QUESTION: 33

A 62-year-old man is undergoing neurologic evaluation. His arteriogram demonstrates the lesion shown in the figure below. Which of the following deficits is compatible with this lesion?

diplopia
transient monocular blindness
ataxia
vertigo
dysarthria

Answer(s): B

Explanation:

The cerebral arteriogram shown in Figure reveals severe stenosis of the common carotid artery proximal to its bifurcation, as well as small lesions in the more distal vessels. Common manifestations are transient monocular blindness (amaurosis fugax), hemiparesis, hemisensory loss, aphasia, and homonymous visual field defects. Ataxia would be an unusual feature of carotid disease and, if present, would suggest involvement of the vertebrobasilar arteries, which results in dysarthria, diplopia, and vertigo.

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QUESTION: 34

A 30-year-old woman who has been human immunodeficiency virus (HIV) positive for 4 years was recently diagnosed with AIDS.
Which of the following immunologic abnormalities would be expected?

increased numbers of CD4+ (helper) T cells
decreased number of CD8+ (suppressor) T cells
cutaneous anergy to usual skin test antigens
normal B-cell function
increased natural killer cell function

Answer(s): C

Explanation:

The new case definition for AIDS in 1993 added pulmonary tuberculosis, invasive cervical cancer, and recurrent pneumonia. This CDC classification system is divided into three categories: category A is symptomatic infection with HIV and includes acute illness and persistent lymphadenopathy; category B includes conditions attributed to HIV infection, such as oral thrush, herpes zoster, and peripheral neuropathy; category C is the AIDS surveillance cases. Anergy to common skin test antigens is a common finding with HIV infection. There is a decline in CD4 cell numbers, a relative increase in the number of T8 cells, which results in a decreased T4:T8 ratio of less than 1. Functional abnormalities occur in both B cells and natural killer cells, which accounts for the increase in certain bacterial infections seen in advanced HIV disease. Elevation of beta2 submicroglobulin, a serologic finding reflecting immunologic dysfunction, is a fairly reliable marker of progressive immunologic decline and the subsequent development of AIDS.

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QUESTION: 35

When you examine the back of an elderly gentleman, you note multiple brown papules and nodules having a "stuck on" appearance. These are shown in Figure. The patient tells you they have been there for years.
Which of the following is the most likely diagnosis?

melanocytic nevi
actinic keratoses
seborrheic keratoses
seborrheic dermatitis
malignant melanoma

Answer(s): C

Explanation:

This man has multiple seborrheic keratoses, which are very common, benign pigmented tumors that occur after age 30, especially on the trunk and face. Melanocytic nevi are usually small, circumscribed, pigmented macules or papules, rather than large "stuck-on" nodules. Actinic keratoses are red, scaly (not dark) lesions on the face and arms that are from suninduced damage. Seborrheic dermatitis is a red, scaly rash along the scalp, eyebrows, and nasolabial folds. Malignant melanoma would be in the differential if it were a single lesion.

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QUESTION: 36

A 58-year-old man is establishing care with you because his insurance changed. His old records have not yet arrived, but he is complaining of palpitations and lightheadedness, so you order the ECG shown in Figure

Which of the following is the most likely problem associated with this pattern?

congenital heart disease
severe aortic valve disease
hypokalemia
atrial septal defect (ASD)
VSD

Answer(s): B

Explanation:

The prolonged, negative QRS vector anteriorly (V1-V3) and wide notched R waves in V5 and V6 are characteristic for LBBB. In RBBB, there is an rSR' complex in V1 and QRS pattern in V6. Accelerated junctional rhythm would not have P waves. Partial blocks, such as left anterior fascicular block, generally do not prolong the QRS duration substantially, but are associated with shifts in the frontal plane QRS axis (left axis deviation). With intraventricular conduction delay, the QRS is between 100 and 120 ms. LBBB is a marker of one of four conditions: severe aortic valve disease, ischemic heart disease, long-standing hypertension, and cardiomyopathy. RBBB is seen more commonly than LBBB in patients without structural heart disease, although RBBB also occurs with congenital heart disease and ASD or valvular heart disease. Hyper- but not hypokalemia may cause intraventricular conduction delay. Myocarditis does not usually lead to LBBB.

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