Question #1

For the past three weeks, a 47-year-old man has had the feeling of heaviness in his chest while pushing his lawn mower. He says he has never been treated for similar symptoms and has no symptoms now. He smoked one pack of cigarettes daily for 20 years but quit smoking seven years ago. Findings on physical examination are normal. Electrocardiography shows no abnormalities. Which of the following is the most appropriate initial diagnostic study?

A. Coronary arteriography

B. Echocardiography

C. Exercise stress test

D. 24-Hour ambulatory cardiac monitoring

E. Myocardial perfusion scan

  • Option (C), exercise stress test, is correct because it is the most appropriate initial step in the workup of a patient with recent chest pain because the test is noninvasive, inexpensive, convenient, and sensitive in this type of patient.

Question #2

A 32-year-old woman has had a rash on her legs for the past three weeks. There are no known infectious contacts. One month ago, she had a bladder infection and was treated with trimethoprim-sulfamethoxazole. Physical examination shows a diffuse rash on the shins, the left medial ankle, and the right medial calf. The rash is tender, diffuse, and recurs in the same areas. A few of the lesions have the appearance of bruising. Which of the following is the most likely diagnosis?

A. Erythema multiforme

B. Erythema nodosum

C. Lichen planus

D. Lichen simplex

E. Nummular eczema

  • The correct answer is Option (B), erythema nodosum, because this type of rash may be antibiotic-related, occurs on the lower extremities below the knees, and has the appearance of bruising. All of these symptoms are present in this clinical scenario.

Question #3

A 41-year-old woman has a nine-month history of nausea, constipation, dyspepsia, general fatigue, arthralgia, and increasing memory loss. She has no history of illness other than her present complaints, and her menses have been regular. Physical examination shows no abnormalities. Laboratory findings include the following levels:

Serum Albumin 4.9 g/dL

Calcium 13.0 mg/dL

Chloride 111 mEq/L

Creatinine 1.0 mg/dL

Phosphate 0.3 mg/dL

Blood urea nitrogen 17 mg/dL

Which of the following is the most likely diagnosis?

A. Cushing syndrome

B. Hyperparathyroidism

C. Hypopituitarism

D. Malabsorption

E. Multiple myeloma

  • Option (B), hyperparathyroidism, is the correct answer. The patient has the classic signs of this condition, which include gastrointestinal, musculoskeletal, and neurologic abnormalities. Additionally, the laboratory values clearly show hypercalcemia and hypophosphatemia, both of which indicate hyperparathyroidism.

Question #4

A 40-year-old man is being examined because he feels weak and tired and has had symptoms of sexual dysfunction. His blood pressure is 100/60 mmHg. Physical examination shows decreased facial, axillary, and pubic hair. Laboratory studies show decreased serum levels of luteinizing and follicle-stimulating hormones, thyroxine, and testosterone; serum thyroid-stimulating hormone level is within normal limits. Which of the following is the most likely diagnosis?

A. Diabetes insipidus

B. Diabetes mellitus

C. Hyperprolactinemia

D. Hypopituitarism

E. Hypothyroidism

  • The correct answer is Option (D), hypopituitarism, based on the common symptoms of gonadotropin deficiency, weakness, fatigue, and sexual dysfunction. The decreased levels of luteinizing and follicle-stimulating hormones indicate hypogonadism. These laboratory findings, in addition to the decreased levels of testosterone, indicate hypopituitarism.

Question #5

A previously healthy 15-month-old boy becomes anxious and begins crying and drooling copiously. A few minutes earlier he had been calmly playing with his toys. Temperature is 36.7°C (98.1°F), pulse rate is 84/min, and respirations are 18/min. On physical examination, the posterior pharynx is mildly injected but otherwise clear. The lungs are clear to auscultation and percussion. Findings on chest x-ray study are normal. Within an hour he is calmer, but he continues to drool heavily. Which of the following is the most appropriate next step?

A. Administration of syrup of ipecac

B. Barium swallow x-ray study

C. Chest physiotherapy

D. Esophagogastroduodenoscopy

E. Insertion of a nasogastric tube

  • The correct answer is Option (D), esophagogastroduodenoscopy, which is the appropriate step to confirm a diagnosis and provide therapeutic treatment.