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1.You are evaluating a generally healthy 33-year-old man with low back The pain began yesterday, occurring suddenly while loading firewood in his truck. He reports that the pain radiates to his right leg. On examination, his range of motion is limited by pain. His lower extremity neurological examination is normal. When you lay the patient on his back and raise his fully extended leg by the heel, he reports pain below the knee at about 30° of elevation. What is the most likely diagnosis?
- Back strain
- An inflammatory condition
- Disk herniation
- Compression fracture
2. A 41-year-old sedentary man presented to you 6 weeks ago with the acute onset of low back pain radiating to the left His neurological examination at the time was normal, but he did not respond to conserva- tive therapy. X-rays are normal. What is the most appropriate next step?
- Flexion and extension radiographs
- Bone scan
- A complete blood count and erythrocyte sedimentation rate
3. A 35-year-old woman presents to you with low back It occurred suddenly when lifting her 6-year-old son yesterday. She has tried aceta- minophen without relief. On examination, her range of motion is limited by pain, and she has tenderness to palpation of the lumbar paraspinal muscles. Which of the following would be the best treatment option?
- Bed rest for three to five days
- Spinal traction
- Nonsteroidal anti-inflammatory agents and return to normal activity
- Opiate analgesia and limited activities
- Oral corticosteroids
4. Despite several months of conservative therapy including physical therapy, one of your 44-year-old male patients has had persistent low back Which of the following interventions has been shown to be effective in the short term?
- An individualized exercise program
- Steroid injections
5. You are evaluating a 31-year-old man complaining of left-sided neck and upper-back He reports worsening discomfort when he turns his head toward the left, with some paresthesias in his left upper extremity. On examination, when you rotate his head to the left and exert downward pressure on his head, it reproduces the pain and paresthesia. Which of the following is the most likely diagnosis?
- Cervical strain
- Cervical disk herniation
6. A 60-year-old woman was the restrained driver in a motor vehicle accident Today, she presents to you for evaluation. She reports neck and upper back pain. On examination, she does not have bony ten- derness, but cannot rotate her head 45° to the right or left. Which of the following is the most appropriate next step in her evaluation?
- Reassurance and nonsteroidal anti-inflammatory agents
- Cervical spine x-rays
- Bone scan
- Dual energy X-ray absorptiometry (DEXA) scan
7. You are assessing a 59-year-old patient with an 80-pack-year history of smoking He stopped smoking 1 year ago. He reports a cough productive of white frothy sputum for the past 4 months. Reviewing his chart, you discover that he had a similar presentation last winter, with a cough that lasted more than 3 months. Given this information, what is his most likely diagnosis?
- Chronic bronchitis
- Recurrent pneumonia
8. You have been treating a 33-year-old woman for asthma for the last three She began with mild symptoms, but has become progressively more short of breath over the last year. She reports weight loss and signifi- cant dyspnea on exertion. She has never smoked, but her husband smokes in the home. Her maternal aunt was a smoker, and died of emphysema in her early 50s. Her chest x-ray reveals flattened diaphragms, a long, narrow heart cardiac silhouette, and increased retrosternal airspace on the lateral projection. Given this clinical picture and x-ray, what is the most likely consideration?
- HIV with chronic lung infection
- Congestive heart failure
- Chronic bronchitis
- Lung cancer due to passive exposure to cigarette smoking
- Alpha 1-antitrypsin deficiency
9. You are caring for a 64-year-old former smoker who complains of increasing shortness of breath with exertion and sometimes at rest. You observe that he is somewhat “barrel-chested,” he breathes with pursed lips, and leans forward resting on his elbows when sitting in your On examination, he has decreased breath sounds and distant heart sounds. You are concerned about chronic obstructive pulmonary disease (COPD) and order office spirometry. Which measurement is most sensitive to diag- nose COPD?
- Total lung capacity (TLC)
- Forced vital capacity (FVC)
- Forced expiratory volume in 1 second (FEV1)
- Forced expiratory flow rate over the interval from 25% to 75% of the total FVC (FEF25–75%)
- FEV1/FVC ratio
10. You have diagnosed a 59-year-old woman with In addi- tion to pulmonary rehabilitation and lifestyle changes, you would like to try medical therapy. What should be your first line therapy in this patient?
- A short-acting beta-adrenergic agent (albuterol)
- A long-acting beta-adrenergic agent (salmeterol)
- An anticholinergic agent (ipratropium)
- A corticosteroid
11. A 64-year-old man with known chronic obstructive pulmonary dis- ease complains of increasing dyspnea despite therapy with ipratropium and a short-acting beta-adrenergic You are considering the addition of theophylline. Which of the following is true of this medication?
- It does not enhance bronchodilation when added to ipratropium and beta- agonists
- It should be considered in patients with cor pulmonale
- The therapeutic range is wide, and the toxicity is low
- Renal disease is a contraindication to the use of theophylline
- Smoking slows the rate of metabolism
12. You are seeing a patient in the office for the first She is a 68-year- old recently retired school teacher with diabetes and hypertension. She is overweight and does not exercise regularly. Which of the following is the best indicator of the presence of renal insufficiency in this patient?
- Her body mass index
- The presence of diabetes
- The presence of hyptertension
- Her calculated or estimated glomerular filtration rate
- Her serum creatinine level
13. You are following a 45-year-old man with difficult to control dia- As such, you are monitoring his kidney function and are alert to changes suggesting the beginning of chronic renal insufficiency. Of the fol- lowing, which would occur first in the setting of chronic renal failure?
- A fall in plasma bicarbonate level
14. You are following a 56-year-old patient who has been diagnosed with hypertension and diabetes for 4 He does fairly well with diet and exercise, and has remained compliant with his medications. Laboratory evaluation demonstrates a normal serum creatinine, no microalbuminuria, but a glomerular filtration rate (GFR) of 70 mL/minute. According to the National Kidney Foundation staging guidelines, what stage of renal failure does this represent?
- Stage 0 renal failure
- Stage 1 renal failure
- Stage 2 renal failure
- Stage 3 renal failure
- Stage 4 renal failure
15. You are seeing a newly diagnosed hypertensive patient in your As you are considering appropriate therapy for this patient you note that his mother had renal failure from hypertension and was on dialysis. Which of the following medications should you consider for blood pressure management?
- An aldosterone antagonist
- An angiotensin-converting enzyme (ACE) inhibitor
- A beta-blocker
- A calcium-channel blocker
- A alpha1-blocker
16. You are seeing a hypertensive patient in you He is well-controlled with hydrochlorozide, and is seeing you for a routine evaluation. His blood pressure at the visit is 118/76. Laboratory evaluation reveals a normal creati- nine and a GFR greater than 90 mL/minute, but he does have microalbumin- uria. Which of the following interventions is indicated in this patient?
- Commend him on his excellent control and make no changes
- Work to achieve better blood pressure control through diet and exercise
- Increase his hydrochlorothiazide dose
- Add an ACE inhibitor
- Check a glycosolated hemoglobin level
17. You are following a patient with hypertension and diabetes in your Despite good blood pressure and glycemic control, his GFR has started to decrease. GFR measurement was 74 mL/minute 3 months ago. At this visit, GFR is 55 mL/minute. Creatinine is within normal limits, and his serum potassium is 5.2 mmol/L (normal is up to 5.1 mmol/L). The patient denies any changes in urination or other problems. Which of the following is most appropriate at this stage?
- See the patient more frequently, at least monthly
- Increase his ACE inhibitor
- Add diuretic therapy
- Refer to a nephrologist
- Refer to a transplant surgeon
18. You are seeing a 48-year-old man with known He has several physical signs of his illness, including spider angiomata, palmar erythema, Dupuytren’s contractures, gynecomastia, testicular atrophy, splenomegaly, and parotid gland enlargement. Which of his physical examination findings are more commonly seen in patients with nonalcoholic causes of cirrhosis?
- Spider angiomata
- Dupuytren’s contractures
- Testicular atrophy
- Parotid gland enlargement
19. You are following a patient who is known to have primary biliary cir- You are following his liver function tests as indicators of disease sever- ity and progression. Which of the following tests, if rising, is the poorest prognostic sign?
- Aspartate aminotransferase (AST)
- Gamma-glutamyl transpeptidase (GGT)
- Alkaline phosphatase
20. You are following a cirrhotic patient with On laboratory eval- uation, you note that he is hyponatremic. Which of the following is the most likely cause of his hyponatremia?
- High levels of antidiuretic hormone secretion
- Hepatic synthetic protein dysfunction causes osmotic losses of sodium
- Shunting of blood away from the kidney to the liver
- First pass excretion of sodium
- Osmotic sodium shifts from the blood to the ascitic fluid