21
44.
A 55-year-old man is brought to the emergency department because of shortness of breath and confusion for 4 hours. He has
hypertension and chronic kidney disease requiring hemodialysis. An ECG shows low voltage with electrical alternans.
Physical examination is most likely to show which of the following findings?
Blood Pressure
Jugular Venous
Pulsus
(mm Hg)
Pulse (/min)
Pressure
Paradoxus
(A)
85/60
120
increased
increased
(B)
85/60
120
increased
normal
(C)
85/60
120
normal
normal
(D)
120/80
80
increased
increased
(E)
120/80
80
normal
increased
(F)
120/80
80
normal
normal
45.
A 54-year-old woman comes to the emergency department because of severe jaw pain since undergoing a painful dental
procedure 1 day ago. The patient was prescribed codeine after the procedure and instructed to take the medication every
4 hours, but she has continued pain despite adherence to this analgesic regimen. Other members of her family also have
experienced poor pain control with codeine. Which of the following is the most likely explanation for this therapeutic failure?
(A) Decreased absorption of codeine
(B) Decreased metabolism of codeine to morphine
(C) Deficiency of κ receptors
(D) Increased plasma protein-binding of codeine
(E) Increased renal clearance of codeine
46.
A 14-year-old girl with a 9-year history of type 1 diabetes mellitus is brought to the physician by her mother for a follow-up
examination. She has been admitted to the hospital twice in the past 3 months because of diabetic ketoacidosis. She
previously had been compliant with monitoring her blood glucose concentration and with her diet and insulin regimen. She
acknowledges that, when she is with her peers, she eats whatever she wants and does not check her blood glucose
concentration. She adds, "I'm embarrassed to inject myself in front of them." The physician is having a great deal of difficulty
with her 15-year-old son who has been truant from school and sneaking out of the house. She says to the patient, "You should
be ashamed for not taking care of yourself. We've all worked so hard to keep you healthy." Which of the following terms best
describes the physician's reaction to the patient?
(A) Countertransference
(B) Identification with the aggressor
(C) Projection
(D) Splitting
(E) Sublimation
47.
A 23-year-old woman with bone marrow failure is treated with a large dose of rabbit antithymocyte globulin. Ten days later,
she develops fever, lymphadenopathy, arthralgias, and erythema on her hands and feet. Which of the following is the most
likely cause of these symptoms?
(A) Cytokine secretion by natural killer cells
(B) Eosinophil degranulation
(C) Immune complex deposition in tissues
(D) Polyclonal T-lymphocyte activation
(E) Widespread apoptosis of B lymphocytes
22
48.
A 30-year-old woman comes to the office because of a 1-day history of malaise, darkening of her skin, weakness, low back
pain, and dark urine. Four days ago, she began treatment with oral trimethoprim-sulfamethoxazole for a urinary tract
infection. Her temperature is 37.3°C (99.2°F), pulse is 106/min, respirations are 14/min, and blood pressure is
110/70 mm Hg. Physical examination shows scleral icterus. Cardiac examination shows a grade 2/6, systolic ejection murmur
with no rubs or gallops. Laboratory studies show:
Hemoglobin
8.8 g/dL
Hematocrit
27%
Mean corpuscular volume
84 μm
3
Red cell
distribution width
14% (N=13–15)
Leukocyte count
9000/mm
3
Platelet count
300,000/mm
3
Serum
Urea nitrogen
20 mg/dL
Creatinine
1 mg/dL
A photomicrograph of a peripheral blood smear is shown. Which of the following is the most likely cause of the findings in
this patient?
(A) Babesiosis
(B) Glucose 6-phosphate dehydrogenase deficiency
(C) HIV infection
(D) Paroxysmal nocturnal hemoglobinuria
(E) Sickle cell crisis
(F) West Nile virus infection
23
49.
A 42-year-old woman comes to the physician because of anxiety, tremor, and a 5-kg (11-lb) weight loss over the past
4 months despite good appetite. Physical examination shows fine thin hair, exophthalmos, goiter, and warm moist skin.
Cardiac examination shows tachycardia and a widened pulse pressure. Which of the following sets of laboratory values is
most likely in this patient's serum?
Thyroid-stimulating
Total Thyroxine
Free
Thyroid-binding
Hormone
(T
4
)
Thyroxine
Globulin
(A)
↑
↑
↑
↑
(B)
↑
↑
normal
↓
(C)
↑
normal
↑
↓
(D)
↓
↑
↑
normal
(E)
↓
normal
normal
↑
(F)
↓
normal
normal
normal
50.
A 29-year-old woman is prescribed carbamazepine for trigeminal neuralgia. She has a strong family history of osteoporosis.
As a result, the physician also advises her to increase her intake of vitamin D. The most likely reason for this
recommendation is that carbamazepine may affect which of the following pharmacokinetic processes?
(A) Absorption
(B) Distribution
(C) Excretion
(D) Metabolism
(E) Protein binding
51.
Over 1 year, a study is conducted to assess the antileukemic activity of a new tyrosine kinase inhibitor in patients with
chronic myeloid leukemia in blast crisis. All patients enrolled in the study are informed that they would be treated with the
tyrosine kinase inhibitor. They are assigned to successive dose cohorts of 300 to 1000 mg/day of the drug. Six to eight
patients are assigned to each dose. Treatment efficacy is determined based on the results of complete blood counts and bone
marrow assessments conducted regularly throughout the study. This study is best described as which of the following?
(A) Case-control study
(B) Crossover study
(C) Open-labeled clinical trial
(D) Randomized clinical trial
(E) Single-blind, randomized, controlled trial
52.
A 64-year-old man with non-Hodgkin lymphoma comes to the physician because of a 3-week history of progressive
numbness in his hands and feet and weakness in his legs when he stands. He received his third course of chemotherapy
4 weeks ago. Physical examination shows areflexia. Which of the following drugs is the most likely cause of these adverse
effects?
(A) Bleomycin
(B) Cyclophosphamide
(C) Cytarabine
(D) Doxorubicin
(E) Fluorouracil
(F) Methotrexate
(G) Vincristine