SINGLE BEST ANSWER SET 2 (100-200)

FAMILY MEDICINE MCQ

ANSWER ALL QUESTIONS.
1

A 19-year-old female comes to your office with a skin rash that is mildly pruritic. The rash
began on her back with a single 3-cm salmon-colored oval lesion. This lesion developed a scaly
border and began to clear centrally. A week later, similar smaller lesions developed on her back,
trunk, and proximal extremities. The long axis of these oval lesions followed the cleavage lines
of the skin. The patient treated these lesions with over-the-counter hydrocortisone and
diphenhydramine (Benadryl), but they did not resolve.
Which one of the following would be the most appropriate management at this time?
A) Famciclovir (Famvir)
B) Prednisone
C) Cetirizine (Zyrtec)
D) Terbinafine (Lamisil)
E) Reassurance

The mother of a newborn has agreed to your suggestion that she breastfeed for at least the first
6 months of her daughters life. Before being discharged from the hospital, she asks you to
clarify some advice she received from friends about the storage and handling of expressed
breast milk.
Which one of the following would be accurate advice?
A) Breast milk can safely be stored at room temperature for up to 8 hours
B) Frozen breast milk should be thawed quickly, preferably in a microwave oven
C) Once thawed, breast milk may safely be refrozen within 4 hours
D) If stored breast milk has separated, it is spoiled
E) OSHA guidelines prohibit the storage of human milk in a common refrigerator in the
workplace

Which one of the following would be the best treatment option for prolapse of a fourth degree
hemorrhoid that cannot be reduced?
A) Rubber band ligation
B) Infrared coagulation
C) Injection sclerotherapy
D) Hemorrhoidectomy
E) A high-fiber diet

A 26-year-old female consults you because she becomes quite anxious in many social
situations, often panicking when she must lead discussions at work. She states that she is
increasingly uncomfortable in social situations and is spending more time alone at home. She
has asthma and notes that her symptoms increased when she used albuterol.
Which one of the following would be the most appropriate therapy?
A) Sertraline (Zoloft)
B) Bupropion (Wellbutrin)
C) Alprazolam (Xanax)
D) Hydroxyzine (Vistaril)
E) Propranolol (Inderal)

A 76-year-old male has fallen twice as a result of buckling of the left knee during ambulation.
Neither fall resulted in injury, and he is advised to use an offset walking cane. The patient is
left handdominant and has normal strength in all four extremities. Crepitus is present in both
knees, but is much more pronounced in the left knee.
Which one of the following describes the best method for use of a cane by this patient?

A) Place the cane in the left hand and advance it at the same time as the left leg
B) Place the cane in the left hand and advance it at the same time as the right leg
C) Place the cane in the right hand and advance it at the same time as the left leg
D) Place the cane in the right hand and advance it at the same time as the right leg
E) Switch the cane between hands at intervals of several hours to distribute the load
equally
A healthy 45-year-old male comes to your office for a routine visit. Findings are normal on a
review of systems and physical examination. After you discuss the findings and provide routine
counseling about a healthy lifestyle, the patient asks if he should have a full-body CT scan just
to make sure he is healthy. Which one of the following would be appropriate advice?
A) This is a reasonable option, but most insurance companies will not pay for it
B) The chance of finding an abnormality is very low, but for a person anxious about his
or her health the reassurance is worth the expense
C) The amount of radiation exposure from low-dose full-body CT is minimal
D) In a healthy patient, incidental findings will lead to unnecessary biopsies, anxiety, and
significant radiation exposure

A 56-year-old white male has a prosthetic heart valve and is anticoagulated with warfarin
(Coumadin). He undergoes bilateral total knee replacement, and the warfarin is discontinued
and replaced with perioperative unfractionated heparin. The day after surgery his platelet count
has fallen from 225,000/mm3 to 75,000/mm3 (N 150,000300,000).
In addition to discontinuing heparin, which one of the following would be most appropriate at
this time?
A) Restart warfarin
B) Begin low molecular weight heparin
C) Begin aspirin
D) Begin lepirudin (Refludan)
E) Place an inferior vena cava filter

A 26-year-old gravida 1 para 0 at 28 weeks gestation has a 1-hour plasma glucose level of 145
mg/dL on a 50 g/hr glucose challenge test. A 3-hour glucose tolerance test confirms gestational
diabetes. You initially recommend home glucose monitoring and treatment with diet and
exercise. You would recommend insulin therapy if her 2-hour postprandial blood glucose levels
are not consistently below a target level of
A) 80 mg/dL
B) 100 mg/dL
C) 120 mg/dL
D) 140 mg/dL
E) 160 mg/dL

A 57-year-old male has laboratory screening performed prior to his annual examination. One
of his six fecal occult blood tests is positive. A CBC, chemistry panel, lipid panel, and
prostate-specific antigen level are all normal.
Which one of the following would be the most appropriate course of action?
A) Repeat the fecal occult blood testing in 3 months
B) Perform a rectal examination in the office, and if a stool guaiac is negative repeat the
fecal occult blood testing in 3 months
C) Refer for colonoscopy
D) Refer for flexible sigmoidoscopy
E) Refer for pre- and post-contrast CT of the abdomen and pelvis

10 The most common cause of chronic cough in adults is

A) gastroesophageal reflux disease

B) asthma
C) upper airway cough syndrome (postnasal drip)
D) nonasthmatic eosinophilic bronchitis
E) ACE inhibitor use
11 A 58-year-old white female who has always been in good health sees you for a routine checkup.
She has recently had two friends affected by cardiovascular disease, and asks if she should be
taking any drugs to help her stay healthy. She does not smoke and her blood pressure is 130/85
mm Hg. Her total cholesterol level is 230 mg/dL, with an HDL level of 70 mg/dL and an LDL
level of 130 mg/dL. Her father had heart problems beginning at age 65.
You recommend exercise, maintaining ideal weight, and staying on a low-saturated fat diet.
Which one of the following additional recommendations would be most appropriate?
A) Hydrochlorothiazide to lower her blood pressure to <120/80 mm Hg, plus aspirin,
81 mg/day, and no additional medications
B) Hydrochlorothiazide, a statin to lower her LDL to <130 mg/dL, and aspirin, 81
mg/day
C) Aspirin, 81 mg/day, and no additional medications
D) Hydrochlorothiazide plus a statin, and no additional medications
E) No medications
12 Which one of the following is an evidence-based clinical recommendation for maternity care?
A) All pregnant women should be screened serologically for herpes simplex virus
infection
B) All pregnant women should be screened for bacterial vaginosis
C) All pregnant women should be screened for asymptomatic bacteriuria by urine culture
D) Only at-risk women should be tested for HIV infection
E) Only women 25 years of age or younger should be screened for chlamydial infection
13 A 3-year-old female is seen for a well child examination. You note that her labia minora seem
to adhere together except for about 4 mm at the upper aspect under the clitoris.
The most appropriate action would be to
A) make no attempt to separate the labia, but monitor for signs of urinary tract infection
B) refer to a pediatric surgeon for separation
C) have the childs mother apply gentle traction twice daily
D) prescribe a lubricating jelly to be applied daily until the labia separate
E) prescribe a topical estrogen cream to be applied daily until the labia separate
14 A 72-year-old patient has an acute onset of joint pain and swelling. Aspiration reveals
monosodium urate crystals. Compared with younger patients, geriatric patients presenting for
the first time with this condition are more likely to
A) be male
B) have a monoarticular presentation
C) have involvement of joints of the upper extremity
D) have podagra (first metatarsophalangeal joint involvement)
E) be free of tophi
15 A 3-month-old male is brought to your office by his exhausted parents. The child is bottle fed
with cows milk formula. For the past 3 weeks he has cried uncontrollably for several hours
most evenings. He refuses the bottle and cannot be distracted. There has been no vomiting,
although he frequently spits up when carried, rocked, or burped. His mother describes 23
normal bowel movements a day. Your examination is unremarkable. The child is gaining

weight appropriately.
The most likely diagnosis is
A) pyloric stenosis
B) annular pancreas
C) infantile colic
D) Hirschsprungs disease
E) casein allergy
16 A 55-year-old male with a 5-year history of type 2 diabetes mellitus comes to your office for
follow-up. He has lost 9 kg (20 lb) in the past year and reports good control of his glucose
levels. His examination is unremarkable, and his blood pressure is 130/80 mm Hg. Laboratory
results reveal a normal CBC and blood chemistry, and his urine is negative for microalbumin.
1c His hemoglobin A is 6.5%, while a lipid profile reveals an HDL level of 42 mg/dL, an LDL
level of 98 mg/dL, and a triglyceride level of 148 mg/dL.
This patients risk of sudden death, myocardial infarction, and stroke can be decreased by
adding
A) niacin
B) lisinopril (Prinivil, Zestril)
C) metoprolol (Lopressor)
D) hydrochlorothiazide
E) simvastatin (Zocor)
17 An otherwise healthy 62-year-old male has been hospitalized with community-acquired
pneumonia for 2 days. He has remained bedridden. When you see him while making rounds,
he mentions that he has noticed increased swelling and pain in his left lower extremity. Lower
extremity ultrasonography reveals a deep venous thrombosis (DVT) in his calf. He has no
previous history of blood clots.
Which one of the following is the best management of this patients DVT?
A) Compression stockings and repeat ultrasonography in 2 days
B) Heparin therapy followed by oral anticoagulation for 3 months
C) Indefinite oral anticoagulation
D) Intravenous thrombolytic therapy
E) Insertion of an inferior vena cava filter
18 Which one of the following statements is true regarding malpractice cases?
A) The majority of patients who sustain medical injury do not sue the physician
B) Family physicians are the most frequently sued physicians
C) The majority of malpractice claims involve trivial injury
D) Plaintiffs typically win cases brought to trial
E) The time between injury and resolution of a case is typically 2 years
19 Influenza A has been isolated in your community. Yesterday, a nurse in the medical-surgical
unit developed significant symptoms of influenza. She did not receive the annual influenza
immunization, and she asks for your advice.
Which one of the following would be most appropriate at this time?
A) Amantadine (Symmetrel)
B) Atorvastatin (Lipitor)
C) Rimantadine (Flumadine)
D) Oseltamivir (Tamiflu)
E) Acyclovir (Zovirax)
20 A 58-year-old white male has a negative screening colonoscopy. He has no symptoms and no

family history of colon carcinoma. His next screening colonoscopy should be scheduled in
A) 1 year
B) 3 years
C) 5 years
D) 10 years
21 Major diagnostic criteria for polycythemia vera include increased red cell mass, normal oxygen
saturation, and
A) hypercapnia
B) thrombocytosis
C) thrombocytopenia
D) hepatomegaly
E) splenomegaly
22 Little League elbow refers to a problem located over the
A) medial epicondyle
B) lateral epicondyle
C) olecranon
D) capitellum
E) ulnar groove
23 The most common cause of hypertension in adolescents is
A) Cushings syndrome
B) essential hypertension
C) hyperthyroidism
D) pheochromocytoma
E) renal disease
24 The presence of nonthrombocytopenic palpable purpura, colicky abdominal pain, and arthritis
is most consistent with which one of the following?
A) Kawasaki disease
B) Takayasu arteritis
C) Wegener granulomatosis
D) Polyarteritis nodosa
E) Henoch-Schnlein purpura
25 An 81-year-old male is scheduled to have an abdominal CT with contrast to assess for a
possible tumor. His medical history is significant for COPD and type 2 diabetes mellitus. His
serum creatinine level is 1.5 mg/dL (N 0.61.5).
Which one of the following would decrease the likelihood of contrast-related nephropathy in
this
patient?
A) Oral acetylcysteine (Mucomyst) begun 24 hours before the procedure
B) Oral acetylcysteine begun 24 hours after the procedure
C) Oral enalapril (Vasotec) begun 24 hours before the procedure
D) Oral enalapril begun 24 hours after the procedure
E) Use of a hyperosmolar contrast medium
26 A 30-year-old female presents with a complaint of years of recurrent insomnia. She often lies
awake with her mind racing, so she uses alcohol nightly to help her fall asleep. She also has
trouble focusing at work. She has been treated for depression several times since age 22, but
she does not improve with antidepressant therapy. She has no family history of psychiatric
disorders.
Which one of the following statements is true regarding this patient?

A) She most likely suffers from obstructive sleep apnea

B) Although she does not have a family history of bipolar disorder, her presentation is
compatible with hypomania
C) She should begin taking venlafaxine (Effexor) to treat her depression
D) Once her sleep issues are addressed, stimulant therapy for attention-deficit disorder
should be considered
27 A 72-year-old white female is experiencing pain due to a vertebral compression fracture. Pain
control with opioid analgesics and calcitonin therapy is not adequate.
Which one of the following would make vertebroplasty an appropriate option?
A) Fracture duration <6 months
B) Degree of vertebral collapse 80%
C) Radiologic evidence of destruction of the posterior vertebral wall
D) New-onset bladder dysfunction thought to have a neurologic etiology
E) New-onset bilateral lower-extremity paresis
28 A 45-year-old male presents to your office in extreme agitation after a verbal altercation with
his boss, during which he was fired. He feels overwhelmed and very angry, and states that he
is going to get his boss and then who knows what.
Which one of the following is true regarding this situation?
A) Physicians have a responsibility to warn and protect intended victims of a patient
B) It is dangerous to ask the patient about suicidal tendencies
C) If the patient is at high risk for suicide and needs inpatient care, but refuses, he may
be allowed to go home if accompanied by a family member
D) You and your staff are not at risk for harm
E) The patients family may be reassured that they are not at risk for harm, as only his
boss has been directly threatened
29 Which one of the following is the most common cause of hyperandrogenism in women?
A) Acromegaly
B) Carcinoma of the ovary
C) Congenital adrenal hyperplasia
D) Cushings syndrome
E) Polycystic ovary syndrome
30 Which one of the following FDA-approved regimens interrupts a pregnancy once implantation
has occurred?
A) Levonorgestrel (Plan B), two 0.75-mg tablets taken 12 hours apart
B) Ethinyl estradiol/levonorgestrel, two 100-:g/0.75-mg doses taken 12 hours apart
C) Mifepristone (RU-486), taken as a single dose
D) Ethinyl estradiol/levonorgestrel, two 100-:g/0.5-mg doses taken 12 hours apart (the
Yuzpe regimen)
E) No currently approved regimen
31 An 18-year-old white female who works at a day-care center sees you because of a cough.
Three weeks ago she developed cold symptoms that have progressed to paroxysms of coughing
with post-tussive emesis. She reports that there are children at the day-care center who have
coughs and colds, but none have been diagnosed with pertussis. She has always been healthy,
has no known drug allergies, and had all of the routine childhood immunizations. A polymerase
chain reaction (PCR) is negative for pertussis and a chest film appears normal.
Which one of the following would be most appropriate at this point?
A) Tetanus diphtheria acellular pertussis (TDaP) vaccine

B) Albuterol
C) Promethazine
D) Azithromycin (Zithromax)
E) Prednisolone (Orapred)
32 A 36-year-old male with a history of a seizure disorder is brought to the emergency department
with generalized tonic-clonic activity. Emergency medical personnel report this has been
ongoing for 15 minutes. After initial resuscitative measures, the preferred medication in this
situation is
A) phenytoin (Dilantin)
B) fosphenytoin (Cerebyx)
C) diazepam (Valium)
D) lorazepam (Ativan)
E) valproate sodium (Depacon)
33 A 62-year-old female presents to the emergency department complaining of right leg and knee
pain. The pain has progressed over the past 2 weeks so that now she is unable to bear weight
on her right leg. She has a history of a recent pulmonary embolus and is on warfarin
(Coumadin). Her INR is therapeutic. On examination she is afebrile. Her pulse rate is 102
beats/min, her blood pressure is 158/96 mm Hg, and her respiratory rate is 14/min. Her right
knee is erythematous, warm, and tender on palpation over the entire knee joint, and a large
effusion is noted. Arthrocentesis reveals numerous WBCs and crystals that are birefringent on
polarizing microscopy.
What is the best initial treatment for the patients knee problem?
A) Ceftriaxone (Rocephin) intravenously, 1.0 g every 24 hr
B) Prednisone orally, 10 mg/day
C) Colchicine, 0.6 mg every 12 hr, up to 4.8 mg total
D) Indomethacin (Indocin) orally, 50 mg every 8 hr
E) Allopurinol (Zyloprim) orally, 100 mg/day
34 Which one of the following is a known risk factor for necrotizing soft-tissue infections?
A) Age <25 years
B) Direct inguinal hernia
C) Hyperalbuminemia
D) Diabetes mellitus
35 A 69-year-old male who has a history of hypertension and ischemic heart disease presents with
fatigue, dyspnea on exertion, and orthopnea. A clinical examination demonstrates pulmonary
rales, tachycardia, a third heart sound, and mild pedal edema. A chest radiograph reveals
cardiomegaly and pulmonary venous congestion, and a two-dimensional echocardiogram
confirms heart failure.
Which one of the following is true regarding the management of this patient?
A) The serum brain natriuretic peptide (BNP) test can accurately differentiate diastolic
from systolic heart failure
B) Optimal treatment for systolic heart failure is necessary to treat diastolic heart failure
C) Drugs that inhibit the production of angiotensin or block angiotensin II receptors are
contraindicated
D) Calcium channel blockers reduce mortality in patients with isolated diastolic
dysfunction
E) $-Blockers are indicated for treating diastolic dysfunction
36 A 40-year-old white male was seen 4 weeks ago for a sudden onset of cough and shortness of

breath. At that visit his oxygen saturation was 92%, but his examination and a chest radiograph
were normal. You prescribed azithromycin (Zithromax) and an albuterol inhaler. Ten days
later he was feeling well and his oxygen saturation was 97%. Today, he returns to the office
with a dry cough and shortness of breath.
On examination he has rare inspiratory rales that clear with deep breaths, and he has an oxygen
saturation of 86%. A chest film and a D-dimer test are normal. Pulmonary function tests show
significant restriction that improves only minimally with albuterol. He has not been exposed to
anyone with a similar illness, has no history of asthma, and has no smoking history or
occupational exposure. However, he reports that 2 months ago his home was flooded after a
heavy rain, and he has been tearing out carpeting that was ruined by the flood.
Which one of the following is the most likely diagnosis?
A) Persistent asthma with acute exacerbations
B) Legionnaires disease
C) Pulmonary embolism, with lupus antibody as the most likely cause of the negative
D-dimer test
D) Hypersensitivity pneumonitis
37 A 75-year-old white female presents with hyponatremia, with a serum level of 118 mEq/L, a
urine osmolality >100 mOsm/kg H O, and a serum osmolality of 242 mOsm/kg H O. She
complains of some fatigue, but is alert and oriented. Her blood pressure is 136/82 mm Hg. She
has normal thyroid, adrenal, cardiac, hepatic, and renal function. You admit her to the hospital
for treatment and observation. Which one of the following is the most appropriate initial
treatment?
A) Administration of 3% normal saline
B) Administration of normal saline
C) Free water restriction
D) Demeclocycline (Declomycin)
38 A high-school gymnast presents to your office with a history of back pain for the past 34
weeks. She reports that symptoms are worse with any hyperextension activity. Examination
demonstrates a hyperlordotic posture with mild tenderness in the lower lumbar spine.
Radiographs demonstrate the classic Scotty dog with a collar appearance of spondylolysis.
Which one of the following statements about this diagnosis is true?
A) Most athletes can resume full activity in 46 weeks
B) Spondylolisthesis >25% requires referral to a spine surgeon
C) Inadequate treatment can lead to complete fracture and spondylolisthesis with
prolonged disability
D) Adolescents should be followed with serial CT every 6 months until they reach
skeletal maturity
39 A 25-year-old female presents to your office with a tick embedded in the skin on her abdomen.
It was likely acquired the previous evening when she was hiking in the woods near her home.
She is currently asymptomatic.
Appropriate management at this point would be to
A) apply a hot match to the body of the tick
B) cover the tick with petroleum jelly
C) remove the tick with blunt angled forceps
D) use topical lidocaine on the site
E) prescribe a 3-week course of doxycycline
40 Which one of the following is a relative contraindication to prescribing rosiglitazone (Avandia)
and pioglitazone (Actos)?
A) Pregnancy

B) Nonalcoholic fatty liver disease

C) Use of insulin
D) Lipodystrophy associated with highly active antiretroviral therapy
E) Anemia
41 Results of a clinical study show a relative risk reduction (RRR) of 33% and an absolute risk
reduction (ARR) of 20%. There are 1000 patients each in the treatment and control groups.
To help determine the potential benefit of the treatment it is necessary to identify the number
needed to treat (NNT).
Which one of the following is the NNT for this clinical study?
A) 3
B) 5
C) 13
D) 130
E) The number cannot be determined from the information provided
42 Which one of the following studies is the diagnostic procedure of choice to detect giant-cell
arteritis?
A) Biopsy of the temporalis muscle
B) Biopsy of the temporal artery
C) CT scan of the temporal artery
D) MRI of the temporal artery
E) An erythrocyte sedimentation rate
43 A 70-year-old retired farmer presents with an angulated right knee and a painful hip. He asks
you about the possibility of getting a new knee, although he is not eager to do so.
You would advise him that the major indication for knee replacement is
A) severe joint pain at rest
B) marked joint space narrowing seen on radiologic studies
C) destruction and loss of motion of the contralateral joint
D) an acutely infected joint
44 A 28-year-old male visits your office because he is planning a ski trip. You practice in a coastal
area, and he plans to be at an altitude of 14,500 feet. On a previous ski trip to the same altitude
he experienced symptoms of headache, poor sleep, anorexia, fatigue, nausea, and vomiting.
He asks you what he can do to prevent these symptoms on his upcoming trip.
Which one of the following would you recommend?
A) Caffeine avoidance
B) Caffeine tablets
C) Furosemide (Lasix)
D) Acetazolamide (Diamox)
E) Fluid restriction
45 When given during acute herpes zoster (varicella) infection, which one of the following drugs
has been shown to reduce the incidence of postherpetic neuralgia?
A) Imipramine (Tofranil)
B) Capsaicin (Zostrix)
C) Amitriptyline
D) Acyclovir (Zovirax)
E) Oral prednisone
46 A 25-year-old female with a longstanding history of depression is doing well on her current
medication. She and her husband are planning a pregnancy. Her psychiatrist has recommended

that she continue taking an SSRI.

Which one of the following poses the greatest risk during pregnancy?
A) Sertraline (Zoloft)
B) Escitalopram (Lexapro)
C) Citalopram (Celexa)
D) Fluoxetine (Prozac)
E) Paroxetine (Paxil)
47 Which one of the following is true concerning community-acquired pneumonia?
A) The absence of a pulmonary infiltrate on a chest film rules out pneumonia
B) Intravenous antibiotics are always more effective than oral antibiotics in treating
uncomplicated pneumonia
C) In patients with uncomplicated pneumonia, the risk of relapse is greatest on the day
prior to planned discharge
D) Hypoxemia is rarely an indication for hospitalization
E) It takes several weeks for all symptoms of pneumonia to resolve
48 You are counseling a 24-year-old female about treatment for her acne. Despite conventional
treatment with topical agents and systemic antibiotics, she continues to experience flares of
inflammatory acne and believes that her acne is severely limiting her social relationships and
her ability to make a favorable impression during job interviews. She asks you about using
isotretinoin (Accutane).
Which one of the following would be accurate advice?
A) Isotretinoin is most useful in treating comedonal acne
B) Concomitant therapy with topical keratolytic agents is usually well tolerated
C) Teratogenicity is the most devastating adverse effect
D) Elevations in liver enzymes often necessitate discontinuing treatment
E) Osteoporosis and osteophyte formation are common late complications of treatment
49 A CBC obtained as part of a life insurance examination of a healthy 33-year-old
African-American male reveals clumped platelets. Which one of the following should you
do next?
A) Repeat the platelet count using a specimen collection tube with an alternative
anticoagulant
B) Refer the patient to a hematologist for bone marrow evaluation
C) Hospitalize the patient for aggressive antiplatelet therapy and parenteral
anticoagulation
D) Treat the result as a laboratory error and take no further action
50 Adult ankylosing spondylitis
A) commonly begins after age 45
B) is more common in women than in men
C) is most commonly initially manifested in knees and hands
D) typically causes early morning pain and stiffness that improves with activity
51 A 24-year-old female presents to your office with lower abdominal pain, dyspareunia, and a
vaginal discharge. She has a history of multiple sex partners. Examination shows that the
cervix is tender to manipulation and the uterus is tender and enlarged to the size expected at 6
8 weeks gestation. No adnexal masses are noted. She has no rebound tenderness on abdominal
examination. Which one of the following indicates that the patient should be hospitalized for
parenteral therapy?
A) No improvement with 24 hours of outpatient antibiotics
B) A previous history of pelvic inflammatory disease

C) An elevated erythrocyte sedimentation rate and WBC count

D) Laboratory confirmation of gonorrhea or chlamydial infection
E) Pregnancy
52 An asymptomatic 60-year-old male who has a history of hypertension comes to your office for
the first time. He has not taken antihypertensive medication in over a year and cannot recall the
name of the drug prescribed. His examination is unremarkable. A CBC, urinalysis, and
chemistry profile are all normal. His blood pressure is 159/92 mm Hg. An EKG shows a sinus
rhythm, but is compatible with left ventricular hypertrophy. An echocardiogram confirms this
finding. Which one of the following would be most appropriate for the management of this
patients hypertension?
A) Hydralazine
B) Minoxidil
C) Doxazosin (Cardura)
D) Amlodipine (Norvasc)
E) Lisinopril (Prinivil, Zestril)
53 Which one of the following is most effective in limiting the complications of COPD?
A) Pneumococcal vaccination
B) Smoking cessation
C) Oral corticosteroids
D) Albuterol
E) Theophylline
54 A 53-year-old male accountant comes to your office with progressive facial weakness on the
left side that began yesterday. He also reports pain behind the left ear and decreased lacrimation
from the left eye. He has been in good health and had his yearly physical examination 1 week
ago, which was normal. His lipid levels, chemistry profile, and CBC were all normal. He has
not been involved in any outdoor activities, nor does he engage in any high-risk sexual
behavior. On examination, the forehead is smooth bilaterally and there is flattening of the left
nasolabial fold and decreased ability to close the left eye. The mouth appears to be drawn to the
right.The remainder of his general examination and neurologic examination are normal.
Which one of the following would be the most appropriate management at this time?
A) Carotid ultrasonography
B) High-resolution CT
C) MRI with gadolinium enhancement
D) Aspirin and observation
E) Prednisone and valacyclovir (Valtrex)
55 You see a 16-year-old white female for a preparticipation evaluation for volleyball. She is 183
cm (72 in) tall, and her arm span is greater than her height. She wears contacts for myopia.
Which one of the following should be performed at this time?
A) An EKG
B) Echocardiography
C) A stress test
D) A chest radiograph
E) Coronary MRI angiography
56 Activated charcoal is ineffective for the treatment of acute ingestions of which one of the
following?
A) Acetaminophen
B) Enteric-coated aspirin

C) Ferrous sulfate
D) Amitriptyline
E) Digoxin
57 You are reviewing laboratory findings in a 64-year-old male hospitalized with acute renal
failure. The patient is not on any long-term medications. His renal function has previously
been normal, but currently his serum creatinine level is 2.8 mg/dL (N 0.61.5), BUN 60 mg/dL
(N 825), and fractional excretion of sodium (FENa) 0.75%. His urine specific gravity is
1.025, and the urine sediment shows only hyaline casts.Based on these findings, which one of
the following conditions is most likely?
A) Hypervolemia
B) Acute pyelonephritis
C) Interstitial nephritis
D) Obstruction due to benign prostatic hypertrophy
E) Hypovolemia
58 An elderly male with mild dementia is involved in a motor vehicle accident, and his son is
concerned that it may no longer be safe for him to drive. Which one of the following has the
legal authority to revoke or restrict this patients drivers license?
A) The patients son
B) A psychiatric consultant
C) The person designated as having power of attorney
D) The family physician
E) A representative of the state department of motor vehicles
59 A 28-year-old female presents 2 weeks post partum complaining of palpitations, diarrhea,
weight loss, and being jumpy. Her examination is normal except for a slightly enlarged and
tender thyroid gland. Her TSH level is 0.02 :U/mL (N 0.55.5), with a higher than normal
level of free T3 . Which one of the following would be the most appropriate treatment?
A) Levothyroxine (Synthroid)
B) Prednisone
C) Propranolol (Inderal)
D) Propylthiouracil
E) Radioactive iodine
60 A 25-year-old elementary school teacher presents with target or iris-like lesions on her palms
and soles. You should suspect
A) -streptococcal infection
B) erythema multiforme
C) urticaria
D) Lyme disease
E) discoid lupus erythematosus
61 A 75-year-old male is brought to your office 1 month after a stroke that involved the left
anterior cerebral artery, manifested by leg weakness, initial incontinence, and slowness in
mentation. He experienced seizure activity on the second day after his stroke, but this was
controlled by phenytoin (Dilantin). He has improved significantly and is now ambulatory. His
family states that he now has episodic confusion, sleepiness, and clumsiness, which is preceded
by paresthesias and dizziness, although no tonic-clonic activity has been noted. He remains
very drowsy for several hours after these episodes. He was wearing a cardiac monitor during
one episode, but it showed nothing remarkable. His phenytoin level is therapeutic, and a CBC,
metabolic profile, and magnesium level are all normal.
Which one of the following would be the most appropriate next step?

A) Discontinue the phenytoin

B) Add phenobarbital to the phenytoin
C) Begin bupropion (Wellbutrin)
D) Begin modafinil (Provigil)
E) Begin lamotrigine (Lamictal)
62 Coronary arteriography would be indicated for which one of the following?
A) A 45-year-old policeman with intermittent chest discomfort suggestive of angina
pectoris who has a negative exercise stress test
B) A 38-year-old asymptomatic bank officer with a family history of heart disease who
is to undergo hernia repair
C) A 72-year-old female with hypertension, asymptomatic PVCs on EKG, hyperlipidemia
for which she refuses treatment, and worsening of her longstanding esophageal reflux
pain
D) A 57-year-old anxious female with sharp anterior chest pain and a mid-systolic click
and murmur
63 A 31-year-old male with type 1 diabetes mellitus is admitted to the hospital with diabetic
ketoacidosis and pneumonia. After initial treatment in the emergency department with
intravenous fluids and insulin, laboratory tests reveal a serum phosphate level of 2.1 mg/dL (N
2.55.0). He is asymptomatic except for related pneumonia symptoms.
Which one of the following would be appropriate management of this patients low serum
phosphate level?
A) No therapy
B) Oral phosphate replacement, 2.53.5 g/day in divided doses
C) Oral phosphate replacement, 2.53.5 g/day in divided doses, and oral vitamin D
supplementation, 400800 IU/day
D) Intravenous phosphate replacement, 0.080.16 mmol/kg over 6 hours
64 A 50-year-old female is ill with an abrupt onset of fever to 39.4E C (103.0E F), frontal
headaches, severe sore throat, and myalgia. She has just returned from a 1-week cruise to the
Caribbean, where she participated in island tours. Her husband, a physician, says that her
symptoms resemble those of infectious mononucleosis, but he is concerned that she may have
something else. Which one of the following is the most likely diagnosis?
A) Salmonella
B) Norovirus
C) Leptospirosis
D) Dengue fever
E) Hepatitis B
65 A 51-year-old healthy female sees you for a routine examination. On a screening questionnaire
she reports having two alcoholic drinks per day on average, but never more than three drinks
on any occasion. She denies problems or symptoms associated with alcohol use.
To reduce the risk of this patient suffering adverse effects from alcohol use you should
A) refer her to Alcoholics Anonymous
B) prescribe naltrexone (ReVia)
C) advise her to quit drinking
D) inform her that her pattern represents at-risk drinking
66 You see a 6-year-old male who has had a sore throat since yesterday. He has not had a fever
and is currently afebrile. He complains of a slight runny nose and cough. On examination you
note a tonsillar exudate and anterior cervical lymphadenopathy. A rapid antigen detection test

for group A $-hemolytic streptococci is negative.

The most appropriate course of action at this point is to
A) perform no further tests and treat symptomatically
B) obtain a throat culture and base antibiotic treatment on the results
C) obtain a throat culture and begin empiric antibiotics at this visit
D) perform no further testing and treat empirically with antibiotics
E) test for mononucleosis and treat symptomatically
67 Which one of the following is correct regarding nonalcoholic fatty liver disease?
A) It is considered a benign condition
B) It is not associated with cirrhosis
C) It is associated with type 2 diabetes mellitus
D) Isolated alkaline phosphatase elevation is the most common associated laboratory
abnormality
E) The diagnosis is usually confirmed by CT
68 A 17-year-old white male presents with facial swelling and difficulty chewing food. He tells
you the symptoms resulted from a fight. On examination you note trismus and left periorbital
swelling.
Which one of the following fractures is most likely?
A) Zygomatic arch
B) Inferior orbital floor
C) Medial orbital floor
D) Basal skull
E) Nasal septum

69 A 38-year-old male is admitted to the hospital because of weakness and is found to have severe
hypokalemia. His urinary electrolytes show significant potassium wasting.
This combination of findings suggests the patient also has a significant deficiency of
A) aldosterone
B) magnesium
C) sodium
D) hydrogen ions
E) calcium
70 A 60-year-old white female is in the intensive-care unit for respiratory failure secondary to
community-acquired pneumonia. She smokes 2 packs of cigarettes per day, but has no other
significant medical or personal history. A medical student is making rounds with you and asks
if the patients thyroid function should be tested.
Which one of the following is true regarding thyroid testing in this situation?
A) Most patients who are critically ill should be tested for occult hypothyroidism
B) Serum TSH is a good screening test for thyroid disease in critically ill patients
C) A low TSH level in this patient would indicate hyperthyroidism
D) A low T level is a frequent finding in patients hospitalized in the intensive-care unit
E) A low T level should be treated with thyroid replacement in hospitalized critically ill
Patients
71 A 33-year-old female presents with 3 months of irregular vaginal bleeding. Prior to this her
menstrual periods were normal. Which one of the following is the most appropriate initial
laboratory test for this patient?

A) Hemoglobin and hematocrit

B) TSH
C) LH and FSH
D) Estradiol
E) hCG
72 Which one of the following statements is true regarding the use of light therapy to treat
seasonal affective disorder?
A) It generally is most effective when administered in the morning
B) Duration of exposure to light is the main determinant of efficacy
C) It is not known to precipitate mania
D) Any light source may be used for treatment
73 Which one of the following is more consistent with Parkinsons disease than with other variant
parkinsonian syndromes?
A) Tremor at the onset of illness
B) Frequent falls at the onset of illness
C) Urinary urge incontinence at the onset of illness
D) Symmetric, bilateral motor manifestations at the onset of illness
74 A 16-year-old male comes to your office after suffering an eversion injury to his ankle while
being tackled in a football game 3 days ago. He was not able to bear weight after the injury and
now has tenderness at the distal tibiofibular joint with no swelling. Compression of the fibula
against the tibia at the mid-calf elicits pain anterior to the lateral malleolus and proximal to the
ankle joint. Stabilizing the leg and rotating the foot externally elicits pain at the same location.
Radiographs are negative.
Which one of the following would be most appropriate at this point?
A) Application of an elastic wrap to the ankle for 2 weeks
B) Therapeutic ultrasound
C) Stress radiographs
D) A CT scan
E) Long-term semirigid support

75 A 45-year-old male comes to your office for follow-up of his diabetes mellitus, which was
diagnosed 3 months ago. He wanted to try lifestyle modification, including diet, exercise, and
weight loss, before trying medications. He has lost 3 kg (7 lb), but still is 14 kg (31 lb)
overweight. His examination is unremarkable, 1c as is his chemistry profile. His hemoglobin A
level is 8.3%. Which one of the following would be most appropriate at this point?
A) Exenatide (Byetta)
B) Glyburide (Micronase, DiaBeta)
C) Insulin
D) Metformin (Glucophage)
E) Rosiglitazone (Avandia)
76 Which one of the following vaccinations is contraindicated in pregnancy?
A) Diphtheria
B) Hepatitis B
C) Influenza
D) Tetanus
E) Varicella

77 A 68-year-old previously healthy male presents to the emergency department with fever and
rigors, chills, cough, fatigue, dyspnea, and pleuritic chest pain. He has no chronic medical
problems and does not smoke. A chest film shows a lobar consolidation.
The most likely bacterial cause of this problem is
A) Staphylococcus aureus
B) Streptococcus pneumoniae
C) Legionella
D) Mycoplasma pneumoniae
E) Chlamydia
78 The only antidepressant with demonstrated efficacy in childhood and adolescent depression is
A) clozapine (Clozaril)
B) fluoxetine (Prozac)
C) lithium
D) imipramine (Tofranil)
E) mirtazapine (Remeron)
79 A 35-year-old male complains of 2 months of right shoulder pain. He does not recall an injury,
but says it is painful to lie on his right side or to work with his right hand above his head. On
examination, the shoulder appears normal and there is no pain with external rotation of the
shoulder, bringing the arm across the body (scarf test), or attempted external and internal
rotation of the shoulder against resistance. Lowering the arm from full abduction (painful arc),
attempted abduction above 45E against resistance, and elevating the internally rotated arm
above 90E against resistance are all painful.
The most likely diagnosis is
A) subdeltoid bursitis
B) adhesive capsulitis
C) impingement syndrome
D) glenohumeral osteoarthritis
E) acromioclavicular osteoarthritis
80 For an African-American child with a body mass index (BMI) greater than the 85th percentile
for age and gender, and whose mother has type 2 diabetes mellitus, screening for type 2
diabetes
should begin at what age?
A) 7 years
B) 10 years
C) 13 years
D) 16 years
E) In adulthood
81 A 76-year-old female is hospitalized for fever and weakness of several days duration. Her
history and physical findings are otherwise unremarkable except for a temperature of 37.1E C
(100.2E F), a pulse rate of 100 beats/min, and a blood pressure of 95/55 mm Hg. A urinalysis
reveals 1015 WBCs/hpf and a urine culture reveals methicillin-sensitive Staphylococcus
aureus.
The most appropriate action at this point is to
A) reculture the urine, as the bacteria on the first urine culture is most likely a skin
contaminant
B) obtain a blood culture and examine the patient for a portal of entry
C) obtain a blood culture and start the patient on intravenous vancomycin (Vancocin)

D) start the patient on oral cephalexin (Keflex)

82 An obese middle-aged adult has acanthosis nigricans. Which one of the following is the most
likely associated illness?
A) Hypothyroidism
B) Diabetes mellitus
C) Gastric adenocarcinoma
D) Lymphoma
E) Addisons disease
83 A 65-year-old nonsmoker is scheduled to undergo right knee replacement. His cardiac history
is negative, and he takes aspirin, 81 mg/day, to prevent cardiovascular problems. He also takes
simvastatin (Zocor), 20 mg/day, for hypercholesterolemia, and metoprolol (Lopressor), 25 mg
twice daily, for hypertension. His body mass index (BMI) is 26 kg/m2, his heart rate is 60
beats/min, and his blood pressure is controlled. Which one of the following is the best
recommendation regarding metoprolol?
A) Withhold 12 hours before and after surgery
B) Withhold 24 hours before and after surgery
C) Withhold 48 hours before and after surgery
D) Withhold the day of surgery and restart it the next morning
E) Continue the drug on his regular schedule when he has surgery
84 The most common cause of monocular vision loss in children and young adults is
A) amblyopia
B) congenital cataract
C) type 1 diabetes mellitus
D) trauma
85 A hospitalized 75-year-old white female requests treatment for joint pain from osteoarthritis.
She currently takes aspirin, 81 mg daily, and has already tried maximum doses of
acetaminophen and over-the-counter topical medications without relief. She has no history of
peptic ulcer disease, gastroesophageal reflux disease, or dyspepsia. You review with her the
benefits and risks of NSAIDs. Which one of the following is true regarding the potential for
gastrointestinal (GI) complications?
A) NSAIDs can increase the risk of GI problems distal to the duodenum, as well as
proximal to the duodenum
B) Most individuals who develop gastric ulcers while using NSAIDs have GI symptoms
C) The main mechanism by which NSAIDs induce GI complications is through a direct
physical irritating effect of the pill on the gastric mucosa as it is absorbed
D) Low-dose enteric-coated aspirin (81 mg daily) does not increase the risk of GI
complications if other NSAIDs are not used concomitantly
E) Most individuals who develop gastric ulcers while using NSAIDs have a positive test
for Helicobacter pylori

86 A 62-year-old white female complains of bone and muscle pain in both legs for several years.
She denies any joint pain or swelling. Her only medication is occasional acetaminophen for
pain. She denies taking vitamins or supplements, although she eats a serving of yogurt every

day. On examination the patient weighs 61 kg (134 lb) and is 157 cm (62 in) tall. Her height
has not changed in the past 2 years. The remainder of the examination is unremarkable.
Laboratory
evaluation reveals that her CBC, erythrocyte sedimentation rate, and creatinine, protein,
albumin, alkaline phosphatase, and TSH levels are all within normal limits. Her serum calcium
level is 9.1 mg/dL (N 8.510.5) and her 25-OH vitamin D level is 16 ng/mL (N 2580).
What is the best initial treatment for this patient?
A) Calcium carbonate, 500 mg twice daily, and vitamin D , 400 IU/day
B) Calcium carbonate, 500 mg 3 times daily, and vitamin D , 800 IU/day
C) Calcium gluconate, 600 mg/day, and vitamin D , 800 IU/day
D) Vitamin D , 800 IU/day
E) Vitamin D , 50,000 IU once a week for 812 weeks
87 54-year-old African-American female is admitted to the hospital for intravenous heparin
therapy for a deep-vein thrombosis of her leg. She had previously been very healthy. Shortly
after admission she begins to experience profound orthostatic hypotension and gastrointestinal
distress. Serial hemoglobin tests are stable, but serum sodium and bicarbonate levels are low.
Her potassium level is slightly elevated. Which one of the following tests would most quickly
determine if she has suffered from acute
adrenal cortex insufficiency (Addisons disease)?
A) A cosyntropin stimulation test
B) A dexamethasone suppression test
C) A renin:aldosterone ratio
D) A serum adrenocorticotropic hormone (ACTH) level
E) Measurement of 24-hour urinary excretion of catecholamines
88 An otherwise healthy 1-year-old male is brought to your office because of increased respiratory
effort, wheezing, and rhinorrhea. He has no fever. On examination he is found to have an
increased respiratory rate and mild retractions. A chest film shows no foreign body or
infiltrates. Oxygen saturation is 94%. Management should include which one of the following?
A) A trial of nebulized albuterol
B) Nebulized epinephrine
C) Oxygen
D) Antibiotics
E) Corticosteroids
89 A 72-year-old Asian-American female is brought to your office by her husband because he
thinks she might have Alzheimers disease. For the past 3 months she has complained of
confusion, poor appetite, and lack of energy. She has been unable to do routine housework. On
brief questioning, her short-term recall seems to be impaired, but a more detailed examination
indicates that her memory is fine.
Which one of the following is the most likely diagnosis?
A) Alzheimers disease
B) Lewy body dementia
C) Frontotemporal dementia
D) Pseudodementia
E) Mild cognitive impairment
90 The U.S. Preventive Services Task Force (USPSTF) makes which one of the following
recommendations regarding screening for speech and language delay in preschool children
using brief, formal screening instruments that are suitable for use in primary care?
A) Screening is strongly recommended for all preschool children because good evidence
exists for substantial benefit over harm

B) Screening is not recommended because it is ineffective

C) Screening is not recommended because the potential harm outweighs the potential benefits
D) The evidence is insufficient to recommend for or against routine screening
91 A 56-year-old male had a 1-cm basal cell carcinoma resected from his temple area. The
pathology report shows that cancer is present in one of the margins of the specimen.
Which one of the following would be the most appropriate next step?
A) Observation of the area and reexcision if a suspicious lesion recurs
B) Topical imiquimod (Aldara)
C) Cryosurgery of the affected area
D) Curettage and electrodesiccation of the affected area
E) Surgical reexcision
92 Chest pain associated with cocaine use
A) should be treated with -blockers
B) has an onset that has a consistent relationship with time of use
C) is associated with characteristic EKG changes
D) is mainly vasospastic in origin
93 Which one of the following statements regarding blood glucose monitoring in patients with
type
1 diabetes is most correct?
A) Blood glucose testing from a fingertip site is preferred
B) Monitoring blood glucose 5 times per day is too often
C) A random blood glucose level of 100 mg/dL is too high
1c D) Continuous blood glucose monitoring can result in higher hemoglobin A levels
94 Which one of the following is seen in patients receiving injectable depot medroxyprogesterone
acetate (DMPA)?
A) More regular and predictable menstrual periods
B) Improvement in acne
C) Fewer migraine headaches compared to patients using combination oral contraceptives
D) Increased bone density
E) Minor weight loss
95 A 65-year-old female presents with a complaint of slowly increasing discomfort in her knees of
3 years duration. An examination and radiograph are consistent with noninflammatory
osteoarthritis. She says that the pain is well-controlled with acetaminophen, but she wants to
know what can be done to prevent further damage to the joint. You recommend
A) referral to a rheumatologist for disease-modifying agents such as methotrexate
B) hyaluranon injections to preserve cartilage
C) corticosteroid injections
D) symptomatic measures only
96 Which one of the following is the most common type of anemia in the geriatric age group?
A) Iron deficiency anemia from blood loss
B) Nutritional anemia from vitamin B deficiency
C) Anemia of chronic disease
D) Hemolytic anemia
E) Myelodysplastic anemia
97 A pregnant 20-year-old female is diagnosed with a Chlamydia infection. She is treated and the
infection is cured, but she tests positive again at a follow-up visit.
In this situation, contacting her sexual partners is considered a reasonable breach of

confidentiality because
A) there is a public health risk
B) there is a risk to the fetus
C) the patients Chlamydia infection has become resistant to antibiotics
D) there is a risk of pelvic inflammatory disease

98 The most common cause of hemoptysis seen in the primary care setting is
A) pulmonary embolism
B) lower respiratory tract infection
C) lung cancer
D) heart failure
E) asthma
99 A 73-year-old white male is brought to your office by his family. He had uncontrolled
hypertension and was found to have renal artery stenosis, but became normotensive following
stent placement. Since then he has lost 6 kg (13 lb) and has no appetite. He is 165 cm (68 in)
tall and currently weighs 59 kg (130 lb). He has been feeling anxious, and during a recent home
repair he cut a hole in a wall and noticed a white material, which he believes is asbestos. He is
concerned that the news media will find out about this, that his home will be condemned, and
that the whole world will know. His affect is flat, and his eye contact is poor. However, he
is alert and oriented. The remainder of the examination is normal. He is given an adequate trial
of paroxetine (Paxil) and venlafaxine (Effexor) with no relief of symptoms, and continues to
lose weight. Which one of the following would be the most effective treatment at this time?
A) Fluoxetine (Prozac)
B) Mirtazapine (Remeron)
C) Lorazepam (Ativan)
D) Methylphenidate (Ritalin)
E) Electroconvulsive therapy (ECT)
100 Which one of the following is considered first-line treatment for shock-resistant ventricular
tachycardia?
A) Amiodarone (Cordarone)
B) Vasopressin (Pitressin)
C) Lidocaine (Xylocaine)
D) Procainamide (Pronestyl)
E) Magnesium