‎⁨الفاينال الكبير الله يستر⁩.pdf

PAEDIATRICS 1. NICU is the abbreviation for: A. Neonatal intensive care unit B. Newborn infant child unit C. Narnia in closet unleashed D. none of them 2. Risk factors of RDS are all EXCEPT: A. Male infants B. Infants born to mothers with diabetes C. Chronic m...

PAEDIATRICS 1. NICU is the abbreviation for: A. Neonatal intensive care unit B. Newborn infant child unit C. Narnia in closet unleashed D. none of them 2. Risk factors of RDS are all EXCEPT: A. Male infants B. Infants born to mothers with diabetes C. Chronic maternal hypertension D. Second-born twins 3. Treatment of bronchiolitis should include all of the following except: A. Supplemental oxygen for infants with hypoxia. B. Intravenous fluids and close monitoring of nutritional status C. Antibiotics D. antipyretics 4. Which one is the most common cause of bronchiolitis? A. RSV B. Adenovirus C. Rhinovirus D. Influenza virus 5. Which age group does pediatrics include? A. 0-1 years B. 13-18 years C. 0-18 years D. 1-3 years 6. Omphalitis is: A. Pathology of the small intestine B. Liver pathology C. Umbilical pathology D. Anus pathology 7. Choose the right answer - have the ability to generate a heartbeat: A. Atrioventricular and sinoatrial nodes B. His cone C. Sympathetic nerves D. All 8. Which of the following characteristics of upper respiratory tract disease is incorrect? A. Adenovirus is characterized by the development of pharyngoconjunctivitis. B.The most common cause of upper respiratory tract disease complicated by bronchiolitis Synthetic –RS virus C. Parainfluenza virus is not characterized by false croup syndrome. D.Rhinoviruses are the most common cause of acute nasopharyngitis. 9. Upper respiratory tract infection in children is not characterized by A. dry cough B. with a runny nose C. rise in temperature, weakness D. severe headache 10. Inspirational breath and stridor are manifested A. in bronchial asthma B. in case of obstructive bronchitis C. in pneumonia D. in case of epiglottitis 11. A 3-year-old child suddenly began to have inspirational stridor in the morning, noisy breathing, change in tone of voice, aggressive cough ,, wheezing: tint, your diagnosis A.Bronchospasm B.Acute bronchitis C. Acute pneumonia D.Acute laryngitis (croup syndrome) 12. Erythrocytes are mainly involved: A. In tissue respiration B. In hemostasis C. Protect the body from the effects of a foreign body D. In allergic processes 13. Which part of the lung experiences the most atelectasis during foreign body aspiration? A. The upper part of the right lung B. Lower part of right lung C. The middle part of the left lung D. lingual segment 14. Hemorrhages on the skin during neonatal sepsis can be explained A. by sensitization of the child's body B. with angiitis and thrombovasculitis C. with irrational antibacterial therapy D. All of the above 15. At what age is the normal pulse rate 100-140? A. 1 year B. 12 year C. 7 year D. Newborn 16. The parent brought the child to the pediatrician, who has a fever up to 38 degrees, swelling and pain in the back lymph nodes of the neck, abdominal pain. On palpation of the abdomen, the doctor noticed an enlargement of the spleen and liver. In the general analysis of blood there is anemia, leukocytosis, but there is no significantly altered leukocyte formula with a leftward deviation. Which blood pathology do you suspect: A. Thalassemia B. Acute leukemia C. Hodgkin's lymphoma D. Infectious mononucleosis 17. The parent called the pediatric brigade due to the following complaints. The 3-year-old child suddenly started having inspirational stridor at midnight, noisy breathing, change of tone of voice, aggressive cough with a "muffled" tinge. What diagnosis can we think of? A. Acute bronchitis. B. Acute pneumonia. C. Acute laryngitis. D. Bronchospasm 18. A 3-year-old child swallowed a 5 tetri flat toy item. On radiography, the item is in the esophagus. Which method of patient management is most appropriate? A. Expectations and observations B. its endoscopic removal C. induce vomiting therapeutically D. Cleansing the intestines with saliva 19. A 15-year-old girl with mucoviscidosis applied to the clinic with hemoptysis. An emergency life threatening complication for a given patient is: A. Massive blood loss B. worsening hypoxemia C. broncho-tracheal obstruction D. Bacterial sepsis 20. A 2-year-old boy with a 3-day history of tactile fever and cough was brought to the emergency room. Deny contact with any disease. The history of reactive lung disease is negative. From the family history, asthma is noteworthy. Taste "T 38.9 C", "HR 144", "RR 44", "BP 120/78", saturation 94% of room air. Psycho-motor development is age- appropriate, manifested by moderate respiratory distress, cough supraclavicular retraction, bilateral impaired breathing on auscultation) Your diagnosis is a variant of bronchial asthma cough. Nebulizer therapy was performed with albuterol 3 times and the patient's condition remained unchanged. Which of the following is the next stage of management: A. giving an additional dose of albuterol; B. oral or intramuscular dexamethasone; C. nebulizer therapy with epinephrine; D. chest radiographic examination; 21. A 7-year-old boy was brought to the clinic because he could not breathe. The child is agitated, speaks, utters individual phrases. Heart rate 114, respiratory rate 46. Auxiliary muscles are involved in respiration, suprasternal retractions are expressed. On auscultation, bronchospasm is diffuse. The severity of the child is assessed as: A. Light B. Medium severity C. severe D. Stopping breathing is inevitable 22. A 3-year-old child presents with a sore throat, fever, anorexia, and a change in tone of voice. Examination reveals unilateral neck wall bulging, anterior neck lymph node hypertrophy and pain, "T-38.9C". Probable diagnosis: A. retropharyngeal abscess B. Peritonsillar abscess C. Ludwig's angina D. Abscess of the masticatory muscle space 23. Which method of tasting is most informative for assessing abdominal organs A. Inspection B. Palpation C. Percussion D. Auscultation 24.Which of the following is not related to nephrolithiasis A. Cystinuria B. Thalassemia C. Hereditary glycine D. Primary hyperoxalia 25. Poststreptococcal glomerulonephritis is most commonly manifested? A. Against the background of streptococcal pharyngitis or streptococcal pyoderma B. 7-14 days after the transfer of tonsillitis C. Two months after the onset of pharyngitis and streptococcal pyoderma D. Only 1 month after transmission of streptococcal pharyngitis 26. What is meant by terming dysphagia A. Pain on swallowing B. Vomiting Pre-existing nausea C. Increased salivation D. Difficulty swallowing 27. A 2-year-old boy with a history of constipation is presented with a complaint: blood in the stool. During the examination you revealed an anal fissure. Treatment of the child includes: A. Bacteriological analysis of feces B. Apply topical steroid cream C. application of topical antibacterial ointment D. the use of fecal softeners and sedentary baths 28. The most common cause of chronic enteritis in children is A. intestinal infections B. Dysbiosis C. Nutritional defects D. Uncorrected congenital or transient fermentopathies 29. The most common cause of esophagitis is A. viral infection B. Bacterial infection C. Gastro-esophageal reflux D. Trauma 30. You test a newborn, the mother notes that she thinks the baby has a big head, it is more than the circumference of the chest. What is your decision: A. The circumference of the newborn's head is above the norm as it should be equal to the circumference of the chest B. Anthropometric data are within the norm. The circumference of the newborn's head should be 2 cm larger than the circumference of the chest. C. The circumference of the newborn's head is small, as in the case of the norm it should exceed the circumference of the chest by 4 cm D. The circumference of the newborn's chest is small since it should be more than 2 cm above its circumference 31. Which statement do you disagree with in the case of malabsorption syndrome? A.The cause is a disorder of digestion and absorption. B. Steatorrhea is an initial change in the stool. C. Accompanied by constipation D. The leading cause of short bowel syndrome is 32. Biochemical tests are necessary to assess the functional state of the liver. Which of the following tests are informative in case of bile duct damage / obstruction? A.Bilirubin - total and direct, liver enzymes - AST, ALT. B. bilirubin - total and direct. C. urea and creatinine D. albumin 33. A 1-month-old girl was brought to the clinic for a 10-day cough. Parents do not report fever, nasal congestion, or rhinorrhea. The baby was examined by a pediatrician 2 weeks ago for conjunctivitis and local eye drops were prescribed. The child's cough is unproductive, periodically aggressive, sometimes followed by vomiting. Babies are well fed. Its "t" -37, "HR" -140, "RR" -28, "pOx" - 100% room air. Physical tasting: pronounced conjunctival initiation, small rash discharge, and conductive wheezing on both sides. What is the correct management of the patient described in the test ? A. Apply at home with erythromycin eye ointment B. Discharge at home with oral erythromycin C. Discharge at home with oral azithromycin D. leave the hospital with oral erythromycin 34. Which of the following is not considered a small intestine A. duodenum B. small intestine C. hip intestine D. cecum 35. What is the meaning of the term "hematemesis" A. bloody vomit B. bloody stools C. tarry stools D. bleeding gums 36. At 11 o'clock in the evening, the mother was awakened by the screams of a 2-year-old child, 1 hour after going to bed. He sat cross-legged on the bed, then shouted, shivered, and sighed. The child was contactless and "could not be thrown into the mind." This episode lasted 5-10 minutes and then he fell asleep at once. The child is generally healthy and has not had any medical problems before. The mother's brother has epilepsy. Currently the child is sober and in contact, the results of the physical examination are within the norm. What is most acceptable in this case? A. Determination of electrolytes, plasma glucose and CT scan of the head B. Provide outpatient observations through a neurologist and EEG C. Conduct and further write research of EEG and its CT D. Calm down and then at home. 37. What does the term "akhalazia" mean? A. Greed B. Pain during feeding C. Loss of relaxation of the lower third of the esophagus (spasm) D. Disorders of taste 38. Which of the following complications is not characteristic of cystic fibrosis? A. Chronic pneumonia, bronchiectasis B. Liver cirrhosis C. Polyhypovitaminosis D. Nephrotic syndrome with arterial hypertension 39. An 8-year-old girl came in with the following complaints: Has had persistent low-grade fever and involuntary unintentional movements for the last 10 days, knee and elbow pain for the last 1 week. Throat swab taken 3 days ago on the recommendation of a pediatrician is negative for "A" group "Streptococcus". On tasting you hear a holistic hollow, predominantly on the apex, you see a rash on the torso and in the proximal part of the limbs. Which of the following diagnostic tests confirms the diagnosis the most: A. Echocardiogram B. ECG C. erythrocyte sedimentation rate D. antistreptolysin "0" test 40. Visceral leishmaniasis is characterized by all symptoms except: A. Hepatosplenomegaly B. Fever C. Anemia D. Leukocytosis 41. Does not cause bile clotting: A. disruption of the diet B. diarrhea C. pregnancy D. hypodynamics 42. Translation of community-acquired pneumonia Etiological agent is: A. Streptococcus Pneumoniae B. Staphylococcus aureus C. Mycoplasma Pneumoniae D. Legionella Pneumophila 43. An 18-month-old baby was sent to the clinic by a pediatrician after an outpatient screening for hemoglobin at 7 g / dL of microcytic, hypochromic erythrocytes. Which part of the anamnestic data is most useful for diagnosis? A. Family history B. Ethnicity C. Anamnesis of diet D. Birth history 44. A 3-year-old child has contact with a TB-infected grandfather. What are our tactics towards the child? A. We are observing B. We do TB skin C. We do not do X-ray examination D. We start prophylactic treatment with isoniazid and rimampicin 45. The risk factors for diabetes belong to everyone except: A. Hereditary predisposition to diabetes B. Abnormal pregnancies, such as large fetuses, miscarriages C. Hypertensive disease D. Childbirth with a fetus weighing 3 to 4 kg 46. Is the most common way of spreading inflammation during primary tuberculosis: A. Bronchogenic B. lymphogenic C. hematogenous D. lympho-hematogenous 47. Your patient is a 17-year-old boy who has been experiencing shortness of breath for the past 1 month. Complaints started after diarrhea. Currently complains of severe weakness, sweating and shortness of breath at rest. On auscultation you hear galloping, wet wheezing bilaterally in the lower extremities. On palpation, the lower edge of the liver extends up to 4 cm from the n / arc. Which of the following studies unequivocally confirms the diagnosis: A. serum troponin "T" B. Echocardiography C. endomyocardial biopsy D. ECG 48. Which of the clinical manifestations of malaria is incorrectly indicated? A. Cold, limb chills, mild cyanosis B. High fever 40-41 degrees C. Profuse sweat flow D. Liver and spleen intact 49. Acquired cytomegalovirus infection is more common in adult children: A. With mononucleosis-like syndrome B. Hepatitis C. with prolonged pneumonia D. with gastroenteritis 50. Diseases of the immune complexes include all of the listed diseases except: A. Serum disease B. Anaphylactic shock C. Systemic lupus erythematosus D. Essential cryoglobulinemia 51. A mother brought a 2-week-old newborn girl to the emergency room with a major complaint of vaginal bleeding. Says to notice a small amount of scarlet blood on the 2 diapers. The child is afebrile, well-nourished, with regular defecation and normal urination. Examination of the external genitalia is without pathology, only a small amount of blood can be seen on the vulva. Which of the following is the most appropriate treatment for cheese: A. General blood test, group and rhesus B. parent education and relaxation C. Internal vaginal examination under anesthesia D. Send the patient to the Child Protection Department and / or call a social worker 52. Belongs to the organs of the immune system: A. Bone marrow B. Thymus C. Lymph nodes D. All listed 53. The following factors contribute to the development of acute leukemia: A. Viruses B. Ionizing radiation C. Chemical mutagens D. The combination of the above factors 53. You are testing a 3-day-old newborn who is breastfeeding. The baby was born on time, weighing 3000 g and 50 cm long. At the moment he weighs 2800 g. The mother is worried about the weight loss of the baby and please ask for advice. What is your recommendation A. Explain to the mother that the child has lost more weight than normal and advise to switch the child to a nutritious diet. B. Explain to the mother that the baby has lost more weight than normal and you want to add artificial formula after breastfeeding. C. Explain to the mother that weight loss is physiological, advise to continue breastfeeding, the baby will regain weight in a maximum of 10-14 days. D. Explain to your mother that weight loss is physiological, you are advised to continue. 54. The major part of iron is absorbed by the human body: A. In the stomach B. In the descending part of Colling C. 12 in the small intestine and small intestine D. In the intestine of the thigh 55. Develops during enhanced blood breakdown: A. Iron deficiency anemia B. Hemolytic anemia C. Aplastic anemia D. Posthemorrhagic anemia 56. Hemopoiesis is characterized by acute leukemias: A. By increasing the number of myelocaryocytes B. With a sharp decrease in erythrocytes and granulocytes C. With an abundance of undifferentiated blast cells D. With hyperplasia of all three branches 57. A 10-year-old boy, a baseball team star, had a sore throat about 2 weeks ago but did not tell his parent because he was afraid he would miss the play-offs. Since several children in this region had rheumatic fever. The mother worries that she too may be in danger. You tell the mother that there are several criteria needed to make a diagnosis. Which is the most common of the following? A. Carditis B. Polyarthritis C. Marginal erythema D. Subcutaneous nodules 57. A 10-year-old boy, the star pitcher for the Salt Lake City Little League baseball team, had a sore throat about 2 weeks ago but did not tell anyone because he was afraid he would miss the play-offs. Since several children have been diagnosed with rheumatic fever in the area, his mother is worried that he may be at risk as well. You tell her that several criteria must be met to make the diagnosis but the most common finding is which of the following? a. Carditis b. Arthralgia c. Erythema marginatum d. Chorea e. Subcutaneous nodules 58. Thalassemia is found: A. In the North American Indians B. In Eastern Europe C. In equatorial Africa D. In the Mediterranean region 59. The presence of bilirubin in the urine indicates: A. Gilbert's disease B. On mechanical jaundice C. On hemolytic jaundice D. All of the above are correct 60. An increase in ALT (alanine aminotransferase) is observed in the blood: A. During necrosis of hepatocytes of any etiology B. In fatty hepatosis C. In diseases of the kidneys D. In hemolytic anemias 61. Which vitamin helps in blood coagulation? A. Vitamin K B. Vitamin C C. Vitamin A D. Vitamin D 62. Two weeks after a viral syndrome, a 2-year-old child develops bruising and generalized petechiae, more prominent over the legs. No hepatosplenomegaly or lymph node enlargement is noted. The examination is otherwise unremarkable. Laboratory testing shows the patient to have a normal hemoglobin, hematocrit, and white blood cell (WBC) count and differential. The platelet count is 15,000/μL. Which of the following is the most likely diagnosis? A. Von Willebrand disease B. Acute leukemia C. Idiopathic (immune) thrombocytopenic purpura (ITP) D. Aplastic anemia 63. The heart is covered by A. epicardium B. pericardium C. supracardium D. endocardium 64. Investigation of choice for detection and characterization of interstitial lung disease is A. MRI B. Chest X-ray C. HRCT D. Ventilation perfusion scan 65. A 4-year-old previously well African American boy is brought to the office by his aunt. She reports that he developed pallor, dark urine, and jaundice over the past few days. He stays with her, has not traveled, and has not been exposed to a jaundiced person, but he is taking trimethoprim sulfamethoxazole for otitis media. The CBC in the office shows a low hemoglobin and hematocrit, while his “stat” serum electrolytes, blood urea nitrogen (BUN), and chemistries are remarkable only for an elevation of his bilirubin levels. His aunt seems to recall his 8-year-old brother having had an “allergic reaction” to aspirin, which also caused a short-lived period of anemia and jaundice. Which of the following is the most likely cause of this patient’s symptoms? A. Hepatitis B B. Hepatitis A C. Hemolytic-uremic syndrome D. Glucose-6-phosphate dehydrogenase deficiency 66. Which one of the following vitamins is not fat soluble? A. A B. B C. D D. E 67. Which one of the following vitamins is anti-hemorrhagic? A. Vitamin B12 B. Vitamin B5 C. Vitamin C D. Vitamin K 68. Name the blood cells, whose reduction in number can cause clotting disorder, leading to excessive loss of blood from the body. A. Erythrocytes B. Leucocytes C. Neutrophils D. Thrombocytes 69. A father brings his 3-year-old daughter to the emergency center after noting her to be pale and tired and with a subjective fever for several days. Her past history is significant for an upper respiratory infection 4 weeks prior, but she had been otherwise healthy. The father denies emesis or diarrhea, but does report his daughter has had leg pain over the previous week, waking her from sleep. He also reports that she has been bleeding from her gums after brushing her teeth. Examination reveals a listless pale child. She has diffuse lymphadenopathy with splenomegaly but no hepatomegaly. She has a few petechiae scattered across her face and abdomen and is mildly tender over her shins, but does not have associated erythema or joint swelling. A CBC reveals a leukocyte count of 8,000/μL with a hemoglobin of 4 g/dL and a platelet count of 7,000/μL. The automated differential reports an elevated number of atypical lymphocytes. Which of the following diagnostic studies is the most appropriate next step in the management of this child? A. Epstein-Barr virus titers B. Serum haptoglobin C. Antiplatelet antibody assay. D. Reticulocyte count 70. The main cause of fever in Hodgkin's lymphoma A. Infectious complications B. The underlying disease C. Autoaggression D. All 71. The condition “where bone marrow stops producing WBCs is called A. anaemia B. leukemia C. leucopenia D. leukoplakia 72. A child is brought to your clinic for a routine examination. She can put on a T-shirt but requires a bit of help dressing otherwise. She can copy a circle well but has difficulty in copying a square. Her speech is understandable and she knows four colors. She balances proudly on each foot for 2 seconds but is unable to hold the stance for 5 seconds. Which of the following is the most likely age of this child? A. 1 year B. 2 years C. 3 years D. 5 year 73. Select the incorrect statement out of the following A. Neutrophils constitute the majority of leucocytes. B. Eosinophils resist infection. C. Basophils secrete histamine and serotonin. D. RBCs in mammals are enucleated and biconvex in shape. 74. The adolescent shown presents with a 14-day history of multiple oval lesions over his back. The rash began with a single lesion over the lower abdomen (A); the other lesions developed over the next days (B). These lesions are slightly pruritic. Which of the following is the most likely diagnosis? A. Contact dermatitis B. Pityriasis rosea C. Seborrheic dermatitis D. Lichen planus 75. Most of our cells are surrounded by— A. Blood B. fluid equivalent to sea water in salt composition C. interstitial fluid D. pure water 76. A previously healthy 5-year-old boy has a 1-day history of low-grade fever, colicky abdominal pain, and a rash. He is well appearing and alert. His vital signs, other than a temperature of 38°C (100.5°F), are completely normal. A diffuse, erythematous, maculopapular, and petechial rash is present on his buttocks and lower extremities, as shown in the photograph. He has no localized abdominal tenderness or rebound; bowel sounds are active. Laboratory data demonstrate Urinalysis: 30 red blood cells (RBCs) per high-powered field, 2+ protein Stool: Guaiac positive Platelet count: 135,000/μL These findings are most consistent with which of the following? A. Anaphylactoid purpura B. Meningococcemia C. Child abuse D. Leukemia 77. Bundle of His‘ is a part of which one of the following organs in humans? A. Heart B. Brain C. Kidney D. Pancreas 78. A 6-year-old boy is often teased at school because he has stooled in his underwear almost daily for the last 3 months. He was toilet trained at 2 years of age without difficulty, but over the last 2 years he has developed ongoing constipation. His family is frustrated because they cannot believe him when he says, “I didn’t know I had to go.” He is otherwise normal; school is going well, and his home life is stable. His only significant finding on examination is stool in the rectal vault. The plain radiograph of his abdomen is shown. Initial management of this problem should include which of the following? A. Barium enema and rectal biopsy B. Family counseling C. Time-out when he stools in his underwear D. Clear fecal impaction and short-term stool softener use 79. Asthma may be attributed to— A. inflammation of the trachea B. accumulation of fluid in the lungs C. bacterial infection of the lungs D. allergic reaction of the mast cells in the lungs. 80. A patient comes to your office for a hospital follow-up. You had sent him to the hospital 3 weeks earlier for persistent fevers but no other symptoms; he was diagnosed with endocarditis and is currently being treated appropriately. Advice to this family should now include which of the following? A. Restrict the child from all strenuous activities. B. Give the child a no-salt-added diet. C. Provide the child with antibiotic prophylaxis for dental procedures. D. Test all family members in the home with repeated blood cultures. 81. The trachea terminates into? A. bronchial tree B. atrium C. bronchi D. alveoli 82. A 5-month-old child with poor growth presents to the ER with generalized tonic-clonic seizure activity of about 30-minute duration that stops upon the administration of lorazepam. Which of the following historical bits of information gathered from the mother is most likely to lead to the correct diagnosis in this patient? A. The child has had congestion without fever for the past 3 days B. The child is developmentally normal, as are his siblings C. The mother has been diluting the infant’s formula to make it last longer D. The mother reports there are two dogs and one cat at home 83. Hypoxia corresponds to? A. any change in the relative rates of development of different cell lines in body B. hardening and loss of elasticity of arteries C. deficiency of oxygen in body tissues D. sudden interruption of blood flow to a portion of brain due to blockage of cerebral blood vessel. 84. 2-year-old boy has been vomiting intermittently for 3 weeks and has been irritable, listless, and anorectic. He “feels warm” to his parents. His use of language has regressed to speaking single words. In your evaluation of this patient, which of the following is the most reasonable diagnosis to consider? A. Expanding epidural hematoma B. Herpes simplex virus (HSV) encephalitis C. Tuberculous meningitis D. Food allergy 85. Vermiform appendix arises from A. caecum B. colon C. rectum D. ileum 86. You are seeing an established patient, a 4-year-old girl brought in by her mother for vaginal itching and irritation. She is toilet trained and has not complained of frequency or urgency, nor has she noted any blood in her urine. Her mother noted she has been afebrile and has not complained of abdominal pain. Mom denies the risk of inappropriate contact; the girl also denies anyone “touching her there.” Your physical examination of the perineum is significant for the lack of foul odor or discharge. You do note some erythema of the vulvar area but no evidence of trauma. Which of the following is the most appropriate course of action? A. Refer to pediatric gynecology for removal under anesthesia of a suspected foreign body in the vagina B. Counsel mother to stop giving the girl bubble baths, have the girl wear only cotton underwear, and improve hygiene C. Refer to social services for suspected physical or sexual abuse D. Swab for gonorrhea and plate on chocolate agar, and send urine for Chlamydia 87. A patient with bleeding gums is advised to take fresh fruits and vegetables in diet specially because he suffers from? A. Scurvy B. night blindness C. beri-beri D. anaemia 88. A 15-year-old is participating in high school football practice in August in Texas. He had complained of headache and nausea earlier in practice, but kept playing after a cup of water. He is now confused and combative. He is dizzy and sweating profusely. His temperature is 41°C (105.8°F). Therapy should consist of which of the following? A. Provide oral rehydration solutions B. Administer acetaminophen rectally C. Order to rest on the bench until symptoms resolve D. Initiate whole body cold water immersion 89. Cyanocobalamine is required for the maturation of? A. RBC B. Platelets C. WBC D. lymph 90. 5-year-old boy is brought into the ER immediately after an unfortunate altercation with a neighbor’s immunized Chihuahua that occurred while the child was attempting to dress the dog as a superhero. The fully immunized child has a small, irregular, superficial laceration on his right forearm that has stopped bleeding. His neuromuscular examination is completely normal, and his perfusion is intact. Management should include which of the following? A. Irrigation and antimicrobial prophylaxis B. Tetanus booster immunization and tetanus toxoid in the wound C. Copious irrigation D. Primary rabies vaccination for the child cases 1.Two weeks after a viral syndrome, a 9-year-old boy presents to your clinic with a complaint of several days of weakness of his mouth. In addition to the drooping of the left side of his mouth, you note that he is unable to completely shut his left eye. His smile is asymmetric, but his examination is otherwise normal. Which of the following is the most likely diagnosis? a. Guillain-Barré syndrome b. Botulism c. Cerebral vascular accident d. Brainstem tumor e. Bell palsy 2. A 4-year-old girl’s grandmother noticed she was limping and had a swollen left knee. The parents report that the patient occasionally complains of pain in that knee. An ophthalmologic examination reveals findings as depicted in the photograph. Which of the following conditions is most likely to be associated with these findings? a. Juvenile ideopathic arthritis (JIA) b. Slipped capital femoral epiphysis c. Henoch-Schönlein purpura d. Legg-Calvé-Perthes disease e. Osgood-Schlatter disease 3. A previously healthy 4-year-old child pictured below presents to the emergency room (ER) with a 2-day history of a brightly erythematous rash and temperature of 40°C (104°F). The exquisitely tender, generalized rash is worse in the flexural and perioral areas. The child is admitted and over the next day develops crusting and fissuring around the eyes, mouth, and nose. The desquamation of skin shown in the photograph occurs with gentle traction. Which of the following is the most likely diagnosis? a. Epidermolysis bullosa b. Staphylococcal scalded skin syndrome c. Erythema multiforme d. Drug eruption e. Scarlet fever 4. A mother calls you on the telephone and says that her 4-year-old son bit the hand of her 2-year-old son 2 days ago. The area around the injury has become red, indurated, and tender, and he has a temperature of 39.4°C (103°F). Which of the following is the most appropriate response? a. Arrange for a plastic surgery consultation at the next available appointment. b. Admit the child to the hospital immediately for surgical debridement and antibiotic treatment. c. Prescribe penicillin over the telephone and have the mother apply warm soaks for 15 minutes four times a day. d. Suggest purchase of bacitracin ointment to apply to the lesion three times a day. e. See the patient in the ER to suture the laceration. 5. The mother of a 3-day-old infant brings her child to your office for an early follow-up visit. The mom notes that the child has been eating well, has had no temperature instability, and stools and urinates well. She notes that over the previous 3 days the child has had a progressive “rash” on the face as pictured here. Which of the following is the most likely diagnosis? a. Herpes simplex infection b. Neonatal acne c. Milia d. Seborrheic dermatitis e. Eczema 6. seven-year-old boy arrives in clinic with a chief complaint of fever and left facial swelling. His mother reports that 2 days ago the area surrounding his left eye became red and swollen. He denies insect bites and trauma. Upon examination of his left eye, you note markedly swollen upper and lower lids, proptosis, and limitation of movement of the eye. His sclera is mildly hyperemic. The next step in managing this patient is which of the following?  a. Parental reassurance and close follow-up b. CBC, blood culture, IM ceftriaxone, and follow-up the next day in clinic c. Ocular antibiotic drops for 7-10 days d. Oral antibiotics for 7-10 days e. Referral to a local hospital for admission, and IV antibiotics 7. A child can walk well holding on to furniture but is slightly wobbly when walking alone. She uses a neat pincer grasp to pick up a pellet, and she can release a cube into a cup after it has been demonstrated to her. She tries to build a tower of two cubes with variable success. She is most likely at which of the following age? a. 2 months b. 4 months c. 6 months d. 9 months e. 1 year 8. A 1-year-old child presents for a well-child check-up, but the parents are concerned about giving the child his immunizations. Which of the following is a true contraindication to the administration of the fourth DTaP (diphtheria, tetanus toxoid, and acellular pertussis) vaccine? a. Child is currently on amoxicillin for an otitis media b. Positive family history of adverse reactions to DTaP vaccine c. A past history of infantile spasms d. Child is currently febrile to 39°C (102.2°F) e. Prolonged seizures 6 days after the last DTaP vaccine 9. For the past year, a 12-year-old boy has had recurrent episodes of swelling of his hands and feet, which has been getting worse recently. These episodes occur following exercise and emotional stress, last for 2 to 3 days, and resolve spontaneously. The last episode was accompanied by abdominal pain, vomiting, and diarrhea. The results of routine laboratory workup are normal. An older sister and a maternal uncle have had similar episodes, but they were not given a diagnosis. He presents today with another episode. Which of the following is the most likely diagnosis? a. Systemic lupus erythematosus b. Heart failure c. Congenital nephrotic syndrome  d. Angioedema e. Henoch-Schönlein purpura 10. A 2-year-old boy is brought into the emergency room with a complaint of fever for 6 days and the development of a limp. On examination, he is found to have an erythematous macular exanthem over his body as shown in image A, conjunctivitis, dry and cracked lips, a red throat, and cervical lymphadenopathy. There is a grade 2/6 vibratory systolic ejection murmur at the lower left sternal border. A white blood cell (WBC) count and differential show predominant neutrophils with increased platelets on smear. Later, he develops the findings as seen in image B. Which of the following is the most likely diagnosis? a. Scarlet fever b. Rheumatic fever c. Kawasaki disease d. Juvenile rheumatoid arthritis e. Infectious mononucleosis 11. You are asked to evaluate an infant born vaginally 3 hours previously to a mother whose only pregnancy complication was poorly controlled insulin dependent gestational diabetes. The nursing staff noticed that the infant was breathing abnormally. On examination, you find that the infant is cyanotic, has irregular, labored breathing, and has decreased breath sounds on the right side. You also note decreased tone in the right arm. You provide oxygen and order a stat portable chest radiograph, which is normal. Which of the following studies is most likely to confirm your diagnosis? a. Nasal wash for viral culture b. Fiberoptic bronchoscopy c. Chest CT d. Chest ultrasound e. Induced sputum culture 12. A previously well 1-year-old infant has had a runny nose and has been sneezing and coughing for 2 days. Two other members of the family had similar symptoms. Four hours ago, his cough became much worse. On physical examination in the ED, he is in moderate respiratory distress with tachypnea and nasal flaring. Upon auscultation, he has easily audible wheezing with scattered crackles bilaterally. His arterial blood gas on room air revealed a pH of 7.46, a PaCO2 of 34 mm Hg, and a PaO2 of 75 mm Hg. His chest radiographs are shown. Which of the following is the appropriate next course of action? a. Monitoring oxygenation and fluid status b. Inhaled epinephrine and a single dose of steroids c. Acute-acting bronchodilators and a short course of oral steroids d. Emergent intubation, mechanical ventilation, and antibiotics e. Chest tube placement 13. A 6-year-old, fully immunized boy is brought to the emergency room with a 3-hour history of fever to 39.5°C (103.1°F) and sore throat. The child appears alert, but anxious and toxic. He has mild inspiratory stridor and is drooling. He is sitting on the examination table leaning forward with his neck extended. A lateral radiograph of his neck is shown below. Which of the following is the most appropriate immediate management of this patient?  a. Examine the throat and obtain a culture. b. Obtain an arterial blood gas and start an IV line. c. Administer a dose of nebulized epinephrine. d. Prepare to establish an airway in the operating room. e. Admit the child and place him in a mist tent. 14. A 10-year-old boy has been having “bellyaches” for about 2 years. They occur at night as well as during the day. Occasionally, he vomits after the onset of pain. Occult blood has been found in his stool. His father also gets frequent, nonspecific stomachaches. Which of the following is the most likely diagnosis? a. Peptic ulcer b. Appendicitis c. Meckel diverticulum d. Functional abdominal pain e. Pinworm infestation 15. A 3-year-old child presents to your office for an evaluation of constipation. The mother notes that since birth, and despite frequent use of stool softeners, the child has only about one stool per week. He does not have fecal soiling or diarrhea. He was born at term and without pregnancy complications. The child stayed an extra day in the hospital at birth because he did not pass stool for 48 hours, but has not been in the hospital since. Initial evaluation of this child should include which of the following? a. Counseling for stool retention and parental reassurance b. A barium enema and rectal manometry c. Plain films of the abdomen d. Increasing fiber intake and maintaining dietary log e. Beginning oral antispasmodic medication 16. A 14-year-old girl, angry at her mother for taking away her MP3 player, takes an unknown quantity of a friend’s pills. Within the first hour she is sleepy, but in the emergency center she develops hypotension and a widened QRS complex of 130 ms on her ECG. The therapy you would initiate for this ingestion is which of the following? a. N-acetylcysteine (Mucomyst) b. Naloxone and N-acetylcysteine (Mucomyst) c. Intensive care unit (ICU) admission and sodium bicarbonate d. Intravenous ethanol e. Intravenous deferoxamine 17. The parents of a 2-month-old baby boy are concerned about his risk of coronary artery disease because of the recent death of his 40-year old maternal uncle from a myocardial infarction. Which of the following is the most appropriate management in this situation? a. Screen the parents for total cholesterol. b. Counsel the parents regarding appropriate dietary practices for a 2-month-old infant and test him for total cholesterol at 6 months of age. c. Reduce the infant’s dietary fat to less than 30% of his calories by giving him skim milk. d. Initiate lipid-lowering agents. e. Recommend yearly ECGs for the patient. 18. A 15-year-old girl with short stature, neck webbing, and sexual infantilism is found to have coarctation of the aorta. A chromosomal analysis likely would demonstrate which of the following? a. Mutation at chromosome 15q21.1 b. Trisomy 21 c. XO karyotype d. Defect at chromosome 4p 16 e. Normal chromosome analysis 19. A newborn is diagnosed with congenital heart disease. You counsel the family that the incidence of heart disease in future children is which of the following? a. 1% b. 2% to 6% c. 8% to 10% d. 15% to 20% e. 25% to 30% 20. During a regular check-up of an 8-year-old child, you note a loud first heart sound with a fixed and widely split second heart sound at the upper left sternal border that does not change with respirations. The patient is otherwise active and healthy. Which of the following heart lesions most likely explains these findings? a. Atrial septal defect (ASD) b. Ventricular septal defect (VSD) c. Isolated tricuspid regurgitation d. Tetralogy of Fallot e. Mitral valve prolapse 21. An ill-appearing 9-week-old baby girl is brought to the emergency room. She is pale and dyspneic with a respiratory rate of 80 breaths per minute. Heart rate is 195 beats per minute, heart sounds are distant, a gallop is heard, and she has cardiomegaly on x-ray. An echocardiogram demonstrates poor ventricular function, dilated ventricles, and dilation of the left atrium. An ECG shows ventricular depolarization complexes that have low voltage. Which of the following is the most likely diagnosis based on this clinical picture? a. Myocarditis b. Endocardial fibroelastosis c. Pericarditis d. Aberrant left coronary artery arising from pulmonary artery e. Glycogen storage disease of the heart 22. A five-month-old child with unrepaired tetralogy of Fallot presents to the clinic with 2 weeks of intermittent low-grade fever, malaise, weight loss, and irritability with movement. His parents have been watching for “tet spells” but have noted no cyanosis. A workup performed at a freestanding clinic the prior day revealed a normal white count, but a blood culture grew Kingella kingae. The next step in management should be: a. Repeat the blood culture and reassure the parents that the child has a viral illness and that the organism in the blood culture is a typical skin contaminant b. Increase the caloric density of his formula to help with weight gain and follow-up next week c. Arrange an evaluation by his cardiologist next week d. Initiate oral clindamycin therapy and follow-up in two days e. Admit directly to the hospital, get two more blood cultures, and start vancomycin 23. A child has a 2-week history of spiking fevers, which have been as high as 40°C (104°F). She has spindle-shaped swelling of finger joints and complains of upper sternal pain. When she has fever, the parents note a faint salmon-colored rash that resolves with the resolution of the fever. She has had no conjunctivitis or mucositis, but her heart sounds are muffled and she has increased pulsus paradoxus. Which of the following is the most likely diagnosis? a. Rheumatic fever b. Juvenile idiopathic arthritis c. Toxic synovitis d. Septic arthritis e. Osteoarthritis 24. A cyanotic newborn is suspected of having congenital heart disease. He has an increased left ventricular impulse and a holosystolic murmur along the left sternal border. The ECG shows left-axis deviation and left ventricular hypertrophy (LVH). Which of the following is the most likely diagnosis? a. Transposition of the great arteries b. Truncus arteriosus c. Tricuspid atresia d. Tetralogy of Fallot  e. Persistent fetal circulation 25. A 3-day-old infant with a single second heart sound has had progressively deepening cyanosis since birth but no respiratory distress. Chest radiography demonstrates no cardiomegaly and normal pulmonary vasculature. An ECG shows an axis of 120° and right ventricular prominence. Which of the following congenital cardiac malformations is most likely responsible for the cyanosis? a. Tetralogy of Fallot b. Transposition of the great vessels c. Tricuspid atresia d. Pulmonary atresia with intact ventricular septum e. Total anomalous pulmonary venous return below the diaphragm 26. During a physical examination for participation in a sport, a 16-year-old girl is noted to have a late apical systolic murmur, which is preceded by a click. The rest of the cardiac examination is normal. She states that her mother also has some type of heart “murmur” but knows nothing else about it. Which of the following is the most likely diagnosis? a. ASD b. Aortic stenosis c. Tricuspid regurgitation d. Mitral valve prolapse e. VSD 27. A previously normal newborn infant in a community hospital nursery is noted to be cyanotic at 14 hours of life. She is placed on a facemask with oxygen flowing at 10 L/min. She remains cyanotic, and her pulse oximetry reading does not change. An arterial blood gas shows her PaO2 to be 23 mm Hg. Bilateral breath sounds are present, and she has no murmur. She is breathing deeply and quickly, but she is not retracting. While you are waiting for the transport team from the nearby children’s hospital, you should initiate which of the following? a. Indomethacin infusion b. Saline infusion c. Adenosine infusion  d. Prostaglandin E1 infusion e. Digoxin infusion 28. A 10-month-old infant has poor weight gain, a persistent cough, and a history of several bouts of pneumonitis. The mother describes the child as having very large, foul-smelling stools for months. The baby is born to a mother with gestational diabetes. Which of the following diagnostic maneuvers is likely to result in the correct diagnosis of this child? a. CT of the chest b. Serum immunoglobulins c. TB skin test d. Inspiratory and expiratory chest x-ray e. Sweat chloride test 29. 3-day-old infant, born at 32 weeks’ gestation and weighing 1700 g has three episodes of apnea, each lasting 20 to 25 seconds and occurring after a feeding. During these episodes, the heart rate drops from 140 to 100 beats per minute, and the child remains motionless; between episodes, however, the child displays normal activity. Blood sugar is 50 mg/dL and serum calcium is normal. Which of the following is most likely true regarding the child’s apneic periods? a. They are due to an immature respiratory center. b. They are a part of periodic breathing. c. They are secondary to hypoglycemia d. They are manifestations of seizures. e. They are evidence of underlying pulmonary disease. 30. A mother calls you frantic because she has just been diagnosed with chicken pox. She delivered 7 days ago a term infant that appears to be eating, stooling, and urinating well. The child has been afebrile and seems to be doing well. Which of the following is the most appropriate step in management? a. Isolate the infant from the mother. b. Hospitalize the infant in the isolation ward. c. Administer acyclovir to the infant. d. Administer varicella-zoster immunoglobulin to the infant. e. Advise the mother to continue regular well-baby care for the infant. 31. A 3-year-old girl is admitted At the clinic with the x-ray shown below. The child lives with her parents and a 6-week-old brother. Her grandfather stayed with the family for 2 months before his return to the West Indies 1 month ago. The grandfather had a 3-month history of weight loss, fever, and hemoptysis. Appropriate management of this problem includes which of the following? a. Bronchoscopy and culture of washings for all family members b. Placement of a Mantoux test on the 6-week-old sibling c. Isolating the 3-year-old patient for 1 month d. Treating the 3-year-old patient with isoniazid (INH) and rifampin e. HIV testing for all family members 32. The infant in the following picture presents with hepatosplenomegaly, anemia, persistent rhinitis, and a maculopapular rash. Which of the following is the most likely diagnosis for this child? a. Toxoplasmosis b. Glycogen storage disease  c. Congenital hypothyroidism d. Congenital syphilis e. Cytomegalovirus disease 33. A 10-year-old girl has had a “cold” for 14 days. In the 2 days prior to the visit to your office, she has developed a fever of 39°C (102.2°F), purulent nasal discharge, facial pain, and a daytime cough. Examination of the nose after topical decongestants shows pus in the middle meatus. Which of the following is the most likely diagnosis? a. Brain abscess b. Maxillary sinusitis c. Streptococcal throat infection d. Sphenoid sinusitis e. Middle-ear infection 34. An 8-year-old is accidentally hit in the abdomen by a baseball bat. After several minutes of discomfort, he seems to be fine. Over the ensuing 24 hours, however, he develops a fever, abdominal pain radiating to the back, and persistent vomiting. On examination, the child appears quite uncomfortable. The abdomen is tender, with decreased bowel sounds throughout, but especially painful in the midepigastric region with guarding. Which of the following tests is most likely to confirm the diagnosis? a. Serum amylase levels b. CBC with differential and platelets c. Serum total and direct bilirubin levels d. Abdominal radiograph e. Electrolyte panel 35. A 2-year-old presents to the emergency center with several days of rectal bleeding. The mother first noticed reddish-colored stools 2 days prior to arrival and has since changed several diapers with just blood. The child is afebrile, alert, and playful, and is eating well without emesis. He is slightly tachycardic, and his abdominal examination is normal. Which of the following is the best diagnostic study to order to confirm the diagnosis? a. Exploratory laparotomy b. Barium enema c. Ultrasound of the abdomen d. Radionucleotide scan e. Stool culture 36. Parents bring a 5-day-old infant to your office. The mother is O negative and was Coombs positive at delivery. The term child weighed 3055 g (6 lb, 1 oz) at birth and had measured baseline hemoglobin of 16 g/dL and a total serum bilirubin of 3 mg/dL. He passed a black tarlike stool within the first 24 hours of life. He was discharged at 30 hours of life with a stable axillary temperature of 36.5°C (97.7°F). Today the infant’s weight is 3000 g, his axillary temperature is 35°C (95°F), and he is jaundiced to the chest. Parents report frequent yellow, seedy stool. You redraw labs and find his hemoglobin is now 14 g/dL, and his total serum bilirubin is 13 mg/dL. The change in which of the following parameters is of most concern? a. Hemoglobin b. Temperature c. Body weight d. Bilirubin e. Stool 37. You are asked to evaluate a 4-year-old boy admitted to your local children’s hospital with a diagnosis of pneumonia. The parents state that the child has had multiple, intermittent episodes of fever and respiratory difficulty over the past 2 years, including cyanosis, wheezing, and dyspnea; each episode lasts for about 3 days. During each event he has a small amount of hemoptysis, is diagnosed with left lower lobe pneumonia, and improves upon treatment. Repeat radiographs done several days after each event are reportedly normal. His examination on the current admission is significant for findings similar to those described above, as well as digital clubbing. Which of the following is the most appropriate primary recommendation? a. Intravenous cephalosporin and oral macrolide therapy b. Modified barium swallow study to evaluate for aspiration c. Nasal swab for viral culture d. Incentive spirometry e. Bronchoalveolar lavage 38. A fully immunized 2-year-old presents to the emergency room with several days of low-grade fever, barking cough, and noisy breathing. Over the past few hours he has developed a fever of 40°C (104°F) and looks toxic. He has inspiratory and expiratory stridor. The family has not noticed drooling, and he seems to be drinking without pain. Direct laryngoscopy reveals a normal epiglottis. The management of this disease process includes which of the following? a. Intubation and intravenous antibiotics b. Inhaled epinephrine and oral steroids c. Inhaled steroids d. Observation in a cool mist tent e. Oral antibiotics and outpatient follow-up 39. A 2-year-old boy is being followed for congenital cytomegalovirus (CMV) infection. He is deaf and developmentally delayed. The child’s mother informs you that she has just become pregnant and is concerned that the new baby will be infected and may develop serious consequences. Which of the following is true? a. The mother has antibodies to CMV that are passed to the fetus. b. The mother’s infection cannot become reactivated. c. The likelihood that the new baby will become clinically ill is approximately 80%. d. Termination of pregnancy is advised. e. The new infant should be isolated from the older child. 40. A previously healthy, active, 18-month-old African American child presents with unilateral nasal obstruction and foul-smelling discharge. The child’s examination is otherwise unremarkable. Which of the following is the most likely diagnosis? a. Foreign body b. Nasal polyps c. Frontal sinusitis d. Deviated septum e. Choanal atresia 41. You admitted to the hospital the previous evening a 1-year-old boy who presented with cough, fever, and mild hypoxia. At the time of his admission, he had evidence of a right upper lobe consolidation on his chest radiograph. A blood culture has become positive in less than 24 hours for Staphylococcus aureus. Approximately 20 hours into his hospitalization, the nurse calls you because the child has acutely worsened over the previous few minutes, with markedly increased work in breathing, increasing oxygen requirement, and hypotension. As you move swiftly to the child’s hospital room, you tell the nurse to order which of the following? a. A second chest radiograph to evaluate for pneumatocele formation  b. A large-bore needle and chest tube kit for aspiration of a probable tension pneumothorax c. A change in antibiotics to include gentamicin d. A sedative to treat the child’s attack of severe anxiety e. A thoracentesis kit to drain his probable pleural effusion 42. You are awakened in the night by your 2-year-old son, who has developed noisy breathing on inspiration, marked retractions of the chest wall, flaring of the nostrils, and a barking cough. He has had a mild upper respiratory infection (URI) for 2 days. Which of the following therapies is indicated? a. Short-acting bronchodilators and a 5-day course of steroids b. Intubation and antibiotics c. Observation for hypoxia and dehydration alone d. Inhaled epinephrine and a dose of steroids e. Rigid bronchoscopy 43. A 13-year-old develops fever, malaise, sore throat, and a dry, hacking cough over several days. He does not appear to be particularly sick, but his chest examination is significant for diffuse rales and rhonchi. The chest radiograph is shown below. Which of the following is the most likely pathogen? a. Staphylococcus aureus b. Mycobacterium tuberculosis c. Haemophilus influenzae d. Streptococcus pneumoniae e. Mycoplasma pneumoniae 44. You receive a telephone call from the mother of a 4-year-old child with sickle-cell anemia. She tells you that the child is breathing fast, coughing, and has a temperature of 40°C (104°F). Which of the following is the most conservative, prudent course of action? a. Prescribe aspirin and ask her to call back if the fever does not respond. b. Make an office appointment for the next available opening.  c. Make an office appointment for the next day. d. Refer the child to the laboratory for an immediate hematocrit, white blood cell count, and differential. e. Admit the child to the hospital. 45. An 8-year-old boy presents to your office for a second opinion. He has a 2-year history of intermittent vomiting, dysphagia, and epigastric pain. His father reports he occasionally gets food “stuck” in his throat. He has been on a proton pump inhibitor for 18 months without symptom relief. His past history is significant only for eczema and a peanut allergy. Endoscopy was performed 6 months ago; no erosive lesions were noted and a biopsy was not performed. You arrange for a repeat endoscopy with biopsy. Microscopy on the biopsy sample reveals many eosinophils. Treatment of this condition should include which of the following? a. Corticosteroids b. Prolonged acid blockade c. Treatment for Candida sp. d. Treatment for Aspergillus sp. e. Observation 46. A 1-week-old previously healthy infant presents to the emergency room with the acute onset of bilious vomiting. The abdominal plain film in the emergency department (A) and the barium enema done after admission (B) are shown. Which of the following is the most likely diagnosis for this patient? a. Jejunal atresia  b. Hypertrophic pyloric stenosis c. Malrotation with volvulus d. Acute appendicitis e. Intussusception 47. A 5-month-old child regularly regurgitates a large portion of her feeds. A pH probe study showed significant periods of low esophageal pH. The child has normal growth and no other significant past medical history. Which of the following is the best management at this point? a. Barium swallow and upper GI series b. Oral reflux medications c. Esophageal manometry d. Close observation only e. Surgical correction with fundoplication 48. A 2-year-old arrives in the emergency center after having swallowed a button battery from one of her toys. She is breathing comfortably, without stridor. Radiographs show the battery to be lodged in the esophagus. Which of the following is the correct next step? a. Induce emesis with syrup of ipecac. b. Admit for observation, and obtain serial radiographs to document movement of the battery. c. Discharge home with instructions to monitor the stool for the battery. d. Immediate removal of the battery via endoscopy. e. Encourage oral intake to assist in passage of the battery. 49. An 18-month-old child presents to the emergency center having had a brief, generalized tonic-clonic seizure. He is now postictal and has a temperature of 40°C (104°F). During the lumbar puncture (which ultimately proves to be normal), he has a large, watery stool that has both blood and mucus in it. Which of the following is the most likely diagnosis in this patient? a. Salmonella b. Enterovirus c. Rotavirus d. Campylobacter e. Shigella 50. A 4-year-old girl is brought to the pediatrician’s office. Her father reports that she suddenly became pale and stopped running while he had been playfully chasing her and her pet Chihuahua. After 30 minutes, she was no longer pale and wanted to resume the game. She has never had a previous episode and has never been cyanotic. Her physical examination was normal, as were her chest x-ray and echocardiogram. An ECG showed the pattern seen on the next page, which indicates which of the following? a. Paroxysmal ventricular tachycardia b. Paroxysmal supraventricular tachycardia c. Wolff-Parkinson-White syndrome d. Stokes-Adams pattern e. Excessive stress during play 51. Ventricular tachycardia A. Usually begins B. May develop gradually C. Dissolved in intravenous adenosine D. may induce ventricular fibrillation 52. It contains the largest number of elastic fibers from the blood vessels listed below A. Beam artery B. Renal artery C. Aorta D. Upper and lower vena cava 53. When does a child secrete meconium? A. In the first 12 hours after birth B. In the first 24 hours after birth C. In the first 48 hours after birth D. Does not allocate 54. What is the meaning of the term "hematemesis" A. bloody vomit B. bloody stools C. tarry stools D. bleeding gums 55. The best method for detecting bronchiectasis is A. pneumotaometry direct B. radiography C. lateral radiography D. computed tomography 56. What are the requirements for proper breastfeeding? A. Breastfeeding It is advisable to continue for up to 1 year B. Exclusive breastfeeding should be continued for up to 4 months C. The baby should be fed according to the needs D. It is not allowed to feed the baby overnight 61) All below stated is correct about breastfeeding. Except? A. Newborn should receive colostrum B. Breast milk protects from infectious diseases C. Breastfeeding should be started within 1 hour after birth D. Breastfeeding should be continued until 1 year 57. Timely newborn gestation A. 32-35 weeks B. 37-42 weeks C. 40-45 weeks D. 28-37 weeks 58. Belong to the early symptoms of phenylketonuria: A. Hydrocephalus B. Convulsions and hypomotor regression C. perkinesis D. Paresis 59. Which organ has the Gleason capsule A. Liver B. Gallbladder C. Pancreas  D. Spleen 60. Mild-grade thyrotoxicosis is characterized by all of the above: A. increased excitability B. Feeling of heart palpitations C. Tightening pain in the heart D. Drowsiness 61. Which of the following processes does not take place in hepatocytes? A. Glucogenesis B. Creating a glycogen supply C. Products of blood clotting proteins D. immunoglobulin products 62. in which case do you suspect meconium ileus A. Meconium is excreted prenatally and amniotic fluid contains meconium B. Meconium is not excreted in the first 6 hours after birth C. Meconium is not excreted in the first 24 hours after birth D. Meconium is not excreted in the first 48 hours after birth 63. In case of acute respiratory infection in children under 2 months of age, the diagnostic criterion for pneumonia is A. the respiratory rate of 60 and more per minute B. 40 and more per minute C. more than 30 per minute D. 50 and more per minute CLINICAL PHARMACOLOGY MIDTERM TESTS Introduction and pharmacokinetics 1. A 3-year-old is brought to the emergency department having just ingested a large overdose of diphenhydramine, an antihistaminic drug. Diphenhydramine is a weak base with a pKa of 8.8. It is capable of entering most tissues, including the brain. On physical examination, the heart rate is 100/min, blood pressure 90/50 mm Hg, and respiratory rate 20/min. Which of the following statements about this case of diphenhydramine overdose is most correct? A. Urinary excretion would be accelerated by administration of NH4Cl, an acidifying agent. B. Urinary excretion would be accelerated by giving NaHCO3, an alkalinizing agent C. More of the drug would be ionized at blood pH than at stomach pH D. Absorption of the drug would be faster from the stomach than from the small intestine E. Hemodialysis is the only effective therapy 2. A 60-year-old patient with severe cancer pain is given 10 mg of morphine by mouth. The plasma concentration is found to be only 30% of that found after intravenous administration of the same dose. Which of the following terms describes the process by which the amount of active drug in the body is reduced after administration but before entering the systemic circulation? A. Excretion B. First-order elimination C. First-pass effect D. Metabolism. E. Pharmacokinetics 3. A 12-year-old child has bacterial pharyngitis and is to receive an oral antibiotic. She complains of a sore throat and pain on swallowing. The tympanic membranes are slightly reddened bilaterally, but she does not complain of earache. Blood pressure is 105/70 mm Hg, heart rate 100/mm, temperature 37.8 °C (100.1 °F). Ampicillin is a weak organic acid with a pKa of 2.5. What percentage of a given dose will be in the lipid-soluble form in the duodenum at a pH of 4.5? A. About 1% B. About 10% C. About 50% D. About 90% E. About 99% 4. Phase 3 clinical trials typically involve: A. Collection of data regarding late-appearing toxicities from patients previously studied in phase 1 trials B. Double-blind, closely monitored evaluation of the new drug in hundreds of patients with the target disease by specialists in academic centers C. Evaluation of the new drug under conditions of actual use in 1000– 5000 patients with the target disease D. Measurement of the pharmacokinetics of the new drug in normal volunteers E. Postmarketing surveillance of drug toxicities 5. A large pharmaceutical company has conducted extensive animal testing of a new drug for the treatment of advanced prostate cancer. The chief of research and development recommends that the company now submit an IND application in order to start clinical trials. Which of the following statements is most correct regarding clinical trials of new drugs? A. Phase 1 involves the study of a small number of normal volunteers by highly trained clinical pharmacologists B. Phase 2 involves the use of the new drug in a large number of patients (1000–5000) who have the disease to be treated under conditions of proposed use (eg, outpatients) C. Chronic animal toxicity studies must be complete and reported in the IND D. Phase 4 involves the detailed study of toxic effects that have been discovered in phase 3 E. Phase 2 requires the use of a positive control (a known effective drug) and a placebo 6. Which of the following statements about the testing of new compounds for potential therapeutic use in the treatment of hypertension is most correct? A. Animal tests cannot be used to predict the types of clinical toxicities that may occur because there is no correlation with human toxicity B. Human studies in normal individuals will be done before the drug is used in individuals with hypertension C.The degree of risk must be assessed in at least 3 species of animals, including 1 primate species D.The animal therapeutic index must be known before trial of the agents in humans 7. A patient is admitted to the emergency department for treatment of a drug overdose. The identity of the drug is unknown, but it is observed that when the urine pH is alkaline, the renal clearance of the drug is much greater than when the urine pH is acidic. The drug is probably a A. Strong acid B. Weak acid C. Nonelectrolyte D. Weak base E. Strong base 8. A 20-year-old college student is brought to the emergency department after taking an overdose of a nonprescription drug. The patient is comatose. He has been hyperventilating and is now dehydrated with an elevated temperature. Serum analyses demonstrate that the patient has an anion gap metabolic acidosis. In the management of this patient, it would be most appropriate to A. Administer acetylcysteine B. Administer fomepizole C. Administer glucagon D. Alkalinize the urine E. Induce vomiting with syrup of ipecac 9. If 10 mg of naproxen produces the same analgesic response as 100 mg of ibuprofen, which of the following statements is correct? A. Naproxen is more efficacious than is ibuprofen. B. Naproxen is more potent than ibuprofen. C. Naproxen is a full agonist, and ibuprofen is a partial agonist. D. Naproxen is a competitive antagonist. E. Naproxen is a better drug to take for pain relief than is ibuprofen. 10. Mr Jones is admitted to the hospital with cough, shortness of breath, and fever. History, physical examination, and culture of the sputum lead to a diagnosis of pneumonia due to gram-negative bacteria. The antibiotic tobramycin is ordered. The clearance and Vd of tobramycin in Mr Jones are 80 mL/min and 40 L, respectively. What maintenance dose should be administered intravenously every 6 h to eventually obtain average steady-state plasma concentrations of 4 mg/L? A. 0.32 mg B. 19.2 mg C. 115 mg D. 160 mg E. 230 mg 11. You are the only physician in a clinic that is cut off from the outside world by violent storms and flooding. A 19-year-old woman is brought to the clinic with severe asthmatic wheezing. Because of the lack of other drugs, you decide to use intravenous theophylline for treatment. The pharmacokinetics of theophylline include the following average parameters: Vd 35 L; CL 48 mL/min; half-life 8 h. If an intravenous infusion of theophylline is started at a rate of 0.48 mg/min, how long would it take to reach 93.75% of the final steady-state concentration? A. Approximately 48 min B. Approximately 7.4 h C. Approximately 8 h D. Approximately 24 h E. Approximately 32 h 12. A 72-year-old male presents with fever, cough, malaise, and shortness of breath. His chest x-ray shows bilateral infiltrates consistent with pneumonia. Bronchial wash cultures reveal Pseudomonas aeruginosa sensitive to cefepime. Which of the following is the best dosing scheme for cefepime based on the drug’s ”timedependent” bactericidal activity? A. 1 g every 6 hours given over 30 minutes. B. 2 g every 12 hours given over 3 hours. C. 4 g every 24 hours given over 30 minutes. D. 4 g given as continuous infusion over 24 hours. 13. A 24-year-old pregnant female presents to the urgent care clinic with fever, frequency, and urgency. She is diagnosed with a urinary tract infection (UTI). Based on potential harm to the fetus, which of the following medications should be avoided in treating her UTI? A. Nitrofurantoin. B. Amoxicillin. C. Cephalexin. D. Tobramycin. 14. Which of the following antibiotics is considered safe to use in neonates? A.Chloramphenicol. B. Sulfamethoxazole/trimethoprim. C. Tetracycline. D. Penicillin G. 15. A 27-year-old pregnant patient with a history of pyelonephritis has developed a severe upper respiratory tract infection that appears to be due to a bacterial pathogen. The woman is hospitalized, and an antibacterial agent is to be selected for treatment. Which antibacterial agent appears to be the safest to use in the pregnant patient? A. Amikacin B. Azithromycin C. Ciprofloxacin D. Erythromycin E. Tetracycline 16. A 48-year-old patient is scheduled for a vaginal hysterectomy. An antimicrobial drug will be used for prophylaxis against postoperative infection. It is proposed that cefazolin, a first-generation cephalosporin, be given intravenously at the normal therapeutic dose immediately before surgery and continued until the patient is released from the hospital. If the patient had been scheduled for elective colonic surgery, optimal prophylaxis against infection would be achieved by mechanical bowel preparation and the use of : A. Intravenous cefoxitin B. Intravenous third-generation cephalosporin C.Oral amoxicillin D. Oral ciprofloxacin E. Oral erythromycin and neomycin 17. In a patient suffering from pseudomembranous colitis due to C. difficile with established hypersensitivity to metronidazole the most likely drug to be of clinical value is A. Amoxicillin B. Chloramphenicol C. Doxycycline D. Levofloxacin E. Vancomycin 18. A 72-year-old male is admitted to the hospital from a nursing home with severe pneumonia. He was recently discharged from the hospital 1 week ago after open heart surgery. The patient has no known allergies. Which of the following regimens is most appropriate for empiric coverage of methicillinresistant Staphylococcus aureus and Pseudomonas aeruginosa in this patient? A. Vancomycin + cefepime + ciprofloxacin. B. Vancomycin + cefazolin + ciprofloxacin. C. Telavancin + cefepime + ciprofloxacin. D. Daptomycin + cefepime + ciprofloxacin. 19. A 25-year-old male presents to the urgent care center with a painless sore on his genitals that started 1 to 2 weeks ago. He reports unprotected sex with a new partner about a month ago. A blood test confirms the patient has Treponema pallidum. Which of the following is the drug of choice for the treatment of this patient’s infection as a single dose? A. Benzathine penicillin G. B. Ceftriaxone. C. Aztreonam. D. Vancomycin. 20. An 18-year-old female presents to the urgent care clinic with urinary frequency, urgency, and fever for the past 3 days. Based on symptoms and a urinalysis, she is diagnosed with a urinary tract infection. Cultures reveal Enterococcus faecalis that is pan sensitive. Which of the following is an appropriate oral option to treat the urinary tract infection in this patient? A. Cephalexin. B. Vancomycin. C. Amoxicillin. D. Cefdinir. 21. A 2-year-old child is brought to the hospital after ingesting pills that a parent had used for bacterial dysentery when traveling outside the United States. The child has been vomiting for more than 24 h and has had diarrhea with green stools. He is now lethargic with an ashen color. Other signs and symptoms include hypothermia, hypotension, and abdominal distention. The drug most likely to be the cause of this problem is A. Ampicillin B. Chloramphenicol C. Clindamycin D. Doxycycline E. Erythromycin 22. A 24-year-old woman comes to a clinic with complaints of dry cough, headache, fever, and malaise, which have lasted 3 or 4 d. She appears to have some respiratory difficulty, and chest examination reveals rales but no other obvious signs of pulmonary involvement. However, extensive patchy infiltrates are seen on chest x-ray film. Gram stain of expectorated sputum fails to reveal any bacterial pathogens. The patient mentions that a colleague at work has similar symptoms to those she is experiencing. The patient has no history of serious medical problems. She takes loratadine for allergies and supplementary iron tablets, and she drinks at least 6 cups of caffeinated coffee per day. The physician makes an initial diagnosis of community-acquired pneumonia. Regarding the treatment of this patient, which of the following drugs is most suitable? A. Amoxicillin B. Clindamycin C. Doxycycline D. Linezolid E. Vancomycin 23. A 67-year-old man is seen in a hospital emergency department complaining of pain in and behind the right ear. Physical examination shows edema of the external otic canal with purulent exudate and weakness of the muscles on the right side of the face. The patient informs the physician that he is a diabetic. Gram stain of the exudate from the ear shows many polymorphonucleocytes and gram-negative rods, and samples are sent to the microbiology laboratory for culture and drug susceptibility testing. A preliminary diagnosis is made of external otitis. At this point, which of the following is most appropriate? A. Amikacin should be administered by intramuscular injection, and the patient should be sent home B. Analgesics should be prescribed for pain, but antibiotics should be withheld pending the results of cultures C. Oral cefaclor should be prescribed together with analgesics, and the patient should be sent home D. The patient should be hospitalized and treatment started with gentamicin plus ticarcillin E. The patient should be hospitalized and treatment started with intravenous imipenem-cilastatin 24. A 50-kg patient with creatinine clearance of 80 mL/min has a gram-negative infection. Amikacin is administered intramuscularly at dose of 5 mg/kg every 8 h, and the patient begins to respond. After 2 d, creatinine clearance declines to 40 mL/min. Assuming that no information is available about amikacin plasma levels, what would be the most reasonable approach to management of the patient at this point? A. Administer 5 mg/kg every 12 h B. Decrease the dosage to a daily total of 200 mg C. Decrease the dosage to 125 mg every 8 h D. Discontinue amikacin and switch to gentamicin E. Maintain the patient on the present dosage and test auditory function 25. A 24-year-old woman has returned from a vacation abroad suffering from traveler’s diarrhea, and her problem has not responded to antidiarrheal drugs. A pathogenic gram-negative bacillus is suspected. Which drug is most likely to be effective in the treatment of this patient? A. Amoxicillin B. Ciprofloxacin C. Sulfacetamide D. Trimethoprim E. Vancomycin 26. A 31-year-old man has gonorrhea. He has no drug allergies, but a few years ago acute hemolysis followed use of an antimalarial drug. The physician is concerned that the patient has an accompanying urethritis caused by C. trachomatis, although no cultures or enzyme tests have been performed. Which of the following drugs will be reliably effective against both gonococci and C. trachomatis and safe to use in this patient? A. Cefixime B. Ciprofloxacin C. Spectinomycin D. Sulfamethoxazole-trimethoprim E. None of the above 27. A 32-year-old male presents to an outpatient clinic with a 5-day history of productive cough, purulent sputum, and shortness of breath. He is diagnosed with community-acquired pneumonia (CAP). It is noted that this patient has a severe ampicillin allergy (anaphylaxis). Which of the following would be an acceptable treatment for this patient? A. Levofloxacin. B. Ciprofloxacin. C. Penicillin VK. D. Nitrofurantoin. 28. A 22-year-old female presents with a 2-day history of dysuria with increased urinary frequency and urgency. A urine culture and urinalysis are done. She is diagnosed with a urinary tract infection (UTI) caused by E. coli. All of the following would be considered appropriate therapy for this patient except: A. Levofloxacin. B. Cotrimoxazole. C. Moxifloxacin. D. Nitrofurantoin. 29. Which of the following drugs is correctly matched with the appropriate adverse effect? A. Levofloxacin—hyperkalemia. B. Nitrofurantoin—pulmonary fibrosis. C. Cotrimoxazole—hepatic encephalopathy. D. Methenamine—nystagmus. 30. A 32-year-old G2P1001 woman at 36 weeks gestation presents to the emergency room with a high fever. The fever started 2 days ago and has progressively worsened. It has been associated with chills, nausea, vomiting, and full body aches. The resident suggests starting trimethoprim–sulfamethoxazole as part of the empiric coverage of her infection until blood cultures return. What side effect would be a contraindication to starting trimethoprim–sulfamethoxazole in a pregnant woman? A. Cartilage damage in fetus B. Discoloration of teeth C. Gray baby syndrome D. Kernicterus E. Ototoxicity 31. A 24-year-old sexually active woman presents with vaginal itching and a greenish, frothy vaginal discharge. Her boyfriend is asymptomatic. She is prescribed with metronidazole for Trichomonas infection. Which of the following is involved in metronidazole’s action? A. Blocking folic acid synthesis B. Disruption of DNA C. Inhibition of PBPs D. Inhibition of ribosomes E. Inhibition of topoisomerase 32. A 16-year-old girl comes to the emergency department suffering from the effects of an aspirin overdose. Which of the following syndromes is this patient most likely to exhibit as a result of this drug overdose? A. Bone marrow suppression and possibly aplastic anemia B. Fever, hepatic dysfunction, and encephalopathy C. Hyperthermia, metabolic acidosis, and coma D. Rapid, fulminant hepatic failure E. Rash, interstitial nephritis, and acute renal failure 33. An 18-month-old boy dies from an accidental overdose of acetaminophen. Which of the following is the most likely cause of this patient’s death? A. Arrhythmia B. Hemorrhagic stroke C. Liver failure D. Noncardiogenic pulmonary edema E. Ventilatory failure 34. A 54-year-old woman presented with signs and symptoms consistent with an early stage of rheumatoid arthritis. The decision was made to initiate NSAID therapy. Although the patient’s disease was adequately controlled with an NSAID and methotrexate for some time, her symptoms began to worsen and radiologic studies of her hands indicated progressive destruction in the joints of several fingers. Treatment with another second-line agent for rheumatoid arthritis was considered. Which of the following is a parenterally administered DMARD whose mechanism of antiinflammatory action is antagonism of tumor necrosis factor? A. Cyclosporine B. Etanercept C. Penicillamine D. Phenylbutazone E. Sulfasalazine 35. A young woman is brought into the emergency room. She is unconscious, and she has pupillary constriction and depressed respiration. Based on reports, an opioid overdose is almost certain. Which of the listed phenanthrene opioids will exhibit a full and immediate response to treatment with naloxone? A. Meperidine. B. Morphine. C. Buprenorphine. D. Fentanyl. 36. A 76-year-old female with renal insufficiency presents to the clinic with severe pain secondary to a compression fracture in the lumbar spine. She reports that the pain has been uncontrolled with tramadol, and it is decided to start treatment with an opioid. Which of the following is the best opioid for this patient? A. Meperidine. B. Fentanyl transdermal patch. C. Hydrocodone. D. Morphine. 37. A 56-year-old patient who has suffered with severe chronic pain with radiculopathy secondary to spinal stenosis for years presents to the clinic for pain management. Over the years, this patient has failed to receive relief from the neuropathic pain from the radiculopathy with traditional agents such as tricyclics or anticonvulsants. Based on the mechanism of action, which opioid might be beneficial in this patient to treat both nociceptive and neuropathic pain? A. Meperidine. B. Oxymorphone. C. Morphine. D. Methadone. 38. A 64-year-old male is preparing for a total knee replacement. He is taking many medications that are metabolized by the CYP450 enzyme system and is worried about drug interactions with the pain medication that will be used following his surgery. Which of the following opioids would have the lowest chance of interacting with his medications that are metabolized by the CYP450 enzyme system? A. Methadone. B. Oxymorphone. C. Oxycodone. D. Hydrocodone. 39. KM is a 64-year-old male who has been hospitalized following a car accident in which he sustained a broken leg and broken arm. He has been converted to oral morphine in anticipation of his discharge. What other medication should he receive with his morphine upon discharge? A. Diphenhydramine. B. Methylphenidate. C. Docusate sodium with senna. D. Docusate sodium. 40. AN is a 57-year-old male who has been treated with oxycodone for chronic nonmalignant pain for over 2 years. He is now reporting increased pain in the afternoon while at work. Which of the following opioids is a short-acting opioid and is the best choice for this patient’s breakthrough pain? A. Methadone. B. Pentazocine. C. Hydrocodone. D. Nalbuphine. 41. A 30-year-old man has been treated with several autonomic drugs for 4 weeks. He is now admitted to the emergency department showing signs of drug toxicity. Which of the following signs would distinguish between an overdose of a ganglion blocker versus a muscarinic blocker? A. Blurred vision B. Dry mouth, constipation C. Mydriasis D. Postural hypotension E. Tachycardia 42. A 75-year-old man who was a smoker is diagnosed with chronic obstructive pulmonary disease and suffers from occasional bronchospasm. Which of the following would be effective in treating him? A. Ipratropium aerosol. B. Scopolamine patches. C. Mecamylamine. D. Oxygen. E. Nicotine. 43. A 50-year-old male farm worker is brought to the emergency room. He was found confused in the orchard and since then has lost consciousness. His heart rate is 45, and his blood pressure is 80/40 mm Hg. He is sweating and salivating profusely. Which of the following treatments is indicated? A. Physostigmine. B. Norepinephrine. C. Trimethaphan. D. Atropine. E. Edrophonium. 44. A patient with chronic obstructive pulmonary disease (COPD) was prescribed a β2 agonist for the relief of bronchospasm. However, the patient did not respond to this treatment. Which of the following drugs or classes of drugs would you suggest for this patient as the next option? A. β1 Agonist. B. Muscarinic agonist. C. Physostigmine. D. Ipratropium. E. Phentolamine. 45. A 4-year-old child was brought to an emergency department after ingesting a product found in the home. Her signs and symptoms include an elevated temperature; hot, dry skin; moderate tachycardia; and mydriasis. The most likely cause of these symptoms is A. Acetaminophen overdose B. Amphetamine-containing diet pills C. Exposure to an organophosphate-containing insecticide D. Ingestion of a medication containing atropine E. Ingestion of phenylephrine-containing eye drops Angina pectoris (IHD) 1. A man is admitted to the emergency department with a brownish cyanotic appearance, marked shortness of breath, and hypotension. Which of the following is most likely to cause methemoglobinemia? A. Amyl nitrite B. Isosorbide dinitrate C. Isosorbide mononitrate D. Nitroglycerin E. Sodium cyanide 2. A 60-year-old man presents to his primary care physician with a complaint of severe chest pain when he walks uphill to his home in cold weather. The pain disappears when he rests. After evaluation and discussion of treatment options, a decision is made to treat him with nitroglycerin. One year later, the patient returns complaining that his nitroglycerin works well when he takes it for an acute attack but that he is now having more frequent attacks and would like something to prevent them. Useful drugs for the prophylaxis of angina of effort include A. Amyl nitrite B. Esmolol C. Sublingual isosorbide dinitrate D. Sublingual nitroglycerin E. Verapamil 2. A 60-year-old man presents to his primary care physician with a complaint of severe chest pain when he walks uphill to his home in cold weather. The pain disappears when he rests. After evaluation and discussion of treatment options, a decision is made to treat him with nitroglycerin. One year later, the patient returns complaining that his nitroglycerin works well when he takes it for an acute attack but that he is now having more frequent attacks and would like something to prevent them. Useful drugs for the prophylaxis of angina of effort include A. Amyl nitrite B. Diltiazem C. Esmolol D. Sublingual isosorbide dinitrate E) Sublingual nitroglycerin 3. A 52-year-old patient comes to the office with a complaint of periodic onset of chest pain, described as a sensation of heavy pressure over the sternum that comes on when he exercises and disappears within 15 min when he stops. After a full physical examination and further evaluation, you make the diagnosis of angina of effort. A drug that is useful in angina but causes constipation, edema, and increased cardiac size is A. Atenolol B. Hydralazine C. Isosorbide dinitrate D. Nitroglycerin E. Verapamil 4. A 45-year-old woman with hyperlipidemia and frequent migraine headaches develops angina of effort. Which of the following is relatively contraindicated because of her migraines? A. Amlodipine B. Diltiazem C. Metoprolol D. Nitroglycerin E. Verapamil 5. A 56-year-old patient complains of chest pain following any sustained exercise. He is diagnosed with atherosclerotic angina. He is prescribed sublingual nitroglycerin for treatment of acute chest pain and also prescribed propranolol to prevent episodes of angina. The β-blocker has the added benefit of preventing which of the following side effects of sublingual nitroglycerin? A. Dizziness. B. Methemoglobinemia. C. Throbbing headache. D. Reflex tachycardia. E. Edema. 6. A 68-year-old man has been successfully treated for exercise-induced angina for several years. He recently has been complaining about being awakened at night with chest pain. Which of the following drugs would be useful in preventing this patient’s nocturnal angina? A. Amyl nitrite. B. Nitroglycerin (sublingual). C. Nitroglycerin (transdermal). D. Esmolol. E. Hydralazine. 7. A 72-year-old male presents to the primary care clinic complaining of chest tightness and pressure that is increasing in severity and frequency. His current medications include atenolol, lisinopril, and nitroglycerin. Which intervention is most appropriate at this time? A. Add amlodipine. B. Initiate isosorbide mononitrate. C. Initiate ranolazine. D. Refer the patient to the nearest emergency room for evaluation. 8. A 62-year-old patient with a history of asthma and vasospastic angina states that he gets chest pain both with exertion and at rest, about ten times per week. One sublingual nitroglycerin tablet always relieves his symptoms, but this medication gives him an awful headache every time he takes it. Which is the best option for improving his angina? A. Change to sublingual nitroglycerin spray. B. Add amlodipine. C. Add propranolol. D. Replace nitroglycerin with ranolazine. 9. A 65-year-old male experiences uncontrolled angina attacks that limit his ability to do household chores. He is adherent to a maximized dose of β-blocker with a low heart rate and low blood pressure. He was unable to tolerate an increase in isosorbide mononitrate due to headache. Which is the most appropriate addition to his antianginal therapy? A. Amlodipine. B. Aspirin. C. Ranolazine. D. Verapamil. 10. A 68-year-old male with a history of angina had a MI last month, and an echocardiogram reveals heart failure with reduced ejection fraction. He as continued on his previous home medications (diltiazem, enalapril, and nitroglycerin), and atenolol was added at discharge. He has only had a few sporadic episodes of stable angina that are relieved with nitroglycerin or rest. What are eventual goals for optimizing this medication regimen? A. Add isosorbide mononitrate. B. Increase atenolol. C. Stop atenolol and increase diltiazem. D. Stop diltiazem and change atenolol to bisoprolol. 11. A patient whose angina was previously well controlled with once-daily isosorbide mononitrate states that recently he has been taking isosorbide mononitrate twice a day to control angina symptoms that are occurring more frequently during early morning hours. Which of the following is the best option for this patient? A. Continue once-daily administration of isosorbide mononitrate but advise the patient to take this medication in the evening. B. Advise continuation of isosorbide mononitrate twice daily for full 24-hour coverage of angina symptoms. C. Switch to isosorbide dinitrate, as this has a longer duration of action than the mononitrate. D. Switch to nitroglycerin patch for consistent drug delivery and advise him to wear the patch around the clock. 12. A 45-year-old man presents with pulmonary hypertension. Which of the following cause–treatment pairs is most relevant to this patient? (A) Angiotensin II–minoxidil (B) Atrial natriuretic peptide–losartan (C) Bradykinin–furosemide (D) Endothelin–ambrisentan llowing cause–treatment pairs is most relevant to this patient (E) Substance P–capsaicin 13. A 54-year-old contractor complains of anginal pain that occurs at rest. On examination, his blood pressure is 145/90 and his heart rate is 90. A treatment of angina that often decreases the heart rate and can prevent vasospastic angina attacks is (A) Diltiazem (B) Nifedipine (C) Nitroglycerin (D) Propranolol (E) Timolol 14. A 54-year-old woman presented with angina of effort. Laboratory assessment of her serum revealed elevated total and LDL cholesterol. The patient was placed on atorvastatin. This drug lowers serum cholesterol by (A) Activating endothelial cell-associated lipoprotein lipase (B) Increasing the shunting of hepatic cholesterol into the biochemical pathway of bile acid synthesis (C) Indirectly increasing hepatic production of LDL receptors (D) Inhibiting the uptake of cholesterol in epithelial cells that line the small intestine (E) Stimulating hepatic fatty acid oxidation 15. A 52-year-old plumber comes to the office with a complaint of periodic onset of chest pain, described as a sensation of heavy pressure over the sternum that comes on when he exercises and disappears within 15 min when he stops. After a full physical examination and further evaluation, you make the diagnosis of angina of effort.In considering medical therapy for this patient, which of the following best describes the beneficial action of nitroglycerin in this condition? (A) Dilation of coronary arterioles reduces resistance and increases coronary flow through ischemic tissue (B) Dilation of peripheral arterioles increases cardiac work (C) Dilation of systemic G - veins results in decreased diastolic cardiac size (D) Increased sympathetic outflow increases coronary flow ↑ (E) Tachycardia increases diastolic coronary flow 16. We prescribe a β-adrenergic blocker for a patient with chronic-stable (“effort induced”) angina, and the incidence and severity of anginal attacks are reduced. Which of the following best explains the pharmacologic action by which the β blocker does this? -a. Decreases myocardial oxygen demand b. Dilates the coronary vasculature c. Exerts antiplatelet/antithrombotic effects d. Reduces total peripheral resistance e. Slows AV nodal conduction velocity 17. A patient with angina is started on a nitroglycerin transdermal delivery system (“skin patch”) for prophylaxis of his angina. He wears the patch 24 h a day, 7 days a week, except for the few minutes when he showers each day. Which of the following is the main concern with “around-theclock” administration of this or other long-acting formulations of nitrovasodilators? a. Cyanide poisoning b. Development of tolerance to their vasodilator actions ~ c. Gradual development of reflex bradycardia in response to successive doses d. Onset of delayed, characteristic adverse responses including thrombosis and thrombocytopenia e. Paradoxical vasoconstriction leading to hypertension Hypertension 1. A 55-year-old man with a strong family history of cardiovascular disease has moderate hypertension and angina pectoris. Blood pressure is 160/109 mm Hg, and the ECG shows left ventricular hypertrophy. The rest of his physical examination and laboratory results are normal. His angina is precipitated by exercise. You have been asked to recommend a drug regimen for both conditions. The antihypertensive drug most likely to aggravate angina pectoris is (A) Captopril (B) Clonidine (C) Hydralazine (D) Methyldopa (E) Propranolol 2. A 46-year-old man has hypertension of 155/95. His cardiac and kidney function is normal. Losartan has been suggested as therapy. This drug provides an antihypertensive effect by which of the following effects? (A) Accelerating the rate of enzymatic inactivation of amine neurotransmitters in the CNS (B) Activating α2-adrenoceptors located in the presynaptic membranes of CNS neurons that regulate peripheral SANS activity (C) Blocking the transport of amine neurotransmitters from the cytoplasm to the inside of synaptic transmitter storage vesicles (D) Inhibiting the uptake of amine neurotransmitters from the extracellular fluid into the cytoplasm in the presynaptic nerve terminus (E) Interfering with the combination of angiotensin II with its receptor 3. A 66-year-old patient is diagnosed with hypertension and angina. A drug with benefits in both conditions is suggested. Which of the following drugs has both nonselective β-blocking and α1-selective blocking action? (A) Atenolol (B) Carvedilol (C) Nadolol (D) Pindolol (E) Timolol 4. A 70-year-old woman with mild to moderate hypertension fell 2 yr ago during a spell of dizziness and broke her hip. During the last 18 mo, her blood pressure has increased. Now she is to be treated for a blood pressure of 170/100 mm Hg. When treating hypertension chronically, orthostatic hypotension is greatest with (A) ACE inhibitors (B) Arteriolar dilators (C) Centrally acting α2 agonists (D) Peripherally acting α1 antagonists (E) Beta blockers 5. A 40-year-old woman was being treated for chronic moderate hypertension. When she went on vacation and forgot her pills, her blood pressure rose markedly and she was admitted to the emergency service with blurred vision, severe headache, and retinal hemorrhages. A drug that is most likely to be followed by rebound hypertension if stopped suddenly is (A) Atenolol (B) Clonidine (C) Labetalol (D) Losartan (E) Prazosin 6. A 57-year-old contractor with hypertension has been treated by 2 different physicians. He now comes to the emergency department with a severe reaction. Questioning reveals that he has been taking captopril and spironolactone. This combination is usually ill-advised because of the risk of (A) Bone loss and osteoporosis (B) Calcium-containing kidney stones (C) Hyperkalemia (D) Metabolic acidosis (E) Postural hypotension 7. After ingestion of a meal that included sardines, cheese, and red wine, a patient taking phenelzine experienced a hypertensive crisis. The most likely explanation for this untoward effect is that phenelzine (A) Acts to release tyramine from these foods (B) Inhibits COMT (C) Inhibits the metabolism of catecholamines (D) Is an activator of tyrosine hydroxylase (E) Promotes the release of norepinephrine from sympathetic nerve endings 8. Your patient is a 50-year-old man with well-controlled Type 2 diabetes and normal renal function (and no microalbuminuria). Which of the following drugs would be the most rational first choice for starting his antihypertensive therapy? A. Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker B. β-adrenergic blocker C. Nifedipine D. Thiazide diuretic E. Verapamil or diltiazem 9. We have a 50-year-old man with asymptomatic hyperuricemia, and we are about to start therapy for newly diagnosed essential hypertension (BP 136/90 mm Hg, based on repeated measurements with the patient supine and at rest). Which of the following antihypertensive drugs is most likely to increase his serum uric acid levels further, and possibly precipitate a gout attack? A. Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker B. β-adrenergic blocker C. Nifedipine D. Thiazide diuretic E. Verapamil or diltiazem 10. We’ve just diagnosed essential hypertension in a 58-year-old female patient. She tends to be tachycardic. Notes written by her ophthalmologist indicate that she has chronic open-angle glaucoma. Which of the following drugs would be the most rational choice for this woman, given only the information presented in this question? A. Captopril B. Diltiazem C. Hydrochlorothiazide D. Timolol E. Verapamil 11. Our newly diagnosed hypertensive patient has a history of vasospastic angina. Which of the following drugs or drug classes would be the most rational for starting antihypertensive therapy because it exerts antihypertensive effects, directly lowers myocardial oxygen demand and consumption, and also tends to inhibit cellular processes that otherwise favor coronary vasospasm? A. Angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker B. β-adrenergic blocker C. Nifedipine D. Thiazide diuretic E. Verapamil (or diltiazem) 12. A 28-year-old woman is receiving drug therapy for essential hypertension. She subsequently becomes pregnant. We realize that the drug she’s been taking for her high blood pressure can have serious, if not fatal, effects on the fetus (it is in pregnancy category X). As a result, we stop the drug and substitute another that is deemed to be equally efficacious in terms of her blood pressure, and safer for the fetus. Which of the following drugs was she most likely taking before she became pregnant? A. Methyldopa B. Captopril C. Furosemide D. Labetalol E. Verapamil 13. We have just diagnosed Stage 1 essential hypertension in a 30-year old man who has a history of asthma. He regularly uses an inhaled corticosteroid, which seems to work well, but does need to use an albuterol inhaler about once every 3 weeks for suppression of asthma attacks. Which antihypertensive drug or drug class poses the greatest risk of exacerbating the patient’s asthma and counteracting the desired pulmonary effects of the albuterol, even though it might control his blood pressure well? A. Diltiazem B. Hydrochlorothiazide C. Labetalol D. Ramipril E. Verapamil 14. A patient has Stage III essential hypertension. After evaluating the responses to several other antihypertensive drugs, alone and in combination, the physician places the patient on oral hydralazine. Which of the following adjunct(s) is/are likely t