4. AST.yearold woman comes tte physician because ofa 3-day history afoyer, rash on her chest andback and dtuse body aches. Sha as acezwe csordor and nas been fang phemtcin fr 1 enh. Sho alsa has Fypetension tected wth nrachifthgzide She has no nem aleigles. She has smcked one-haf pack ol igeretes sal for 40 yeers ancl annks ane glass afwine dally Her temperatreis 382°C (101 1°}, pise is Tami, ad tlaod pressures 13070 mmHg. Puse cxmeny an roam ft shows an oxygen saliraion of 3% Softmcblelamph nodes ae palpated’ the cervied ela, aa inguial chars, hey measure ess than 1m each Therois an fryinematous maculepapuler rsh over fhe Tunk The abdomen s tender inthe ngh Upper qUecra, and he lverecge fs palpated 3.cm below te higecostal margin, Laboratory sues shove Homezoent 40% Leukocyte count o.c00imm ‘Spertad neurophis 5 Eosinophils 10% Lymprocyss 20% Nonosyes oe Paneer cour, oem? Senum Creatine maid. ast 10UL ALT s70uL Hepattis¢ artibody neaanve Hesag gabe AnH necatve nL HBsAg agate ood cutues ae negative. Which of te ellowing isthe mast approprete nex stp inmanagement? ‘| Measuemercof serum afetopretain concentrationBlood cutures are negative, Which of he folowing is the most propriate ret step in management? ‘A) Measuremertot serum ofetopr 6) Serum pervownusantbogy essex (C}Discentuaton of phenyain herapy D)Prechisone therapy EE) Switch tom tyarochiorahaide to tsinopi FI Bene marrow biopsy G}Lumph node bicpsy2. A 20yearold manis brought the emergency department 20 minutes ater the sudan onset of severe headache ‘olowed tyloss of conselcusness fer Taminutes esterday he mpped andtel down ene Aight of stars He ws lard for apprcsrataly 5 mines ee th all bu eras chert unirured Hela hac sce, nasal congestion, fond cough for days rected vith espinn and pseuchenhecrine. One week ago, nelad 8 severe headache tat persisted for 1 hour andwas aleve vi asprin Cn aval Is porous Hs temperate 837 °C (100°F) Blse is 100irin respratens are tami, end blood pressures 180/80 mm Hp, The puis are rund and reactive Toligh Ocua! movements are ful Funduseapic examination shows ne abnormaltiss. Tete 1s rodarateruchal rigaty with foreard fin Muscle tones nermal. Deep tendon reteees are increased bit symmetical. Babinski ‘3901S presen blatoraly Te pation movas hs eatremves symmetrical in response o part simul. ACT scan afte head without cantastis shown Wich fhe falling is he mast ely cause of is pire’ oss ot A Bactriel meninaiis )Hoadtrauma C}Heipas simple anceps (Rupe bony aneurysm ) Tuberevaus manage‘The respense options forthe nat 2 Woms ee tie emo, Select one answer for each ne sa Fer oath patont th verbgo, sleet the most katy agnosis -) Acoustic schwannoma EE) Benign postienalyerige (C) Cerebellar amonhge 1) Complex parva seme E)Endolyrenate sta F) Hypenvertaion snarome GiMeniatedseasa Hp Postural ypotension ) Vertebrobasilar arsiort isc atack 2, A S0yesr-old man hashed episodes of sudden severe dzainass ver the past 3 yoo, He descibes these ebisodes ssa sensation of spina. The ae associted wth Sweating palo, nausea ad occasional yomng. Ha nas not noted at obvicusproupitart The episodes acaur 35 oten as weekly ancl as mquery as evry Starman, ‘They usiallest 203 hours. Hehesnoiced a decreese in heering and w consanhssing noise in he rght ar.Examination shove hoarnglss inthe right eaFor each patent with verigo, select the most ely agnosis, 8) Reouste sehearnoma ) Benign postienalvenigo C)Cerebearamonhae Dj Complex paral sere E)Endelynpnanc fem F) Hypenentiltion syndrome ‘GhMenire disease H)Posturalhypotersion 1 Velstrabasiarransient ischemic tack “4, Quer the past2years, 3S,year-old woman hashad episodes ef a sinning sensation The episodes occu aoruny, ae associated wth nausea and vomiting, and lst about ‘Thaur. The fist epsede occurred when he atplanein which she was Favaing ascendadto clusing allide Subsoquert episodes have occured on ebvairs, and she has had mid episodes when she sneezes. Twa years aga, she sustained s concussion afer fal. Examination shows decreesedheanng nthe nig e3r5. A Syeatold boy ith cerebral paly fs broughtto the physician fo a schea physical examination. He didnct uakurlite age of 3 years andisustleaming to use utensils to Teedhimser He woats hearing aids because o lateral Sensorreutelneatng oss. Ho raceWespysical,cccupatona, ana speech thaapy. He se that percertl for height and weight he has remained belew the 8h percentile forhead cicumfetence since bith, Examinction shaw right esaropia, Tete is increased muscketone in al ‘oemites,bistra ane spastoty, ard aise Wperatica He has an aiewe gat Psychomotic sing shows and of 6S. A CT scan ofthe head shows puntata Iypatintensites long te venicuer margins Wtich a fe falowing isthe mstlkely undatlng cause of is cits abnermalibes? 1) Chonic sd exposure 8B) Congenital cfomegalerirs infection ©) Fragile X sanstome 1) Phenyketenuna | Tuberous sclerosis6, Tiros days ator atmission to tha hosatal because of an hour history of woaiaess and rumbress of te ht sce ofthe face and ht ypparetomibes, 32-year-old ‘women bevomes comatose, Onaissian se was raated wth aspinn Sho has ibromusculr dysplasia Her pulse fs rin, and blood pressure is TROFT00 mma. Shes otregponsie to verbal or tackle sumul. Eaminaton shows an Sim et pup that snaneactva anda 3. gt pyol Ua fs eactva, Ha et eyois deviatd outer ‘There is accasionalmavement of tho lf hand ancfoct snd no mavemento fe night side of tho face or rgtt exremibes. Deep tendon reeves are inthe ight unger nd lower euremtios. Babine sig is preserton to righ. Her serum sodium concetiatonis 131 mEgL. Which of following isthe mostkaly iaanoais? 2) Carebetar neraterna Bi) Matabotc encephalopathy ©) Mabrainhemennage ) Porte irateton | Une temietion'A47-yearcld women comes he physician because cf aban istry fcificuly waking, constartheadache, end uinatyinconinence. Her symptoms have wersened var thapast ont Tracie ih atamcghen an buptan Nas he eleva far nestacha. She hes had mid amor) ipakriartsinem ametor hile eosin 5 {years ago m hich se lst canscusness. She hs had two generalized tonic-clonic seizures over he past year Her ister has rutple sclerosis, The peters Wal signs are ‘hth petal mts Exariaon shows none kang inte ier ate ower exterves ana increased rusela ere in be lowar exons Deep ters eke ae rama) in the upper extremities and orskin fe leer exremiis setinsk sign ispresent bsterly, Her gaits troad-hased and spashc Sersatan is tact. hich ofthe {olovang iste mest hey locaton fthispatets sia? )Cauca equine 5) Cone spinal cova (C)Paracautal corbralcotox DyPons| EE) Tharacic spinal cars8 AdTyearcliman comes to the physician because of 2 3. mont history of interne pain ofthe night sda this face The pan begins inthe region tthe er radiates tothe Chin, and ast fr 1 te 2 sacanes. tis procintatecby expecure to cold wether, chnkng 3 cold Loud, eating, and trusting fisoeth He as hyoetension anc Sastosscphageal raf chseose Medications inci tyroctioraby aids end aracids ie signe are ntnin normal its Examination shcisn abnormal. Wich ofthe fallnng isthe most appropnate pharmacotherapy or pain nts patent? +8) Capsaicin 8) Cabamazopine ©)Dielfanae Fluoxetine E}oyeodone©, 87-year-old man s brought to the plysiian by his ie becuse ofa 6-month history of diflcuty remembering bath recent and remote exes. Heals has hadley ‘maverments af fi ae andegs er weeks He nas hac loss of belanca and has fal cover has whi Nalhg Has mata. Exerination shes equ ryoelnic Jstking o al earemties,inctased muscle tne, and hyperactive rflowes Babs signs prsertbiteraly, ACCT scan of th heed shores milton. Cerebrospinal uid ‘analysis shows no abrormalies except for a prota cancanaton of 80 maid. EEG shoes a generalized slow background iterupied by syrchrenous Shap ave Complexes, Which ofthe folowais fe most hey diagnosis? ‘A Creuale-Jakeb disease 3}Dement's, Azheimertype >)Dementa with Lewy bodies 2) Hepatoentular degeneration (ion disease) =) Muinfact (vascular dementiato the hospitaforelumbar laminectomy. One day postoperative he hase lvgrade fever secancayto a unary ractinfecten. He also has 10. A Btxyearclciman is admit tamieuy sleeping ate, and weaterc wah lorazepam is started. Two d2ys postoperatively ne becomes dowsy anc confused On examination, pe s AMcutto acuse, and his speecn is slurred He's able to ansner a few simple quesnons, Biche irks thathe Isat home and hat he years 1956. He cogperetes pony wth ermal strength tesa Tha fmainer of tha xara shows ne eenarnalas Wich ha elowng isthe rat key ages? [A)Catetrlirarcticn 2)Demenva, aimaimer ype CC) Metabo encaphalopaty D)Noncormusive stas epilepteus ) Siaureltemetoma11, A 12yeacold ois broughto the phyicin because of equent headaches over the pas 2 mans aed vomiting and nausea for 2 days Her chitopractc alysicen ackised her parents o ssck addtional cvlution because she has not respondad te maniouiaton and maseage thragy. The pabont akos no prescption tcabons, bul eerie fab takes mutple supplements including magadosse cf muvtamins Hermother hada stomach vis wrk ago, The paves bined presoure 6 120180 mm He, Neurolaac examination shows no abnorralues. picloaraph fhe Ope Kinase shoem Laboratory sites show Serum he 140 meet ke AZ neg, Proletin nga. Urine spocme rawy 1030, ‘which ofthe foloranais the moat ely cause of bis padents optic ndings? 1 Diabetes nsoaus ) Frontlicoo tumor C}Piuiiay miroaconoma 1} Systemic uous enheratoaus E) Vitamin tones12, A 77-year-old manisbrougitto the emergency department 3 hours ater the aevts cose ot ESSTEROUEREBENTEES on akening is moming He has also noted sion tested with tenobol He has vomnteconce nthe emergency department. Hs temper s 37°C (95 6°), pulse is B5/min 1m. Bom pups are react to Sic swalovdng water He has typ respratons ate 2m, andbioed pressures 170/100 ren Hg Examnaion shows lttpioss. The lt puplis 2mm, and Me rig pup rompers is decreased over te side ce face ance right side of he ligt. Tere is coarse nystagmus on letra gaze. Muscle sengmh is norma. Sensat on Dad The mest el eause of ase inangsis occusen of wich e tha oloving atares? A) Lett mile corebral B) Le posterior interior cervetar C)Letverteal (Dy Pttimile cote E)Rogt posterior infos F)Rgttveneoral sraballar418. A S2year-ld man s brought te emergency depanment by a end because of a taveek histor of increesingly bizare behavior. Ear t's evening, the patie stated te hive at 100 mils perhour, weauig in and cat ef tac on heirerstat highoay unl ane of is passengers comvincedhim io crop ber of thet apartment His end hen Insistea.ontraing hints the nosptal fer evaliaon The patent works at a brokerage fim andhas been aie ce anit an severa occasions Mis past week Several Oofhis customs hate starlets compan tat he cals ale at ight anclaks about pln fr thar meno that donet make sense His herd describes his behacor as ‘ammleteyincharacesic because he was prewausl a access money manager The petient peal drinks aur beers on weelnigttsandup to a dezen an weekends [86°F], puso is S5/nn, espiralens are 1am, andbioodprasturais 140/90 mm Hg, Frycal examen stews no cer abnatmaliies cn Hestemperatris 3 ‘rerte tans ecaminetion, his enc sineoprapnately aright He specs quel ands cficuttsitrrugt He says tat he fupset aan ding brougreto the emergency ‘departmon Ne then laughs ard statas Pla cen iaar eventing up He Says Mat he Nas recelved @ Secret messoge regarding anew economic devebperert thal wl ‘enable al of his customers andhim to became weaty. He hes been staying up nights chang tallou and ow krams exact What needs to be dane. Urine txcobgy Scfooningis hogatve, hich ofa folovangis He mest he agnosis? 2) Atetion dehictiyptactnty dsordr 5) Bipolar asorder ©) Cyelotymie sorder 1) Delusional tsorder Major depressive dcerder win psychotic features F) Schaoetectve disorder 65) Schizophrenis| H) Substonceirlucee mood dlserder14. Anz year-old women comes 1 te physic because ofa 1-year history ef neck sss ISERAHSAMETRSERES hr he. inary inccetinence, aed Unsteasiness wen waking Medicalhistoyincles osteoanhrts, pep ulcer dlseese, ard hyperiprdemia, Curent mecicatiors ar ‘Shohas a isto of leone abuse utes abstainactrom artking fr 5 years Neurologic examin shows op off leupper emery and creased tone math lower emtemiies uel aengh ints pper extort 28 Dog tenon refs a 2» ath ices and orca bnteray, obese cape, ens 2 ‘notes on nies Seba ia prosertitraly Surscon pup ane tomers dotoased on tots Gosalfarh annanaPromocapaon ord tise hich ore folosing ethno ely agnosie? sensetiono bration are markedly decreased atte ares andtoes. Shohas 8 -A)Bieteralbrachiaplexopatny 1) Epidural cre compression (C}Perasagitalmeringioma DiPeripheral neurone, ) Sponieric conicalmyelonaty15 AS7yoa-old man witha 10year story of ADS comos to the emergency depart because of Say ste of dase Peadachs and rl ysaknoss of tis stand He has neta fver er chil, He has been unable otleratehighW active artrevewral hereps duo te sovee nausea. His ory medication is timethapri.suFamcthoxazok. Hs CD T-ymplocyte court 2 weoks aap was Sn Nonnd2500),anelplasina IV wralldad was 100,000 coplasin., He is ae ard evened fa porson placa, moet arate Hs uses in. en ood esas SO mm Hg Misc senmh 5 8in elas Nasi nat Saws ro oh Toca franas Lsbsray Ses shows ‘seun Ne" same gL Ke 3emegt, c Sa meat HCO 25mESL Creatine mga Uni "Secu s0megL ‘Osmelaity S50 mOsmotkg H,0 ACT scan of te head shows 8 rng-enhancng STERNER SASTEDAS: Vic ofthe folowing s te most ikeW explanation for these laboretry ndings? A Acute tubular necrosis 5) Ackison disease CiFtpovolemis 1D) Sat-nasting nephropathy E)Synetome oftnaperopiate secretion of ADH (vasopressin)18. A previous hacthy 21-yeer-cd men isbrought tothe physician 1MEORRSREOSEIRE- ur to his nGREERBUBctunng calle football game, Examinaticn shows @ bulge artanor tothe shoulder. Anaya he righ shoulder shows anentetir diocation. Aer coed reducon, there is rumbnacs ver the plone lateral a and mared -nealeess of atcuction hich ofthe falloving isthe most kal ste of ervey? 1) Musculocutaroaus ner athe wrist 4) Racialnerve above tie ebay i] Redialnere atthe elbow) 1 Rathalnere atte wrist 1M) Suprascapularnores N) Theracodonsa none 1 Uner nerve athe elton A) alla noe 6 Centcalnerve roca he censcal foramen ©) Leng thvacic nerve 1) Moaian nerve above ta bow EE) Modian nove atthe bows F) Median ner at to wrist 1G] Miseulooutaneous nene above the eats | Misculooutaneous nen atthe elbow17, 826 monte boy fs brought othe physician fora followup examinaton 2 weks afer compltng 2 day cours of amoxcilin for an ear infection His father is ‘oncemed because nis son nas nad mary earrtectore since nh, andhis speech sae toUnderstnd. The cla Wake and ms uh onl occesonal als and see 0 Climb on funiture. He can stack sevenbiock without dficuty He's atthe Oth porcebleor height and weight During the amination he does not say ay rel gible ‘nord, andhe marnitenty habbies or streams Examinaton shows revscted yrmpenic membranes vith pocr mvernent wth pneumsicotoseapy. Which of re flowing is themost apprepiate nee stp in management? A)Roassurance 8) Meesurementaf bled lead cencertation C)Ausiemesy )CT stan oftne head ) 10Day couse orhgh-dose emaneluinclawlanate F nsenton of ympsanostory tubes'842.yea-cc men comesto the piysician because of Je says hat he eels the uge ovoid small vames fui ‘vary? touts. Occasional, ne has boen unable to reach te bahtoern inte. Sk ments 290, Ne sustained a acre of CE one dove tb sralow pool Hated ‘uachineresis wth loss of sensation to pirpick below CB. He was hasitalzed and underwent surgical decompression and sabization lewd by mmabizsion ng halo bravafor 3 months He hes regained rast motot end senseryruicton. Hs temperatures 37°C (98 6F), pulses Tain an reguay, and blood pressures 12070 ra He Crarilnowes ar intact, Nusck strength is 45 in he deteid and biceps muscles bisteralyandis 55 oftermise Deap tondenrelaes are I+ betray in he biceps and 3+ Dlataraly mia ticeps, quadiceps, and gestocnomius muscles Bani signs psa bateraly Sersatonto priprick andtomparatueismidly daereasad belo the Upper chest Wich ofthe fling is the mst ikoly cause of is patients unary sympIoms? a)Demsorhyperefenia ) Diabetes insnidus C)Placeid bladder 1) Ovation ncontrence ) ute abstivenon10. A previously neat 25.year-cld woman isbxouattio the emorgony department 30 minutss ater boing stuck by ametor vehicle. On aval sho is aot and xontet ne reports leg pan Herta signs are ihn noma ims. Examination shoves ormal sensory andmctorunchon in hs fct Poster ial and dorsalis pedis pulses are rma. rays show a mirialy displaced comminutad mdahef fracture of fe Bia. The lower earomiy ie eplrta inte emergency depanmert, and the panere is admited fer cbscrvation Three heurs later, she has numbness ine foc ane increasing pan inher lower extremly Evaminaton ny shows decreased seniatonto Ight ouch over 8, Wien fhe follwing ste most apprepiae next step in management? 68) Moasuementofcompanmentprossiras ( Artcooguiantnerapy By Angcarapny Closed reducion F) News exploration 6} Open reduction enly HH Open reduction enitsmal ration20, A S7-yor-oldman coms tothe physician because of 2.weok history of constartneadach,abdorrinalpaln and cizness. Hees had generalized weakness and ‘decreased vision ering this period He has no history af serous ness or wsual problem and takes no medeatons. Hehas lived and wevkecton aruralfarm alo isi Hanks 402 of ernemads iquor tke Umes woeldy His cod pressures 1382 mmHg. The pupils ae arte and rct slowly fo Light grt The pales unio to road tary eters onthe Snellen chatbit can count fngers hel oct in or f his fae, Funduscopie examinaton shows pal of te epic cscs. Abdominal examinetion shows dts tandemess but no rebound. Muscle stengh S45 i all areritos. Exposure owhch cho olowng Lon s the mosey cause ots patent's Synpioms? A)nHexane E) Methanol (cpm yt hetone organophosphate E)Toliens Fy Tichloroctiene21, A previously neat 72.year- oll womans brouorto th physician ayer daughter because cf progressive memoryless and confusion dunnathe past 18 months. Athough shotas had md fgetlness for 5 years her symptoms cramaticaly increased dng he past 1é montis. AnS, gall isheard. Theres anghtcarokd brut Peripheral the tlownng ste most eoproptiate phamscctnerspy? ee ih ed Babi son is res pulbes are cer ayaspitin B)Clopicoor C1 Dinidemole DyHepenn E)Wararin22, An 1¢year-cld men comesto the plysician because of aiculy wang for 1 week Exarinaton chowsweual il that are consbcted equaly in beth eyes on clase and satactestng Heh colepsing efrton muscle stenat testing inthe lek exterrides. He staggers rom side to side when walking but does ntl On Romberg testa, he ‘brunt also thee. Thre is emsensory loss to Ight ouch, prnprick, brain, and proplocapton on te that stops excl tho midline, Vch of bo flowang isthe most kel dsgnosis? A) Cerebellar degeneration BB} Cervical spinal cord compression (©) Conversion ciserder Dj Gullain Bane sncrome EE) Mute seeross F) Sonsory nouropty (3) Tabas daoaic Ho itamin [eaten175, A50.yeer-oldrmanhas had ln back pan radiating othe ight buttock an posterior thigh othe knee since Hing a 0. weight 18 heurs ago. He hes had urinary Incarimence cunng iste. The Achiles tendon refx s eosenton te nf, and tere Is decreased penanal sensation Saige raising causes &maregincreese in paininthe pestanot thigh andleg Witch of the folowing the most key causa ofthese fangs? '§) Cauda equa compression 3) Epidural hematoma C)Lurbesacral stain 1)S1 ner root edieapaty EE) Transverse myalits24, in 87-yeer-od woman brouahto the physician by her sonbecouss af a 7-monthhistnyaf dacaasing ability ofneton indenenceny She sno longer able tows Checks and oten gets lestwnio ving. She nas yportonsion and ryperlpidema. Cunert medications include chbrthazide and pravastan. Her teiporamra 6 37°C [BEO°F, pulser atin, respirations are 12min, andbloodpreseye is 170/100 mimHg.Physica examinaticn shows no aherabnetmalis Maria status examination Shon’ poor concentration, She 6 orertadto parson and place bunetto ime. She sable to recal zero out of neo objects fer § minutss. Cognition and conatuctonal aly re decreased Leboratery ndings are win the elaence range Which fhe ollwing is he most appropiate next step in dagnous? A) Megsuremertof serum ammonia concentration 6) Nevropsxhelosicaltesing C}PET sean | Mofthe brain EJEESsides weakness inking the face, arm, and leg. She had heumanc fever 25, A 325year-cld women isbrougteto the emergency department hour after theacite onset (ung ehlaiood are was ld at that tne hat she Pada heart murmur. Her pulse is 92ImnanaitequayIneqular Evaminaten shows Moderate ef-sided weakness Babine sign s present on the le. ich of he Flowing isthe mostikaly cause ofthese indings? A) Ail ibeliton 15) Meningovaocuar spi BB) Bactanal endocarditis Hi micraine C)Ceratc eer assertion I Mivaivate prolapse D}Corata atherosclerosis 4} Pater foramen ovale E) Diabetes mals i] Subsevian steal snctome F)Fertersion Li Weniculr septal defect,28. A-42yoar-oldmanis brought te emergency department 20 minutes ater the onset of generalzed tonic-clonic seiaues, He hes year History ot seizure aisarder treo wth parvom, bul he oss not aks fis meciciion 2s prescn bed, He nas long-standing alcaosm He sshiporcus: Neuroiake samnation shows no focal ndings. His femogleincancentaton's && gia, and mean corpuscular vaire is 105 pm®. A deficiency of which che folowing is the most Ike cause of is panents hemapiogetnaings? A)Fole acid 5) Marin, vain) C) amine bance ) Vitamin Be } Vitamin, feosaerin) F] Vitamin CA 12.yoerol i isbrougitto te plysiclan by ne parents because of a 2. eek histoy/of sudden, unconfalae movements of Nr foc, arms, and loys. hon she etempts ymptnms donot occur dining sleep. She has noched loss of canscewsness.Two mons ago, she to contol tese movements, they increase in Fequency andintensity haga (0 tvoct tha resokecotoul eaten Het parents for tat she Wal feed, pees Wal Schoo) and has not hed any raceistessors Her trrpteae 15.37 5 (96°F, pubes GCimin, respirations are 20min, and bldod pressures BAD mm Hg. Examination shows recuert regular, scesmesie rewemers othe face land ips aedlower esteribes. The emandes oe avarinalon sms fo abnermalbes & CT scan he baad ae ah EES sho ho abrsmales, #hic o Bie falling isthe most key aiagrosis? 8) Absonce setae 6) Compl pata seis (©) Comrsion cor 1) Sitenhem chorea )Teuretecisrder23. A prowousyneatty 72 year-old man's broughto the pysicin day cathe suaden loss of ston in his te that resoved within 4 minutes. hed asia episod inte same eyo 2 veeks ago, He has not had headache, fatigno, weakness, jaw pain, or aificuy breathing He appears wel His puse I 72min, eepretions ae Iain, fendbbodpressireis 17205 mm Hy Examination stawsno ebnormallas Ayre 26, eaysysole mumut is heerdulth oxcasonel scopic boats. Which of he folesing is the most sporepats nem step in diagnosis? A) Sitlamp examination of et ye E)Dsterminatin of ervinocite sed mention rte (C)24Hour amtulatory ECG mentoring D) Carotid dip utrasonogtepty E)Echacarsioaranty F)CT scan ofthe need29. An s23oar-oll woman with derrila,Alziime ype, broughto the prysicia by ner husband because he nashed progressive culty feeding het aver the past “4 ieeks, He says she na longer sna food at he pus inher mous, even wth promi. She no anger seys his name, anche belles at she does not recognize him. FHenas ben her pimay categier for 4 yoars. She does nl havo an edvace ec He says ho does not want io hasta er death, He waris0 corr a take care ct het ethome buris cancemed abahis diy to do so. He declines placement of a gasrostamy hb Shels 183.m (Sf n)alared weighs dy (8), Bhs 17 hone ‘Sho agers wal oerrad bur malnourished Sees net onenla io ptsan, oes, ar me, The remainder af Be examen shoves No abnetmalies Wh FB OKIINS Js the most epproprete recommen on? ‘Oral mubvtemin supplementation at home £2} Oralnutitonel supplemertationathom Hospice care echeme ) Acnission tothe hositalfr total parenteral rttion ) Transfert. siled nursing care facity for be feeding30, A.47-yar-old man comas tothe physician because of @10-d2y history of aoping of aright eyelid, He has no history of serous less and takes no medications. Vt ‘Signs re in real mits. Physical exainaton shows anheross ver me right side ef te face, The nght eyeld creeps 3 mn, Ther pus 3 nm, and the lt pups Se, bom pups ae reactive. Visual aculy ts 200 on eight and 2075 one ot Ctenal ners ate ofonvise nic Muscle stergin |S & treughout Deep tanden semis intact An MRS cfwnich of te fallwing is mostikeytecorfim ne slagrasis? rete ore T+ teaughet. 5 A)Lowerneck B)Mecuile C}Miebrain Dp Ocular orbit E)Pons$1, A S2:year-ok4 man comes tothe physician because of 8 {mnt History of rumbness andtinglina ofthe ring and smal fngers of his right han het radiates tos palm, His ‘mpioms ae now constant and Sxacorbated al ng He has 3 2 eek sion of doxreaued gip sengh and wastng ofthe smal muscles nhs vigrtend He has nati neck arm pain Feur mantis ago, ne was clagnosed nif pancreaic cancer, since hen, he uncerwent Whipple procechre andi curren ecehing chemaherapy wih ‘gamotabine, Since his elagnosis, he ha had tgnficant alu and an T8-ka 40-0] wot less. Hove 173 cme 88 nal and now welds hg (120 by Bs 18 kan? His tempereture is 37°C (88 6°F), pulse s min, and ble pressive s 120/79 mm Ha, Theres Wasting of the rterosseous muscles on enol Muscle eng is 35 in tho nghtilerosseous analypabinar muscles and laxor crim protndus othe fing and emallingers ii ul eleanor Daap london reflxes xo 2+ vous, Babine signs absent. Senseiono pinpnc and temparatie fz decreased over he ner aepact ofthe pel and dersum of he hand andring end smal rs, neuro} exsminaion shoves no abnomsies. Wich ofthe olovsng isthe rast key cause ofthis pebert's symptoms? propaceptonis ntact. The remainder of A}. CB nena rootntation by tumor E)Conicaelsc nemianon (C) Chematerapyneuroticiy (D)Unarnewe compression ) Vitamin 8, (cobalamin defcienoy32, AAT-¥ear-cld man ho recent emigrated from Moicots brousht to he emergency denarment {hour ater a (general ome-chrvc saute Pat ted 3 minuas He has a Swed history of constant headaches. He s aenise Fait. He is somal acive, He has smoked ane neck of cigarettes daly fer 22 oars Phsical and neurelagic fearnations show no abrermaltes.an MRI ef te brain ¢ show. Wich of tha fllowang sto most Halk actor for ‘he development o his patents condkion? 8) Arbor infocvon 6) Artopecstome infection CC} Fecal cortaminatan attoad ) Sevualirercouse with an infected pater E)Smoting tobacco38, An82.year-olf womans brouateto the emergency deparment because ofan & hour histry of fever and progressive confsion Four days oo, sho attended picnic and ats barbecuad fot dogs and homemade unpastoun2ed chess, Sha has savas pemphigus treated wilh daly cralfredhisone. On artval shes somnolent Her temperature is 244°C (103°F} Phisical examination shows aad neck. Neurlogic examination shons rafal ngs. A lumber furcture vel turbid lad. Cerebrospinal ad ‘analysis shows tue noi, Protein 130 moi, Leukooye coure 2auiran? ‘Segmertedneutophls 6% Manecyes 40% A.tam stain of carebrespind uid shows numereus gram-positive bscill.iich of he foloning isthe mest kel causal oroarism? A Bacitus subi ) Cesium permagens C)Connetactenum species Dy) Haemapiius ituencae E) isin monaevieganes Fy Streptococcus preumonioe24. 4 a7-yser-cktmanis ncughtta the emergency department by his rierds 20 minites ater agenaralzd toric conc seizure that lasted 2 minutas Hs ha ban smoking crack cacaine whentha seme bagan Hels uesperslo, Examinatan shows a 7mm diate ff pup thats nanreacovoto 1g. There is eroaping oho ngFEION=T He has nteritent decerebratepostunnginthe night uppet and loner exremibes. Deep land refloes ae Iypetarine on the ight Balin sighs present onthe head shaw anirtracerebelnemaimage. When fhe flluana types c cerebral hemston's the mosclkey ceuse chs condtion? face Nahe. ACT seen of AyConal £8) Corebalartonaitar CC) Subftene Dy Tanstereonal EpUpwerd26, & 27-year-old women comes tothe chysicien becouse of afilSIEESeREEERTEGTESSIEESTGHHIN and sin wih movement of he rigtt eye. Her visual seus 207200, inthe tt eye and 20720;n the topo. The pups are eaual, te iGRRRURINESBBERAS tet att but reacts consensual to Ightin he opposite pup. Funduscopic ‘examination shoes noel ndings. Ata llrcup sit & weoks late, sion no rg ye Is 20180. There is mil pal ofthe rit cae dsc. The remand of he ‘amination is unchangod, Thispatertis at greetsttskfor which of te Folbang? 8) Carabraintereton B)Lymne disease CC) Muto sleroois lupus enbomatosus gener enulomaosisinthe rttempcral area end pain nthe aw when chewing. Over 436, A T3yearldweman comesta the physician because ofa ‘te past 2 ment, she hashed duse painine back shoulders, and exramies Mc's worse on mid exertion. Thor istondemess{0 papal ove! to temporal muscies Dilsteraly Neuraldgic exarinaton shows no focalfinangs. Which fhe flours fe most kel cause of spelen imo pal? 8) Choc fatigue sycome 5) Fibramyaiga ChLyme disease 1D) Poet heumaties E)Rheumatoid aris F) Systemic linus ervhemstosusFA 2yearela gna me sudgen ease at Prysieal examination shows an ital jaws nornal vi sigrs. Sho surat to KIS spe. Anas of cerebrospinal uid sh 1m (Na-T) area protein Jaetatapeotes The ser crcl: Crem stan shows no orpanss Wiehe elude ot kay agros scl crear ea among scuie heer gnarl songs carla atone E}eredct alananif Dung is ume, stohas had a 38. A Shel yonan ot REE ore se pyician becuz tinaing sonsation mn heistan has ad increasino Aicuty wth eve, such as ef heuratord atts sanptomsiave been Exatninaon shave mated aural eaaneors and ne hxoIe ‘managae th cooosiertd bilaterally Deep tendon ofexes are # the upper exromiies Yihich of he folowing iste mast eppromate nent spin clagnosis? A Measuremert a serum eres kinase acivy B) Xreysotthehands ©) DEXA scan D) MRlof he cenicalspine E] Electonyosraphy and nerve conduction studies38, A 27:yea-cld women is brouch SHBHSRISRESEELEETEEa S.y22k history af duble sion She says thal he double vision most often curs when she looks upward fentothe nght She scien asyrotamatc inte moming Her fiends nave commented on eroopiness of het eels Her onl medicatan sen oral contraceptive Examination shows blatra ptosis hats greater nthe ight eye than in helt The plosiss worsened by gazing upward for 0 seconds There is weakness of abduct of ‘Me right eye and mid Weeiess of te fortl muscle, The remahcer ate neuloalc examinenon shows no abriomaies. Which of folontngis te most eoprogn ate intial pharmacotherapy for tis pian? A) Azathioprine ) Cyclosporine CChtmmune gobuin Dj Preerisens E)Pyeosugrinetaper | rou ier suden ans ncoorcnatlon and curses, he as allen saveraltmes Pree xaiination 40. A 7ayear.olimansbreugtto te emergen Shoe ebiont oases iste get ane eames ianea is oteve doe" notes Fes ceertast person eutett place are ans ‘aque andrernbing inrisnisiary Wtich ofthe faleutng ste most Ikaly agnosis? A)Factsich ata 'B)Hepatoletcular degeneration (lzon seas) 6) Spinocerevetar axe, po Dy weeks encopreiopanyive sired soeech and gat unsteadness. She also has had mil ecigital head 41, AS7.yeaccol woman comes te the physician because of tach moming for Seeks She has pe 2 dlabetes melits wel controled wrth diet She takes no medicetions, Exainabon sh [GIMIONOUE. To tonque devas ote night on prowusion. Cee cranial nares are tac Her gal bth anormal baco, Muscle steahic45 mthe vices, yet ‘extensors, tetossel, and inbsoas muses bistraly. Deep tendon rales ere 3 dfusaly,Babinskt signs preset bial, Sensory examination shows ro ‘which oftefolloung isthe most kot ciaanosis? sbrerral A)Epiaural apscoss Epidural spinal cord metastasis C}Suingomyeta 1D) Tumor ofthe foramen magnum E) Venebralostecmpoits“2. A anes oman nasiclonss ot te SRL HESS 20-9) cr ivr, Eaton cs \ecakress of dofSI6SRS oyersicn of te gt anki vrsion an ee ‘eric otha alow sh rest vaylocabon of te esl? 4) Basal ganglia H) Frontoparicta cortex 2) Brachalpios 1 reamed capsule ©) Branston 4) Lumar nerve rack ) Centcalnene root ] Lumbosaeralplews } Commen peroneal nerve L) Median none | F) Conus medulans My Muscla 66] Femeraineree N) Scate nerve43, A 2Syearcld women has had da “Th pain generally begins as adil ache soon ater. id gradual crsens.Thepainis vaceroatoe aretoved by 08. Whit fthefollwing she most katy sagrosis? A)Cetebralneatlasn E)Custerheadact (Creve sinusitis DD) Migraine wath aura E) Migraine vatrout eure F) Temporal arenas Tension ype headache HyTigemina| pouralsa44, 8 74.veor.cld womans brought othe emergency daparment | hour ater the sudden onset of petal les. She has hadlon-arade fever, occinital headaches, pain of ‘ho SCMESTETBSMICIGANMME.and morning stness for 2 mors. Her tomperaio is 37 ‘end bhod presse ic 13808 mmHg. There generalzee mnt ereoess ture wesineteor aon. Gurney ramon shore ov enc Ae SSNS ic 2 lonng ems Gaanesie? 8) Pbvornoaits 5) Povartas nodosa } Poymyesixs 1) Systemic upus enghemetosus E]Temporal eters,45. A SSPSRRGIA cornes to tna pryscian because ot 'sothenise asympromatic. He sale icsnen ‘Which ore folowing isthe mostapproprias pheemacomstapy? |) Amitigtine i Mitedpine 5) Chnicine HyNtroprsside )Dexamatnasone pPreansane D)Etgsxamine . Propraneol E}buproten Ky Surat pean“46, & 2.yearcld man is comatose 3 hours ater being fit betind the tear vith bat while cecting in a softball game, He was dazedfor af seconds aftr thoinury but was lua an aialin the emergency department 2 hours ago. Exeminabon at hettime showed alge biuse behind thee ar, no ofr abnormalities were noted ich of he folkming isthe mostikolyexplenaonfor hose fnaings? A) Elcroplysioagc eystuncion B)Epidurathemonhaae (Cj Hemontiage int the cerebral hemisphere }Sheanng and csrupion of axons ) Subduralhemerhage47 A 67-yoe-old woman comes tothe physician because of 4 year histor of radualyprosrassive shaking f her head and hands. The shaking decreases ster she inks a th aorastabn Sho has censumed four ‘las ef wine. She sight hand dominant. She has a ister of hypertension voated ih benazeprl and hyper idea te ‘lasses of vie dail for 35 years, Her blood pressures 14222 rm Hg. Examination shows 6 rpid rerar of fe heed and vice. Thee is@fighreqioncy tamara he hands on finger nose teeing. Which ofthe allowing the most appropiate pharmaccthetaay ers pales omar? '8}Carbidopa avodopa 5) Disuiarn C}Phonpoin D)Preerioi| E)Tmenyphenay48, A 32.yearcld women comes othe pysicien becausa ofa 6neekctistry of lifculy fling asloop and cal marina awakening. Sho says that she istredthroughouth ‘Say and has bacome increasing table th family and coverkers, She finds cet ogo ta werk She has nt ncicedaryimrevement inher sleep despite rot ‘kinking cafes pastroan or vecising nthe vering. Seno longarenye gardening and taching her chiarento mao clei. She fel Quy about how har sleep Sprvaion'safechng her family. She has had a decreased appetite resuiing in ad%kg [10.b) weightloss ding he past O weeks. Shehas no story ofpsychiaic liness. She akos no medication. Sho doos net smoke or use le ekuas arid oy osceslonaly cis alcohol. She appoers rac Her irperaiuo ie $1°C (086°, plso is in, ae blond pressure 116/74 mm, Physica examnation shows no atnoimalties Mental stakis xaranatcnshcia 2 sad aft She becomes tah and sa that sho has boon Sad ince her eer yeas agnased wh ina cece 4 ants ago. She cays, "nay thought about kllng yee, bul voudnever tt my chidren mint ‘yay addtionls psychotherapy, which o he folbning isthe most appropeats nial siepinmanagement? 1) Sippon gop for relatives of cence ics )Buspione than, CC Diphennytraminetharapy at bec me Dj Plusete tater E)Lorazapam rerapy49, A2T-yearcd men comes to he emergency department because he hes Neen unable to void for 24 hours. Over the nest 8 deys,he hes hac gradualy pre Iagweeiress. He rad me onset oti Dack pain 7 days ago vhs workng nt gordon Ho Nasa hisoy ot mravanous dug ba HS tomperatre Is 36:8°C(102°F) Exarinaton shows moderate weakress and hyperetna ofine lover extemies bilateral Babin sighs present bleteraly Sensad onto pinpics decreased below Tre um lcus, ered seston ta igh touch, pene propcespion,anckeraion is deeroased esr bom nae exteres heh ofthe ola ste ast ike locate or B)Conus medulans CC} Femoral nen DjLumbarnene rect E) Lumbasaca lens FF) Newemuscuarinction HH) Tracie spinal cord lunar neve50) A BT-yacrola woman's brought o me emergerey depermertty har nustand 1 rout ar ha sudden once ncompretenstle speach fat Began shen er brealtase Her husband desebes her speech during te episode as fuent and well ariculredbu fl af ilogieal word combinations, making tImpassiblforher tobe understood. He ‘says at se dso dd na seem fo understand ni oroloe/certmands. She has hypertension, nypeiplaemla, and astra. Curent medcatens incu evestatn nd Isinopsl Shei alta to asprin. On sti her language finctonis norms Her pulse is €Oirin and requir, and blood pressures 152/86 mm Hg Physical and reutlogic ‘veriravons shown etmormaties Eenoearaiography stems na abormaives Carats pl ultasonoay ey ss 20% sonnets oe le comenon cared ary Ths Fightisnormal Wich othe following isthe most appropiate eererton to decrease bis patos ik for hur episodes? A) Clopidogrel therapy 6B) Esrogen replacement thorapy C)Preprenobi therapy 1) Waranin therapy Let carotid endarterectomy