine as a child. tuberculine skin testing results indicate a 16mm area of induration at the tuberculine skin testing site. Physical examination is normal. Which of the following us the most appropriate next step in the management of this patient?

A 32 years male is undergoing investigation for pain and stiffness at the lower back, which is (the pain) decreased by excersise and hot shower for the past 10 years. No history of dermatological diseases, ophtalmological or intestinal as well. He did not suffer from infections of the gastrointestinal or genitourinary systems. On examination blood pressure and pulse -normal. Sacroiliac joints and lumbar spine are painful upon in palpation. There is a complete loss of bending forward at the lower spine. Standing straight against the wall, he cannot touch the wall with the back of his head. X-ray images reveal complete fusion of the sacroiliac joints on both sides and a square shape of vertebral bodies throughout the lumbar and thoracic spine. In addition to initiation of NSAID’s and physiotherapy, the next most appropriate treatment for this patient is:

A 51 years old woman is evaluated during a routine exam. she have no history of hypertension , no tabaco use , and no family history of heart disease .she take conjugated estrogen combined with medroxyprogesterone acetate for intolerable hot flashes .physical examination is normal, BMI 31. Fast lipid panel: Total cholesterol 218 mg/dl, HDL 42 mg/dl, LDL 128 md/dl, triglyceride 240 mg/dl. The next appropriate step is:

A 75 year-old men with type 2 diabetes mellitus is evaluated in the emergency department for draining chronic ulcer on the left foot, erythema and fever. Drainage initially began 3 weeks ago. Current medication include metformin and biguanide. On physical examination he is not ill appearing. Temp is 37.9, other vital signs are normal. The left foot is slightly warm and erythematous. A plantar ulcer that is draining purulent material is present over the fourth metatarsal joint. A metal prob makes contacts with bone. the reminder of the examination is normal. The leukocyte count is normal and an ESR rate is 70mm /h. A plane radiograph of the foot shows numerous leukocytes, gram positive cocci in clusters, and gram negative rods. Which of the following is the most appropriate management now?

Which of the following is most closely related with Gullian Barre syndrome?

A 68 years old woman is being examined. Last year she had a painful rash in the side of her back that was self-limited. She doesn’t recall a history of chickenpox. She takes no medication, no allergy. Her vital sign are normal, and physical examination is normal. Her CBC, liver enzyme, and serum chemistry are normal. She has scheduled an influenza vaccine for today. The vaccine strategy for today is:

A 27 year old previously healthy woman is diagnosed with community acquired pneumonia, for which she receives ceftriaxone therapy. Medical history is otherwise non contributory. Routine and mycobacterial sputum clusters are performed. The patient recovers uneventfully over the subsequenttwo weeks and a follow up radiograph shows improvement. The routine sputum culture revels only normal flora, however after 3 weeks the mycrobacterial cultures groves 2 colonies of mycobacterium avium complex. Which is the most appropriate next step in management?

The use of proton pump inhibitors (PPIs) can result in

A 60 year old woman has a persistent pain after an episode of herpes zoster 3 month ago, involving the right side T4 dermatome. She claim that the pain interfere with her sleep. History is normal. Vital sign are normal. The lesion is crusted over and appears heals. The most appropriate treatment for this patient is:

A19 years old male college student has 2 day history of urethral discharge and burning sensation on urination. He has had 3 female sexual partners in the past month. Physical examination discloses a scant mucoid discharge from the urethral oriffice. No rashes or other lesions are seen. Gram stain of the urethral secretions shows greater than 12 polymorphonuclear cells/ HFP. No intra – or extra-cellular organism are seen. Which of the following is the most appropriate treatment?

A 78-year-old man arrives to urgent care clinic with new onset of chest pain. He describes it as crushing in the left substernal area. Non radiating, present for 14 hours. No prior episodes. He has history of hypertension and hyperlipidemia. He is taking aspirin, hydrochlorothiazide, atorvastatin. b.p. 100/70 on right arm , 105/72 on left arm. Pulse 100. Respiration rate 16/. no jugular vein distension , no murmurs , no rubs. lungs are clear , no peripheral edema. Laboratory: platelets 120.000, serum creatinine kinase 450, troponin 60. Initial ecg shows st segment elevation of 2mm in ii, iii, and avf also st segment depression in v2 v3. Chest x-ray appears normal. Which of the following is the best management for this patient?

A 36 yr old. With low HDL. No chest pain. History of 10 pack a year smoking. . She is overwight with no coronary disease history. BP133/82 mm HG. BMI 29. Heart examination is normal with no murmur or gallop rhythm. Total cholesterol is 198 mg/dl, HDL 33, LDL 129. Triglyceride 18. The management of this patient is:

A 65-year-old man is evaluated in the emergency department for a 3-day history of gradually worsening low back pain and fever. On physical examination, temperature is 38.0°C (100.4°F); other vital signs are normal. General examination, including neurologic examination, is normal. MRI of the spine shows enhancement of the L3-L4 end plates and inflammation of the disk space. No epidural enhancement or paravertebral collections are seen. The patient is hospitalized. Which of the following is the most appropriate next management step?

A 59 y/o male, evaluated for chest pain, sometimes accompanied by a burning sensation, which begad about 4 weeks ago. The pain comes during periods of both excertion and rest. He has a known history of hypertension for which he takes nifedipine. The patient recently sustained a knee injury that prevented him to walk without a cane. On physical examination he is found to be afebrile, b/p 138/86, pulse 74, respiratory rate 16, body mass index 28.no signs of heart failure. Laboratory: cholesterol 210, ldl 140, hdl 40, creatinine 1.2, cardiac enzymes negative. ecg shows LVH , with normal sinus rate. And no changes from prior ecg. Which is the most appropiate test to perform next?

A32-years-old man has a 5 day history of persistent nasal congestion and pain in the right forehead area associated with a clear nasal discharge and mild cough. The patient reports that he has had similar episodes in the past that were helped by antibiotics. Medical history is otherwise unremarkable and he currently take no medication .on physical examination, vital sings including temperature are normal. Mild right suborbital ridge tenderness is present the nares are patent with a clear mucoid discharge. There is no pharyngeal erythema or exudate. The lungs are clean to auscultation which of the following is the beast initial management?

A 65 year-old male is evaluated because a screen urine culture for insurance policy grows more then 10⁵ colony forming ut/mL E coli. There is no fever, disuria, urinary frequency or other symptomes. Medical history is unremarkble. There are no allergies, no medications. Physical examination is normal. What is the most appropriate treatment for this patient?

Which of the following is not a diagnostic criteria for diabetes mellitus?

Which of the following is true regarding hypovolemic shock?

A 25 years-old woman is evaluated in urgent care because of the recent onset of heel pain, that is especially sever when jogging. She has been takin ibuprofen for the past 7 days. Her additional medications are low-dose oral contrraception, that she has been taking for the past 5 years and multivitamines. She does not smoke cigarettes, is otherwise healthy, there is no history of hypertention. Physical examination reveals 162/102 mmHg, puls 90 beats/min, BMI 24. The remainder of the examination, including cardiopulmonary, fundoscopic and neurological examination, is normal. Which of the following is the most appropriate management of this patient’s hypertension?

A 28-years-old man is evaluated for 2 month history of recurrent confusion, palpitation, and diaphoresis occurring whenever he misses breakfast. The symptoms are relieved with eating. His medical history is otherwise unremarkabl and he takes no medications. On physical examination vital signs are normal and BMI is 26.the rest of the general physical examination is normal .results of laboratory studies show a fasting plasma GLU 52 mg/dl and insulin 18u/ml (normal 2-20). Which is the most appropriate next step in diagnosis?

A 35 years-old male comes for a new patient evaluation. He takes no medications. His parents both have diabetes mellitus. On physical examination blood presure 160/100 mmHg, BMI . The remainder of the examination is unremarkble. Lab studies, including serum electrolites, BUN, ceatinine levels, urinalisis are normal. In addition to lifestyle modifications, which is the most appropriate next step in this patient’s management?

A 45-year-old man is evaluated for a 3-month history of fatigue, constipation, and polyuria. He also has a 5-year history of hypertension. Current medications are losartan and diltiazem. Physical examination findings, including vital signs, are normal. Calcium 11.4 mg/dL (2.9 mmol/L) Creatinine 1.1 mg/dL (97.2 μmol/L) Glucose, fasting 88 mg/dL (4.9 mmol/L) Phosphorus 2.2 mg/dL (0.71 mmol/L) Thyroid-stimulating hormone 1.2 μU/mL (1.2 mU/L). Measurement of which of the following levels should be done next?

A 22 years-old woman is evaluated at an on-site medical center after callapsing while running a marathon. She’s disoriented. During the evaluation she expiriences a generalised tonico-clonic seizure lasting 3 minutes. A wristband indicated diabetes mellitus. On physical examination, temperature is normal, blood presure 120/60 mmHg, puls rate 100, respiratory rate 28. There is no evidence of hypovolemia or edema. Cardiopulmonary examination is normal. On neurological examination she is confused, but has no evidance of focal neurological deficit. On laboratory examination glucose is 120 mg/dl, sodium 118 mg/dl. What is the most appropriate next step in this pacient’s management?

A 56-year-old man presents to your office with complaints of “chronic” diarrhea. He states that he has had loose stools for the past 2 days. He denies blood in the stool, fever, and has no weight loss and no recent travel. Appropriate management at this time includes

A 45 year old woman is evaluated for a 6 – months history of weakness, menstrual irregularities hirsutism, Insomnia and emotional lability. She also reprts an 8-kg weight gain during this period. She was previously healthy. She takes no medications. On physical examination, temperature is 36, blood pressure is 172/190 mmhg, pulse rate is 68/min, respiration rate is 16 /min, and bmi is 32. The patient has a rounded, plethoric face with increased supraclavicular and dorsal fat pads. There are areas of unexplained eccymoses over the upper and lower extremities. Abdominal examination reveals purpule striae. She has proximal muscle weakness. Results of routine laboratory studies are normal except for serum potassium level of 3.4 meq/l. Which of the following is the most appropriate next test for this patient?

A 60 yr old man is evaluated during routine examination. The patient has smoked a pack of igarettes for 25 years. He has tried to quit smoking with nicotine gum and varenicline, but has been nsuccessful. He has mild airway obstruction, but has good exercise tolerance and no cough, sputum roduction or hemoptysis. The importance of smoking cessation is reviewed with the patient….

A 67 year old woman is transferred to the cardiothoracic intensive care unit (icu_ after undergoin repair of an abdominal aortic aneurism. she has a -12 year history of type 2 diabetes mellitus. Her blood glucose level arraival at the icu is 289 mg/dl . although no longer on cardiopulmonary bypass pump treatment to- control her blood glucose level during her icu stay:

A 44 years old is evaluated for a 6 month history of dyspnea, regurgitation of sour fluid and eructation. There is not associated fever, chills, weight loss or vomiting. The condition failed to respond to 6 weeks of omeprazole theraphy. The patients medical history includes hypertension, diabetes mellitus and obesity (BMI 36). Her mediacations are lisinopril, methformin and insulin glargine. On examination vital signs are normal, there is mild epigastric tenderness without rebound and stool is negative for occult blood. Which of the following is the most appropriate next diagnostic step in the evaluation of this patient?

A76 year old woman is reevaluated after results of thyroid function tests, performed 2 weeks ago are abnormal. The patient otherwise feels well. She has a history of hypertension, atrial fibrillation, gastroesophageal reflux disease and depression. Current medication are metoprolol, amiodarone , warfarin , omeprazole, and sertraline. Respiration rate 15/min .the thyroid gland is smooth and normal size. Cardiac examination reveals an irregular rhythm. Deep tendon reflexes are normal. Laboratory studies:Tsh 6.5 u/mlThyroxine (t4), free 2.4 ng/dl (31 pmol /l)Triiodothyronine (t3), free 0.8 ng/l (1.2 pmol/ l )Which of the following medications is most responsible for the laboratory result?

A 25 year old man is evaluated for 6 month history of eight loose, non bloody stools a day. He also has abdominal pain and small joint arthritis. The patient has a 5 year history of chrons disease, initially treated with corticosteroids but then maintained on azathioprine therapy. Small bowel radiographic series shows no stricturing disese but som, e active jejuno ileitis. Azathioprine metabolites were recently measured and were found to be at therapeutic concentration. Which of the following is the most appropriate additional therapy for this patient?

An 18 year old woman is evaluated for tachycardia, nervousness, decreased exercise tolerance and weight loss of 6 months duration, she has otherwise been healthy. Her sister has graves disease. She takes no medications. On physical examination, blood pressure 128/ 78 mmhg. Pulse rate is 124/min, respiration rate is 16/min and bmi is 19.5.The is no proptosis. An examination of the neck reveals a smooth thyroid gland that is greater than 1.5 times the normal size. Cardiac examination reveals regular tachycardia with grade 2/6 early systolic murmur at the base. Her lungs are clear to auscultation .laboratory studies:Human chorionic gonadotropin – negativeTsh < 0.01 u/mlThyroxine (t4), free 5.5ng/dl (71 pmol/l)Triiodothyronine (t3) free 5.5ng/dl (71 pmol/l)Which of the following is the most appropriate treatment regiment at this time?

A 72 year old man is evaluated for 2 month history of epigastric discomfort associated in the past 6 weeks with 4.6kg weight loos. He has dark urine and light stool. The patient has no significant medical history and takes no medications. On physical examination vital signs are normal, there is scleral icterus, visible jaundiced skin and mild epigastric tension. Laboratory studies are significant for total bilirubin of 8.2 mg/dl and alkaline phospatase of 648 U/L. CT scan of the abdomen shows fullness in the head of the pancreas and biliary dilation but no evident pancreatic mass.which of the following is the most appropriate next step in the management of this patient?

A 12 yr old boy develops progressive symptoms of fever, lassitude, arthralgias, headache, and abdominal pain. Physical examination shows hepatosplenomegaly. Further questioning discovers that he and his family live in a rural area and include unpasteurized dairy products in their diet. The most likely etiologic agent of this illness is:

Crohn’s disease is associated with which of the following:

A 47 y W, is admitted for primary examination. No complaints and no pathological findings on examination. Her father died from MI at the age of 71. The mother is 81 y old and still alive. There is no cancer in the family history, but a friend of the patient was diagnosed with cancer of the large intestine and she is concerned regarding her risk to develop the same. On examination the PB and the pulse are normal, BMI=25.5. No other findings. Laboratory analysis is normal. Which of the following is the most appropriate investigation for early detection of cancer of the large intestine in this patient?

Which of the following is true?

An obese 75 old women is evaluated for persistent hyperglycemia. She has followed a strict regimen of diet and exercise in an attempt to control her hyperglycemia. Home blood glucose monitoring has shown preparendial levels between 120 and 160 mg/dl and occasional postparendial levels exceeding 200 mg/dl. She has a history of hypertension and hyperlipidemia. Current medication include lisinopril, hydrochlorothiazide, and pravastatin. Vital signs and physical examination findings are normal. Except BMI of 30.the serum creatine level is 0.8 mg/dl and the urine is negative for micro albuminuria.Which of the following is the most appropriate step in treatment to improve her glycemic control:

72 W, 72 years is being investigated for complaints about increasing pain in her right knee for the past year. The pain is more severe in the medial part of the joint, aggravated by stress and decreases during rest. She has no morning stiffness and swelling. She felt no jamming or recoil in this joint. On examination blood pressure and pulse are normal, there is an increase of bone at the proximal and distal interphalangeal joints. No signs of effusion in the right knee joint. Passive flexion and extension of the right knee cause pain. Tests, including complete blood count, ESR and C-reactive protein were normal. X-ray of the right knee joint is normal. In addition to acetaminophen as needed, which of the following is most appropriate next step in treating this patient: