Case Based 3 2010

Minimum Passing Grade: 75%

STOP! IF YOU ARE USING AN OLD VERSION INTERNET EXPLORER, YOU MIGHT
NOT BE ABLE TO TAKE THIS EXAM. YOU WILL ENCOUNTER SCRIPTING
ERRORS. PRESS ALT H , click on "about internet explorer" ON YOUR COMPUTER
TO DETERMINE YOUR VERSION. IF IT IS LESS THAN 8, YOU NEED TO UPGRADE.
OR YOU CAN DOWNLOAD MOZILLA FIREFOX AT http://www.mozilla.com/en-US/
FOR THE BEST EXAM EXPERIENCE.

Time Allowed for Exam: 4 hrs 0 mins

1.An 18-year-old accidentally drinks antifreeze. Within a half an hour, he starts to

experience nausea, vomiting, and headache. He becomes very stuporous. He then has
a seizure. His friends realize something is wrong, so they summon the paramedics.
What problem would be expected?
a) metabolic acidosis
b) respiratory alkalosis
c) Metabolic alkalosis
d) Respiratory acidosis

2.A 50-year-old man comes to you with an 8-year history of uncontrolled hypertension
and recent onset of chest pain during exertion. His blood pressure is 150/95 mmHg, and
based on investigations including a stress test and an echocardiogram, a diagnosis of
stable angina was made. All the blood parameters were normal. Even with beta blockers
at maximal dosage, the angina persisted. What is the most appropriate drug to add to
this patient’s regimen?
a) Angiotensin-Converting enzyme inhibitors (ACEI)
b) Aldosterone antagonists
c) Angiotensin Receptor Blockers (ARB)
d) Calcium channel blockers (CCB)
e) Central alpha 2 agonists

3.A 54-year-old man complains of severe low back pain and right-sided sciatica
persisting for 3 months. A radiograph of the lumbar spine revealed moderate disc space
narrowing at L5/S1. The MRI showed a right L5/S1 paracentric disc herniation causing
posterolateral displacement of the right S1 nerve root. Which of the following statements
concerning this condition is true?
a) Most patients will require surgery
b) It is more common in the cervical spine
c) Herniated discs are in a final stage of degeneration
d) Changes in bowel and/or bladder function may occur
e) Radiographs are the most common method of diagnosis

4.A 63-year-old white male has started to have episodes of chest pain that awaken him
at night. The doctor tells this patient that he has variant angina. What finding on an EKG
done during an episode of his pain would be most consistent with variant angina?
a) ST segment elevation
b) ST segment depression
c) Q waves
 d) Tachycardia
e) Prolonged PR interval

5.A 33-year-old woman presents to the clinic stating that for the last couple of days she
feels that she is having an 'out of body experience' but still has 'a grip on reality.' Her
history reveals previous episodes similar to the one she is having today. She has denied
any drug or alcohol use. During her childhood she was molested by an uncle and was in
an abusive relationship during her early 20s. She states that she does not handle stress
well and believes she has had panic attacks in her past. This episode began after her
boss threatened to fire her over her constant tardiness. Her physical exam is
unremarkable. What is the most appropriate diagnosis for this patient?
a) Anxiety and depression
b) Schizophrenia
c) Substance abuse
d) Temporal lobe epilepsy
e) Depersonalization disorder

6.An 18-year-old woman presents with shortness of breath, cough, malaise, and
dyspnea on exertion. Her symptoms began abruptly approximately 2 hours ago. She has
no history of illness or disease and has been very healthy up until this point. Physical
exam revealed a thin, ill-appearing young woman in obvious respiratory distress. Her
oxygen saturation was 82% and she had decreased breath sounds bilaterally. Vital signs
are as follows: Blood pressure 128/88 mm Hg, Pulse 124/min, Respiratory Rate 26 per
minute, Temp 97.8 degrees Fahrenheit. Spontaneous pneumothorax is suspected in the
patient. Which of the following concerning the patient’s probable diagnosis is true?
a) Women are affected more often than men
b) Peak incidence is between 40 and 50 years
c) They are usually the result of trauma
d) Smoking can increase the chance of developing this condition
e) The trapped air is fixed and will not shift to the highest point when the patient is
moved

7.A 21-year-old woman presents at 10 weeks gestation with vaginal bleeding and lower
abdominal cramping. This is her second pregnancy and she is concerned about losing
her baby. Examination demonstrates bright red blood coming through a closed cervical
os. What is the most likely diagnosis?
a) Inevitable abortion
b) Complete abortion
c) Threatened abortion
d) Incomplete abortion
e) Habitual abortion

8.A 4-year-old girl presents you with her parents who witnessed her falling on an
outstretched right dominant arm with her elbow fully extended from a slide (about 4 feet
fall) 30 minutes ago. There was no loss of consciousness, but there was extreme pain
and she immediately grabbed her right forearm and her right elbow. There was an
obvious deformity at the elbow. Which of the following is the most likely diagnosis?
a) Proximal humerus fracture
b) Distal radius fracture
c) Supracondylar humerus fracture
d) Lateral epicondyle humerus fracture
 e) Medial condyle humerus fracture

9.A 34-year-old woman presents with redness and swelling of the joints of her hands.
She has noted that the symptoms are worse in the morning. On physical examination,
redness and swelling of her DIP and PIP joints on both hands are noted. Radiographic
imaging of her hands reveals joint erosion and space narrowing. Her sedimentation rate
(ESR) is elevated and her rheumatoid factor is negative. What is the most likely
diagnosis?
a) Osteoarthritis
b) Ankylosing spondylitis
c) Rheumatoid arthritis
d) Dupuytren’s contracture
e) Fibromyalgia

10.A 24-year-old man comes to your clinic with a complaint of radial-sided non-dominant
wrist pain following a fall on his outstretched hand 3 days ago. He didn’t seek
immediate medical attention “because there was no swelling”. Despite self
treatment of ice and analgesics, his wrist has continued to hurt, especially with ulnar
deviation and trying to open a jar or grip the steering wheel of his car. You examine the
patient and determine his tenderness is in the anatomic snuffbox of the wrist.
Radiographs are normal in all views. Which of the following is the proper treatment at
this time for this man?
a) Elastic bandage for support, continue ice and analgesics, follow up as needed
b) Wrist volar splint, continue ice and analgesics, follow up in a month
c) Thumb spica splint, limit use, follow up in 2 to 3 weeks for repeat radiographs
d) Immediate referral to an orthopedic surgeon
e) Routine referral to an orthopedic surgeon

11.A 60-year-old female has been diagnosed by you as having major depression. You
have completed the history, physical, and lab testing and started the patient on
antidepressant medication. You also feel she would benefit from talking to someone
about some of stressful events that have occurred in the past. Which of the following
therapies would you consider for the same?
a) Family therapy
b) Brief interpersonal psychotherapy
c) Group therapy
d) Behavior therapy
e) Cognitive therapy

12.A 45-year-old man presents to the hospital complaining of a 1-month history of

difficulties walking up the stairs to his apartment. He also reports that the joints of his
hands have been paining. He is not taking any medications. On examination, his BP is
120/80mm/Hg and PR 72/min. Laboratory investigations reveal positive anti-nuclear
antibodies. Muscle biopsy reveals atrophy of type II muscle fibers. Question: What is the
most likely cause of his muscle weakness?
a) Alcoholism
b) Hyperthyroidism
c) Cushing's disease
d) Hypothyroidism
e) Systemic Lupus Erythematosus
13.When a rectovaginal exam is performed, the body of the uterus is palpated. This
finding indicates that the uterus is in what type of position?
a) An anteverted uterus
b) A retroflexed uterus
c) A retroverted uterus
d) A second-degree prolapsed uterus
e) A third-degree prolapsed uterus

14.A 67-year-old man was cleaning out his garage and noticed an insect crawling on his
leg. The insect bit him and was then killed by the man. He discarded it and went about
his business. 2 days later, he went to the Emergency Department with complaints of
pain, itching, and swelling of the affected leg. The insect had a violin-shaped pattern on
its back. What was the insect responsible?
a) Scorpion
b) Black widow spider
c) Wasp
d) Mosquito
e) Brown recluse spider

15.A 28-year-old woman came to the ER presenting with vaginal bleeding, abdominal
pain, and light headedness. The patient said that pain started 5 hours ago, sharp and
increasing in severity, then bleeding followed. Her last menstrual period was 76 days
ago and she used to have regular menses every 31 days. She is sexually active with
multiple partners. She was treated several times for STD. On examination, the patient is
hypotensive, and on abdominal examination there is tenderness and rebound;
tenderness especially at right hypochondrial area. What is the most likely diagnosis?
a) Acute appendicitis
b) Ruptured ectopic pregnancy
c) Threatened abortion
d) Endometriosis
e) Inevitable abortion

16.A 45-year-old man presents to your office complaining of a 2-month history of

weakness of his shoulder muscles. He reports he has been gaining a lot of weight,
though he has not changed his diet. He drinks alcohol everyday. On examination, his BP
is 145/85 mm/Hg and PR 95/min. He is obese but not pale or jaundiced. Laboratory
investigations reveal normal transaminases and creatine kinase. A muscle biopsy shows
selective atrophy of type II muscle fibers. What is the most likely cause of his muscle
weakness?
a) Alcoholism
b) Hyperthyroidism
c) Cushing's disease
d) Hypothyroidism
e) Systemic Lupus Erythematosus

17.A 16-year-old boy states that he was camping with his family in Arizona and was
bitten by an insect that he did not see. The wound was cleaned and the boy's camping
trip continued without any further interruption. Approximately 5 hours after being bitten,
he began feeling intense pain, itching, fever, and nausea. The affected area was red
initially, but then became blistered and bluish in color. At the time of presentation the
area showed signs of necrosis. What is the insect that most likely caused this patient's
symptoms?
a) Brown recluse spider
b) Wasp
c) Hornet
d) Black widow spider
e) Yellow jacket

18.A 51-year-old male with a history of Marfan syndrome presents to the emergency
department with tearing chest pain that radiates to the back and neck. On examination,
the patient is hypertensive, and a high-pitched decrescendo diastolic murmur at the left
sternal border and diminished peripheral pulses are noted. Based on the patient’s
most likely diagnosis, what is the immediate diagnostic imaging modality of choice?
a) Posterior-anterior chest x-ray (PA CXR)
b) Computed tomography scan of the chest and abdomen (CT scan)
c) Magnetic resonance imaging of the chest (MRI)
d) 12-lead Electrocardiogram (ECG)
e) Transesophageal echocardiography (TEE)

19.In reviewing your hospital's policies, you notice the presence of an Institutional Ethics
Committee that can provide ethics consultations. The provision of an ethics consultation
by an Institutional Ethics Committee is best represented by the statement that:
a) Any patient, parent, guardian, or family member should be able to initiate an
ethics consultation
b) Refusal of a patient, parent, or guardian to permit an ethics consultation should
be respected and honored
c) Only the physician directly involved in the care of the patient should be able to
request an ethics consultation without fear of reprisal
d) Anonymous requests for consultation should only be accepted in the absence of
an identified person willing to speak on the issue raised
e) The process of consultation should be open and readily accessible to all persons
involved in the patient's care

20.A 38-year-old woman presents to your clinic with the complaint of a tender mass on
the dorsum of her right dominant wrist for the past 3 months. It has fluctuated in size and
even gone away for a while. She works in a factory where she uses her hands
extensively, and now the mass is bothering her enough to cause her to have trouble
doing her job. The doctor tells you that this patient has a dorsal wrist ganglion cyst.
Which of the following treatment options would you offer first in this patient?
a) AROM
b) PROM
c) Observation
d) Immobilization & activity modification

21.A 45-year-old woman came to the outpatient clinic presenting with fatigue. On review
of her symptoms, she admitted that she has a good appetite and no cold intolerance.
She denied feeling depressed or having any pain. Her bowel habit is once a day, and
she is 240 pounds, 5 feet 4 inches tall. She has no urinary troubles. She gave history of
snoring at night and repetitive awakening in the middle of night, as reported by her
husband. What is the most likely diagnosis?
a) Narcolepsy
 b) Sleep apnea
c) Hidden malignancy
d) Diabetes mellitus
e) Hypothyroidism

22.A 62-year-old woman presents to the Emergency Department with right-sided chest
pain and shortness of breath. Her symptoms began abruptly about 2 hours ago. Her
history is significant for a 30-year smoking history, but she has been relatively healthy
otherwise. Examination reveals a thin, frail, ill-appearing woman in respiratory distress.
She was tachypneic with decreased breath sounds on the right. A chest radiograph
showed a large right-sided pneumothorax. Vital signs are as follows: Blood pressure
100/66 mm Hg, Pulse 126/min, Respiratory Rate 24 per minute, Temp 97.2 degrees
Fahrenheit. Which of the following concerning a secondary spontaneous pneumothorax
is true?
a) There is an increased risk in smokers
b) Recurrence rate is about 80%
c) They are always visible on an inspiratory chest radiograph
d) They are usually idiopathic and do not necessarily represent an underlying
disease process
e) It occurs more often in women

23.A 56-year-old woman came to the outpatient clinic presenting with lightheadedness
for 1 week. She experiences it usually when she gets up from her bed. She is
hypertensive. She gave a 3-day history of a diarrhea. She reported eating some old
food. She doesn't have any hearing problems, ear pain, tinnitus, or discharge. She
denies any headache, vomiting, abnormal weakness, or sensations. You suspect this
patient has:
a) Stroke
b) Transient ischemic attack (TIA)
c) Meniere's disease
d) Orthostatic hypotension
e) Benign positional vertigo

24.At the obstetric department, a baby who is totally blue. The baby is relieved when he
cries. He is a full term, average weight, vaginal delivery. There were no complications
throughout pregnancy or during birth. What is the most likely diagnosis?
a) Tracheoesophageal fistula
b) Meconium aspiration
c) Respiratory distress syndrome
d) Bilateral choanal Artesia
e) Central respiratory depression

25. 57-year-old Caucasian woman presents to your clinic complaining of a 2-week

history of feeling weak. She is an artist who has been chain smoking for 30 years. On
examination, she is wasted but not dehydrated. Her BP is 116/70 mmHg. Laboratory
investigations reveal plasma sodium of 122 mEq/L with a high urine osmolality. A chest
radiograph reveals a rounded opacity in the right lung field What is the most likely
diagnosis?
a) Lambert-Eaton myasthenic syndrome
b) Hypertrophic pulmonary osteoarthropathy
c) Horner’s syndrome
 d) Ectopic adrenocorticotropic hormone (ACTH) secretion
e) Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

26.A 38-year-old man presents to the Emergency Department with the complaint of pain
and inability to extend his middle finger DIP joint following a sudden jamming type injury
when attempting to catch a football thrown by his son 3 hours ago. His radiographs are
normal. What is his diagnosis based on this history?
a) Swan neck deformity
b) Mallet finger
c) Boutonnière deformity
d) DIP dislocation
e) Trigger finger

27.A 37-year-old woman presents with a history of right-sided facial weakness and
periauricular discomfort since she awoke this morning. She is afebrile. What is the most
likely diagnosis?
a) Trigeminal neuralgia
b) Bell's Palsy
c) Multiple sclerosis
d) Myasthenia gravis
e) Primary lateral sclerosis

28.A 34-year-old woman received a renal transplant 18 months ago for her diabetic
kidney disease. Her transplant is functioning well. Social and family histories are
negative for alcohol or substance abuse. Pre-transplant, her stress echocardiogram
showed no ischemic defects or arrhythmias and mild concentric left ventricular
hypertrophy.Attention to which of the following preventive measures will prevent one of
the leading causes of death in this patient?
a) Blood pressure and lipid control
b) Contraceptive counseling
c) Advise regular seat belt use
d) Increased consumption of grapefruit
e) Screening testicular ultrasounds

29.A 32-year-old woman presents to your clinic with the complaint of dominant right
hand pain and paresthesia of the thumb, index, and middle fingers for the past 3 months.
She works in a retail sales office where she spends much of the day on the computer
keyboard typing. What associated physical finding may indicate an advanced Carpal
Tunnel Syndrome?
a) Thenar atrophy
b) Hypothenar atrophy
c) Weakness on extension of the DIP joints
d) Decreased gap to 2 mm on 2-point discrimination test
e) Weak radial artery pulse

30.A 25-year-old sexually active man notices a painless sore on his penis. 2 weeks later
he goes to his doctor. On questioning, he denies any discharge or pain with urination.
On physical examination, the sore is still present and he is afebrile. He is found to have
palpable inguinal lymph nodes. The lymph nodes are enlarged, but painless. Dark-Field
examination is done on an exudate from the lesion. The results of the Dark-Field
examination are positive. Question: What is the most likely diagnosis?
 a) Syphilis
b) Condyloma acuminatum
c) Herpes genitalis
d) Chancroid
e) Gonorrhea

31.A 23-year-old woman presents with a painful right arm. Tissue pressure in the arm is
55 mmHg. There is also swelling and tenderness to the touch. Patient has extreme pain
when the fingers of the right hand are flexed. There is no erythema present and no
purulent exudate is seen. What is the treatment for this patient's symptoms?
a) Antibiotics
b) Steroids
c) Surgery
d) Watchful waiting
e) Immobilization

32.A 27-year-old man has several disfiguring nodules on his skin. He has about a dozen
café au lait spots ranging in size from 2 cm and upward on his trunk and armpits. In
addition, he has vertigo, weakness in his facial muscles, numbness in his face, and
atrophy of the muscles of mastication. This condition seems to run in his family, as his
brother and his father have a similar condition. What cranial nerve is responsible for the
changes in the muscles of mastication?
a) Cranial nerve V
b) Cranial nerve VII
c) Cranial nerve VIII
d) Cranial nerve IX
e) Cranial nerve X

33.Your patients, a 21-year-old female and a 25-year-old male, have come to you for
counseling a few weeks after their marriage and honeymoon. They are concerned about
dyspareunia and would like for you to explain its causes and how they might deal with it.
You explain that dyspareunia may be characterized by
a) inadequate lubrication
b) its equal occurrence in both sexual partners
c) vaginismus not being causative
d) amenorrhea being statistically causative
e) a complete lack of pain during intercourse

34.A 12-year-old girl with recently diagnosed bronchial asthma is prescribed 1-2 puffs of
salbutamol metered dose inhaler (MDI). Which of the following is the primary mechanism
of action (in asthma) of the drug prescribed to this patient?
a) Antimuscarinic action and decrease of vagal tone in the airways
b) Stimulation of beta2 adrenergic receptors on the bronchial smooth muscle
c) Adenosine antagonism and non-selective inhibition of phosphodiesterase
d) Activation of glucocorticoid receptor to produce anti-inflammatory effect
e) Stabilizing effect on the sensitized mast cell degranulation

35.A 45-year-old man presents to the emergency room complaining of a 3-month history
of weakness of his shoulder muscles. He also reports tingling sensations in his feet. He
is not taking any medications. He is a divorced waiter who lives alone and drinks alcohol
everyday. On examination his BP is 140/90mm/Hg and PR 92/min. He is obese and
pale, with a tinge of jaundice. He has telangiectasia. Laboratory investigations reveal
elevated GGT levels. An electromyogram is normal. What is the most likely cause of his
muscle weakness?
a) Alcoholism
b) Hyperthyroidism
c) Cushing's disease
d) Hypothyroidism
e) Systemic Lupus Erythematosus

36.A 24-year-old college graduate presents with paroxysmal attacks of headaches,

anxiety, and excessive sweating for the past month. On examination, there is no pallor,
icterus, edema, or lymphadenopathy. His BP is 150/78 mmHg. Biochemical
investigations reveal an elevated blood sugar level and increased levels of urinary VMA
(vanillyl mandelic acid). He was diagnosed with pheochromocytoma, a diagnosis that is
confirmed by a CT scan showing a mass on the left. On being informed of the condition
and the treatment options available to him, he consents to surgery. During surgery, after
location of the adrenal tumor, the vein that needs to be ligated before excision is the left
adrenal vein. The left adrenal vein drains into which of the following veins?
a) Inferior vena cava
b) Renal vein
c) Gonadal vein
d) Azygous vein
e) Inferior mesenteric vein

37.Your last appointment of the day is with a couple in their nineties. The husband wants
to consult with you about his wife and how long she has to live. You have been treating
his wife for the past 3 years for general decline in health. His wife does not have any
specific health problems. What will you tell him?
a) Elicit the reason for his concern
b) You shouldn’t think about your wife dying.
c) Have you made funeral arrangements?
d) Are you hoping your wife will not live much longer?
e) I don’t know how long she will live.

38.You are auscultating a 32 year-old African American male while simultaneously

measuring his ECG. The first heartsound corresponds with what activity on an ECG?
The beginning of the P wave
The P-Q interval
The QR interval
The RS interval
The end of the T wave

39.A 66-year-old man presents with a 2-month history of numbness of his lower limbs
and a feeling of being tired. He has been a strict vegetarian for the past 2 years. On
examination he is pale with an ataxic gait and diminished proprioceptive sensation in his
legs. A peripheral blood smear reveals macrocytic red cells. What is the most likely
diagnosis?
a) Iodine deficiency
b) Zinc deficiency
c) Copper deficiency
d) Folic acid deficiency
 e) Cobalamin deficiency

40.A 40-year-old type 2 diabetic patient arrives with her fasting blood sugar is 200
mg/dL. The patient informs that she has not been adhering to a strict diabetic diet
pattern. She is redirected to a dietician who gives her a new diabetic diet chart. The
patient is advised to cut down on her high carbohydrate diet. The aerobic conversion of
1 mole of glucose to 2 moles of pyruvate is accompanied by the generation of how many
moles of adenosine triphosphate (ATP)?
a) 2
b) 4
c) 8
d) 10
e) 12

41.While reviewing a study regarding a new medication called Vasolaxin, you read the
following statement claimed by researchers of the study: "In clinical trials, Vasolaxin
lowered diastolic blood pressure in patients with chronic hypertension by an average of
15% (p-value of <0.10)." Which of the following statements is true regarding this claim?
a) Less than 10% of patients experienced no effect from Vasolaxin.
b) Greater than 90% had favorable clinical results from Vasolaxin.
c) The observed value has a less than 10% chance of occurring by chance alone.
d) There is a 90% chance of reproducibility of this experimental study.
e) Less than 10% of subjects fell outside of 2 standard deviations of the mean for
diastolic blood pressure.

42.In a classical conditioning experiment, an animal is taught to fear a red light by

pairing red light with the presentation of a mild shock. The experimenter then finds that
the animal shows a fear response to a green light as well. This is called:
a) Extinction
b) Spontaneous recovery
c) Higher-order conditioning
d) Stimulus discrimination
e) Stimulus generalization

43.A 16-year-old Hispanic girl presents to the hospital complaining of a 3-day history of
painful swellings in her groin. On examination, you note multiple yellow pustules around
the hair follicles. What is the causative organism?
a) Candida albicans
b) Trichomonas vaginalis
c) Haemophilus ducreyi
d) Varicella-zoster virus
e) Staphylococcus aureus

44.A 52-year-old woman is found to have an area of calcification on chest X-ray. It is

determined that she has dystrophic calcification, rather than metastatic calcification.
Which of the following conditions is associated with her condition?
a) Hyperparathyroidism
b) Immobilization
c) Coagulative necrosis
d) Milk-alkali syndrome
e) Sarcoidosis
45.An 18-year-old African American man presents to the hospital complaining of bilateral
pretibial pain for 1 day, which began while he was training for a marathon, though he did
not sustain any injury to his legs. He gives a history of similar body pains since his
childhood. He also reports that his older brother died of a similar illness at the age of 22
years. On examination, he has mild pallor and a tower-shaped skull. On successful
management of his acute symptoms, what vaccine would you recommend for him to
receive?
a) Hepatitis A vaccine
b) Rabies vaccine
c) Pneumococcal vaccine
d) Lyme disease vaccination
e) Measles vaccination

46.An 18-month-old girl presents to the emergency room with a painful left arm. After
eliciting her history and performing an examination, it is determined that she has
suffered a pulled elbow with subluxation of the head of the radius. There is no evidence
of any other trauma on examination. The next step in treating this patient should be
a) Orthopedic consult to schedule open reduction
b) Discharge with oral analgesics and orthopedic follow-up in 1 week
c) Closed reduction in the emergency room
d) Admit the patient for observation
e) Call Child Protective Services as you suspect child abuse

47.You are seeing a couple for the first time. They have come in for prenatal counseling.
They want to know if they should consider a home birth with a midwife. What is one of
the first things you would tell them about this option?
a) Home birth is a consideration; let’s discuss the pros and cons.
b) No, a home birth will end in tragedy.
c) The baby will be damaged if the baby is not born in a hospital.
d) Midwives do not know what they are doing.
e) Home birth is the only way to go.

48.A 78-year-old female who is a known case of congestive cardiac failure presents to
the clinic with complaints of ulcers on her right foot for the past 2 days. Examination
reveals bilateral pitting pedal edema with 2 small 2X2 cm venous ulcers at the medial
malleolus of her right foot along with increased jugular venous pressure (JVP),
hepatomegaly, and S3 gallop on cardiac auscultation. The patient is advised
compression stocking for the venous ulcer. Application of compression stocking helps
reduction of edema through which of the following hemodynamic mechanism?
a) Increasing capillary hydrostatic pressure
b) Increasing capillary permeability
c) Increasing tissue hydrostatic pressure
d) Increasing tissue oncotic pressure
e) Increasing venous pressure

49.A 13-year-old girl is brought to her family doctor because her mother is concerned
about her weight loss, excessive exercise, surreptitious laxative use, and odd eating
habits. The doctor is alarmed: it is immediately apparent that she is abnormally thin and
weak. Her laboratory results are as follows: TEST RESULTS REFERENCE RANGE
calcium 9.8 mg/dL 8.4-10.2 mg/dL potassium 2.9 mEq/L 3.5-5.0 mEq/L sodium 139
mEq/L 135-145 mEq/L glucose (fasting) 65 mg/dL 70-110 mg/dL An EKG is performed.
What EKG finding would be most consistent with these laboratory results?
a) Osborne waves
b) Q waves
c) Peaked T waves
d) Sine wave pattern
e) U waves

50.A 22-year-old woman sees you for a physical examination. When questioning her for
the medical history, you discover that she has a history of rheumatic fever. Upon
listening to her heart, you detect a murmur. Which valvular abnormality did you probably
hear?
a) Mitral regurgitation
b) Aortic regurgitation
c) Mitral stenosis
d) Aortic stenosis
e) Tricuspid stenosis