1.

A 55-year-old woman with a long-standing history of atrial fibrillation secondary to

mitral
regurgitation comes to the emergency department with a painful right foot. The patient
reports that, over the past few hours, her foot has become more painful and now is
nearly insensate. She describes the pain as burning and states that it is not relieved by
any intervention. She takes warfarin, atenolol, digoxin, and aspirin. On physical
examination, her pulse is irregularly irregular. Her lungs are clear, and she has a loud
holosystolic murmur heard best at the apex. Her right foot is gray and cool to the touch
and has poor capillary refill. Dorsalis pedis and posterior tibial pulses are absent on the
right. Her prothrombin time is 14.4 seconds (INR 1.4). Which of the following is the
most
appropriate course of action?
A. Arrange for her to be seen by a vascular surgeon in the emergency department now
B. Arrange for her to be seen by a neurologist within the next few days
C. Arrange for her to undergo an MRI of the head that day
D. Ask her to make an appointment to be in seen in your office within 1 week
E. Instruct her to soak her leg in warm water and to place a fitted stocking on her
affected leg

2. A 67-year-old man with emphysema comes to the physician for a routine checkup. He
reports that his symptoms have remained stable, with frequent coughing and dyspnea,
despite compliance to his medications, which include oral prednisone, aminophylline,
inhaled metaproterenol, and rotating courses of antibiotics. On physical examination, he
has a barrel-chest and distant breath sounds in both lung fields with soft expiratory
wheezes. An arterial blood gas reveals an arterial pH of 7.32, a pCO2 of 47 mm Hg, and
a pO2 of 53 mmHg. Which of the following would most likely prolong his survival?
A. Continuous home oxygen therapy
B. High-dose oral prednisone
C. Influenza vaccine
D. Pneumococcal vaccine
E. Tracheostomy
3. A 40-year-old woman comes to the clinic complaining of abdominal pain, pruritus, and
fatigue. The symptoms began insidiously some months ago and have progressed to the

point that the woman has difficulty leaving her house for lack of energy. She uses
topical steroid and antihistamine creams with only little relief and has lost 15 pounds in
the last 2 months. Examination is remarkable for mildly icteric sclera, moderate
nontender hepatomegaly, and numerous excoriations on her skin. Laboratory studies
are remarkable for a total bilirubin of 4.0 mg/dL and an alkaline phosphatase level of
980 U/L. Based on this presentation, an antimitochondrial antibody ELISA test is
ordered, which is strongly positive. Given this woman's condition, which of the following
is the most appropriate initial treatment for her liver disease?

A. Interferon and ribavirin

B. Lamivudine
C. Liver transplantation
D. Prednisone
E. Ursodeoxycholic acid

4. medical student. In the middle of describing how he feels that other people are out to
kill
him, the patient suddenly stops talking and begins staring into space. Approximately 20
seconds later, he starts talking about how his mother was not a very good parent and
was excessive in her discipline during his childhood. Which of the following terms best
describes this behavior?
A. Echolalia
B. Echopraxia
C. Mutism
D. Satyriasis
E. Thought blocking