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* Pls any one send me NBME downloaded Qs
 #254042  
  aniwsu - 12/21/07 20:30
 
  pls pls any body send me NBME down loaded Qs..
My e mail : inusa29@yahoo.com
 
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* Re:Pls any one send me NBME downloaded Qs
#1097554
  candace - 12/22/07 13:01
 
  this is nbme2, the answers may or may not b right! i'll post rest soon


Block 1




1.) A 50-year-old man with a 20-year history of type
2 diabetes mellitus has had sensory neuropathy for 2 weeks.
Pulses are decreased at the ankle. There is no peripheral edema. His serum
glucose levels have been between 150 mg/dL and 200 mg/dL over the past 6
months. Which of the following is the most effective measure to prevent
serious foot infections?

A) Use of support hose

B) Use of well-fitted shoes

C) Prophylactic antibiotics

D) Daily aspirin and dipyridamole

E) Decrease in serum glucose level


2.) A 63-year-old woman comes to the emergency
department because of palpitations for 1 hour. She was diagnosed with
hyperthyroidism 2 months ago but has not received treatment. Three
hours before arrival, she drank two bottles of beer with dinner. Her blood
pressure is 90/60 mm Hg, and pulse is 85/min and irregularly irregular.
Examination shows a variation in intensity of S1. There is an absence of
waves in the venous pulse. An ECG is shown. Which of the following is
the most likely cardiac rhythm disturbance?

A) Atrial fibrillation

B) Atrial flutter

C) Multifocal atrial tachycardia

D) Paroxysmal atrial tachycardia

E) Second-degree atrioventricular block, Wenckebach type

F) Sick sinus syndrome

G) Sinoatrial exit block, type II

H) Torsades de pointes

I) Wandering pacemaker

J) Wolff-Parkinson-White syndrome


3.) A 5-year-old girl is brought to the physician 30 minutes after
being bitten on the forearm by her cat. Examination shows a small
puncture wound covered with dried blood. She is at increased risk of
infection for which of the following reasons?

A) Arm wounds are more susceptible to infection

B) Salivary enzymes in cats augment infection

C) It is difficult to cleanse pathogens from this wound

D) The Staphylococcus species involved is particularly virulent

E) Young children are less able to resist infection than adults


4.) A 4-year-old girl is brought to the physician because of pallor
and jaundice for 2 days. She had previously been well, although she was
treated for jaundice with phototherapy for 2 weeks while a newborn.
Her mother and two additional maternal relatives underwent splenectomy
during childhood for unknown reasons. Examination of the patient shows
jaundice. The spleen tip is palpated 4 cm below the left costal margin.
Which of the following blood smear findings is most likely to explain this
family's condition ?

A) Elliptocytes

B) Howell-Jolly bodies

C) Schistocytes

D) Sickle cells

E) Spherocytes


5.) A sexually active 20-year-old woman has had fever, chills,
malaise, and pain of the
vulva for 2 days. Examination shows a vulvar pustule that has ulcerated and
formed multiple satellite lesions. Nodes are palpated in the inguinal and
femoral areas. A smear of fluid from the lesions establishes the diagnosis.
Which of the following is the most likely causal organism?

A) Chlamydia trachomatis

B) Haemophilus ducreyi

C) Neisseria gonorrhoeae

D) Streptococcus pyogenes (group A)

E) Treponema pallidum


6.) A 5-year-old boy is brought to the physician 1 hour after
urinating bright red blood. He has been taking ibuprofen since injuring his
right flank while wrestling with friends yesterday; he also has been
taking penicillin for 3 days for streptococcal pharyngitis. His
temperature is 36.7 C (98 F), blood pressure is 90/48mm Hg, pulse is 108/min,
and respirations are 18/min. Examination shows purple ecchymoses over
the shins and right flank; there is tenderness of the right
costovertebral area. The abdomen is nontender. Genital examination shows no
abnormalities. There is no edema. Urinalysis shows gross blood;
microscopic examination shows 5–10 leukocytes/hpf and erythrocytes that
are too numerous to count. Which of the following is the most likely
explanation for this patient's hematuria?

A) Acute pyelonephritis

B) Ibuprofen-induced acute papillary necrosis

C) Post-streptococcal glomerulonephritis

D) Rhabdomyolysis

E) Traumatic injury to the kidney


7.) A 16-year-old girl comes to the physician for her first prenatal
visit at 12 weeks' gestation. She has not had any immunizations since
the age of 5 years. She has received the following immunizations at the
recommended ages:

5 Diphtheria-tetanus-pertussis
3 Hepatitis B
1 Measles-mumps-rubella
4 Oral poliovirus

Examination shows no abnormalities. Which of the following is the most
appropriate immunization to administer at this visit?

A) Diphtheria-tetanus-pertussis

B) Diphtheria (child)-tetanus toxoid

C) Diphtheria (adult)-tetanus toxoid

D) Haemophilus influenzae type b

E) Hepatitis B

F) Inactivated poliovirus


8.) A 12-year-old boy is brought to the physician because of
temperatures to 40.2 C (104.4 F), lethargy, and a stiff neck for 2 days. A
diagnosis of pneumococcal meningitis is made, and the child is admitted to
the hospital for antibiotic therapy. Serum studies 24 hours after
admission show:

Na+ 117 mEq/L
Cl– 89 mEq/L
HCO3– 25 mEq/L

Which of the following is the most likely explanation for these findings?

A) Excessive cortisol release

B) Hyperaldosteronism

C) Inappropriate secretion of ADH (vasopressin)

D) Increased production of leukotriene C4


9. )An asymptomatic 57-year-old man with a 3-year history of type 2
diabetes mellitus comes for a routine follow-up visit. Examination shows no
abnormalities. Serum studies show:
Aspartate aminotransferase (AST, GOT) 76 U/L
Alanine aminotransferase (ALT, GPT) 86 U/L
Iron 260 µg/dL Total iron-binding capacity 300 µg/dL (N=250–450)
Ferritin 1200 ng/mL Antinuclear antibody negative
Serologic testing for hepatitis is negative. Which of the following is
the most appropriate next step in management?

A) Corticosteroid therapy

B) Interferon therapy

C) Penicillamine therapy

D) Chronic phlebotomy

E) No therapy indicated


10.) A 26-year-old man has had anxiety and insomnia since he lost his
job 1 month ago. He also has had palpitations, daily headaches, and
flatulence. He has no history of psychiatric disorders. His mother has
a history of bipolar disorder, mixed, and his father has alcoholism;
his younger sister had a history of drug abuse but has been abstinent
from drugs for 3 years. Which of the following is the most likely
diagnosis?

A) Adjustment disorder

B) Bipolar disorder, depressed

C) Generalized anxiety disorder

D) Major depressive disorder

E) Post-traumatic stress disorder



11.) A previously healthy 32-year-old man comes to the emergency
department because of a 12-hour history of fatigue and shortness of breath
at rest. He takes no medications. His temperature is 7 C (98.6 F),
blood pressure is
96/58 mm Hg, pulse is 110/min, and respirations are 22/min. Examination shows
scleral icterus and conjunctival pallor. There is no
hepatosplenomegaly. Laboratory
Studies show:
Hemoglobin 6.2 g/dL
Serum Leukocyte count 8800/mm3
Bilirubin, total 8.5 mg/dL
Reticulocyte count 16%
Direct 1.5 mg/dL
Platelet count 245,000/mm3
Lactate dehydrogenase 1260 U/L


A) Acute toxic hepatitis

B) Alcoholic hepatitis

C) Cholangiocarcinoma

D) Chronic idiopathic cirrhosis

E) Common bile duct calculus

F) Congestive hepatitis

G) Gallstone pancreatitis

H) Gilbert's syndrome

I) Infectious hepatitis

J) Intravascular hemolysis

K) Primary biliary cirrhosis

12.) A 24-year-old third-year medical student comes to the student
health clinic for
evaluation of jaundice which he noticed this morning. He has had no abdominal
pain, itching, or weight change. He takes no medications. He describes recent
anxiety over anticipation of the upcoming Step 2 examination. His
temperature is
37 C (98.6 F), blood pressure is 120/80 mm Hg, pulse is 76/min, and
respirations
are 12/min. Examination shows no abnormalities except for scleral icterus.

Laboratory studies show:

Hemoglobin 15 g/dL Serum
Leukocyte count 7000/mm3
Alkaline phosphatase 90U/L
Platelet count 240,000/mm3
Aspartate aminotransferase Serum (AST, GOT) 23 U/L
Bilirubin, total 3.5 mg/dL
Alanine aminotransferase Direct 0.7 mg/dL (ALT, GPT) 27 U/L


A) Acute toxic hepatitis

B) Alcoholic hepatitis

C) Cholangiocarcinoma

D) Chronic idiopathic cirrhosis

E) Common bile duct calculus

F) Congestive hepatitis

G) Gallstone pancreatitis

H) Gilbert's syndrome

I) Infectious hepatitis

J) Intravascular hemolysis

K) Primary biliary cirrhosis

13.) A 37-year-old woman with a 2-year history of hypertension comes
for a follow-up
examination; her hypertension has worsened despite treatment with a low-sodium
diet and a ß-adrenergic blocking agent. She has a history of rheumatic
fever and
Graves' disease treated with 131I. Her blood pressure is 160/106 mm Hg, and
pulse is 80/min. Serum studies show:

Na+ 135 mEq/L
Cl– 100 mEq/L
K+ 3.4 mEq/L
HCO3– 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.8 mg/dL

Urinalysis is within normal limits. Renal ultrasonography shows a left
kidney with a
markedly irregular contour; it is 2.8 cm smaller than the right.


A) Adrenal cortex

B) Adrenal medulla

C) Aorta

D) Renal arteries

E) Renal glomeruli

F) Thyroid gland

14.) A 27-year-old woman comes to the physician because of muscle weakness and
cramps for 2 weeks. She has been taking a ß-adrenergic blocking agent for
hypertension for 2 years. She had chronic lymphocytic thyroiditis (Hashimoto's
disease) 1 year ago. Her blood pressure is 160/108 mm Hg, and pulse is 60/min.
Serum studies show:

Na+ 140 mEq/L
Cl– 110 mEq/L
K+ 2.2 mEq/L
HCO3– 30 mEq/L
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1 mg/dL

Magnetic resonance angiography of the abdomen shows normal findings.

A) Adrenal cortex

B) Adrenal medulla

C) Aorta

D) Renal arteries

E) Renal glomeruli

F) Thyroid gland

15.) A 24-year-old man is hospitalized for treatment of a posterior
dislocation of the
right knee sustained in a motorcycle collision. Six hours after closed
reduction,
previously present distal pulses in his foot are absent, but the foot
has remained
warm. Which of the following is the most appropriate next step in management?


A) Elevation of the limb and observation for 24hours

B) Nitroprusside therapy

C) Sympathetic block

D) Femoral arteriography

E) Embolectomy with a Fogarty catheter through aproximal arteriotomy

D) Inflammation of the origin of the plantar fascia





16.) A healthy 4-year-old girl is brought for a well-child
examination. A grade 2/6
systolic ejection murmur is heard along the upper left sternal border.
S2 is widely
split and does not vary with respiration. A soft mid-diastolic murmur
is heard along
the lower left sternal border. Examination shows no other
abnormalities. Which of
the following is the most likely diagnosis?


A) Aortic stenosis

B) Atrial septal defect

C) Coarctation of the aorta

D) Mitral valve prolapse

E) Patent ductus arteriosus

F) Pulmonary stenosis

G) Tetralogy of Fallot

H) Transposition of the great arteries

I) Ventricular septal defect

J) Normal heart



18.) A previously healthy 57-year-old woman comes to the physician
because of three
episodes of blurred vision in the right eye over the past 3 weeks; each episode
lasts approximately 5minutes. Retinal examination shows a small
refractile body at
The bifurcation of a retinal artery. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate next step in
diagnosis?

A) Cerebral angiography

B) Echocardiography

C) Electroencephalography

D) Duplex scan of the carotid arteries

E) MRI of the brain


19.) A 67-year-old woman comes to the physician for her first influenza virus
vaccination. She has a history of untreated hypertension. Her blood pressure is
160/100 mm Hg, and pulse is 100/min. Shortly after administration of the
influenza virus vaccine, she develops shortness of breath, hives, and
angioedema.
Which of the following is most likely to have prevented this reaction?


A) Inquiry about an egg allergy

B) Heterophile agglutination test

C) Skin test with histamine reagent

D) ß-Adrenergic blocking agent therapy

E) Amantadine therapy

F) Insulin therapy

G) Rimantadine therapy



20.) A 7-year-old girl is brought to the physician because of a 2-day
history of fever,
headache, sore throat, and swollen glands. She does not have a runny nose,
congestion, or cough. She has no allergies to medications. Her temperature is
38.6C (101.4 F), blood pressure is 100/60 mm Hg, pulse is 120/min, and
respirations are 16/min. Examination shows a swollen, erythematous oropharynx
With tonsillar exudates. The anterior cervical lymph nodes are enlarged and
tender. No other abnormalities are noted. Which of the following is
the most likely
causal organism?

A) Adenovirus

B) Corynebacterium diphtheriae

C) Group A streptococcus

D) Haemophilus influenzae

E) Mycoplasma pneumoniae


21.) A 70-year-old nursing home resident is admitted to the hospital because of
progressive obtundation over the past 2 days. He has tachycardia,
tachypnea, and
hypotension. Bilateral basilar crackles and an S3 gallop are heard on
auscultation.
Examination shows jugular venous distention and peripheral edema. Swan-Ganz
catheterization shows a cardiac index of 1.8 L/min/m2 (N=2.5–4.2), a mean
Pulmonary capillary wedge pressure of 23 mm Hg (N=1–10), and markedly
Increased systemic vascular resistance. Which of the following is the
most likely
diagnosis?

A) Cardiogenic shock

B) Hypovolemic shock

C) Neurogenic shock

D) Septic shock



22.) A 42-year-old man with alcoholism is brought to the emergency
department by a
friend because of fever and progressive shortness of breath for 12 hours. His
friend reports that they were eating leftover chicken and drinking
beer earlier in
the day when the patient suddenly choked and vomited. Six hours later, he
developed sweating, chills, and shortness of breath. He has not had any
subsequent nausea, vomiting, hematemesis, or abdominal pain. He has smoked
Two packs of cigarettes daily for 22 years and drinks 12 to 18 beers
daily. He is in
moderate respiratory distress. His temperature is 39.3 C (102.8 F),
blood pressure
is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination
shows no jugular venous distention. Breath sounds are decreased halfway up the
left lung with increased dullness. Cardiac examination shows a normal
S1 and S2;
no murmurs are heard. There is no abdominal tenderness. Bowel sounds are
hypoactive. X-ray films of the chest show a left pleural effusion and
air in the
mediastinum. Thoracentesis is performed.
Laboratory studies show:
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Bands 10%
Lymphocytes 5%
Serum Protein 6 g/dL
Lactate dehydrogenase 200 U/L
Pleural fluid Leukocyte count 8000/mm3
Segmented neutrophils 98%
Monocytes 2%
Protein 4.2 g/dL
Amylase 140 U/L
Lactate dehydrogenase 180 U/L
Gram's stain
WBC present
Organisms none

Which of the following is the most likely diagnosis?

A) Congestive heart failure

B) Esophageal rupture

C) Pancreatitis

D) Pericarditis

E) Tuberculosis


23.) A 2-year-old girl with tricuspid atresia has increasing
respiratory distress for 2
days. She has been recovering uneventfully from an operation 10 days
ago to join
systemic venous return with pulmonary arterial circulation. Over the
past 4 days,
she has been weaned off mechanical ventilation, started on oral feedings, and
is receiving chest physiotherapy for atelectasis. Her temperature is
37.4 C (99.3 F),
blood pressure is 98/64 mm Hg, pulse is 120/min, and respirations are 46/min.
Examination shows nasal flaring, grunting, and intercostal
retractions. An x-ray
film of the chest shows large bilateral pleural effusions.
Thoracentesis yields 300
mL of whitish-yellow fluid. The supernatant remains uniformly opaque on
centrifugation. Which of the following is the most likely cause of the pleural
effusions?

A) Chylothorax

B) Congestive heart failure

C) Empyema

D) Pulmonary embolism

E) Superior vena cava obstruction


24.) A 23-year-old man is brought to the physician by his mother
because he has heard
a voice over the past month telling him to hurt himself. His mother
says that her
son has no friends and is a lifelong loner; since graduating from high
school, he
has been unable to hold a job. He admits to smoking marijuana occasionally and
drinking six beers weekly. Examination shows a poorly groomed man with poor
eye contact. He has a flat affect and limited facial expression. He
says he has no
intention of harming himself or others. Which of the following is the most
appropriate next step in management?

A) Schedule a follow-up visit in 4 weeks

B) Prescribe oral risperidone and schedule a follow-up visit in 2 weeks

C) Admit him to the partial hospital program and prescribe oral
lithium carbonate

D) Admit him to the psychiatric unit for detoxification

E) Admit him to the psychiatric unit and prescribe oral imipramine



25.) A 23-year-old man is brought to the physician by his mother
because he has heard
a voice over the past month telling him to hurt himself. His mother
says that her
son has no friends and is a lifelong loner; since graduating from high
school, he
has been unable to hold a job. He admits to smoking marijuana occasionally and
Drinking six beers weekly. Examination shows a poorly groomed man with poor
Eye contact. He has a flat affect and limited facial expression. He says he
has no intention of harming himself or others. Which of the following
is the most
appropriate next step in management?


A) Schedule a follow-up visit in 4 weeks

B) Prescribe oral risperidone and schedule a follow-up visit in 2 weeks

C) Admit him to the partial hospital program and prescribe oral
lithium carbonate

D) Admit him to the psychiatric unit for detoxification

E) Admit him to the psychiatric unit and prescribe oral imipramine




26.) An 18-month-old boy is brought for a well-child examination. He
was born at 37
weeks' gestation and weighed 2800 g (6 lb 3oz). There were no prenatal or
perinatal complications. Developmental history indicates that he is
able to run and
walk up stairs while holding his mother's hand. He can hold a crayon
but does not
Scribble spontaneously. He is at the 40th percentile for length and
50th percentile
for weight. Examination shows a crude pincer grasp. Which of the
following is the
most appropriate assessment of fine and gross motor development?


Fine Motor Gross Motor
Development Development

A) Delayed normal

B) Normal delayed

C) Delayed delayed

D) Normal normal



27.) Five months after beginning fluoxetine to treat
obsessive-compulsive disorder, a
19-year-old man states that he discontinued his medication 2 months ago because
he had begun to worry about taking his medication every day. His
initial response
to the medication was good. His symptoms have now returned, and his morning
ritual of cleaning and grooming consumes so much time that his job is
in jeopardy.
In addition to education about the nature of his disorder and its
treatment, which
of the following is the most appropriate next step in management?


A) Tell the patient to schedule a return visit as needed

B) Offer to change the medication

C) Request that the patient's parents superviseadministration of medication

D) Monitor the patient's compliance by weekly blood tests

E) Begin a trial of cognitive-behavior therapy




28.) A 32-year-old woman comes to the physician because of a 3-month history of
increasing pain and stiffness in her wrists, hands, and ankles. During
this period,
she also has had progressive fatigue and morning stiffness lasting 2
hours. She has
a 1-year history of rheumatoid arthritis treated with naproxen.
Examination shows
redness, swelling, and warmth over the wrist, hand, and ankle joints
bilaterally.
There are nontender subcutaneous nodules over the extensor surfaces of both
elbows. X-ray films of the hands show diffuse osteopenia and erosions
over several
of the distal metacarpal bones. Which of the following is the most appropriate
pharmacotherapy?

A) Add oral cyclophosphamide

B) Add oral gold

C) Add oral methotrexate

D) Add oral penicillamine

E ) Switch to oral ibuprofen



28.) A previously healthy 62-year-old man comes to the physician
because of a 2-month
history of progressive shortness of breath and a mild nonproductive cough. He
does not smoke. He worked in a foundry most of his adult life before retiring 2
years ago. Vital signs are within normal limits. Crackles are heard at
both lung
Bases with no wheezes. Cardiac examination shows an accentuated P2. The
remainder of the examination shows no abnormalities. An x-ray film of the chest
shows prominent interstitial markings at the lung bases. Echocardiography shows
an ejection fraction of 55%. Pulmonary function testing is most likely to show
which of the following?

A) Decreased FEV1:FVC ratio

B) Decreased maximal inspiratory effort

C) Decreased total lung capacity

D) Increased forced vital capacity

E) Normal carbon monoxide diffusion capacity



29.) A 55-year-old man is admitted to the hospital because of
progressive shortness of
breath for 10 days. He has a history of chronic venous stasis and deep venous
thrombosis. He has been treated with warfarin since he had several pulmonary
emboli 2 years ago; he takes no other medication. He has smoked two packs of
Cigarettes daily for 30 years. He weighs 109 kg (240 lb) and is 165 cm
(65 in) tall.
Examination shows jugular venous distention. Echocardiography is most likely to
show which of the following?

A) Left ventricular dilation

B) Mitral stenosis

C) Pericardial thickening and tamponade

D) Right ventricular hypertrophy and dilation

E) Tricuspid stenosis


30.) A 32-year-old woman comes to the physician because of weakness of
the lower
extremities for 2 days. Three years ago, she had pain and partial loss
of vision of
the right eye; the vision returned to normal after 6 weeks. There is
mild pallor of
the right optic disc. She has impaired tandem gait. Babinski's sign is present
bilaterally. There is mild spasticity of the lower extremities and
mild weakness of
the iliopsoas and hamstring muscles. Serum creatine kinase activity is 50 U/L.
Which of the following is the most likely diagnosis?

A) Amyotrophic lateral sclerosis

B) Becker's muscular dystrophy

C) Diffuse sensorimotor peripheral neuropathy

D) Duchenne's muscular dystrophy

E) Hyperkalemic periodic paralysis

F) Hypokalemic periodic paralysis

G) Multiple sclerosis

H) Myasthenia gravis

I) Myasthenic (Lambert-Eaton) syndrome

J) Myotonic muscular dystrophy

K) Polymyositis

L) Pontine astrocytoma

M) Pontine infarction

N) Spinal cord tumor

O) Transverse myelitis



31.) A healthy 42-year-old man comes to the physician for a life
insurance evaluation.
He smoked one-half pack of cigarettes daily for 20 years but quit 10
years ago. His
father died of a myocardial infarction at the age of 65 years. The
patient weighs 93
kg (205lb) and is 178 cm (70 in) tall. His blood pressure is 160/110 mm Hg,
pulse is 96/min, and respirations are 16/min. Physical examination,
ECG, and an x-
ray film of the chest show no abnormalities. Laboratory studies are
within normal
limits except for a serum cholesterol level of 206 mg/dL. Which of the
following is
the greatest risk factor for cerebral infarction in this patient?

A) Genetic profile

B) History of smoking

C) Hypercholesterolemia

D) Hypertension

E) Obesity


32.) A previously healthy 56-year-old woman comes to the physician because of
jaundice and dark urine for 3 weeks. She has a 1-year history of generalized
pruritus. She takes no medications. Examination shows jaundice and several
ecchymoses over the forearms and thighs. The liver and spleen are enlarged and
nontender. Laboratory studies show:

Prothrombin time 18 sec
Serum Protein Total 8.5 g/dL
Albumin 3.8 g/dL
Bilirubin Total 5 mg/dL
Direct 2 mg/dL
Alkaline phosphatase 150 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
Antimitochondrial antibody assay is strongly positive.

A CT scan of the abdomen shows hepatosplenomegaly.
Endoscopic retrograde cholangiopancreatography shows no abnormalities.

Because of her condition, this patient is at greatest risk for which
of the following
deficiencies?


A) Niacin

B) Vitamin A

C) Vitamin B2 (riboflavin)

D) Vitamin B12 (cyanocobalamin)

E) Vitamin C


33.) An asymptomatic 52-year-old man comes for a
follow-up
examination 1 month after he passed renal calculi. He
has a history of renal
calculi 2 years ago. Serum uric acid and calcium
levels and urinary
oxalate excretion are within normal limits. Urinary
calcium excretion is
increased. In order to avoid recurrence of renal
calculi, which of the
following is the most appropriate pharmacotherapy for
this patient?

A
) Bicarbonate

B
) Calcium lactate

C
) Methenamine mandelate

D
) Probenecid

E
) Thiazide diuretic


34.

A 57-year-old woman is brought to the emergency
department because of
abdominal pain for 12 hours. Over the past 3 hours,
the pain has become
severe and generalized. Over the past month, she has
had mild upper
abdominal discomfort that is relieved by eating. She
has a history of
recurrent migraines treated with sumatriptan as
needed. Her temperature
is 38.2 C (100.8 F), blood pressure is 170/95 mm Hg,
and pulse is
110/min. Abdominal examination shows mild distention;
there is marked
rigidity with diffuse tenderness. Bowel sounds are
absent. Rectal
examination shows no abnormalities; test of the stool
for occult blood is
negative. Laboratory studies show:


Hematocrit 36%
Leukocyte count 16,500/mm3
Serum
Na+ 145 mEq/L
Cl– 106 mEq/L
K+ 3.8 mEq/L
HCO3– 19 mEq/L
Urea nitrogen (BUN) 32 mg/dL

Which of the following is the most appropriate next
step in diagnosis?

A
) X-ray films of the abdomen while supine and
standing

B
) Abdominal ultrasonography

C
) Upper gastrointestinal series with contrast

D
) HIDA scan

E
) Fiberoptic endoscopy of the upper
gastrointestinal tract



35. An 18-year-old man comes to the physician
because of itchy
lesions on his penis for 2 weeks and itching around
his wrists and ankles
for 1 week. He is sexually active and does not
consistently use condoms.
Examination shows scattered, crusted lesions on the
penis and no
significant inguinal lymphadenopathy. There are
excoriated papules on the
wrists and ankles, a few papules between the fingers,
and excoriations
along the belt line. Which of the following is the
most likely
diagnosis?

A
) Disseminated primary herpes simplex

B
) Eczema

C
) Scabies

D
) Secondary syphilis

E
) Vasculitis


36. An asymptomatic 62-year-old man comes for a
follow-up visit.
One month ago, he had acute cystitis treated with
ciprofloxacin. At his
initial visit, a urine culture grew Klebsiella
pneumoniae. He has a
2-year history of chronic prostatitis and has had four
episodes of
cystitis over the past year. His temperature is 36.9
C (98.4 F).
Examination, including prostate examination, shows no
abnormalities. Which of
the following is the most appropriate measure to
prevent recurrent
episodes of cystitis in this patient?

A
) Trimethoprim-sulfamethoxazole prophylaxis

B
) Insertion of a Foley catheter

C
) Total prostatectomy

D
) Transurethral prostatectomy

E
) No treatment is available


37. A 32-year-old woman comes for a routine health
maintenance
examination. Examination shows a bloody discharge
from the nipple of her
left breast. There is no palpable mass. On
questioning, she says that
she never noted the discharge and does not perform
breast
self-examinations. Which of the following is the most
likely diagnosis?

A
) Breast abscess

B
) Breast cyst

C
) Breast hematoma

D
) Fibroadenoma

E
) Fibrocystic changes of the breast

F
) Intraductal adenoma


38. A 35-year-old woman is brought to the physician
by her husband
because of increasing memory loss and involuntary
"dancing" movements
over the past 6 weeks. She has had difficulty
remembering things,
particularly recent events. She has had no
disturbances in sleep or appetite.
Her medical history is unremarkable. She does not
remember her mother
who died 25 years ago, but her father told her that
her mother had
similar symptoms several years before her death.
Neurologic examination
shows involuntary choreiform movements. She has a
childlike affect. She
describes her mood as good. On recall testing, she
can remember one out
of three objects after 3 minutes with distraction; she
cannot remember
the other objects with prompting. She cannot remember
the date of her
marriage or her previous address. The most likely
cause of these
symptoms is a lesion at which of the following
locations?

A
) Caudate nucleus

B
) Parietal lobe

C
) Prefrontal lobe

D
) Putamen

E
) Temporal lobe


39. A 67-year-old man comes to the physician
because of insomnia for
2 years. He goes to bed at 11:00 PM after taking a
bath but does not
fall asleep until midnight. He usually wakes up twice
each night: once
around 3:00 AM to void and again at 6:00 AM. He stays
in bed until his
alarm goes off at 7 AM. He is concerned because he
used to sleep 8
hours daily. He recently retired from his job as an
attorney. He takes
no medications. He drinks one beer with lunch 3 days
each week and one
glass of wine with dinner each evening. He walks 1
mile daily after
dinner. Physical examination shows no abnormalities.
His mood is
neutral, and cognition is intact. Urine toxicology
screening is negative.
Which of the following is the most likely cause of
this patient's
symptoms?

A
) Advanced sleep phase syndrome

B
) Alcohol abuse

C
) Delayed sleep phase syndrome

D
) Major depressive disorder

E
) Melatonin deficiency

F
) Poor sleep hygiene

G
) Normal aging


40. An asymptomatic 37-year-old woman comes for a
follow-up
examination 1 year after receiving a renal transplant.
Current medications
include felodipine, enalapril, cyclosporine,
pravastatin, and penicillin
G. She appears well. Her temperature is 36.8 C (98.2
F), blood
pressure is 160/95 mm Hg, pulse is 80/min, and
respirations are 12/min.
Examination shows no other abnormalities. Which of
the following
medications is the most likely cause of this patient's
hypertension?

A
) Cyclosporine

B
) Enalapril

C
) Felodipine

D
) Penicillin G

E
) Pravastatin


41. A 4080-g (9-lb) male newborn is delivered at
term to a
32-year-old woman, gravida 2, para 1. Apgar scores
are 8 and 9 at 1 and 5
minutes, respectively. Examination in the delivery
room shows fracture of
the right clavicle. Which of the following is the
most likely sequela
of this condition?

A
) Correction only with casting

B
) Correction only with physical therapy

C
) Left-hand dominance

D
) Permanent nerve damage

E
) Spontaneous healing without treatment


42. A 22-year-old man with schizoaffective disorder
is brought to
the emergency department 2 hours after the sudden
onset of neck and back
pain. The symptoms began after taking one of his
medications for his
psychiatric disorder. The dosage was increased
yesterday, but he does
not recall the names of either of his medications. He
has no other
history of serious illness. Physical examination
shows rigid contraction
of the neck and back muscles with arching. On mental
status
examination, he is alert and cooperative and hears a
faint voice that tells him to
wash windows. He is oriented to person, place, and
time. Which of the
following medications is most likely responsible for
this patient's
symptoms?

A
) Clozapine

B
) Haloperidol

C
) Lithium carbonate

D
) Trazodone

E
) Valproic acid

43. A 52-year-old woman, gravida 3, para 3, comes
to the physician
because of irregular vaginal bleeding over the past 2
months. She has
hypertension treated with enalapril and type 2
diabetes mellitus well
controlled with diet. Menopause occurred 2 years ago.
Her maternal aunt
had breast cancer at the age of 70 years. The patient
weighs 88 kg
(195 lb) and is 160 cm (63 in) tall. Examination
shows no other
abnormalities. An endometrial biopsy specimen shows
adenocarcinoma. Which of
the following is the most significant predisposing
factor for this
patient's endometrial cancer?

A
) Heredity

B
) Hypertension

C
) Parity

D
) Type 2 diabetes mellitus

E
) Weight


44. A 67-year-old man is brought to the emergency
department 2 hours
after the onset of weakness and double vision. He has
hypertension and
hyperlipidemia treated with metoprolol, captopril, and
atorvastatin.
His blood pressure is 190/106 mm Hg. Neurologic
examination shows
left-sided facial weakness including the forehead.
There is palsy of left
conjugate gaze, and the left eye fails to adduct on
right gaze.
Vertical eye movements are intact. Muscle strength is
3/5 in the right upper
and lower extremities. Deep tendon reflexes are
brisk, and Babinski's
sign is present on the right. Which of the following
is the most
likely location of this patient's lesion?

A
) Bilateral thalamic

B
) Left frontal

C
) Left pontine

D
) Right caudate

E
) Right midbrain


45. Six weeks after spontaneous drainage of an anal
abscess, a
32-year-old man has persistent blood-stained purulent
fluid on his
underwear. He has not had significant anal pain since
drainage of the boil.
Bowel movements are normal. Which of the following is
the most likely
diagnosis?

A
) Anal fissure

B
) Fistula in ano

C
) Pruritus ani

D
) Thrombosed external hemorrhoids

E
) Thrombosed internal hemorrhoids


46. A previously healthy 14-year-old girl is
brought to the
physician because of a 2-day history of fever and pain
and swelling of the
right knee. She remembers injuring the knee while
playing soccer last
week, but she was able to finish the game. She has no
history of rash or
joint pain. Her sister has inflammatory bowel
disease. The patient's
temperature is 39 C (102.2 F), blood pressure is
110/80 mm Hg, pulse is
95/min, and respirations are 20/min. Examination of
the right knee
shows swelling, tenderness, warmth, and erythema;
range of motion is
limited. Which of the following is the most
appropriate next step in
management?

A
) X-ray film of the right knee

B
) Gastrointestinal series with small-bowel

follow-through

C
) Nuclear scan of the right knee

D
) MRI of the right knee

E
) Antibiotic therapy

F
) Arthrocentesis




block 2

dolly123 - 11/07/06 17:58 #548028




1.

A 25-year-old man is brought to the emergency
department after being
discovered semiconscious and incoherent at home. On
arrival, he is
stuporous. His blood pressure is 105/70 mm Hg, pulse
is 80/min, and
respirations are 12/min. Examination shows cool, damp
skin. The pupils are
pinpoint and react sluggishly to light. Which of the
following is the
most likely substance taken?

A
) Alcohol

B
) Barbiturates

C
) Cocaine

D
) Heroin

E
) LSD



2. A 15-year-old girl is brought to the emergency
department by her
20-year-old sister because of a 1-week history of
fatigue, nausea, and
abdominal pain. Menarche was at the age of 12 years,
and her last
menstrual period was 3 weeks ago. She has not had
vaginal discharge. She
is sexually active, and she and her partner use
condoms inconsistently.
Her temperature is 37 C (98.6 F), blood pressure is
110/60 mm Hg, and
pulse is 95/min. Abdominal examination shows mild
bilateral lower
quadrant tenderness. Before a pelvic examination and
a pregnancy test can
be performed in this patient, consent must be obtained
from which of the
following?

A
) The court

B
) The patient

C
) The patient's parent

D
) The patient's sister

E
) No consent is necessary



3. A previously healthy 57-year-old man comes to
the physician
because of a nonpruritic rash over both legs for 1
week and a low-grade
fever for 2 days. He recently returned from a 2-week
canoe trip on a river
in Minnesota. His temperature is 37.2 C (99 F).
Examination shows a 4
x 6-cm, macular, dark pink, ovoid lesion on the right
posterior hip
with central clearing and a punctate eschar near the
center. There are
macular ring lesions with central clearing over the
medial tibia and
anterior thighs of the lower extremities. He has no
lymphadenopathy.
Which of the following is the most likely causal
organism?

A
) Borrelia burgdorferi

B
) Brucella melitensis

C
) Francisella tularensis

D
) Leptospira interrogans

E
) Rickettsia rickettsii


4. A 57-year-old woman comes to the physician
because of a 2-year
history of increasing menstrual flow. She has not had
hot flashes,
insomnia, or change in bowel or bladder function. Her
last menstrual period
was 2 weeks ago. Pelvic examination shows a
normal-appearing vulva,
vagina, and cervix. The uterus is consistent in size
with an 8-week
gestation. Bimanual examination shows a 4-cm, firm,
nontender left ovary. An
endometrial biopsy specimen shows atypical complex
endometrial
hyperplasia. Which of the following is the most likely
cause of this patient's
hyperplasia?

A
) Adrenal adenoma

B
) Brenner tumor

C
) Carcinoid tumor

D
) Granulosa cell tumor

E
) Hyperthecosis

F
) Islet cell tumor

G
) Sertoli-Leydig cell tumor


5. A 67-year-old woman comes to the physician
because of vaginal
bleeding for 10 days. She has been soaking one
sanitary pad daily.
Menopause was 10 years ago. Her last Pap smear 5
years ago showed normal
findings. Her temperature is 37 C (98.6 F), blood
pressure is 128/78 mm
Hg, pulse is 70/min, and respirations are 12/min.
Pelvic examination
shows a normal-appearing cervix and a small amount of
blood at the
cervical os. There is moderate thinning of the
vaginal mucosa. The uterus
is irregular and consistent in size with a 10-week
gestation. There
are no adnexal masses. Rectovaginal examination shows
no abnormalities.
Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in diagnosis?

A
) Transvaginal ultrasonography of the pelvis

B
) Colposcopic-guided biopsy

C
) Endometrial biopsy

D
) Endometrial ablation

E
) Culdocentesis


6. During a routine examination, a 32-year-old man
has a blood
pressure of 120/80 mm Hg. He is concerned because his
father, grandfather,
and two uncles have hypertension. He works as a
systems programmer for
a large computer company and frequently has to meet
tight deadlines.
He has smoked one pack of cigarettes daily for 10
years. He is 4.5 kg
(10 lb) overweight and drinks three cups of coffee
daily. Which of the
following measures is most likely to reduce this
patient's risk for
hypertension over the next 5 years?

A
) Increase intake of dietary fiber

B
) Restrict caffeine

C
) Stress management

D
) Weight loss


7. A previously healthy 16-year-old boy comes to
the physician
because of persistent pain in his left testicle for 24
hours. He has not
had any penile discharge. There is no history of
trauma, but he plays
soccer every day. Two months ago, he had sexual
intercourse for the
first time, and he used a condom. Examination shows
an edematous,
erythematous, exquisitely tender left scrotum that is
lower than the right.
Elevating the left testicle relieves the pain. The
cremasteric reflex is
present. Urinalysis shows 10 leukocytes/hpf and 1+
leukocyte esterase.
A technetium 99m scan shows increased uptake in the
left testicle.
Which of the following is the most likely cause of the
pain?

A
) Cystitis

B
) Epididymitis

C
) Spermatocele

D
) Testicular torsion

E
) Testicular tumor


8. A 47-year-old woman comes to the physician
because of persistent
nonproductive cough for 6 weeks. She has not had
fever or weight loss.
She has hypertension treated with enalapril for the
past 3 months. She
does not smoke. There is no history of lung disease.
She weighs 54 kg
(120 lb) and is 163 cm (64 in) tall. Her temperature
is 37 C (98.6 F),
blood pressure is 130/80 mm Hg, pulse is 70/min, and
respirations are
12/min. Examination and an x-ray film of the chest
show no
abnormalities. Which of the following is the most
likely mechanism of this
patient's cough?

A
) Decreased plasma renin activity

B
) Decreased serum angiotensin II levels

C
) Increased serum angiotensin I levels

D
) Increased serum bradykinin levels

E
) Increased serum histamine levels


9. A 57-year-old man has been hospitalized for 2
days for treatment
of unstable angina pectoris. He is currently
receiving intravenous
heparin and undergoing evaluation for coronary artery
bypass grafting.
His blood pressure is 160/90 mm Hg, pulse is 88/min,
and respirations are
16/min. Laboratory studies show:

Platelet count 90,000/mm3
Prothrombin time 12 sec (INR=1.1)
Partial thromboplastin time 35 sec

Which of the following is the most likely cause of
these findings?

A
) Excessive platelet destruction

B
) Factor VIII deficiency

C
) Inadequate platelet production

D
) Uncontrolled activation of coagulation and
fibrinolytic cascades

E
) Vitamin K deficiency


10. A study is conducted to assess the
effectiveness of a new blood
test for early detection of prostate cancer. Ten
thousand healthy men
over the age of 50 years are randomly assigned to
receive either annual
rectal examination or annual screening with the new
blood test. After
5 years, results show that of the 50 men in the blood
test group that
were diagnosed with prostate cancer, 40 were living 2
years after the
diagnosis was made. In comparison, only 15 out of 45
men in the rectal
examination group survived 2 years after being
diagnosed with prostate
cancer. Researchers conclude that the blood test
increases survival
compared with rectal examination. Which of the
following potential flaws
is most likely to invalidate this conclusion?

A
) Age of the patients

B
) Diagnostic bias

C
) Lead time bias

D
) Recall bias

E
) Type II error


11.

A 62-year-old man comes to the emergency department
because of
progressive shortness of breath for 3 days. He has
not had chest pain,
orthopnea, or paroxysmal nocturnal dyspnea. He
completed chemotherapy for
small cell carcinoma of the lung 10 months ago. He
has a history of twice
nightly nocturia that has resolved over the past 3
days. He smoked two
packs of cigarettes daily for 30 years but quit 1 year
ago. His blood
pressure is 96/60 mm Hg, and pulse is 116/min. There
is jugular venous
distention to the angle of the jaw. The lungs are
clear to
auscultation. Cardiac examination shows distant heart
sounds, an S1 and S2, and no
gallops or rubs. The liver has a span of 12 cm and is
tender. There
is no pedal edema. Laboratory studies show:


Hemoglobin 10 g/dL
Serum
Na+ 135 mEq/L
Cl– 110 mEq/L
K+ 4.2 mEq/L
HCO3– 22 mEq/L
Urea nitrogen (BUN) 40 mg/dL
Creatinine 1.6 mg/dL

An ECG shows diminished amplitude of the QRS
complexes. An x-ray film
of the chest shows clear lung fields with an enlarged
cardiac
silhouette. Which of the following findings is most
likely to be accentuated?

A
) Cardiac output

B
) Fall in systolic arterial pressure with
inspiration

C
) Left ventricular end-diastolic pressure

D
) Mitral regurgitation

E
) Ventricular septal wall motion



12. A 35-year-old woman comes to the physician
because of two
12-hour episodes of dizziness over the past 3 months.
During episodes, she
experiences the acute onset of rotatory vertigo and
imbalance, decreased
hearing, tinnitus, a sense of fullness of the right
ear, and vomiting.
Examination shows a mild hearing loss of the right
ear. Which of the
following is the most likely diagnosis?

A
) Acoustic neuroma

B
) Benign positional vertigo

C
) Brain stem transient ischemic attacks

D
) Meniere's disease

E
) Viral labyrinthitis


3. An obese 33-year-old woman has had four 12-hour
episodes of
severe, sharp, penetrating pain in the right upper
quadrant of the abdomen
associated with vomiting but no fever. She has no
diarrhea, dysuria, or
jaundice and is asymptomatic between episodes. There
is slight
tenderness to deep palpation in the right upper
quadrant. Which of the
following is the most appropriate next step in
diagnosis?

A
) Supine and erect x-ray films of the abdomen

B
) Upper gastrointestinal series

C
) Ultrasonography of the upper abdomen

D
) CT scan of the abdomen

E
) HIDA scan of the biliary tract

14. An otherwise healthy 19-year-old woman comes to
the physician
because of a 3-year history of intermittent facial
blemishes. She drinks
wine occasionally on weekends. She takes no
medications. Examination
shows multiple 1- to 2-mm red and white papules and
larger red nodules
on the forehead and cheeks. Which of the following is
the most
appropriate initial pharmacotherapy?

A
) Oral isotretinoin

B
) Systemic corticosteroids

C
) Topical benzoyl peroxide

D
) Topical corticosteroids

E
) Topical metronidazole



15. A previously healthy 67-year-old man comes to
the physician
because of a 4-month history of hand weakness,
intermittent tingling of the
small fingers of his hands, and mild neck pain.
Examination shows
wasting, weakness, and fasciculations of the
interossei muscles. Sensation
is decreased to pinprick and vibration in the small
fingers of each
hand. Triceps tendon reflexes are decreased. Which
of the following is
the most likely diagnosis?

A
) Amyotrophic lateral sclerosis

B
) Cervical spondylosis

C
) Multiple sclerosis

D
) Myasthenia gravis

E
) Myasthenic (Lambert-Eaton) syndrome

F
) Myotonic muscular dystrophy

G
) Polymyalgia rheumatica

H
) Polymyositis

I
) Progressive neuropathic (peroneal) muscular

atrophY



16. A 19-year-old college student comes to student
health services
because of constant worrying since starting his
freshman year 6 months
ago. He attends college several hundred miles away
from his hometown.
He reports feeling constantly scrutinized by other
students and
professors. He feels embarrassed and anxious in class
and is in constant fear
of blushing. He has started to skip his classes
because of his anxiety
and worries that he will not be able to complete the
school year. He
drinks alcohol occasionally because it helps him
overcome his fear of
being embarrassed in front of others. He does not use
illicit drugs.
Physical examination shows no abnormalities. On
mental status
examination, he is mildly anxious. He exhibits fair
eye contact and shifts
uncomfortably in his chair. Laboratory studies are
within normal limits.
Which of the following is the most appropriate
pharmacotherapy for this
patient?

A
) Disulfiram

B
) Donepezil

C
) Fluoxetine

D
) Haloperidol

E
) Methylphenidate

F
) Valproic acid


17.

A 42-year-old woman comes for a follow-up examination.
Two weeks ago,
her blood pressure was 152/94 mm Hg during a routine
visit. Her blood
pressure today is 150/94 mm Hg, pulse is 76/min, and
respirations are
14/min. Examination shows no other abnormalities.
Serum studies show:


Na+ 142 mEq/L
Cl– 105 mEq/L
K+ 4 mEq/L
HCO3– 26 mEq/L
Urea nitrogen (BUN) 12 mg/dL
Glucose 101 mg/dL
Creatinine 0.8 mg/dL

An ECG shows no abnormalities. Which of the following
is the most
appropriate next step in management?

A
) Measurement of plasma renin activity

B
) Serum lipid studies

C
) 24-Hour urine collection for measurement of
metanephrine level

D
) Echocardiography

E
) Captopril renal scan


18. A 6-year-old boy with cystic fibrosis is
brought to the
physician by his mother because his skin has been cool
and clammy for 30
minutes. Earlier in the day, he had been playing
outdoors, and the
temperature was 99 F. When returning indoors, he was
thirsty and restless. His
blood pressure is 70/40 mm Hg, and pulse is 120/min.
Examination shows
dry mucous membranes. Serum sodium level is 128
mEq/L, and serum
chloride level is 87 mEq/L. Which of the following is
the most likely
explanation for these findings?

A
) Excessive sweat electrolyte level

B
) Excessive sweat volume

C
) Excessive urinary output

D
) Excessive vasopressor secretion

E
) Inadequate sweat production



19.

A 27-year-old primigravid woman at 29 weeks' gestation
comes to the
emergency department because of a 24-hour history of
increasingly severe
right-sided abdominal pain and no appetite. She has
vomited twice over
the past 4 hours. She has not had vaginal bleeding.
Her temperature
is 38.2 C (100.8 F). Examination shows exquisite
tenderness of the
right lateral flank and the fundus. There are no
peritoneal signs. Bowel
sounds are absent. The fetal heart rate is 144/min.
Laboratory
studies show:


Hematocrit 37%
Leukocyte count 16,000/mm3
Serum
Total bilirubin 1.1 mg/dL
Amylase 32 U/L
Lactate dehydrogenase 110 U/L
Urine WBC 3–5/hpf

Which of the following is the most likely diagnosis?

A
) Abruptio placentae

B
) Appendicitis

C
) Cholelithiasis

D
) Colitis

E
) Pyelonephritis


20. A 32-year-old woman has had a lump in her neck
for 6 months.
She has a 1.2-cm solitary left thyroid nodule.
Fine-needle aspiration
cytology of the mass is consistent with a low-grade
papillary malignancy.
Which of the following is the most appropriate next
step in management?

A
) Thyroid scan

B
) 131I therapy

C
) Propylthiouracil therapy

D
) Thyroxine therapy

E
) Left thyroid lobectomy


For each patient with vaginal bleeding, select the
most likely
diagnosis.


A
) Bacterial vaginosis

B
) Precocious puberty

C
) Urinary tract infection

D
) Vaginal foreign body

E
) Vaginal laceration

F
) von Willebrand's disease

21. A 12-year-old girl is brought to the physician
by her mother
because of heavy vaginal bleeding since her first
menstrual period began 1
week ago. She has to change sanitary pads every 2
hours, and her
mother is concerned that this is not normal. Her
blood pressure is 80/60 mm
Hg, and pulse is 110/min. Breast and axillary and
pubic hair
development are Tanner stage 4. Pelvic examination
shows normal external
genitalia, a small normal-appearing cervix, and a
small uterus. Her
hemoglobin level is 7 g/dL.



22. A 7-year-old girl is brought to the physician
by her mother 4
hours after she noticed that her daughter had blood on
her underwear.
She has no signs of sexual development. Examination
shows normal
external genitalia. There is a foul-smelling
discharge.


23.

A 10-year-old girl is brought to the physician because
of temperatures
to 40 C (104 F) and headaches for 1 week. Her mother
says that fever
and chills occur every other day and typically last
for several hours.
She appears ill and is lethargic during febrile
episodes. She and her
family returned from a trip to West Africa 2 weeks
ago. She currently
appears ill. Her temperature is 40 C (104 F), blood
pressure is 94/64
mm Hg, pulse is 146/min, and respirations are 20/min.
Examination shows
mild scleral icterus and conjunctival pallor. The
liver edge is
palpated 3 cm below the right costal margin, and the
spleen tip is palpated 3
cm below the left costal margin. Laboratory studies
show:


Hemoglobin 8 g/dL
Leukocyte count 6400/mm3
Segmented neutrophils 46%
Eosinophils 5%
Lymphocytes 40%
Monocytes 9%
Serum
Na+ 132 mEq/L
Cl– 98 mEq/L
K+ 4.2 mEq/L
HCO3– 16 mEq/L
Urea nitrogen (BUN) 21 mg/dL
Bilirubin
Total 5.2 mg/dL
Direct 0.8 mg/dL
Aspartate aminotransferase (AST, GOT) 64 U/L
Alanine aminotransferase (ALT, GPT) 98 U/L
Urine
Color tea
Blood strongly positive
RBC occasional

Which of the following measures is most likely to have
prevented this
condition?

A
) Hepatitis A vaccine

B
) Typhoid vaccine

C
) Oral isoniazid prophylaxis

D
) Oral mefloquine prophylaxis

E
) Oral trimethoprim-sulfamethoxazole prophylaxis

F
) Intramuscular immune globulin



24. A 6-month-old boy is brought to the physician
because of
seizures over the past week. His parents note that
during this period, he has
had 10 to 20 episodes of throwing out his arms for 1
to 2 seconds then
crying as if he were afraid of something. He was born
at term
following an uncomplicated pregnancy and delivery.
Development is appropriate
for age. Two days ago, treatment with amoxicillin was
begun for otitis
media. He appears pale and apathetic. Examination
shows multiple
white patches over the skin that become more distinct
with Wood's lamp
examination. Neurologic examination shows no
abnormalities. An MRI of the
brain is shown. Which of the following is the most
likely diagnosis?

A
) Congenital cytomegalovirus encephalopathy

B
) Congenital toxoplasmosis encephalopathy

C
) Hypoxic-ischemic encephalopathy

D
) Neurofibromatosis

E
) Tuberous sclerosis


25.

An ELISA is used to detect Chlamydia trachomatis
infection in patients
seen at a family planning clinic. In the first 500
patients, cultures
are also done to check the accuracy of the ELISA. The
results are
listed below:


Chlamydia culture
+

-

ELISA
+

38
5
-

2


455


Which of the following is the positive predictive
value of the ELISA?

A
) 2/40

B
) 5/43

C
) 38/40

D
) 38/43

E
) 38/493



26. A 27-year-old woman is brought to the emergency
department by
her mother who found her comatose 30 minutes ago. Her
mother says that
her daughter had been having lower abdominal pain and
vaginal bleeding
over the past week. The patient had an ectopic
pregnancy 2 years ago
and was also treated with doxycycline for pelvic
inflammatory disease at
that time. Her blood pressure is 40/20 mm Hg, pulse
is 160/min, and
respirations are 24/min. The abdomen is distended and
rigid with
decreased bowel sounds. Hemoglobin level is 4.2 g/dL,
and leukocyte count is
12,500/mm3. Culdocentesis is positive. Which of the
following is the
most appropriate next step in management?

A
) Bromocriptine therapy

B
) Clomiphene therapy

C
) Conjugated estrogen therapy

D
) Ergot derivative therapy

E
) Hysteroscopy

F
) Laparoscopy

G
) Dilatation and curettage

H
) Endometrial ablation

I
) Exploratory laparotomy

J
) Total abdominal hysterectomy



27. A 43-year-old man comes to the emergency
department because of
fever, chills, malaise, cough, and pleuritic chest
pain for 3 days; the
cough is productive of foul-smelling, purulent sputum.
He has
alcoholism. His temperature is 39.2 C (102.6 F),
blood pressure is 110/70 mm
Hg, pulse is 120/min, and respirations are 14/min.
Hemoglobin level is
15 g/dL, and leukocyte count is 25,000/mm3. An ECG
shows normal
findings. An x-ray film of the chest shows a 4-cm
cavity in the superior
segment of the right lower lobe and an air-fluid
level. While awaiting
results of sputum culture, which of the following is
the most appropriate
next step in management?

A
) Observation

B
) Broad-spectrum antibiotic therapy

C
) Isoniazid therapy

D
) Intravenous amphotericin B therapy

E
) Tube thoracostomy


28.

A 12-year-old girl with type 1 diabetes mellitus is
brought to the
physician because of shortness of breath and fatigue
for 1 day. Since
menarche began 4 months ago, she has had one episode
of diabetic
ketoacidosis per month; prior to that she had been
stable. Her blood pressure is
110/70 mm Hg, pulse is 140/min, and respirations are
36/min. She
appears to be moderately dehydrated. Laboratory
studies show:


Serum
Na+ 132 mEq/L
Cl– 90 mEq/L
K+ 5.9 mEq/L
HCO3– 6 mEq/L
Urea nitrogen (BUN) 48 mg/dL
Glucose 600 mg/dL
Creatinine 2.8 mg/dL
Urine
Glucose 4+
Ketones 3+
Protein 1+

Which of the following is the most likely underlying
cause of this
patient's respiratory disorder?

A
) Acute interstitial nephritis

B
) Acute renal failure

C
) Diabetic nephropathy

D
) Hyperinsulinemia

E
) Increased plasma ketone level


29. A 28-year-old woman develops fatigue and
orthopnea 3 weeks after
the uncomplicated delivery of her first child. Her
blood pressure is
115/78 mm Hg, and pulse is 112/min. Crackles are
heard at both lung
bases. The point of maximal impulse is laterally
displaced and diffuse;
an S3 is present. There is 2+ pedal edema. An x-ray
film of the chest
shows vascular cephalization of pulmonary vasculature
and Kerley B lines.
Which of the following is the most appropriate next
step in management?

A
) Measurement of serum creatine kinase and lactate
dehydrogenase
activities

B
) Echocardiography

C
) Dipyridamole thallium scan

D
) Ventilation-perfusion lung scans

E
) Myocardial biopsy


30. A previously healthy 22-year-old woman comes to
the physician
because of a paroxysmal cough for 2 weeks. She works
as an oncology
nurse. Her temperature is 37 C (98.6 F). Examination
shows no
abnormalities except for intermittent coughing spells
during the examination. An
x-ray film of the chest is normal. Cultures of
nasopharyngeal
secretions grow Bordetella pertussis. Which of the
following is the most
appropriate pharmacotherapy for this patient?

A
) Amoxicillin

B
) Amoxicillin-clavulanate

C
) Cefprozil

D
) Erythromycin

E
) Penicillin G


31. A 5-year-old girl is brought to the physician
because of a 2-day
history of temperatures to 39.5 C (103.1 F) and pain
in the right side.
She has had two episodes of vomiting during this
period but no diarrhea
or symptoms of upper respiratory tract infection. She
has
vesicoureteral reflux and a history of recurrent
urinary tract infections. She
appears ill. Her temperature is 39.8 C (103.6 F),
blood pressure is
110/60 mm Hg, pulse is 150/min, and respirations are
25/min. Examination
shows right-sided costovertebral angle tenderness. In
addition to
obtaining urine cultures, which of the following is
the most appropriate next
step in management?

A
) Intravenous pyelography

B
) Renal ultrasonography

C
) Voiding cystourethrography

D
) Intramuscular antibiotic therapy and
reexamination in 24 hours

E
) Intravenous antibiotic therapy


32. A 10-year-old boy is brought to the physician
because of
weakness and decreased appetite for 3 months. He
weighs 30 kg (66 lb) and is
142 cm (56 in) tall; he has had a 2.3-kg (5-lb) weight
loss since his
last examination 6 months ago. He appears thin. Deep
tendon reflexes
are brisk. Chvostek's sign is positive. His serum
calcium level is 6.5
mg/dL, and serum intact parathyroid hormone level is
190 pg/mL
(N=9–65). In addition to calcium supplementation,
which of the following is
the most appropriate next step in management?

A
) Oral phosphate supplementation

B
) Oral vitamin D supplementation

C
) Intranasal calcitonin therapy

D
) Parenteral bisphosphate therapy

E
) Parenteral parathyroid hormone therapy


33. A healthy 8-year-old girl is brought to the
physician in July
for a well-child examination. Her mother says that
her daughter is
spending the summer at a nearby lake. Over the past
month, she has had two
episodes of painful sunburn despite her mother's
efforts, including SPF
25 sunblock just before she goes swimming and urging
her to wear a hat
and long-sleeved garments. The child takes no
medications. She has
blond hair, blue eyes, and a fair complexion. The
mother seeks advice
about preventing further sun damage to her child's
skin. Which of the
following is the most appropriate recommendation?

A
) Prohibit swimming on cloudless days

B
) Apply the sunblock lotion 45 minutes before
swimming

C
) Change to a higher-level SPF lotion

D
) Apply Burrow's solution compresses after each
overexposure

E
) Daily use of antioxidant vitamin supplement

F
) Early treatment of any sun overexposure with
topical
corticosteroids





34. Two days after admission to the hospital
because of a 3-day
history of slurred speech, double vision, and
dysphagia, a 24-year-old
woman becomes quadriplegic and requires intubation and
mechanical
ventilation. Her medical history is unremarkable.
One week ago, she attended a
family picnic; several of her family members have had
abdominal cramps
and diarrhea since the picnic. Her temperature is 37
C (98.6 F), blood
pressure is 120/80 mm Hg, and pulse is 120/min.
Examination shows dry
mucous membranes, large unreactive pupils,
ophthalmoplegia, and
profound facial weakness. There is areflexia,
quadriplegia, and no movement
of the palate and tongue. Sensation is normal.
Babinski's sign is
absent. Which of the following is the most
appropriate pharmacotherapy?

A
) Antitoxin

B
) Azathioprine

C
) Interferon

D
) Pyridostigmine

E
) Riluzole



35. A 2325-g (5 lb 2 oz) male newborn is delivered
at 33 weeks'
gestation; Apgar scores are 7 and 8 at 1 and 5
minutes, respectively. The
13-year-old mother had no prenatal care and did not
know how much
weight she gained. During the pregnancy, the mother
smoked marijuana and
took over-the-counter vitamins occasionally; she did
not drink alcohol
and had no illness except for an upper respiratory
tract infection 4
months ago. She did not know she was pregnant until 2
weeks ago; her
family is unaware of her condition. She has had one
sexual partner. During
the hospital stay, the newborn and his mother have no
complications.
The newborn is at greatest risk for morbidity and
mortality from which
of the following?

A
) Child abuse

B
) Congenital syphilis

C
) Hypocalcemia

D
) Lead poisoning

E
) Seizures


36. A 2-month-old girl is brought to the physician
because of a
2-week history of progressive difficulty breathing and
poor feeding. She
has had rapid and labored breathing and sweating
during feedings. There
is no history of fever or viral illness. Her
temperature is 37 C (98.6
F), blood pressure is 80/60 mm Hg, pulse is 130/min,
and respirations
are 40/min. Bilateral crackles are heard at both lung
bases. A grade
4/6 holosystolic murmur is heard along the left
sternal border; the
precordium is hyperdynamic. The liver edge is
palpated 4 cm below the
right costal margin. An x-ray film of the chest shows
cardiomegaly and
pulmonary congestion. Which of the following is the
most likely
underlying mechanism for this child's condition?

A
) Decreased systemic vascular resistance

B
) Increased pulmonary vascular resistance

C
) Increased systemic vascular resistance

D
) Intracardiac left-to-right shunt

E
) Intracardiac right-to-left shunt



37. A 37-year-old man comes to the physician 6
months prior to
traveling to sub-Saharan Africa for 1 year. He has no
history of hepatitis
and has no high-risk behavior for hepatitis B. Which
of the following
is the most appropriate recommendation to prevent
hepatitis during and
after his trip?

A
) Immune globulin

B
) Hepatitis B immune globulin (HBIG) only

C
) Hepatitis B vaccine series only

D
) Hepatitis B vaccine series and HBIG

E
) Hepatitis B vaccine series and hepatitis A
vaccine



38.

A 67-year-old man comes to the physician because of a
2-month history
of progressive shortness of breath. He has had a
4.5-kg (10-lb) weight
loss over the past 4 months. He has not had chest
pain. He has
congestive heart failure treated with furosemide,
digoxin, and enalapril. He
has smoked two packs of cigarettes daily for 30 years.
He appears
alert and is in no acute distress. His temperature is
37.2 C (99 F), blood
pressure is 140/85 mm Hg, pulse is 84/min, and
respirations are 18/min.
Examination shows no jugular venous distention. There
is dullness to
percussion, and breath sounds are decreased at the
left base. Cardiac
examination shows a laterally displaced point of
maximal impulse, normal
S1 and S2, and an S3 at the apex. There is 1+ edema
over the
extremities. An x-ray film of the chest shows an
enlarged cardiac silhouette,
left hilar fullness, and a moderate-sized left pleural
effusion.
Thoracentesis yields straw-colored fluid. Laboratory
studies show:


Serum
Glucose 90 mg/dL
Protein 7 g/dL
Lactate dehydrogenase 300 U/L
Pleural fluid
pH 7.25
Glucose 75 mg/dL
Protein 4.5 g/dL
Lactate dehydrogenase 280 U/L
Leukocyte count 2000/mm3
Segmented neutrophils 15%
Lymphocytes 85%

A Gram's stain and acid-fast stains are negative for
any organisms.
Which of the following is the most likely cause of
this patient's pleural
effusion?

A
) Bacterial pneumonia

B
) Collagen vascular disease

C
) Congestive heart failure

D
) Malignancy

E
) Pulmonary embolus with infarction

F
) Viral pleuritis


39. A previously healthy 67-year-old woman is
admitted to the
hospital because of a 2-week history of dark urine,
clay-colored stools, and
increasing jaundice. She has had a 9-kg (20-lb)
weight loss over the
past 2 months due to loss of appetite. She also has
had generalized
itching that is most severe at night. She has not had
any abdominal pain.
Examination shows no abnormalities except for
jaundice. Which of the
following is the most likely diagnosis?

A
) Common bile duct stone

B
) Drug-induced jaundice

C
) Hemolytic jaundice

D
) Pancreatic carcinoma

E
) Viral hepatitis


40. A 2-year-old boy is brought to the physician
because of fever
and listlessness for 12 hours. He has had recurrent
episodes of
pneumonia and otitis media over the past year. Two
maternal uncles died of
pneumonia in early childhood. One year ago, he was at
the 50th percentile
for height and weight; he is currently at the 25th
percentile for
height and 10th percentile for weight. He appears
ill. His temperature is
39 C (102.2 F), blood pressure is 60/40 mm Hg, pulse
is 160/min, and
respirations are 36/min. Examination shows cool and
mottled extremities.
A blood culture grows Streptococcus pneumoniae. Serum
IgE, IgG, and
IgM levels are markedly decreased. Which of the
following diagnostic
tests is most likely to be abnormal?

A
) Candidal skin test

B
) Flow cytometry identification of B lymphocytes

C
) Nitroblue tetrazolium test

D
) T-lymphocyte receptor stimulation by concanavalin
A

E
) Total serum hemolytic complement assay





41. A 1-week-old newborn has had poor feeding,
vomiting, and
progressive lethargy over the past 4 days. She was
born at term; pregnancy,
labor, and delivery were uncomplicated, and she had no
congenital
anomalies. She is being breast-fed. She has a
healthy 2-year-old brother; a
sister died at 10 days of age after a full-term birth.
Examination
shows decreased muscle tone and poor responsiveness;
reflexes are normal.
Serum bicarbonate level is 8 mEq/L, pH is 7.15, and
plasma ammonia
level is 10 times the upper limit of normal. Which of
the following is the
most likely cause?

A
) Mitochondrial disorder

B
) Mucopolysaccharidoses disorder

C
) Organic acid metabolism disorder

D
) Renal tubular acidosis

E
) X-linked leukodystrophy


For each patient with an infection, select the most
likely causal
organism.


A
) Chlamydia trachomatis

B
) Clostridium botulinum

C
) Clostridium tetani

D
) Group A streptococcus

E
) Group B streptococcus

F
) Listeria monocytogenes

G
) Neisseria gonorrhoeae

H
) Streptococcus pneumoniae

42.

A premature 18-hour-old newborn is intubated and
mechanically
ventilated because of progressive respiratory
distress. Labor was complicated
by maternal fever and increased leukocyte count;
membranes ruptured 36
hours before delivery. His blood pressure and urine
output have
decreased since birth. The newborn appears acutely
ill, and peripheral pulses
are not palpable; the skin is pale, cool, and mottled.
The liver edge
is palpable 4 cm below the right costal margin. His
leukocyte count is
5000/mm3, platelet count is 48,000/mm3, and partial
thromboplastin time
is 60 sec. An x-ray film of the chest shows diffuse,
bilateral,
interstitial infiltrates.



43. A 6-year-old boy has been unable to walk for 2
days because of a
sore right knee. Three weeks ago he had a sore throat
and fever that
resolved within 2 days. He appears acutely ill. His
temperature is 39.2
C (102.5 F), and pulse is 120/min. A grade 2/6
pansystolic murmur is
heard at the apex. The right knee is red, tender, and
swollen; any
motion is painful. His leukocyte count is 15,000/mm3,
and erythrocyte
sedimentation rate is 120 mm





44. A 70-year-old woman comes to the physician
because of fatigue
and increasing difficulty in her daily functioning
over the past 2
months. During the day, she lies in bed for hours and
cries. She has had a
10.9-kg (24-lb) weight loss over the past 4 weeks,
eats only cookies,
has lost interest in almost everything, and wishes to
kill herself. Her
husband died 4 months ago. Physical examination and
laboratory studies
show normal findings except for decreased serum
albumin and total
protein levels. Which of the following is the most
likely diagnosis?

A
) Adjustment disorder with depressed mood

B
) Bereavement

C
) Bipolar disorder, depressed

D
) Dysthymic disorder

E
) Major depressive disorder




45. A 42-year-old woman comes to the physician
because of increasing
low back pain for 2 days. She is a daily intravenous
drug user. She
has a history of pyelonephritis, abscesses at
injection sites, and
pelvic inflammatory disease. Her temperature is 39 C
(102.2 F), blood
pressure is 130/70 mm Hg, pulse is 84/min, and
respirations are 20/min.
Examination shows warm, dry skin, a supple neck, and
no jugular venous
distention. There is tenderness over L4. Pelvic
examination shows mild
erythema around the cervical os and scant discharge;
there is no adnexal
or cervical motion tenderness. Her hematocrit is 30%,
leukocyte count
is 10,600/mm3, and serum glucose level is 110 mg/dL.
Urinalysis is
within normal limits. Which of the following is the
most appropriate next
step in management?

A
) Echocardiography

B
) Renal ultrasonography

C
) MRI of the back

D
) Colposcopy

E
) Laparoscopy


46. A 13-year-old boy is brought to the physician
by his mother
because of frequent headaches over the past 5 weeks.
He describes the
headaches as dull pain across his forehead; they occur
four to five times
weekly. Acetaminophen does not relieve the pain. His
mother states
that occasionally he has nausea without vomiting. He
has schizophrenia
well controlled with risperidone. Physical
examination shows no
abnormalities. An MRI of the brain is most likely to
show which of the
following?

A
) Bilateral increased caudate nuclei

B
) Decreased cerebellar volume

C
) Hippocampal symmetry

D
) Increased lateral ventricle size

E
) Multiple white-matter hyperintensities
Report Abuse

* block 3:---

dolly123 - 11/07/06 17:59 #548031



1. A 42-year-old woman, gravida 2, para 2, comes to
the physician
because of a 3-month history of swelling of her legs
and mild abdominal
pain and bloating. Abdominal examination shows no
abnormalities.
Rectovaginal examination shows fullness in the right
adnexa. Transvaginal
ultrasonography shows an irregular mass in the right
ovary with some
solid components to a predominantly cystic lesion.
Her serum CA 125 level
is 120 U/mL (N<35). Treatment with which of the
following is most
likely to have prevented this patient's symptoms?

A
) Antiestrogens

B
) Antiprogestationals

C
) Medroxyprogesterone

D
) Oral contraceptives

E
) Ovulation-inducing drugs




2. A 15-year-old girl is brought to the physician 3
months after she
had a blood pressure of 150/95 mm Hg at a routine
examination prior to
participation in school sports. She is asymptomatic
and has no history
of serious illness. Twelve months ago, she was
diagnosed with a
urinary tract infection and treated with oral
trimethoprim-sulfamethoxazole.
She currently takes no medications. Subsequent blood
pressure
measurements on three separate occasions since the
last visit have been: 155/94
mm Hg, 145/90 mm Hg, and 150/92 mm Hg. She is at the
50th percentile
for height and 95th percentile for weight. Her blood
pressure today is
150/90 mm Hg confirmed by a second measurement, pulse
is 80/min, and
respirations are 12/min. Examination shows no other
abnormalities. Her
hematocrit is 40%. Urinalysis is within normal limits.
Cardiac and
renal ultrasonography shows no abnormalities. Which
of the following is
the most appropriate next step in management?

A
) Exercise and weight reduction program

B
) Measurement of urine catecholamine levels

C
) Measurement of urine corticosteroid levels

D
) Captopril therapy

E
) Hydrochlorothiazide therapy



3. Over the past 4 years, a 40-year-old woman has
had increasing
episodes of loss of urine and difficulty emptying her
bladder. She has
had no dysuria. She has a 30-year history of type 1
diabetes mellitus.
She weighs 66 kg (145 lb) and is 175 cm (69 in) tall.
Pelvic
examination shows a moderate cystocele. Postvoiding
catheterization yields 700
mL of clear urine. Which of the following is the most
likely cause of
the patient's genitourinary symptoms?

A
) Carcinoma of the bladder

B
) Detrusor instability

C
) Neurogenic bladder

D
) Urethral diverticulum

E
) Uterine prolapse



4. A 57-year-old man comes to the emergency
department because of an
episode of confusion, nervousness, sweating, and
palpitations 1 hour
ago. He has had four similar episodes over the past 3
weeks; they last 2
to 3 minutes and are relieved by ingesting solid food
or liquids. His
blood pressure is 140/74 mm Hg, pulse is 76/min, and
respirations are
18/min. Examination shows no other abnormalities.
The most appropriate
next step in diagnosis is serum measurement of which
of the following?

A
) Fasting gastrin level

B
) Fasting insulin and glucose levels

C
) Glucagon level

D
) Glucose and somatostatin level

E
) Glucose and vasoactive intestinal

5. An otherwise healthy 15-year-old girl is brought
to the physician
because she has never had a menstrual period. She
reports that breast
development started 1 year ago and pubic and axillary
hair development
began 6 months ago. Examination shows normal
genitalia. Breast
development is Tanner stage 4, and pubic hair
development is Tanner stage 3.
Which of the following is the most appropriate next
step in management?

A
) Reexamination in 1 year if the patient has not
had menarche

B
) Measurement of serum follicle-stimulating hormone
and luteinizing
hormone levels

C
) Measurement of serum thyroid-stimulating hormone
and prolactin
levels

D
) Karyotype analysis

E
) Progesterone withdrawal test

F
) Pelvic ultrasonographypolypeptide levels





6.

A 2-month-old boy is brought to the physician because
of a 6-week
history of persistent diarrhea and vomiting, most
pronounced after formula
feedings. He has had a 113-g (4-oz) weight loss since
birth. He
currently weighs 3100 g (6 lb 13 oz) and is 51 cm (20
in) in length. He
appears irritable. Examination shows jaundice. The
lungs are clear to
auscultation. No murmurs are heard. The liver is
palpated 2 to 3 cm
below the right costal margin, and the spleen is
palpated 1 to 2 cm below
the left costal margin. Laboratory studies show:


Serum
Glucose 35 mg/dL
Bilirubin (total) 2.3 mg/dL
Urine
Glucose negative
Reducing substances 3+

Which of the following is the most likely mechanism of
these findings?

A
) Decreased gluconeogenesis

B
) Decreased insulin secretion

C
) Increased glucagon secretion

D
) Increased gluconeogenesis

E
) Increased insulin secretion

F
) Insulin resistance



7. A 75-year-old man has had hypertension for 25
years. There is an
unusually prominent pulsation of the abdominal aorta
in the upper
midabdomen. A systolic bruit is heard at this site.
Femoral, popliteal, and
pedal pulses are present. Which of the following is
the most
appropriate initial diagnostic study?

A
) X-ray film of the abdomen

B
) Abdominal ultrasonography

C
) Doppler ultrasonography of the arteries of the
legs

D
) Abdominal aortography

E
) Intravenous pyelography



8. A 14-year-old boy is brought to the physician
because of constant
right knee pain for 2 weeks. The pain is not relieved
by rest or
analgesics. There is no history of trauma. He is at
the 50th percentile
for height and above the 95th percentile for weight.
He walks with a
limp but is not in distress. His vital signs are
within normal limits.
Examination shows full range of motion of both knees;
passive abduction
and internal rotation of the right hip produce pain.
There is no
swelling of either knee or hip. Neurologic
examination shows no
abnormalities. Which of the following is the most
likely diagnosis?

A
) Juvenile rheumatoid arthritis

B
) Osgood-Schlatter disease

C
) Septic arthritis

D
) Slipped capital femoral epiphysis

E
) Toxic synovitis



9. A previously healthy 72-year-old man comes to
the physician
because of a 2-year history of hand tremors and
progressive difficulty
walking. He lives alone and has no close relatives.
He is alert and
oriented. Physical examination shows a decreased rate
of eye blinking.
Neurologic examination shows masked facies and a
pill-rolling resting
tremor of both hands. There is cogwheel rigidity of
the upper extremities
and generalized bradykinesia. His handwriting has
become small and
illegible. He has a slow, shuffling, festinating gait
with a tendency to
lean forward. Postural reflexes are impaired. This
patient is at
greatest risk for injury due to which of the
following?

A
) Bradykinesia

B
) Cogwheel rigidity

C
) Decreased rate of eye blinking

D
) Postural reflex impairment

E
) Tremor




10. A 47-year-old woman comes for a routine health
maintenance
examination. She has a 10-year history of type 2
diabetes mellitus that is
well controlled with an oral hypoglycemic agent. Her
mother died of a
myocardial infarction at the age of 38 years. The
patient weighs 82 kg
(180 lb) and is 163 cm (64 in) tall. Her blood
pressure is 150/95 mm
Hg. Examination shows multiple small skin tags below
the eyebrows and
on the nose and eyelids. Which of the following is
the most appropriate
next step in diagnosis?

A
) Measurement of serum follicle-stimulating hormone
level

B
) Serum lipid studies

C
) 24-Hour urine collection for measurement of
creatinine clearance

D
) X-ray film of the chest

E
) ECG

F
) No further studies indicated




11.

A previously healthy 15-year-old boy is brought to the
physician
because of a 5-day history of fever, intractable
nausea and vomiting, sore
throat, and muscle pain. His mother has been giving
him ibuprofen and
amoxicillin that was remaining from a previous
streptococcal throat
infection. He appears ill, and his lips are parched.
His temperature is
38.9 C (102 F), blood pressure is 120/74 mm Hg while
supine and 100/70 mm
Hg while standing, and pulse is 92/min while supine
and 120/min while
standing. Examination shows dry mucous membranes.
The oropharynx is
erythematous without exudate. There is shotty
cervical adenopathy. The
abdomen is soft without organomegaly. Laboratory
studies show:


Serum
Na+ 138 mEq/L
Cl– 98 mEq/L
K+ 3.4 mEq/L
HCO3– 21 mEq/L
Urea nitrogen (BUN) 55 mg/dL
Glucose 105 mg/dL
Creatinine 1.3 mg/dL
Amylase 40 U/L
Urine
Ketones moderate
WBC negative
RBC negative
Na+ 8 mEq/L
Protein negative

Which of the following is the most likely explanation
for this
patient's renal insufficiency?

A
) Acute tubular necrosis

B
) Amoxicillin-induced acute interstitial nephritis

C
) Ibuprofen-induced renal failure

D
) Post-streptococcal glomerulonephritis

E
) Severe volume depletion



12. A 77-year-old woman is brought to the emergency
department after
collapsing at home. Six hours ago, she had the sudden
onset of massive
bright red rectal bleeding. On arrival, her blood
pressure is 90/60 mm
Hg, and pulse is 120/min. Abdominal examination shows
no
abnormalities. Insertion of a nasogastric tube yields
clear aspirate. Her
hematocrit is 28%. Which of the following is the most
likely diagnosis?

A
) Colon cancer

B
) Diverticulosis

C
) Duodenal ulcer

D
) Hemorrhoids

E
) Inflammatory bowel disease



13. A previously healthy 27-year-old woman comes to
the emergency
department 1 hour after a 30-minute episode of
shortness of breath,
nausea, diaphoresis, and crushing substernal chest
pain radiating to the
left shoulder; the episode resolved spontaneously.
She is currently
asymptomatic. Her blood pressure is 110/84 mm Hg,
pulse is 70/min, and
respirations are 16/min. Examination shows no
abnormalities. An ECG shows
a normal sinus rhythm and no other abnormalities. Ten
minutes later,
she sits up in bed stating that her symptoms have
returned. Her blood
pressure now is 150/105 mm Hg, pulse is 120/min, and
respirations are
24/min. A repeat ECG shows 5-mm ST-segment elevation
in leads II, III,
and aVF. Her symptoms resolve after administration of
aspirin and
nitroglycerin. An angiography is ordered and shows no
evidence of coronary
atherosclerosis. Which of the following is the most
appropriate
pharmacotherapy?

A
) Angiotensin-converting enzyme (ACE) inhibitor

B
) Aspirin

C
) Benzodiazepine

D
) Calcium-channel blocking agent

E
) Corticosteroids

F
) Thiazide diuretic



Na+(mEq/L) Cl–(mEq/L) K+(mEq/L) HCO3–(mEq/L)
pH Specific
gravity

A
)
132 89 2.8 39 5.0 1.025

B
)
133 110 3.9 16 6.0 1.015

C
)
163 117 4.3 22 5.5 1.003

D
)
165 115 4.5 19 5.0 1.030


14. An 8-week-old boy is brought to the physician
by his mother
because of persistent vomiting for 2 days. He has
spit up intermittently
since birth. He has had no diarrhea. He appears
irritable. His
temperature is 38 C (100.4 F), blood pressure is 90/60
mm Hg, pulse is
130/min, and respirations are 25/min. Examination
shows a sunken anterior
fontanelle. Mucous membranes are dry. The lungs are
clear to
auscultation. Heart sounds are normal. The abdomen
is scaphoid, and bowel
sounds are active.



15. A 7-week-old boy is brought to the physician
because of fever,
irritability, and lethargy for 3 days. He has had no
vomiting,
diarrhea, or symptoms of an upper respiratory tract
infection. He always seems
hungry to his mother despite being fed 3 ounces of
formula every 3
hours. His mother also notes that he has many wet
diapers throughout the
day and night. He currently appears irritable. His
temperature is 37.8
C (100 F), blood pressure is 80/50 mm Hg, pulse is
150/min, and
respirations are 25/min. Examination shows a sunken
anterior fontanelle.
Mucous membranes are dry. There is tenting of the
skin. Examination
shows no other abnormalities. Urinalysis is negative
for glucose and
protein.



16.

A 57-year-old woman is extubated and transferred to
the recovery room
after a cholecystectomy. She appears restless. Her
blood pressure is
120/70 mm Hg, pulse is 80/min, and respirations are
10/min. Arterial
blood gas analysis on room air shows:


pH 7.24
PCO2 85 mm Hg
PO2 60 mm Hg

Intravenous naloxone therapy is begun, but she does
not improve. Which
of the following is the most appropriate next step in
management?

A
) Encouraging deep breathing and cough

B
) Administration of 40% oxygen via nasal cannula

C
) Administration of furosemide

D
) Transfusion of 1 unit of packed red blood cells

E
) Reintubation and mechanical ventilation



17. A previously healthy 24-year-old woman is
brought to the
physician by her husband because of several episodes
of loss of consciousness
over the past 4 days. Her husband reports that during
episodes, she
jerks her arms and legs wildly. Each episode lasts up
to 1 hour; between
episodes, her behavior is normal. She is planning to
move to another
state because of her husband's work. She has been
extremely anxious and
upset about the move because she will have to leave
her mother, who was
recently diagnosed with breast cancer. There is no
family history of
seizure disorder. Her temperature is 36.7 C (98 F),
blood pressure is
130/80 mm Hg, pulse is 84/min, and respirations are
18/min. Neurologic
examination shows no abnormalities.
Electroencephalography shows
normal findings during an episode of shaking. Which
of the following is the
most likely underlying cause?

A
) Catatonia

B
) Complex partial seizure

C
) Conversion reaction

D
) Dissociative fugue

E
) Malingering

F
) Tonic-clonic seizure



18. A 37-year-old man comes to the physician
because of a 3-month
history of increasing pain of his shoulders and upper
arms. Over the
past 2 weeks, he has also had difficulty lifting heavy
objects off shelves
in his garage. Two days ago, he burned his hand by
touching a hot pan
and felt little discomfort. He sustained a concussion
in a motor
vehicle collision at the age of 29 years. He has no
allergies. He takes no
medications. He does not smoke cigarettes or use
illicit drugs, and he
drinks one to two beers daily. Muscle strength is
decreased equally in
both arms. Temperature and pain sensation are
decreased in both hands,
but light touch is normal. Muscle strength and
sensation are normal in
the lower extremities. Neurologic examination shows
no other
abnormalities. Which of the following is the most
likely diagnosis?

A
) Alcoholic peripheral neuropathy

B
) Ankylosing spondylitis

C
) Guillain-Barré syndrome

D
) Herniated intervertebral disc

E
) Multiple sclerosis

F
) Polymyositis

G
) Syringomyelia




19. A 62-year-old woman with ovarian cancer comes
to the emergency
department because of fever for 2 days. Ten days ago,
she received
chemotherapy with paclitaxel and carboplatin. She
feels tired but has not
had nausea or vomiting. Her temperature is 39.5 C
(103.1 F), blood
pressure is 100/60 mm Hg, and pulse is 115/min. The
lungs are clear to
auscultation. Examination shows a soft, nontender
abdomen. Her
hematocrit is 32%, leukocyte count is 800/mm3, and
platelet count is
105,000/mm3. Serum electrolyte levels are within
normal limits. Which of the
following is the most appropriate next step in
treatment?

A
) Plasmapheresis

B
) Additional chemotherapy

C
) Intravenous antibiotic therapy

D
) Intravenous corticosteroid therapy

E
) Transfusion of 2 units of leukocytes

F
) Transfusion of 2 units of packed red blood cells



20.

A 47-year-old woman who is visiting from Australia
comes to the
physician because of increasing urine output over the
past month. She has had
no dysuria or hematuria. She has a history of chronic
headaches,
peptic ulcer disease, and urinary tract infections.
An evaluation 18 months
ago for headaches, including CT scan of the head,
showed no
abnormalities; treatment with ibuprofen and phenacetin
was initiated at that time,
and her headaches have been well controlled. Her
temperature is 37.1 C
(98.8 F), blood pressure is 140/82 mm Hg, pulse is
78/min, and
respirations are 14/min. Examination shows no
abnormalities. Laboratory
studies show:


Hematocrit 32%
Mean corpuscular volume 88 µm3
Serum
Glucose 130 mg/dL
Creatinine 1.7 mg/dL
Urine
Protein 2+
WBC 8–10/hpf
RBC none
Bacteria none
Nitrates none

Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in management?

A
) Intravenous pyelography

B
) Discontinue current medication

C
) Antibiotic therapy for recurrent urinary tract
infections

D
) Insulin therapy for diabetes mellitus

E
) Upper endoscopy



20.

A 47-year-old woman who is visiting from Australia
comes to the
physician because of increasing urine output over the
past month. She has had
no dysuria or hematuria. She has a history of chronic
headaches,
peptic ulcer disease, and urinary tract infections.
An evaluation 18 months
ago for headaches, including CT scan of the head,
showed no
abnormalities; treatment with ibuprofen and phenacetin
was initiated at that time,
and her headaches have been well controlled. Her
temperature is 37.1 C
(98.8 F), blood pressure is 140/82 mm Hg, pulse is
78/min, and
respirations are 14/min. Examination shows no
abnormalities. Laboratory
studies show:


Hematocrit 32%
Mean corpuscular volume 88 µm3
Serum
Glucose 130 mg/dL
Creatinine 1.7 mg/dL
Urine
Protein 2+
WBC 8–10/hpf
RBC none
Bacteria none
Nitrates none

Test of the stool for occult blood is negative. Which
of the following
is the most appropriate next step in management?

A
) Intravenous pyelography

B
) Discontinue current medication

C
) Antibiotic therapy for recurrent urinary tract
infections

D
) Insulin therapy for diabetes mellitus

E
) Upper endoscopy



21. A previously healthy 85-year-old man has had
abdominal
distention, decreased caliber of stools, and decreased
appetite over the past 2
weeks and a 9-kg (20-lb) weight loss over the past 3
months. On
sigmoidoscopy, he is found to have a constricting
adenocarcinoma of the
sigmoid colon; imaging studies show three 1-cm
metastases to the liver.
Which of the following is the most appropriate next
step in management?

A
) No treatment

B
) Radiation therapy

C
) Chemotherapy

D
) Combination radiation therapy and

chemotherapy

E
) Resection of the colon tumor


22. An 8-year-old girl with asthma is brought to
the physician 1
week after an acute exacerbation treated with a 5-day
taper course of oral
prednisone. This was her first asthma attack of the
fall season.
Medications include an inhaled corticosteroid daily
and a bronchodilator
metered-dose inhaler as needed. Her last
immunizations were at the age
of 5 years prior to entering kindergarten. Her
temperature is 37 C
(98.6 F), pulse is 92/min, and respirations are
28/min. Examination shows
end-expiratory wheezing with forced expiration.
Administration of
which of the following vaccines is most appropriate at
this visit?

A
) Haemophilus influenzae type b

B
) Influenza virus

C
) Meningococcal

D
) 23-Valent pneumococcal

E
) Varicella



23. A 27-year-old man is brought to the hospital by
family members
because he has remained in his room for 3 days. He
has refused to go to
work or eat with the family, and he expresses concern
that family or
friends may try to kill him. One week ago, he was
despondent when his
girlfriend of 5 years abruptly ended their
relationship. He has no
history of psychiatric illness. Which of the following
is the most likely
diagnosis?

A
) Adjustment disorder with depressed mood

B
) Bipolar disorder

C
) Brief psychotic disorder

D
) Dysthymic disorder

E
) Schizoaffective disorder


24. A 35-year-old primigravid woman at 20 weeks'
gestation comes to
the physician because of vaginal pressure and a
watery, pink vaginal
discharge for 1 day. Her temperature is 37.5 C (99.5
F). The uterus is
palpated at the umbilicus. Fetal heart rate is
140/min. Speculum
examination shows that the upper vagina is filled with
bulging, shiny,
smooth membranes. The cervix cannot be palpated.
Which of the following is
the most likely mechanism for these findings?

A
) Abruptio placentae

B
) Cervical incompetence

C
) Premature labor

D
) Uterine anomaly

E
) Uterine infection


25. A previously healthy 45-year-old woman has had
fever and
progressive confusion over the past 2 days. She is
now unable to perform
activities of daily living. Her temperature is 38 C
(100.4 F). She is
oriented only to person. There is no rash, and the
neck is supple. A CT
scan of the head shows normal findings. Cerebrospinal
fluid analysis
shows:

Leukocyte count 20/mm3
Glucose 45 mg/dL
Protein 110 mg/dL
Erythrocyte count
1000/mm3

Which of the following is the most likely diagnosis?

A
) Bacterial meningitis

B
) Acute alcohol intoxication

C
) Brain stem infarction

D
) Cerebral infarction

E
) Cryptococcal meningitis

F
) Enterovirus infection

G
) Hepatic encephalopathy

H
) Herpes simplex encephalitis

I
) Huntington's disease

J
) Hypoglycemia

K
) Lyme disease


26. A 57-year-old man with multiple myeloma comes
to the physician
because of a 12-hour history of fever, sharp chest
pain with deep
inspiration, and cough productive of blood-tinged
sputum. His temperature is
38.3 C (101 F), blood pressure is 120/78 mm Hg, pulse
is 112/min, and
respirations are 28/min. Crackles are heard at the
right lung base.
His hemoglobin level is 9.2 g/dL, leukocyte count is
2600/mm3, and
platelet count is 96,000/mm3. Empiric antibiotics
should be directed against
which of the following organisms?

A
) Listeria monocytogenes

B
) Neisseria meningitidis

C
) Pseudomonas aeruginosa

D
) Streptococcus bovis

E
) Streptococcus pneumoniae


27. A 19-year-old primigravid woman is brought to
the emergency
department because of a 4-hour history of heavy
vaginal bleeding. She has
vomited daily for the past month. Her last menstrual
period was 15
weeks ago. She has not received prenatal care. She
takes no medications.
Her temperature is 37 C (98.6 F), blood pressure is
140/90 mm Hg, pulse
is 80/min, and respirations are 20/min. Abdominal
examination shows a
uterus consistent in size with a 20-week gestation
with no adnexal
masses or tenderness. There is pedal edema. A serum
pregnancy test is
positive. Urinalysis shows 1+ protein. Which of the
following is the
most likely cause of this patient's vaginal bleeding?

A
) Abruptio placentae

B
) Ectopic pregnancy

C
) Hydatidiform mole

D
) Hyperthyroidism

E
) Preeclampsia


28. A 40-year-old man has the sudden onset of
excruciating head and
neck pain while carrying books from the basement to
the attic. His
temperature is 37 C (98.6 F), blood pressure is 130/90
mm Hg, and pulse is
90/min. He has photophobia and develops eye pain with
lateral eye
movements. His neck is markedly stiff and cannot be
passively flexed. He
has diffuse hyperreflexia in all extremities with
normal strength and
sensation. Plantar reflexes are flexor bilaterally.
Which of the
following is the most likely diagnosis?

A
) Cervical osteoarthritis

B
) Meningitis

C
) Ruptured cervical disc

D
) Subarachnoid hemorrhage

E
) Syringomyelia



29. A 59-year-old woman comes to the emergency
department because of
shortness of breath for 2 days. She had stage II
breast cancer 5 years
ago treated with lumpectomy, radiation, and
chemotherapy. Her
temperature is 37.5 C (99.5 F), blood pressure is
90/60 mm Hg, and respirations
are 24/min. Examination shows jugular venous
distention. Heart sounds
are distant. Which of the following is the most
appropriate next step
in management?

A
) Antibiotic therapy

B
) Anticoagulant therapy

C
) Intravenous digoxin therapy

D
) Intravenous furosemide therapy

E
) Chemotherapy

F
) Radiation therapy

G
) Pericardiocentesis


30. A 57-year-old man comes for a routine follow-up
examination. He
has a 10-year history of an intermittent facial rash.
He has been
taking propranolol for 2 months for hypertension.
Examination shows
several erythematous pustules and papules involving
the nose and central
face. There are telangiectasias at the base of the
papules. Which of the
following is the most likely explanation for these
findings?

A
) Acne rosacea

B
) Acne vulgaris

C
) Basal cell carcinoma

D
) Discoid lupus erythematosus

E
) Seborrheic dermatitis



31. A 42-year-old man comes to the physician
because of malaise,
muscle and joint pain, and temperatures to 38.4 C
(101.1 F) for 3 days.
Three months ago, he underwent cadaveric renal
transplantation resulting
in immediate kidney function. At the time of
discharge, his serum
creatinine level was 0.8 mg/dL. He is receiving
cyclosporine and
corticosteroids. Examination shows no abnormalities.
His leukocyte count is
2700/mm3, and serum creatinine level is 1.6 mg/dL;
serum cyclosporine
level is in the therapeutic range. A biopsy of the
transplanted kidney
shows intracellular inclusion bodies. Which of the
following is the most
appropriate next step in management?

A
) Increase the dosage of corticosteroids

B
) Increase the dosage of cyclosporine

C
) Begin amphotericin therapy

D
) Begin ganciclovir therapy

E
) Begin heparin therapy


32. A 5-month-old boy is brought to the physician
because of a
24-hour history of fever, cough, noisy breathing, and
difficulty feeding.
His symptoms began 3 days ago with nasal discharge,
mild cough, and
chest congestion. He appears somewhat irritable and
is crying. His
temperature is 38.5 C (101.3 F), pulse is 108/min, and
respirations are
32/min and shallow with a prolonged expiratory phase.
On examination, the
throat appears normal. A few small anterior and
posterior cervical
nodes are palpable. Both eardrums are pink but have
normal landmarks and
mobility. There is good air entry with diffuse
bilateral expiratory
wheezes on auscultation. An x-ray film of the chest
shows hyperinflation.
Which of the following is the most likely pathogen?

A
) Adenovirus

B
) Haemophilus influenzae

C
) Mycoplasma pneumoniae

D
) Respiratory syncytial virus

E
) Streptococcus pneumoniae


3. Three days after undergoing a right hip
replacement for
rheumatoid arthritis, a 77-year-old man is brought to
the physician because of a
2-day history of pain, burning, and itching of his
left eye and left
side of his forehead. He has the sensation that there
is a speck of dirt
in his left eye. Current medications include
prednisone and
methotrexate. Examination of the left eye shows
conjunctival injection and
swelling of the upper eyelid. There is an
erythematous rash over the left
side of the forehead and tenderness to palpation from
the upper eyelid
to the vertex. A photograph of the rash is shown.
Which of the
following is the most appropriate next step in
management?

A
) Measurement of erythrocyte sedimentation rate

B
) MRI of the brain with contrast

C
) Acyclovir therapy

D
) Corticosteroid therapy

E
) Lumbar puncture


34. A 54-year-old man with chronic obstructive
pulmonary disease
undergoes a total hip arthroplasty for avascular
necrosis of the femoral
head. On the second postoperative day, he has
diffuse, profound
weakness and vomiting. His blood pressure is 85/50 mm
Hg, and pulse is
100/min. The operative site is clean and dry, with
minimal output from the
drains. Hemoglobin level is 13.8 g/dL, serum sodium
level is 132 mEq/L,
and serum potassium level is 5.8 mEq/L. Which of the
following is most
likely to confirm the diagnosis?

A
) Measurement of serum thyroid-stimulating hormone
level

B
) Direct antiglobulin (Coombs') test

C
) ACTH stimulation test

D
) Ventilation-perfusion lung scans

E
) Echocardiography


35. A previously healthy 47-year-old nulliparous
woman is brought to
the emergency department by ambulance because of acute
low back pain
radiating to the right posterior leg for 2 hours. The
pain began when
she bent over at work to retrieve a file from the
lowest drawer of a
filing cabinet. She does not smoke cigarettes or
drink alcohol.
Examination shows right paraspinous muscle spasm and
pain in the lower back with
right straight-leg raising at 30 degrees. She says
that she plans to
file a claim for a work-related injury. Which of the
following findings
is the strongest risk factor for a prolonged episode
of pain in this
patient?

A
) Arrival for care in an ambulance

B
) Claim that pain is work-related

C
) Gender

D
) Nulliparity

E
) Positive straight-leg raising test

F
) Radiation of the pain into the posterior lower
extremity



36. A healthy 27-year-old woman comes to the
physician for an annual
examination. She is concerned about her risk for an
abnormal Pap smear
in the future. A history of use of which of the
following would
increase her risk for cervical cancer?

A
) Alcohol

B
) Cervical cap

C
) Cigarettes

D
) Isotretinoin

E
) IUD


37. A 72-year-old man is brought to the physician
by his daughter
because of painless jaundice for 1 month. His wife
died 10 years ago,
and his daughter is his only child. Before examining
the patient, the
daughter asks to speak privately with the physician
and asks that she be
given the results of any tests. She specifically
requests that he not
be given any "bad news." The patient is alert. His
vital signs are
within normal limits. Examination shows scleral
icterus and jaundice.
There is mild abdominal tenderness on palpation. He
is oriented to
person, place, and time. A CT scan of the abdomen
shows a pancreatic mass
with bile duct obstruction and probable metastatic
lesions in the
liver. Which of the following is the most appropriate
next step?

A
) Abide by the daughter's wishes

B
) Ask the patient if he wishes to discuss his test
results,
preferably with his daughter present

C
) Tell the daughter it is a legal requirement to
tell the patient
any and all results of medical testing

D
) Consult with the hospital attorney

E
) Ask another physician to take over the

patient's care



38. A 66-year-old man has had numbness and tingling
in the hands and
feet for 2 weeks. He lives in a homeless shelter and
is well fed. He
has been treated for pulmonary tuberculosis for 4
months with
isoniazid, rifampin, ethambutol, and pyrazinamide. He
is compliant with his
medication regimen but continues to abuse alcohol.
His temperature is 37
C (98.6 F), blood pressure is 136/76 mm Hg, pulse is
72/min, and
respirations are 20/min. He is well nourished but
depressed and irritable.
There is decreased sensation to pain and touch in the
hands and feet in
a stocking-glove distribution. Which of the following
is the most
likely nutritional deficiency?

A
) Folic acid

B
) Niacin

C
) Vitamin A

D
) Vitamin B1 (thiamine)

E
) Vitamin B2 (riboflavin)

F
) Vitamin B6

G
) Vitamin B12 (cyanocobalamin)

H
) Vitamin C

I
) Vitamin D

J
) Vitamin E

K
) Vitamin K



39. A 63-year-old man is brought to the emergency
department 3 hours
after the acute onset of severe right-sided flank
pain. He has a
9-year history of gout. His blood pressure is 110/84
mm Hg, pulse is
78/min, and respirations are 16/min. Examination
shows normal bowel sounds
and no abdominal tenderness or masses. Urinalysis
shows 40
erythrocytes/hpf. Intravenous pyelography confirms a
right ureteral calculus.
Which of the following is the most likely underlying
mechanism of this
patient's urolithiasis?

A
) An increase in urinary pH

B
) Damage to the epithelial lining of the ureters

C
) Lack of inhibitors of crystal formation

D
) Presence of urease-splitting bacteria

E
) Urinary supersaturation with uric acid


40. A 27-year-old nulligravid woman comes to the
physician for
preconceptional counseling. She has a mechanical
mitral heart valve and
chronic rheumatoid arthritis. Her cardiac status is
New York Heart
Association Class II. She feels well. Current daily
medications include
warfarin, prednisone, and acetaminophen with codeine.
Examination shows
no abnormalities except for audible clicking from the
heart valve.
Which of the following is the most appropriate advice
for this patient?

A
) Chemical dependency counseling before pregnancy

B
) Discontinuation of anticoagulant therapy during
pregnancy

C
) Discontinuation of prednisone during pregnancy

D
) Switching from warfarin to heparin before
pregnancy

E
) No change in treatment before or during pregnancy



41. A 60-year-old man comes to the physician
because of difficulty
sleeping and concentrating and a 5-kg (10-lb) weight
loss over the past
3 months. He also has become withdrawn. He has had
chronic pain since
sustaining fractures of the left lower extremity,
pelvis, and several
ribs in a motor vehicle collision 2 years ago. He has
a previous
history of alcohol abuse. He takes a nonsteroidal
anti-inflammatory drug.
Which of the following is the most appropriate
pharmacotherapy?

A
) Carbamazepine

B
) Chlordiazepoxide

C
) Disulfiram

D
) Lithium carbonate

E
) Nortriptyline


42. An 82-year-old man comes to the physician
because of a 3-day
history of low back pain that radiates to the right
leg. He also has had
a lesion over the right shin and weakness of the right
foot. He began
taking prednisone 2 weeks ago for acute bronchitis.
He has chronic
obstructive pulmonary disease, benign prostatic
hypertrophy, and glaucoma.
Examination shows numerous papular and vesicular
lesions over the right
anterior and posterior shin. There is weakness of
right knee flexion,
ankle dorsiflexion, plantar flexion, eversion, and
inversion; the right
ankle reflex is absent. Sensation to pinprick and
cold is decreased
over the right lower extremity. Which of the
following is the most
likely causal organism?

A
) Borrelia burgdorferi

B
) Epstein-Barr virus

C
) Herpes simplex virus 1

D
) Poliovirus

E
) Treponema pallidum

F
) Varicella-zoster virus



43. A 30-year-old woman comes to the physician
because of
long-standing unhappiness that may have started when
she was rejected by her
classmates as a teenager. She says that although she
has good days, many
days are dominated by negative thoughts about herself.
She appears
somewhat sad and tends to be readily critical of
herself. Although she
sleeps satisfactorily, she often finds her energy
level decreased by the
end of the day. She also has been forgetful. She
weighs 59 kg (130 lb)
and is 157 cm (62 in) tall. Physical examination and
laboratory
studies show no abnormalities. Which of the following
is the most likely
diagnosis?

A
) Adjustment disorder with depressed mood

B
) Depersonalization disorder

C
) Dissociative identity disorder

D
) Dysthymic disorder

E
) Hypothyroidism

F
) Major depressive disorder

G
) Schizoaffective disorder


For each patient with cough, select the most
appropriate next step in
diagnosis.


A
) Measurement of serum a1-antitrypsin level

B
) Methacholine challenge test

C
) Quantitative measurement of serum antibody levels

D
) Sweat chloride test

E
) Ventilation-perfusion lung scans

44. A 27-year-old woman comes to the physician
because of
intermittent episodes of shortness of breath and cough
over the past 4 months.
She says that cold weather and exercise can
precipitate her symptoms.
Examination shows no abnormalities. The lungs are
clear to auscultation
and percussion. An x-ray film of the chest and
spirometry show no
abnormalities.


A 32-year-old woman comes to the physician because of
a 4-month history
of fatigue, cough, and shortness of breath with
exertion. She has had
two episodes of pneumonia and one episode of severe
sinusitis over the
past 2 years. She has never smoked. She takes no
medications.
Crackles are heard at the left lung base. An x-ray
film of the chest shows a
left lower lobe infiltrate and scarring of the right
base.


46. A 32-year-old man is brought to the emergency
department 30
minutes after being involved in a motor vehicle
collision. He was the
restrained driver. On arrival, he is alert and has
shortness of breath.
His blood pressure is 80/50 mm Hg, pulse is 130/min,
and respirations
are 30/min. Examination shows jugular venous
distention and abrasions
over the left hemithorax. The trachea is deviated to
the right. Breath
sounds are absent on the left. Which of the following
is the most
likely cause of the hypotension?

A
) Cardiogenic shock

B
) Congestive heart failure

C
) Decreased systemic vascular resistance

D
) Decreased venous return

E
) Hypovolemic hypoperfusion

F
) Increased systemic vascular resistance

BLOCK 4:--

1. A previously healthy 2-year-old boy is brought
to the physician
20 minutes after an episode of cyanosis and loss of
consciousness that
lasted 3 minutes. The symptoms occurred after his
mother scolded him
for climbing onto the dining room table. The mother
says that the child
began to cry, let out a deep sigh, stopped breathing,
and jerked his
arms and legs back and forth. On arrival, he is alert
and active.
Neurologic examination shows no focal findings. Which
of the following is
the most appropriate next step in management?

A
) Reassurance

B
) Electroencephalography

C
) CT scan of the head

D
) Anticonvulsant therapy

E
) Lumbar puncture



2. A case-control study is conducted to assess the
risk for
intussusception in infants under the age of 1 year who
receive the rotavirus
vaccine. The medical records of all those who
received the vaccine and
those who did not receive the vaccine over a 6-month
period are
reviewed. Results show 125 cases per 100,000
infant-years for infants who
received the vaccine compared to 45 cases per 100,000
infant-years for
infants who did not receive the vaccine. The
investigators conclude that
the relative risk for intussusception is 1.9 times
greater in infants
who receive the rotavirus vaccine (95% confidence
interval of 0.5–7.7 and
p=0.39). Which of the following is the most accurate
interpretation of
these results?

A
) The results do not show an association between
rotavirus vaccine
and intussusception, but they may be related

B
) The results show sufficient statistical power to
identify an
association between rotavirus vaccine and
intussusception

C
) Rotavirus vaccine is associated with a 39% risk
for
intussusception

D
) Rotavirus vaccine causes intussusception in 1.9%
of infants

E
) Rotavirus vaccine prevents 80 cases of
intussusception per 100,000
infant-years



3.

A 42-year-old woman, gravida 3, para 3, comes to the
emergency
department 24 hours after the onset of moderate
epigastric pain radiating to
the back. Her last menstrual period was 3 weeks ago.
She has no history
of serious illness and has never undergone an
operative procedure. She
weighs 72 kg (160 lb) and is 157 cm (62 in) tall. Her
temperature is
37.2 C (99 F), blood pressure is 130/90 mm Hg, and
pulse is 100/min.
Abdominal examination shows mild distention,
epigastric tenderness, and
voluntary guarding. Test of the stool for occult
blood is negative.
Laboratory studies show:


Hematocrit 44%
Leukocyte count 12,000/mm3
Serum
Na+ 138 mEq/L
Cl– 100 mEq/L
K+ 4 mEq/L
HCO3– 25 mEq/L
Bilirubin, total 1.6 mg/dL
Alkaline phosphatase 100 U/L
Aspartate aminotransferase
(AST, GOT) 14 U/L
Alanine aminotransferase
(ALT, GPT) 12 U/L
Amylase 1100 U/L

Ultrasonography shows gallstones; the gallbladder wall
is 1 mm and the
common bile duct is 5 mm in diameter. Which of the
following is the
most likely diagnosis?

A
) Acute cholecystitis

B
) Acute pancreatitis

C
) Acute perihepatitis

D
) Ascending cholangitis

E
) Duodenal ulcer

F
) Viral hepatitis


4. A 13-year-old girl is brought to the emergency
department because
of shortness of breath for 2 hours. The symptoms
began after consuming
chili, cornbread, and fruit salad with strawberries,
kiwi, and bananas.
She has a 1-year history of shortness of breath while
playing soccer or
baseball and uses a bronchodilator inhaler as needed
while exercising.
She is allergic to penicillin and pineapples. Her
blood pressure is
80/60 mm Hg, pulse is 120/min and regular, and
respirations are 20/min
with use of accessory muscles. Examination of the
lungs shows poor air
entry bilaterally with diffuse expiratory wheezes.
Which of the
following is the most appropriate initial
pharmacotherapy?

A
) Inhaled bronchodilators

B
) Inhaled cromolyn sodium

C
) Inhaled ipratropium bromide

D
) Intravenous corticosteroids

E
) Subcutaneous epinephrine


5.

A 52-year-old woman comes to the emergency department
6 days after knee
arthroplasty because of constant, right-sided chest
pain and shortness
of breath for 24 hours. Her blood pressure is 110/50
mm Hg, pulse is
114/min, and respirations are 24/min. Examination of
the heart, lungs,
and extremities shows no abnormalities. Arterial
blood gas analysis on
room air shows:


pH 7.49
PCO2 29 mm Hg
PO2 66 mm Hg

Ventilation-perfusion lung scans show a low
probability for pulmonary
embolus. An ECG shows sinus tachycardia; an x-ray
film of the chest
shows no abnormalities. After the evaluation, the
patient is pain-free
and wishes to go home. Which of the following is the
most appropriate
next step in management?

A
) Discharge home and reexamination in 2 weeks

B
) Exercise stress test

C
) Pulmonary function tests

D
) Echocardiography

E
) Pulmonary angiography

F
) Ibuprofen therapy

6. A 25-year-old woman comes to the physician
because of "spells"
characterized by sweating, palpitations, and shortness
of breath that
have awakened her at night several times over the past
3 months. She
resigned from her job as a sales clerk 6 months ago
and now works from home
as a telemarketer. She recently began going to the
grocery store late
at night because she is too nervous around people.
She says that she
has been feeling sad lately. On mental status
examination, she is fully
oriented, and her range of affect is full. Which of
the following is
the most likely diagnosis?

A
) Adjustment disorder with anxiety

B
) Adjustment disorder with depressed mood

C
) Dysthymic disorder

D
) Generalized anxiety disorder

E
) Major depressive disorder

F
) Panic disorder with agoraphobia

G
) Post-traumatic stress disorder



7. A 65-year-old woman has a 6-month history of
progressive
irritability, palpitations, heat intolerance, frequent
bowel movements, and a
6.8-kg (15-lb) weight loss. She has had a neck mass
for more than 10
years. 131I scan shows an enlarged thyroid gland with
multiple areas of
increased and decreased uptake. Which of the
following is the most
likely diagnosis?

A
) Defect in thyroxine (T4) biosynthesis

B
) Graves' disease

C
) Multinodular goiter

D
) Riedel's thyroiditis

E
) Thyroid carcinoma

F
) Thyroiditis

G
) Toxic adenoma

H
) Triiodothyronine (T3) thyrotoxicosis


A
) Acute gastrointestinal bleeding

B
) Adrenal insufficiency

C
) Aortic valve rupture

D
) Cardiac tamponade


E
) Congestive heart failure

F
) Pneumonia

G
) Pulmonary embolism

H
) Sepsis

8. A previously healthy 62-year-old man is brought
to the emergency
department by paramedics 40 minutes after the sudden
onset of severe
shortness of breath while dressing this morning. He
is unable to provide
additional medical history. He is in severe
respiratory distress. His
temperature is 37.8 C (100 F), blood pressure is 90/60
mm Hg, pulse is
120/min and regular, and respirations are 24/min.
Examination shows
marked jugular venous distention. The lungs are clear
to auscultation.
Cardiac examination shows a nondisplaced and discrete
point of maximal
impulse and normal S1 and S2; there is an S4 and a
right parasternal
heave. Abdominal examination shows no abnormalities.
There is no edema
of the lower extremities. Laboratory studies show:


Hematocrit 40%
Leukocyte count 14,000/mm3
Platelet count 350,000/mm3


Arterial blood gas analysis on 5 L/min of oxygen:


pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg


A previously healthy 67-year-old woman is brought to
the emergency
department by paramedics 40 minutes after the sudden
onset of shortness of
breath while shopping. She is unable to provide
additional medical
history. She is in severe respiratory distress. Her
temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is
120/min and regular,
and respirations are 24/min. Examination shows marked
jugular venous
distention. Diffuse crackles are heard throughout all
lung fields.
Cardiac examination shows an enlarged point of maximal
impulse and normal
S1 and S2; there is an S3. Abdominal examination
shows no
abnormalities. There is no edema of the lower
extremities. Laboratory studies
show:


Hematocrit 38%
Leukocyte count 12,000/mm3
Platelet count 350,000/mm3


Arterial blood gas analysis on 5 L/min of oxygen:


pH 7.5
PCO2 16 mm Hg
PO2 64 mm Hg




10. A mentally competent 76-year-old man is in the
terminal stage of
multiple myeloma. He is unable to move and requires
24-hour nursing
care. Increasing doses of narcotics are needed to
control severe pain.
As a result, when he is pain-free, respiratory
function is impaired and
consciousness is clouded. The patient says he cannot
live with this
degree of pain and asks to be given a lethal injection
of pain
medication. Which of the following is the most
appropriate step regarding the
pain medication?

A
) Reduce the dosage so as not to impair respiration

B
) Administer the dosage necessary to control pain
despite
respiratory impairment

C
) Administer the dosage necessary to control pain
and add a
centrally acting stimulant

D
) Appeal to the family to convince the patient to
tolerate a bit
more pain




11. A 2-day-old newborn is brought to the physician
because of a
generalized rash for 6 hours. The newborn is active,
alert, and feeding
well. His temperature is 36.9 C (98.4 F).
Examination shows a rash
consisting of numerous white and pale yellow papules
with a large base of
macular erythema over the trunk and extremities.
Wright's stain of
scrapings from the lesions shows eosinophils. Which
of the following is
the most appropriate next step in management?

A
) Reassurance

B
) Topical corticosteroid therapy

C
) Intravenous acyclovir therapy

D
) Intravenous ampicillin and gentamicin therapy

E
) Intravenous nafcillin therapy



12. A 4-year-old boy is brought for a well-child
examination. He
uses two-word phrases, can say his first name but not
his last name, and
cannot identify colors. He is just beginning toilet
training. His
7-year-old sister has a learning disability and
attends special education
classes. Genital development is Tanner stage 1;
testes are large.
Which of the following is the most appropriate next
step in diagnosis?

A
) Reexamination in 6 months

B
) Thyroid function tests

C
) DNA testing

D
) Measurement of bone age

E
) CT scan of the head



3. A 72-year-old man is brought to the physician
because of a 2-day
history of nausea and vomiting. The vomitus has been
clear, and no
blood has been noted. He has had a decreased appetite
for the past week.
There is no associated pain or altered bowel function.
He reports that
he is not seeing things correctly. He takes warfarin
and digoxin for
atrial fibrillation, hydrochlorothiazide for
hypertension, and potassium
supplements that he discontinued 3 weeks ago when he
ran out of
tablets. His temperature is 37 C (98.6 F), blood
pressure is 144/88 mm Hg,
and pulse is 52/min and irregular. Bowel sounds are
normal. The abdomen
is soft and nontender without rebound or guarding. No
organomegaly or
masses are palpated. Which of the following is the
most likely
diagnosis?

A
) Acute pancreatitis

B
) Brain tumor

C
) Diabetic gastroparesis

D
) Diabetic ketoacidosis

E
) Drug toxicity

F
) Food poisoning

G
) Gastric bezoar

H
) Gastric carcinoma

I
) Pyloric channel ulcer

J
) Small-bowel obstruction

K
) Uremia


14. A 27-year-old primigravid woman at 12 weeks'
gestation comes to
the emergency department 2 hours after the sudden
onset of bright red
vaginal bleeding. She has not had abdominal cramping.
Pelvic
examination shows a small amount of brownish blood in
the posterior fornix of
the vagina. The cervix is closed. The uterus is
palpable 3 cm above the
pelvic brim. Fetal heart tones are easily audible at
167/min by
Doppler. Which of the following is the most likely
diagnosis?

A
) Abruptio placentae

B
) Ectopic pregnancy

C
) Incomplete abortion

D
) Placenta previa

E
) Threatened abortion

F
) Normal pregnancy


15. A 72-year-old man is brought to the physician
by his son because
of a 4-day history of increasing confusion and memory
problems. The
son says that his father's ability to function
independently has been
generally declining over the past few years, and he
has become much more
impaired over the past week. The patient has had at
least three to four
previous episodes of a sudden decline of cognitive
functioning over the
past 3 years without full recovery. He has a history
of hypertension.
His blood pressure is 160/95 mm Hg without orthostatic
changes.
Neurologic examination shows no focal findings.
Mini-Mental State Examination
score is 21/30. Which of the following is the most
likely underlying
pathophysiologic process?

A
) Central nervous system demyelination

B
) Central nervous system infection

C
) Diffuse axonal injury

D
) Diffuse cortical atrophy

E
) Left temporal lobe infarction

F
) Multiple, small, central nervous system
infarctions

G
) Subdural hematoma



16. A 72-year-old woman comes for a routine health
maintenance
examination. She has a 3-year history of occasional
loss of small amounts
of urine when she coughs or sneezes. She has had no
pain or burning
with urination. She has hypertension treated with
daily
hydrochlorothiazide. She underwent an appendectomy at
the age of 10 years. She has
three children and had uncomplicated pregnancies.
Examination shows no
abnormalities except for a moderate cystocele. Which
of the following is
the most likely cause of this patient's urinary
symptoms?

A
) Chronic infectious trigonitis

B
) Large intravesical calculus

C
) Obstetric trauma

D
) Polycystic kidney disease

E
) Spastic neurogenic bladder


17. A 47-year-old woman is brought to the emergency
department by
her husband because of hallucinations and agitation
for 6 hours. She has
a 10-year history of alcoholism. Her last alcoholic
drink was 48 hours
ago. She is agitated and inattentive. Her
temperature is 38.3 C (101
F), blood pressure is 190/120 mm Hg, and pulse is
110/min. She is
oriented to person but not to place or time. During
the examination, she
shrieks, "Make the lizards go away." Which of the
following is the most
appropriate initial step in management?

A
) Electroencephalography

B
) CT scan of the head

C
) Intravenous ampicillin therapy

D
) Intravenous haloperidol therapy

E
) Intravenous lorazepam therapy


18. A 27-year-old woman comes to the physician
because of a 3-week
history of fever, night sweats, rash on both legs,
nonproductive cough,
and pain and swelling in her wrists and knees. She
has not had weight
loss. Her temperature is 37.7 C (99.8 F), blood
pressure is 110/70 mm
Hg, pulse is 96/min, and respirations are 14/min. The
lungs are clear
to auscultation. Cardiac examination shows no
abnormalities. There is
swelling and warmth over the wrists and knees
bilaterally and tender
red nodules on the anterior surface of both lower
extremities. An x-ray
film of the chest shows bilateral hilar fullness.
Which of the
following is the most likely diagnosis?

A
) Carcinoma of the lung

B
) Histoplasmosis

C
) Hodgkin's disease

D
) Sarcoidosis

E
) Tuberculosis


19. A 52-year-old woman comes to the physician
because of difficulty
climbing stairs for 4 months. She has also noted that
her thighs hurt
when she presses on them. She has had increasing
difficulty combing
her hair because she tires easily. On examination,
she pushes herself
out of the chair with her arms. There is weakness of
the proximal
muscles of the extremities. Which of the following is
the most likely
diagnosis?

A
) Cauda equina syndrome

B
) Cerebellar degeneration

C
) Cervical spinal cord compression

D
) Diabetic polyneuropathy

E
) Femoral artery insufficiency

F
) Guillain-Barré syndrome

G
) Lumbar spinal stenosis

H
) Multiple sclerosis

I
) Normal-pressure hydrocephalus

J
) Polymyositis

K
) Sensory neuropathy

L
) Tabes dorsalis




20. A 72-year-old man comes to the physician
because of generalized
weakness and night sweats for 6 months. During this
period he has had
a 5-kg (11-lb) weight loss. He has had polycythemia
vera for 12 years
treated with hydroxyurea and multiple phlebotomies.
Examination shows
cachexia. The liver is enlarged and nontender with a
span of 13 cm;
the spleen is enlarged. Hematocrit is 27%, leukocyte
count is 3200/mm3,
and platelet count is 150,000/mm3. A blood smear is
shown. Which of
the following is the most likely diagnosis?

A
) Acute myelogenous leukemia

B
) Cirrhosis of the liver

C
) Hodgkin's disease

D
) Miliary tuberculosis

E
) Myelofibrosis



21. A 30-year-old man has had increasingly severe
low back pain
since lifting a heavy object at work 3 days ago. The
pain does not radiate
and is not associated with bowel or bladder problems.
He has a history
of occasional stiffness and mild pain in his lower
back. There is
bilateral paravertebral muscle tenderness in the
lumbar region and limited
flexion of the lumbosacral spine. Examination of the
lower extremities
shows normal muscle strength and sensation;
straight-leg raising is
negative bilaterally. Deep tendon reflexes at the
knees and ankles are
normal. Which of the following is the most
appropriate next step in
management?

A
) Exercises to strengthen abdominal muscles

B
) Exercises to strengthen paravertebral muscles

C
) Bed rest for 5 to 7 days

D
) Use of a muscle relaxant

E
) Use of a nonsteroidal anti-inflammatory drug




22. A 42-year-old woman, gravida 2, para 2, has had
increasing
fatigue, dyspnea, orthopnea, and paroxysmal nocturnal
dyspnea over the past
2 days. She has had several episodes of hemoptysis;
she had one
episode of pulmonary edema during pregnancy 2 years
ago. A loud S1, a
snapping sound in diastole, and a rumbling diastolic
murmur are heard at the
apex. Which of the following is the most likely cause
of her
condition?

A
) Atrial myxoma

B
) Bicuspid aortic valve

C
) Postpartum cardiomyopathy

D
) Rheumatic heart disease

E
) Viral myocarditis


3. A 37-year-old woman has had unilateral breast
pain, fever, and
chills for 24 hours. She breast-feeds her 1-month-old
newborn. Her
temperature is 38 C (100.4 F). Examination shows
swelling, erythema, and
localized tenderness of the left breast. Which of the
following is the
most appropriate next step in management?

A
) Application of ice packs to the affected breast

B
) Use of a breast pump

C
) Immediate discontinuation of breast-feeding

D
) Bromocriptine therapy

E
) Penicillinase-resistant antibiotic therapy


24. A 19-year-old woman, gravida 2, para 1, at 39
weeks' gestation
is admitted in labor. Contractions occur every 2 to 3
minutes. The
cervix is 4 cm dilated and 80% effaced. She requests
an epidural for pain
control. Ten minutes after the epidural is
administered, she becomes
nauseated and diaphoretic and vomits. Her blood
pressure is 60/palpable
mm Hg. A fetal heart tracing shows sustained fetal
decelerations. The
cervix is now 8 cm dilated. The most appropriate next
step in
management is administration of which of the
following?

A
) Ephedrine

B
) Magnesium sulfate

C
) Nifedipine

D
) Oxytocin

E
) Terbutaline


25. An asymptomatic 47-year-old man comes for a
routine follow-up
examination 3 weeks after sustaining an inferior wall
myocardial
infarction. His recovery was complicated by transient
premature ventricular
contractions during the first 2 days of
hospitalization. An exercise
stress test prior to discharge showed no pain at 70%
of his predicted
maximum exercise capacity. Medications include daily
aspirin and
pravastatin. His blood pressure is 136/80 mm Hg,
pulse is 80/min and regular,
and respirations are 16/min. Cardiopulmonary
examination shows no
abnormalities. Which of the following is the most
appropriate additional
pharmacotherapy for this patient?

A
) Clonidine

B
) Metoprolol

C
) Quinidine

D
) Sulfinpyrazone

E
) Verapamil



26. A 35-year-old woman is brought to the emergency
department by
her family because of shortness of breath, tightness
in her chest, and
palpitations for 2 hours. Over the past 11 months,
she has had five
similar episodes; during the last episode 3 weeks ago,
she was treated with
an intravenous medication that caused conversion to
sinus rhythm. Her
blood pressure is 95/60 mm Hg, and pulse is 165/min
and regular. The
lungs are clear to auscultation. Which of the
following is the most
likely underlying dysrhythmia?

A
) Accelerated idioventricular rhythm

B
) Accelerated junctional rhythm

C
) Atrial fibrillation

D
) Multifocal atrial tachycardia

E
) Normal sinus rhythm

F
) Paroxysmal supraventricular tachycardia

G
) Premature supraventricular beats

H
) Premature ventricular beats

I
) Sick sinus syndrome

J
) Sinus bradycardia

K
) Sinus tachycardia

L
) Ventricular fibrillation

M
) Ventricular tachycardia





27.

A 4-year-old boy is brought to the emergency
department because of a
1-day history of fever and increasing difficulty
breathing. Over the
past year, he has had recurrent bacterial infections
including cervical
lymphadenitis, septic arthritis, and pneumonia. His
temperature is 38.9
C (102 F), blood pressure is 80/60 mm Hg, pulse is
115/min, and
respirations are 38/min and labored. Breath sounds
are decreased over the
left anterior chest. Scattered crackles are heard on
auscultation. A
thoracentesis shows purulent fluid. Laboratory
studies show:


Hematocrit 36%
Leukocyte count 18,000/mm3
Segmented neutrophils 85%
Lymphocytes 15%
Platelet count 200,000/mm3
Pleural fluid
Leukocyte count 75,000/mm3
Segmented neutrophils 98%
Lymphocytes 2%

Nitroblue tetrazolium test is abnormal. A Gram's
stain of the pleural
fluid shows numerous gram-positive cocci in the
segmented neutrophils.
An x-ray film of the chest shows left lower lobe
pneumonia with pleural
effusion. The most likely cause of this patient's
symptoms is a defect
of which of the following?

A
) Chemotaxis

B
) Immotile cilia

C
) Opsonization

D
) Phagocytic oxidative metabolism

E
) Phagocytosis

F
) T-lymphocyte function



28. A 59-year-old woman comes to the emergency
department 45 minutes
after the onset of chest discomfort that is not
relieved by three
nitroglycerin tablets. Over the past 3 months, she
has had similar episodes
characterized by nonradiating pain and a feeling of
heaviness; the
episodes were exacerbated by exertion or heavy meals
and were slowly
relieved by rest. Sublingual nitroglycerin has
provided rapid relief of
symptoms in the past. She has hypercholesterolemia,
type 2 diabetes
mellitus, and peptic ulcer disease. She smoked two
packs of cigarettes daily
for 25 years but quit 5 years ago. She appears
anxious and diaphoretic
and is nauseated. Examination shows no other
abnormalities except for
an S4. Which of the following is the most likely
diagnosis?

A
) Acute aortic dissection

B
) Angina pectoris

C
) Esophageal spasm

D
) Myocardial infarction

E
) Pulmonary embolism



29. A 27-year-old woman comes to the physician
because of
increasingly severe daily headaches over the past 3
months. The headaches are
diffuse and often occur at the base of the skull. For
the past month,
she has had brief episodes of visual darkening when
standing. She has
been amenorrheic for the past year and has had an
18-kg (40-lb) weight
gain during this period. She now weighs 118 kg (260
lb) and is 152 cm
(60 in) tall. Funduscopic examination shows
papilledema, several flame
hemorrhages, and an enlarged blind spot bilaterally.
Visual acuity is
20/20 bilaterally. A CT scan of the head shows no
abnormalities. Which
of the following is the most likely underlying cause
of these findings?

A
) Cerebral venous occlusion

B
) Communicating hydrocephalus

C
) Cytotoxic edema

D
) Idiopathic intracranial hypertension

E
) Impaired absorption of cerebrospinal fluid

F
) Infratentorial mass lesion

G
) Interstitial edema

H
) Overproduction of cerebrospinal fluid

I
) Vasogenic edema



30. A 75-year-old man with a 3-year history of
progressive cognitive
impairment due to dementia, Alzheimer's type, has had
nocturnal
disorientation for 2 weeks. He lives at home with his
wife. He is otherwise
healthy and takes no medications. Physical
examination shows normal
findings. He is disoriented to time and place, has
poor short-term
memory, is unable to do simple arithmetic, and has a
poor understanding of
general information. Which of the following is the
most appropriate
initial step in management?

A
) Increase in home nighttime lighting

B
) Prescription for chloral hydrate

C
) Prescription for diazepam

D
) Prescription for haloperidol

E
) Use of nighttime mechanical restraints



31. A 62-year-old woman comes to the physician
because of severe
pain and swelling of her right knee for 1 day. She
has no history of
joint disease or trauma to the knee. She has
hypertension treated with
hydrochlorothiazide and type 2 diabetes mellitus
treated with glyburide.
She is sexually active only with her husband, and they
have sexual
intercourse one to two times each week. Her
temperature is 37 C (98.6 F),
blood pressure is 140/84 mm Hg, and pulse is 80/min.
Examination of
the right knee shows edema, erythema, and exquisite
tenderness to light
touch; there is an effusion. The remainder of the
examination shows no
abnormalities. Which of the following is the most
likely mechanism of
these findings?

A
) Immune complex deposition

B
) Inflammatory reaction to antisynovial antibodies

C
) Inflammatory reaction to monosodium urate
crystals

D
) Neisseria gonorrhoeae infection

E
) Streptococcus pneumoniae infection


32. Two days after a cholecystectomy, a 42-year-old
woman has
shortness of breath. Her temperature is 37.5 C (99.5
F), blood pressure is
110/70 mm Hg, pulse is 103/min, and respirations are
24/min. There is
abdominal tenderness. Examination shows no other
abnormalities. An
x-ray film of the chest shows minimal linear markings
in the right lower
lobe. Arterial blood gas analysis on 45% oxygen
shows:

pH 7.41
PCO2 40 mm Hg
PO2 52 mm Hg

Which of the following is the most likely explanation
for her hypoxia?

A
) Acute respiratory distress syndrome

B
) Atelectasis

C
) Congestive heart failure

D
) Fat embolism syndrome

E
) Pneumonia

F
) Pneumothorax



33. A 37-year-old woman comes to the emergency
department because of
a 3-day history of increasingly severe abdominal pain,
nausea, and
vomiting. Twelve years ago, she had a hysterectomy
because of severe
dysfunctional uterine bleeding. Her temperature is 37
C (98.6 F), blood
pressure is 106/70 mm Hg, pulse is 110/min, and
respirations are 12/min.
Examination shows a distended, tympanic abdomen with
diffuse tenderness
but no guarding; bowel sounds are hypoactive. Her
leukocyte count is
10,000/mm3, and hematocrit is 44%. An x-ray film of
the abdomen is
shown. Which of the following is the most appropriate
initial step in
management?

A
) CT scan of the abdomen

B
) Intravenous neostigmine therapy

C
) Esophagogastroduodenoscopy

D
) Nasogastric intubation

E
) Laparotomy



34. A healthy 27-year-old woman comes for a routine
health
maintenance examination. Her blood pressure is 185/90
mm Hg. Examination shows
no other abnormalities except for hypertensive
retinopathy. Serum
studies show a sodium level of 140 mEq/L, potassium
level of 4 mEq/L, and
creatinine level of 1.1 mg/dL. A complete blood
count, serum
catecholamine levels, and urinalysis are within normal
limits. At two subsequent
visits, her blood pressure is 190/100 mm Hg and 182/96
mm Hg,
respectively. Which of the following is the most
appropriate next step in
diagnosis?

A
) 24-Hour urine collection for measurement of
creatinine clearance

B
) 24-Hour urine collection for measurement of
17-hydroxycorticosteroid and total 17-ketosteroid
levels

C
) Measurement of serum aldosterone level

D
) Magnetic resonance angiography of renal vessels

E
) CT scan of the abdomen



35. A 76-year-old man has had fatigue and loss of
interest in daily
activities over the past 4 months. He sleeps poorly
and has had a
4.5-kg (10-lb) weight loss during this period. He
states that he has
probably lived long enough. His blood pressure is
110/78 mm Hg, and pulse
is 68/min. Examination shows a slow return of deep
tendon reflexes.
Measurement of which of the following serum levels is
the most
appropriate next step in management?

A
) Calcium

B
) Creatinine

C
) Glucose

D
) Testosterone

E
) Thyroid-stimulating hormone


36. A 29-year-old woman is brought to the physician
by her father.
She has been working continuously without sleep for 3
days on a project
which she claims "Allah and Jesus have told me to do"
that will "unify
all knowledge in physics and medicine and philosophy."
She hears the
voice of her dead brother telling her that she will be
"the next Virgin
Mary." Her father states that she was treated for
depression for 1 year
at the age of 19 years. Which of the following is the
most likely
diagnosis?

A
) Bipolar disorder

B
) Borderline personality disorder

C
) Major depressive disorder

D
) Schizophrenia

E
) Substance-induced mood disorder



37. A 67-year-old man is hospitalized for treatment
of renal
insufficiency. Three days after admission, his pulse
is 40/min. An ECG shows
tall, tented T waves. Serum studies show a sodium
level of 134 mEq/L,
potassium level of 6.9 mEq/L, and glucose level of 85
mg/dL. The most
appropriate next step in management is intravenous
administration of
which of the following?

A
) Calcium, furosemide, and 3% saline

B
) Calcium, insulin, and digitalis

C
) Calcium, insulin, and glucose

D
) Glucose, furosemide, and phosphate

E
) Glucose, glucagon, and bicarbonate


38. Six months after the delivery of her fourth
child, a 37-year-old
woman undergoes laparoscopic tubal ligation. Menses
occur at regular
28-day intervals. During the operation, she is found
to have a small
dark lesion in the cul-de-sac and filmy adhesions
surrounding the
ovaries. A biopsy specimen of a cul-de-sac lesion
confirms the diagnosis of
endometriosis. Which of the following is the most
appropriate next step
in management?

A
) Danazol therapy

B
) Gonadotropin-releasing hormone agonist therapy

C
) Oral contraceptive therapy

D
) Total abdominal hysterectomy and bilateral
salpingo-oophorectomy

E
) No further treatment indicated


A
) Administration of parenteral antibiotics

B
) Admission to the hospital for medical management

C
) Admission to the hospital for operative
management

D
) Colon contrast studies

E
) Discharge for follow-up by personal physician

F
) Endoscopy

G
) MRI of the abdomen

H
) Observation in the emergency department

39. A previously healthy 6-month-old boy is brought
to the emergency
department because of a 12-hour history of
intermittent episodes of
inconsolable crying associated with drawing up of the
legs. Over the past
6 hours, he has had intermittent diarrhea that is
reddish and mucoid,
and for the past 3 hours he has been somnolent. On
examination, he is
sleepy but arousable. His temperature is 38.1 C
(100.6 F), blood
pressure is 90/55 mm Hg, pulse is 140/min, and
respirations are 38/min. He
cries when his abdomen is palpated; a mass is felt in
the right lower
quadrant. His leukocyte count is 12,400/mm3 (50%
segmented neutrophils,
8% bands, 1% eosinophils, 40% lymphocytes, and 1%
monocytes). Serum
electrolyte levels are within normal limits. An x-ray
film of the
abdomen shows no free air.


A
) Administration of parenteral antibiotics

B
) Admission to the hospital for medical management

C
) Admission to the hospital for operative
management

D
) Colon contrast studies

E
) Discharge for follow-up by personal physician

F
) Endoscopy

G
) MRI of the abdomen

H
) Observation in the emergency department

40. A previously healthy 14-year-old girl is
brought to the
emergency department because of abdominal pain for 12
hours. She has a 1-week
history of brownish vaginal discharge. Menarche was
at the age of 12
years, and her periods have occurred at regular 28-day
intervals over
the past year. Her last menstrual period was 7 weeks
ago. Her
temperature is 37 C (98.6 F), blood pressure is 85/55
mm Hg, pulse is 145/min,
and respirations are 24/min. Abdominal examination
shows generalized
tenderness, and there is guarding with rebound in the
right lower
quadrant. Her hematocrit is 24%, and leukocyte count
is 9400/mm3 (60%
segmented neutrophils, 3% bands, 1% eosinophils, 35%
lymphocytes, and 1%
monocytes). Serum electrolyte levels are within
normal limits.


41. A 49-year-old woman is admitted to the hospital
because of renal
failure. She has had episodes of flank pain over the
past 20 years.
She has also had nocturia 2 to 3 times nightly for 10
years. Her blood
pressure is 160/100 mm Hg. Examination shows pale
mucous membranes. A
mass is palpated in the right flank. Which of the
following is the
most likely diagnosis?

A
) Horseshoe kidney

B
) Nephrolithiasis

C
) Papillary necrosis

D
) Polycystic kidney disease

E
) Renal cell carcinoma


42. On routine annual screening, an asymptomatic
27-year-old man has
a positive PPD skin test. One year ago, a PPD skin
test was negative.
He works as a nurse. Three years ago, he was
diagnosed with hepatitis
A after a trip to South America. Examination shows no
abnormalities.
His serum aspartate aminotransferase (AST, GOT)
activity is 10 U/L, and
serum alanine aminotransferase (ALT, GPT) activity is
14 U/L. An x-ray
film of the chest shows no abnormalities. Which of
the following is
the most appropriate chemoprophylaxis?

A
) Isoniazid and folic acid supplementation

B
) Isoniazid and rifampin

C
) Isoniazid and vitamin B1 (thiamine)
supplementation

D
) Isoniazid and vitamin B6 supplementation

E
) No prophylaxis indicated


43.

A 4-month-old boy is brought to the physician because
of a 2-day
history of fever and progressive redness around his
right eye. He has had
persistent diarrhea and oral candidiasis since birth
and was treated for
pneumococcal pneumonia at the age of 2 months. He
appears ill. His
temperature is 39 C (102.2 F), pulse is 130/min, and
respirations are
25/min. Examination shows violaceous preseptal
(periorbital) cellulitis
and oral candidiasis. Laboratory studies show:


Hemoglobin 10 g/dL
Leukocyte count 3000/mm3
Segmented neutrophils 85%
Lymphocytes 15%
Platelet count 350,000/mm3
Serum
IgA <5 mg/dL
IgG 300 mg/dL
IgM <5 mg/dL

Which of the following is the most likely diagnosis?

A
) AIDS

B
) Chronic granulomatous disease

C
) Severe combined immunodeficiency

D
) Thymic-parathyroid dysplasia (DiGeorge syndrome)

E
) X-linked agammaglobulinemia



44. One week after undergoing an uncomplicated
liver transplant for
biliary atresia, a 3-year-old boy appears jaundiced.
Examination shows
scleral icterus. His serum aspartate aminotransferase
(AST, GOT)
activity has increased to 1300 U/L, and serum alanine
aminotransferase (ALT,
GPT) activity has increased to 2500 U/L. His serum
bilirubin level is
3.5 mg/dL, and serum alkaline phosphatase activity is
100 U/L. Which
of the following is the most likely artery responsible
for this
patient's gastrointestinal symptoms?

A
) Hepatic

B
) Ileocolic

C
) Inferior mesenteric

D
) Left gastric

E
) Left gastroepiploic

F
) Middle colic

G
) Posterior penetrating

H
) Right colic

I
) Right gastroepiploic

J
) Splenic

K
) Superior hemorrhoidal

L
) Superior mesenteric



45. A 2-year-old girl has had fever and bloody
diarrhea for 10 days.
A stool culture obtained 7 days ago grew Salmonella
species sensitive
to amoxicillin. A blood culture was negative.
Despite beginning oral
amoxicillin therapy 4 days ago, her diarrhea has
persisted. Current
examination shows no other abnormalities except for a
temperature of 38.6 C
(101.5 F). Which of the following is the most likely
explanation for
the failure of amoxicillin to improve her symptoms?

A
) Amoxicillin does not alter the course of
Salmonella enteritidis

B
) Amoxicillin has caused pseudomembranous colitis

C
) Amoxicillin is absorbed at the level of the
jejunum, leaving no
drug to be delivered to the colon

D
) Oral amoxicillin is not absorbed into the
systemic circulation in
the presence of diarrhea

E
) Salmonella has expressed an inducible ß-lactamase
that inactivates
amoxicillin


46.

A 23-year-old man comes to the physician because of a
1-month history
of intermittent right-sided abdominal pain, nausea,
and vomiting. He
has sickle cell disease and has been treated several
times for painful
crises. Examination of the abdomen shows tenderness
to palpation of the
right upper quadrant on inspiration. Laboratory
studies show:


Hematocrit 25%
Leukocyte count 11,000/mm3
Serum
Bilirubin
Total 3.2 mg/dL
Direct 0.3 mg/dL
Alkaline phosphatase 56 U/L

Ultrasonography of the gallbladder shows a filling
defect. Which of
the following is the most likely cause of this
patient's
hyperbilirubinemia?

A
) Aggregation of cholesterol in the gallbladder

B
) Inhibition of glucuronosyltransferase

C
) Lysis of erythrocytes

D
) Malnutrition-induced cirrhosis

E
) Neoplastic growth in the gallbladder


BLOCK 1

1. 1. e
2. a
3. B
4. E
5. a? b?
6. b
7. b
8. C
9. D
10. A
11. J
12. H
13. d
14. a
15. d
16. b
17.
18. d
19. A
20. c
21. A
22. B
23. a
24. b
25. B/D
26. A
27. e
28. C
29. D
30. G
31. D
32. B
33. E
34. A
35. c
36. a
37. f
38.A
39. G
40. a
41. E
42. B
43. E
44. D
45. D/B
46. F

BLOCK 2
1 .D
2.B
3.A
4. G??
5. C
6. C
7.B
8.D
9.A
10.C??
11.C
12.D
13. C
14.C
15.A
16.C
17. A /?? E
18.B
19.B
20.E
21.E
22.D
23.D
24. E
25.C
26.F
27.B
28.E
29.B
30.D
31.E
32.B
33.A
34.A
35.E
36.E
37.E
38.F
39.D
40.B ??
41.E
42.D
43.E
44. E
45. C( OSTEOMYLITIS)
46.D


BLOCK 3

1.d
2.c
3.c
4.b
5.a
6.a
7.b
8.d
9.c
10.b
11.e
12.b
13.d
14.a
16.e
17.c
18.g
19.c
20.b
21.e
22.b
23.c
24.b
25.h
26.e
27.c
28.d?
29.g
30.a
31.d.
32.d
33.c
34.c
35.b
36.c.
37.b
38.d
39.a
40.d
41.e.
42.f
43.d
44.b
45.c
46.d

BLOCK 4

1.a
2.a
3.b?
4. e/a
5.e/b
6.f
7.c
8.c/g
9.g
10.a/c.. very controvertial plz explain
11.a
12.c
13.e
14.e
15.f
16.c
17.e/d
18.d
19.j
20.a /? E
21.e/d
22.d
23.a
24.a?
25.b
26.f
27.d
28.d
29.d
30.a
31.b
32.b
33.d nosogastric suction
34.d
35.e
36.a
37.b
38e?
39.d
40.d
41.d
42.d
43.c
44.a
45.b??
46.c



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  NBME Form 1 Step 2

Section 1:--


1. A 70-year-old woman has had increasing abdominal pain over the past
2 days. She has renal failure and has been receiving peritoneal
dialysis for 18 months; her last treatment was 2 hours ago. She
appears toxic. Her temperature is 39 C (102.2 F), and blood pressure
is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep
palpation with rebound tenderness. Leukocyte count is 18,000/mm3.
Which of the following is the most appropriate next step?

A ) X-ray films of the abdomen

B ) Comparison of abdominal fluid amylase with serum amylase activity

C ) Gram's stain of abdominal fluid

D ) Ultrasonography of the abdomen

E ) CT scan of the abdomen and pelvis

2. A 5-year-old girl is brought to the physician because of
temperatures to 40 C (104 F), tachypnea, and a nonproductive cough for
12 hours. Four days ago she was treated with an oral antibiotic for
suspected pneumococcal pneumonia. Examination shows diminished breath
sounds over the lower right lung fields and dullness to percussion at
the right costophrenic angle. Which of the following is the most
likely diagnosis?

A ) Bronchopleural fistula

B ) Empyema

C ) Lung abscess

D ) Pleurodynia

E ) Pneumothorax

3. A 40-year-old man is brought to the emergency department 1 hour
after a high-speed motor vehicle collision. On arrival, he is awake
and alert but has severe pain over the sternum. His systolic blood
pressure is 80 mm Hg, pulse is 80/min, and respirations are 10/min. An
ECG shows multifocal premature ventricular contractions but no
ST-segment changes. His PO2 is 100 mm Hg. After 1 L of lactated
Ringer's solution is administered, his PO2 decreases to 60 mm Hg while
breathing 4 L/min of oxygen by nasal cannula. Pulmonary capillary
wedge pressure has increased from 14 mm Hg to 24 mm Hg (N=1–10). Which
of the following is the most likely explanation for the patient's poor
response to fluid resuscitation?

A ) Inadequate administration of fluids

B ) Myocardial contusion

C ) Myocardial infarction

D ) Pulmonary contusion

E ) Traumatic rupture of the aorta

4. A 21-year-old African American college student has had increasing
fatigue over the past 3 weeks. Since an episode of cystitis treated
with trimethoprim-sulfamethoxazole 3 weeks ago, he has been unable to
keep up with his physical education classes. For 6 months, he has been
following a vegetarian diet that has been supervised by student health
services. Examination shows no abnormalities. His hemoglobin level is
10 g/dL, mean corpuscular volume is 85 μm3, and reticulocyte count is
15%. Which of the following is the most likely cause of anemia in this
patient?

A ) Anemia secondary to infection

B ) Antibiotic therapy

C ) Gastrointestinal blood loss

D ) Sickle cell disease

E ) Vegetarian diet

5. An 87-year-old nursing home resident with dementia, Alzheimer's
type, is admitted to the hospital because of progressive lethargy and
decreased appetite for 3 days. She had a flu-like illness followed by
a deep cough 1 week ago. Over the past 10 months, she has been
hospitalized once for bacterial pneumonia. She is responsive only to
painful stimuli. Her temperature is 38.6 C (101.5 F), blood pressure
is 110/60 mm Hg, pulse is 123/min and regular, and respirations are
28/min. Examination shows dry mucous membranes. There is no
adenopathy. Crackles are heard in the right lung base. An x-ray film
of the chest shows an infiltrate at the right lung base. The remainder
of the examination shows no abnormalities. Which of the following is
the most likely predisposing factor for this patient's pneumonia?

A ) Decreased airway elasticity

B ) Decreased baroreflex

C ) Decreased gag reflex

D ) Decreased thyroid function

E ) Diastolic cardiac dysfunction

F ) Impaired cardiac response to exercise

G ) Impaired T-lymphocyte function

H ) Impaired thirst

I ) Increased lung compliance

J ) Renal salt wasting

6. A 27-year-old woman comes to the physician because of feelings of
anxiety about attending her 10-year high school reunion. She has a
2-year history of profound anxiety, palpitations, and sweating
associated with an uneasiness around people; she avoids family
gatherings and visiting friends because she is afraid of being
embarrassed. She acknowledges that this fear is unreasonable. She does
not use illicit drugs but says that alcohol makes her more comfortable
around people. Her blood pressure is 130/90 mm Hg, and pulse is
88/min. On physical examination, she appears healthy and well
nourished. Occasional wheezing is heard over the left lung field. The
remainder of the examination shows no abnormalities. On mental status
examination, she appears worried. Her leukocyte count is 9000/mm3 with
a normal differential. Which of the following is the most likely
diagnosis?

A ) Alcohol abuse

B ) Anxiety disorder due to a general medical condition

C ) Asthma

D ) Generalized anxiety disorder

E ) Panic disorder with agoraphobia

F ) Social phobia

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with urinary incontinence, select the most likely cause.


A ) Detrusor instability

B ) Interstitial cystitis

C ) Overflow incontinence

D ) Stress incontinence

E ) Urethra diverticulum

F ) Urinary fistula

7. A previously healthy 44-year-old woman, gravida 4, para 4, comes to
the physician because of a 9-month history of progressive loss of
small amounts of urine while running; she now has to wear an absorbent
pad. Examination shows a second-degree cystourethrocele.

For each patient with urinary incontinence, select the most likely cause.


A ) Detrusor instability

B ) Interstitial cystitis

C ) Overflow incontinence

D ) Stress incontinence

E ) Urethra diverticulum

F ) Urinary fistula

8. One day after an uncomplicated spontaneous vaginal delivery, a
23-year-old woman, gravida 1, para 1, has the onset of loss of small
amounts of urine. She received epidural anesthesia during labor and
delivery. Examination shows an episiotomy without evidence of
hematoma. She is voiding 50 to 75 mL of urine at a time. Postvoid
residual volume is 300 mL.

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with cognitive impairment, select the most likely diagnosis.


A ) Acute stress disorder

B ) Dementia, Alzheimer's type

C ) Dissociative amnesia

D ) General paresis

E ) Head trauma

F ) Hepatolenticular degeneration (Wilson's disease)

G ) HIV encephalitis

H ) Huntington's disease

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

K ) Niacin deficiency

L ) Normal-pressure hydrocephalus

M ) Parkinson's disease

N ) Pick's disease

O ) Schizophrenia, catatonic type

P ) Normal aging

9. An 82-year-old woman is brought to the physician by her
granddaughter because of a 6-week history of increasing forgetfulness.
She is a retired schoolteacher and lives independently. Her
granddaughter is concerned because on several occasions she has left
the stove on when she went to bed. During conversations with her
granddaughter, she has difficulty remembering past events and seems
unconcerned about her memory lapses. The patient describes trouble
sleeping through the night and has had a decreased appetite resulting
in a 4.5-kg (10-lb) weight loss over the past month. She has a history
of similar symptoms 2 and 5 years ago that were successfully treated
with medication. She appears unkempt and has poor personal hygiene.
Her temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, and
pulse is 80/min and regular. Mental status examination shows
psychomotor retardation, a flat affect, impaired ability to recall
past events, and trouble repeating three numbers in sequence. She is
unable to recall the names of recent presidents. Her serum urea
nitrogen (BUN) level is 25 mg/dL, and serum creatinine level is 1.7
mg/dL.

For each patient with cognitive impairment, select the most likely diagnosis.


A ) Acute stress disorder

B ) Dementia, Alzheimer's type

C ) Dissociative amnesia

D ) General paresis

E ) Head trauma

F ) Hepatolenticular degeneration (Wilson's disease)

G ) HIV encephalitis

H ) Huntington's disease

I ) Major depressive disorder

J ) Multi-infarct (vascular) dementia

K ) Niacin deficiency

L ) Normal-pressure hydrocephalus

M ) Parkinson's disease

N ) Pick's disease

O ) Schizophrenia, catatonic type

P ) Normal aging

10. A 42-year-old computer science professor is brought to the
physician by her husband, who reports insidious changes in his wife's
personality and behavior. He reports that she believes that aliens
have been speaking to her and tampering with their heating and
air-conditioning systems. He says that she was upset when she turned
40 years old, and her symptoms have developed since that time. She was
adopted, and her family history is unknown. Physical examination shows
vermicular movements of the tongue and bilateral writhing motions of
the upper extremities. Mental status examination shows indifference to
her condition and mild to moderate difficulty with memory and
calculations.

11. A 5-month-old boy is brought for a follow-up examination. He was
born at 37 weeks' gestation and has had persistent wheezing since
shortly after birth despite treatment with nebulized and oral
bronchodilators and oral corticosteroids. His diet consists of 32
ounces of iron-fortified cow's milk-based formula daily. He appears
well nourished and happy. On examination, there is moderate relief of
wheezing with extension of the neck. Which of the following is the
most likely mechanism of this infant's wheezing?

A ) Allergic reaction to cow's milk

B ) Aspiration of a foreign body

C ) Compression of the airway by a vascular ring

D ) Concurrent upper respiratory tract infection

E ) Persistent immaturity of lungs

12. An 18-month-old boy is brought to the emergency department because
he has not used his left arm since he fell while walking and holding
hands with his 8-year-old sister 2 hours ago. On examination, he holds
his left upper extremity at his side with his forearm pronated. There
is no tenderness of the left lower extremity, but there is restricted
movement of the elbow. The remainder of the examination shows no
abnormalities. Which of the following is the most appropriate initial
step in management?

A ) Passive hypersupination of the forearm

B ) Application of figure-of-8 strap

C ) Administration of analgesics and application of ice

D ) Aspiration of the elbow joint

E ) In-place splint immobilization of the elbow

13. A 6-month-old girl is brought to the physician for a routine
health maintenance examination. She was born with a lumbosacral
myelomeningocele which was successfully repaired at 2 days of age. The
anterior fontanelle is 6 x 8 cm and bulging, and the posterior
fontanelle is 3 x 4 cm and bulging. She has severe motor and sensory
deficits involving both lower extremities. A head growth chart shows
the following values:
Age
Head circumference (cm)

Birth
34.2
1 month
36.6
2 months
38
4 months
44
6 months
47

Which of the following is the most likely cause of increased
intracranial pressure?

A ) Acute cerebral edema

B ) Decreased absorption of cerebrospinal fluid

C ) Dilation of cerebral arteries

D ) Intracranial mass lesion

E ) Obstruction of lateral sinus

F ) Obstruction of superior vena cava

G ) Obstruction of cerebrospinal fluid flow

H ) Overproduction of cerebrospinal fluid

14. An 18-year-old primigravid woman comes for her initial prenatal
visit at 16 weeks' gestation. She is not sure about the date of her
last menstrual period but says that the pregnancy probably occurred
immediately after she stopped taking oral contraceptives 5 months ago.
Maternal serum α-fetoprotein (MSAFP) level is increased to 3 multiples
of the median. Which of the following is the most appropriate next
step in management?

A ) Repeat measurement of MSAFP level

B ) Triple screening for MSAFP, serum β-hCG, and serum estriol levels

C ) Ultrasonography

D ) Amniocentesis for measurement of α-fetoprotein level

E ) Amniocentesis for chromosomal analysis

15. A 28-year-old man is brought to the emergency department by police
because of severe pain in the right lower quadrant of the abdomen for
36 hours. He has been incarcerated in the county jail, and his court
hearing is scheduled in 12 hours. He takes no medications. Abdominal
examination shows no rebound. Complete blood count, liver tests, and
erythrocyte sedimentation rate are within normal limits. An x-ray film
of the abdomen shows a normal gas pattern. Test of the stool for
occult blood is negative. Which of the following is the most likely
diagnosis?

A ) Adjustment disorder

B ) Conversion disorder

C ) Depressive disorder not otherwise specified

D ) Factitious disorder

E ) Hypochondriasis

F ) Malingering

G ) Somatization disorder

16. A 6-year-old girl is brought to the physician because of a 4-week
history of headache, fatigue, and decreased appetite. During this
period, she has had nausea and vomiting. At the age of 4 years, she
was diagnosed with poststreptococcal glomerulonephritis. She is at the
15th percentile for height and the 10th percentile for weight.
Examination shows no abnormalities. Her serum urea nitrogen (BUN)
level is 50 mg/dL. Which of the following is most likely to limit
progression of this patient's renal failure?

A
) Increased potassium and sodium bicarbonate intake

B
) Decreased sodium and daily calorie intake

C
) Low-protein diet

D
) Strict fluid restriction

E
) Dialysis

17. A previously healthy 62-year-old man comes to the emergency
department because of abdominal pain for 48 hours. His temperature is
38.6 C (101.5 F), blood pressure is 130/80 mm Hg, pulse is 110/min,
and respirations are 15/min. Abdominal examination shows diffuse left
lower quadrant tenderness with no peritoneal signs. Rectal examination
shows no abnormalities; test of the stool for occult blood is
negative. His leukocyte count is 14,700/mm3. Which of the following is
the most appropriate next step in diagnosis?

A
) Barium enema

B
) CT scan of the abdomen

C
) Colonoscopy

D
) Cystoscopy

E
) Exploratory laparotomy

18. A previously healthy 3-month-old girl is brought to the emergency
department because of a 3-day history of grunting and increasing
difficulty breathing. She appears ill. Her temperature is 36.7 C (98
F), pulse is 160/min, and respirations are 76/min. Examination shows
grunting, nasal flaring, and marked intercostal retractions. Bronchial
breath sounds and occasional bilateral crackles are heard on
auscultation. Serum studies show:

Ca2+ 5.6 mg/dL
Phosphorus 11 mg/dL
Alkaline phosphatase 250 U/L

Capillary blood gas analysis on 100% oxygen:

pH 7.36
PCO2 38 mm Hg
PO2 46 mm Hg

An x-ray film of the chest shows bilateral, diffuse interstitial
infiltrates and absence of the thymic shadow. Bronchoalveolar lavage
is positive for numerous Pneumocystis carinii. Which of the following
is the most likely mechanism of these findings?

A ) Adenosine deaminase deficiency

B ) Consumption of complement

C ) Defective opsonization

D ) Destruction of CD4+ T lymphocytes

E ) Developmental arrest of maturation of B lymphocytes

F ) Dysmorphogenesis of the third and fourth pharyngeal pouches

G ) Impaired chemotaxis

H ) Impaired phagocytic oxidative metabolism

19. A 4-year-old boy is brought to the emergency department 20 minutes
after being involved in a motor vehicle collision. He was an
unrestrained passenger. On arrival, his blood pressure is 110/70 mm
Hg, pulse is 100/min, and respirations are 32/min with grunting and
retractions. Examination shows multiple bruises over the chest.
Arterial blood gas analysis while breathing 40% oxygen shows:

pH 7.38
PCO2 34 mm Hg
PO2 66 mm Hg

An x-ray film of the chest obtained 4 hours later shows diffuse
infiltrates on the right side. Which of the following is the most
likely diagnosis?

A
) Acute respiratory distress syndrome

B
) Aspiration pneumonia

C
) Fat embolism

D
) Hemothorax

E
) Pulmonary contusion

20. A 72-year-old man comes to the physician because of a 7-month
history of leg weakness and dry eyes and mouth. He also has had a
10.4-kg (23-lb) weight loss over the past 4 months despite no change
in appetite. He has smoked one and a half packs of cigarettes daily
for 50 years. He drinks 4 oz of alcohol daily. He has peptic ulcer
disease and emphysema. Medications include cimetidine, theophylline,
and low-dose prednisone. Examination shows mild ptosis. He has a
barrel-shaped chest. Breath sounds are distant. There is moderate
weakness of the proximal muscles of the lower extremities. Reflexes
are absent. He has difficulty rising from a chair. Sensory examination
shows no abnormalities. An x-ray film shows a hyperinflated chest and
a 3 x 4-cm mass in the right hilum. His neurologic findings are most
likely due to a lesion involving which of the following?

A
) Muscle membrane

B
) Parasympathetic nervous system

C
) Peripheral nerve

D
) Presynaptic neuromuscular junction

E
) Sympathetic nervous system

21. A 42-year-old man comes to the emergency department because of a
2-week history of increasingly severe headaches and a 2-day history of
nausea, vomiting, neck stiffness, and unsteadiness. He has type 2
diabetes mellitus treated with glyburide. His temperature is 38.1 C
(100.5 F). Funduscopic examination shows bilateral papilledema.
Neurologic examination shows mild meningismus and diffusely brisk deep
tendon reflexes. He walks with a moderately broad-based gait. He is
able to recall two out of three objects after 5 minutes and makes
several errors on serial sevens. A CT scan of the head shows no
abnormalities. Cerebrospinal fluid analysis shows a glucose level of
18 mg/dL, a protein level of 108 mg/dL, and a leukocyte count of
59/mm3 (1% segmented neutrophils and 99% lymphocytes); a cryptococcal
antigen assay is positive. Which of the following is the most
appropriate pharmacotherapy for this patient?

A
) Acyclovir

B
) Amphotericin B

C
) Itraconazole

D
) Penicillin

E
) Vancomycin

22. A 3-year-old girl is brought to the physician after her mother
noted blood on her underpants. Examination shows genital condylomata
acuminata in the perineal, peri-introital, labial, and anal areas.
Some of the pedunculated condylomata appear to have caused the
bleeding. She has no visible intravaginal condylomata or vaginal or
anal tears. Her mother has a palmar wart on her hand but no history of
condylomata acuminata. Her mother has a boyfriend who does not live
with them and who has never been left alone with the girl. They live
with the mother's 27-year-old brother who only baby-sits the children
when they are asleep. Which of the following is the most appropriate
next step in management?

A
) Psychiatric assessment of the mother

B
) DNA typing of the mother's palmar wart for papillomavirus

C
) Treatment of the mother's palmar wart

D
) Vaginal, anal, and throat cultures for Chlamydia trachomatis and
Neisseria gonorrhoeae in the child

E
) Laser therapy of the condylomata acuminata in the child

23. A 55-year-old man has had crushing substernal chest pain on
exertion over the past 6 weeks. He had a myocardial infarction 2
months ago. He takes nitroglycerin as needed and one aspirin daily. He
has smoked two packs of cigarettes daily for 30 years. Examination
shows normal heart sounds and no carotid or femoral bruits. Treatment
with a β-adrenergic blocking agent is most likely to improve his
symptoms due to which of the following mechanisms?

A
) Decreasing diastolic relaxation

B
) Decreasing myocardial contractility

C
) Dilating the coronary arteries

D
) Peripheral vasodilation

E
) Preventing fibrin and platelet plugs

24. A previously healthy 52-year-old woman comes to the physician
because she has had a large pimple on her right hand for 2 weeks that
has failed to heal. She resides in southeastern USA where she owns a
nursery and garden shop. Examination shows a painless red papule on
the hand with several nontender subcutaneous nodular lesions above it.
Which of the following is the most likely diagnosis?

A ) Blastomycosis

B ) Candidiasis

C ) Coccidioidomycosis

D ) Histoplasmosis

E ) Sporotrichosis

25. A 28-year-old woman at 28 weeks' gestation reports excessive
fatigability and dyspnea. Her blood pressure is 118/74 mm Hg, pulse is
110/min and regular, and lungs are clear to auscultation. The cardiac
apex is not palpable. S1 is loud, and there is a sharp sound after S2.
A low-frequency diastolic murmur is heard at the apex that increases
in intensity before S1. Which of the following is the most likely
diagnosis?

A
) Aortic regurgitation

B
) Ebstein's anomaly

C
) Mitral regurgitation

D
) Mitral stenosis

E
) Tricuspid regurgitation

26. A 27-year-old woman comes to the physician because of a 2-year
history of intermittent diarrhea and severe cramping abdominal pain.
The stools are watery, occasionally foul-smelling, and nonbloody. She
is currently pain-free and has not had diarrhea for 2 days. She also
has intermittent constipation. She has not had fever or weight loss.
She returned from a trip to Mexico 3 months ago. She had an
appendectomy at the age of 12 years and a cesarean delivery 4 years
ago. Examination shows no abnormalities. Which of the following is the
most likely diagnosis?

A
) Bacterial gastroenteritis

B
) Crohn's disease

C
) Intermittent small-bowel obstruction

D
) Irritable bowel syndrome

E
) Laxative abuse

27. An asymptomatic 21-year-old woman is found to have an adnexal mass
on pelvic examination. She uses oral contraceptives. A photograph of
the mass is shown. Which of the following is the most likely
diagnosis?

A
) Benign cystic teratoma

B
) Corpus luteum cyst

C
) Dysgerminoma

D
) Endometrioma

E
) Mucinous cystoadenoma

28. A 16-year-old girl is brought to the physician because of episodes
of palpitations over the past 6 months. The episodes occur when she
runs or plays basketball. She is otherwise asymptomatic. Her blood
pressure is 124/46 mm Hg, pulse is 78/min, and respirations are
18/min. She weighs 55 kg (121 lb) and is 180 cm (71 in) tall. Her arm
span is 188 cm (74 in), and the upper segment to lower segment ratio
is 0.85. Her fingers appear long and are hyperextensible. A grade 4/6,
early diastolic murmur is heard along the upper and middle left
sternal border with radiation to the apex. Peripheral pulses are
bounding. Which of the following is the most likely cause of these
findings?

A
) Aortic incompetence

B
) Aortic stenosis

C
) Mitral incompetence

D
) Mitral stenosis

E
) Pulmonary incompetence

F
) Pulmonary stenosis

G
) Tricuspid incompetence

H
) Tricuspid stenosis

29. A previously healthy 87-year-old woman comes to the physician
because of a 4-month history of vulvar itching. Examination shows
excoriated areas from scratching and a white, thin vulva. The labia
minora are absent, and there are small fissures at the introitus. The
remainder of the examination shows no abnormalities. Which of the
following is the most likely diagnosis?

A
) Escherichia coli infection

B
) Lichen sclerosus

C
) Squamous cell carcinoma

D
) Trichomoniasis

E
) Vulvar melanoma

F
) Vulvar vestibulitis

30. One month after undergoing an uneventful renal transplant for
chronic renal failure secondary to glomerulonephritis, a 38-year-old
woman is hospitalized because of increased serum urea nitrogen (BUN)
and creatinine levels. Prior to transplantation, she had been
receiving hemodialysis for 3 years. Current medications include
cyclosporine and prednisone. Examination shows no abnormalities. Over
the past 48 hours, urine output has remained stable. Both renal biopsy
and a radionuclide scan confirm the diagnosis of acute rejection.
Which of the following is the most effective treatment?

A
) Immediate discontinuation of cyclosporine

B
) Increased dosage of corticosteroids

C
) Diuresis and alkalinization of the urine

D
) Renal dialysis for 1–2 weeks

E
) Transplant nephrectomy

31. An 18-year-old man comes to the physician 1 week after he had a
blood pressure of 140/110 mm Hg during a routine precollege
examination. His temperature is 37.1 C (98.7 F), blood pressure is
140/100 mm Hg, pulse is 92/min, and respirations are 12/min. The upper
extremities appear to be more muscular than the lower extremities.
Radial pulses are normal; femoral, posterior tibial, and dorsalis
pedis pulses are decreased. A grade 2/6 systolic murmur is heard over
the precordium, anterior chest, and back. An ECG shows left
ventricular hypertrophy. Which of the following is the most
appropriate next step in management?

A ) Limiting physical activity

B ) Repeat blood pressure measurement in 1 month

C ) Initiate a low-sodium diet and exercise program

D ) Pharmacologic management

E ) Operative treatment

32. A 77-year-old woman comes to the physician because of a 2-day
history of cramping abdominal pain and distention accompanied by
nausea and vomiting. She is otherwise healthy and has no history of
abdominal operations. Her temperature is 37.4 C (99.4 F), blood
pressure is 110/86 mm Hg, pulse is 112/min, and respirations are
24/min. Cardiopulmonary examination shows no abnormalities.
Examination of the abdomen shows distention and mild diffuse
tenderness; bowel sounds are high-pitched. An x-ray film of the
abdomen shows air-fluid levels throughout the small bowel and air in
the liver; there is no gas in the colon or free air. Which of the
following is the most likely diagnosis?

A
) Adhesive small-bowel obstruction

B
) Cecal cancer

C
) Gallstone ileus

D
) Intussusception

E
) Mesenteric infarction

F
) Ruptured appendicitis

G
) Small bowel lymphoma

33. Four hours after undergoing a cesarean delivery at term followed
by tubal ligation, a 37-year-old woman, gravida 2, para 2, has
dizziness and confusion. The operation was uncomplicated, and blood
loss is estimated to be 800 mL. Patient-controlled epidural analgesia
has been moderately effective for pain. Her blood pressure now is
80/40 mm Hg, decreased from 120/72 mm Hg intraoperatively, and pulse
is 152/min, increased from 96/min intraoperatively. Breath sounds are
decreased bilaterally. No murmurs are heard. Abdominal examination
shows distention and tenderness. Bowel sounds are absent. The incision
is intact with no drainage. She is disoriented to person, place, and
time. Her hematocrit is 23%; preoperative hematocrit was 35%. Which of
the following is the most likely cause of the hemodynamic changes?

A
) Epidural-related hypotension

B
) Insufficient intraoperative fluid replacement

C
) Postoperative intra-abdominal hemorrhage

D
) Supine hypotensive syndrome

E
) Underestimated intraoperative blood loss

34. A 42-year-old woman comes to the physician for evaluation of
persistently increased blood pressures. At her last two office visits
during the past 3 months, her blood pressure has ranged between
150–170/105–115 mm Hg. During this period, she has had occasional
headaches. In addition, she has had an increased urine output over the
past 6 weeks that she attributes to a diet high in sodium. She is
otherwise healthy and takes no medications. Her blood pressure today
is 168/115 mm Hg, pulse is 68/min, and respirations are 14/min.
Funduscopic examination shows mild arteriovenous nicking. The point of
maximal impulse is not displaced. There is no edema, abdominal bruits,
or masses. Serum studies show:

Na+
144 mEq/L
Cl–
90 mEq/L
K+
2.9 mEq/L
HCO3–
32 mEq/L
Urea nitrogen (BUN)
20 mg/dL
Creatinine
1.2 mg/dL

Which of the following is the most likely underlying cause of this
patient's hypertension?

A
) Autonomous production of aldosterone

B
) Catecholamine-producing tumor

C
) Decreased arterial distensibility caused by atherosclerosis

D
) Excess production of atrial natriuretic peptide

E
) Juxtaglomerular cell hypertrophy and sclerosis

35. A previously healthy 4-year-old girl is brought to the physician
because of fever and refusal to walk for 1 day. She appears mildly
ill. Her temperature is 38.6 C (101.5 F), pulse is 120/min, and
respirations are 22/min. The right knee is erythematous and swollen.
She holds her right knee in flexion and resists any attempted movement
of her right leg. She cries when the right knee is moved. Which of the
following is the most appropriate next step in management?

A
) Acetaminophen with codeine therapy

B
) Arthrocentesis

C
) Bone marrow aspiration

D
) Bone scan

E
) Immobilization and traction

F
) Lyme titer

G
) MRI of the spine

H
) Physical therapy

I
) Reassurance

J
) Serum rheumatoid factor assay

K
) Systemic antibiotic therapy

36. An 18-year-old man comes for an examination prior to participation
in school sports. He states that he has had a dull ache in the scrotum
since being hit in that area during a basketball game 2 months ago.
Examination shows a 2-cm, hard, nontender mass in the right testicle.
The mass does not transilluminate or change in size when the patient
is placed in the supine position. Which of the following is the most
likely cause?

A
) Cystic dilations of the efferent ductules

B
) Dilated pampiniform venous plexus

C
) Fluid accumulation within the tunica vaginalis testis

D
) Germinal cell tumor

E
) Vascular trauma

37. A 14-year-old boy is brought to the physician by his parents
because of a 2-year history of increasing academic problems. His
parents say that he has always been hyperactive and distractible, but
now his academic performance has deteriorated to the point that he is
failing ninth grade. His teachers say that his hyperactivity is
disrupting the classroom. He weighs 54 kg (120 lb) and is 152 cm (60
in) tall. Sexual development is Tanner stage 5; examination shows
macro-orchidism, which was not shown on previous examinations. He has
a high forehead and long, protruding ears. He exhibits poor eye
contact during the examination. Psychoeducational testing shows an IQ
of 70. Which of the following is the most likely diagnosis?

A
) Attention-deficit/hyperactivity disorder

B
) Autistic disorder

C
) Down syndrome

D
) Fetal alcohol syndrome

E
) Fragile X syndrome

F
) Lesch-Nyhan syndrome

G
) Pervasive developmental disorder, not otherwise specified

H
) Prader-Willi syndrome

I
) Rett's disorder

J
) Seminiferous tubule dysgenesis (Klinefelter's syndrome)

38. A 32-year-old woman comes to the physician because of vaginal
discharge for 2 weeks. She has been sexually active with one female
partner for 5 years. She has not been treated with antibiotics over
the past 2 years. Her last Pap smear was 6 years ago when she was
sexually active with a male partner. She has not used illicit drugs or
alcohol. Examination shows a grayish vaginal discharge with a pH
greater than 4.5. A wet mount preparation of the vaginal discharge is
most likely to show which of the following?

A
) Budding yeast

B
) Clue cells

C
) Ferning

D
) Leukocytes in sheets

E
) Trichomonas vaginalis

39. A 57-year-old woman with breast cancer comes to the physician
because of increasing neck pain over the past 3 days. She has fallen
frequently because of muscle weakness. Vital signs are within normal
limits. Examination shows hyperreflexia of all extremities. There is
tenderness over the cervical spine. Serum calcium level is 11 mg/dL.
X-ray films show metastases to the cervical spine. Which of the
following is the most appropriate next step in management?

A
) Application of a soft cervical collar

B
) Physical therapy

C
) Mithramycin therapy

D
) Tamoxifen therapy

E
) Spinal cord decompression and cervical stabilization

40. A 57-year-old man comes to the physician because of intermittent
urinary incontinence over the past 6 months. He has loss of small
amounts of urine when he coughs or sneezes. He has not had pain or
blood with urination. He has a 15-year history of type 2 diabetes
mellitus with peripheral neuropathy, retinopathy, and gastroparesis.
Current medications include metoclopramide and glyburide. He appears
well. Rectal examination shows a normal-sized prostate. Neurologic
examination shows decreased sensation in a stocking-glove
distribution. Achilles tendon reflexes are absent bilaterally. Test of
the stool for occult blood is negative. Urinalysis shows 2+ protein
with no leukocytes or erythrocytes. His postvoid residual volume is
500 mL. Which of the following is the most likely mechanism of this
patient's incontinence?

A
) Central nervous system disorder

B
) Functional incontinence

C
) Intrinsic sphincter deficiency

D
) Overflow incontinence from acontractile bladder

E
) Overflow incontinence from bladder outlet obstruction

F
) Pelvic floor muscle weakness

G
) Retroperitoneal fibrosis

H
) Retroperitoneal lymphadenopathy

I
) Urinary tract infection

41. A 27-year-old primigravid woman at 38 weeks' gestation is admitted
in labor. Her pregnancy has been uncomplicated, and a routine prenatal
visit 2 days ago showed no abnormalities. On admission, fetal heart
tones cannot be heard. Ultrasonography shows little amniotic fluid,
fetal edema, and no evidence of a fetal heartbeat. After 1 hour, she
delivers a 3175-g (7-lb) stillborn infant; examination of the infant
shows no obvious abnormalities except for mild edema. The placenta and
membranes appear normal. Which of the following is the most
appropriate immediate course of action?

A
) Notify the hospital liability department

B
) Obtain consent for fetal organ donation from the parents

C
) Recommend autopsy of the infant

D
) Tell the mother not to worry since she can get pregnant again

E
) Tell the parents that there is a 1 in 4 chance of recurrence in
future pregnancies

42. A previously healthy 16-year-old high school wrestler comes to the
physician because of a rash on his forearms and the back of his legs
for 1 week. He is allergic to pollen and dust. Examination shows
patches of erythema with mild lichenification over the antecubital and
popliteal fossae. There are clusters of painful umbilicated vesicles
at sites of active skin inflammation. Which of the following is the
most likely diagnosis?

A
) Eczema herpeticum

B
) Herpes zoster

C
) Keratosis pilaris

D
) Lichen planus

E
) Pityriasis rosea

43. A 5-week-old boy is brought to the physician because of vomiting
for 3 days. Switching from a cow's milk-based formula to a soy-based
formula and one bottle of an electrolyte solution has not decreased
his vomiting. His mother says that there is no yellow color to the
vomitus, but it is forceful and occurs immediately after he has had 1
to 2 ounces of liquid. He appears to vomit more liquid than he drank.
He has one mustard-colored seedy stool daily. Examination shows no
abnormalities. Which of the following is the most likely explanation
for his vomiting?

A
) Duodenal atresia

B
) Gastroesophageal reflux

C
) Hypertrophic pyloric stenosis

D
) Lactose intolerance

E
) Protein malabsorption

F
) Rotavirus infection

44. A 28-year-old woman is hospitalized after taking a massive
overdose of acetaminophen tablets in a suicide attempt. She has type 1
diabetes mellitus and major depressive disorder refractory to
tricyclic antidepressant therapy. Despite appropriate therapy, she
develops rapidly progressive hepatic failure and becomes progressively
encephalopathic. On the 6th day of hospitalization, she is comatose. A
CT scan of the brain shows mild diffuse swelling. An appropriately
crossmatched, size-appropriate donor liver is available. Which of the
following is the most appropriate course of action regarding
transplantation?

A
) Do not proceed with the transplantation because diabetes mellitus is
a contraindication

B
) Do not proceed with the transplantation because hepatic function is
likely to return over the next week

C
) Do not proceed with the transplantation because major depressive
disorder places the patient at risk for another suicide attempt

D
) Do not proceed with the transplantation because the onset of
encephalopathy and CT findings suggest bacterial meningitis

E
) Proceed with the transplantation

45. A 3-year-old boy who is HIV positive is brought for a routine
examination. His diet is appropriate for age. His medications include
three antiretroviral drugs and trimethoprim-sulfamethoxazole for
Pneumocystis carinii prophylaxis. Laboratory studies show:

Hemoglobin 8.6 g/dL
Mean corpuscular hemoglobin 38 pg/cell
Mean corpuscular hemoglobin concentration 30% Hb/cell
Mean corpuscular volume 101 μm3
Leukocyte count 5600/mm3
Segmented neutrophils 60% (many hypersegmented)
Bands 3%
Lymphocytes 37%
Red cell distribution width 21% (N=10–16)

Which of the following is most likely to have prevented this patient's anemia?

A
) Folic acid supplementation

B
) Iron supplementation

C
) Thyroid supplementation

D
) Vitamin B12 (cyanocobalamin) supplementation

E
) Monthly intravenous immune globulin therapy

46. A 20-year-old man is brought to the emergency department on a
summer day 20 minutes after developing headache, nausea, and unsteady
gait while running the last 2 miles of a marathon. On arrival, he is
confused and disoriented. His temperature is 40 C (104 F), blood
pressure is 100/60 mm Hg, and pulse is 155/min. His skin is warm and
dry. Neurologic examination shows no focal findings. Which of the
following is the most likely mechanism of this patient's condition?

A
) Depletion of total body potassium

B
) Depletion of total body sodium

C
) High-output cardiac failure

D
) Inadequate dissipation of body heat

E
) Release of creatine kinase from muscle cells


__________________________________________________________________________________

Form 1--Section 2:--

1. A 77-year-old woman is brought to the physician by her son for a
routine health maintenance examination. She says that she feels well.
Her son reports that 1 month ago, she got lost while driving home from
the local supermarket. Two weeks ago, she forgot to turn off the stove
after cooking dinner. She has been wearing bilateral hearing aids
since audiometry 2 years ago showed bilateral high-frequency hearing
loss. Her visual acuity corrected with glasses is 20/25 in both eyes.
Neurologic examination shows mild fine tremors of the hands when the
arms are outstretched; the tremor is not present at rest. Muscle
strength is 5/5 in all extremities. Deep tendon reflexes are decreased
at the ankles and 2+ elsewhere. Her gait is normal. Sensation to
vibration is mildly decreased over the toes. On mental status
examination, she is awake, alert, and conversant. Her language
function is normal. She is oriented to person, place, and time and
recalls one out of three objects after 10 minutes. Which of the
following findings in this patient warrants further evaluation?

A
) Decreased deep tendon reflexes at the ankles

B
) Decreased sensation to vibration over the toes

C
) High-frequency hearing loss

D
) Memory loss

E
) Tremor of the outstretched hands

2. A 10-year-old girl is brought to the emergency department because
of diffuse, aching abdominal pain, nausea, and recurrent vomiting over
the past 5 hours. She has an 8-year history of type 1 diabetes
mellitus treated with 20 U of NPH and 6 U of regular insulin in the
morning and 14 U of NPH and 5 U of regular insulin in the evening. She
appears lethargic but is easily arousable. There is an obvious odor of
ketones on her breath. Her blood pressure is 100/70 mm Hg, pulse is
95/min, and respirations are 20/min and deep. Serum studies show:

Na+ 142 mEq/L
K+ 5.3 mEq/L
HCO3– 6 mEq/L
Glucose 710 mg/dL

Which of the following laboratory findings is most likely to be increased?

A ) Arterial pH

B ) Serum C-peptide level

C ) Serum magnesium level

D ) Serum osmolality

E ) Serum phosphorus level

3. A healthy 24-year-old woman comes for a routine health maintenance
examination. Menses occur at regular 28-day intervals and last 5 to 6
days. Her last menstrual period was 3 weeks ago. She takes no
medications. Bimanual examination shows a 5-cm, mildly tender left
adnexa. A pregnancy test is negative. Which of the following is the
most appropriate next step in management?

A
) Repeat examination in 2 weeks

B
) Measurement of serum CA 125 level

C
) Measurement of serum α-fetoprotein level

D
) CT scan of the pelvis

E
) Diagnostic laparoscopy

4. A 24-year-old primigravid woman at 18 weeks' gestation comes for a
routine prenatal visit. She has had increased bowel movements over the
past 9 weeks; the stools are sometimes covered with mucus and blood.
Use of over-the-counter antidiarrheal drugs has not relieved her
symptoms. Pregnancy has been otherwise uncomplicated. She has never
traveled outside the USA. Examination shows erythematous, tender
nodules over the anterior surface of both lower extremities; some of
the nodules have a violaceous hue. The uterus is consistent in size
with an 18-week gestation. Rectal examination shows no hemorrhoids or
fissures. Fetal heart tones are audible by Doppler. Which of the
following is the most likely diagnosis?

A
) Amebiasis

B
) Diverticulitis

C
) Hyperperistaltic diarrhea

D
) Inflammatory bowel disease

E
) Viral gastroenteritis

5. A 32-year-old woman at 38 weeks' gestation comes for a routine
prenatal visit. During routine screening at 28 weeks' gestation, she
tested positive for hepatitis B surface antigen. Her pregnancy has
been otherwise uncomplicated. Examination shows a uterus consistent in
size with a 38-week gestation. Which of the following measures is most
likely to decrease the risk for hepatitis B infection in her newborn?

A
) Recommendation of bottle-feeding rather than breast-feeding

B
) Maternal administration of hepatitis B immune globulin (HBIG) now

C
) Neonatal administration of HBIG after delivery and hepatitis B
vaccine at 3 months of age

D
) Neonatal administration of HBIG and hepatitis B vaccine immediately
after delivery

E
) Cesarean delivery

6. A 37-year-old woman comes to the physician because of progressive
shortness of breath over the past 5 years; she now has fatigue and
shortness of breath with mild exertion. She has a history of mitral
stenosis secondary to rheumatic fever at the age of 15 years. She was
asymptomatic until 5 years ago when she developed severe shortness of
breath during pregnancy. She was treated with diuretics, low-sodium
diet, and bed rest, and she was able to deliver the baby at term. Her
only medication is hydrochlorothiazide. Her temperature is 37 C (98.6
F), blood pressure is 110/80 mm Hg, pulse is 100/min and regular, and
respirations are 26/min. Cardiac examination shows an obvious opening
snap in S2. A grade 3/6, late diastolic murmur is heard at the apex. A
right ventricular lift is palpated along the left sternal border.
Which of the following is most likely increased in this patient?

A
) Blood flow to the lower lung fields

B
) Diastolic filling time

C
) Left-to-right shunt of blood

D
) Left ventricular end-diastolic pressure

E
) Pulmonary artery pressure

7. A 5-year-old girl with ventricular septal defect is scheduled for
tonsillectomy in 2 weeks. She has no known drug allergies. Her
temperature is 37 C (98.6 F). Examination shows no abnormalities.
Which of the following is the most appropriate prophylaxis prior to
tonsillectomy?

A
) Amoxicillin

B
) Ciprofloxacin

C
) Rifampin

D
) Tetracycline

E
) Trimethoprim-sulfamethoxazole

F
) No prophylaxis indicated

8. An 8-year-old girl with type 1 diabetes mellitus is brought to the
emergency department 10 minutes after being involved in a motor
vehicle collision. She was in the back seat of a small automobile that
was rear-ended. Initially, she was alert during transport and reported
bilateral thigh pain, but then she stopped talking, closed her eyes,
and became unresponsive to voice; on arrival, she responds to noxious
stimuli with brief grimaces and no withdrawal. Her blood pressure is
40/palpable mm Hg, pulse is 148/min, and respirations are 28/min. Air
entry is symmetric. The pupils are equal and react to light. No
cardiac murmur is heard. The abdomen is soft. There is swelling of the
upper portions of both thighs. Her hematocrit is 37%. Which of the
following is the most appropriate next step in management?

A
) Measurement of arterial blood gases

B
) X-ray film of the chest

C
) CT scan of the head

D
) Administration of 50% dextrose in water

E
) Infusion of 0.9% saline


9. A previously healthy 16-year-old boy is brought to the emergency
department 20 minutes after an episode of left arm shaking that lasted
approximately 3 minutes. Over the past 2 days, he has had fever and
emotional lability. On arrival, his temperature is 38.9 C (102 F). He
is somnolent and disoriented to person, place, and time. He responds
poorly to pain. Neurologic examination shows no other abnormalities.
Laboratory studies show:


Hematocrit 34%
Leukocyte count 6000/mm3
Segmented neutrophils 50%
Lymphocytes 50%
Platelet count 280,000/mm3



Analysis of cerebrospinal fluid shows:
Leukocyte count 120/mm3
Segmented neutrophils 20%
Lymphocytes 80%
Erythrocyte count 300/mm3
Glucose 60 mg/dL
Protein 400 mg/dL

Which of the following is the most likely cause of this patient's
neurologic findings?

A
) Bacterial infection

B
) Congenital malformation

C
) Fungal infection

D
) Hemorrhage

E
) Immune-mediated demyelination

F
) Parasitic infection

G
) Viral infection

10. A 72-year-old man with hypertension has had increasingly severe
back pain over the past 2 months. He had a myocardial infarction 4
years ago. He has marked tenderness over T11, T12, L1, and L2. An
x-ray film of the lumbosacral spine shows osteoblastic lesions in
these vertebrae. Which of the following is the most likely diagnosis?

A
) Abdominal aneurysm

B
) Fibrosarcoma

C
) Metastatic prostate carcinoma

D
) Multiple myeloma

E
) Osteosarcoma

11. A 64-year-old woman has moderately severe postoperative pain 1 day
after a total abdominal hysterectomy and bilateral
salpingo-oophorectomy. Which of the following is the most appropriate
analgesic pharmacotherapy?

A
) Oral aspirin-codeine compound

B
) Oral diazepam

C
) Oral ibuprofen

D
) Intermittent intravenous naloxone

E
) Patient-controlled intravenous morphine

F
) Transcutaneous administration of fentanyl

12. A 37-year-old woman comes to the physician because of a 1-day
history of throbbing facial pain. She describes the pain as 7 out of
10 in intensity. Over the past 9 days, she has had nasal congestion,
purulent nasal discharge, sore throat, and a nonproductive cough. She
does not smoke. Her husband and children have had no recent illness.
Her temperature is 38.5 C (101.3 F). Examination shows congested nasal
mucosa and purulent discharge on the left. There is tenderness to
palpation over the left cheek and no transillumination over the left
maxillary sinus. The tympanic membranes are normal, and there is no
erythema of the throat. Examination shows no cervical adenopathy. The
lungs are clear to auscultation. Which of the following is the most
likely causal organism?

A
) Haemophilus influenzae type b

B
) Moraxella catarrhalis

C
) Staphylococcus aureus

D
) Streptococcus pneumoniae

E
) Streptococcus pyogenes (group A)

13. A 42-year-old woman comes to the physician for an annual pelvic
examination and Pap smear. Over the past year, she has had increasing
fatigue and difficulty sleeping. She has two children who both attend
college. She is currently looking for part-time work outside the home.
Her husband has been busy in a new start-up business. Examination
shows no abnormalities. Laboratory studies show:

Hemoglobin 15 g/dL
Mean corpuscular volume 95 μm3
Leukocyte count 6000/mm3 with a normal differential
Serum
Na+ 145 mEq/L
Cl– 102 mEq/L
K+ 4.5 mEq/L
HCO3– 25 mEq/L
Urea nitrogen (BUN) 18 mg/dL
Creatinine 1.0 mg/dL
Alkaline phosphatase 70 U/L
Aspartate aminotransferase
(AST, GOT) 22 U/L
Alanine aminotransferase
(ALT, GPT) 19 U/L
γ-Glutamyltransferase
(GGT) 83 U/L
(N=5–50 U/L)

Which of the following is the most likely explanation for this
patient's laboratory abnormalities?

A
) Acetaminophen

B
) Alcohol

C
) Diphenhydramine

D
) Estrogen effect

E
) Ibuprofen

14. Five weeks after vaginal delivery of a healthy full-term newborn,
a 22-year-old woman, gravida 1, para 1, is brought to the physician by
her mother because of depressed mood for 2 weeks. Her mother is
concerned that her daughter is not able to take care of her infant.
Physical examination shows no abnormalities. She is quiet and tearful
and does not engage in conversation easily. She states that she lives
alone with her infant and has had thoughts of suicide and infanticide.
Which of the following is the most appropriate next step in
management?

A
) Reassurance

B
) Long-term outpatient counseling

C
) Antipsychotic therapy

D
) Selective serotonin reuptake inhibitor therapy

E
) Admission to the hospital for treatment

15. A 72-year-old man comes for a routine follow-up examination. He
has chronic obstructive pulmonary disease treated with β-adrenergic
agonists and ipratropium by metered-dose inhaler and mild arterial
insufficiency of the lower extremities treated with aspirin. His blood
pressure is 160/60 mm Hg, pulse is 70/min, and respirations are
12/min. Funduscopic examination shows arteriovenous nicking. Pedal
pulses are decreased bilaterally. Which of the following
antihypertensive drugs is most likely to cause adverse effects in this
patient?

A
) α2-Adrenergic agonist

B
) α-Adrenergic blocking agent

C
) β-Adrenergic blocking agent

D
) Angiotensin-converting enzyme (ACE) inhibitor

E
) Calcium-channel blocking agent

F
) Loop diuretic

G
) Thiazide diuretic

H
) Vasodilator

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with loss of consciousness, select the most likely diagnosis.


A
) Aortic stenosis

B
) Carotid sinus hypersensitivity

C
) Conversion reaction

D
) Hypertrophic obstructive cardiomyopathy

E
) Hypoglycemia

F
) Mitral valve prolapse

G
) Orthostatic hypotension

H
) Pulmonary embolus

I
) Seizure

J
) Vasovagal syncope

K
) Vertebrobasilar insufficiency

16. A 15-year-old boy is brought to the emergency department 30
minutes after a 2-minute episode of loss of consciousness after
completing a 400-meter race. On awakening, he says that he feels fine
except for shortness of breath. He weighs 82 kg (180 lb) and is 191 cm
(75 in) tall. His blood pressure is 110/70 mm Hg, pulse is 70/min and
regular, and respirations are 15/min. The lungs are clear to
auscultation. A grade 2/6 systolic murmur is heard at the left sternal
border with minimal radiation to the neck; the murmur becomes louder
when he stands.

For each patient with loss of consciousness, select the most likely diagnosis.


A
) Aortic stenosis

B
) Carotid sinus hypersensitivity

C
) Conversion reaction

D
) Hypertrophic obstructive cardiomyopathy

E
) Hypoglycemia

F
) Mitral valve prolapse

G
) Orthostatic hypotension

H
) Pulmonary embolus

I
) Seizure

J
) Vasovagal syncope

K
) Vertebrobasilar insufficiency

17. A 62-year-old woman is brought to the emergency department 1 hour
after a 1-minute episode of loss of consciousness; her symptoms began
when she stood up after she passed a dark, watery stool. She has had
diarrhea and dark stools for 2 days. She has been receiving warfarin
therapy for deep venous thrombosis for 2 weeks. On arrival, her blood
pressure is 82/60 mm Hg, and pulse is 150/min and regular. She is
unable to stand. The lungs are clear to auscultation. A grade 2/6
systolic murmur is heard at the second right intercostal space with no
radiation. Examination shows a soft, nontender abdomen. There is 1+
edema of the right lower extremity with no tenderness. Test of the
stool for occult blood is positive.

18. A 50-year-old woman has had progressive dyspnea over the past 2
weeks and constant, sharp chest pain for 4 days. The pain is localized
to the center of the chest and is worse while supine. She underwent a
right, modified radical mastectomy and adjuvant chemotherapy for
breast cancer 3 years ago. She has a history of hypothyroidism treated
with thyroid replacement therapy. She has smoked one pack of
cigarettes daily for 30 years and drinks two ounces of alcohol daily.
She is dyspneic and diaphoretic. Her temperature is 37.2 C (99 F),
blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg,
pulse is 110/min, and respirations are 28/min. Examination shows
jugular venous distention to the angle of the mandible. The liver span
is 14 cm with 4 cm of shifting abdominal dullness. Arterial blood gas
analysis on room air shows a pH of 7.50, PCO2 of 30 mm Hg, and PO2 of
70 mm Hg. An x-ray film of the chest shows an enlarged cardiac
silhouette with a globular configuration. An ECG shows sinus
tachycardia with nonspecific ST-segment changes diffusely. Which of
the following is the most appropriate next step in management?

A ) Echocardiography

B ) CT scan of the abdomen

C ) Ventilation-perfusion lung scans

D ) Bronchoscopy

E ) Paracentesis

19. A 3-year-old boy is brought to the physician because of a 7-day
history of fever and a painful swollen lymph node in his groin. This
is his sixth episode of lymph node swelling; the previous episodes
resolved after drainage and prolonged antibiotic therapy. He also had
pneumonia at the age of 12 months that required chest tube placement
for drainage. A maternal uncle died during childhood of recurrent
infections. The patient is at the 5th percentile for height and
weight. His temperature is 38.5 C (101.3 F). Examination shows a warm,
tender, erythematous lymph node in the right inguinal area. There are
several healed incisions over the inguinal area and neck from old
drainage sites. Laboratory studies show:

Hematocrit 35%
Leukocyte count 17,000/mm3
Segmented neutrophils 65%
Bands 10%
Lymphocytes 25%
Platelet count 350,000/mm3

A Gram's stain of the lymph node aspirate shows numerous segmented
neutrophils filled with bacteria; cultures grow Staphylococcus aureus.
Which of the following is the most likely mechanism for these
findings?

A
) Adenosine deaminase deficiency

B
) Consumption of complement

C
) Defective opsonization

D
) Destruction of CD4+ T lymphocytes

E
) Developmental arrest of maturation of B lymphocytes

F
) Dysmorphogenesis of the third and fourth pharyngeal pouches

G
) Impaired chemotaxis

H
) Impaired phagocytic oxidative metabolism

20. A 67-year-old woman has been intubated for 1 week after undergoing
a left lobectomy for lung cancer. She has chronic obstructive
pulmonary disease. Her preoperative functional vital capacity was 40%
of predicted. She is awake and alert. Her blood pressure is 130/75 mm
Hg, and pulse is 72/min. The ventilator settings are a synchronized
intermittent mandatory ventilation of 8/min, FIO2 of 40%, and
positive-end expiratory pressure of 5 cm H2O. Arterial blood gas
analysis shows:

pH 7.42
PCO2 47 mm Hg
PO2 90 mm Hg
O2 saturation 96%

Which of the following is the most appropriate next step in management?

A
) Antibiotic therapy

B
) Bronchodilator therapy

C
) Chest physiotherapy

D
) Decrease inotropes

E
) Diuretic therapy

F
) Fiberoptic bronchoscopy

G
) Heparin therapy

H
) Incentive spirometry

I
) Increase FIO2

J
) Increase inotropes

K
) Increase respiratory rate

L
) Placement of thoracostomy tube

M
) Tracheostomy

N
) Wean from the ventilator

21. A 67-year-old woman is brought to the emergency department because
of severe chest pain 4 hours after undergoing outpatient endoscopy and
dilatation of an esophageal stricture caused by reflux. At discharge,
she reported no chest pain. Three hours later, she vomited a small
amount of blood and had severe pain. She is pale. Her temperature is
38 C (100.4 F), blood pressure is 140/85 mm Hg, pulse is 125/min, and
respirations are 22/min. Examination shows crepitus in the neck and
moderate epigastric tenderness. The lungs are clear to auscultation,
and breath sounds are equal bilaterally. Rectal examination shows no
masses; test of the stool for occult blood is positive. Which of the
following is the most likely cause of these symptoms?

A
) Bleeding from erosive esophagitis

B
) Esophageal perforation

C
) Mallory-Weiss syndrome

D
) Myocardial infarction

E
) Perforated gastric ulcer

22. An 87-year-old woman is brought to the physician by her son
because of progressive memory loss over the past 2 years. Her son says
that she repeats herself frequently and has been forgetting to take
her routine medications. She takes hydrochlorothiazide for mild
systolic hypertension and levothyroxine for hypothyroidism. She had
vulvar cancer 10 years ago treated with wide excision. Her blood
pressure is 138/78 mm Hg. Physical examination is within normal limits
for her age. Mini-Mental State Examination score is 23/30. Laboratory
studies, including serum vitamin B12 (cyanocobalamin), thyroxine (T4),
and thyroid-stimulating hormone levels, are within normal limits. A CT
scan of the head shows mild volume loss. Which of the following is the
most appropriate pharmacotherapy?

A
) β-Adrenergic agonist

B
) Cholinesterase inhibitor

C
) Dopamine agonist

D
) Prednisone

E
) Selective serotonin reuptake inhibitor

23.

A newborn is in severe respiratory distress immediately following
delivery. She was born at 35 weeks' gestation to a 35-year-old woman,
gravida 2, para 1, aborta 1, who did not receive prenatal care. The
newborn's pulse is 60/min, and respirations are irregular and labored.
Examination shows pallor with perioral cyanosis, anasarca,
hepatosplenomegaly, and scattered petechiae. Cord blood hemoglobin is
4 g/dL, and reticulocyte count is 18%. A direct antiglobulin (Coombs')
test is positive. Which of the following sets of blood groups is most
likely in the mother and her newborn?


Mother Newborn

A
)
A, Rh-positive O, Rh-positive

B
)
A, Rh-positive O, Rh-negative

C
)
A, Rh-negative O, Rh-negative

D
)
O, Rh-positive O, Rh-negative

E
)
O, Rh-negative O, Rh-positive

24. After an uncomplicated laparoscopic cholecystectomy, a 62-year-old
man has not had any urine output since the Foley catheter was removed
12 hours ago. During the hour before the operation, the 40 minutes of
operating room time, and the 2 hours in the recovery room, his fluid
input was 2.5 L and urine output was 1 L. Since that time, he has been
receiving intravenous 5% dextrose in water with 0.45% saline and
morphine. He is awake and alert and has a moderate amount of abdominal
pain. Preoperative serum studies showed:

Na+ 137 mEq/L
K+ 4.2 mEq/L
Urea nitrogen (BUN) 18 mg/dL
Creatinine 1.2 mg/dL

One hour after receiving an intravenous bolus of 0.9% saline, the
patient does not produce any urine. Which of the following is the most
appropriate next step in management?

A
) Increase in the dose of morphine

B
) Intravenous administration of an additional bolus of 0.9% saline

C
) Intravenous administration of doxazosin

D
) Intravenous administration of furosemide

E
) Reinsertion of a Foley catheter

25. A healthy 55-year-old man comes for an initial health maintenance
examination. His last visit to a physician was over 10 years ago. He
does not smoke and drinks only on social occasions. Examination shows
no abnormalities. Which of the following immunizations should be
administered?

A
) Hepatitis A vaccine

B
) Influenza virus vaccine

C
) Measles-mumps-rubella vaccine

D
) Pneumococcal vaccine

E
) Diphtheria-tetanus toxoid

26. A 19-year-old man comes to the physician because of frequent
nosebleeds over the past 3 weeks. He has bipolar disorder currently
well controlled with lithium carbonate, bupropion, and valproic acid.
Physical examination shows no abnormalities except for dried blood in
the nares. Mental status examination shows an anxious mood and slight
motor restlessness. Serum studies show a lithium carbonate level of
1.3 mEq/L (therapeutic range=0.6–1.2), and valproic acid level of 77
μg/mL (therapeutic range=40–100). Which of the following is the most
appropriate next step in management?

A
) Measurement of serum aspartate aminotransferase (AST, GOT) activity

B
) Measurement of serum bupropion level

C
) Platelet count

D
) Discontinuation of lithium carbonate therapy

E
) Discontinuation of valproic acid therapy

27. An asymptomatic 32-year-old man comes for a routine health
maintenance examination. He has a 10-year history of frequent sinus
and pulmonary infections. He had an anaphylactic reaction to a blood
transfusion following a motor vehicle collision 3 years ago. His
temperature is 37 C (98.6 F). Examination shows mild erythema in the
posterior pharynx. The lungs are clear to auscultation. A complete
blood count and serum protein electrophoresis are within normal
limits. Which of the following is the most likely cause of the
frequent infections?

A
) Colonization with Streptococcus pneumoniae

B
) Common variable immunodeficiency

C
) HIV infection

D
) Selective IgA deficiency

E
) X-linked agammaglobulinemia

28.

A 37-year-old man is brought to the emergency department 6 hours after
the onset of constant, increasingly severe abdominal pain and nausea.
His symptoms awoke him from sleep, and he has vomited once since that
time. He has no history of similar symptoms, and he does not take any
medications or use alcohol or illicit drugs. Family history is
noncontributory. He is in acute distress and lying in the fetal
position. Any movement exacerbates the pain. His temperature is 37.8 C
(100 F), blood pressure is 108/68 mm Hg, pulse is 112/min, and
respirations are 24/min. The lungs are clear to percussion and
auscultation. Examination shows a rigid abdomen; bowel sounds are
absent. Laboratory studies show:


Hemoglobin 14 g/dL
Leukocyte count 18,200/mm3
Platelet count 150,000/mm3



Serum

Urea nitrogen (BUN) 34 mg/dL
Creatinine 1.9 mg/dL
Total bilirubin 1.2 mg/dL



An x-ray film of the chest shows a small amount of free air under the
left diaphragm. Administration of antibiotics and fluids is begun.
Which of the following is the most appropriate next step in
management?

A
) Barium swallow

B
) CT scan of the abdomen

C
) Intravenous administration of an H2-receptor blocking agent

D
) Upper endoscopy

E
) Laparotomy

29. A 52-year-old woman with alcoholism comes to the physician after a
serum cholesterol level of 290 mg/dL was found on a routine screening.
She drinks a pint of vodka daily. She takes captopril for hypertension
and glyburide for type 2 diabetes mellitus. She also has intermittent
episodes of gout. Fasting serum studies show:

Total cholesterol 252 mg/dL
HDL-cholesterol 80 mg/dL
Triglycerides 300 mg/dL
Glucose 118 mg/dL
Thyroid-stimulating hormone 4.5 μU/mL

Which of the following is the most appropriate next step in management?

A
) Alcohol cessation

B
) Better control of diabetes

C
) Switch from captopril to calcium-channel blocking agent therapy

D
) Gemfibrozil therapy

E
) Thyroid replacement therapy

30. A 23-year-old woman has pain, cramping, and swelling of the right
calf 3 days after an uncomplicated labor and delivery. The right foot
is swollen, and there is marked tenderness with dorsiflexion and
palpation of the right calf. Examination shows no other abnormalities.
A complete blood count and serum electrolyte levels are within normal
limits. Which of the following is the most likely cause of this
condition?

A
) Hypercoagulable state of pregnancy

B
) Hyperuricemia

C
) Peripheral artery aneurysm

D
) Platelet embolus

E
) Prolonged pressure on the vena cava during delivery

31. A 2-month-old boy is brought to the physician for a well-child
examination. He smiles spontaneously and vocalizes without crying, but
he does not appear to laugh or squeal. He will not work for a toy that
is out of his reach. Which of the following is the most appropriate
assessment of language and psychosocial development?

Language
Psychosocial
development
development

A
)
Normal
normal

B
)
Normal
delayed

C
)
Delayed
normal

D
)
Delayed
delayed

32. A previously healthy 24-year-old woman comes to the physician
because of a low-grade fever and a nonproductive cough for 7 days. She
has been able to continue her daily activities. Her temperature is
37.7 C (99.9 F). A few scattered inspiratory crackles are heard in the
thorax. An x-ray film of the chest shows patchy infiltrates in both
lungs. Which of the following is the most appropriate initial
pharmacotherapy?

A
) Amoxicillin

B
) Cefaclor

C
) Ciprofloxacin

D
) Erythromycin

E
) Trimethoprim-sulfamethoxazole

33. A 45-year-old woman comes to the emergency department because of
shortness of breath, chest pain, dizziness, and mild numbness and
tingling around the lips for 2 hours. She says that she feels like she
is going to die. She had three similar episodes last week when she was
vacationing at the Grand Canyon; the first episode occurred while
crossing a narrow bridge on a donkey. She takes a hypoglycemic drug
for type 2 diabetes mellitus, verapamil for hypertension, and
sumatriptan as needed for migraine. She is mildly diaphoretic and
appears pale. Her blood pressure is 130/90 mm Hg, pulse is 120/min,
and respirations are 28/min. Serum glucose level is 120 mg/dL. An ECG
shows sinus tachycardia. Sublingual nitroglycerin therapy does not
relieve her symptoms and gives her a headache. The most appropriate
next step in management is administration of which of the following?

A
) Haloperidol

B
) Lorazepam

C
) Oxygen

D
) Sumatriptan

E
) Verapamil

34. A 67-year-old man is brought to the emergency department 4 hours
after the onset of severe midlumbar back pain. He is anxious, pale,
and diaphoretic. His temperature is 37.1 C (98.8 F), blood pressure is
105/65 mm Hg, and pulse is 120/min. Examination shows no other
abnormalities. X-ray films of the lumbar spine show degenerative disc
disease with calcifications anterior to the vertebral bodies. Which of
the following is the most likely diagnosis?

A
) Aortoiliac occlusion

B
) Herniated nucleus pulposus

C
) Lumbar discitis

D
) Lumbar strain

E
) Pyelonephritis

F
) Ruptured aortic aneurysm

G
) Spinal stenosis

35. A 17-year-old boy is brought to the emergency department by his
parents because of bizarre behavior for 6 hours. Last night he was out
with friends, and since returning, he has been confused and has
"trashed" his room. His blood pressure is 165/95 mm Hg. He is
hypervigilant, has little spontaneous speech, and is disoriented to
place and time. He appears catatonic but abruptly becomes assaultive
two times and needs to be restrained. Which of the following is the
most likely substance taken?

A
) Cocaine

B
) Ecstasy

C
) LSD

D
) Methaqualone

E
) PCP

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with back pain, select the most likely diagnosis.


A
) Herniated disc

B
) Lumbar spinal stenosis

C
) Metastatic cancer

D
) Muscle strain

E
) Osteoporotic compression fracture

F
) Sacroiliitis

G
) Spinal epidural abscess

H
) Spondylolisthesis

36. A 57-year-old woman is brought to the physician 2 days after the
sudden onset of severe low back pain; the pain does not radiate to the
lower extremities. The pain began when she was lifting her grandson.
She does not have weakness or sensory loss in the legs and has had no
urinary incontinence. She has a 10-year history of rheumatoid
arthritis treated with prednisone. Her temperature is 37 C (98.6 F),
blood pressure is 130/60 mm Hg, and pulse is 64/min. Examination shows
deformities of the interphalangeal joints of the hands and exquisite
tenderness to percussion over the lumbar spine. Bilateral straight-leg
raising to 80 degrees does not increase the pain. Muscle strength and
sensation are intact in the lower extremities. Deep tendon reflexes
are 2+ bilaterally. Babinski's sign is absent bilaterally.

For each patient with back pain, select the most likely diagnosis.


A
) Herniated disc

B
) Lumbar spinal stenosis

C
) Metastatic cancer

D
) Muscle strain

E
) Osteoporotic compression fracture

F
) Sacroiliitis

G
) Spinal epidural abscess

H
) Spondylolisthesis

37. A previously healthy 32-year-old plumber comes to the physician
because of a 3-week history of constant, dull, low back pain that does
not radiate to the extremities. The pain began after he unloaded heavy
equipment from his van. It increases with activity and is temporarily
relieved by bed rest and ibuprofen. Examination shows tenderness to
palpation over the lumbar paraspinal region bilaterally. The pain
increases with forward or lateral movements of the spine. Muscle
strength and sensation are intact in the lower extremities. Bilateral
straight-leg raising to 80 degrees does not increase the pain. Deep
tendon reflexes are 2+ bilaterally. Babinski's sign is absent
bilaterally.

38. A 72-year-old man comes to the physician because of a 2-month
history of urination twice nightly and occasional urinary frequency
and urgency. He has a 15-year history of type 2 diabetes mellitus now
moderately well controlled with glyburide. His father was diagnosed
with prostate cancer at the age of 70 years, and his sister died of
complications from systemic lupus erythematosus. His blood pressure is
135/86 mm Hg. Cardiopulmonary examination shows no abnormalities.
Abdominal examination shows no suprapubic fullness or tenderness.
There is mild enlargement of the prostate with no palpable nodules.
His postvoid residual volume is 10 mL. Serum studies show a urea
nitrogen (BUN) level of 45 mg/dL and creatinine level of 3.8 mg/dL.
Urine dipstick shows 3+ protein. Which of the following is most likely
to have prevented progression of this patient's renal disease?

A
) Intermittent Foley catheterization

B
) Intravenous mannitol therapy

C
) Oral cyclophosphamide and prednisone therapy

D
) Oral enalapril therapy

E
) Oral finasteride therapy

F
) Oral prednisone therapy only

G
) Oral terazosin therapy

39. Two hours ago, a 24-year-old man had the sudden onset of pain in
the right side of his chest that has become increasingly severe. He is
now having difficulty breathing. His temperature, blood pressure, and
pulse are normal. An x-ray film of the chest is shown. Which of the
following is the most appropriate next step in management?

A
) Bed rest and sedative therapy

B
) Antibiotic therapy

C
) Anticoagulant therapy

D
) Tube thoracostomy

E
) Immediate thoracotomy

40. A 21-year-old college student comes to the physician because of
acne that developed 4 days ago while she was taking her medical
college admission test. She is concerned about her appearance and
plans to be in a wedding in 3 weeks. She has had similar episodes that
have resolved completely without treatment. Examination shows acute
acne over the face with a predominance of comedones and pustules.
There is no evidence of chronic scarring. Which of the following is
the most appropriate initial step in treatment?

A
) Dietary restriction of chocolates and simple sugars

B
) Dietary restriction of milk products

C
) Topical acyclovir

D
) Topical hydrocortisone cream

E
) Topical retinoic acid

41. A 67-year-old woman comes for a routine health maintenance
examination. She exercises regularly. She is not sexually active. At
her last visit 1 year ago, her serum cholesterol level was 180 mg/dL,
and fasting serum glucose level was 80 mg/dL; a Pap smear and
mammography showed normal findings. Two years ago, flexible
sigmoidoscopy showed no abnormalities. Today, she weighs 63 kg (140
lb) and is 165 cm (65 in) tall. Her blood pressure is 120/80 mm Hg.
Examination shows no abnormalities. Which of the following is the most
appropriate screening test for this patient?

A
) Pap smear

B
) Measurement of serum cholesterol level

C
) Measurement of serum glucose level

D
) Mammography

E
) Flexible sigmoidoscopy

42. A 62-year-old man has had the gradual onset of fatigue and
shortness of breath over the past 3 years. There is striking jugular
venous distention with a large wave occurring with S2. The carotid
upstroke is normal. Cardiac examination shows a lifting systolic
motion of the sternum and no palpable point of maximal impulse. A
grade 3/6, holosystolic, plateau-shaped murmur that is loudest on
inspiration is heard at the lower left sternal border. The liver is
enlarged and tender, and the abdomen is swollen with a fluid wave.
There is marked ankle edema. Which of the following is the most likely
cause of the murmur?

A
) Aortic stenosis

B
) Mitral regurgitation

C
) Mitral stenosis

D
) Tricuspid regurgitation

E
) Ventricular septal defect

43. A 24-year-old woman comes to the physician because of constant,
severe pain in her neck, shoulders, and back for 3 months. She has
been unable to enjoy her usual activities because of the pain. Use of
over-the-counter ibuprofen and aspirin has not relieved her symptoms.
She has a history of irritable bowel syndrome. Examination shows
multiple tender spots over the neck, shoulders, and lumbar spine.
Range of motion of all joints is full. There is no evidence of
synovitis. Fluorescent serum antinuclear antibody and rheumatoid
factor assays are negative. Which of the following is the most likely
diagnosis?

A
) Ankylosing spondylitis

B
) Fibromyalgia

C
) Polymyalgia rheumatica

D
) Polymyositis

E
) Seronegative rheumatoid arthritis

44. A 72-year-old man comes to the physician because of a 6-month
history of mild to moderate shortness of breath when climbing stairs.
He had a myocardial infarction 2 years ago and has had an ejection
fraction of 35% since then. His only medication is a β-adrenergic
blocking agent. The lungs are clear to auscultation. Cardiac
examination shows an S4 gallop. There is no peripheral edema.
Laboratory studies are within normal limits. An ECG shows no acute
changes. Which of the following is the most appropriate
pharmacotherapy?

A
) α-Adrenergic blocking agent

B
) Angiotensin-converting enzyme (ACE) inhibitor

C
) Angiotensin2-receptor blocking agent

D
) Nitrates

E
) Thiazide diuretic

45. A 42-year-old woman comes to the physician because of a 3-month
history of a recurrent vivid dream that several men are assaulting her
and her children. Upon awakening, she is anxious and distressed by the
frightening images. She realizes that it is just a dream but is afraid
to go back to sleep. She does not know why she is having this
particular dream because she has never been the victim of an assault.
She drinks two to three cups of coffee each morning. She does not use
illicit drugs. Physical examination shows no abnormalities. There is
no evidence of depressed mood or hallucinations. Laboratory studies
are within normal limits. Which of the following is the most likely
diagnosis?

A
) Acute stress disorder

B
) Nightmare disorder

C
) Panic disorder

D
) Sleep apnea

E
) Sleep terror disorder

46. A 57-year-old man is brought to the emergency department 30
minutes after he was found on the floor of his house; he has left hip
pain and shortness of breath. He has renal failure but has missed his
last two dialysis treatments. His renal failure was caused by
inadvertent ingestion of ethylene glycol. His renal function did not
improve, and he is currently on the transplantation list. Medications
include amlodipine and doxazosin. On arrival, his temperature is 37.5
C (99.5 F), blood pressure is 150/100 mm Hg, pulse is 95/min and
regular, and respirations are 24/min. His breathing is rapid and deep.
Crackles are heard in the lung bases. Examination shows a soft
abdomen. Bowel sounds are normal. The left lower extremity is
externally rotated. Laboratory studies show:

Serum
Na+ 135 mEq/L
Cl– 102 mEq/L
K+ 7.1 mEq/L
HCO3– 12 mEq/L

Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula:

pH 7.22
PCO2 31 mm Hg
PO2 61 mm Hg

An ECG shows peaked T-waves. It will be at least 45 minutes before
dialysis can be started. Which of the following is the most
appropriate next step in management?

A
) Observation until dialysis is initiated

B
) Intravenous calcium gluconate

C
) Intravenous glucose and insulin

D
) Intravenous 0.9% saline

E
) Intravenous sodium bicarbonate

F
) Rectal sodium polystyrene sulfonate (Kayexalate)
__________________________________________________________________________________________________________________________________

Section 3:--

1. A 26-year-old woman is brought to the emergency department because
of marked confusion for 2 hours; she also has had a flu-like illness
for 3 days. Over the past 6 weeks, she has had increased fatigue,
weakness, and nausea. She recently started thyroid hormone replacement
therapy for autoimmune thyroiditis; 1 week ago, her serum
thyroid-stimulating hormone level was 3 μU/mL. Her temperature is 38 C
(100.4 F), blood pressure is 80/40 mm Hg, and pulse is 140/min. She
appears confused and lethargic. Examination shows cool, mottled skin.
There is generalized hyperpigmentation, especially involving the
palmar creases. The lungs are clear to auscultation. Abdominal
examination shows diffuse mild tenderness and no rebound. Laboratory
studies show:

Hemoglobin 10 g/dL
Leukocyte count 9000/mm3
Segmented neutrophils 55%
Eosinophils 20%
Lymphocytes 25%
Serum
Na+ 124 mEq/L
Cl– 92 mEq/L
K+ 6.4 mEq/L
HCO3– 16 mEq/L

An x-ray film of the chest and urinalysis show normal findings. An ECG
shows sinus tachycardia with peaked T waves. Which of the following is
most likely to confirm the primary cause of this patient's condition?

A
) Measurement of pulmonary artery pressure

B
) Measurement of right atrial pressure

C
) Measurement of serum antithyroglobulin antibody level

D
) Measurement of serum lactate dehydrogenase activity

E
) Measurement of serum thyroid-stimulating hormone level

F
) ACTH stimulation test

G
) Dexamethasone suppression test

H
) Blood cultures

I
) Echocardiography

2. A 27-year-old man comes to the physician because of a 1-week
history of shortness of breath with exertion, paroxysmal nocturnal
dyspnea, and swelling of his feet. He has not had chest pain or
palpitations. He has been healthy except for a "bad cold" 1 month ago
that resolved spontaneously after 10 days. His temperature is 37 C
(98.6 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and
respirations are 24/min. Examination shows jugular venous distention
to 8 cm. Bilateral basilar crackles are heard. Cardiac examination
shows a diffuse, laterally displaced point of maximal impulse. There
is a normal S1 and S2 and an S3. Examination shows 2+ pretibial edema
bilaterally. An ECG shows no abnormalities. Echocardiography is most
likely to show which of the following?

A
) Asymmetric septal hypertrophy

B
) Bicuspid aortic valve with stenosis

C
) Diffuse hypokinesia and dilation of the ventricles

D
) Dyskinesia of the left ventricular apex

E
) Mitral valve prolapse

3.

A 35-year-old man is brought to the emergency department because of
intractable nausea and vomiting of nonbilious fluid over the past 48
hours. He has a history of duodenal ulcer disease treated with
H2-receptor blocking agents. His temperature is 37 C (98.6 F), blood
pressure is 90/60 mm Hg, pulse is 130/min, and respirations are
10/min. Examination shows mild epigastric tenderness. Which of the
following are the most likely serum electrolyte findings?


Na+ Cl– K+ HCO3–
(mEq/L) (mEq/L) (mEq/L) (mEq/L)

A
)
115 80 4.0 25

B
)
140 80 2.5 40

C
)
145 100 5.0 15

D
)
150 105 2.5 25

E
)
160 135 5.0 25

4. A 3-year-old boy is brought for a follow-up examination. He just
completed a 10-day course of amoxicillin that has not resolved his
right ear pain. He appears irritable. His temperature is 38.9 C (102
F). Examination shows downward and lateral displacement of the right
auricle with tenderness to palpation of the posterior auricular area;
his neck is supple. Which of the following is the most appropriate
next step in diagnosis?

A
) Bone scan

B
) CT scan of the head

C
) Tympanometry

D
) Lumbar puncture

E
) Tympanocentesis

5. A 67-year-old man has had shortness of breath on exertion for 3
months; he has had an 11.3-kg (25-lb) weight loss during this period.
He has smoked two packs of cigarettes daily for 25 years. He appears
chronically ill. Examination shows decreased breath sounds on the
left; heart sounds are normal. An x-ray film of the chest shows a
large left-sided pleural effusion. Which of the following is the most
appropriate next step in diagnosis?

A
) Bronchoscopy

B
) Thoracoscopy

C
) Closed pleural biopsy

D
) Open pleural biopsy

E
) Thoracentesis

6. A program for the primary prevention of coronary artery disease is
implemented in a community in the USA. Assuming that diagnostic
procedures and detection remain the same, which of the following
measures involving the disease is most effective in monitoring the
program?

A
) Case fatality

B
) Hospitalization

C
) Incidence

D
) Mortality

E
) Prevalence

7. A 77-year-old woman comes to the physician because of low back pain
for 3 months. She has hypertension controlled with a calcium-channel
blocking agent and type 2 diabetes mellitus controlled with diet. Her
vital signs are within normal limits. Examination shows no spinal or
costovertebral angle tenderness; straight-leg raising produces pain in
the low back at the L2–4 range. Knee jerk and ankle reflexes are 2+
bilaterally. Babinski's sign is absent bilaterally. Urinalysis shows
5–10 epithelial cells/hpf, 2–5 leukocytes/hpf, and few bacteria. Which
of the following is the most appropriate pharmacotherapy?

A
) Acetaminophen

B
) Gold

C
) Methotrexate

D
) Prednisone

E
) Probenecid

8. A 32-year-old woman who is HIV positive has a CD4+ lymphocyte count
of 800/mm3 (Normal ≥ 500). Her health maintenance regimen should
include immunization against which of the following pathogens?

A
) Haemophilus influenzae type b

B
) Hepatitis A

C
) Influenza virus

D
) Neisseria meningitidis

E
) Streptococcus pyogenes (group A)

9. A 32-year-old woman comes to the physician because of bright red
rectal bleeding and severe stabbing pain with each bowel movement over
the past 2 weeks. She has blood-streaked stools, and there is blood on
the toilet paper. Over the past 2 months, she has had mild
constipation with no change in the caliber of the stool. Examination
shows a small anal fissure at the posterior midline. Rectal
examination is painful, but no abnormalities are detected except for a
small amount of bright red blood from the fissure. Which of the
following is the most appropriate next step in management?

A
) Anesthetic ointment and stool softeners

B
) Anal dilatation under anesthesia

C
) Debridement and closure of the fissure under anesthesia

D
) Surgical flaps

E
) Lateral internal sphincterotomy

10. A 28-year-old nulligravid woman comes for a routine health
maintenance examination. She has had progressively severe dysmenorrhea
over the past 6 months adequately controlled by nonsteroidal
anti-inflammatory agents. Pelvic examination shows a normal vagina and
cervix. The uterus is retroverted and fixed, and there is nodularity
of the cul-de-sac. A 6-cm left adnexal mass is palpated. Transvaginal
ultrasonography shows a 7-cm septated adnexal mass. Four weeks later,
there is no change in the size of the adnexal mass. Which of the
following is the most appropriate diagnostic test?

A
) Measurement of serum CA 125 level

B
) Barium enema

C
) CT scan of the pelvis

D
) MRI of the pelvis

E
) Laparoscopy

11. A 67-year-old woman is hospitalized because of abdominal pain and
persistent copious vomiting for 24 hours. Two weeks ago, she was
hospitalized for treatment of atrial fibrillation; after cardioversion
to a normal sinus rhythm, she began treatment with warfarin. Yesterday
at a follow-up visit, her INR was 6, and her medication was
discontinued. She takes no other medications. Her temperature is 37 C
(98.6 F), blood pressure is 100/78 mm Hg, pulse is 120/min and
regular, and respirations are 20/min. The abdomen is distended and
moderately tender; there is voluntary guarding in the epigastrium.
There are no masses, organomegaly, or obvious hernias. Rectal
examination shows no abnormalities. Test of the stool for occult blood
is negative. Her hemoglobin level has decreased from 13 g/dL yesterday
to 7.8 g/dL today. An ECG shows a normal sinus rhythm. Which of the
following is the most likely explanation for this patient's abdominal
symptoms?

A
) Internal small-bowel herniation

B
) Intestinal ischemia from a cardiac embolus

C
) Intramural hematoma of the proximal small bowel

D
) Intussusception of the small bowel

E
) Malrotation of the small bowel

12. A 32-year-old man with alcoholism is brought to the emergency
department by friends because he has been unable to stand without
support and has had "funny eye movements"; they report that he has
been drinking approximately 18 beers daily over the past month and has
been increasingly confused over the past 5 days. He is awake and
confused but is noncombative. His speech is slurred, and his breath
smells of alcohol. His temperature is 37.2 C (99 F), blood pressure is
180/60 mm Hg, pulse is 110/min, and respirations are 18/min. Physical
examination shows sixth cranial nerve palsy, horizontal diplopia,
strabismus, and an asymmetric horizontal-gaze evoked nystagmus.
Neurologic examination shows no focal weakness or numbness. When
helped up and told to walk, he has a broad-based, uncertain gait. When
asked how he arrived at the emergency department, he relates that "I
drove to this place to visit some friends." The most likely cause of
these findings is a deficiency of which of the following?

A
) Folic acid

B
) Magnesium

C
) Vitamin B1 (thiamine)

D
) Vitamin B12 (cyanocobalamin)

E
) Zinc

13. A 32-year-old woman, gravida 2, para 2, comes to the physician
because she has been amenorrheic for 4 months. Examination shows a
well-estrogenized vagina and no evidence of virilization or other
abnormalities. A serum pregnancy test is negative. She is given
medroxyprogesterone and has the onset of bleeding 3 days later. Which
of the following is the most likely cause of her condition?

A
) Anovulation

B
) Asherman's syndrome

C
) Hypopituitarism

D
) Menopause

E
) Premature ovarian failure

14.

A previously healthy 47-year-old woman comes to the emergency
department because of a 36-hour history of nausea, vomiting, and
abdominal pain that radiates to her back. Over the past 3 years, she
has had intermittent episodes of cramping abdominal pain 1 to 2 hours
after meals; the pain lasts for several hours and resolves
spontaneously. She does not smoke and drinks one to two glasses of
wine each evening. There is a family history of coronary artery
disease and hypertension. Her temperature is 37 C (98.6 F), blood
pressure is 100/60 mm Hg, pulse is 120/min, and respirations are
20/min. Abdominal examination shows moderate epigastric and right
upper quadrant tenderness with no guarding or rebound; bowel sounds
are decreased. Laboratory studies show:


Hematocrit 45%
Leukocyte count 9000/mm3 with a normal differential
Serum
Total bilirubin 1.5 mg/dL
Alkaline phosphatase 120 U/L
Aspartate aminotransferase (AST, GOT) 78 U/L
Amylase 365 U/L
Lipase 1223 U/L (N=1–160)
Triglycerides 300 mg/dL

Which of the following is the most likely diagnosis?

A
) Acute cholecystitis

B
) Alcoholic hepatitis

C
) Alcoholic pancreatitis

D
) Ascending cholangitis

E
) Gallstone pancreatitis

F
) Hepatitis A

G
) Pancreatic cancer

H
) Peptic ulcer disease

I
) Triglyceride-induced pancreatitis


15. A healthy 37-year-old primigravid woman at 12 weeks' gestation
comes for a routine prenatal visit. The pregnancy was achieved by in
vitro fertilization. She does not use tobacco, alcohol, or drugs. She
is a hematologist and works 10 to 12 hours daily. Two previous
ultrasonographies have shown a triplet gestation. She weighs 66 kg
(145 lb) and is 178 cm (70 in) tall. Her blood pressure is 116/70 mm
Hg, and pulse is 72/min. Examination shows a uterus consistent in size
with a 16-week gestation. Her pelvis is normal-sized. This patient is
at greatest risk for which of the following?

A
) Abruptio placentae

B
) Hepatitis B

C
) HIV infection

D
) Preterm labor

E
) Uterine rupture

16. A 67-year-old man is brought to the emergency department because
of a 3-day history of fever and headache. Five years ago, he underwent
placement of a mechanical aortic valve for treatment of sequelae of
rheumatic fever. He appears ill. His temperature is 40 C (104 F),
blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are
22/min. A grade 3/6, systolic ejection murmur is heard. Neurologic
examination shows mild left hemiparesis. Babinski's sign is present on
the left. There is no nuchal rigidity. This patient is at greatest
risk for which of the following complications?

A
) Brain abscess

B
) Carotid artery occlusion

C
) Encephalitis

D
) Hydrocephalus

E
) Venous sinus thrombosis

17. A 67-year-old woman comes for a routine health maintenance
examination. She drinks 1 ounce of alcohol daily. Her blood pressure
is 138/62 mm Hg, pulse is 76/min and regular, and respirations are
14/min. The lungs are clear to auscultation. The remainder of the
examination shows no abnormalities. Laboratory studies show:

Hemoglobin
12.8 g/dL
Serum

Ca2+
11.9 mg/dL
Creatinine
0.8 mg/dL
Phosphorus
2.8 mg/dL
Total protein
6.5 g/dL
Albumin
4.2 g/dL
Ionized calcium
5.8 mg/dL (N=4.5–5.1)

Which of the following is the most appropriate next step in management?

A
) Measurement of serum alkaline phosphatase activity

B
) Measurement of serum parathyroid hormone level

C
) Measurement of serum vitamin D level

D
) Serum and urine protein electrophoresis

E
) X-ray film of the chest

F
) Skeletal survey

G
) Bone scan

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with papilledema, select the most likely diagnosis.


A
) Bacterial meningitis

B
) Cerebral infarction

C
) Cryptococcal meningitis

D
) Glioblastoma multiforme

E
) Herpes simplex encephalitis

F
) Hypertensive encephalopathy

G
) Idiopathic intracranial hypertension

H
) Intracerebral hemorrhage

I
) St. Louis encephalitis

18. A 25-year-old woman comes to the emergency department because of
increasingly severe bifrontal headaches over the past 6 months. During
this period, she has had transient episodes of blindness lasting 1 to
2 seconds. She has not had nausea or vomiting. She has a long-standing
history of difficulty losing weight. She currently weighs 113 kg (250
lb) and is 152 cm (60 in) tall. Her blood pressure is 120/80 mm Hg.
Visual field testing shows enlarged blind spots. The remainder of the
neurologic examination shows normal findings. A CT scan of the head
with and without contrast shows no abnormalities. Examination of the
cerebrospinal fluid shows:

Opening pressure 300 mm H2O
Glucose 70 mg/dL
Protein 25 mg/dL
WBC 1/mm3
RBC 0/mm3

Gram's stain and cultures are negative.

For each patient with papilledema, select the most likely diagnosis.


A
) Bacterial meningitis

B
) Cerebral infarction

C
) Cryptococcal meningitis

D
) Glioblastoma multiforme

E
) Herpes simplex encephalitis

F
) Hypertensive encephalopathy

G
) Idiopathic intracranial hypertension

H
) Intracerebral hemorrhage

I
) St. Louis encephalitis

19. A 25-year-old man with a history of intravenous drug use comes to
the emergency department because of a progressive diffuse headache,
generalized malaise, and low-grade fever for 2 months. During this
period, he has had a poor appetite resulting in a 6.8-kg (15-lb)
weight loss. His temperature is 38 C (100.4 F). Examination shows
¬¬neck stiffness. Mental status examination shows no abnormalities.
Cranial nerve examination shows weakness of the lateral rectus muscle
on the right and bilateral papilledema. A CT scan of the head with and
without contrast shows moderate ventricular enlargement. Examination
of cerebrospinal fluid shows:

Opening pressure 220 mm H2O
Glucose 35 mg/dL
Protein 150 mg/dL
WBC 100/mm3
Lymphocytes 100%
RBC 1/mm

20. An asymptomatic 32-year-old woman comes for a routine health
maintenance examination. Her mother and sister have a history of low
back pain and disc herniation. The patient is a postal worker. She
weighs 86 kg (190 lb) and is 165 cm (65 in) tall. Her blood pressure
is 130/78 mm Hg, pulse is 74/min, and respirations are 16/min. Range
of motion of the spine is normal and without pain. There is no
scoliosis or excessive kyphosis of the back. Which of the following is
the most effective strategy to decrease this patient's risk for
developing low back pain?

A
) Change in job

B
) Limit physical activity

C
) Stretching exercises

D
) Weight-loss program

E
) Nonsteroidal anti-inflammatory drug therapy

F
) Prophylactic brace

21. Three days after being hospitalized for treatment of a hip
fracture sustained in a fall, a 62-year-old woman becomes acutely
short of breath and coughs up a small amount of blood-tinged sputum.
She appears anxious. Her blood pressure is 110/70 mm Hg, pulse is
110/min, and respirations are 24/min. Examination shows no other
abnormalities. Arterial blood gas analysis on 40% oxygen by face mask
shows:

pH 7.40
PCO2 38 mm Hg
PO2 70 mm Hg

Ventilation-perfusion lung scans show multiple segmental areas of
mismatch on the right. Which of the following is the most appropriate
next step in management?

A
) Pulmonary angiography

B
) Dopamine therapy

C
) Heparin therapy

D
) Urokinase therapy

E
) Intubation

22. A 24-year-old man is brought to the emergency department by police
1 hour after his ex-wife found him stumbling around in the yard. His
blood pressure is 100/70 mm Hg, pulse is 90/min, and respirations are
16/min. The pupils are equal and reactive to light; the sclerae are
injected. During the examination, he laughs without obvious reason,
makes religious statements, and asks if there is anything to eat or
drink. Mental status examination shows a broad range of affect; there
is no evidence of thought disorder except for mild paranoia. Which of
the following is the most appropriate next step in management?

A
) Observation in the emergency department

B
) Intramuscular administration of naloxone

C
) Intravenous administration of 50% dextrose

D
) Intravenous administration of lorazepam

E
) Oral administration of chlorpromazine


23. A 17-year-old boy sustains a head injury and loses consciousness
after diving into a freshwater lake from a platform. After being
submerged for 3 minutes, he is rescued. He is initially cyanotic but
then begins to cough and breathe spontaneously after a 5-minute
resuscitation. Over the next 36 hours, which of the following
complications is most likely?

A
) Acute respiratory distress syndrome

B
) Bacteremia

C
) Bacterial pneumonia

D
) Hypernatremia

E
) Metabolic alkalosis

24. A 15-year-old boy is brought to the emergency department 30
minutes after being involved in a motor vehicle collision. He was the
unrestrained passenger. On arrival, he is disoriented. His blood
pressure is 80/40 mm Hg, pulse is 112/min, and respirations are
24/min. There is no jugular venous distention. Examination of the
chest shows dullness to percussion and decreased breath sounds over
the right hemithorax. Which of the following is the most likely
diagnosis?

A
) Diaphragmatic rupture

B
) Flail chest

C
) Hemothorax

D
) Massive aspiration

E
) Pneumothorax

25. An 18-year-old man comes to the physician for an initial
examination because of a 3-year history of fatigue and migrating joint
pain. He has brought a large folder containing information about
previous medical consultations, laboratory tests, and x-ray films. He
takes no medications. He weighs 50 kg (110 lb) and is 173 cm (68 in)
tall. Physical examination shows no other abnormalities. On mental
status examination, he is preoccupied with his symptoms. When asked
about his mood, he states that the future appears bleak, and that he
is too tired to think about it. Which of the following is the most
appropriate next step in management?

A
) Ask about further symptoms of obsessions and compulsions

B
) Ask about sexual history including sexual orientation and practices

C
) Ask about suicidal feelings

D
) Ask about travel history over the past 6 months

E
) Obtain a detailed exercise history

F
) Measurement of serum Lyme (Borrelia burgdorferi) antibody level

G
) Urine toxicology screening

26. An 80-year-old woman has had bleeding gums for 3 weeks. Her diet
has consisted of only tea and toast for 2 years. She appears thin and
weak. Vital signs are normal. Her gums are hypertrophied and exude
blood with pressure. There are ecchymoses of the inner thighs and
small hemorrhages around the hair follicles. The remainder of the
examination shows normal findings. Supplementation with which of the
following vitamins is most likely to have prevented this condition?

A
) A

B
) B12 (cyanocobalamin)

C
) C

D
) D

E
) E

27. A 30-year-old woman, gravida 2, para 1, is brought to the
emergency department in labor. An episiotomy is performed. Following
delivery of the head, the shoulders do not follow with the usual
traction and maternal pushing. Which of the following is the most
appropriate next step in management?

A
) Flexing the woman's knees toward her shoulders

B
) More forceful traction and fundal pressure

C
) Delivering the posterior arm

D
) Rotating the head 180 degrees

E
) Symphysiotomy

28.

A 32-year-old man comes to the physician because of a 3-day history of
low back pain, urinary hesitancy, and pain with urination. He has had
several similar episodes over the past 3 years. He has not had any
urethral discharge or recent sexual contacts. His temperature is 37.2
C (98.9 F), and blood pressure is 126/76 mm Hg. The lungs are clear to
auscultation; there is no costovertebral angle tenderness. Abdominal
examination shows no tenderness or masses. There is no tenderness to
palpation of the lower back. Straight-leg raising to 90 degrees is
negative. There are no motor or sensory deficits in the lower
extremities. Rectal examination shows a diffuse, minimally enlarged,
tender prostate with no masses. Laboratory studies show:


Serum prostate-specific antigen 6 ng/mL (N<4)
Urine
Specific gravity 1.020
Blood negative
Glucose negative
Ketones negative
Leukocyte esterase negative
Nitrites negative

Which of the following is the most likely diagnosis?

A
) Benign prostatic hypertrophy

B
) Cystitis

C
) Epididymitis

D
) Prostate cancer

E
) Prostatitis

F
) Pyelonephritis

G
) Urolithiasis

29. A 16-year-old boy with neurofibromatosis is brought for a
follow-up examination. His uncle also has neurofibromatosis. He has a
1-year history of headaches during which his parents say he appears
pale. Six months ago, he underwent operative treatment for an optic
nerve glioma. His blood pressure is 164/105 mm Hg, pulse is 102/min,
and respirations are 14/min. The thyroid glands are not enlarged. No
murmurs are heard, and radial pulses are equal. Abdominal examination
shows no abnormalities. Which of the following is the most likely
cause of this patient's high blood pressure?

A
) Catecholamine-producing tumor

B
) Carcinoma of the thyroid gland

C
) Essential hypertension

D
) Overproduction of aldosterone from an adrenal adenoma

E
) Postsubclavian coarctation of the aorta

30. A 14-month-old girl is brought to the physician because of a
14-hour history of irritability and episodes of drawing her knees
toward her chest. During this period, she has vomited nonbilious fluid
twice and had a bowel movement containing a small amount of blood. She
had an upper respiratory tract infection 2 weeks ago. She is listless
except for intermittent episodes of discomfort. Her temperature is 38
C (100.4 F). Abdominal examination shows right-sided tenderness
without guarding or rebound; bowel sounds are present. Rectal
examination shows bright red blood and mucus. An x-ray film of the
abdomen shows no abnormalities. Which of the following is the most
appropriate next step in management?

A
) X-ray film of the upper gastrointestinal tract with contrast

B
) Water-soluble contrast enema

C
) Corticosteroid enemas

D
) Admission to the hospital for total parenteral nutrition

E
) Immediate laparotomy

31. An asymptomatic 47-year-old man comes for a preemployment
examination. He has never been hospitalized. He is a computer
programmer, and he plays handball once weekly. His maternal
grandmother had type 2 diabetes mellitus, and a paternal uncle had
heart disease. The patient's blood pressure is 126/80 mm Hg.
Examination shows no abnormalities. His total serum cholesterol level
is 225 mg/dL. Which of the following is the most appropriate next step
in management?

A
) Step 2 American Heart Association cardiac diet

B
) Serum lipid studies while fasting

C
) Exercise stress test

D
) Oral cholestyramine and niacin therapy

E
) Oral pravastatin therapy at bedtime

32. A 25-year-old woman comes to the physician because of a 3-month
history of the unexplained urge to eat a few tablespoons of cornstarch
daily. The amount of cornstarch ingested has increased gradually
during this time. She has leiomyomata uteri; she is otherwise healthy.
Her weight is unchanged from her last visit 1 year ago; she weighs 61
kg (135 lb) and is 168 cm (66 in) tall. Her blood pressure is 120/80
mm Hg, and pulse is 100/min. Physical examination shows mild pallor.
Neurologic examination shows no abnormalities. She is embarrassed
about her problem. She has no compulsive behavior or obsessive
thoughts. An ECG shows sinus tachycardia. Which of the following is
the most appropriate next step in management?

A
) Psychiatric assessment

B
) Complete blood count

C
) Thyroid function studies

D
) Urine toxicology screening

E
) Admission to an eating disorders clinic

F
) Antipsychotic therapy

G
) Folic acid supplementation

H
) Selective serotonin reuptake inhibitor therapy

33. A 30-year-old woman comes to the physician for a follow-up
examination 4 months after starting treatment with lithium carbonate;
during this period she has had a 3.2-kg (7-lb) weight gain. Her
medication was prescribed soon after the birth of her son to treat
racing thoughts, increased spending, and overtalkativeness; she has
had difficulty sleeping for more than 2 hours nightly. Her symptoms
decreased after 2 weeks of lithium carbonate therapy. She continues to
take lithium carbonate (300 mg three times daily). Her temperature is
37 C (98.6 F), blood pressure is 120/80 mm Hg, and pulse is 70/min.
Examination shows normal findings. The most appropriate next step is
measurement of which of the following?

A
) Fasting serum glucose level

B
) Leukocyte count

C
) Serum alkaline phosphatase activity

D
) Serum creatinine level

E
) Serum thyroid-stimulating hormone level

34. On a routine examination, a 2-year-old boy has a hemoglobin level
of 10.5 g/dL, hematocrit of 30%, and mean corpuscular volume of 72
μm3. He drinks four to five 8-oz bottles of milk daily. He maintains a
regular diet but does not eat vegetables. Which of the following is
the most likely diagnosis?

A
) Folic acid deficiency

B
) Iron deficiency

C
) Sickle cell disease

D
) Thalassemia

E
) Vitamin B6 deficiency

35. A 57-year-old man is brought to the physician by his wife because
his skin has appeared yellow for 3 weeks. Examination shows jaundice
and scleral icterus. His total serum bilirubin level is 8 mg/dL with a
direct component of 6.2 mg/dL. A CT scan of the abdomen shows a large
lesion in the head of the pancreas. When the results are initially
discussed, the patient says that he does not want to hear the report,
and his wife agrees to abide by his wishes. Which of the following is
the most appropriate course of action?

A
) Withhold the results as the patient wishes

B
) Contact the patient's children to discuss the results

C
) Consult with the hospital ethics committee

D
) Insist on telling the patient the results

E
) Refer him to another physician

36. A previously healthy 52-year-old man comes to the physician
because of a 3-month history of increased urinary volume and increased
urinary frequency at night. He has had a 6.8-kg (15-lb) weight loss
during this period despite no change in appetite. His father has
hypertension, and his mother has hypertension and type 2 diabetes
mellitus. He currently weighs 95 kg (210 lb) and is 178 cm (70 in)
tall. His blood pressure is 160/85 mm Hg in both arms. Examination
shows no other abnormalities. His nonfasting serum glucose level is
280 mg/dL. Which of the following serum levels is most likely to be
increased in this patient?

A
) Bicarbonate

B
) Glucagon

C
) HDL-cholesterol

D
) Insulin

E
) Ketones

37. Three days after hospitalization for heparin treatment of deep
venous thrombosis of a left superficial femoral vein, a 52-year-old
woman has prolonged bleeding from a venipuncture site. She had a
pulmonary embolus 2 years ago. Her temperature is 37.5 C (99.5 F).
Examination shows multiple ecchymoses at the venipuncture sites with
oozing of fresh blood. Laboratory studies show:

Hemoglobin
10.5 g/dL
Platelet count
25,000/mm3
Prothrombin time
14 sec (INR=1.3)
Partial thromboplastin time
65 sec
Plasma fibrinogen
300 mg/dL (N=200–400)
Serum creatinine
1.1 mg/dL

Which of the following is the most likely diagnosis?

A
) Adverse drug reaction

B
) Disseminated intravascular coagulation

C
) Excessive blood loss from anticoagulation

D
) Factor VIII deficiency

E
) Factor IX deficiency

F
) Immune thrombocytopenic purpura

G
) Thrombotic thrombocytopenic purpura

38. A 37-year-old woman comes to the physician because of an itchy
rash over her trunk for 2 weeks. She has not had fever, chills,
shortness of breath, chest pain, or gastrointestinal symptoms. She has
a history of recurrent urinary tract infections and has been taking
trimethoprim-sulfamethoxazole prophylaxis for the past year. She is in
mild distress. Her temperature is 37.5 C (99.5 F), blood pressure is
96/62 mm Hg, pulse is 78/min, and respirations are 14/min. Examination
shows a maculopapular erythematous rash over the trunk. Laboratory
studies show:

Leukocyte count 10,500/mm3
Segmented neutrophils 72%
Bands 1%
Eosinophils 15%
Lymphocytes 4%
Monocytes 8%
Serum
Urea nitrogen (BUN) 12 mg/dL
Creatinine 0.9 mg/dL
Urine
WBC 2/hpf
RBC 2/hpf

Which of the following is the most likely cause of these findings?

A
) Eczema

B
) Medication adverse effect

C
) Staphylococcal skin infection

D
) Streptococcal skin infection

E
) Urinary tract infection

39. A 19-year-old primigravid woman at 34 weeks' gestation comes to
the physician for a routine prenatal visit. Her pregnancy has been
uncomplicated. She has no history of serious illness. She takes no
medications and has no known allergies. Examination shows a uterus
consistent in size with a 34-week gestation. A routine clean-catch
urine culture grows greater than 100,000 colonies/mL of Escherichia
coli. Which of the following is the most appropriate pharmacotherapy?

A
) Ampicillin

B
) Ciprofloxacin

C
) Clindamycin

D
) Doxycycline

E
) Trimethoprim-sulfamethoxazole

40. A 13-year-old girl is brought for a well-child examination. Menses
have occurred every other month since menarche 10 months ago. Her last
menstrual period was 1 week ago. She is not sexually active. Sexual
development is Tanner stage 3. Examination shows no abnormalities.
Which of the following is the most appropriate next step in
management?

A
) Discussion of pregnancy prevention

B
) Measurement of serum luteinizing and follicle-stimulating hormone levels

C
) Urine β-hCG test

D
) Pelvic examination

E
) Estrogen therapy

F
) Diagnostic laparoscopy

41. A 72-year-old man comes to the emergency department after a
5-minute episode of blindness in the right eye. Over the past month,
he has had headache and pain in the jaw with chewing. His temperature
is 38.1 C (100.6 F). Examination shows tender, nodular temporal
arteries with decreased pulses. His erythrocyte sedimentation rate is
92 mm/h. Which of the following is the most appropriate immediate step
in management?

A
) Carotid ultrasonography

B
) Aspirin therapy

C
) Cefotaxime therapy

D
) Corticosteroid therapy

E
) Temporal artery biopsy

42. A 42-year-old man comes for a routine health maintenance
examination. There is no family history of coronary artery disease,
and he does not smoke. His weight is appropriate for his height. His
blood pressure is 120/80 mm Hg. Serum lipid studies show a total
cholesterol level of 190 mg/dL, HDL-cholesterol level of 40 mg/dL, and
triglyceride level of 150 mg/dL. Which of the following is the most
appropriate next step in management?

A
) Recommend the Step 2 National Cholesterol Education Program diet

B
) Measure serum LDL-cholesterol level now

C
) Measure total serum cholesterol level in 5 years

D
) Prescribe prophylactic aspirin

E
) Begin treatment with lovastatin

43. A 28-month-old boy has a history of cyanosis since birth with
episodes of syncope. Examination shows cyanosis and clubbing. The
lungs are clear to auscultation. There is a right ventricular heave, a
systolic click, a single S2, and a grade 3/6 systolic murmur. Which of
the following is the most likely diagnosis?

A
) Bicuspid aortic valve

B
) Coarctation of the aorta

C
) Mitral stenosis

D
) Patent ductus arteriosus

E
) Tetralogy of Fallot

44. A healthy 18-year-old woman comes for a routine health maintenance
examination. Menses occur at regular 28-day intervals. Her last
menstrual period was 2 weeks ago. She is sexually active with one
partner, and she and her partner use condoms inconsistently for
contraception. Her maternal grandmother was diagnosed with breast
cancer at the age of 65 years, her paternal grandfather was diagnosed
with colon cancer at the age of 72 years, and her maternal grandfather
died of a myocardial infarction at the age of 66 years. Examination
shows no abnormalities. Which of the following is the most appropriate
screening test for this patient?

A
) Complete blood count

B
) Fasting serum lipid studies

C
) Test of the stool for occult blood

D
) Testing for Neisseria gonorrhoeae and Chlamydia trachomatis

E
) Urinalysis

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each child with fever and cough, select the most likely diagnosis.


A
) α1-Antitrypsin deficiency

B
) Cystic fibrosis

C
) Pneumothorax

D
) Pulmonary alveolar proteinosis

E
) Pulmonary aspergillosis

F
) Pulmonary hemorrhage

G
) Pulmonary tuberculosis

45. A 20-month-old girl is brought to the physician because of fever
and cough for 2 days. She has had several similar episodes since the
age of 4 months. Three months ago, she and her family visited her
grandmother in Finland for 2 weeks. She is at the 25th percentile for
length and 5th percentile for weight. She appears thin and pale. Her
temperature is 38 C (100.4 F), pulse is 150/min, and respirations are
40/min. Examination shows mild clubbing. Wheezing and bilateral
crackles are heard at the lung bases. An x-ray film of the chest shows
streaky densities bilaterally with mild hyperinflation.

For each child with fever and cough, select the most likely diagnosis.


A
) α1-Antitrypsin deficiency

B
) Cystic fibrosis

C
) Pneumothorax

D
) Pulmonary alveolar proteinosis

E
) Pulmonary aspergillosis

F
) Pulmonary hemorrhage

G
) Pulmonary tuberculosis

46. A previously healthy 16-year-old boy is brought to the physician
because of fever and cough with right-sided chest pain for 2 weeks.
Six months ago, he visited his grandparents in Albania for 2 weeks. He
weighs 54 kg (120 lb) and is 173 cm (68 in) tall. He appears thin and
pale. His temperature is 38.2 C (100.8 F), pulse is 76/min, and
respirations are 36/min. Examination shows shallow respirations with
decreased breath sounds at the right lung base. An x-ray film of the
chest shows a right pleural effusion and hilar adenopathy.
__________________________________________________________________________________________________________________________________

Section 4:--

1. A previously healthy 52-year-old man comes to the emergency
department because of hiccups for 1 week. He has smoked two packs of
cigarettes daily for 30 years. He does not drink alcohol. He is alert
and oriented. His temperature is 37 C (98.6 F), blood pressure is
150/95 mm Hg, pulse is 70/min, and respirations are 12/min. Physical
and neurologic examinations show no abnormalities. His serum sodium
level is 120 mEq/L. An x-ray film of the chest shows a right hilar
mass. Which of the following is the most appropriate next step in
treatment?

A
) Bisphosphonate therapy

B
) Calcitonin therapy

C
) Calcium therapy

D
) Dexamethasone therapy

E
) 5% Dextrose in 0.225% saline therapy

F
) 5% Dextrose in 0.45% saline therapy

G
) 5% Dextrose in water therapy

H
) Fluid restriction

I
) Hydrocortisone therapy

J
) Lactated Ringer's solution

K
) Mannitol therapy

L
) Potassium therapy

M
) 0.9% Saline therapy

N
) 3% Saline therapy

O
) Sodium bicarbonate therapy

2. A 67-year-old man comes to the physician because of a 6-month
history of double vision, slurred speech, and difficulty swallowing
liquids. Initially, his symptoms were intermittent but now occur daily
and are worse at the end of the day. Over the past week, he has had
shortness of breath with exertion. He has pernicious anemia treated
with monthly vitamin B12 (cyanocobalamin) injections and autoimmune
thyroid disease currently treated with thyroid replacement therapy.
Examination shows bilateral ptosis and disconjugate gaze. There is
bilateral facial weakness and hypernasal speech. The tongue is weak,
and the gag reflex is reduced. Muscle strength is 4/5 in the proximal
muscles of the upper and lower extremities. Deep tendon reflexes are
2+ diffusely. Babinski's sign is absent. Sensory examination shows no
abnormalities. A CT scan of the chest is shown. Which of the following
is the most likely diagnosis of this patient's intrathoracic lesion?

A
) Aspiration pneumonia

B
) Bronchogenic carcinoma

C
) Lung metastasis

D
) Sarcoidosis

E
) Thymoma

F
) Thyroid carcinoma

3. A 32-year-old man receiving intensive chemotherapy for Hodgkin's
disease has a temperature of 39 C (102.2 F). His respirations are
40/min. Widespread crackles are heard in all lung fields. An x-ray
film of the chest shows a diffuse alveolar and interstitial pattern.
Which of the following is the most likely causal organism?

A
) Aspergillus species

B
) Candida albicans

C
) Coccidioides immitis

D
) Pneumocystis carinii

E
) Streptococcus pneumoniae

4. A 20-year-old African American man with sickle cell disease comes
to the physician because of a 1-week history of shortness of breath on
exertion, fatigue, and generalized weakness. He has had no fever,
chills, night sweats, or cough productive of sputum. His only
medication is oxycodone for joint pain. He weighs 68 kg (150 lb) and
is 168 cm (66 in) tall. His temperature is 36.7 C (98 F), blood
pressure is 120/70 mm Hg, pulse is 76/min, and respirations are
18/min. Examination shows no abnormalities. Laboratory studies show:

Hematocrit 20%
Mean corpuscular volume 110 μm3
Leukocyte count 2300/mm3
Reticulocyte count 1.8%

Which of the following is the most likely mechanism for these findings?

A
) Adverse drug reaction

B
) Atrophy of gastric mucosa

C
) Bacterial overgrowth in the small intestine

D
) Increased demand for folic acid

E
) Increased demand for vitamin B12 (cyanocobalamin)

F
) Malabsorption

G
) Vitamin B1 (thiamine) deficiency

5. A 44-year-old woman comes to the emergency department 2 days after
being discharged from the hospital for abdominal pain; an exploratory
laparoscopy showed no abnormalities. Over the past 5 years, she had
been admitted to the hospital numerous times for the evaluation of a
variety of symptoms; all work-ups had been negative. Her temperature
is 39.2 C (102.6 F). Examination shows a reddened, indurated
laparoscopic wound. She is admitted to the hospital and given
intravenous antibiotics. On the second hospital day, a nurse witnesses
the patient rubbing saliva into her laparoscopy site. Which of the
following is the most likely diagnosis?

A
) Adjustment disorder with disturbance of conduct

B
) Conduct disorder

C
) Conversion disorder

D
) Factitious disorder

E
) Hypochondriasis

F
) Major depressive disorder

G
) Oppositional defiant disorder

H
) Somatization disorder

6. A 37-year-old woman is brought to the emergency department because
she has been unable to see out of her right eye since awakening 2
hours ago. She states that any movement of the eye is painful.
Examination shows visual acuity of 20/200 in the right eye and 20/20
in the left eye. The optic fundi are normal. The left pupil reacts
normally to light. The right pupil is poorly reactive to direct light.
The remainder of the eye examination shows no abnormalities. Which of
the following is the most likely site of the lesion?

A
) Left optic nerve

B
) Left optic radiation

C
) Left optic tract

D
) Left visual cortex

E
) Optic chiasm

F
) Retina

G
) Right optic nerve

H
) Right optic radiation

I
) Right optic tract

J
) Right visual cortex

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with peripheral nerve dysfunction, select the most
likely site of nerve injury.


A
) Axillary nerve

B
) Cervical nerve root at the cervical foramen

C
) Long thoracic nerve

D
) Median nerve above the elbow

E
) Median nerve at the elbow

F
) Median nerve at the wrist

G
) Musculocutaneous nerve above the elbow

H
) Musculocutaneous nerve at the elbow

I
) Musculocutaneous nerve at the wrist


J
) Radial nerve above the elbow

K
) Radial nerve at the elbow

L
) Radial nerve at the wrist

M
) Suprascapular nerve

N
) Thoracodorsal nerve

O
) Ulnar nerve above the elbow

P
) Ulnar nerve at the elbow

Q
) Ulnar nerve at the wrist

7.

A previously healthy 42-year-old carpenter comes to the physician
because of a 6-month history of pain and numbness in his dominant hand
that awakens him at night. He describes numbness in his long and index
fingers after driving for extended periods of time. Examination shows
minimal atrophy of the thenar muscles. There is normal sensation to
light touch on the little finger and the palm of the right hand.
Sensation to light touch is decreased at the tip of the thumb, index
finger, and long finger. X-ray films of the right elbow and wrist show
no abnormalities.

For each patient with peripheral nerve dysfunction, select the most
likely site of nerve injury.


A
) Axillary nerve

B
) Cervical nerve root at the cervical foramen

C
) Long thoracic nerve

D
) Median nerve above the elbow

E
) Median nerve at the elbow

F
) Median nerve at the wrist

G
) Musculocutaneous nerve above the elbow

H
) Musculocutaneous nerve at the elbow

I
) Musculocutaneous nerve at the wrist


J
) Radial nerve above the elbow

K
) Radial nerve at the elbow

L
) Radial nerve at the wrist

M
) Suprascapular nerve

N
) Thoracodorsal nerve

O
) Ulnar nerve above the elbow

P
) Ulnar nerve at the elbow

Q
) Ulnar nerve at the wrist

8. A previously healthy 37-year-old man comes to the physician because
of a 2-month history of pain in the forearm and little finger of his
dominant hand; he has been working as a receptionist for 6 months. He
describes numbness in his little finger and weakness of his grip.
There is decreased sensation to light touch at the tip of the little
finger. Paresthesias are elicited with compression of the cubital
tunnel.

9. A 3-month-old boy is brought for a well-child examination. He has
poor head control. Examination shows generalized hypotonia. The point
of maximal impulse is at the left anterior axillary line. The liver
edge is palpated 4 cm below the right costal margin. The spleen is not
palpable. Which of the following is the most likely diagnosis?

A
) Congenital muscular dystrophy

B
) Glycogen storage disease, type II (Pompe's disease)

C
) GM1 gangliosidosis

D
) Infant botulism

E
) Ventricular septal defect

10. Over the past 3 months, a 30-year-old woman has had intermittent
episodes of headache, palpitations, sweating, and irritability. Her
blood pressure is 150/100 mm Hg while supine and 149/100 mm Hg while
standing, and pulse is 90/min while supine and 110/min while standing.
Examination shows no abnormalities except for pallor. Which of the
following is the most likely location of this patient's lesion?

A
) Adrenal gland

B
) Brain

C
) Heart

D
) Kidney

E
) Thyroid gland

11. A 19-year-old man is brought to the emergency department 45
minutes after sustaining a single, large stab wound to the right upper
quadrant of the abdomen. He is obtunded. His blood pressure is
60/palpable mm Hg, and pulse is 148/min. Breath sounds are equal
bilaterally. Examination shows a 4-cm laceration in the right upper
quadrant in the midclavicular line. The abdomen is distended. Which of
the following is the most appropriate next step in management?

A
) X-ray films of the abdomen and pelvis

B
) Angiography

C
) Contrast study of the wound tract

D
) CT scan of the abdomen

E
) CT scan of the chest

F
) Laparoscopy

G
) Peritoneal lavage

H
) Laparotomy

I
) Local wound exploration

12. A 52-year-old woman comes to the physician because of decreased
libido; this symptom began 8 months ago, after she underwent a total
abdominal hysterectomy and bilateral salpingo-oophorectomy for
leiomyomata uteri and menorrhagia. She has been taking hormone
replacement therapy with conjugated estrogen since the operation.
Examination shows a moist, rugated vagina. Which of the following is
the most likely cause of these findings?

A
) Decreased androgens

B
) Decreased estrogen

C
) Decreased follicle-stimulating hormone (FSH)

D
) Decreased luteinizing hormone (LH)

E
) Decreased progesterone

F
) Decreased prolactin

G
) Increased androgens

H
) Increased estrogen

I
) Increased FSH

J
) Increased LH

K
) Increased progesterone

L
) Increased prolactin

13.

A 7-day-old newborn is brought for a well-child examination. He was
born at home. His mother has taken acetaminophen for perineal
discomfort. The newborn is breast-feeding well. He is at the 75th
percentile for length and weight. Examination shows no abnormalities.
After vaccination with hepatitis B, he has prolonged bleeding at the
injection site. There is no family history of excessive bleeding.
Laboratory studies show:


Hemoglobin 16 g/dL
Leukocyte count 6800/mm3
Segmented neutrophils 48%
Bands 2%
Lymphocytes 50%
Platelet count 280,000/mm3
Prothrombin time 20 sec (INR=1.6)
Partial thromboplastin time 60 sec

Which of the following is the most likely mechanism for these findings?

A
) Autoimmunization

B
) Bacterial toxic effect

C
) Factor VIII deficiency

D
) Factor IX deficiency

E
) Immunoglobulin deficiency

F
) Iron deficiency

G
) Pharmacologic effect

H
) Viral toxic effect

I
) Vitamin deficiency

J
) Zinc deficiency

14.

A 67-year-old man with long-standing signs and symptoms of congestive
heart failure is admitted to the hospital because of progressive
shortness of breath. Examination shows no other abnormalities. An
x-ray film of the chest shows cardiomegaly, cephalization of blood
vessels, and a right-sided pleural effusion. Which of the following
sets of pleural fluid findings is most likely in this patient?


Leukocyte Segmented
Protein Glucose count neutrophils Monocytes
(g/dL) (mg/dL) (/mm3) (%) (%)

A
)

2.5


10


10,000


50


50

B
)

2.5


90


2000


60


40

C
)

3.8


40


30,000


80


20

D
)

4.5


60


10,000


20


80

E
)

4.5


90


2000


50


50

15. For 8 weeks, a 52-year-old man with a 5-year history of type 2
diabetes mellitus has had deep burning pain in the ball of his right
foot and big toe when the foot is raised above chest level. He also
has cramping in his right calf when he walks more than 50 feet. He has
smoked two packs of cigarettes daily for 30 years. Femoral pulses are
palpable; pedal pulses are absent. Which of the following is the most
likely diagnosis?

A
) Aortoiliac stenosis

B
) Femoral popliteal stenosis

C
) Mononeuropathy

D
) Vasculitis

E
) Venous stasis

16. A 1-year study of a new drug to treat hypertension is conducted.
One hundred patients with hypertension are enrolled; 50 patients are
given the new drug and another 50 patients are given
hydrochlorothiazide. All patients completed the trial. One noted
unexpected effect is increased growth of scalp hair which occurred in
those taking the new drug, a nonstatistically significant difference
(p>0.10). This effect has also been reported in studies of other
similar drugs in the new therapeutic class. The investigators of the
study concluded that the new drug did not cause hair growth. Which of
the following features of this study is most likely to affect the
validity of this conclusion?

A
) Differential follow-up

B
) Lead time bias

C
) Length of the study

D
) Sample size

E
) Self-selection

17. A 38-year-old woman, gravida 2, para 1, at 38 weeks' gestation has
had no fetal movement for 36 hours. Her prenatal course, prenatal
tests, and fetal growth have been normal. Fetal heart tones are heard
by Doppler. Which of the following is the most appropriate next step
in management?

A
) Routine prenatal visit in 1 week

B
) Maternal hydration

C
) Nonstress test

D
) Immediate induction of labor

E
) Amniocentesis

18. A healthy 7-year-old boy is brought to the physician 1 week after
he was exposed for several hours to a child with chickenpox. The
patient and his healthy sister have not had chickenpox. They have not
received varicella vaccine. Which of the following is the most
appropriate management for the patient and his sister at this time?

A
) Administer acyclovir as prophylaxis

B
) Administer immune globulin, intravenously

C
) Administer aspirin therapy if vesicles appear

D
) Advise the parents to keep the siblings home from school to prevent
exposing their classmates

E
) Inform the parents that a vesicular rash may appear at any time over
the next 2 weeks

19. A 6-year-old boy is brought to the physician by his mother because
of progressive visual loss over the past year. Over the past 2 years,
he has had deterioration of his hearing, speech, writing, and
intellectual performance. His maternal uncle had similar symptoms.
Visual acuity is 20/200 bilaterally. Funduscopic examination shows
optic atrophy. His hearing is markedly impaired. There is weakness and
spasticity of all extremities. Deep tendon reflexes are extremely
hyperactive. Babinski's sign is present bilaterally. On mental status
examination, he is not oriented to place, year, month, or the names of
his siblings. An MRI of the brain shows marked symmetric white matter
disease involving all lobes. Diagnostic studies are most likely to
show which of the following?

A
) Abnormally decreased serum cholesterol level

B
) Acanthocytes on blood smear

C
) An excess of very long chain fatty acids

D
) Normal nerve conduction studies

E
) Vitamin E deficiency

20. A 22-year-old primigravid woman at 16 weeks' gestation is brought
to the emergency department because of progressive shortness of breath
over the past 48 hours. Her temperature is 37 C (98.6 F), blood
pressure is 120/70 mm Hg, pulse is 100/min, and respirations are
24/min. Scattered wheezes are heard. Pelvic examination shows a uterus
that extends to the umbilicus. Fetal heart tones are absent. Her
hematocrit is 32%, leukocyte count is 11,000/mm3, and serum β-hCG
level is 300,000 mIU/mL. Pulse oximetry on room air shows an oxygen
saturation of 92%. An x-ray film of the chest shows multiple round
densities throughout all lung fields. Which of the following is the
most likely diagnosis?

A
) Bacterial pneumonia

B
) Choriocarcinoma

C
) Pulmonary embolism

D
) Tuberculosis

E
) Viral pneumonia

21. A 42-year-old man comes to the physician because of progressive
swelling of the legs over the past 2 months. He has a history of stage
IIA Hodgkin's disease treated 1 year ago with radiation therapy to the
neck and chest. His temperature is 37 C (98.6 F), blood pressure is
102/80 mm Hg, pulse is 110/min, and respirations are 22/min.
Examination shows jugular venous distention that increases with
inspiration. The lungs are clear to auscultation. Cardiac examination
shows a nondisplaced point of maximal impulse; heart sounds are
distant. An early diastolic sound is heard at the apex. Abdominal
examination shows mild distention with shifting dullness. The liver is
pulsatile, and its edge is palpated 4 cm below the right costal
margin. There is 2+ peripheral edema extending up to the knees. Which
of the following is the most likely mechanism of this patient's
increased central venous pressure?

A
) Constrictive pericarditis

B
) Cor pulmonale

C
) Left-sided congestive heart failure

D
) Mitral stenosis

E
) Tricuspid stenosis

22. A 5-year-old boy is brought to the emergency department 30 minutes
after he fainted at home after standing up from a sitting position.
His symptoms began 3 days ago with diarrhea and vomiting. He has had
no urine output for 18 hours. He is alert but quiet. His temperature
is 37.5 C (99.5 F), blood pressure is 75/45 mm Hg, pulse is 120/min,
and respirations are 28/min. Examination shows dry lips and tenting of
the skin. There is no abdominal tenderness. Bowel sounds are
hyperactive. The remainder of the examination shows no abnormalities.
His capillary refill time is 5 seconds. Intravenous bolus doses of
0.9% saline are administered. Bladder catheterization yields 5 mL of
urine. Urinalysis is most likely to show which of the following?

A
) Blood

B
) Erythrocyte casts

C
) Hyaline casts

D
) Leukocyte casts

E
) Oxalate crystals

23.

A 2-year-old boy is brought to the physician because of fever and
cough for 2 days. He had Streptococcus pneumoniae meningitis at the
age of 1 year, S. pneumoniae bacteremia at the age of 18 months, and
pneumonia at the age of 22 months. Two maternal uncles died before the
age of 2 years from "infection." His temperature is 39.8 C (103.6 F),
pulse is 150/min, and respirations are 60/min. Examination shows
subcostal retractions on inspiration. Laboratory studies show:


Hemoglobin 10 g/dL
Leukocyte count 36,000/mm3
Segmented neutrophils 70%
Bands 20%
Lymphocytes 8%
Monocytes 2%
Platelet count 240,000/mm3
Serum
IgA <5 mg/dL
IgG 30 mg/dL
IgM <5 mg/dL

An x-ray film of the chest shows an infiltrate in the left upper lobe.
Which of the following is the most appropriate next step in
management?

A
) Reexamination in 12 weeks

B
) Prednisone therapy only

C
) Prednisone, vincristine, doxorubicin, asparaginase, and methotrexate therapy

D
) Zidovudine (AZT), lamivudine (3TC), and ritonavir therapy

E
) Intravenous immunoglobulin infusion

F
) Bone marrow transplantation

G
) Thymus transplantation

24.

A previously healthy 13-year-old girl is brought to the physician
because of a 2-month history of intermittent abdominal pain and loose
stools. She has had a 2.3-kg (5-lb) weight loss during this period due
to a decreased appetite, but she drinks up to 1 liter of fruit juice
daily. At her last visit 9 months ago, she was at the 50th percentile
for height and the 50th percentile for weight. She is now at the 50th
percentile for height and the 10th percentile for weight. Her
temperature is 37.8 C (100 F), pulse is 80/min, and respirations are
18/min. Examination shows no other abnormalities. Test of the stool
for occult blood is positive. Laboratory studies show:


Hemoglobin 8.5 g/dL
Leukocyte count 9100/mm3
Segmented neutrophils 55%
Lymphocytes 35%
Monocytes 10%
Platelet count 650,000/mm3
Erythrocyte sedimentation rate 75 mm/h

Serum

Na+ 139 mEq/L
Cl– 101 mEq/L
K+ 3.2 mEq/L
HCO3– 23 mEq/L
Urea nitrogen (BUN) 8 mg/dL
Glucose 73 mg/dL
Creatinine 0.2 mg/dL

A barium enema shows patches of ulcerations along the proximal colon
with reflux of dye into the terminal ileum. Which of the following is
the most appropriate next step in management?

A
) Eliminate fruit juice from the patient's diet

B
) Switch to a gluten-free diet

C
) H2- receptor blocking agent therapy

D
) Prednisone and aminosalicylate therapy

E
) Bowel resection

25. An asymptomatic 57-year-old man comes to the physician for a
routine health maintenance examination. He has smoked one pack of
cigarettes daily for 37 years. His blood pressure is 180/112 mm Hg,
and pulse is 82/min. Abdominal examination shows a bruit in the right
upper quadrant and no masses. His hematocrit is 42%, serum urea
nitrogen (BUN) level is 23 mg/dL, and serum creatinine level is 1.4
mg/dL. Which of the following is the most likely cause of this
patient's bruit?

A
) Accumulation of lipids in the arterial wall

B
) Hypertrophy of the arterial wall media

C
) Infiltration of arterial wall by giant cells

D
) Infiltration of round cells in the arterial wall

E
) Reflex vasodilation

26. An otherwise healthy 4-month-old girl is brought to the physician
because of a birthmark on her arm that has increased in size over the
past several weeks. Examination shows a 3 x 2-cm, bright red, raised,
soft, nontender, compressible patch over the left forearm. Which of
the following is the most appropriate next step in management?

A
) Topical corticosteroid therapy

B
) Biopsy

C
) Laser therapy

D
) Excision

E
) No intervention is necessary

27. A 7-year-old girl is brought to the physician in September because
of fever and sore throat for 1 day. She is in the third week of second
grade. Her temperature is 38.6 C (101.5 F). Examination shows an
erythematous pharynx and slightly enlarged tonsils without exudate.
There is no significant cervical lymphadenopathy. A rapid test for
group A streptococcus is negative. Which of the following is the most
appropriate next step in management?

A
) Monospot test

B
) Throat culture

C
) Intramuscular penicillin therapy

D
) Oral erythromycin therapy

E
) Oral penicillin therapy

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with weakness, select the most appropriate test to
establish the cause of the condition.


A
) Brain stem auditory evoked potentials

B
) Carotid ultrasonography

C
) Chromosomal analysis for trinucleotide repeat

D
) Electroencephalography

E
) Electromyography and nerve conduction studies

F
) MRI of the spine


G
) Muscle biopsy

H
) Repetitive nerve stimulation

I
) Somatosensory evoked potentials

J
) SPECT scan

K
) Temporal artery biopsy

L
) Visual evoked potentials

28. A 57-year-old man is brought to the emergency department 6 hours
after the onset of weakness of his right face, arm, and leg. Three
days ago, he had an episode of sudden visual loss in his left eye that
he describes as "a shade coming down." The episode resolved completely
within 10 minutes. He has hypertension and type 2 diabetes mellitus,
both poorly controlled with lisinopril and glyburide. Examination
shows expressive aphasia and right lower facial droop. There is
moderate weakness on the right, worse in the upper extremity than the
lower extremity. Deep tendon reflexes are 3+ in the right extremities
and 2+ in the left extremities. Babinski's sign is present on the
right. Sensory examination shows no abnormalities.

For each patient with weakness, select the most appropriate test to
establish the cause of the condition.


A
) Brain stem auditory evoked potentials

B
) Carotid ultrasonography

C
) Chromosomal analysis for trinucleotide repeat

D
) Electroencephalography

E
) Electromyography and nerve conduction studies

F
) MRI of the spine


G
) Muscle biopsy

H
) Repetitive nerve stimulation

I
) Somatosensory evoked potentials

J
) SPECT scan

K
) Temporal artery biopsy

L
) Visual evoked potentials

29. A previously healthy 27-year-old woman is brought to the emergency
department because of a 2-day history of weakness of her arms and legs
and numbness of her hands and feet and a 4-hour history of mild
shortness of breath while supine. The weakness began in her feet and
has progressed to involve the hands. She describes a sensation of
"electrical shocks" extending from the buttocks to the feet. Today,
she tripped and fell several times and was unable to button clothes or
hold utensils. Three weeks ago, she had a mild upper gastrointestinal
illness that resolved within 5 days. Her respirations are 20/min and
shallow. There is mild facial weakness; cranial nerves are otherwise
intact. Muscle strength in the upper and lower extremities is 4/5
proximally and 2/5 distally. There is areflexia. Babinski's sign is
absent bilaterally. Sensation to vibration is slightly decreased at
the fingers and toes.

30.

A 72-year-old man comes to the physician with his wife because of
chronic abdominal pain and headaches for 4 months. His wife states
that he has become more forgetful over the past 6 months. He has a
history of gout. He has smoked one pack of cigarettes daily for 50
years and drinks 10 oz of homemade whiskey daily. He takes no
medications. His temperature is 36.8 C (98.3 F), blood pressure is
160/98 mm Hg, pulse is 74/min, and respirations are 16/min. Neurologic
examination shows mild short-term memory loss and decreased sensation
to pinprick in the distal extremities. He has an ataxic gait. There
are gouty tophi on the dorsal aspect of the left elbow. Laboratory
studies show:


Hematocrit 33%
Mean corpuscular volume 70 μm3
Serum
Urea nitrogen (BUN) 17 mg/dL
Glucose 90 mg/dL
Creatinine 2 mg/dL
Uric acid 14 mg/dL

Which of the following is the most appropriate next step in management?

A
) Measurement of blood lead level

B
) Measurement of serum porphobilinogen level

C
) CT scan of the abdomen

D
) MRI of the brain

E
) Carbidopa-levodopa therapy

31. A county health officer investigates an outbreak of illness among
persons attending a church picnic. The illness is characterized by the
onset of nausea and vomiting 3 to 4 hours after attending the picnic.
All affected persons recover without specific therapy. The
investigation implicates egg salad as the vehicle of transmission.
This episode is consistent with a foodborne outbreak caused by which
of the following?

A
) Clostridium perfringens

B
) Giardia lamblia

C
) Salmonella species

D
) Staphylococcus aureus

32. A 62-year-old woman comes to the physician because of generalized
weakness for 2 weeks. She has a 20-year history of arthritis of the
hands treated with aspirin and acetaminophen. She had two episodes of
urinary tract infections 5 and 11 years ago, respectively. Examination
shows no abnormalities except for Heberden's nodes on the hands.
Laboratory studies show:

Erythrocyte sedimentation rate
15 mm/h
Serum

Na+
136 mEq/L
Cl–
100 mEq/L
K+
4.9 mEq/L
HCO3–
20 mEq/L
Urea nitrogen (BUN)
41 mg/dL
Creatinine
4 mg/dL
Urine

Protein
1+
WBC
2–4/hpf
RBC
none
Bacteria
none
Squamous epithelial cells
occasional
Granular casts
occasional

Renal ultrasonography shows no abnormalities. Which of the following
is most likely to have prevented this condition?

A
) Periodic PPD skin testing

B
) Screening for autoimmune causes of glomerulonephritis

C
) Periodic renal ultrasonography

D
) Avoidance of analgesics

E
) Suppressive antibiotic therapy for treatment of urinary tract infections

33. A 60-year-old man comes to the physician because of increasing
shortness of breath for 1 week; it occurs at rest and is exacerbated
by exertion. He has not had chest pain. He has smoked two packs of
cigarettes daily for 40 years. Between the ages of 18 and 30 years, he
worked in a warehouse with exposed bare insulation; for the past 15
years, he has driven a taxi. Medications include ipratropium bromide
and albuterol metered-dose inhalers. His temperature is 37 C (98.6 F),
blood pressure is 170/95 mm Hg, pulse is 100/min, and respirations are
24/min. Anterior and posterior diffuse wheezes are heard. Cardiac
examination shows no murmurs. There is mild pretibial edema. An x-ray
film of the chest shows calcified pleural plaques on the right
hemidiaphragm and a 2-cm pleural-based mass. With regard to the
findings on the x-ray film, which of the following is most likely to
have prevented this patient's condition?

A
) Appropriate immunizations

B
) Different occupation

C
) Different medications

D
) Hypertension screening

E
) Smoking cessation

34. A previously healthy 67-year-old man is admitted to the hospital
because of lethargy, confusion, muscle cramps, and decreased appetite
for 7 days. He appears ill. His temperature is 37 C (98.6 F), blood
pressure is 120/70 mm Hg, pulse is 98/min, and respirations are
20/min. Breath sounds are diminished at the right lung base.
Neurologic examination shows no abnormalities except for lethargy.
Serum studies show:

Na+
114 mEq/L
K+
4.3 mEq/L
Creatinine
1 mg/dL
Thyroid-stimulating hormone
4.1 μU/mL

An x-ray film of the chest shows a 2-cm nodule in the right lower lobe
and mediastinal adenopathy. A biopsy specimen of the nodule is most
likely to show which of the following?

A
) Adenocarcinoma

B
) Clear cell carcinoma

C
) Mesothelioma

D
) Small cell carcinoma

E
) Squamous cell carcinoma

35. A 62-year-old woman comes to the physician because of bloating and
cramping abdominal pain and intermittent diarrhea over the past 5
years. Her symptoms have increased over the past month since she
started a new diet that emphasizes yogurt and cottage cheese as
low-fat sources of calcium and protein. Vital signs are within normal
limits. Abdominal examination shows diffuse tenderness to palpation
with no rebound tenderness; there are no masses or organomegaly. Bowel
sounds are increased. Test of the stool for occult blood is negative.
Which of the following is the best explanation for this patient's
diarrhea?

A
) Impaired intestinal motility

B
) Inflammatory process

C
) Malabsorption

D
) Secretory process

36. A 52-year-old woman comes to the physician because of a 3-month
history of intermittent bloody discharge from the right breast. She
does not perform regular monthly breast self-examinations. She has a
3-year history of major depressive disorder treated with fluoxetine.
Examination of the breasts shows no abnormalities. No masses are noted
on palpation. Serosanguineous fluid can be expressed from the nipple
of the right breast by pressing on the left side of the areola. Which
of the following is the most likely diagnosis?

A
) Cystosarcoma phyllodes

B
) Fat necrosis

C
) Fibroadenoma

D
) Fibrocystic changes of the breast

E
) Galactorrhea

F
) Hyperprolactinemia

G
) Intraductal papilloma

H
) Mastitis

I
) Paget's disease of the breast

37. A 6-month-old girl is brought to the physician because of poor
feeding and labored breathing for 2 months. She has had recurrent
respiratory tract infections since birth. Examination shows a
to-and-fro murmur in the second left intercostal space, a loud S2,
bounding peripheral pulses, and a widened pulse pressure. Which of the
following is the most likely diagnosis?

A
) Atrial septal defect (ostium primum type)

B
) Atrial septal defect (ostium secundum type)

C
) Atrioventricular canal

D
) Coarctation of the aorta

E
) Hypoplastic left heart syndrome

F
) Patent ductus arteriosus

G
) Tetralogy of Fallot

H
) Transposition of the great arteries

I
) Tricuspid atresia

J
) Ventricular septal defect

38. A 70-year-old man comes to the physician because of urinary
hesitancy and frequency for 9 months. His temperature is 37.5 C (99.5
F). Examination shows a circumcised penis with no urethral discharge.
Testicular examination shows no abnormalities. Rectal examination
shows an enlarged rubbery prostate that is nontender to palpation.
Urinalysis shows many leukocytes and no erythrocytes. Gram's stain of
urine shows gram-negative rods. Which of the following is the most
likely cause of this patient's condition?

A
) Infection of the epididymis

B
) Infection of the prostate

C
) Infection of the urethra

D
) Neurogenic bladder

E
) Outflow obstruction of the bladder

39. A 32-year-old woman comes to the physician because of lethargy and
boredom since the birth of her son 5 months ago. She worries about her
ability to care for him and has had frequent palpitations. She is
unable to fall back asleep after nighttime feedings. She stopped
breast-feeding 1 month ago. Her son is healthy, and growth and
development are normal for his age. Her blood pressure is 122/80 mm
Hg, pulse is 58/min, and respirations are 18/min. Physical examination
shows no abnormalities. She remembers one out of three objects after 5
minutes. Her serum cholesterol level is 265 mg/dL. The most
appropriate next step in diagnosis is measurement of which of the
following serum levels?

A
) Cortisol

B
) Estrogen

C
) Progesterone

D
) Prolactin

E
) Thyroid-stimulating hormone

40. The genetic disease institute at a university hospital has
developed a rapid screening test for a serious but treatable inherited
metabolic disorder. Although this disorder is predominantly found in a
particular ethnic group, it is also found sporadically throughout the
entire population. The screening test has a sensitivity of 95% and a
specificity of 90%. When used in an ethnically prescreened population
where the prevalence of this disorder is 30%, the positive predictive
value is 80% and the negative predictive value is 96%. The institute
proposes to use this screening test on the general population where
the prevalence of this disease is 0.1%. Which of the following is the
most likely result of this screening program?

A
) Negative predictive value decreases

B
) Positive predictive value decreases

C
) Sensitivity decreases

D
) Specificity decreases

41. A 32-year-old woman comes to the physician because of a 1-year
history of increasingly severe dull pain in her lower back and
buttocks. She also has had morning stiffness of the lower back that
lasts for 1 to 2 hours. There is no history of trauma. Her job does
not require heavy lifting. Her blood pressure is 110/70 mm Hg, pulse
is 68/min and regular, and respirations are 16/min. Cardiopulmonary
examination shows no abnormalities. There is tenderness to palpation
over the sacroiliac joints bilaterally and decreased flexion and
extension of the lumbar spine. An x-ray film of the lumbosacral spine
shows sclerosis of the sacroiliac joints. Laboratory studies are most
likely to show which of the following findings in this patient?

A
) Decreased erythrocyte sedimentation rate

B
) Histocompatibility human leukocyte antigen B27

C
) Increased serum antinuclear antibody titer

D
) Increased serum carcinoembryonic antigen (CEA) level

E
) Positive serum rheumatoid factor

42. A 6-month-old boy is brought to the physician because of
respiratory distress for 1 day. He had a persistent dry cough 3 days
ago. He has not had a fever or nasal discharge, but he has had chronic
watery stools. He is at the 50th percentile for height and 10th
percentile for weight. He appears ill and is in respiratory distress.
His temperature is 37 C (98.6 F), pulse is 140/min, and respirations
are 78/min. Pulse oximetry shows an oxygen saturation of 70% while
breathing room air. Examination shows white plaques on the mucous
membranes of his mouth and diffuse adenopathy. There are intercostal
retractions, and diffuse crackles are heard throughout all lung
fields. In addition to oxygen and antibiotic therapy, which of the
following is the most appropriate next step in management?

A
) Stool culture for bacterial pathogens

B
) Urinalysis

C
) HIV testing

D
) Quantitative measurement of immunoglobulins

E
) Nitroblue tetrazolium testing

F
) Platelet morphology evaluation

G
) Tympanocentesis

43. A 42-year-old man is brought to the physician by his wife because
of a 2-month history of staring spells that last 1 to 2 minutes each.
During episodes, he also smacks his lips and picks at his shirt
collar. Four years ago, he was comatose for 2 weeks after sustaining a
head injury in a motorcycle collision; he required 6 months of
rehabilitation. He reports that, over the past year, he has had
intermittent episodes of smelling burnt rubber that occur
approximately every 2 weeks. He hears an intense hissing sound during
these episodes. Examination shows no abnormalities. Which of the
following is the most likely diagnosis?

A
) Absence seizures

B
) Complex partial seizures

C
) Transient ischemic attack

D
) Tourette's disorder

E
) Limbic encephalopathy

44.

A 47-year-old woman is admitted to the hospital for evaluation of a
2-week history of increased irritability and racing thoughts. Her
family reports that she argues with anyone who does not agree with
her. She has been talking incessantly at a rapid rate and pacing
around the house. She says that, for years, she has been hearing the
voice of God telling her that she has been chosen for a special
mission. She has barely slept for the past week, waiting to hear
further messages from God. She is disheveled and dehydrated. Serum
studies show:


Na+ 137 mEq/L
Cl– 96 mEq/L
K+ 3.8 mEq/L
HCO3– 22 mEq/L
Urea nitrogen (BUN) 30 mg/dL
Glucose 68 mg/dL
Creatinine 1.2 mg/dL

Mental status examination shows disorganized thoughts and flight of
ideas. She is agitated and has difficulty staying seated. She is too
distractible to perform cognitive tests. Toxicology screening is
negative. Which of the following is the most likely diagnosis?

A
) Acute renal failure

B
) Borderline personality disorder

C
) Diabetes insipidus

D
) Narcissistic personality disorder

E
) Schizoaffective disorder

F
) Schizoid personality disorder

45. A 20-year-old man comes for a routine health maintenance
examination. He has a 15-year history of difficulty relaxing his hands
after tightly gripping objects or after shaking hands. His father has
cataracts and frontal baldness. Examination shows thin forearms. There
is moderate weakness of the hands and difficulty releasing after
gripping with his hands. Which of the following is the most likely
diagnosis?

A
) Amyotrophic lateral sclerosis

B
) Cervical spondylosis

C
) Multiple sclerosis

D
) Myasthenia gravis

E
) Myasthenic (Lambert-Eaton) syndrome

F
) Myotonic muscular dystrophy

G
) Polymyalgia rheumatica

H
) Polymyositis

I
) Progressive neuropathic (peroneal) muscular atrophy

46. A 47-year-old man is admitted to the hospital after threatening to
harm a radio announcer he believed was broadcasting his thoughts. Over
the past 20 years, he has had multiple psychiatric hospitalizations
for threatening people who he believed were plotting against him,
trying to control his mind, or causing him to hear voices by
implanting devices in his head. Past symptoms improved with
neuroleptic therapy; after discharge, he discontinued the medication
and his symptoms worsened. Which of the following is the most
appropriate pharmacotherapy to decrease this patient's risk for future
hospitalization?

A
) Clozapine

B
) Fluphenazine hydrochloride

C
) Haloperidol decanoate

D
) Risperidone

E
) Trifluoperazine hydrochloride
___________________________________________________________________

Answers:

FORM1 block 1:
1) e 2) b 3) b 4) d 5) c 6) f 7) d 8) a 9) b 10) h 11) d 12) a 13) g?
14) a 15) f 16) c 17) c 18) f 19)e 20) d 21) b 22) d 23) d 24) e 25) d
26) d 27) a 28) a 29) b 30) d 31) e 32) b 33) b 34) a? 35) b 36) d 37)
e 38) e 39) e? 40) d 41) c 42) a 43) c 44) e 45) a 46) d

FORM 1 block 2

1) b 2) d 3) d 4) d 5) d 6) e 7) a 8) e 9) g 10) d 11) e 12) d 13) b
14) e 15) c 16) d 17) g 18) a 19)h 20) l 21) b 22) b 23) e 24) e 25) e
26) c 27) d 28) e 29) a 30) a 31) b 32) d 33) c 34) g 35) e 36) e 37)
d 38) d 39) d 40) e 41) d 42) d 43) b 44) b? 45) b 46) b

Form 1 block 3

1) f 2) c? 3) b 4) c 5) e 6) c 7) a 8) a? 9) a 10) d? 11) b 12) c 13)
a 14) e 15) d 16) b 17) b 18) g 19)i?? 20) c 21) c 22) d 23) a 24) c
25) c 26) c 27) a? 28) e 29) a? 30) b 31) e 32) g 33) b 34) b 35) a
36) d 37) f 38) b 39) b? 40) a? 41) d 42) e 43) e 44) d 45) b 46) g?

Form 1 block 4

1) H/M 2) e 3) d 4) d 5) d 6) g 7) f 8) p 9) b 10) h 11) h 12) h? 13)i
14) b? 15) b 16) d 17) d 18) e 19)c 20) b 21) a? 22) c 23) e 24) d 25)
a 26) e 27) a 28) b 29) e 30) a 31) d 32) d 33) b 34) d 35) c 36) g
37) f 38) e 39) e 40) b 41) b 42) c 43) b 44) e 45) f 46) c

More answers:


NBME FORM 1 ANSWERS
BLOCK 1
1- C
2 -B
3 -B
4- B
5 -C
6 -F
7- D
8 -B
9 -H
10 -
11-C / B ?
12- A
13- G
14 –C
15- F
16-C
17- B
18- F
19- E
20 –D
21- B
22-D / C ?
23-B
24-E
25-D
26-D
27-A
28-A
29-B
30- B
31- E / D
32-C
33-C
34-A
35-B
36-D
37-E
38-B
39-E
40-D
41-C
42-A
43-C
44-E
45-A
46-D

block 2
1-b
2-d?
3-a
4-d
5-d
6-e
7-f
8-e / next ? c
9-g??
10-c
11-e
12-d
13-B/ d??
14-e
15-c
16- D
17- G
18- E
19- H
20- K
21- B
22- B
23- E
24- E
25- E
26- C
27- B
28- E
29- A
30- A
31- A
32- C / D
33- B
34- F
35- E
36- E
37- D
38- D
39- D
40- E
41- D
42- D / E
43- B
44- B
45- B
46- B
BLOCK 3
1 F
2 C
3 B
4 B
5 E
6 C
7 A
8 C OR E ( if strept pyogens is the same as strept pneumonia then its E)
9 A
10 E
11 C
12 C
13 A
14 E
15 D
16.a
17.b?g?
18.g
19.a?c?
20.b?d?
21.c
22.a
23.a
24.c
25.a?b?
26.c
27.a?b?
28.e?g?
29.a
30.b
31 B
32 B
33 E
34 B
35 A
36 D
37 A
38 B (why such a low bp in this patient,)?
39 E
40 B
41 D
42 C
43 E
44 D
45 B
46 G

BLOCK 4
1-m
2-e
3-e
4-d
5-d
6-g
7-f
8-q
9-a
10-a
11-h
12-?a
13-c
14-?b
15-b
16-?c
17-c
18-e
19-?c
20-b
21-a
22-c
23-e
24-d
25-b
26-e
27-c
28-?b
29-e
30-a
31-d
32-d
33 e
34-d
35-c
36-g
37-f
38-e
39-e
40-b
41-b
42-c
43-e
44-e
45-i
46-a
 
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* Re:Pls any one send me NBME downloaded Qs
#1097561
  candace - 12/22/07 13:08
 
  NBME 3--answers not sure
BLOCK 1
1. A
2. B
3. A
4. A
5. A
6. D
7. C
8. C
9. E
10. C
11. D
12. D
13. F
14. D
15. B
16. E
17. C
18. D
19. A
20. A
21. D
22. I
23. A
24. E
25. C
26. E
27. B
28. C
29. C
30. F
31. D
32. E
33. C
34. A
35. E
36. I
37. A
38. A
39. E
40. B
41. D
42. E
43. A
44. C
45. D
46. B
BLOCK 2
1. E
2. B
3. F
4. D
5. B
6. C
7. E
8. C
9. E
10. B
11. A
12. B
13. A
14. A
15. A
16. C
17. E
18. B
19. C
20. I
21. N
22. B
23. B
24. M
25. L
26. O
27. D
28. B
29. E
30. E
31. D
32. E
33. D
34. A
35. C
36. D
37. B
38. C
39. C
40. K
41. B
42. G
43. A
44. B
45. A
46. B
BLOCK 3
1. C
2. E
3. A
4. E
5. C
6. E
7. D
8. C
9. D
10. E
11. A
12. B
13. F
14. F
15. E
16. E
17. B
18. B
19. C
20. B
21. C
22. D
23. E
24. E
25. B
26. A
27. B
28. D
29. B
30. D
31. A
32. E
33. B
34. E
35. B
36. B
37. A
38. F
39. D
40. D
41. C
42. C
43. H
44. B
45. A
46. D
BLOCK 4
1. D
2. B
3. C
4. E
5. B
6. D
7. A
8. B
9. D
10. C
11. E
12. E
13. F
14. A
15. C
16. A
17. A
18. B
19. B
20. E
21. E
22. D
23. E
24. A
25. A
26. C
27. C
28. B
29. B
30. A
31. D
32. D
33. A
34. B
35. B
36. D
37. M
38. G
39. C
40. C
41. A
42. D
43. A
44. E
45. B
46. A

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* Re:anybody have nbme3 answers
#1026799
coolamazon - 11/01/07 15:58

nb3 section1
1. A 12-year-old girl with chronic renal failure has had persistent
epistaxis for 15 days. Laboratory studies show:

Hemoglobin 7.2 g/dL
Platelet count 175,000/mm3
Bleeding time 12 min
Prothrombin time 12 sec
Partial thromboplastin time (activated) 30 sec
Serum urea nitrogen (BUN) 125 mg/dL

Which of the following is the most likely cause of the epistaxis?
O A) Acquired platelet dysfunction
O B) Circulating immune complexes
O C) Erythropoietin deficiency
O D) Factor III deficiency
O E) Hypocalcemia




Answer is A


2. A 57-year-old woman comes to the physician because of depressed
mood and daily crying episodes since the death of her father 6 weeks
ago. She has had difficulty concentrating, decreased libido, and a
3.2-kg (7-Ib) weight loss during this period. She is less interested
in her usual activities but continues to work productively. She sleeps
for about 8 to 10 hours every night. Over the past 2 weeks, she has
been smoking and drinking more frequently, she now smokes one-half
pack of cigarettes daily and drinks two to three glasses of wine every
other day. She has no history of serious illness and takes no
medications. She is 163 cm (5 ft 4 in) tall and weighs 80 kg (176 Ib),
BMI is 30 kg/m2. Her temperature is 37°C (98.6°F), pulse is 641min,
and blood pressure is 108160 mm Hg. The remainder of the examination
shows no abnormalities. Mental status examination shows a sad mood and
restricted affect. Her speech is normal in rate and rhythm. There is
no evidence of suicidal ideation or hallucinations. She can recall
three of three objects after 5 minutes. Long-term memory is intact.
Which of the following is the most likely diagnosis?

O A) Alcohol dependence
O B) Bereavement
O C) Bipolar disorder
O D) Cyclothymic disorder
O E) Dysthymic disorder
O F) Major depressive disorder
O G) Malingering


Answer is B

3. An 80-year-old man is brought to the emergency department on an
80-degree day 2 hours after a syncopal episode while playing golf. He
plays golf twice weekly. An ECG obtained at his last examination 6
months ago showed occasional premature ventricular contractions
(PVCs). On arrival, his temperature is 38°C (100.4°F), blood pressure
is 150/90 mm Hg, pulse is 80/min and regular, and respirations are
22/min. Cardiac examination shows a grade 3/6, late-peaking systolic
ejection murmur. No bruits are heard over the carotid arteries, but
the upstrokes are delayed. Which of the following is the most likely
cause of the syncope?

O A) Aortic stenosis
O B) Heat stroke
O C) Hypertensive cardiomyopathy
O D) Platelet emboli
0 E) PVCs




ANSWER AAAA

4. Five days after sustaining a 6-cm laceration through the skin and
subcutaneous tissue of the left upper extremity with a clean knife, a
52-year-old man has increasing tenderness in the area of the
laceration. Treatment at the time of injury included cleansing and
dressing of the wound. The wound is now erythematous, and yellow pus
is expressed when pressure is applied. Which of the following is the
most likely mechanism for the accumulation of pus?
O A) Chemotaxis
O B) Dysplasia
O C) Hyperoxia
O D) Metaplasia
0 E) Vasoconstriction


ANSWER AAAA

5. Twenty-four hours after splenectomy for blunt trauma sustained in a
motor vehicle collision, a previously healthy 25-year-old man has
oliguria and pain at the incision site. Intraoperative complications
included a 30-minute period of hypotension and a total blood loss of
2.5 L requiring 4 units of packed red blood cells. Currently, his
temperature is 38°C (100.4°F), blood pressure is 120180 mm Hg, pulse
is 1001min, and respirations are 14/min. Central venous pressure is 8
cm H 2O (N=5-8). The lungs are clear to auscultation, and breath
sounds are heard bilaterally. Abdominal examination shows no
distention, bowel sounds are absent. A Foley catheter is in place, and
over the past 3 hours, his urine output has been 20 mL/h. Laboratory
studies show a hematocrit of 28%, a serum urea nitrogen (BUN) level of
30 mg1dL, and a serum creatinine level of 2.5 mgfdL, serum electrolyte
levels are within normal limits. Which of the following is the most
likely explanation for these findings?
O A) Acute tubular necrosis
O B) Foley catheter malfunction
O C) Hypervolemia
O D) Transfusion reaction
0 E) Ureteral injury



ANSWER AAAA

6. A 32-year-old man comes to the physician for a second opinion
regarding an enlarged cervical lymph node that he noted 6 weeks ago.
He has not had pain or tenderness but has been unable to return to
work despite normal findings on a biopsy of the node 4 weeks ago. He
had a mild upper respiratory tract infection 1 month ago. His maternal
uncle recently died of lymphoma. He states that cancer runs in his
family, and that for the past several years he has thought that he
will have some kind of cancer eventually. Which of the following is
the most likely diagnosis?
O A) Asthma
O B) Conversion disorder
O C) Factitious disorder
O D) Hypochondriasis
O E) Malingering
O F) Pulmonary embolus
0 G) Somatization disorder


ANSWER DDDD

7. A 32-year-old woman, gravida 3, para 2, at 40 weeks' gestation is
admitted to the hospital in labor. Vaginal and anal cultures at 36
weeks' gestation were positive for group B streptococcus. She has no
known drug allergies. Which of the following is the most appropriate
pharmacotherapy for this patient before delivery?
O A) Intravenous azithromycin
O B) Intravenous clindamycin
O C) Intravenous penicillin
O D) Oral amoxicillin and clavulanate
O E) Oral erythromycin
O F) No treatment until after delivery



Ccccccc


8. A 38-year-old woman comes to the physician because of a low-grade
fever and generalized rash for 4 days. She is currently receiving
cefazolin therapy for chronic osteomyelitis. Her temperature is 38.2°C
(100.8°F), blood pressure is 1501108 mm Hg, and pulse is 1001min.
There is a faint diffuse maculopapular rash. Examination of the back
shows no costovertebral angle tenderness. Cardiac and pulmonary
examinations show no abnormalities. Laboratory studies show:

Leukocyte count 10,8001mm3
Segmented neutrophils 60%
Bands 8%
Eosinophils 4%
Lymphocytes 20%
Monocytes 8%

Serum
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1.6 mg/dL
Urine
WBC 121hpf
RBC 81hpf
RBC casts none
WBC casts rare

Eosinophils are found in the urine sediment. Which of the following is
the most likely explanation for these findings?

O A) Acute tubular necrosis
O B) Fibromuscular dysplasia
O C) Interstitial nephropathy
O D) Polyarteritis nodosa
O E) Pyelonephritis
O F) Wegener's granulomatosis


Ccccccccccccccccc

9. A healthy 60-year-old woman comes to the physician for a routine
examination. She has no history of illness over the past year and has
never had an operation. She takes no medications. Menopause occurred 6
years ago. She weighs 57 kg (125 lb) and is 160 cm (63 in) tall.
Pelvic examination shows atrophic external genitalia and a small,
midpositioned uterus. The left ovary is 3 x 3 cm, the right ovary is
not palpable. Which of the following is the most appropriate next step
in management?

O A) Reexamination in 1 month
O B) Reexamination in 1 year
O C) Obtain patient's medical records
O D) Measurement of serum progesterone level
O E) Pelvic ultrasonography


Eeeeeeeeeeeeeeeeeeeeee


10. On the fifth day of a 7-day cruise in the western Caribbean, a
37-year-old woman develops headaches, fever, chills, abdominal
discomfort, and watery diarrhea over a 12-hour period. Many other
passengers and crew members have had similar symptoms. Her temperature
is 37°C (98.6°F). Abdominal examination shows diffuse tenderness
without rebound, bowel sounds are hyperactive. Her leukocyte count is
11,000/mm3. Gram's stain of a stool specimen shows a small number of
neutrophils. A stool culture grows Salmonella enteritidis. Two days
after treatment with bismuth subsalicylate and oral rehydration, her
symptoms subside. Which of the following is the most appropriate
immediate measure to prevent further spread of this pathogen?

O A) Cancellation of shore leave for all crew members
O B) Elimination of seafood and shellfish from the ship's menu
O C) Exclusive use of pasteurized eggs
O D) Hyperchlorination of the ship's drinking water
O E) Reassignment of all food-handling personnel to other duties
O F) Treatment of all affected persons with doxycycline


CCCCCCCCCCCCCCCCCC

11. A 57-year-old man with a 10-year history of type 2 diabetes
mellitus comes to the physician fora routine examination. His last
office visit was 6 months ago. He feels well. Current medications
include enalapril and glyburide. He is 168 cm (5 ft 6 in) tall and
weighs 84 kg (185 Ib), BMI is 30 kg/mZ. His pulse is 60/min, and blood
pressure is 100/70 mm Hg. Funduscopic examination shows soft and hard
exudates. Laboratory studies show
Hemoglobin Al. 12%
Serum
Urea nitrogen (BUN) 23 mg/dL
Creatinine 1.4 mg/dL
Urine protein 1+
Which of the following is the most appropriate additional pharmacotherapy?

O A) Atenolol
O B) Captopril
O C) Hydrochlorothiazide
O D) Metformin
0 E) Verapamil



DDDDDDDDDDDDDDDDDDDDD

12. An 82-year-old man is brought to the physician by his neighbors
because he looks ill." They say that he subsists primarily on hot dogs
and canned meats and that his slovenly habits have attracted rats to
the neighborhood. He does not drink alcohol but is forgetful.
Examination shows a pleasant, dirty, confused man who appears thin. He
has diffuse purpura on his legs and perifollicular inflammation. Which
of the following is the most likely cause of these findings?
O A) Aplastic anemia
O B) Leukemia
O C) Rat-bite fever
O D) Scurvy
O E) Warfarin ingestion



DDDDDDDDDDDDDDDDDDD

13. A 6-month-old girl is brought to the physician because of fever,
cough, and coryza for 1 day. Her pulse is 1001min, and respirations
are 501min. Her cough is harsh and sounds like a dog's bark. There is
inspiratory stridor and intercostal retractions. Which of the
following is the most likely diagnosis?
O A) Asthma
O B) Bacterial tracheitis
O C) Bronchiolitis
O D) Foreign body in the small airways
O E) Foreign body in the trachea
O F) Laryngotracheobronchitis
O G) Pneumonia
O H) Pneumothorax
0 I) Pulmonary edema


Laryngotracheobronchitis===CROUP

FFFFFFFFFFFFFFFFFFFF


14. An 80-year-old man has had poor balance for 6 months. He has a
history of hypertension treated with hydrochlorothiazide. His blood
pressure is 136/86 mm Hg. Neurologic examination shows mild tremor of
the hands when his arms are outstretched and decreased
vibratory sensation at the knees. Deep tendon reflexes of the
quadriceps and gastrocnemius-soleus muscles are hyperactive.
Babinski's sign is present bilaterally. He is unable to stand with his
eyes closed. Which of the following is most consistent with normal
age-related changes?

O A) Babinski's sign
O B) Hyperactive deep tendon reflexes of the gastrocnemius-soleus muscles
O C) Inability to stand with the eyes closed
O D) Reduced vibratory sensation at the knees
0 E) Tremor of the outstretched hands



Should be ddddddd


15. A previously healthy 6-month-old boy is brought to the physician
because of a 12-hour history of vomiting and diarrhea. He vomits after
all feedings, the vomitus does not contain blood or bile. His mother
says that he has had fewer wet diapers than usual during this period.
He appears dehydrated and is crying without tears. He is at the 50th
percentile for length and 30th percentile for weight. He appears
lethargic. His temperature is 38°C (100.4°F), pulse is 180/min, and
blood pressure is 60/40 mm Hg. Examination shows sunken eyes, dry
mucous membranes, and a sunken anterior fontanel. Arterial blood gas
analysis on room air shows:
pH 7.2
PCO2 38 mm Hg
PO2 90 mm Hg

Which of the following is the most likely explanation for this
patient's arterial blood gas findings?
O A) Excessive metabolic acid formation
O B) Impaired ventilation
O C) Increased chloride loss (àincrease HCO3 which is not the case here)
O D) Increased CO2 concentration in the extracellular fluid
0 E) Increased metabolic acid produced by the gastrointestinal tract



AA,?? hypovolumic septic shock-à hypoperfusion to organs-àlactiic acidodis



16. A 42-year-old man is brought to the emergency department because
of a 2-day history of muscle spasms and jaw stiffness. He is sexually
active with three partners and uses condoms inconsistently. He has a
5-year history of intravenous heroin use. He appears irritable. His
temperature is 38.8°C (101.8°F), pulse is 120/min, and blood pressure
is 152/96 mm Hg. Physical examination shows facial and paraspinal
muscle spasms and rigidity; stimulation of the muscles results in
paroxysmal spasms. Mobility of the jaw is decreased. Neurologic
examination shows hyperreflexia. Which of the following is most likely
to have prevented this condition?
O A) Consistent condom use
O B) Botulism antitoxin therapy
O C) Prednisone therapy
O D) Rifampin therapy
O E) Tetanus toxoid vaccination
0 F) Vitamin B1 (thiamine) supplementation


I chose EEE

17. A 72-year-old woman comes to the physician because of increasing
episodes of urinary incontinence over the past 6 months. Her
incontinence usually occurs at night, she feels no sensation to
urinate prior to the episodes. The episodes are less frequent if she
schedules her trips to the bathroom and restricts liquid intake
several hours prior to bedtime. She has a 20-year history of type 2
diabetes mellitus. Current medications include metformin and
glyburide. Funduscopic examination shows mild retinopathy. Pelvic
examination shows normal vaginal mucosa. Sensation to pinprick is
decreased in a stocking-glove distribution. Urinalysis shows 1 +
protein and no leukocyte esterase or nitrites. Which of the following
is the most likely cause of this patient's urinary symptoms?

O A) Functional incontinence
O B) Hypersensitivity of the detrusor muscle
O C) Overflow of urine from large residual volumes
O D) Urethral atrophywith loss of urethrovesical angle
O E) Normal aging


I chose CCC

18. An afebrile 2-year-old boy has had right ear pain for 3 days. He
has been swimming everyday for the past week. Purulent fluid is
draining from the right external ear canal, and manipulation of the
pinna is painful. No abnormalities are noted on visualization of
tympanic membranes. Which of the following is the most likely causal
organism?
O A) Haemophilus influenzae type b
O B) Moraxella catarrhalis
O C) Pasteurella multocida
O D) Pseudomonas aeruginosa
O E) Streptococcus pneumoniae


I chose DDD

19. Over the past 2 weeks, a 60-year-old man has had shortness of
breath on exertion. He also has paroxysmal nocturnal dyspnea with
two-pillow orthopnea. He has taken aspirin daily since a myocardial
infarction 3 years ago. He has a history of atrial fibrillation well
controlled with digoxin and type 2 diabetes mellitus treated with
diet. His blood pressure is 136188 mm Hg, pulse is 98/min and
irregular, and respirations are 20/min. Jugular-venous pressure is
increased. Breath sounds are decreased over the right lung base..
there is dullness to percussion. Cardiac examination shows an S.
gallop. There is 2+ edema of the lower extremities. Pulse oximetry
shows an oxygen saturation of 90%. Which of the following is the most
appropriate next step in diagnosis?
O A) X-ray film of the chest
O B) Ambulatory ECG monitoring
O C) Thallium stress test
O D) Echocardiography
O E) Ventilation-perfusion lung scans


Ddddddd


20. A 47-year-old woman comes to the emergency department because of
severe abdominal pain for 3 hours. The pain began after a 2-week
drinking binge. She has a 15-year history of alcoholism. She has no
history of jaundice or hepatitis. Current medications include
multivitamins and iron. Her temperature is 38°C (100.4°F), blood
pressure is 110/80 mm Hg, and pulse is 110/min. Examination shows mild
jaundice and diffuse spider angiomata over the trunk and abdomen. The
liver is tender to palpation. A complete blood count shows mild anemia
with normal red cell indices. Ultrasonography of the abdomen shows
normal-sized hepatic ducts. Which of the following is the most likely
set of laboratory findings?

Total Indirect Alkaline
Bilirubin Bilirubin Phosphatase Reticulocyte
(mg/dL) (mg/dL) (U/L) (ALT, GPT) (U/L) Count (%)
O A) 2 0.9 80 30 1.2
O B) 3 2.8 70 30 1.0
O C) 3 2.8 80 20 3.0
O D) 4 2.0 800 200 1.5
O E) 4 1.0 150 400 1.0


AAAAAAAAAAAAAAAAAAAAAAAAA
(Mixed hyperbilirubinemia due to alcohol damage to the liver)

21. A 3-month-old boy is brought to the physician in January because
of difficulty breathing, clear nasal discharge, and cough for 24
hours. His temperature is 37.6°C (99.6°F), blood pressure is 88/54 mm
Hg, pulse is 168/min, and respirations are 60/min. Bilateral wheezing,
prolonged expiration, and a grade 2/6 systolic murmur along the left
sternal border are heard. The liver is palpated 3 cm below the right
costal margin. An x-ray film of the chest shows bilateral
hyperinflation and no cardiomegaly. Which of the following is the most
likely diagnosis?
O A) Adenovirus pneumonia
O B) Congestive heart failure
O C) Influenza A virus pneumonia
O D) Respiratory syncytial viral bronchiolitis
O E) Staphylococcal pneumonia
0 F) Status asthmaticus


DDDDDDDDDDDDDDDDD

22. A 22-year-old woman comes to the physician because of diffuse
constant headaches and vision problems for 3 months, the headaches are
worse in the morning when she awakens from sleep. She also has had
brief episodes of loss of vision in both eyes. She has had an 18-kg
(40-Ib) weight gain over the past year. She now weighs 100 kg (220 lb)
and is 163 cm (64 in) tall. Visual acuity is 20/30 bilaterally. Visual
fields are full, but the blind spots are enlarged bilaterally.
Funduscopic examination shows marked blurring of the optic disc
margins bilaterally. The remainder of the neurologic examination shows
no abnormalities. Which of the following is the most likely diagnosis?
O A) Amaurosis fugax
O B) Central retinal vein occlusion
O C) Glaucoma
O D) Macular degeneration
O E) Migraine
O F) Nutritional optic neuropathy
O G) Optic neuritis
O H) Pituitary adenoma
O I) Pseudotumor cerebri
0 J) Temporal arteritis


Answer should be IIIII



23

AAAAAAAAAAAAAAAAAA




24. A 49-year-old man has had progressive shortness of breath over the
past year. He now has dyspnea after walking up one flight of stairs.
He has fine crackles bilaterally on auscultation of the lungs.
Spirometry shows:

Vital capacity (VC) decreased
FEV1 decreased
Ratio of FEV, to VC increased

Arterial blood gas analysis on room air:
pH 7.42
PCO2 60 mm Hg
PO2 34 mm Hg

Which of the following is the most likely diagnosis?
0 A) Asthma
p B) Bronchiectasis
o C) Chronic bronchitis
p D) Emphysema
p E) Pulmonary fibrosis



EEEEEEEEEEEEEEEEEEEEEEEE


25. A previously healthy 24-year-old woman, gravida 3, para 3, is
brought to the emergency department because of deep, sharp,
intermittently severe pain in the left lower quadrant of the abdomen
for 2 hours. Her last menstrual period was 3 weeks ago. She takes no
medications. She is in obvious distress and is lying on her left side
with her lower extremities drawn up against her abdomen. Her
temperature is 37°C (98.6°F), blood pressure is 140/70 mm Hg, and
pulse is 125/min. Abdominal examination shows rigidity and tenderness.
Pelvic examination shows a 12-cm mass in the left lower quadrant of
the abdomen. Which of the following is the most appropriate next step
in management?

O A) Ultrasound-guided aspiration
O B) Dilatation and curettage
O C) Exploratory laparotomy
O D) Hysterectomy



CCCCCCCCCCCCCCCCCCCCCCCCCCC




26. Fourteen hours after admission to the hospital for treatment of
severe hypertension, a 32-year-old woman has stridor. On admission,
she was given captopril. She appears anxious. Her blood pressure is
140/85 mm Hg, pulse is 140/min, and respirations are 32/min.
Examination shows swelling of the lips and tongue. Diffuse stridorous
wheezes are heard on auscultation. There is diminished air movement.
Which of the following is the most appropriate next step in
management?

p A) Observation only
p B) Measurement of serum captopril level
O C) Measurement of serum IgE level
o D) X-ray film of the chest
0 E) Tracheal intubation


EEEEEEEEEEEEEEEEEEEEEEEE

27. A 65-year-old woman has had progressive irritability,
palpitations, and heat intolerance for 6 months. She has had a 7-kg
(15-Ib) weight loss during this period. She has had a neck mass for
more than 10 years. 1311 scan shows an enlarged thyroid gland with
multiple areas of increased and decreased uptake. Which of the
following is the most likely diagnosis?
O A) Graves' disease
O B) Multinodular goiter
O C) Thyroiditis
O D) Toxic adenoma
0 E) Triiodothyronine (T3) thyrotoxicosis



BBBBBBBBBBBBBBBBBBBBBBB

For each patient with chronic knee pain, select the most appropriate
next step in management.

C A) Anterior cruciate ligament reconstruction
C B) Arthroscopic partial meniscectomy
C C) Quadriceps strengthening exercises
C D) Sympathetic blockade
C E) Total knee replacement
C F) Upper tibial osteotomy


CCCCCCCCCCCCCCCCCCCCCCCCCCCCCC


30. A 70-year-old man comes to the physician because of knee pain that
has been present for 10 years. He is unable to comfortably walk
further than one block and has difficulty sleeping because of the
pain. He has pain on both medial and lateral sides of the knee. Range
of motion is from 15 to 100 degrees, there is a bowleg deformity when
he stands.

EEEEEEEEEEEEEEE

31. A 55-year-old man with alcoholic cirrhosis is hospitalized for 2
weeks in April for treatment of gastrointestinal bleeding. His last
immunization for diphtheria-tetanus (Td) was 6 years ago. Which of the
following is the most appropriate management prior to discharge?

O A) Administration of immune globulin
O B) Inactivated poliovirus vaccine
O C) Influenza virus vaccine
O D) Pneumococcal vaccine
0 E) Td toxoids

DDD


32. One week after cholecystectomy for acute cholecystitis, a
57-year-old woman comes to the physician because of a 1-day history of
abdominal cramps and watery, green, foul-smelling diarrhea. She
finished a 7-day course of cefoxitin 3 days ago. She appears
dehydrated. Her temperature is 39.8°C (103.6°F), pulse is 115/min, and
blood pressure is 105/70 mm Hg. Abdominal examination shows moderate
distention and diffuse tenderness, there is no guarding. Test of the
stool for occult blood is positive, the stool contains leukocytes. Her
hemoglobin level is 10.8 g/dL, and leukocyte count is 39,000/mm3. The
patient is admitted to the hospital, and administration of intravenous
fluids is begun. Which of the following is the most appropriate next
step in pharmacotherapy?
O A) Intravenous amphotericin
O B) Intravenous ampicillin, clindamycin, and gentamicin
O C) Intravenous corticosteroids
O D) Oral diphenoxylate and atropine
0 E) Oral metronidazole



EEEEEEEEEEEEEEEEEEE



A picture here


33. A 32-year-old comes to the physician because of painless growths
around her anal region that she first noticed 4 months ago. Over the
past 10 years, she has had sexual intercourse with multiple partners.
She has a 4-year history of Crohn's disease. Medications include
sulfasalazine and metronidazole. Her father has psoriasis. A
photograph of the lesions is shown. Examination shows no other
abnormalities. Which of the following is the greatest risk factor for
this condition?
O A) Crohn's disease
O B) Family history of psoriasis
O C) Multiple sexual partners
O D) Treatment with metronidazole
0 E) Treatment with sulfasalazine


CCCCCCCCCCCCCCCCCCCCCC



The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with dysphagia, select the most likely diagnosis.

O A)Achalasia
O B)Adenocarcinoma of the esophagus
O C)Candidal esophagitis
O D) Diffuse esophageal spasm
O E) Polymyositis
0 F)Refluxesophagitis
0 G)Scleroderma (systemic sclerosis)
0 H)Squamous cell carcinoma of the esophagus
0 I)Viral esophagitis


34. A 42-year-old man with an 8-year history of intermittent
difficulty swallowing solids and liquids has had increasingly severe
exacerbations because of stress over the past 6 months. He also has
nocturnal regurgitation and cough. Esophageal motility studies show
failure of relaxation of the lower esophageal sphincter.


AAAAAAAAAAAAAAA


For each patient with dysphagia, select the most likely diagnosis.

• A) Achalasia 0 F)Refluxesophagitis
Q B) Adenocarcinoma of the esophagus 0 G)Scleroderma (systemic sclerosis)
p C) Candidal esophagitis 0 H)Squamous cell carcinoma of the esophagus
p D) Diffuse esophageal spasm 0 I)Viral esophagitis
0 E) Polymyositis


35. A 45-year-old woman has had generalized weakness for 1 year,
increasing difficulty walking up stairs over the past 6 months, and
difficulty swallowing for 1 month. Examination shows weakness of the
proximal muscles of the extremities. Ear, nose, and throat
examinations and manometry show decreased contractions of the pharynx
with decreased upper esophageal tone.

EEEEEEEEEEEEEEEE


36. A 42-year-old man with hypertension is brought to the emergency
department 1 hour after the onset of chest discomfort, severe
headache, irritability, and confusion. His blood pressure is 2201148
mm Hg. Examination shows papilledema. Urinalysis shows blood. An ECG
shows ischemic changes with left ventricular hypertrophy. A CT scan of
the head shows no abnormalities. Which of the following is the most
appropriate pharmacotherapy?

O A) Atenolol
O B) Captopril
O C) Diltiazem
O D) Furosemide
O E) Guanethidine
O F) Hydralazine
O G) Losartan
O H) Methyldopa
O I) Nitroprusside
O J) Prazosin
0 K) Thiazide diuretic


IIIIIIIIIIIIIIIIIIII


37. A 2-year-old girl is found floating facedown in a swimming pool.
On rescue, she immediately coughs and breathes spontaneously. She is
conscious and oriented. Without treatment, which of the following is
the most likely outcome for this child?
A) Complete recovery
B) Development of acute respiratory distress syndrome
C) Hemolysis
D) Pulmonary hypertension
E) Severe neurologic deficit


AAAAAAAAAAAAAAAAAAAAAAAAAAA


38. A 25-year-old woman has had daily cough and wheezing for 4 months.
She has had difficulty sleeping because of her symptoms. Inspiratory
and expiratory wheezes are heard with a slightly prolonged exhalation
phase. Rz Adrenergic agonist therapy by inhalation is begun. She is
still mildly symptomatic during the day with bronchospastic episodes
occurring three times weekly at night. Which of the following
medications should be added to the regimen?
O A) Inhaled glucocorticoids
O B) Inhaled ipratropium
O C) Oral erythromycin
O D) Oral furosemide
0 E) Oral theophylline

AAAAAAAAAAAAAAAAAAAAAAAAA

39. Five years after being shot in the right thigh, a 21-year-old man
comes to the emergency department because of a busing sensation
adjacent to the scar. At the time of the initial wound, he was
discharged after 6 hours of observation with no fractures or
soft-tissue
swelling. A loud murmur is heard on auscultation, there is a thrill.
He has dilated varicose veins with incompetent valves in the lower
leg. Which of the following is the most likely diagnosis?
O A) Arterial spasm
O B) Arteriovenous fistula
O C) Deep venous thrombosis
O D) Occlusion of the superficial femoral artery
O E) Pseudoaneurysm

bbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbbb


40. A study is conducted to investigate the prevalence of past
infection with genital herpes among students attending a large
coeducational Midwestern university. After obtaining informed consent,
the study participants undergo antibody testing for herpes simplex
virus 2 (HSV). Which of the following is the most important factor in
determining the validity of a positive test?

A) The number of sexual partners of the student
B) The proportion of students infected with HSV
C) The proportion of students with negative tests
D) The proportion of students with positive tests
E) The total number of students screened


BBBBBBBBBBBBBBBBB MY ANSWER

41. During a routine examination, a 20-year-old man is found to have a
firm, bilaterally enlarged thyroid gland and lymphadenopathy. His
father died of thyroid cancer at the age of 40 years. Which of the
following hormones is most likely associated with this patient's
findings?
O A) ACTH
O B) ADH (vasopressin)
O C) Aldosterone
O D) Calcitonin
O E) Growth hormone
O F) G3-hCG
O G) Insulin
O H) Parathyroid hormone
O I) Thyroid-stimulating hormone
0 J) Thyroxine (T4)


DDDDDDDDDDDDDDDDDDDDDDDDD

42. Twelve days after sustaining a cerebral infarction, a 72-year-old
man has fever and cough. Initial symptoms included inability to move
his right arm and leg, swallow, speak, or respond to questions. He has
been receiving a diet of pureed foods since he recovered his ability
to swallow 3 days ago. He is wearing false teeth. His temperature now
is 38.8°C (101.8°F), blood pressure is 135/85 mm Hg, pulse is 94/min,
and respirations are 28/min. Examination shows moderate weakness of
the facial muscles and right extremities. Gag reflex is absent. Breath
sounds are decreased, and there is dullness to percussion over the
right lung base posteriorly. An x-ray film of the chest shows an
infiltrate in the posterior basal segment of the right lung. Which of
the following is most likely to prevent recurrence of this patient's
lung condition?
O A) Removal of false teeth
O B) Suppression of gastric acid production
O C) Chronic antibiotic prophylaxis
O D) Administration of metoclopramide to increase gastrointestinal motility
O E) Insertion of a feeding jejunostomy tube

Should be AAAAAAA


43. A previously healthy 72-year-old man is brought to the physician
because of two episodes of transient paresis in the left arm during
the past 2 days; each episode lasted for 3 to 4 minutes. No bruits are
heard over the carotid arteries, and there are no cardiac murmurs.
Carotid duplex ultrasonography and confirmatory arteriography show a
30% stenosis of the internal carotid arteries bilaterally. Which of
the following is the most appropriate next step in management?
A) Aspirin therapy
B) Heparin therapy
C) Nifedipine therapy
D) Placement of a carotid endovascular stent
E) Carotid endarterectomy


AAAAAAAAAAAAAAAAAA


44. A 35-year-old man with a 10-year history of persistent
hallucinations and delusions comes for a follow-up examination. He has
been treated with haloperidol, chlorpromazine, and fluphenazine with
minimal relief of symptoms. He is currently taking haloperidol. On
examination, he walks slowly with no arm swing and has no facial
movements. Which of the following is the most likely cause of his
motor behavior?
O A) Excess limbic y-aminobutyric acid activity
O B) Increased serum prolactin level
O C) Nigrostriatal dopamine blockade
O D) Noradrenergic depletion in the frontal lobe
O E) Ventral tegmental dopamine blockade

CCCCCCCCCCCCCCCCCCCCCC


45. An 82-year-old woman comes to the physician because of a 2-month
history of progressive shortness of breath with exertion and a 3-week
history of right upper quadrant abdominal discomfort. She has chronic
obstructive pulmonary disease, hypertension, and
rheumatoid arthritis. Medications include methotrexate,
hydrochlorothiazide, naproxen, albuterol metered-dose inhaler, and
aspirin. Examination shows pallor. Breath sounds are decreased. The
liver is enlarged, firm, and mildly tender. Test of the stool for
occult blood is positive. Her hematocrit is 27%, and mean corpuscular
volume is 76 pm3. A CT scan of the abdomen shows multiple hypodense
lesions in the liver. Which of the following is the most likely
diagnosis?
O A) Cholangiocarcinoma
O B) Hepatocellular carcinoma
O C) Lymphoma
O D) Metastatic colon cancer
O E) Metastatic lung cancer
O F) Metastatic pancreatic cancer

DDDDDDDDDDDDDDDDDDDDDDDDD

46. On routine health maintenance examination, a 23-year-old man has a
systolic murmur. There is no family history of heart disease. His
blood pressure is 110170 mm Hg, and pulse is 601min. Cardiac
examination shows a point of maximal impulse in the fifth intercostal
space at the midclavicular line, there is a normal S1 and a split,
fixed S2. A grade 216, systolic ejection murmur is heard at the left
sternal border, there is no change with inspiration, Valsalva's
maneuver, or hand grip. An exercise stress test shows no
abnormalities. Which of the following is the most likely cause of this
patient's cardiac murmur?
O A) Aortic stenosis
O B) Atrial septal defect
O C) Hypertrophic cardiomyopathy
O D) Mitral valve prolapse
O E) Ventricular septal defect


BBBBBBBBBBBBBBBBBBBBBBBBBB


nbme3 sec2
#223301
quansar - 09/25/07 00:43

here you go the section 2, I will work on the sec3/4 in next few days




1. For the past 10 years, a 28-year-old woman has followed a strict
diet that prohibits dairy products, meat, fish, and fowl. On routine
examination, her hematocrit is 30%, and mean corpuscular volume is 122
pm3. Which of the following is the most
appropriate next step in diagnosis?

O A) Erythrocyte folate determination
O B) Serum iron and total iron-binding capacity determinations
O C) Serum thyroid hormone determination
O D) Serum urea nitrogen (BUN) determination
O E) Serum vitamin B12 (cyanocobalamin) determination

EEEEEEEEEEEEEEE


2. A 47-year-old man comes to the physician because of a persistent
nonproductive cough for 3 months. He has not had fever, rhinorrhea, or
nasal congestion. He was seen by a physician 3 months ago for the
cough and treated with amoxicillin and an over-the-counter cough
medication. He has a 3-month history of hypertension well controlled
with lisinopril. He is in no distress. He weighs 79 kg (175 lb) and is
178 cm (70 in) tall. His temperature is 37.1°C (98.8°F), blood
pressure is 130178 mm Hg, pulse is 721min and regular, and
respirations are 161min. Examination shows no abnormalities. A
complete blood count and x-ray films of the chest show no
abnormalities. Which of the following is the most appropriate next
step in management?

O A) X-ray films of the sinuses
O B) Discontinue lisinopril therapy
O Q Add a beclomethasone inhaler to the medication regimen
O D) Add ciprofloxacin to the medication regimen
O E) Add hydrocodone to the medication regimen


BBBBBBBBBBBBBBBBBBBBB

3. A 12-year-old girl is brought to the physician by her mother
because she is concerned about her daughter's difficulty making
friends and socializing. Her development and adjustment had been
normal until 6 months ago when she began to refuse to use restrooms at
school or eat in the cafeteria. Her mother describes her as a quiet,
serious child who does not readily interact with other people. Her
teachers report that her concentration varies. at times, she appears
to be daydreaming. On examination, she is reserved but pleasant and
appears to be of normal intelligence. Her speech is normal in rate and
rhythm. She says that she is concerned that her voice will fail her if
she has to read aloud in class. Which of the following is the most
likely diagnosis?

O A) Attention-deficitthyperactivity disorder, inattentive type
O B) Autistic disorder
O C) Expressive language disorder
O D) Oppositional defiant disorder
O E) Selective mutism
O F) Social phobia
O G) Age-appropriate behavior

FFFFFFFFFFFFFFFFFF



A picture here for q4

4. A 25-year-old woman is brought to the emergency department 45
minutes after being hit in the right eye with a tennis ball. She has
severe pain and decreased vision in the injured eye. Visual acuity is
201400 on the right. A photograph of the eye is shown. Which of the
following is the most likely diagnosis?
O A) Acute angle-closure glaucoma
O B) Anterior iritis
O C) Cataract
O D) Hyphema
O E) Hypopyon

DDDDDDDDDDDDDDD

5. A 44-year-old woman is brought to the emergency department 40
minutes after being stabbed in the left groin. Her blood pressure is
128/84 mm Hg, pulse is 100/min, and respirations are 16/min.
Examination of the wound shows a small hematoma and no external
bleeding. Popliteal and pedal pulses are palpable in the left lower
extremity below the injury. Lacerations of the femoral artery and vein
are found and repaired. Two days postoperatively, she has
progressively severe pain of the left lower extremity and swelling of
the leg from the knee down. Which of the following is the most likely
cause of her new symptoms?

O A) Arterial embolism
O B) Compartment syndrome
O C) Lymphatic disruption from the injury
O D) Thrombosis of the femoral vein
0 E) Wound hemorrhage

BBBBBBBBBBBBBB


6. The crude mortality rate for coronary artery disease in Community A
is twice the crude mortality rate for coronary artery disease in
Community B. The age-standardized mortality rates for coronary artery
disease in the two communities are the same. These findings are most
consistent with which of the following inferences?

A) Coronary artery disease mortality in the elderly is higher in
Community A than Community B
B) Coronary artery disease mortality in young adults is higher in
Community A than Community B
C) The population of Community B is younger than the population of Community A
D) The proportionate mortality from coronary artery disease is higher
in Community A than Community B
E) The two communities have similar age distributions

CCCCCCCCCCCCCC

7. An otherwise healthy 28-year-old man comes to the physician because
of a dry hacking cough for 3 months. A routine examination 6 months
ago showed no abnormalities. His paternal grandfather had colon
cancer. Examination today shows normal findings. An x-ray film of the
chest shows a large anterior mediastinal mass. Which of the following
is the most likely origin of this neoplasm?
O A) Colon
O B) Kidney
O C) Prostate
O D) Stomach
0 E) Testicle

EEEEEEEEEEEEEEEEEE

A testis tumor may become metastatic and manifest with large
retroperitoneal and/or chest lesions, while the primary tumor is
nonpalpable. Scrotal ultrasonography may locate the primary tumor.
Histopathology of the primary testis often shows a focus of tumor
surrounded by fibrous scar, termed burned-out testis cancer.

8. A 50-year-old man has a cardiac arrest during sexual intercourse.
He is promptly resuscitated and recovers uneventfully from an acute
anterior wall myocardial infarction. At discharge from the hospital,
he and his wife inquire about the safety of future sexual intercourse.
Which of the following is the most appropriate advice?
O A) Psychiatric consultation is necessary
O B) Sexual intercourse should be performed while wearing an
ambulatory ECG monitor
O C) Sexual intercourse will be safe when exercise tolerance improves
O D) They should wait 3 months before having sexual intercourse
O E) They should have sexual intercourse as soon as possible to
overcome the fear of another event



CCCCCCCCCCCCCCCCCC



9. A 68-year-old woman with terminal metastatic breast cancer is
living at home with her son. She has a living will requesting that she
be allowed to "die in peace." She is unresponsive to voice and has not
had any food or liquids for 3 days. Her son disagrees with her
decision not to accept further therapy, including chemotherapy,
antibiotics, hospitalization, and enteral or parenteral nutrition.
Which of the following is the most appropriate next step in
management?
p A) Abide by the decisions of the next of kin
p B) Obtain a court order to allow additional therapy to be given
O C) Start enteral feedings
p D) Admit her to the hospital
0 E) No further intervention


EEEEEEEEEEEEEEEEEEE


10. A 57-year-old woman comes to the physician for a follow-up
examination. She has a 5-year history of hypercalcemia, which was
diagnosed with routine laboratory studies, and her serum calcium
levels have ranged from 10.8 mg/dL to 11.5 mg/dL. She declined further
evaluation in the past because she "felt well." She takes no
medications. Her last menstrual period was 7 years ago. She maintains
a weight of 67 kg (148 lb) and is 170 cm (67 in) tall, BMI is 23
kg/m2. Her blood pressure is 126/80 mm Hg, and pulse is 66/min.
Examination shows no abnormalities. Which of the following is the most
appropriate next step to assess her risk for fracture?

O A) 24-Hour urine collection for measurement of collagen cross-links excretion
O B) Bone densitometry
O C) Bone-specific measurement of serum alkaline phosphatase activity
O D) Posteroanterior and lateral x-ray films of the thoracic spine and hips
O E) Biopsy of the iliac crest


BBBBBBBBBBBBBBBBBBBBBBB



11. A 30-year-old woman, gravida 4, para 3, is admitted to the
hospital in labor at 38 weeks' gestation. The cervix is 4 cm dilated.
Contractions occur every4 minutes. The fundal height is 40 cm. The
membranes are intact. The fetal lie cannot be determined by abdominal
examination, and no presenting part is palpable in the pelvis. Which
of the following is the most appropriate next step in management?

O A) Ultrasonography
O B) Administration of oxytocin
O C) Administration of tocolytic drugs
O D) Amniotomy
O E) Cesarean delivery


AAAAAAAAAAAAAAAAA


12. Six days after undergoing a laparoscopic cholecystectomy for acute
cholecystitis, a 35-year-old woman comes to the physician because of
fever and abdominal pain for 3 days. She is jaundiced. Her temperature
is 38°C (100.4°F). Abdominal examination shows distention and
incisions that are healing normally. Leukocyte count is 12,000/mm3,
and total serum bilirubin level is 7.9 mg/dL. Which of the following
is the most likely cause of the jaundice?

O A) Anesthetic-related hepatitis
O B) Common bile duct injury
O C) Fulminant hepatic failure
O D) Reaction to perioperative antibiotics
O E) Subhepatic abscess

BBBBBBBBBBBBB


13. A 9-year-old boy is brought to the physician because of
progressive weakness and a purple-red discoloration over his cheeks
and upper eyelids over the past 8 weeks. His symptoms began shortly
after a camping trip, and he now is unable to climb stairs, walk long
distances, comb his hair, or dress himself. His mother says that she
was careful to apply his sunscreen on the trip and can recall no tick
bites or exposure to poisonous plants. His only medication is a
topical corticosteroid for several dry, scaly patches of the skin. He
appears weak and lethargic. He is at the 75th percentile for height
and 25th percentile for weight, he has had no change in his weight
since his last examination 9 months ago. His temperature is 37.7°C
(99.8°F), blood pressure is 110/68 mm Hg, pulse is 105/min, and
respirations are 28/min. Examination of the skin shows a purple-red
discoloration over the cheeks and eyelids, periorbital edema,
erythematous plaques and scales over the elbows and knees, and
flat-topped red papules over all knuckles. There is generalized
weakness and atrophy of the proximal muscles. Which of the following
is the most likely diagnosis2

O A) Dermatomyositis
O B) Duchenne's muscular dystrophy
O C) Eczema
O D) Lyme disease
O E) Psoriasis
O F) Rocky Mountain spotted fever
O G) Seborrhea
0 H) Systemic lupus erythematosus


AAAAAAAAAAAAAAAA

14. An 82-year-old man is brought to the emergency department because
of the sudden onset of confusion 48 hours ago. His family says that he
previously had been functional and independent. His temperature is
37.5°C (99.5°F), blood pressure is 110/70 mm Hg, pulse is 90/min, and
respirations are 12/min. The skin is warm and clammy. Bowel sounds are
hypoactive, and there is guarding and tenderness in the right lower
quadrant of the abdomen. Examination of the heart, lungs, and
extremities shows no abnormalities. He is drowsy but arousable and
oriented to person but not place or time. There are no focal deficits.
Which of the following is the most likely
diagnosis?
O A) Appendicitis
O B) Colon cancer
O C) Meningitis
O D) Pneumonia
0 E) Urinary tract infection

AAAAAAAAAAAAAAAA

15. Two hours after emergency cholecystectomy, a 48-year-old woman has
an oxygen saturation of 84% and a PO2 of 56 mm Hg on 2 Lfmin of oxygen
via nasal cannula. Her blood pressure is 120180 mm Hg, and
respirations are 16/min. Decreased breath sounds are heard on the
right, and there is decreased excursion on inspiration bilaterally.
There is minimal dullness over the right base. Examination shows no
jugular venous distention or pedal edema. An x-ray film of the chest
shows increased density over the right lower lung field, the tracheal,
mediastinal, and cardiac silhouettes are shifted to the right. The
right lung field appears considerably smaller than the left lung
field. Which of the following is the most likely cause of these
findings?
O A) Atelectasis
O B) Pleural effusion
O C) Pneumonia
O D) Pneumothorax
0 E) Pulmonary embolism

AAAAAAAAAAAA



16. A 47-year-old man comes to the physician because of low-grade
fever and malaise for 3 months. He was infected with hepatitis B 25
years ago. He appears well nourished but ill. His temperature is
37.7°C (99.8°F), blood pressure is 110170 mm Hg, pulse is 801min, and
respirations are 121min. Examination shows slight jaundice and
hepatomegaly. The spleen is not palpable, and there is no ascites or
dependent edema. Serum studies show:

Total bilirubin 3 mg1dL
Alkaline phosphatase 160 U!L
Aspartate aminotransferase (AST, GOT) 230 U!L
Alanine aminotransferase (ALT, GPT) 275 U!L

Serum a-fetoprotein level is markedly increased. Ultrasonography of
the right upper quadrant of the abdomen shows a 5-cm, solid lesion in
the right lobe of the liver. Biopsy is most likely to show which of
the following?
O A) Focal nodular hyperplasia
O B) Hepatic adenoma
O C) Hepatocellular carcinoma
O D) Metastatic adenocarcinoma
0 E) Regenerating liver nodule


CCCCCCCCCCCCCCCCCC



17. A previously healthy 30-year-old woman has had a painless lump in
her neck for 2 days. Her mother was treated for a thyroid tumor at the
age of 35 years. Her 28-year-old sister has an increased serum
calcitonin level but no thyroid mass. Examination shows a palpable
thyroid nodule. Her serum calcitonin level is increased. Which of the
following diagnoses should be excluded prior to surgical treatment of
the thyroid gland?
O A) Adrenocortical carcinoma
O B) Lung carcinoma
O C) Ovarian carcinoma
O D) Parathyroid carcinoma
O E) Pheochromocytoma

EEEEEEEEEEEEEEEEEEEEE



18. A 67-year-old man comes to the physician because of a 1-month
history of shortness of breath with exertion, easy fatigability, and
mild ankle swelling. Five years ago, he underwent successful
chemotherapy with doxorubicin for lymphoma. Moist crackles are heard
throughout both lungs. An S3 is heard. The liver edge is palpated 4 cm
below the right costal margin. There is 2+ pitting edema of the
pretibial region, ankles, and feet. Which of the following is the most
likely underlying cause of this patient's symptoms?
O A) Aortic sclerosis
O B) Cardiotoxicity
O C) Cirrhosis
O D) Mediastinal obstruction
0 E) Pneumonitis

BBBBBBBBBBBBBBBBBBBB

The response options for the next two items are the same. You will be
required to select one answer for each item in the set.

For each patient with vaginal bleeding during pregnancy, select the
most likely diagnosis.

O A)Abortion of a blighted twin
O B)Cervicitis
O C)Ectopic pregnancy
O D)Focal decidual necrosis
O E) Gestational trophoblastic disease
0 F) Incomplete abortion
0 G) Ovarian torsion
0 H) Ruptured ovarian cyst
0 I) Threatened abortion


19. A 23-year-old woman, gravida 2, para 0, has had vaginal spotting
and abdominal cramps for 2 days. Her last menstrual period was 8 weeks
ago. A home pregnancy test was positive 2 weeks ago. She underwent a
salpingectomy4 years ago following an ectopic pregnancy. Examination
shows a closed cervix, an enlarged uterus, and no adnexal masses.
Transvaginal ultrasonography shows an empty uterus. Serum 3-hCG level
is 8000 mIU1mL.

CCCCCCCCCCCCCCCC

For each patient with vaginal bleeding during pregnancy, select the
most likely diagnosis.

C A) Abortion of a blighted twin 0 F) Incomplete abortion
C B) Cervicitis ) Ovarian torsion
0 C) Ectopic pregnancy H) Ruptured ovarian cyst
0 D) Focal decidual necrosis I) Threatened abortion
0 E) Gestational trophoblastic disease


20. A 25-year-old woman has had painless vaginal postcoital bleeding
for 2 hours. Her last menstrual period was 10 weeks ago. A pregnancy
test is positive. There is a small amount of dark blood in the vaginal
canal. She has a reddened, friable cervical os.


IIIIIIIIIIIIIIIIIIIIIIII



21. A previously healthy 62-year-old man comes to the physician
because of a 1-year history of numbness and weakness of the right
hand. He is a carpenter and has no history of injury to his hand.
Examination shows wasting of muscle mass in the first web space.
Sensation to touch is decreased along the ring and little fingers.
There is weakness of abduction and adduction of the fingers. Which of
the following is the most likely site of nerve injury?
O A) Axillary nerve
O B) Long thoracic nerve
O C) Median nerve above the elbow
O D) Median nerve at the elbow
O E) Median nerve at the wrist
O F) Musculocutaneous nerve above the elbow O G) Musculocutaneous
nerve at the elbow
O H) Musculocutaneous nerve at the wrist
O I) Radial nerve above the elbow
O J) Radial nerve at the elbow
O K) Radial nerve at the wrist
O L) Suprascapular nerve
O M) Thoracodorsal nerve
0 N) Ulnar nerve at the elbow

NNNNNNNNNNNNNNNNNNNNN

22. A 45-year-old man comes to the physician for a follow-up visit. He
has had recurrent ulcer disease for 8 years, his symptoms are
currently relieved with antacid therapy. He had one episode of
bleeding 1 year ago that required a blood transfusion. He appears
pale. His hemoglobin level is 10.6 g/dL, mean corpuscular volume is 78
pm3, and reticulocyte count is 0.8%. Which of the following additional
laboratory findings is most likely?

Serum Iron Iron-binding Capacity (TIBC) Saturation of Serum Ferritin
(pg/dL) (pg/dL) (N=250-400) TIBC (%) (ng/mL)
O A) 30 120 25 50
O B) 40 360 11 10
O C) 60 180 33 80
O D) 80 200 40 120
0 E) 100 150 67 600

BBBBBBBBBBBBBBB




23. A 6-year-old girl is brought to the physician because of a 1-day
history of vomiting, headache, and weakness. One month ago, she
underwent resection of an astrocytoma and placement of a
ventriculoatrial shunt for residual hydrocephalus, her postoperative
course had been uncomplicated. Currently, she is drowsy and irritable.
Her temperature is 37.5°C (99.5°F), blood pressure is 126/54 mm Hg,
pulse is 82/min, and respirations are 24/min. Funduscopic examination
shows papilledema. Reflexes are brisk with hypertonia in the lower
extremities.

Which of the following is the most likely underlying mechanism for
these symptoms?

O A) Carcinomatous infiltration of cerebrospinal fluid
O B) Malfunction of ventriculoatrial shunt
O C) Overproduction of cerebrospinal fluid from a choroid plexus papilloma
O D) Recurrence and extension of the astrocytoma
O E) Thrombosis of the superior sagittal sinus



BBBBBBBBBBBB

The response options for the next three items are the same. You will
be required to select one answer for each item in the set.

For each patient with a respiratory problem, select the most
appropriate next step in management.

O A)Administration of BCG vaccine
O B)Administration of an inhaled bronchodilator
O C)Administration of oxygen
O D)Arterial blood gas analysis
O E)Bronchoscopy
O F)Culture of the pharynx for bacteria
O G)Direct laryngoscopy
O H) Gastric washings for acid-fast bacteria
O I) Intravenous infusion of saline
O J) Isoniazid and rifampin therapy O K) Lumbar puncture
O L) Measurement of serum aspirin level
O M) Subcutaneous administration of epinephrine.
N) Viral culture of respiratory secretions
00) X-ray films of the chest
O P) X-ray films of the neck


24. A previously healthy 8-year-old boy is brought to the emergency
department because of swelling of the lips and difficulty breathing
for 20 minutes. The symptoms began when he was helping his father
clean the gutters on their house. He appears anxious. His temperature
is 37.2°C (99°F), pulse is 1201min, and respirations are 50/min. Pulse
oximetry shows an oxygen saturation of 96%. His lips and eyes appear
puffy. He has subcostal and intercostal retractions. Auscultation of
the chest shows diffuse bilateral wheezing.


MMMMMMMMMMMMMMMMMM



For each patient with a respiratory problem, select the most
appropriate next step in management.

O A)Administration of BCG vaccine 0 I) Intravenous infusion of saline
O B)Administration of an inhaled bronchodilator O J) Isoniazid and
rifampin therapy
Oc)Administration of oxygen O K) Lumbar puncture
O D)Arterial blood gas analysis O L) Measurement of serum aspirin level
O E)Bronchoscopy O M) Subcutaneous administration of epinephrine
O F)Culture of the pharynx for bacteria O N) Viral culture of
respiratory secretions
O G)Direct laryngoscopy 00) X-ray films of the chest
O H)Gastric washings for acid-fast bacteria O P) X-ray films of the neck


25. A 16-year-old girl is brought to the emergency department because
of heavy breathing for 8 hours, and vomiting and ringing in the ears
for 1 hour. She recently broke up with her boyfriend and has been
threatening to hurt herself. She appears somnolent but is arousable
and answers questions appropriately. Her temperature is 37.5°C
(99.5°F), pulse is 88/min, and respirations are 50/min. Pulse oximetry
shows an oxygen saturation of 96%. She has no retractions, nasal
flaring, or cough. The lungs are clear to auscultation.


L) Measurement of serum aspirin level



For each patient with a respiratory problem, select the most
appropriate next step in management.

0 A)Administration of BCG vaccine 0 I) Intravenous infusion of saline
0 B)Administration of an inhaled bronchodilator 0 J) Isoniazid and
rifampin therapy
0 C)Administration of oxygen 0 K) Lumbar puncture
0 D)Arterial blood gas analysis O L) Measurement of serum aspirin level
0 E)Bronchoscopy 0 M) Subcutaneous administration of epinephrine
0 F)Culture of the pharynx for bacteria 0 N) Viral culture of
respiratory secretions
O G)Direct laryngoscopy O) X-ray films of the chest
O H)Gastric washings for acid-fast bacteria 0 P) X-ray films of the neck


26. A previously healthy 6-year-old boy is brought to the physician
for a follow-up examination after a PPD skin test produced an
induration greater than 15 mm. He has had no cough or fever. He has a
good appetite and is at the 50th percentile for height and weight. He
appears well. His temperature is 37.2°C (99°F), pulse is 88/min, and
respirations are 18/min. The lungs are clear to
auscultation.

OOOOOOOOOOOOOOOOOOOO



27. A 25-year-old nulligravid woman comes to the emergency department
because of severe pain in the right lower quadrant of the abdomen for
4 hours. She has had no nausea, vomiting, fever, or chills. Three
weeks ago, a right adnexal mass was found on routine examination. Her
last menstrual period was 3 days ago. Her temperature is 37.2°C
(99°F), blood pressure is 110/70 mm Hg, and pulse is 92/min. Pelvic
examination shows right adnexal tenderness. Hemoglobin level is 13
g/dL, and leukocyte count is 9000/mm3. Pelvic ultrasonography shows a
small amount of free fluid in the cul-de-sac. Which of the following
is the most likely cause of the pain?
O A) Appendicitis
O B) Endometriosis
O C) Ovarian hemorrhage
O D) Ruptured ovarian cyst
O E) Torsion of the adnexa
0 F) Tubal obstruction

DDDDDDDDDDDDDDDDDDDDD

28. A 15-year-old boy comes to the physician because of acne over his
face for 1 year. He prefers not to use any oral medications.
Examination shows 10 to 15 pustules. Which of the following is the
most effective treatment for this patient's symptoms?

p A) Avoidance of chocolate, fatty foods, and caffeine
p B) Use of benzoyl peroxide soap
O C) Vigorous scrubbing of affected areas
p D) Application of vitamin A and vitamin E to affected areas
p E) Ultraviolet light therapy

BBBBBBBBBBBBBBBBBBBBBBBBBB


29. A 3-year-old boy with acute lymphoblastic leukemia has had fever
for 3 days. He completed his last course of chemotherapy 6 days ago.
He has had no malaise, rash, or anorexia and has had no known contact
with sick children in preschool. He appears well. His temperature is
38.6°C (101.5°F), blood pressure is 75160 mm Hg, pulse is 100/min, and
respirations are 22/min. Examination shows normal findings. Laboratory
studies show:
Hemoglobin 10.1 g/dL (N=11.5-15.5)
Leukocyte count 2200/mm3
Segmented neutrophils 5%
Bands 1%
Lymphocytes 65%
Atypical lymphocytes 11%
Monocytes 18%
Platelet count 35,000/mm3

Which of the following is the most appropriate next step in management?

O A) Schedule a follow-up visit and discharge without medication
O B) Observe him in the office for 3 hours, discharge without
medication if examination remains unchanged
O C) Discharge him with oral broad-spectrum antibiotic therapy
O D) Admit him to the hospital for observation
O E) Admit him to the hospital for intravenous broad-spectrum antibiotic therapy

EEEEEEEEEEEEEEEEEEEEEE



30. A 72-year-old woman is brought to the emergency department 1 hour
after the sudden onset of right facial droop and weakness of the right
arm and leg. She takes captopril for hypertension and daily aspirin.
Her blood pressure is 150/90 mm Hg, pulse is 80/min, and respirations
are 161min. Examination shows a left carotid bruit and right central
facial paralysis. There is moderate expressive aphasia. A CT scan of
the head shows no abnormalities. Which of the following is the most
appropriate initial pharmacotherapy?
O A) Oral ticlopidine
O B) Oral warfarin
O C) Sublingual nifedipine
O D) Intravenous nitroprusside
O E) Intravenous tissue plasminogen activator




EEEEEEEEEEEEEEEEEEEEEE/




31. A previously healthy 37-year-old woman comes to the physician
because of a 3-month history of episodes of severe anxiety, shortness
of breath, palpitations, and numbness in her hands and feet. Her vital
signs are within normal limits. Physical examination shows no
abnormalities. Thyroid function studies and an ECG show no
abnormalities. Which of the following is the most appropriate
pharmacotherapy?
A) Lithium carbonate
B) Methylphenidate
O C) Olanzapine
p D) Paroxetine
0 E) Valproic acid

DDDDDDDDDDDDDD



32. A 37-year-old nulligravid woman comes to the physician because she
has not been able to conceive for 2 years. Her 40-year-old husband has
a child by a previous marriage. Her last menstrual period was 6 weeks
ago, menses have occurred at increasingly infrequent intervals over
the past year. Fifteen years ago, she was treated for one episode of
Chlamydia trachomatis infection. She weighs 59 kg (130 lb) and is 170
cm (67 in) tall. Examination shows no abnormalities. Serum studies
show:

R-hCG <5 mlUfmL
Follicle-stimulating hormone 50 mlU1mL
Luteinizing hormone 45 mlUfmL
Prolactin 13 ngfmL
Thyroid-stimulating hormone 3 pU/mL

Which of the following is the most likely cause of this patient's infertility?

O A) Hypothalamic amenorrhea
O B) Hypothyroidism
O C) Pituitary adenoma
O D) Polycystic ovarian disease
O E) Premature ovarian failure
0 F) Tubal factor


EEEEEEEEEEEEEEEEE

33. A 47-year-old woman comes to the physician because of a 2-day
history of fever and joint pain. Six days ago, she completed a 10-day
course of dicloxacillin for folliculitis. She appears comfortable. Her
temperature is 38.6°C (101.5°E), pulse is 721min and regular,
respirations are 161min, and blood pressure is 120176 mm Hg.
Examination shows an urticarial rash over the trunk and extremities.
There is moderate generalized lymphadenopathy and diffuse joint
tenderness. The remainder of the examination shows no abnormalities.
Which of the following is the most likely cause of these symptoms?
O A) Epstein-Barr virus infection
O B) IgE-mediated allergic reaction
O C) Mycobacterium haemophilum infection
O D) Serum sickness
0 E) Staphylococcal sepsis

· DDDDDDDDDDDDDDDDDDDD


34. A 34-year-old man is brought to the emergency department by his
family because of a decreased need for sleep, increased goal-directed
activity, increasingly irritable and unstable mood, and
uncharacteristic sexual promiscuity over the past week. Yesterday, he
quit his long-standing job at a hardware store and plans to move to
Washington, DC, to become the "Senator-in-Chief." He says that this
position is being created especially for him by the president. He
believes that he has developed supersensitive hearing and is now able
to hear conversations of people hundreds of miles away. He has no
history of drug use, and there is no personal or family history of
psychiatric illness. On examination, he is extremely irritable and
agitated, threatening to "punch out anyone who tries to mess with me."
Which of the following is the most likely diagnosis?
O A) Bipolar disorder
O B) Cyclothymic disorder
O C) Delusional disorder
O D) Schizophrenia
O E) Schizophreniform disorder

AAAAAAAAAAAAAAAAAAAAAAAA

.


35. A 17-year-old girl has had flu-like symptoms, low-grade fever, and
malaise for 3 days and mild jaundice for 2 days. Serum studies show an
aspartate aminotransferase (AST, GOT) activity of 670 UIL and an
alanine aminotransferase (ALT. GPT) activity of 860 U/L. Serum IgM
antibody to hepatitis A is positive. Which of the following is most
likely to minimize the risk for this disease in family members?
O A) Acyclovir therapy for family members
O B) Hepatitis B vaccination for family members
O C) Immune globulin therapy for family members
OD) Interferon alfa-2b therapy for family members
0 E) Use of separate toilet facilities by the patient

CCCCCCCCCCCCCCCCC


36. One day after missing her dialysis treatment, a 27-year-old woman
comes to the physician because of generalized weakness. Her blood
pressure is 95172 mm Hg, and pulse is 45/min and regular. Examination
shows a well-functioning arteriovenous fistula in the left upper
extremity. Muscle strength is 315 in all extremities. An ECG shows
third-degree atrioventricular block. Laboratory studies are ordered.
Which of the following is the most appropriate next step in
management?
O A) Kayexalate-sorbitol enema
O B) Intravenous administration of calcium gluconate
O C) Oral administration of sodium polystyrene sulfonate (Kayexalate)
O D) Immediate placement of a pacemaker
O E) No treatment pending laboratory results


DDDDDDDDDDDDDDDDDD

37. A previously healthy 2-year-old boy is brought to the physician
because of fever and abdominal pain for 24 hours. His developmental
milestones are appropriate for age. He is fully alert and responsive.
His temperature is 38.6°C (101.5°F), blood pressure is 85/60 mm Hg,
pulse is 1001min, and respirations are 20/min. Examination shows
suprapubic tenderness to deep palpation but no guarding or rebound.
There are no palpable abdominal masses or costovertebral angle
tenderness. The penis is circumcised, there is no urethral discharge.
Urinalysis shows 20-30 leukocytes/hpf, 5-6 erythrocytes/hpf, and
nitrites. A urine culture grows 100,000 colonies/mL of Escherichia
coli sensitive to all tested antibiotics. Amoxicillin therapy is
initiated. Five days later, he is afebrile and asymptomatic.
Ultrasonography of the kidneys shows no abnormalities. Which of the
following is the most appropriate next step in management?

O A) Discontinue the antibiotic in 2 days and reexamine only if symptoms recur
O B) Voiding cystourethrography
O C) Intravenous pyelography
O D) Cystoscopy
O E) No further testing


BBBBBBBBBBBBBBBBBBBBBBB

38. A 62-year-old woman comes to the physician because of increasingly
severe low back pain over the past month. Prolonged periods of rest
have not relieved her symptoms. Sensorimotor examination of the lower
extremities shows no abnormalities. Her hematocrit is 32%, and serum
calcium level is 12 mgfdL. An x-ray film of the chest shows no
abnormalities. An x-ray film of the spine is shown. Which of the
following is the most likely diagnosis?
O A) Herniated nucleus pulposus
O B) Mechanical low back pain
O C) Metastatic carcinoma
O D) Osteopetrosis
0 E) Spinal stenosis


ccccccccccccccccc


39. A 43-year-old man comes to the physician for evaluation and
management of cardiac risk factors 8 weeks after sustaining a
myocardial infarction. He takes aspirin and metoprolol daily, and he
does not smoke cigarettes. His father and brother both had myocardial
infarctions before the age of 50 years, their serum cholesterol levels
are unknown. There is no family history of diabetes mellitus. He
weighs 86 kg (190 lb) and is 180 cm (71 in) tall. His blood pressure
is 130170 mm Hg, pulse is 68/min, and respirations are 14/min. Two
years ago, his serum cholesterol level was 245 mg/dL. Fasting serum
glucose level is 88 mg/dL. Which of the following is the most
appropriate next step to evaluate his cardiac risk factors?


O A) Random measurements of serum cholesterol level
O B) Measurement of fasting serum cholesterol level only
O C) Fasting serum lipid studies only
O D) Oral glucose tolerance test and fasting serum lipid studies
O E) Oral glucose tolerance test and measurement of fasting serum
cholesterol level

CCCCCCCCCCCCCCCCCCCC



40. A 47-year-old man comes to the physician because of a 3-week
history of increasing facial swelling and a 1-week history of morning
headaches and mild shortness of breath. He had previously felt well.
He completed a course of chemotherapy 4 months ago for small cell
carcinoma of the lung. His temperature is 37.2°C (98.9°F), blood
pressure is 142180 mm Hg with an 8-mm Hg paradoxical pulse, pulse is
84/min, and respirations are 18/min. Examination shows significant
diffuse facial and periorbital edema. The optic discs are sharp, and
ocular movements are intact. The lungs are hyperresonant bilaterally
with a moderately prolonged expiratory phase. Mild rhonchi are heard
on inspiration and expiration. An x-ray film of the chest shows a
10-cm mass in the right upper lobe and apex. Which
of the following is the most likely explanation for these findings?
O A) Chemotherapy-induced bone marrow toxicity
O B) Chemotherapy-related cardiac toxicity
O C) Hypercoagulable state secondary to malignancy
O D) Interstitial metastatic pulmonary disease
O E) Intracranial metastases
O F) Lymphatic obstruction
O G) Malignant pericarditis
O H) Paraneoplastic syndrome
O I) Pleural metastases
O J) Soft tissue metastases
0 K) Vascular obstruction


KKKKKKKKKKKKKKKKK


41. A 13-month-old girl is brought for a well-child examination. There
is no history of prenatal or perinatal problems. Her diet consists of
breast milk, juice, legumes, cooked vegetables, and fruit. She has had
three ear infections treated successfully with amoxicillin and two
episodes of diarrhea since birth. She will pull to a stand and stand
alone for 1 minute but has not begun to walk. She is able to pick up
raisins with her thumb and forefinger but is unable to feed herself
with a spoon. Which of the following is the most appropriate
assessment of fine and gross motor development?

`` Fine Motor Gross Motor
Development Development
O A) Normal normal
O B) Normal delayed
O C) Delayed normal
O D) Delayed delayed

AAAAAAAAAAAAAAAAAAA

42. An 18-month-old girl is brought to the physician because of
intermittent shortness of breath over the past 6 months. Her mother
notes that her daughter often squats to relieve her symptoms.
Examination shows cyanosis and clubbing of the fingers. A prominent
right ventricular impulse with a grade 3/6, systolic ejection murmur
is heard best in the third left intercostal space. An ECG shows right
ventricular hypertrophy. An x-ray film of the chest shows a
small-sized heart and decreased pulmonary blood flow. Which of the
following is the most likely diagnosis?
O A) Atrial septal defect (ostium primum type)
O B) Atrial septal defect (ostium secundum type)
O C) Atrioventricular canal
O D) Coarctation of the aorta
O E) Hypoplastic left heart syndrome
O F) Patent ductus arteriosus
O G) Tetralogy of Fallot
O H) Transposition of the great arteries
O I) Tricuspid atresia
0 J) Ventricular septal defect

GGGGGGGGGGGG


43. A 5-day-old girl has been feeding poorly since birth. She weighed
2900 g (6 lb 7 oz) at birth and now weighs 2600 g (5 lb 12 oz).
Physical examination shows an enlarged clitoris and labial fusion. A
sibling born 5 years ago died at 1 week of age. A life-threatening
complication of this syndrome results from failure to produce which of
the following?
O A) Aldosterone
O B) Cholesterol
O C) Estrogen
O D) Insulin
0 E) Testosterone


AAAAAAAAAAAAAAAAAAA

44. A 57-year-old hospitalized man undergoes right subclavian venous
catheterization for hyperalimentation. He is currently being treated
for a small bowel fistula. While the results of an x-ray film of the
chest to check the catheter position are pending, the patient suddenly
becomes agitated. His blood pressure is 70150 mm Hg, and pulse is
1101min. Examination shows jugular venous distention. The lungs are
clear to auscultation. Breath sounds are equal bilaterally. The
trachea is midline. An x-ray film of the chest shows a catheter in the
superior vena cava, transversing the right ventricle and crossing to
the left of the midline. Which of the following is the most likely
cause of this patient's hypotension?
O A) Air embolism
O B) Pericardial tamponade
O C) Pulmonary artery perforation
O D) Staphylococcal bacteremia
O E) Tension pneumothorax

BBBBBBBBBBBBBBBBBBBBBB

45. Twenty-four hours after hospitalization for fixation of a femoral
fracture, a 35-year-old construction worker has nausea, agitation, and
insomnia. His blood pressure is 1501100 mm Hg. He is oriented but
anxious. Which of the following is the most appropriate next step in
diagnosis?
O A) Inquire about recent alcohol intake
O B) Examination of a urine specimen for fat bodies
O C) Leukocyte count with differential
O D) ECG
0 E) Pulmonary arteriography

AAAAAAAAAAAAAAAAAAA

46. A previously healthy 27-year-old woman comes to the physician
because of a 3-month history of moderate abdominal pain that improves
for a short time after she eats. She has not had any rectal bleeding.
Her temperature is 36.4°C (97.5°F), blood pressure is 110170 mm Hg,
and pulse is 80/min. Abdominal examination shows midepigastric
tenderness. Her hemoglobin level is 12 gfdL, and leukocyte count is
80001mm3. Serum Helicobacterpylori antibody assay is positive. Which
of the following is the most appropriate next step in management?
O A) HIDA scan
O B) Amoxicillin, clarithromycin, and omeprazole therapy
O C) Ciprofloxacin therapy
O D) Omeprazole, magnesium hydroxide, and metoclopramide therapy O E)
Ranitidine therapy


BBBBBBBBBBBBBBBBBBBB


Report Abuse

* Re:anybody have nbme3 answers
#1026804
coolamazon - 11/01/07 15:59

nbme 3,BLOCK 3:

BLOCK 3
1. A 32-year-old man comes to the physician for a second opinion
regarding an enlarged cervical lymph node that he noted 6 weeks ago.
He has not had pain or tenderness but has been unable to return to
work despite normal findings on a biopsy of the node 4 weeks ago. He
had a mild upper respiratory tract infection 1 month ago. His maternal
uncle recently died of lymphoma. He states that cancer runs in his
family, and that for the past several years he has thought that he
will have some kind of cancer eventually. Which of the following is
the most likely diagnosis?
A) Asthma
B) Conversion disorder
C) Factitious disorder
D) Hypochondriasis
E) Malingering
F) Pulmonary embolus
G) Somatization disorder
Answer: D
2. 32 y/o woman given captopril for sev HTN now has stridor 14 hrs
later.shes anxious bp 140 /85 pulse 140 RR 32 .exam shows sweeling of
lips n tongue.diffuse stridorous wheezes heard on ausc + diminished
air movemnt.
most app nxt step in Mx
measure serum captopril
CXR
observe only
measure serum IgE
tracheal intubation
Answer: E
3. Pt with GBS, what to do at delivery? IV penicillin
4. A 22-year-old woman comes to the physician because of diffuse
constant headaches and vision problems for 3 months; the headaches are
worse in the morning when she awakens from sleep. She also has had
brief episodes of loss of vision in both eyes. She has had an 18-kg
(40-lb) weight gain over the past year. She now weighs 100 kg (220 lb)
and is 163 cm (64 in) tall. Visual acuity is 20/30 bilaterally. Visual
fields are full, but the blind spots are enlarged bilaterally.
Funduscopic examination shows marked blurring of the optic disc
margins bilaterally. The remainder of the neurologic examination shows
no abnormalities. Which of the following is the most likely diagnosis?
A ) Amaurosis fugax
B ) Central retinal vein occlusion
C ) Glaucoma
D ) Macular degeneration
E ) Migraine
F ) Nutritional optic neuropathy
G ) Optic neuritis
H ) Pituitary adenoma
I ) Pseudotumor cerebri
J ) Temporal arteritis
Answer: I
5. a healthy 60 yo female came for routine examination. she has no h/o
illness or surgeries since last year.she takes no medications. she
attained menopause 6 yrs ago. she wighs 60 kg and is 160 cm tall.
pelvic exam showed atrophic external genitalia and small midpositioned
uterus. the left ovary is 3x3cm,rt ovary is not palpable.what is the
next best step in the managment of this management?
A)re examination in 1 month
B) re examination in 1 year
C) obtain patients medical records
D)measure serum progesterone
E)pelvic ultrasonography.
Answer: C
6. A 47-year-old woman comes to the emergency department because of
severe abdominal pain for 3 hours. The pain began after a 2-week
drinking binge. She has a 15-year history of alcoholism. She has no
history of jaundice or hepatitis. Current medications include
multivitamins and iron. Her temperature is 38°C (100.4°F), blood
pressure is 110/80 mm Hg, and pulse is 110/min. Examination shows mild
jaundice and diffuse spider angiomata over the trunk and abdomen. The
liver is tender to palpation. A complete blood count shows mild anemia
with normal red cell indices. Ultrasonography of the abdomen shows
normal-sized hepatic ducts. Which of the following is the most likely
set of laboratory findings?
Total Indirect Alkaline Alanine
Bilirubin Bilirubin Phosphatase Aminotransferase Reticulocyte
(mg/dL) (mg/dL) (U/L) ALT, GPT) (U/L) Count (%)
A)2 0.9 80 30 1.2
B)3 2.8 70 30 1.0
C)3 2.8 80 20 3.0
D)4 2.0 800 200 1.5
E)4 1.0 150 400 1.0
Answer: B
7. 5 years after being shot in the thing, a 21yo comes with a buzzing
sensation adjacent to the scar. A the time of the initial wound, he
was discharged after 6 hours of observation and would cleaning. A loud
murmur is hear on auscultation, there is a thrhill. He has dilated
varicose vening with incompetent valvles in the lower legs. Dx?
Arterial spasm, AV fistula, DVT, Occlusion of the superficial femoral
artery, Pseudoaneurysm
Answer: B
8. 5 days after sustaining a 6cm laceration through the skin and
subcutaneous tissue of the left upper extremity with a clean knife, a
52-year-old man has increasing tenderness in the area of the
laceration. Treatment at the time of injury included cleansing and
dressing of the wound. The wound is now erythematous, and yellow pus
is expressed when pressure is applied. Which of the following is the
most likely mechanism for the accumulation of pus?
A. Chemotaxis
B. Dysplasia
C. Hyperoxia
D. Metaplasia
E. Vasoconstriction
Answer: A
9. 40 yr male with c/o jaw stiffnes and muscle spasm brought to ER.
H/o heroin abuse. sexually active with multiple partners uses condon
inconsistently. temp 38. 3 C. he is irritable. examination shows
facial and paraspinal muscle spasm and rigidity and stimulation cause
paroxysmal spasm. bp 150/ 96. pulse 120. mobility of jaw is decreased
and neurological examination shows hyper reflexia. which of the
following have most likely prevented this condition..
1. use of condom
2. tetanus toxoid vaccination
3. thiamine ( vit B 1)
4.prednisone therapy
5. rifampin therapy
6. botulism antitoxin therapy
Answer: B/2
10. Question about a guy whos wife dies and 6 weeks later hes still
crying and not sleeping, but no suicidal ideations – Normal
Bereavement
11. A 12-year-old girl with chronic renal failure has had persistent
epistaris tor 15 days. Laboratory studes show
Hemoglobin 7 2g/dL
Platelet count VSMGImm1
Bleeding time 12mm
Prothrombin time 12 sec
Partial thromboplastin Dme (activated) 30 sec
Serum urea nitrogen (BUN) 125mc/dL
Which of the following is the most likely cause ol the epistaxis?
A) Acquired platelet dysfunction
B) Circulating immune complexes
C) Erythropoietin deficiency
D) Factor III deficiency
E) Hypocalcemia
Answer: B
12. question said fixed, split S2 – ASD
13. 19yo has fever, sore throat, HA, cervical lymphadenopathy for 5
days. Pharynx is red and swollen with enlarged tonsils and exudates.
Tender and palpable axillary and inguinal lymph nodes as well. Spleen
tip is palpable. Leukocyte is 14000 (60% atypical, 15% mono).
Pathogen? Adeno, CMV, EBV, Group A Strep, Toxo
Answer: C
14. An 80-year-old man has had poor balance for 6 months. He has a
history of hypertension treated with hydrochlorothiazide. His blood
pressure is 136186 mm Hg. Neurologic examination shows mild tremor of
the hands when his arms are outstretched and decreased vibratory
sensation at the knees. Deep tendon reflexes of the quadriceps and
gastrocnemius-soleus muscles are hyperactive. Babinski's sign is
present bilaterally. He is unable to stand with his eyes closed. Which
of the following is most consistent with normal age-related changes?
A) Babinski's sign
B) Hyperactive deep tendon reflexes of the gastrocnemius-soleus muscles
C) Inability to stand with the eyes closed
D) Reduced vibratory sensation at the knees
E) Tremor of the outstretched hands
Answer: D
15. Tx for bronchospastic episodes occurring at night in someone who
already is on B2 agonist for daily cough and wheezing? Inhaled
steroid, inhaled ipratropium, oral erythro, oral furosemide and oral
theophylline
Answer: A
16. 12 days after cerebral infarct 70 y/o man has fever and cough
.initial Sx included inability to move Rt arm & leg , swallow, speak
,respond to Q's. he is wearing false teeth .temp 101.8 bp 135/85 pulse
94 rr 28. exam shows moderate weakness of facial muscles and Rt
extremity.gag refelx is absent .breath sounds dec...dullness to perc
over Rt lung base posteriorly.CXR shows infiltrate in post basal
segment of rt lung .which of the folloiwng is most likely to Prevent
recurrence of this pts lung condition?
a removal of his false teeth
b suppression of gastric acid production
c chronic Ab prophylaxis
d metoclopramide to inc GIT motility
e insertion of feeding jejunostomy tube
Answer: A
17. Question said VC is decreased, FEV1 is decreased and ratio of FEV1
to VC is increased, all answer were obstructive, only one was
restrictive: Pulm Fibrosis
18. a 2 y/o girl found floating facedown in a sweeming pool.on rescue,
she immediately coughs and breath spontaneously. She is conscious, and
oriented..without treatment which of the following is most likely
outcome of the child?
a)complete recovery
b)development of ARDS
c) hemolysis
d) pulmonary HT
e) severe neurological deficit
Answer: A
19. A previously healthy 6-month-old boy is brought to the physician
because of a 12-hour history of vomiting and diarrhea. He vomits after
all feedings, the vomitus does not contain blood or bile. His mother
says that he has had fewer wet diapers than usual during this period.
He appears dehydrated and is crying without tears. He is at the 50th
percentile for length and 30th percentile for weight. He appears
lethargic. His temperature is 38°C (100.4°F), pulse is 180/min, and
blood pressure is 60/40 mm Hg. Examination shows sunken eyes, dry
mucous membranes, and a sunken anterior fontanel. Arterial blood gas
analysis on room air shows:
pH 7.2
PCO2 38 mm Hg
PO2 90 mm Hg
Which of the following is the most likely explanation for this
patient's arterial blood gas findings?
A) Excessive metabolic acid formation
B) Impaired ventilation
C) Increased chloride loss
D) Increased CO2 concentration in the extracellular fluid
E) Increased metabolic acid produced by the gastrointestinal tract
Answer: C
20. 24hrs after splenectomy for blunt truama sustained in MVA,
previously healthy 25yr old man has oliguria and pain at the incision
site. intra operative complication was 3o min hypotension and total
blood loss 2.5L required 4 units of Packed RBC. Now temp 100.4F, Bp
120/80 mmhg, PR 100, rep 14, CVP 8 cm H2O. Lungs clear, + breath sound
bilaterally.
Abd exam shows no distension, bowel sounds absent, a foley catheter is
in place and over the past 3hrs urine output has been 20 ml/hr. Lab
show Hct 28%, BUN 30 mg/dl, Cr 2.5 mg/dl, electrolytes normal what's
the likely explanation
a. ATN
b Foley catheter malfunction
c Hypovolemia
d. Transfusion reaction
e. ureteral injury
Answer: A
21. guy with 30% stenosis of internal carotid, next step: Aspirin
therapy, Heparin therapy, Nifedipine therapy, placement of carotid
endovascular stent, carotid endarterectomy
Answer: A
22. during a routine exam 20 y/o man is found to have firm bilaterally
enlarged thyroid gland and lymphadenopathy .his father died of
tghyroid Ca at 40. which hormone is most likely associated with this
pts findings
ACTH
ADH
aldosterone
calcitonin
growth H
Bhcg
insulin
PTH
TSH
T4
Answer: D
23. A previously healthy 24-year-old woman, gravida 3, para 3, is
brought to the emergency department because of deep, sharp,
intermittently severe pain in the left lower quadrant of the abdomen
for 2 hours. Her last menstrual period was 3 weeks ago. She takes no
medications. She is in obvious distress and is lying on her left side
with her lower extremities drawn up against her abdomen. Her
temperature is 37°C (98.6°F), blood pressure is 140/70 mm Hg, and
pulse is 125/min. Abdominal examination shows rigidity and tenderness.
Pelvic examination shows a 12-cm mass in the left lower quadrant of
the abdomen. Which of the following is the most appropriate next step
in management?
A ) Ultrasound-guided aspiration
B ) Dilatation and curettage
C ) Exploratory laparotomy
D ) Hysterectomy
Answer: C
24. One week after cholecystectomy for acute cholecystitis, a
57-year-old woman comes to the physician because of a 1-day history of
abdominal cramps and watery, green, foul-smelling diarrhea. She
finished a 7-day course of cefoxitin 3 days ago. She appears
dehydrated. Her temperature is 39.8°C (103.6°F), pulse is 115/min, and
blood pressure is 105/70 mm Hg. Abdominal examination shows moderate
distention and diffuse tenderness; there is no guarding. Test of the
stool for occult blood is positive; the stool contains leukocytes. Her
hemoglobin level is 10.8 g/dL, and leukocyte count is 39,000/mm3. The
patient is admitted to the hospital, and administration of intravenous
fluids is begun. Which of the following is the most appropriate next
step in pharmacotherapy?
A ) Intravenous amphotericin
B ) Intravenous ampicillin, clindamycin, and gentamicin
C ) Intravenous corticosteroids
D ) Oral diphenoxylate and atropine
E ) Oral metronidazole
Answer: E
25. An afebrile 2-year-old boy has had right ear pain for 3 days. He
has been swimming every day for the past week. Purulent fluid is
draining from the right external ear canal, and manipulation of the
pinna is painful. No abnormalities are noted on visualization of
tympanic membranes. Which of the following is the most likely causal
organism?
A) Haemophilus influenzae type b
B) Moraxella catarrhalis
C) Pasteurella multocida
D) Pseudomonas aeruginosa
E) Streptococcus pneumoniae
Answer: D
26. 42yo with HTN and 1 hour onset of chest discomfort, HA,
irritability and confusion. His BP is 220/148, (+) papilledema. ECG
shows ischemic changes with LVH. CT scan is negative. Best tx:
Atenolol, Captopril, Diltiazem, Furosemide, Guanethidine, Hydralazine,
Losartan, Methyldopa, Nitroprusside, Prazosin, Thiazide diuretic.
Answer: C
27. 72 y/o woman C/C urinary incontinence 6 months with no senstion to
urinate prior to episodes.the episodes r less frquent if she schedules
her trips to the bathroom and restricts liquid intake prior to
beddtime.she has 20 Yr Hx DM 2 is on meformin and glyburide.has mild
retinopathy .pelvic exam nL vaginal mucosa.sesation to pinprick
decreased in glove stocking dist.U/A +1 protein. Which is the most
likely cause of pts urinary symptoms.
functional incontinence
normal aging
overflow of urine from large residual volumes
hypersensitivity of detrusor muscle
urethral atrophy with loss of uretherovesical angle
Answer: B
28. 57 yr m, 10 yr type 2 DM routine check. He feels well. Current
medication enalapril, glyburide. 168 cm tall 185 lb weight; BMI 30.
Pulse 60/min, BP 100/70 mmhg. Funduscope soft and hard exudates. Lab:
HB A1c 12%
BUN 23
Cr 1.4
Urine protein 1+
Which of the following is the most appropriate addition pharmacotherapy?
A. Atenolol
B. Captopril
C. Hydrochlorothiazide
D. Metformin
E. Verapamil
Answer: D
29. 65 y/o woman
C/C palpitations heat intolerance wt loss 7 lb -for 6 months
neck mass -10 yrs
131 i scan shows enlarged thyroid with mutiple areas of inc and dec uptake
most likely DX
graves
multinod goitre
thyroiditid
toxic adenoma
T3 thyrotoxicosis
Answer: B
30. 18 y/o female knee pain since 5 year.. pain is worse with
prolonged sitting and going up and donw stairs. on examination she has
10 degree hyperextense of both elbow.. she become apprehensive when
lateral directed pressure is applied.. x ray is normal
what is the diagnosis??
a) anterior cruciate ligament reconstruction
b) arthroscopic partial meniscectomy
c) quadriceps strengthening excercises
d) sympathetic blockage
e) total knee replacement
f) upper tibial osteotomy
Answer: C
31. A 70-year-old man comes to the physician because of knee pain that
has been present for 10 years. He is unable to comfortably walk
further than one block and has difficulty sleeping because of the
pain. He has pain on both medial and lateral sides of the knee. Range
of motion is from 15 to 100 degrees, there is a bowleg deformity when
he stands – same choices as # 30??
Answer: E
32. A 35-year-old man with a 10-year history of persistent
hallucinations and delusions comes for a follow-up examination. He has
been treated with haloperidol, chlorpromazine, and fluphenazine with
minimal relief of symptoms. He is currently taking haloperidol. On
examination, he walks slowly with no arm swing and has no facial
movements. Which of the following is the most likely cause of his
motor behavior?
A ) Excess limbic γ-aminobutyric acid activity
B ) Increased serum prolactin level
C ) Nigrostriatal dopamine blockade
D ) Noradrenergic depletion in the frontal lobe
E ) Ventral tegmental dopamine blockade
Answer: C
33. a study is conducted to investigate prevalence of past infection
with genital herpes among students attending a large coeducational
midwestern Uni.after obtaining informed consent the participants
undergo antibody testing for HSV2.which of the following is the most
imp factor in determining validity of a positive test
the no of sexual partners of the student
proportion of students infected with HSV
proportion of studenst with negative tests
proportion of students with positive tests
the total no of students screened
Answer: E
34. Tx for GAD – Buspiron
35. some nasty vaginal anal warty looking picture – it said what is
the strongest risk factor crohns, family ho psoriasis, multiple sexual
partners, treatment with metronidazole, treatment with sulfasalazine
Answer: C
36. An 82-year-old woman comes to the physician because of a 2-month
history of progressive shortness of breath with exertion and a 3-week
history of right upper quadrant abdominal discomfort. She has chronic
obstructive pulmonary disease, hypertension, and rheumatoid arthritis.
Medications include methotrexate, hydrochlorothiazide, naproxen,
albuterol metered-dose inhaler, and aspirin. Examination shows pallor.
Breath sounds are decreased. The liver is enlarged, firm, and mildly
tender. Test of the stool for occult blood is positive. Her hematocrit
is 27%, and mean corpuscular volume is 76 μm3. A CT scan of the
abdomen shows multiple hypodense lesions in the liver. Which of the
following is the most likely diagnosis?
A ) Cholangiocarcinoma
B ) Hepatocellular carcinoma
C ) Lymphoma
D ) Metastatic colon cancer
E ) Metastatic lung cancer
F ) Metastatic pancreatic cancer
Answer: D
37. An 80 year old man is brought to ED on an 80 degree day 2 hrs
after running a syncopal episode while playing golf. He plaus golf
twice weekly. An ECG obtained at his last examination 6 months ago
showed occassional premature ventricular contractions. On arrival his
temp is 38C(100.4F), Q3. BP is 150/90mmHg, pulse is 80/min and
regular, respirations are 22/min. Cardiac examination shows grade 3/6
late-peaking systolic ejection murmur. No bruits are heard over the
carotid arteries, but the upstrokes are delayed. Which of the
following is the most likely cause of the syncope.
a. Aortic stenosis
b. Heat Stroke
c. Hypertensive cardiomyopathy
d. Platelet emboli
e. PVCs
Answer: A
38. A 38-year-old woman comes to the physician because of a low-grade
fever and generalized rash for 4 days. She is currently receiving
cefazolin therapy for chronic osteomyelitis. Her temperature is 38.2°C
(100.8°F), blood pressure is 1501108 mm Hg, and pulse is 1001min.
There is a faint diffuse maculopapular rash. Examination of the back
shows no costovertebral angle tenderness. Cardiac and pulmonary
examinations show no abnormalities. Laboratory studies show:
Leukocyte count 10,8001mm3
Segmented neutrophils 60%
Bands 8%
Eosinophils 4%
Lymphocytes 20%
Monocytes 8%
Serum
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1.6 mg/dL
Urine
WBC 121hpf
RBC 81hpf
RBC casts none
WBC casts rare
Eosinophils are found in the urine sediment. Which of the following is
the most likely explanation for these findings?
A) Acute tubular necrosis
B) Fibromuscular dysplasia
C) Interstitial nephropathy
D) Polyarteritis nodosa
E) Pyelonephritis
F) Wegener's granulomatosis
Answer: C
39. 43 y old man with a 8 year history of inter. difficulty of
swallowing solids and liquids has had increasingly severe
exacerberation since 6 months due to stress. he has nocturnal
regurgitation and cough. esophageal motility show failure of
relaxation of lower esophageal sphincter.what is the diagnosis
1) achalasia
2) sqamous cell ca
3) adenocarcinoma
4) reflux esophagitis
5) diffuse esophageal spasm
6) viral esophagitis
7) candidial esophagitis
8) scleroderma
Answer: A
40. A 45-year-old woman has had generalized weakness for 1 year,
increasing difficulty walking up stairs over the past 6 months, and
difficulty swallowing for 1 month. Examination shows weakness of the
proximal muscles of the extremities. Ear, nose, and throat
examinations and manometry show decreased contractions of the pharynx
with decreased upper esophageal tone. Same answers as question 39?
Answer: 8
41. A 6-month-old girl is brought to the physician because of fever,
cough, and coryza for 1 day. Her pulse is 100/min, and respirations
are 50/min. Her cough is harsh and sounds like a dog's bark. There is
inspiratory stridor and intercostal retractions. Which of the
following is the most likely diagnosis?
A ) Asthma
B ) Bacterial tracheitis
C ) Bronchiolitis
D ) Foreign body in the small airways
E ) Foreign body in the trachea
F ) Laryngotracheobronchitis
G ) Pneumonia
H ) Pneumothorax
I ) Pulmonary edema
Answer: F
42. On the 5th day of a 7 day cruise in the western caribbean, 37 yr
old women develops headache, fever, chills, abddiscomfort, ans watery
diarrhea over 12 hr period. Many other passengers and crew haave had
similar syptoms.
PE: tept 98.6 F abd exam shows diffuse tenderness without rebound,
bowel sounds are hyperactive. Leucocytes 11,000, Gm stain of stool
shows small # of neutrophils, a stool culture grows Salmonella
enteritidis, 2 days after Rx with bismuth susalicylates and oral
rehydration, her syptoms subsides.
what's appropritae immediate measure to prevent further spread of pathogens?
a. cancellation of shore leave for all crew members
b. elimination of seafood and shellfish from the ship menu
c. exclusive use of pasteurized eggs
d. hyperchlorination of the ship's drinking water
e. reaasignment of all the food handling personnel to other duties
f. Rx of all affected persons with doxycycline
Answer: C
43. Over the past 2 weeks, a 60-year-old man has had shortness of
breath on exertion. He also has paroxysmal nocturnal dyspnea with
two-pillow orthopnea. He has taken aspirin daily since a myocardial
infarction 3 years ago. He has a history of atrial fibrillation well
controlled with digoxin and type 2 diabetes mellitus treated with
diet. His blood pressure is 136188 mm Hg, pulse is 98/min and
irregular, and respirations are 20/min. Jugular-venous pressure is
increased. Breath sounds are decreased over the right lung base..
there is dullness to percussion. Cardiac examination shows an S.
gallop. There is 2+ edema of the lower extremities. Pulse oximetry
shows an oxygen saturation of 90%. Which of the following is the most
appropriate next step in diagnosis?
A) X-ray film of the chest
B) Ambulatory ECG monitoring
C) Thallium stress test
D) Echocardiography
E) Ventilation-perfusion lung scans
Answer: A
44. A 3-month-old boy is brought to the physician in January because
of difficulty breathing, clear nasal discharge, and cough for 24
hours. His temperature is 37.6°C (99.6°F), blood pressure is 88/54 mm
Hg, pulse is 168/min, and respirations are 60/min. Bilateral wheezing,
prolonged expiration, and a grade 2/6 systolic murmur along the left
sternal border are heard. The liver is palpated 3 cm below the right
costal margin. An x-ray film of the chest shows bilateral
hyperinflation and no cardiomegaly. Which of the following is the most
likely diagnosis?
A) Adenovirus pneumonia
B) Congestive heart failure
C) Influenza A virus pneumonia
D) Respiratory syncytial viral bronchiolitis
E) Staphylococcal pneumonia
F) Status asthmaticus
Answer: D
45. Old guy with perifollicular inflammation, purpura and confused – Scurvy
46. A 55-year-old man with alcoholic cirrhosis is hospitalized for 2
weeks in April for treatment of gastrointestinal bleeding. His last
immunization for diphtheria-tetanus (Td) was 6 years ago. Which of the
following is the most appropriate management prior to discharge?
A) Administration of immune globulin
B) Inactivated poliovirus vaccine
C) Influenza virus vaccine
D) Pneumococcal vaccine
E) Td toxoids
Answer: C

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* Re:All questions to nbme 3 - plz check my answers!
#907497
drjiggy - 09/03/07 15:16

BLOCK 4:
1. Six days after undergoing a laparoscopic cholecystectomy for acute
cholecystitis, a 35-year-old woman comes to the physician because of
fever and abdominal pain for 3 days. She is jaundiced. Her temperature
is 38°C (100.4°F). Abdominal examination shows distention and
incisions that are healing normally. Leukocyte count is 12,000/mm3,
and total serum bilirubin level is 7.9 mg/dL. Which of the following
is the most likely cause of the jaundice?
A) Anesthetic-related hepatitis
B) Common bile duct injury
C) Fulminant hepatic failure
D) Reaction to perioperative antibiotics
E) Subhepatic abscess
Answer: B
2. 47yo comes because of increasing facial swelling 1 week of morning
HA and mild SOB. He previously felt well. He finished Chemotx for
small cell ca of lung 4 months ago. Temp is 98.9. There is diffuse
facial and periorbital edema. – Dx SVC syndrome
3. The crude mortality rate for coronary artery disease in Community A
is twice the crude mortality rate for coronary artery disease in
Community B. The age-standardized mortality rates for coronary artery
disease in the two communities are the same. These findings are most
consistent with which of the following inferences?
A ) CAD mortality in the elderly is higher in Community A than Community B
B ) CAD mortality in young adults is higher in Community A than
Community B C ) The population of Community B is younger than the
population of Community A
D) The proportionate mortality from CAD is higher in Com A than Community B
E ) The two communities have similar age distribution
Answer: C
4. 44 y/o woman brought to emergency 40 minutes after being stabbled
in lft groin.bp 128/84 pulse 100 RR 16 .exam shows small hematoma and
no external bleeding.popliteal and pedal pulses are palpablein lft
lower ext below injury .laceartions of fem art n vein r found and
repaired.2 days post op she has progresively sev pain of lft lower ext
and swelling of leg from knee downward..wats most likely cause of her
new Sx?
lymphatic disruption from injury
thrombosis of fem vein
wound hemorrage
compartment syndrome
arterial embolism
Answer: D
5. Crazy guy with crazy thoughts for one week – Schizophreniform disorder
6. A 23-year-old woman, gravida 2, para 0, has had vaginal spotting
and abdominal cramps for 2 days. Her last menstrual period was 8 weeks
ago. A home pregnancy test was positive 2 weeks ago. She underwent a
salpingectomy 4 years ago following an ectopic pregnancy. Examination
shows a closed cervix, an enlarged uterus, and no adnexal masses.
Transvaginal ultrasonography shows an empty uterus. Serum ß-hCG level
is 8000 mIU/mL.
A) Abortion of a blighted twin
B) Cervicitis
C) Ectopic pregnancy
D) Focal decidual necrosis
E) Gestational trophoblastic disease
F) Incomplete abortion
G) Ovarian torsion
H) Ruptured ovarian cyst
I) Threatened abortion
Answer: C
7. A 25-year-old woman has had painless vaginal postcoital bleeding
for 2 hours. Her last menstrual period was 10 weeks ago. A pregnancy
test is positive. There is a small amount of dark blood in the vaginal
canal. She has a reddened, friable cervical os. Same answers as
question 6.
Answer: I
8. A 72-year-old woman is brought to the emergency department 1 hour
after the sudden onset of right facial droop and weakness of the right
arm and leg. She takes captopril for hypertension and daily aspirin.
Her blood pressure is 150/90 mm Hg, pulse is 80/min, and respirations
are 16/min. Examination shows a left carotid bruit and right central
facial paralysis. There is moderate expressive aphasia. A CT scan of
the head shows no abnormalities. Which of the following is the most
appropriate initial pharmacotherapy?
A ) Oral ticlopidine
B ) Oral warfarin
C ) Sublingual nifedipine
D ) Intravenous nitroprusside
E ) Intravenous tissue plasminogen activator
Answer: E
9. A 50-year-old man has a cardiac arrest during sexual intercourse.
He is promptly resuscitated and recovers uneventfully from an acute
anterior wall myocardial infarction. At discharge from the hospital,
he and his wife inquire about the safety of future sexual intercourse.
Which of the following is the most appropriate advice?
A ) Psychiatric consultation is necessary
B ) Sexual intercourse should be performed while wearing an ambulatory
ECG monitor
C ) Sexual intercourse will be safe when exercise tolerance improves
D ) They should wait 3 months before having sexual intercourse
E ) They should have sexual intercourse as soon as possible to
overcome the fear of another event
Answer: E (Refer to Kaplan, says sex can start right after discharge)
10. 28 y/o man has dry hacking cough for 3 months.his paternal grandpa
had colon Ca exam NL ..CXR large anterior mediastinal mass.wats most
likely origin of this neoplasm?
colon
kidney
prostate
stomach
testicle
Answer: E
11. Easy question on Tetralogy of fallot. Question said the kid squats
and is cyanotic c RVH.
12. Guy with cough, already on amoxicillin – add steroid
13. Question of a guy with recurrent ulcers, MCV is 78, wants to know
what serum iron, TIBC, saturation of TIBC and ferritin will be like
(Low, High, High, Low)
14. A 3-year old boy with acute lymphoblastic leukemia has had fever
for 3 days. He completed his last course of chemotherapy 6 days ago.
He has had no malaise, rash, or anorexia and has had no known contact
with sick children in preschool. He appears well. His T is 38.6
degree, BP is 75/60mm Hg, pulse is 100/min, and respiration are
22/min. Examination shows normal findings. Laboratory studied show: Hb
10.1 (n=11.5-15.5)
Leukocyte count 2200/mm3, segmented neutrophils 5%, Bands 1%,
lymphocytes 65%, atypical lymphocytes 11%, monocytes 18%, platelet
count 35000/mm3. Which of the following is the most appropriate next
step?
A. Schedule a follow-up visit and discharge without medication
B. Observe him in the office for 3 hours, discharge without medication
if examination remains unchanged
C. Discharge him with oral broad-spectrum antibiotic therapy
D. Admit him to the hospital for observation
E. Admit him to the hospital for intravenous broad-spectrum antibiotic therapy
Answer: E
15. a 15 y/o boy comes to the physician because of acne over his face
fo 1 year. He prefers not to use any oral medication. Examination
shows 10 to 15 pustules. which of the following is the most effective
treatment for this patient's symptoms
a) Avoidance of chocolate, fatty foods, and caffeine
b) Use of benzoyl peroxide soap
c) Vigorous scrubing of affected areas
d) Application of vitamin A and E of affected areas
e) Ultraviolet light therapy
Answer: B
16. Vegetarian, MCV is 122 – B12
17. 24 hrs after the fixtation of femur fracture, 35 yr old
construction worker develops insomnia, nausea ,agitation. his bp is
150/100, oriented but anxious.which of the following is the most
appropriate next step in diagnosis?
a. inquire about recent alcohol intake
b. ecg
c. pulm.arteriography
d. examination of urine specimen for fat globule
e.leukocye count wit differential.
Answer: A
18. a 12 y/o grl is brought to th e physician by her mother because
she is concerned about her doughter�s difficulty making friends and
socialising. her development and adjustment has been normal until 6
months ago, whe she began to refuse to use restrooms at school or eat
in the cafeteria. her mother describes her as a quiet serious child
who does not readily interact with other people. her teachers report
that her concentration varies, at times she appears to be daydreaming.
on examination, she is reserved but pleasant and appears to be of
normal inteligence. her speech is normal in rate and rythm. she says
that se is concerned that her voice will fail her if she has to read
aloud in class. which of the following is the most likely diagnosis?
a) adhd, innatentive type.
b) autistic disorder
c) expressive language dissorder
d) oppositional defiant disorder
e) selective mutism
f) social phobia
g) age appropriate behavior
Answer: F
19. Loss of sensation of last two fingers – Ulnar nerve at the elbow
20. a 68 y/o woman with terminal metastatic breast cancer is living
with her son. She has a living will requesting that she be allowed to
die in peace. she is unresponsive to voice and has not had any food
for 3 days. Her son disagrees her desicion not to accept further
therapy, including, chemotherapy, antibiotics, hospitalization and
enteral or parenteral nutrition. which of the following is the most
appropriate next step in management?
a) abide to the decisions of the next of kin.
b) obtain a court order to allow additional therapy to be given
c) start enteral feedings
d) admit her to the hospital
e) no further intervention
Answer: E
21. a 17 y/o girl has had flu-like symptoms, low grade fever and
malaise for 3 days and mild jaundice for 2 days. serum studies show:
AST: 670, ALT: 860,. SERUM IgM for hepatitis A is positive. which of
the following is most likely to minimize the risk for this diseace in
family members?
a) acyclovir therapy for family members.
b) Hepatits B vaccination for family members
c) Immune globuline therapy for family members
d) interferon alfa 2b for family members
e) use of separate toilet facilities by the patient
Answer: C
22. A 43-year-old man comes to the physician for evaluation and
management of cardiac risk factors 8 weeks after sustaining a
myocardial infarction. He takes aspirin and metoprolol daily, and he
does not smoke cigarettes. His father and brother both had myocardial
infarctions before the age of 50 years; their serum cholesterol levels
are unknown. There is no family history of diabetes mellitus. He
weighs 86 kg (190 lb) and is 180 cm (71 in) tall. His blood pressure
is 130/70 mm Hg, pulse is 68/min, and respirations are 14/min. Two
years ago, his serum cholesterol level was 245 mg/dL. Fasting serum
glucose level is 88 mg/dL. Which of the following is the most
appropriate next step to evaluate his cardiac risk factors?
A ) Random measurements of serum cholesterol level
B ) Measurement of fasting serum cholesterol level only
C ) Fasting serum lipid studies only
D ) Oral glucose tolerance test and fasting serum lipid studies
E ) Oral glucose tolerance test and measurement of fasting serum
cholesterol level
Answer: B
23. Guy with HBV for 25 yearrs, Increased AFP – Dx? HCC
24. a 5 y/o girl has been feeding poorly since birth. she weghted 2900
gr at birth and now weights 2600 gr. physical exam shows an enlarged
clitoris and labial fusion. A sibling born 5 years ago died al 5 years
of age. A life threatening complication of this syndrome results from
failure to produce which of the following?
a) aldosterone
b) cholesterol
c) estrogen
d) insulin
e) testosterone
Answer: A
25. a previously healthy 3 y/o boy presents with fever abd pain for 24
hrs.milestones app for age ..fully alert responsive. 101.5 temp ...
85/60 bp ...100 pulse RR 20 .exam shows suprapubic tenderness but no
gaurding or rebound.no and masses or costv angel tendernes.no urethral
discharge,
U/A shows 20- 30 leuk 5,6 eryth culture grows 100,000 colonies e coli
all sensitive to ab's..amox is initiated ..5 days later hes afebrile +
asx U/S kidneys NL ..which of teh following is most app nxt stp Mx?
discontinue Ab's in 2 days and reexamine only is Sx recur
VCUG
IVP
cystoscopy
no further testing
Answer: B
26. Two hours after emergency cholecystectomy, a 48-year-old woman has
an oxygen saturation of 84% and a PO2 of 56 mm Hg on 2 L/min of oxygen
via nasal cannula. Her blood pressure is 120/80 mm Hg, and
respirations are 16/min. Decreased breath sounds are heard on the
right, and there is decreased excursion on inspiration bilaterally.
There is minimal dullness over the right base. Examination shows no
jugular venous distention or pedal edema. An x-ray film of the chest
shows increased density over the right lower lung field; the tracheal,
mediastinal, and cardiac silhouettes are shifted to the right. The
right lung field appears considerably smaller than the left lung
field. Which of the following is the most likely cause of these
findings?
A ) Atelectasis
B ) Pleural effusion
C ) Pneumonia
D ) Pneumothorax
E ) Pulmonary embolism
Answer: A
27. Picture of a hyphema
O A)Administration of BCG vaccine
O B)Administration of an inhaled bronchodilator
O C)Administration of oxygen
O D)Arterial blood gas analysis
O E)Bronchoscopy
O F)Culture of the pharynx for bacteria
O G)Direct laryngoscopy
O H) Gastric washings for acid-fast bacteria
O I) Intravenous infusion of saline
O J) Isoniazid and rifampin therapy
O K) Lumbar puncture
O L) Measurement of serum aspirin level
O M) Subcutaneous administration of epinephrine.
N) Viral culture of respiratory secretions
00) X-ray films of the chest
O P) X-ray films of the neck


28. A previously healthy 8-year-old boy is brought to the emergency
department because of swelling of the lips and difficulty breathing
for 20 minutes. The symptoms began when he was helping his father
clean the gutters on their house. He appears anxious. His temperature
is 37.2°C (99°F), pulse is 120/min, and respirations are 50/min. Pulse
oximetry shows an oxygen saturation of 96%. His lips and eyes appear
puffy. He has subcostal and intercostal retractions. Auscultation of
the chest shows diffuse bilateral wheezing.
Answer: M

29. A 16-year-old girl is brought to the emergency department because
of heavy breathing for 8 hours, and vomiting and ringing in the ears
for 1 hour. She recently broke up with her boyfriend and has been
threatening to hurt herself. She appears somnolent but is arousable
and answers questions appropriately. Her temperature is 37.5°C
(99.5°F), pulse is 88/min, and respirations are 50/min. Pulse oximetry
shows an oxygen saturation of 96%. She has no retractions, nasal
flaring, or cough. The lungs are clear to auscultation
Answer: L

30. Guys PPD came back over 15mm. Next step - CXR
28. Question on dermatomyosits
29. Easy Q – Tx for H.pylori – Amox, Clarithromycin, Omeprazole
30. A guy taking doxorubicin gets S3 and crackles – Cardiotoxicity
31. Picture of spine with degenerative changes and pt has high
calcium. Dx? Herniated nucleus polposus, mechanical low back pain, met
carcinoma, osteopetrosis, spinal stenosis
32. A 37-year-old nulligravid woman comes to the physician because she
has not been able to conceive for 2 years. Her 40-year-old husband has
a child by a previous marriage. Her last menstrual period was 6 weeks
ago; menses have occurred at increasingly infrequent intervals over
the past year. Fifteen years ago, she was treated for one episode of
Chlamydia trachomatis infection. She weighs 59 kg (130 lb) and is 170
cm (67 in) tall. Examination shows no abnormalities. Serum studies
show:
ß-hCG<5 mIU/mL
Follicle-stimulating hormone 50 mIU/mL
Luteinizing hormone 45 mIU/mL
Prolactin 13 ng/mL
Thyroid-stimulating hormone 3 µU/mL
Which of the following is the most likely cause of this patient's infertility?
A) Hypothalamic amenorrhea
B) Hypothyroidism
C) Pituitary adenoma
D) Polycystic ovarian disease
E) Premature ovarian failure
F) Tubal factor
Answer: E
33. An 82-year-old man is brought to the emergency department because
of the sudden onset of confusion 48 hours ago. His family says that he
previously had been functional and independent. His temperature is
37.5°C (99.5°F), blood pressure is 110/70 mm Hg, pulse is 90/min,
and respirations are 12/min. The skin is warm and clammy. Bowel sounds
are hypoactive, and there is guarding and tenderness in the right
lower quadrant of the abdomen. Examination of the heart, lungs, and
extremities shows no abnormalities. He is drowsy but arousable and
oriented to person but not place or time. There are no focal deficits.
Which of the following is the most likely diagnosis?
A ) Appendicitis
B ) Colon cancer
C ) Meningitis
D ) Pneumonia
E ) Urinary tract infection
Answer: B (probable A though)

34. A 6-year-old girl is brought to the physician because of a 1-day
history of vomiting, headache, and weakness. One month ago, she
underwent resection of an astrocytoma and placement of a
ventriculoatrial shunt for residual hydrocephalus; Her postoperative
course had been uncomplicated. Currently, she is drowsy and irritable.
Her T 37.5 degree, BP 126/54 mmHg, pulse is 82/min, and respirations
are 24/min. Funduscopic examination shows papilledema. Reflexes are
brisk with hypertonia in the lower extremities. Which of the following
is the most likely underlyiong mechanism for these symptoms?
A. Carcinomatous infiltration of cerebrospinal fluid
B. Malfunction of ventriculoatrial shunt
C. Overproduction of cerebrospinal fluid from a choroid plexus papilloma
D. Recurrence and extension of the astrocytoma
E. Thrombosis of the superior sagittal sinus
Answer: B

35. A 30 year old woman, g4p3, is admitted to the hospital in labor at
38 weeks gestation. The cervix is 4 cm dilated. Contractions occur
every 4 minutes. The fundal height is 40 cm, the membranes are intact.
The fetal lie cannot be determined by abd examination, and no
presenting part is palpable in the pelvis. Which of the following is
the most appropriate next step in management?
A. Ultrasonography
B. Administration of oxytocin
C. Administration of tocolytic drugs
D. Amniotomy
E. Cesarean delivery
Answer: A
35. See above
36. A previously healthy 30-year-old woman has had a painless lump in
her neck for 2 days. Her mother was treated for a thyroid tumor at the
age of 35 years. Her 28-year-old sister has an increased serum
calcitonin level but no thyroid mass. Examination shows a palpable
thyroid nodule. Her serum calcitonin level is increased. Which of the
following diagnoses should be excluded prior to surgical treatment of
the thyroid gland?
A) Adrenocortical carcinoma
B) Lung carcinoma
C) Ovarian carcinoma
D) Parathyroid carcinoma
E) Pheochromocytoma
Answer: E
37. A 57-year-old woman comes to the physician for a follow-up
examination. She has a 5-year history of hypercalcemia, which was
diagnosed with routine laboratory studies, and her serum calcium
levels have ranged from 10.8 mg/dL to 11.5 mg/dL. She declined further
evaluation in the past because she "felt well." She takes no
medications. Her last menstrual period was 7 years ago. She maintains
a weight of 67 kg (148 lb) and is 170 cm (67 in) tall, BMI is 23
kg/m2. Her blood pressure is 126/80 mm Hg, and pulse is 66/min.
Examination shows no abnormalities. Which of the following is the most
appropriate next step to assess her risk for fracture?
A) 24-Hour urine collection for measurement of collagen cross-links excretion
B) Bone densitometry
C) Bone-specific measurement of serum alkaline phosphatase activity
D) Posteroanterior and lateral x-ray films of the thoracic spine and hips
E) Biopsy of the iliac crest
Answer: B
38. 13-month-old girl is brought for a well-child examination. There
is no history of prenatal or perinatal problems. Her diet consists of
breast milk, juice, legumes, cooked vegetables, and fruit. She has had
three ear infections treated successfully with amoxicillin and two
episodes of diarrhea since birth. She will pull to a stand and stand
alone for 1 minute but has not begun to walk. She is able to pick up
raisins with her thumb and forefinger but is unable to feed herself
with a spoon. Which of the following is the most appropriate
assessment of fine and gross motor development?
Fine motor development Gross motor development
A Normal Normal
B Normal Delayed
C Delayed Normal
D Delayed Delayed
Answer: A
39. a previously healthy 37 yo woman comes to the physician beccause
ofa 3 mth hx of episodes of severe anxiety, SOB, palpitaltions and
numbness in her hands and feet. her vital signs are within normal
limits, PE shows no abnormalities, thyroid function studies and an ECG
show no abn. which of the following is the most appropriate
pharmacology?
lithium
methyphenidate
olanzapine
paroxetine
valproic acid
Answer: D
40. Tx for 3rd degree AV block – Immediate placement of a pacemaker
41. A 57-year-old hospitalized man undergoes right subclavian venous
catheterization for hyperalimentation. He is currently being treated
for a small bowel fistula. While the results of an x-ray film of the
chest to check the catheter position are pending, the patient suddenly
becomes agitated. His blood pressure is 70/50 mm Hg, and pulse is
110/min. Examination shows jugular venous distention. The lungs are
clear to auscultation. Breath sounds are equal bilaterally. The
trachea is midline. An x-ray film of the chest shows a catheter in the
superior vena cava, transversing the right ventricle and crossing to
the left of the midline. Which of the following is the most likely
cause of this patient's hypotension?
A ) Air embolism
B ) Pericardial tamponade
C ) Pulmonary artery perforation
D ) Staphylococcal bacteremia
E ) Tension pneumothorax
Answer: E
42. 25year old nulligravid woman comes to the ER because of severe
pain in the RLQ of the abdomen for 4 hours. She has had no nausea,
vomiting, fever or chills. Three weeks ago, a right adnexal mass was
found on routine exam. Her LMP was 3 days ago. Her temp is 99, BP is
110/70 pulse is 92. Pelvic exam shows right adnexal tenderness. Hb is
13, WBC is 9000. Pelvic U/S shows small amount of free fluid in the
cul-de-sac. What is the cause of her pain? Appendicitis,
Endometriosis, Ovarian hemorrhage, Ruptured ovarian cyst, Torsion of
the adnexa, Tubal obstruction
Answer: D
43. A 47-year-old woman comes to the physician because of a 2-day
history of fever and joint pain. Six days ago, she completed a 10-day
course of dicloxacillin for folliculitis. She appears comfortable. Her
temperature is 38.6°C (101.5°F), pulse is 72/min and regular,
respirations are 16/min, and blood pressure is 120/76 mm Hg.
Examination shows an urticarial rash over the trunk and extremities.
There is moderate generalized lymphadenopathy and diffuse joint
tenderness. The remainder of the examination shows no abnormalities.
Which of the following is the most likely cause of these symptoms?
A ) Epstein-Barr virus infection
B ) IgE-mediated allergic reaction
C ) Mycobacterium haemophilum infection
D ) Serum sickness
E ) Staphylococcal sepsis
Answer: D



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* Re:Pls any one send me NBME downloaded Qs
#1097643
  falcon1 - 12/22/07 14:15
 
  THANKS FOR THE WORK U DID FOR US

GL FOR UR EXAM
 
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* Re:Pls any one send me NBME downloaded Qs
#1097943
  candace - 12/22/07 19:15
 
  welcome...! waiitn for the result!  
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* Re:Pls any one send me NBME downloaded Qs
#1097955
  theking - 12/22/07 19:21
 
  its better to find the answers yourself.i did nbme forms and at least 30% of the answers are not correct.many of the questions are not as simple as they seem so,read the questions carefully.  
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