Block 1

1. A 3-month old infant with DiGeorge syndrome is brought to the office by his mother 1 week after a 2-week hospitalization
for treatment of an abscess at a previous intravenous site. This was the patient’s second serious infection requiring
admission to the hospital, and his mother thinks that he is getting sick again. She says his temperature this morning was
38.5C (101.3F) and he has not shown interest in feeding today. He was born at term. Physical examination at birth showed
a cleft palate. Echocardiography obtained at birth disclosed a right-sided aortic arch. The infant is 50cm (20 in; 10th
percentile) long and weighs 4593 g (10 lb 2 oz; 3rd percentile); head circumference is 38 cm (15 in; 3rd percentile). Vital
signs now are temperature 38.0C (100.4F), pulse140/min, respirations 28/min, and blood pressure 92/58 mm Hg. Physical
examination discloses a tender area of induration with erythema on the right foot. You suspect the infant has a cellulitis
and arrange for admission to the hospital. Which of the following is the most likely cause of his recurrent infections?

A. Congenital heart defect

B. Hypogammaglobulinemia
C. Insufficiently treated prior infection
D. Malnutrition
E. T-lymphocyte deficiency

2. A 15-year-old boy is brought to the office by his mother 1 hour after having an episode of weakness and numbness of all
extremities, loss of vision, and syncope. The episode lasted 10 minutes, after which he regained consciousness and was
normal. Two weeks ago he had a surfing accident, during which he struck his head and neck on the surfboard. He did not
seek medical attention at the time. On questioning now in the office, he says that since the accident he has had
intermittent episodes of vertigo that have lasted 5 minutes each. Vital signs are normal. Physical examination discloses no
abnormalities. Which of the following are most appropriate next step in evaluation?

A. EEG
B. Emergent MRI/MRA of the brain and cervical spine
C. C. Observation at home
D. Observation in the hospital with plans to reevaluate if he has another syncopal episode
E. X-ray of the cervical spine with swimmer’s view

3. A 74-year-old white man comes to the office for evaluation of his blood pressure, which recently showed two sparate
readings of 180/74 mm Hg and 176/78 mm Hg You review this chart and see that his last visit was 3 years ago, at which
time his blood pressure was 164/80 mm Hg. He currently takes no medication. He is 183 cm (6ft) tall and weighs 79 kg
(175 lb), BMI is 24 kg/m^2. Physical examination is normal except for a blood pressure of 170/80 mm Hg. You recommend
an exercise program and diet modification with decreased salt intake. At a follow0up visit 3 months later he has lost 2.2 kg
(5 lb). He says he restricted his salt intake, however, his blood pressure remains elevated at 168/70 mm Hg. You
recommend a trial of pharmacotherapy. You have reviewed the results of a randomized controlled trial assessing the
effects of antihypertensive treatment to reduce the risk for stroke. In this study, 4736men and women with elevated
systolic blood pressure were randomly assigned to a placebo, diuretic, or cardioselective beta-blocking medication.
Patients were monitored for 5 years. The effects of treatment on blood pressure are shown in the table below.

Change in blood pressure (mean mm Hg +/- standard deviation)

Assignment Systolic Diastolic
Placebo -2 +/- 4.2 +1.5 +/- 3.6
Diuretic -12.2+/-6.8* -3 +/- 4.2
Beta-blocking medication -14.3 +/- 10.7** +0.8 +/- 6.9
*p = 0.002, **p<0.01 (compared with placebo)
Item 1 of 2:
Compared with the placebo, which of the following is the most appropriate conclusion based on these data?
A. Beta-blocking medication decreases diastolic blood pressure
B. Beta-blocking medication decreases diastolic blood pressure more than the diuretic
C. Diuretic decreases diastolic blood pressure
D. Diuretic decreases systolic blood pressure
E. Diuretic plus beta-blocking medication acts synergistically to decrease bood pressure
4. Item2 of 2:
The patient is concerned about the potential for adverse effects of the medication and wants more information about the
benefits of treatment. You review the following results of a study related to stroke and cardiovascular events.
Risk reduction for antihypertensive therapy compared with placebo
Risk reduction for antihypertensive therapy compared with placebo
Event Relative Risk Confidence Interval
Fatal stroke 0.71 0.31 to 1.59
Nonfatal stroke 0.63 0.49 to 0.82
Transient ischemic attack 0.75 0.54 to 1.04
Myocardial infarction 0.67 0.47 to 0.96
Angioplasty 0.86 0.47 to 1.59
Coronary artery bypass grafting 0.63 0.40 to 1.00

Based on these data, you advertise the patient that reducing blood pressure through drug therapy is likely to decrease
which of the following?
A. His need for angioplasty
B. B. His need for Coronary artery bypass grafting
C. His risk for a fatal stroke
D. D. His risk for a nonfatal stroke
E. E. His risk for a transient ischemic attack

5. An 83-year-old woman is admitted to the hospital because of fever and fecal impaction. She has poor vision due to
macular degeneration and she is not very mobile. After disimpaction and recovery, she falls and breaks her hip on the
second hospital day. You refer to a case-control study of in-hospital hip fractures that notes an odds ratio of 2.0 (95%
confidence interval [CI], 1.2 to 3.3) for the presence of vision impairment. Which of these following is the most
appropriate statement regarding the 95% CI in this study?
A. On repeated trials, the probability that the odds ratio falls outside 1.2 and 3.3 is 5%
B. On repeated trials, the probability that the odds ratio is greater than 3.3 is 5%
C. On repeated trials, the probability that the odds ratio is less than 1.2 is 5%
D. On repeated trials, the probability that the odds ratio is less than 1.2 is 5%
E. The probability that the observed odds ratio arose by chance alone is less than 5%

6. A 56-year-old African American woman with a 6-year history of type 2 diabetes mellitus comes to the office for a follow-
up examination. She brings her fingerstick blood glucose log to the office and says, “I check my sugar about the three
times weekly and it has been running high lately.” Medical history is also significant for hypertension, hypercholesteremia,
and coronary artery disease, for which she underwent three-vessel coronary artery bypass grafting 2 years ago.
Medications include rosiglitazone, hydrochlorothiazide, amlodipine, atorvastatin, and aspirin. She has smoked one-half
pack of cigarettes daily for the past 40 years. She drinks one caffeinated beverage daily but does not drink alcoholic
beverages. She is 178 cm (5 ft 5 in) tall and weighs 73 kg (160 lb); BMI is 27 kg/m^2. Vitals signs are temperature 37.2 C
(98.9F), pulse 90/min, respirations 16/min, and blood pressure 135/88 mm Hg. Ocular examination discloses flat optic
discs without vascular changes. Auscultation of the neck discloses a soft right carotid bruit. Breath sounds in the upper
lung fields are decreased. Sensation is decreased to monofilament testing in the feet, bilaterally. Additional physical
examination should be directed at which of the following?
A. Axillae
B. Eyelids
C. Joints
D. Toenails
E. Tongue

7. A 57 year old Mexican American man comes to the office for evaluation of hyperlipidemia. He was hospitalized for
unstable angina and underwent a percutaneous angioplasty of the proximal left anterior descending coronary artery 3
months ago. He first had heart trouble about 7 years ago when he had a subendocardial myocardial infarction. He
stopped smoking cigarettes 1 year ago, but had smoked at least one pack daily for 25 years. His current medications are
aspirin and metoprolol, daily. His height is 170 cm (5 ft 7 in) and weight is 95 kg (210 lb); BMI is 33 kg/m^2. Vital signs are
 temperature 37.5 C (99.5F), pulse 64/min, respirations 18/min, and blood pressure 118/72 mm Hg. Results of a recent
serum lipid screening are shown:

Cholesterol
Total 280 mg/dL
HDL 32 mg/dL
LDL 202 mg/dL
Triglycerides 230 mg/dL

In addition to dietary and weight loss, you are considering drug therapy for lowering hhis serum cholesterol
concentration. You review two recent randomized, placebo-controlled studies comparing the efficacy of HMG-CoA
reductatse inhibitors with placebo in preventing recurrent cardiovascular events, including acute myocardial infarction
and death. The results of the two studies are shown
Effect of HMG CoA reductase inhibitors on cardiovascular events
Study No. of subjects Treatment Cardiovascular events Relative risk reduction, % Absolute risk events during
study, % 95% CI reduction, %
1 4444 Drug A 20 25 (16 to 54) 7
Placebo 27
2 4159 Drug B 10 23 (8 to 38) 3
Placebo 13
Based on this information, which of the following is the correct number needed to be treated with drug B to prevent one
cardiovascular event?
A. 3
B. 7
C. 15
D. 33
E. 67

8. A 73-year-old Danish American woman with a history of osteoarthritis comes to the office because of back pain for the
past 4 weeks. She says she has pain with twisting and turning motion. On physical examination she has lancinating
midthoracic tenderness. She is 152 cm (5 ft) tall and weighs 54 kg (120 lb); BMI is 23 kg/m^2. Which of the following is the
most likely diagnosis?
A. Breast cancer
B. Compression fracture of a vertebra
C. Herniated intervertebral disk
D. Lumbosacral strain
E. Spinal stenosis

9. A 77-year-old man who is in a nursing home is seen for he first time since transfer from the hospital 1 week ago. He had
been hospitalized after a stroke. Vital signs now are normal. Physical examination shows residual hemiparesis. The patient
is slightly confused. Prostate gland is slightly enlarged. He has a Foley catheter that was inserted in the hospital because of
incontinence. Which of the following is the most appropriate next step?
A. Change to in-and-out catheterization twice per day
B. Determine serum creatinine concentration
C. Determine serum prostate specific antigen concentration
D. Obtain consultation with a urologist
E. Order ultrasonography of the prostate
 10. A 74-year-old white woman comes to the office because of left wrist pain since she slipped on ice and fell in her driveway
2 hours ago. She says, “I was carrying a heavy bag in my right hand, so I only had my left hand to catch myself. I hit the
ground on my bottom, but my left hand helped cushion the fall. It really hurts over my wrist, and it’s hard for me to move
it.” Medical history is remarkable for hypertension and allergic rhinitis. Medications include enalapril and loratadine. She
is 168 cm (5 ft 6 in) tall and weighs 53 kg (118 lb); BMI is 19 kg/m^2. Vital signs are temperature 37.2 C (99F), pulse
80/min, respirations 20/min, and blood pressure 136/88 mm Hg. Physical examination discloses swelling and pain to
palpation over the left distal forearm, with decreased flexion and extension. Neurovascular examination shows no
abnormalities. X-rays of the left wrist show a nondisplaced distal radial fracture. After appropriately treating the patient’s
left wrist, which of the followingadditional diagnostic studies would be helpful in managing this patint?
A. DEXA scan of the spine and hip
B. Measurement of erythrocyte sedimentation rate
C. Measurement of serum alkaline phosphatase concentration
D. Serum protein electrophoresis
E. X-rays of the lumbar spine

(forgot to take pic of actual question)

11. Item 1 of 2: This patient’s condition is most likely the result of which of the following?
A. A congenital defect
B. Intravenous drug use
C. Toxic medication effect
D. An underlying malignancy
E. A viral illness

12. Item 2 of 2: This patient’s condition will most likely require which of the following interventions?
A. Balloon angioplasty
B. Heart transplantation
C. Long-term medication
D. No intervention
E. Radio-ablative therapy

13. A 20-year-old woman comes to the emergency department during an acute asthmatic attack. She is treated with oxygen
and beta-adrenergic agonist drugs. Which of the following would be the most compelling reason to intubate this patient?
A. Pulse of 120/min
B. Peripheral cyanosis
C. Respirations of 30/min
D. Stupor
E. Vomiting
14. A 43-year-old woman is brought to the emergency department by her husband because of dyspnea. She is agitated and
repetitively says, “I can’t breathe, I can’t breathe.” Her husband says “this breathing problem started abruptly 30 minutes
ago and it seems to be getting worse. Doctor, what’s wrong with my wife? She’s never had a problem like this before.” He
says his wife has been healthy, though she has seemed depressed since being laid off from work 4 weeks ago. Vital signs
today are temperature 37.0 C (98.6F), pulse 105/min, respirations 24/min, and blood pressure 100/70 mm Hg. Physical
examination discloses a tall, thin woman with labored breathing and mild circumoral cyanosis. Auscultation of the chest
discloses no breath sounds on the right side. STAT Chest x-ray shows right-sided tension pneumothorax. Following
appropriate management, additional history should be obtained regarding which of the following?
A. Long-term use of birth control pills
B. Pulmonary sarcoidosis in a sibling
C. Recent prescription for antidepressant therapy
D. Sedentary lifestyle
E. Smoking illicit drugs

15. A 2-hour-old newborn is brought to the emergency department by his parents after he was noted to have problems with
bottle feeding during the first feeding after a home delivery. The mother states that her son takes a bottle readily but
immediately begins to spit up the formula and seems unable to swallow. The parents have not noted any respiratory
symptoms but say that the infant has more saliva than any of their other six children had at birth. On arrival, the newborn
is alert and in no respiratory distress. He weighs 3800 g (8 lb 6 oz). Vital signs are temperature 37.1 C (98.9 F), respirations
40/in, and systolic blood pressure 60 mm Hg. Physical examination shows an alert, comfortable infant who is in no
respiratory distress. The infant has a moderate amount of drooling. Auscultation of the chest discloses clear lungs
bilaterally and a soft systolic ejection murmur. The abdomen is scaphoid without evidence of a mass. A nasogastric tube is
passed until the marking on the tubing shows 12cm (5 in). Which of the following studies is most likely to confirm the
diagnosis?
A. Chest x-ray
B. ECG
C. Esophagography with contrast
D. Flexible bronchoscopy
E. Ultrasonography of the chest

16. A 12-year-old Hispanic boy is brought to the office by his parents after attempting to stab his dog. The boy’s parents state
that they had seen him taking a knife from the kitchen and were able to grab the knife from his hand before he used it. He
gave it up without a struggle. When asked what he was doing, he said, “Nothing.” For the past few days, his mother
noticed a strong odor coming from his room and found that he had been urinating in jars and keeping them under his bed.
When questioned about this, he said, “I had to do it,” but offered no other explanation. Upon interviewing the boy alone
now, he says, “I was going to stab my dog as a sacrifice to carry out my orders. Sometimes I hear voices telling me to hurt
animals, and sometimes I receive my orders in messages sent through the television.” Physical examination today,
including neurologic examination, discloses no abnormalities. Which of the following is the most appropriate initial urine
laboratory test at this time?
A. Copper concentration
B. Culture
C. Heavy metal concentration
D. Porphobilinogen concentration
E. Toxicologic screening for illicit drugs
17. A 69-year-old African American woman comes to the office for the first time because of weakness and fatigue that have
developed since her husband died 10 months ago. Although she has not been to a physician for the past 2 years, she has
continued to take her “blood-pressure pills,” which she obtains at a hospital pharmacy from an old prescription. She says
that her appetite is not very good and that she skips a lot of meals. Vital signs are temperature 36.8 C (98.2 F), pulse
88/min, respirations 18/min, and blood pressure 156/70 mm Hg. Physical examination shows no abnormalities. A blood
sample is obtained and blood smear is shown. Results of additional laboratory studies are obtained and shown:

Blood

Hematocrit 28%
Hemoglobin 8.4 g/dL
Mean corpuscular volume (MCV) 70 m^3
Red cell distribution width (RDW) 16 (N = 11.5-14.5)

Which of the following is the most appropriate next step?

A. Blood type and crossmatch for transfusion

B. Bone marrow aspiration
C. Colonoscopy
D. CT scan of the abdomen
E. Upper gastrointestinal barium study

18. A 74-year-old woman comes to the office because of crampy abdominal pain and bloody diarrhea for the past 3 days. She
has had mild angina for several years, which has been treated with propranolol and 81-mg aspirin. Temperature is 37.5 C
(99.5 F). Physical examination discloses mild tenderness in the left upper abdominal quadrant. No mass is present. Rectal
examination is normal except for bloody discharge on the examining globe. Leukocyte count is 12, 500/mm^3. Which of
the following is most likely diagnosis?
A. Carcinoma of the left colon
B. Granulomatous colitis
C. Ischemic colitis
D. Lymphoma
E. Ulcerative colitis
19. A 66-year-old man comes to the office for a routine health maintenance examination. Medical history is significant for
type 2 diabetesmellitus and myocardial infarction 5 years ago. Medications include simvastatin, enalapril, metformin,
metoprolol, and 81-mg aspirin. BMI is 38 kg/m^2. Vital signs are temperature 37.0 C (98.6 F), pulse 90/min, respirations
16/min, and blood pressure 140/80 mm Hg. Physical examination discloses a large varicocele located in the left scrotum
that was not present 6 months ago. The patient states that he cannot see his scrotum but that he felt the swelling 1 moth
ago. The remainderof the physical examination discloses no abnormalities. Results of laboratory studies are pending.
Which of the following is the most likely diagnosis?
A. Benign prostatic hyperplasia
B. Cryptorchidism
C. Fournier gangrene
D. Renal cell carcinoma
E. Testicular torsion

20. A 3-year-old Native American child returns to the office with his aunt 2 days after an initial visit for evaluation of
temperature to 40 C (104 F) and difficulty breathing of 3 days’ duration. His appetite for solids and liquids had been
decreased during that time. Treatment with amoxicillin, systemic corticosteroids, and nebulized albuterol therapy was
initiated, but the child’s fever has persisted. The child lives with his aunt and three cousins in a trailer on a reservation.
The mother’s location is unknown. He was born at term. Medical history is significant for three hospital admissions for
bronchiolitis and asthma. Family history is remarkable for asthma in his mother and cousin, and type 1 diabetes mellitus in
several relatives. He has no known allergies to medications. The child is 93 cm (37 in; 10th percentile) and weighs 12 kg (26
lb; just below 5th percentile). Weight has decreased 600 g (1.5 lb) during the past 3 weeks. Temperature today is 39.8 C
(103.6 F). The child appears tired and restless. Physical examination shows flushed tympanic membranes, injected
conjunctivae bilaterally, and erythema of the pharynx. There is no cervical adenopathy. Auscultation of the lungs discloses
crackles and dullness over the left chest posteriorly and scattered, high-pitched wheezes in all lung fields. Chest x-ray
shows left lower lobe consolidation. Results of laboratory studies are shown:

WBC 34, 200/mm^3

Neutrophils, segmented 57%
Neutrophils, bands 22%
Lymphocytes 8%
Monocytes 10%
Eosinophils 3%

Which of the following is the most likely cause of these current findings?
A. Penicillin-resistant pneumococci
B. Response to albuterol
C. Response to amoxicillin
D. A second, new infection
E. Underlying tuberculosis
21. An 18-year-old woman comes to the office because of a 4-year history of skin lesions that worsen during the week prior to
her menstrual period. Her menstrual cycle is typically 28 to 30 days. Her last menstrual period was 21 days ago. She takes
no medications. She is 165 cm (5 ft 5 in) tall and weighs 51 kg (112 lb); BMI is 19 kg/m^2. Vital signs are temperature 36.4
C (97.5 F), pulse 84/min, respirations 20/min, and blood pressure 100/60 mm Hg. Physical examination shows the skin
condition shown in the photograph. Physical examination should specifically focus on locating similar lesions over which
part of the body?
A. Axilla
B. Buccal mucosa
C. Groin
D. Lower extremities
E. Upper chest

22. A 38-year-old woman, gravida 2, para 2, comes to the office because she has had heavy menstrual bleeding since the birth
of her second child 3 years ago. She also has had increased clotting and duration of period length from 5-7 days. Her
current menstrual period began 5 days ago. Medical history is significant for chronic hypertension and two cesarean
deliveries, the last of which was followed by a tubal ligation. Medications include metoprolol. The patient has smoked on
pack of cigarettes daily for the past 15 years. She is 160 cm (5 ft 3 in) tall and weighs 77 kg (169 lb); BMI is 30 kg/m^2.
Vital signs are temperature 37.1 C (98.7 F), pulse 98/min, respirations 20/min, and blood pressure 128/79 mm Hg. Pelvic
examination discloses a slightly enlarged uterus, normal ovaries, and a moderate amount of blood in the vaginal vault
without brisk bleeding. The remainder of the physical examination shows no abnormalities. Pelvic ultrasonography
discloses normal ovaries bilaterally. Urine pregnancy test is negative. Results of laboratory studies show a hematocrit of
32% and a hemoglobin concentration of 10.6 g/dL. Which of the following is the most appropriate next step in evaluation?
A. Endometrial biopsy
B. Fasting glucose: insulin ratio
C. Fractional dilatation and curettage
D. Measurement of serum prolactin concentration
E. Serum follicle-stimulating hormone: luteinizing hormone ratio

23. A 74-year-old white man with dementia is transferred to the hospital from a nursing home because of necrosis of the
distal phalanx of the second toe on his right foot. He denies localizing pain. He has a history of hypertension, coronary
artery disease, congestive heart failure and mild renal insufficiency. Vital signs are temperature 37.0 C (98.6 F), pulse
92/min, respirations 16/min, and blood pressure 160/80 mm Hg. On physical examination he is thin and is in no distress.
Examination of the head, ears, eyes, nose, and throat is normal. Chest has bilateral crackls at both lung bases> Cardiac
examination shows regular rate and rhythm with no murmurs. The abdomen is scaphoid and no masses are present. The
extremities are thin and the distal phalanx of the second right toe is black and mummified. Mild erythema is present on
the adjacent proximal skin but no purulence is noted. Bilateral carotid and femoral artery bruits are noted. Radial pulses
are full. Pulsatile masses measuring approximately 2 x 2 cm are palpable in both popliteal fossae. Dorsalis pedis and
posterior tibial pulses are 3+ bilaterally. Which of the following is the most likely cause of this patient’s gangrene?
A. Arterial embolus
B. Arteritis
C. Large artery vaso-occlusive disease
 D. Obliterative angiopathy
E. Raynaud syndrome

24. A 24-year-old woman was admitted to the hospital last evening because of abdominal pain. Yesterday she had onset of
severe, crampy, left lower quadrant pain, nausea, and vomiting. She came to the emergency department when the pain
did not improve after 2 hours. She was given morphine and the pain decreased. She takes no medications and does not
drink alcoholic beverages or smoke cigarettes. Her menstrual period is due to start in 3 days. Her menstrual cycles occur
regularly. Vital signs today are temperature 37.2 (99.0 F), pulse 90/min, respirations 17/min, and blood pressure 110/70
mm Hg. Physical examination shows no abnormalities except for mild left lower quadrant tenderness with deep palpation.
Urine pregnancy test is negative. Results of laboratory studies obtained on admission are shown:

Serum Blood
Albumin 4.6 g/dL Hematocrit 37%
Urea nitrogen 24 mg/dL Hemoglobin 12.2 g/dL
Creatinine 1.1 mg/dL WBC 7500/mm^3
Calcium 10.8 mg/dL Urine
Na+ 140 mEq/L Specific gravity 1.020
K+ 4 mEq/L Glucose Negative
Cl- 107 mEq/L Protein 1+
HCO3- 24 mEa/L Ketones Negative
Phosphorus 3.1 mg/dL WBC 0-2/hpf
RBC 3+/hpf
Bacteria Negative

Noncontrast CT scan of the abdomen shows an obstructing left ureteral stone. Which of the following studies is most
likely to confirm the underlying diagnosis?
A. Serum gastrin concentration
B. Serum parathyroid hormone concentration
C. Serum protein electrophoresis
D. Total protein in a 24-hour urine specimen
E. Urine culture and sensitivity

25. An 82-year-old nursing home resident is admitted to the hospital through the emergency department because of acute
cholecystitis confirmed by biliary ultrasonongraphy. The patient has a history of hypertension, diabetes mellitus, and
vascular dementia with aphasia. Medications include Lisinopril, insulin, and aspirin. While in the emergency department,
vital signs were temperature 38.5 C (101.3 F), pulse 104/min, respirations 20/min, and blood pressure 170/90 mm Hg.
Abdominal examination disclosed an intact gastrostomy tube and localized abdominal tenderness with fullness in the right
upper quadrant. Results of laboratory studies obtained at that time are shown:
Serum
ALT 120 U/L
AST 90 U/L
Amylase 50 U/L
Bilirubin, total 1.4 mg/dL
Blood
Hematocrit 42%
WBC 15, 600/mm^3

Intravenous ampicillin-sulbactam and crystalloid solution are administered. During the next 24 hours, the patient remains
febrile and physical examination discloses increasing right upper quadrant tenderness. You recommend cholecystectomy.
The patient has a “Do Not Resuscitate: Do Not Intubate” order but the patient’s guardian agrees to the operation. At this
time, which of the following is the most appropriate step?
A. Ask the guardian to temporary suspend the order and proceed with the operation
B. Attempt the operation under regional anesthetic without intubation
C. Continue present medical management
D. Obtain a court order to proceed with the operation
E. Provide comfort measures only
26. A 58-year-old homeless man is brought to the emergency department by the shelter manager because, the manager says,
“I noticed him weaving when he walks and his speech is slurred. He wasn’t like that when he came in this morning. “ The
patient says he is nauseated and has a headache. Vital signs are temperature 36.1 C (97 F), pulse 80/min, respirations
16/min, and blood pressure 150/90 mm Hg. On physical examination he is oriented but his speech is slurred. His gait is
ataxic and he is unable to do the finger -to-nose test. The remainder of the examination is normal. He vomits during the
examination. Results of initial laboratory studies are shown:

Serum
Na+ 140 mEq/L
K+ 3.0 mEq/L
Cl- 90 mEq/L
HCO3- 12 mEq/L
Glucose 120 mg/dL

These findings are most indicative of which of the following?

A. Alcohol intoxication
B. Antifreeze intoxication
C. Carbon monoxide poisoning
D. Diabetic ketoacidosis
E. Lead poisoning

27. You regularly visit a 66-year-old African American woman at her home. She has had multiple sclerosis for the past 20
years. She is now quadriplegic and relies on her family for support and care. In addition, a visiting nurse service provides a
home health aide 5 days weekly. Today she tells you she has been somewhat depressed recently. She says, “My husband
and I just keep arguing about little things.” Her husband is present during this interview. Which of the following is the
most appropriate response to this situation?

A. Arrange for a social worker to visit through the visiting nurse service
B. Ask the husband to leave so you can discuss the matter with the patient, alone
C. Ask the patient and her husband about the nature of their disagreements
D. Ask to speak to the husband in another room
E. Prescribe an antidepressant medication

28. A 2-month-old infant is admitted to the hospital because of lung congestion of several days’ duration. On admission, he
has low-grade fever and tachypnea. The mother, who is a nurse, states that the child had severe conjunctivitis at about 1
week of age, which was successfully treated with ophthalmic erythromycin ointment. Chest x-ray shows hyperinflation
and multiple areas of pulmonary interstital infiltrates. Which of the following is the most likely mode of transmission or
acquisition of the organism causing this child’s illness?

A. Breast feeding
B. Droplet inhalation
C. Nosocomial
D. Transplacental
E. Through an infected cervix at birth
29. You are evaluating a 15-year-old African American girl for possible iron deficiency anemia. She has a hemoglobin
concentration of 11 g/dL. To determine the lowest value of hemoglobin that would be considered normal in this patient,
you retrieve a study from the medical literature that compared hemoglobin values with the results of laboratory
investigations for iron deficiency anemia in female, African American adolescents. The results are shown. Based on these
data, the cutoff number of hemoglobin that would result in the least amount of misdiagnoses is which of the following?

A. 10.0 g/dL
B. 10.5 g/dL
C. 11.0 g/dL
D. 11.5 g/dL
E. 12.0 g/dL

30. A 65-year-old woman whom you referred for evaluation of hoarseness returns to the office with a diagnosis of carcinoma
of the larynx. You believe that she understands the risks and potential adverse effects of the two alternative treatments:
an operation or radiation therapy, which have been explained by the respective specialists. However, she requests your
opinion regarding her probable rate of survival following each treatment. You are aware of two large independent case
series reporting results of the two alternative treatments. The first is a report from a university medical center of 163
consecutive patients who underwent operations alone, in which 32% had a 5-year survival rate. The other is a report from
a prestigious private hospital of 82 consecutive patients who underwent radiation therapy alone, with a 5-year survival
rate of 50%. Which of the following is the most appropriate advice to your patient based on this evidence?

A. An operation and radiation therapy in combination will most likely provide the best survival
B. An operation is likely to provide better survival
C. Radiation therapy is likely to provide better survival
D. Radiation therapy is preferable because it is associated with a lower risk of complications
E. You cannot make a recommendation based on this evidence

31. A 28-year-old woman brings her 7-year-old, nonidentical, twin daughters to the office for well-child evaluations. They
have each had two to three upper respiratory tract infections in the past year but have been otherwise healthy. The
woman and her husband had been tested for cystic fibrosis carrier status before she became pregnant. He is not a carrier
of cystic fibrosis; she is a carrier. The woman states, “I want my girls tested to see if they are cystic fibrosis carriers now. I
don’t want them to go through life with this burden that I have.” Which of the following is the most appropriate
response?

A. “Being a carrier is actually quite common. We are all carriers of something.”

B. “Do you think that the children would understand if I explained the test to them?”
C. “I have some pamphlets on cystic fibrosis that you can read.”
D. “Tell me more about how you feel about your own test results.”
E. “You should be glad that carrier testing is available for some diseases.”
 32. A 72-year-old white woman with emphysema comes to the office because of a 2-week history of unsteadiness when she
rises from bed in the morning. She says she feelsgroggy for 10 to 15 seconds on standing, after which her sense of balance
improves; she has not fallen. She has not had visual symptoms, headache, or focal weakness. She uses a salmeterol
metered dose inhaler and takes no other medications. The patient is 165 cm (5 ft 5 in) tall and weighs 56 kg (123 lb); bMI
is 20 kg/m^2. Vital signs are temperature 36.6 C (97.8 F), pulse 88/min supine and 96/min standing, respirations 22/mi
and unlabored, and blood pressure 158/76 mm Hg supine and 122/60 mm Hg standing. Physical examination is
unchanged from previous visits. Neurologic examination shows no focal findings. The patient asks, “Do a lot of people my
age have this problem, or is it just me?” In determining the severity of the patient’s orthostatic blood pressure change in
copmparison with those of other patients her age, you refer to a recent study of orthostatic changes in blood pressure
measurements in outpatients older than 65 years of age. The data are shown.

Postural Blood Pressure Changes (Supine to Standing)

Mean Change in Pressure Standard Deviation of Change
Systolic blood pressure - 4 mm Hg 15 mm Hg
Diastolic blood pressure - 2 mm Hg 11 mm Hg

In the study, change in blood pressure is normally distributed. In explaining the severity of the patient’s orthostatic blood pressure
change in relation to that of the patient’s in this study, which of the following should the patient be told?

A. The degree of orthostatic is less than the average orthostatic change in people her age
B. The degree of orthostatic change of her blood pressure is right in line with what is expected in someone her age
C. The degree of orthostatic change in her diastolic blood pressure is relatively greater than the change in her systolic
pressure
D. The degree of orthostatic change in her systolic blood pressure is higher than that of 98% of patints her age
E. Orthostatic blood pressure changes as large as hers are common, occurring in approximately one in six people her age

33. The husband of one of your partners comes to see you because he is concerned that his wife is abusing drugs. He
discovered recently that she was prescribing large amounts of meperidine for patients and was picking up the
prescriptions herself. You have known both the husband and his wife for several years, and you consider the wife to be a
colleague and friend. She has been missing a great deal of work recently, and she seems irritable and reclusive. A local
pharmacist verifies that the prescription refills in question have been frequent and suspicious. Your partner comes in later
that afternoon and says, “I know my husband was here talking with you. Look, if you will just help me, I promise never to
use drug again. You will ruin my career if you say anything to anyone. Besides, this was just a brief problem because of
back spasm.“ Which of the following is the most appropriate response?

A. You must report her drug use to the appropriate authorities

B. You must tell all your partners and have a conference with her and her husband together
C. You will be watching her carefully at work to ensure that she is not taking drugs
D. Y will have her husband closely monitor her behavior for evidence of drug use
E. You will help her if she will agree to turn in her controlled drug license
Answers Block 1

1. E
2. B
3. D
4. D
5. A
6. D
7. D
8. B
9. A
10. A
11. A
12. E
13. D
14. E
15. C
16. E
17. C
18. C
19. D
20. A
21. E
22. A
23. A
24. B
25. A
26. B
27. C
28. E
29. C
30. E
31. D
32. D
33. A
Block 2

1. A 29-year-old white woman is brought to the emergency department by her husband because of a 10-hour history of
numbness in her left leg. She also had a 1-month history of general fatigue, loss of balance, and falls. She has not had
fever or infections. She takes no medications and says she does not drink alcoholic beverages. She has been previously
healthy, although she says she had similar symptoms for 3 weeks after her daughter was born 5 years ago. Her husband
tells you privately that he suspects she has been drinking alcoholic beverages because her speech was slurred several days
ago. Vital signs are normal. Pupillary reflexes are normal. Extraocular motor examination shows bilateral impairment of
adduction. Examination of the extremities shows bruises in various stages of healing. Gait is mildly ataxic, but motor
strength is normal. Sensory examination to light touch and pain discloses no abnormalities. Which of the following is the
most likely diagnosis?
A. Alcohol abuse
B. Central nervous system vasculitis
C. Chronic subdural hematoma
D. Domestic abuse
E. Multiple sclerosis

2. A 68-year-old African American man with no significant past medical history comes to the office for evaluation of low back
pain that started 4 months ago. He is concerned that he might have cancer because his uncle died of bone cancer. There
are no relief of the patient’s pain with ibuprofen, aspirin or naproxen taken successively during 4 weeks at recommended
therapeutic doses for over-the-counter use, although he did get moderate relief with 1 week of bed rest. He has
otherwise been healthy and is pleased that he has lost 4.5 kg (10lb) in the past 6 months by not eating between meals. His
height is 188 cm (6 ft 2 in) and his weight is 82 kg (180 lb); BMI is 24 kg/m^2.

Medical History sensitivity Specificity

Age > 50 years 0.77 0.07
Previous history of cancer 0.31 0.98
Unexplained weight loss 0.15 0.94
Failure of 1 month of anti-inflammatory medication 0.31 0.90
No relief with bed rest 0.90 0.46
Duration of pain > 1 month 0.50 0.81

The medical history that is most suggestive of cancer as a cause of this patient’s back pain is which of the following?
A. Age
B. Failure to improve with medication
C. 4-month duration of pain
D. Relief with bedrest
E. Weight loss

3. A 16-year-old white football player is brought to the emergency department by the athletic trainer at his high school after
he was tackled from behind by another player during a football game 45 minutes ago. The patient says that his knee
buckled during the tackle and he had excruciating knee pain. The trainer says, “I think his knee might have been dislocated
and then relocated while I manipulated it on the football field.” The patient says he has been in excellent health and does
not take medication. Vital signs are temperature 37.0 C (98.6 F), pulse 92/min, and respirations 14/min. Physical
examination discloses a well-nourished young man who complains of severe pain in his right knee. There is marked soft-
tissue swelling around the right knee, extending into calf. The knee joint is loose and unstable anteriorly and posteriorly.
The patella is ballotable and passive flexion is limited. Distal neurovascular examination is normal. Which of the following
injuries did the patient most likely sustain?
A. Cruciate ligament disruption
B. Rupture of gastrocnemius
C. Rupture of the patella tendon
D. Tear of the collateral ligament
E. Tear of the meniscus
 4. A 40-year-old woman is in the hospital following an emergency operation for repair of a perforated duodenal ulcer 36
hours ago. She is lethargic but agitated, and she reports abdominal pain. She has a history of corticosteroid -dependent
rheumatoid arthritis treated with prednisone and type 1 diabetes mellitus treated with insulin therapy. She received
intravenous fluids and narcotic pain medication postoperatively. Vital signs are temperature 37.0 C (98.6 F), pulse 96/min,
respirations 24/min, and blood pressure 90/60 mm Hg. Results of laboratory studies are shown:

Serum
Urea nitrogen 34 mg/dL
Creatinine 1.8 mg/dL
Na+ 129 mEq/L
K+ 5.5 mEq/L
Cl- 108 mEq/L
HCO3- 14 mEq/L
Glucose 70 mg/dL

Urine output during the past 8 hours is 300 mL. The patient’s current condition is most likely caused by which of the
following?

A. Adrenaocortical insufficiency
B. Diabetic ketoacidosis
C. Hypovolemia
D. Narcotic overdosage
E. Sepsis

5. A 72-year-old white man returns to the office after being diagnosed with poorly differentiated non-small cell lung cancer.
The patient’s medical history is otherwise unremarkable and he takes no medications. He smoked one pack of cigarettes

A. Coal mine
B. Cotton mill
C. Grain elevator
D. Power company
E. Shipyard

The following vignette applies to the next 2 items:

A 62-year old man comes to the office for follow-up of benign prostatic hypertrophy (BPH), which was diagnosed 1 week ago. He
had described a 5-month history of increased nocturia, double voiding, and decreased strength of urinary flow; he had not had
these symptoms before. He has no personal family history of prostate cancer. He takes no medications and he has no allergies.
Physical examination 1 week ago was remarkable for an enlarged prostate without nodularity. Urinalysis and prostate specific
antigen tests were normal. Today, he has brought some newspaper articles about saw palmetto and wonders about its use in
treatment of his symptoms. You recall a recent meta-analysis about the effectiveness of saw palmetto for BPH. In this study, saw
palmetto was compared with placebo. The results are shown.

Saw Palmetto Versus Placebo in the Symptomatic Treatment of Benign Prostatic Hypertrophy
Treatment
Improvement in Symptoms Placebo Saw Palmetto Statistical Significance
Patient-reported 191/330 (58%) 242/329 (74%) p<0.001
Physician-assessed 100/262 (38%) 165/262 (63%) p<0.001

Item 1 of 2
6. Which of the following is the most accurate interpretation of these data regarding patients taking saw palmetto?
A. Improvement is seen in both physician-assessed and in patient-reported symptoms
B. Patient-reported symptoms are more improved than are physician-assessed symptoms
C. Statistical significance is not important compared with symptom improvement
D. Statistically significance changes in physician-assessed symptoms do not result in decreased symptoms for patients
E. No conclusion can be drawn from the present information
 Item 2 of 2
7. Based on the physician-assessment data, the number of patients who need to be treated with saw palmetto to show
significant improvement in one patient is which of the following?

A. 4
B. 6
C. 12
D. 25
E. 38

8. A 24-hour-old female newborn, who was born at approximately 38 weeks’ gestation, is noted in the newborn nursery to
be jittery and persistently crying. The newborn’s 18-year-old mother, gravida 1, para 1, underwent uncomplicated
spontaneous vaginal delivery 24 hours ago and did not receive prenatal care. The newborn’s APGAR scores were8 and 9 at
1 and 5 minutes, respectively. Physical examination at the time of birth disclosed no abnormalities. Now, vital signs are
temperature 37.) C (98.6 F), pulse 160/min, and respirations 50/min. Pulse oximetry on room air shows an oxygen
saturation of 99%. The infant is crying and jittery; physical examination discloses no other abnormalities. Serum glucose
concentration is within the reference range. Toxicology screening of the meconium and urine is obtained; results of
meconium screening are pending. Urine tests positive for cocaine. Which of the following is the most appropriate opening
remark to the newborn’s mother?

A. “Cocaine was found in your baby’s urine, thus we need to call social services”
B. “It is important that you share all medical information with us when we ask.”
C. “Your baby is addicted to cocaine and will need to be treated.”
D. “Your baby was acting differently from what was expected, so we ordered tests.”

9. A 6-month-old male infant is brought to the office by his parents because of the onset of a facial rash 3 days ago.
Pregnancy and delivery were normal, but during the neonatal period a slightly red and scaly rash was noted on his scalp
and forehead. Treatment with 1% hydrocortisone cream controlled the rash. The patient’s growth and development have
been normal. He is the third child in the family and both of his siblings have asthma; one sibling also has atopic dermatitis.
Vital signs today are axillary temperature 39.0 C (102.2F), pulse 100/min, and respirations20/min. The patient is fussy.
Physical examination discloses the eruption shown in the photography. There is no adenopathy. The remainder of the
physical examination discloses no abnormalities. The most appropriate next step is to the order which of the following?

A. Bacterial culture of the skin

B. Biopsy of the skin
C. KOH preparation of the skin
D. Scabies preparation of the skin
E. No test is necessary
10. A 15-year-old Asian American boy begun hemodialysis, three times weekly, 2 months ago because of progressive renal
disease. He is having a great deal of difficulty tolerating dialysis and complying with the diet, and he has been missing
school frequently. His nephrologist recommends switching to home peritoneal dialysis and evaluating the patient for a
renal transplantation. You are the primary care physician for the boy’s family, which includes his 48-year-old mother, his
8-year-old sister and his 6-year-oldbrother, all of whom are healthy. All three family members are compatible with the
patient’s parents are divorced, and the whereabouts of the father are 36-year-oldpaternal aunt also has a compatible
blood type but no antigens in common. The patient’s parents are divorced, and the whereabouts of the father are
unknown. The mother works two jobs to support the children. Which of the following candidates is the most appropriate
living related donor?

A. Brother
B. Father
C. Mother
D. Paternal aunt
E. Sister

11. A 34-year-old Latino man returns to the health center for reevaluation of chronic allergies. During a previous visit 6 weeks
ago antihistamine therapy was prescribed. Today the patient says, “The medicine you prescribed helped my runny nose
and itchy eyes, but now I have trouble hearing; it sounds like people around me are talking in a barrel.” The patient has a
history of sleep apnea. He works in a factory and is frequently exposed to noise from heavy machinery; he does not wear
hearing protection. He has smoked one pack of cigarettes daily for 10 years. He has a family history of hearing loss. The
patient is 175 cm (5 Ft 9 in) tall and weighs 91 kg (200 lb); BMI is 30 kg/m^2. Today vital signs are normal. Physical
examination shows intact tympanic membranes that are retracted bilaterally and are amber in color with a visible
meniscus. Nasal turbinates are pale and boggy without purulent exudate. The remainder of the physical examination
shows no abnormalities. Which of the following factors in the patient’s history is most consistent with the patient’s
current condition?

A. Chronic allergies
B. Cigarette smoking
C. Exposure to lung machinery
D. Family history of otosclerosis
E. Sleep apnea

12. A 45-year-old womanis admitted to the hospital because of pain and swelling in her right calf.Medical history is significant
for systemic lupus erythematosus with a lupus anticoagulant. Current medications include prednisone, celecoxib, and iron
supplements. She is 163 cm (5ft 4 in) tall and weighs 68 kg (150 lb);BMI is 26 kg/m^2. Vital signs are temperture 36.1 C
(97.0 F), pulse 70/min respirations 18/min, and blood pressure 117/75mm Hg. Heart and lung examinations disclose no
abnormalities. There is livedo reticularis on both legs. The right calf is swollen and painful to palpation. There is minimal
erythema. Duplexultrasonography of the legs shows a right0sided deep venous thrombosis (DVT). Low-molecular-weight
heparin and warfarin are initiated, and you explain to the patient that she should be able to go home in the next 24 hours
after learning how to self0inject her medication. You consider the following data from a large randomized controlled trial
comparing administration of outpatient low-molecular-weight heparin (LMWH) to administration of standard intravenous
unfractionated heparin (IVUFH) in the hospital.

LMWH IVUFH p value

DVT recurrence (%) 5.3% 6.9% 0.31
Bleeding (%) 0.5% 2.0% 0.56
Death (%) 6.9% 8.0% 0.72
Length of stay (days) 1.1 6.5 <0.05

A. IVUFH is associated with significantly more DVT recurrence than LMWH

B. LMWH causes death in 6.9%of patients
C. LMWH is safer than IVUFH
D. LMWH therapy is equivalent to IVUFH regarding recurrence, bleeding and death
E. There is a 56% chance that IVUFH causes less bleeding than LMWH
13. A 76-year-old woman is admitted to the hospital because of a hip fracture. She lives alone, she has a history of
schizophrenia, and has recently become moderately demented as a result of several small cerebral infarctions. She
refuses an operation on her hip. On mental status examination, she is disoriented to month, year, and place. She recalls
only one of three objects after 5 minutes and cannot perform simple calculations. She denies auditory hallucinations. She
knows that she has broken her hip and that the surgeons are recommending an operation. When asked why she is
refusing the operation, she says, “Radiotransmitting equipment was placed inside me 20 years ago when I had my
gallbladder out.” The clinical feature most pertinent to a judgment about her competence to refuse the operation is which
of the following?

A. Deficiencies in attention and calculation

B. Deficits in short-term memory
C. Delusions about the operation
D. Diagnosis of schizophrenia
E. Diagnosis of schizophrenia
F. History of multiple infarcts

14. Two tests are being evaluated to identify chlamydia infection of the cervix. Two hundred women are tested. Definitive
diagnosis is made by culture. The following results are found:

Number with Number without

chlamydial infection Chlamydial Infection
(Total = 40) (Total = 160)

Test X
Abnormal 35 15
Normal 5 145
Test Y
Abnormal 30 5
Normal 10 155

Which of the following is the most accurate statement that can be made about this evaluating?

A. Test X is superior to test Y

B. The positive predictive value of test Y is higher than that of test X
C. The sensitivity of test X is 70% (35/50)
D. The specificity of test Y is 75% (30/40)
E. Test X is more specific than test Y

15. A 68-year-old Asian American man is admitted to the hospital for evaluation of progressive dementia. His daughter says
that he has lived with her and her family for the past 2 years, and that during the past 3 months she has noticed that he
seems distant and now does not come to dinner when called. He is able to move about the hospital room in his
wheelchair. He is reluctant to stand and walk, and when he does, he is clumsy and has difficulty lifting his feet off the
floor. Chest x-ray shows a right apical infiltrate consistent with a mass or reactivated tuberculosis. Urinalysis shows a
leukocyte count of 8/hpf and presence of leukocyte esterase. Serum studies, including vitamin B12 (cobalamin) and folate
concentrations, VDRL, and thyroid function studies, are all within the reference ranges. CT scan of the head shows cortical
atrophy and widened ventricles. Lumbar puncture for examination of cerebrospinal fluid is done, and 25 mL of
cerebrospinal fluid is removed for analysis. Oral ciprofloxacin therapy is initiated. One day later, the patient is eating and
engaging in conversation. His daughter notes that he walked to the bathroom by himself. Which of the following is the
most likely explanation for the patient’s improvement?

A. Consumption of a nutritious meal

B. Oral ciprofloxacin therapy
C. Recovery from the phenomenon of “sun-downing”
D. Removal of cerebrospinal fluid
E. Withdrawal from an environmental contaminant
16. A 25-year-old nulligravid woman, who was admitted to the hospital 1 day ago for presumed acute cholecystitis, continue
to have fever and abdominal pain. On admission he patient had reported a 1-day history of right upper quadrant
abdominal pain and fever. She also had had mild low pelvic pain for 1 week that was still present on admission. She had
not had nausea, diarrhea, or shortness of breath. The patient’s temperature on admission was 38.4 C (101.2 F). Results of
a clean-catch urinalysis showed 10-20 WBCs/hpf but no bacteria on microscopic examination. Intravenous ampicillin-
sulbactam therapy was initiated and ultrasonography of the abdomen was scheduled for today. Medical history is
otherwise unremarkable and the patient’s only medication is an oral contraceptive. She is sexually active with one male
partner and does not use condoms. Vital signs are temperature 38.3 C (101.0 F), pulse 110/min, respirations 18/min, and
blood pressure 136/78 mm Hg. Physical examination discloses regular tachycardia and continued tenderness to palpation
of the right upper quadrant. Murphy sign is not present. The remainder of the physical examination, including pelvic
examination, discloses no abnormalities. Results of laboratory studies obtained this morning are shown:

Serum Blood
ALT 50 U/L Hematocrit 36%
AST 52 U/L Hemoglobin 11.0 g/dL
Alkaline phosphatase 100 U/L WBC 21, 600/mm3
Bilirubin, total 0.8 mg/dL Neutrophils, segmented 80%
Protein Neutrophils, bands 1%
Albumin 3.6 g/dL Platelet 365, 000 mm3
Ultrasonography of the abdomen shows perihepatic fluid and thickening of the liver capsule. The gallbladder, biliary
tracts, and hepatic parenchyma appear normal. There is no pericolic fluid. Which of the following is the most likely causal
organism of this patient’s illness?

A. Chlamydia trachomatis
B. Enterococcus faecalis
C. Escherichia coli
D. Streptococcus agalactiae

17. A 26-year-old special education teacher comes to the office because she is considering pregnancy. Her husband has a 6-
year-old healthy child from a previous marriage. The patient has had two spontaneous abortions, one at age 20 years and
the other 1 year ago. She is healthy and takes no medications. There are three children in one of her classes who have
spina bifida, and she is concerned about potential neural tube deformities with her own pregnancy. She hands you an
article from the medical literature, which shows:

• The risk for neural tube defects in the general population is 1/1000
• The risk for neural tube defects in the first pregnancy is 0.7/1000
• After three miscarriages of unknown cause, the risk for neural tube defects increases to 3/1000
• Folic acid (4 mg) taken daily prior to conception and during the first trimester decreases the rate of
neural tube defects by 72%
• The risk for neural tube defects increases after age 28 years

Based on these data, which of the following is the most accurate statement regarding her fetus’s risk for neural tube
defects?

A. Because of her age and two miscarriages her risk is greater than 1/1000
B. Because of her miscarriages her risk is increased to 2/1000
C. If she does not take folic acid, her risk is 0.7/1000
D. The risk is so small that is not worth consideration
E. Taking folic acid should decrease her risk to less than 0.3/1000
18. A 1-day old female neonate who was born at home is brought to the emergency department by her mother because of
oozing of blood from the umbilical cord stump. She was born via spontaneous vaginal delivery at 38 weeks’ gestation to a
28-year-old woman who has two older children. The mother, who had a closed head injury 6 years ago and remains on
Dilantin for a subsequent seizure disorder, had no prenatal care. There was no prolonged rupture of membranes at the
time of delivery. There is no history of bleeding disorders in the mother’s family, and the baby’s father is unknown. The
neonate weighs 2835 g (6lb 4 oz) and appears generally healthy. Physical examination shows petechiae over the scalp and
face. There is no hepatosplenomegaly or audible murmur. Which of the following is the most likely diagnosis?

A. Disseminated intravascular coagulation

B. Folic acid deficiency
C. Isoimmune thrombocytopenia
D. Protein C deficiency
E. Vitamin K deficiency

19. A 50-year-old white man comes to the office because of a 3-month history of a chronic productive cough and progressive
dyspnea on exertion. He smoked two packs of cigarettes daily until 18 months ago and has been working independently
for many years as a sandblaster. Physical examination shows a barrel chest, prolonged expiratory phase, and scattered
wheezing and rhonchi. X-ray of the chest is shown. The mechanism most likely responsible for his symptoms is which of
the following?

A. Abnormality of chloride receptors

B. Deficiency of 1-antitrypsin
C. Heightened airway reactivity to inhaled irritants and antigens
D. Immune-complex formation
E. Inflammatory response stimulated by reaction to insoluble particulates

20. A 17-year-old girl gives birth to a 1722-g (4-lb) newborn at 30 weeks’ gestation. The girl has had no prenatal care. She is
unmarried and plans to keep the baby. The newborn is admitted to the neonatal intensive care unit. The mother’s vital
signs are temperature 37. C (98.6 F), pulse 80/min, respirations 14/min, and blood pressure 100/68 mm Hg. On interview,
the girl admits to using heroin regularly during her last trimester. It is most appropriate to notify which of the following?

A. Child protective services

B. The girl’s parents
C. The newborn’s father
D. The police
E. No notification is necessary
21. A 55-year-old second-grade teacher comes to the office because of several weeks of blurry vision. She says, “I just got my
eyes checked last month. My vision was fine then.” For years she has struggled with being overweight, often gaining
weight during the school year but losing what she had gained during the summer vacation. Random serum glucose
determination 4 months ago was 145 mg/dL and hemoglobin A1c was in the normal range. She is single and lives with her
parents. She is 168 cm (5 ft 6 in) tall and weighs 104 kg (230 lb); which is 17 kg (37 lb) more than her last visit 4 months
ago; BMI is 37 kg/m2. Vital signs now are temperature 37.0 C (98.6 F), pulse 85/min, respirations 16/min, and blood
pressure 140/85 mm Hg. Visual acuity in each eye is 20/40 while corrected with prescription eyeglasses. The remainder of
the physical examination discloses no abnormalities except for generalized obesity. Fingerstick blood glucose
concentration is 305 mg/dL. With regard to her weight, which of the following is the most appropriate statement?

A. “Don’t you think you should be more determined about your diet?
B. “Have you been intolerant of cold weather recently?”
C. “Tell me what has been going on in your life for the past 4 months”
D. “Why have you failed to lose weight?”
E. “You have brought on diabetes because you have been unable to control your eating.”

A 54-year old man with a 10-year history of hypertension comes to the office for a follow-up examination. He says he feels
well and complains only of decreased libido and occasional impotence. He averages three alcoholic beverages daily and
enjoys walking 30 minutes each evening with his wife. His current medications include losartan, hydrochlorothiazide, and
acetaminophen for arthritis pain in the knees. On physical examination he has moderate central obesity. Height is 1.78 cm
(5 ft 10 in) and weight is 91 kg (200 lb). BMI is 28 kg/m2. Blood pressure is 148/92 mm Hg. Laboratory studies show a
serum creatinine concentration of 0.8 mg/dL, serum potassium concentration of 4.5 mEq/L, and blood glucose
concentration of 110 mg/dL.

22. Item 1 of 2
Which of the following is the most appropriate conclusion about this patient’s condition?

A. Acetaminophen is reducing the effectiveness of the antihypertensive medications

B. His alcohol intake is sufficient to worsen control of his blood pressure
C. His blood pressure appears to be under reasonable control
D. Losartan and hydrochlorothiazide should not be used in combination
E. Walking should be avoided until his blood pressure is better controlled

23. Item 2 of 2
Which of the following is the most likely cause of his impotence and decreased libido?

A. Acetaminophen
B. Alcohol
C. Hydrochlorothiazide
D. Losartan
E. Obesity
24. A 78-year-old white woman is admitted to the hospital because of inability to care for herself at home due to the recent
onset of shortness of breath and weakness. She has been your patient for 10 years and you have been treating her for
type 2 diabetes mellitus for the past 5 years. Records show she has a 9-month period of depression following the death of
her husband 7 years ago. She has been in otherwise good health. On further questioning, she says she has symmetric
tingling or prickling sensation of both her legs. Pulse is 96/min and blood pressure is 110/68 mm Hg. On physical
examination the patients edentulous and the anterior half of her tongue is smooth and reddened. Her skin is pale. Heart
and lung examinations are normal. Abdomen is obese without organomegaly. The rectal examination is normal and test of
the stool for occult blood is negative. Results of initial laboratory studies are shown:
Serum Blood
Folate 6.5ng/mL (N=1.89-9.0) Hematocrit 22 %
Vitamin B12 50 pg/mL (N=100-700) Hemoglobin 7 g/dL
Iron 50 g/dL (N = 50-170) MCV 107 m3
Iron Binding Capacity 250 g/dL (N – 200-300) MCHC 36% Hb/cell
Urinalysis Normal
Examination of the peripheral blood smear will likely show erythrocytes with which of the following characteristics?

A. Crescent-shaped with pointed ends

B. Elliptical, oval or cigar-shaped; there are variations in shape
C. Macro-ovalocytes
D. Spur-like or thorny projections on the surface; they look like underwater mines
E. A target with hemoglobin deposited in the center forming the target

25. A 62-year-old man with a history of chronic obstructive pulmonary disease is admitted to the hospital because of
progressive shortness of breath and increasing cyanosis. Vital signs are temperature 39.2 C (102.5 F),pulse 110/min,
respirations 32/min, and blood pressure 60/40 mm Hg.Auscultation of the chest discloses rales in the right basewith
dullness to percussion. His skinis mottled. Pulmonary capillary wedge pressure is 2 mmHg. Which of the following is the
most likely physiologic mechanism underlying the hypotension?

A. Increased cardiac output

B. Increased pulmonary vascular resistance
C. Left ventricular outflow obstruction
D. Obstruction of the airway
E. Peripheral vasodilation

26. A 7-week-oldinfant is brought to the office for a well-child examination. He is the second child of healthy parents and was
born vaginally after an uncomplicated, full-term pregnancy. The couple’s first child is a girl. On physical examination both
testes are palpable in the scrotum and there is bilateral scrotal enlargement as shown. The infant is asymptomatic. The
parents have not noticed any changes in the scrotal size since birth. There are no bulges at the level of the external ring
and the spermatic cords are not enlarged. The scrotal pouches transilluminate and the fluid cannot be pushed back into
the abdomen. Which of the following is the most likely diagnosis?

A. Bilateral congenital lymphedema

B. Bilateral inguinal hernias
C. Bilateral inguinal hernias with hydroceles
D. Bilateral physiologic hydroceles
E. Bilateral testicular tumors
27. A 48-year-old man in apparent good health comes to the office for a periodic health evaluation. This is his first visit to
your office. History and physical examination are normal except that his blood pressure is 154/87 mm Hg. You recall a
recent reporting the literature of a study on adults who were referred to a tertiary care center for new onset of
hypertension. The authors concluded: Six percent of adults referred with newly detected hypertension were found to
have surgically curable causes. The authors suggest that imaging, endocrinologic, and metabolic studies should be done
on all adults with newly diagnosed hypertension. You consider whether you should apply this recommendation to your
patient. In addition to reading the article to determine whether the methods were valid and the results were correct,
which of the following is the most important additional determinant?

A. the availability of the diagnostic procedures at your hospital

B. The complications that occurred with the surgical procedures
C. The cost of the studies performed
D. Whether the study setting is comparable to your practice
E. Whether the study was retrospective or prospective in design

28. A 42-year-old warehouse shipping clerk is referred to the office by his supervisor because of low back pain and back
stiffness that began 3 days ago when he loaded heavy boxes onto a truck. He says the pain does not radiate to his
buttocks or legs. His health is otherwise good and he has no history of significant illness. Several years ago he had an
episode of mild low back pain that resolved without medical attention. He does not smoke cigaretts or drink alcoholic
beverages, and he takes no medications. Vital signs are normal. Physical examination discloses mild tenderness of the
paraspinous muscles. There is no muscle wasting of the lower extremities. Straight leg-raising test is negative bilaterally.
Motor strength and sensory findings are normal, and deep tendon reflexes are intact and symmetric. Which of the
following is the most appropriate diagnostic study to order at this time?

A. Dual photon densitometry of the spine

B. Radionuclide bone scan
C. Serum protein electrophoresis
D. X-rays of the lumbosacral spine
E. No diagnostic study is necessary at this time

29. A 54-year-old woman is referred to the office from another facility because of an elevated serum gastrin concentration
obtained 1 week ago during an evaluation of indigestion. Medical history is significant for hypertension osteoarthritis,
hyperlipidemia, and a gastric ulcer diagnosed 4 years ago, at which time she had been taking naproxen for osteoarthritis.
Current medications include atorvastatin, acetaminophen, omeprazole, and metoprolol. BMI is 22 kg/m2. Vital signs are
temperature 37.0 C (98.6 F), pulse 88/min, respirations 16/min, and blood pressure 126/82 mm Hg. Pulse oximetry on
room air shows an oxygen saturation of 97%. Physical examination during the previous visit disclosed clear lungs, regular
heart rhythm, and audible S1 and S2. Bowel sounds were normactive; palpation of the abdomen disclosed no tenderness
or organomegaly. Test of the stool for occult blood was negative. Serum gastrin concentration from 1 week ago is 300
pg/mL (N<100). Which of the following is the most appropriate next step in evaluation?

A. CT scan of the abdomen

B. Diagnostic laparoscopy
C. Radionuclide scan for identifying neuroendocrine tumors
D. Repeat measurement of serum gastrin concentration after discontinuation of omeprazole therapy
E. Upper endoscopy
30. A 70-year-old woman is brought to the office by her son because of a 1-year history of progressively decreasing mental
acuity and sluggishness. She lives alone in a 100-year-old home. She has a history of type 2 diabetes mellitus treated with
diet, and rheumatoid arthritis treated with a nonsteroidal anti-inflammatory medication (NSAID). She underwent total
abdominal hysterectomy 20 years ago, and she takes estrogen therapy and a calcium supplement. She is 160 cm (5 ft 3 in)
tall and weighs 54 kg (120 lb); BMI is 21 kg/m2. Vital signs are temperature 36.4 C (97.5 F), pulse 60/min, respirations
10/min, and blood pressure 140/96 mm Hg. She is alert and oriented to person, place, and year. Funduscopic examination
discloses no abnormalities. The thyroid is small but palpable. Lungs are clear to auscultation. Cardiac examination
discloses no abnormalities. Ankle reflexes are delayed. She is able to recall one of three objects after 5 minutes. Results of
laboratory studies are shown:

Serum Blood
Urea nitrogen 22mg/mL Hematocrit 34 %
Creatinine 1.4 mg/dL Hemoglobin 11.2 g/dL
Na+ 142 mEq/L WBC 5500/mm3
K+ 4.0 mEq/L MCV 84 m3
HCO3- 102 mEq/L
TSH 100 U/mL
Thyroxine (T4) 2.4 g/dL

Which of the following is the most likely underlying cause of this patient’s condition?

A. Chronic lead poisoning

B. Vitamin B12 (Cobalamin) deficiency
C. Hashimoto thyroiditis
D. Multiple cerebral infarcts
E. Neurosyphilis
31. A 68-year -old man comes to the emergency department because of a temperature of 38.9 C (102.0 F) and shaking chills
for the past 5 days. He has not had any abdominal or pelvic pain, polyuria, or dysuria. He underwent cystoscopy 3 weeks
ago for evaluation of hematuria after urinalysis showed 60 RBC/hpf at his annual health maintenance examination 1
month ago; results of cystoscopy showed benign prostatic hyperplasia. Complete blood count and renal panel at his
annual examination were within the reference ranges, and ECG was normal. He has essential hypertension well controlled
with amlodipine. Medical history is also significant for a systolic ejection heart murmur noted since childhood. Vital signs
now are temperature 38.9 C (102.0 F), pulse 110/min, respirations 16/min, and blood pressure 120/80 mm Hg. Physical
examination shows a lesion of the left frontal area of the forehead, as shown. Cardiac examination discloses a grade 2/6
systolic ejection murmur in the aortic area that radiates faintly to the carotid arteries. Empiric antibiotics are
administered. Results of laboratory studies are shown:

Blood
Hematocrit 34%
Hemoglobin 12.2 g/dL
WBC 12, 200/mm3
Neutrophils 90%
Lymphocytes 10%
Urine
RBC 50/hpf
WBC 12/hpf

Which of the following is the most likely diagnosis?

A. Bacterial endocarditis
B. Bacterial prostatitis
C. Hydronephrosis
D. Inferior wall myocardial infarction
E. Polyarteritis nodosa
32. A 60-year-old woman is admitted to the hospital because of a 6-month history of chronic diarrhea and fatigue. Medical
history is significant for partial Roux-en-Y gastrectomy and vagotomy 10 years ago for refractory ulcer disease. She is 160
cm (5 ft 3 in) tall and weighs 45 kg (99 lb); BMI is 18 kg/m2. Vital signs on admission are temperature 36.8 C (98.2 F), pulse
100/min, respirations 18/min, and blood pressure 110/60 mm Hg. Physical examination shows pallor. The abdomen is
protuberant with no tenderness or organomegaly. The remainder of the physical examination, including neurologic
examination, discloses no abnormalities. Serum Vitamin B12 (cobalamin) concentration is 70 pg/mL (N= 200-900) and
serum folate concentration is 6 ng/mL (N = 6-20). Shilling test shows poor absorption of Vitamin B12 (cobalamin), which is
not corrected with administration of intrinsic factor. Which of the following is the most likely explanation for the
laboratory results?

A. Bacterial overgrowth syndrome

B. Error in performance of the Schilling test
C. Pernicious anemia with intrinsic factor deficiency
D. Poor oral intake of vitamin B12 (cyanocobalamin)

33. A 23-year-old man is admitted to the hospital from the emergency department, where police officers had brought him 4
hours ago, after he threatened local radio station staff because he believed the radio was broadcasting his thoughts. On
arrival at the emergency department the patient was aggressive and required restraint and intramuscular administration
of haloperidol and benztropine. Now on admission, the patient is sleepy but cooperative. He appears muscular. BIM is 22
kg/m2. Vital signs are temperature 38.0 C (100.4 F), pulse 100/min, respirations 20/min, and blood pressure 125/56 mm
Hg supine and 120/60 mm Hg standing. Mouth is dry. Lungs are clear to auscultation. Heart sounds are normal. The
abdomen is soft and bowel sounds are hypoactive. The patient has not urinated or had a bowel movement since arrival in
the emergency department. Which of the following is likely explanation for this patient’s condition?

A. 1-Adrenergic receptor antagonism

B. Blockade of muscarinic acetylcholine receptors
C. Dopamine-2 receptor antagonism
D. Uncoupling mitochondrial oxidative phosphorylation
Block 2 Answers

1. E
2. B
3. A
4. A
5. E
6. A
7. A
8. D
9. E
10. C
11. A
12. D
13. C
14. B
15. D
16. A
17. E
18. E
19. E
20. A
21. C
22. B
23. B
24. C
25. E
26. D
27. D
28. E
29. D
30. C
31. A
32. A
33. B
A. Benign prostatic
B. Chest x-ray findings
C. Cigarette smoking
D. History of chemical exposure
E. Pica

Question 2

A. Adding the herb supplement and decreasing the dosage of her medication
B. Allowing her to discontinue her present medication and begin the herb supplement
C. Encouraging her to continue her present therapy for at least 2 more months
D. Inquiring about side effects resulting from her present therapy
E. Suggesting that she discontinue her present medication and begin a low-sodium diet
A. “I insist that you follow my recommendations as long as you are my patient.”
B. “I prefer that you find another physician.”
C. “I will be available to treat your hypertension and will monitor you for side effects from the supplement.”
D. “You may be placing yourself at risk, and I cannot be held responsible.”
E. “You may be placing yourself at risk, and I would like you to sign a note releasing me from any responsibility.

A. Histamine provocative test

B. 24-hour urine catecholamine concentrations
C. MR angiography of the renal arteries
D. Phentolamine test
E. Serum cortisol concentration

A. Electromyography and nerve conduction studies

B. Lumbar puncture for examination of cerebrospinal fluid
C. MRI of the lumbosacral spine
D. PET scan
E. Visual evoked potentials

A. Abdominal bruit
B. Accessory nipple
C. Branchial cleft remnant
D. Hepatomegaly
E. Pitting of fingernails

A. Change in environment and routine

B. Drug interaction
C. Hypoglycemia
D. Intracranial bleed
E. Normal-pressure hydrocephalus
A. Determination of serum electrolyte concentrations
B. CT scan of the abdomen
C. Supine x-ray of the abdomen
D. Upper gastrointestinal barium study
E. Urinalysis
F. No study is indicated at this time

A. The medication should not have been released without larger clinical trials to exclude the adverse event of hemolytic
anemia
B. Hemolytic anemia is less likely to occur with the newer medication compared with older medication
C. Incidence of hemolytic anemia with the newer medication cannot be greater than with the older medication
D. The power of the clinical trials is insufficient
E. The risk for hemolytic anemia with the newer medication is reduced by at least one-half compared with the older
medication

A. Cervical cancer
B. Cirrhosis
C. Colon cancer
D. Constipation
E. Pancreatitis

A. CT angiography of the chest

B. MRI of the heart
C. Transthoracic echocardiography
D. Ventilation-perfusion lung scans
A. Renal ultrasonography
B. Serum creatinine concentration
C. Test for orthostatic proteinuria
D. Urine calcium: creatinine ratio
E. Urine culture and sensitivity

A. Family history of attention-deficit/hyperactivity disorder

B. History of atopic disease
C. History of bullous impetigo
D. Linear growth history
E. Vaccination history

A. Apgar scores
B. Cigarette and alcohol use
C. Maternal age
D. Maternal socioeconomic status
E. Premature delivery

A. Hemopericardium
B. Intrabronchial blood
C. Intraparenchymal blood
D. Intrapleural blood
E. Pneumothorax
F. Subpleural blood

A. Drug-induced effects at the AV node

B. Drug-induced negative inotropic effects
C. Drug-induced potentiation of vasodilator effects producing hypotension
D. Increased sensitivity of the carotid sinus reflex
E. Neurocardiogenic syncope
Question 18

A. Ethical and legal conflicts must be decided by the physician alone

B. Ethical and legal conflicts that involve a hospitalized patient are resolved by actions that protect the institution from
liability
C. Governmental statutes must be considered integral to solving an ethical dilemma
D. Legal mandates invalidate or supersede the ethical principles involved
E. Patients whose care involves a medicolegal dilemma should make the final judgement as to how to resolve the dilemma

A. Obtain antinuclear antibody study

B. Obtain culture of a lesion for Streptobacillus moniliformis
C. Obtain throat culture for -hemolytic Streptococcus species
D. Obtain viral culture
E. No diagnostic step is indicated at this time; provide supportive care only

A. Aortic regurgitation
B. Conjunctivitis
C. Malar rash
D. Pale, red-pink macular rash
E. Ulnar deviation of the digits

A. Mild tenderness in the left lower quadrant

B. A normal sonogram of the pelvis
C. A positive pregnancy test
D. Pyuria
E. Suprapubic tenderness
A. Asking the power company for data on exposure risks
B. Doing a literature search on the subject
C. Obtaining the consultation of EMR experts
D. Performing in-depth interviews with community leaders
E. Undertaking a case-control study of exposed residents

A. Ask the patient to provide consent for her own evaluation and treatment
B. Contact the hospital attorney to provide consent to evaluate and treat the patient
C. Examine the patient without parental permission to determine if a life-threatening condition exists
D. Explain to the patient that no evaluation or treatment can be provided until permission is obtained from a parent
E. Obtain consent from the patient’s sister to evaluate and treat the patient

A. Autonomy
B. Beneficence
C. Justice
D. Nonmaleficence
E. Standard of care

A. CT angiography
B. Serum prostate-specific antigen concentration
C. Ultrasonography of the bladder
D. Urinalysis
E. X-ray of the kidneys, ureter, and bladder

A. Determination of serum thyroid-stimulating hormone concentration

B. EEG
C. MRI of the brain
D. Sleep study
E. Test for visual acuity

A. Mammography
B. Measurement of bone density
C. Pap smear
D. Serum chemistry profile
E. X-ray of the chest

A. Begin intravenous fluid resuscitation

B. Intubate the patient
C. Obtain consultation with the hospital ethics committee
D. Place a transvenous pacemaker
E. Speak with the family about the patient’s prognosis and “code” status
A. Cost
B. Negative predictive value
C. Reliability
D. Sensitivity
E. Specificity

A. “Do you think you could be depressed?”

B. “Does your family have any history of depression?”
C. “My nurse tells me you are tired. How have you been sleeping recently?”
D. “My nurse tells me you are tired. How have you been sleeping recently?”
E. “You look tired. Have you been having any problems at home?”

A. Adverse effect of medication

B. Cancer
C. Diabetes mellitus
D. Stress
E. Travel history

A. Cystic fibrosis is mainly the result of spontaneous mutations, which makes prenatal diagnosis difficult and prenatal testing insensitive
B. If their affected child has the F508 mutation, then there is a 50% chance that a new baby would also be affected
C. If their affected child has known cystic fibrosis mutations, then amniocentesis could diagnosis the disease in an unborn child
D. If their affected child’s cystic fibrosis mutation cannot be identified, then this represents a spontaneous mutation and future offspring
will be spared
E. Only if their affected child has the F508 mutation can prenatal testing be done accurately
Block 3 Answers
1. E
2. D
3. D
4. C
5. B
6. A
7. A
8. A
9. A
10. D
11. B
12. A
13. E
14. E
15. E
16. D
17. A
18. B
19. C
20. E
21. D
22. C
23. B
24. C
25. A
26. D
27. B
28. A
29. E
30. E
31. C
32. B
33. C
Block 4

A. Her current reduction in smoking will not improve her condition, as too much damage has been done
B. Her current reductioin in smoking will result in fewer respiratory tract infections
C. Her lung function wil continue to deteriorate at an accelerated rate, despite her current reduction in smoking
D. If she stops smoking, her lung function will deteriorate less rapidly
E. If she stops smoking, her lung function will return to normal

A. Intravenous dopamine
B. Intravenous metoprolol
C. Intravenous reteplase
D. Oral aspirin
E. Oral verapamil

A. Intravenous antibiotic therapy

B. Narcotic analgesia and straining of all urine until the pain resolves
C. Oral antibiotic therapy
D. Prolonged electronic fetal and uterine monitoring
E. Repeat maternal renal ultrasonography after the pregnancy is completed

A. Median survival for patients with this disease is 2 to 4 years

B. The patient could live 10 more years with radiation therapy
C. The patient has 50% chance of living 5 more years
D. The patient’s life expectancy is the same as that of other men in his age group
A. Administer antibiotics, intravenously
B. Await results of joint fluid culture before initiating treatment
C. Immobilize the knee, prescribe ibuprofen and arrange outpatient follow-up tomorrow
D. Order urgent MRI of the knee
E. Prescribe a trial of colchicine

A. CT scan of the pelvis

B. Endometrial biopsy
C. Initiation of high-dose estrogen therapy
D. Observation only
E. Pelvic ultrasonography

A. They are at increased risk and they should be tested for the BRCA-1 and BRCA-2 mutations
B. They are at increased risk because her mother is a first-degree relative
C. They are at increased risk because they have had children
D. They are not at increased risk because of her mother’s age at diagnosis
E. They are not at increased risk because they are young

A. Hepatitis A vaccine
B. Cholera vaccine
C. Influenza vaccine
D. Polio vaccine
E. Rabies vaccine

A. Astrocytoma
B. Basal cell carcinoma
C. Laryngeal neoplasm
D. Melanoma
E. Thyroid neoplasm
Question 10

Question 11

A. Prescribe depot medroxyprogesterone for birth control at this time

B. Prescribe folic acid therapy
C. Recommend mammography prior to becoming pregnant
D. Recommend refraining from sexual intercourse until the couple is married
E. Screen the patient for sexually transmitted diseases

A. Intra-arterial streptokinase
B. Intravenous recombinant tissue plasminogen activator (tPA)
C. Intravenous unfractionated heparin
D. Left carotid angioplasty and stent placement
E. Right carotid endarterectomy

A. Elastic compression stockings

B. Intravenous heparin
C. Sequential compression devices
D. Subcutaneous “Mini-dose” heparin
E. Subcutaneous low-molecular-weight heparin
 A. Add hydrocholorothiazide
B. Discontinue Lisinopril
C. Prescribe cholestyramine
D. Prescribe gemfibrozil
E. Prescribe glyburide

A. Intramuscular methylprednisolone
B. Inhaled fluticasone
C. Inhaled ipratropium
D. Oral theophylline
E. Oral trimethoprim-sulfamethoxazole

A. Administer human diploid cell rabies vaccine and rabies immunoglobulin

B. Administer human diploid cell rabies vaccine only
C. Administer rabies immunoglobulin only
D. No rabies immunoprophylaxis is indicated

A. After 7 days of intravenous antibiotics

B. After five treatments with radiation therapy
C. After plasmapheresis
D. After transfusion with 1 U of packed erythrocytes
E. As scheduled

A. Ampicillin for 2 weeks

B. Choamphenicol for 2 weeks
C. Either ampicillin or chloramphenicol for as long as it takes to eradicate the organism
D. A sulfonamide and yogurt (Lactobacillus) diet for 3 weeks
E. No antibiotics
A. Age of the patient
B. Choice of antibiotic therapy
C. Decision to remove the prosthesis
D. Infecting organism

A. Colonoscopy
B. Chest x-ray
C. Felxible Sigmoidoscopy
D. Serum lipid profile
E. Three times test of stool for occult blood

A. Alcoholism
B. Hypercholesterolemia
C. Hypertension
D. Obesity
E. Type 2 diabetes mellitus

A. Development of seizures
B. Progressively debilitating course
C. Spontaneous recovery during adolescence
D. Spontaneous recovery within a year
E. Waxing and waning course throughout childhood and adolescence

A. Admit the patient to the hospital for repeat upper gastrointestinal endoscopy
B. Admit the patient to the hospital for serial ECGs and cardiac enzyme determinations
C. Arrange consultation with a gastroenterologist
D. Arrange for an outpatient thallium stress test
E. Instruct the patient to schedule an appointment with his primary care physician within the next several days
A. Absent thymus
B. Blindness
C. Deafness
D. Hypothyroidism
E. Pulmonary stenosis

A. Inhaled fluticasone
B. Inhaled salmeterol
C. Oral azithromycin
D. Oral prednisone
E. Oral trimethoprim0sulfamethoxazole

A. Chemotherapy
B. Laser ablation of the lesion
C. Radiation therapy
D. Referral for hospice care
E. Surgical resection of the left upper lobe
A. ALT and AST activities
B. INR
C. Jaundice
D. Neurologic examination
E. Platelet count

A. Clotrimazole cream
B. Oral cephalexin
C. Oral fluconazole
D. Oral ketoconazole
E. Oral penicillin

A. Administration of levofloxacin prior to transfusion

B. Transfusion of (deglycerolized) frozen red blood cells
C. Transfusion of irradiated red blood cells
D. Transfusion of leukodepleted red blood cells

A. Ganciclovir
B. Interferon beta-1a
C. Methotrexate
D. Methylprednisolone
E. Vitamin B12 (Cyanocobalamin)
A. Acupuncture
B. Cervical chordotomy
C. Epidural analgesia
D. Radiation therapy
E. Transcutaneous electrical nerve stimulation (TENS)

A. Myocardial infarction
B. Retinopathy
C. Sepsis
D. Stroke
E. Ulcers of the lower extremities
Block 4 Answers

1. D
2. D
3. C
4. D
5. A
6. D
7. D
8. A
9. E
10. D
11. A
12. B
13. B
14. E
15. D
16. B
17. D
18. E
19. E
20. C
21. A
22. C
23. E
24. E
25. C
26. D
27. E
28. E
29. B
30. D
31. B
32. D
33. B
Block 5

A. CT scan of the spine

B. DEXA scan
C. MRI of the spine
D. Referral for spinal fusion
E. No additional intervention is indicated

A. Clonidine
B. Glyburide
C. Metformin
D. Naproxen
E. St John’s wort

A. Adenosine
B. Epinephrine
C. Furosemide
D. Nitroprusside
E. Prostaglandin E1

A. “At this point I think we should start looking for an underlying problem with your daughter’s immune system.”
B. “I think your daughter is healthy, but she may be infected with a particularly virulent strain of bacteria.”
C. “Most children do not have this many sore throats. Perhaps we should consider a problem with her ability to absorb and metabolize
antibiotics.”
D. “Your daughter appears very healthy. Most children have between seven and nine upper respiratory tract infections per year.”
E. “Your daughter’s problem is unusual. Do you have any pets at home?”

A. Irrigate both ears

B. Order CT scan of the head
C. Recommend an over-the-counter cerumenolytic
D. Refer the patient to an otolaryngologist
E. No intervention is indicated
A. It is associated with coronary artery aneurysms
B. It is associated with hepatosplenomegaly
C. It is contagious to others
D. It is metastatic
E. It is self-limiting

A. Kelp
B. Spinach
C. Spirulina tablets
D. Sweetened condensed milk
E. Yogurt containing live cultures

A. Calculate her waist-to-hip ratio

B. Discuss dietary habits
C. Obtain oral glucose tolerance test
D. Obtain serum lipid profile
E. Obtain serum thyroid-stimulating hormone concentration

A. Do bilateral orchiectomy
B. Initiate total androgen blockade
C. Obtain consultation with a medical oncologist for possible chemotherapy
D. Obtain tissue biopsy of the affected area
E. Refer the patient for emergency radiation

A. Continue administering propylthiouracil and add thyroxine

B. Continue administering the same dose of propylthiouracil
C. Give radioactive iodine therapy
D. Reduce the dose of propylthiouracil by 50%
E. Refer her for a subtotal thyroidectomy

A. Finasteride therapy
B. Propantheline therapy
C. Propranolol therapy
D. Reevaluation in 1 month
E. Terazosin therapy
A. Compress the bag valve device more vigorously and rapidly
B. Confirm correct placement of the endotracheal tube
C. Immediately establish an airway via cricothyroid puncture
D. Place an 18-gauge needle into the left chest
E. Place the patient on a ventilator with 10 mm of positive end-expiratory pressure

A. Begin weight training

B. Increase walking frequency to five to six times weekly
C. Switch to bicycle riding
D. No change is necessary

A. An exercise program is contraindicated because of her asthma

B. An exercise program is not needed because she is at low risk for osteoporosis
C. Exercise would likely
D. She may begin a walking program for which the pace is moderate and gradually increasing
E. She would require cardiac stress testing before beginning any routine exercise program

A. Continuous infusion of prostaglandin E1

B. Endotracheal intubation
C. Intravenous administration of ampicillin and gentamicin
D. Rapid infusion of a bolus of 0.9% saline
E. Transfusion of paced red blood cells

A. Calorie monitoring for 2 weeks, then reevaluation

B. Insertion of a gastrostomy tube
C. Referral for hospice care
D. Upper gastrointestinal barium study
E. Weekly serum prealbumin concentration monitoring, then reevaluation

A. Amphotericin
B. Fluconazole
C. Methicillin
D. Methyprenisolone
E. Vancomycin
F. No additional pharmacotherapy is required
A. Administration of corticosteroid therapy
B. Continuous positive airway pressure ventilation
C. Referral for hospice care
D. Respiratory isolation
E. Surgical intervention

A. “Once her symptoms resolve, she may resume training.”

B. “She can continue to compete at that level if she gains 10 lb.”
C. “She can continue training as long as she consumes 1500 mg of calcium daily.”
D. “She is likely to develop scoliosis if she continues training at this level.”
E. “She will need to stop skating until after she has her adolescent growth spurt.”

A. CT scan of the pelvis

B. Cyclic progesterone therapy
C. Endometrial ablation
D. Endometrial biopsy
E. Gonadotropin-releasing hormone agonist therapy
F. Routine gynecologic screening
Question 21

A. Dementia
B. Hypesthesia of the legs
C. Problems with coordination
D. Spasticity of the legs
E. Tremor of the hands and feet

A. Hyperosmolar, non-ketotic coma

B. Ketoacidosis
C. Necrobiosis lipoidica diabeticorum
D. A serious hypoglycemic reaction
E. Symptomatic hyperglycemia after hypoglycemia

A. Calcium gluconate
B. Diltiazem
C. Magnesium sulfate
D. Potassium chloride
E. Quinidine

A. Increasingly severe pain

B. Malignant degeneration
C. Radial neve compression
D. Secondary infection
E. Varying size of the ganglion

A. Chest x-ray
B. Determination of antinuclear antibody titer
C. Determination of serum parathyroid hormone concentration
D. Repeat determination of serum calcium concentration
E. Serum protein electrophoresis
A. Discontinue aspirin therapy
B. Obtain complete blood count and coagulation studies
C. Obtain CT can of the abdomen
D. Prescribe oral antibiotic therapy
E. Prescribe vaginal estradiol
F. Recommend increased fluid intake and straining the urine for calculi

A. Anoscopy and fistulotomy

B. Cefazolin therapy and sitz baths
C. CT scans of the abdomen and pelvis
D. Incision and curettage of the abscess
E. Lower gastrointestinal barium study

A. Chlordiazepoxide
B. Haloperidol
C. Hydroxyzine
D. Naloxone
E. Physostigmine

A. Calcium supplementation
B. Ingestion of daily aspirin
C. Ingestion of supplemental iron
D. Ingestion of supplemental vitamin C
E. Low-carbohydrate diet

A. Lorazepam
B. Olanzapine
C. Paroxetine
D. Propranolol
E. No pharmacotherapy is indicated
A. Acute pulmonary edema
B. Complex ventricular arrhythmias
C. Drug toxicity
D. Hip fracture
E. Respiratory failure

A. Keep her in the emergency department until crossmatched bloodis available

B. Transfer her to a nearby hospital with neonatal intensive care capabilities
C. Transport her to the labor and delivery triage area
D. Transport her to the operating room
E. Transport her to the radiology department for ultrasonography

A. An abdominal retropubic urethropexy

B. Behavioral therapy with bladder retraining
C. Periurethral collagen injections
D. Psychiatric evaluation
E. Urodynamic testing

A. Consultation with a surgeon

B. Decompressive sigmoidoscopy
C. Tube cecostomy
D. No further action is indicated
A. Actinomycosis
B. Aspergillosis
C. Mucomycosis
D. Nocardiosis
E. Tuberculosis

A. Aspiration of the mass

B. Danazol therapy
C. Excisional biopsy with frozen section
D. Incisional biopsy
E. Observation for three menstrual cycles

A. Order x-ray of the sinuses

B. Prescribe a cromolyn inhaler
C. Prescribe an oral cephalosporin
D. Prescribe oral cetirizine
E. Prescribe oral prednisone

A. Alveolar membrane diffusing capacity

B. Forced expiratory volume in 1 second
C. Resting PCO2 tension
D. Resting PO2 tension
E. Vital capacity

A. Ceftriaxone
B. Dapsone
C. Ganciclovir
D. Isoniazid
E. Pentamidine isthionate

A. Codeine
B. Diazepam
C. Diphenhydramine
D. Ibuprofen
E. No pharmacotherapy is indicated

A. Aortic valve replacement

B. Atenolol therapy
C. Balloon valvuloplasty
D. Cardiac rehabilitation program
E. Isosorbide dinitrate therapy

A. Do optic nervesheath decompression

B. Do temporal artery biopsy
C. Evaluate the appearance of the optic nerve and retina
D. Obtain MRI of the brain
E. Prescribe high-dose prednisone therapy
F.

A. Anemia
B. Hepatotoxicity
C. Pancreatitis
D. Pulmonary fibrosis
E. Seizures
Block 5 answers
1. E
2. D
3. E
4. D
5. A
6. E
7. E
8. B
9. E
10. D
11. E
12. B
13. B
14. D
15. A
16. C
17. E
18. D
19. A
20. F
21. B
22. D
23. B
24. E
25. A
26. D
27. A
28. A
29. D
30. E
31. C
32. D
33. D
34. E
35. A
36. E
37. A
38. D
39. B
40. E
41. C
42. A
43. C
44. B