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goldenhand - doc_heart
#1
Hi goldenhand,
do u have step 2 nbme form 1,2,3 .i downloaded them the 2nd time from ur current post.
but it seems to be step1 nbme forms (all 4 of it).
step 2 forms r 3 in No.
Reply
#2
Sorry ,I apologise about that,so here are NBME 1 & 2 right here copy pasted,NBME uploaded & here is the link
http://rapidshare.com/files/54036541/ck_nbme3.rar

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
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#3
goldenhand --- You are one the most generous people out there. Thank you so much!
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#4
do have nbme for step 3, please post it if you can.......

THANKS SOOOOOOOOOOO MUCH.
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#5
thanks alot goldenhand.
i really appreciated ur efforts.
u did more than i cud even think of....Smile
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#6
MW.
Aiissman,it will take me sometime to check my step III dvd's to see if I have it or not.
May be in 10-12 hrs.
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#7
Thanks goldenhand, any ways you deserve this name.
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#8
three cheers for goldenhand..
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#9
Hi..

If you have Mira remembered questions from step 2ck experience....can you please email it to me at rohini_peace.

Thanks.
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#10
My collection of remembered questions

it was based mostly of med and paeds..
-q's on..
herpetic whitlow,
child with a wart on finger-etiology,
Chlamydia infection rx,
atpical pnemonia rx,
heamochromatosis type of cardiomyopathy,
pilonidal sinus rx,
Loads of inheritance and On female incontinance,
MS-MRI pics and description-dx,
PNH,9;22 translocation ? CML,
post ercp rise of temps? cause- cholangitis,
tension pneumothorax,
post splenctomy wht mx??sickle cl aneamia kid..which vaccine-an same for both,
M.avium intracelluare.prophylactic drug,
boy came with a bee sting and treated with adrenaline..wht wud u do to prevent future such episodes..i didnt ahd a cue for this as the options were-dont let him play outside,carry adrenaline, prophylactic antihistamines,and use of insect repellants, confine to indoors..i choose insect repellants....i dono..,
pt on frusemide and digoxin-wht are the serum K+ and Hco3- levels in body,
which anti hptn ive causes peripheral oedema,
erythema toxicum,
praderwilli synd,
whts the defect in klinefelters,
patau synd,
women with 1 amenorrhea and weak femoral pulses wht do u do next,
PDA u use indomethacin-mode of action,
abdo perforation,
2 q's on normal pressure hydrocephalus,
CRAO,
2 q's on temporal arteritis,
3 q's on SIADH,
dermato myositis,polymyalgia,compartment synd,conduct disorder,cocaine abuse,amphetamine abuse,DT,addisons disease,
lady with hypercalcemia and lytic lesions in humerus dx?, how do u prevent transmission from m other to baby( mother already on anti- HIVDRUGS),
intususseption, pyloric atenosis,
rectal prolapse in an nicaraguan child?? cause,
pap smear- high grade sq dysplasia wht u do next??,
cerebral palsy 2 q's,
stain for pnemocystis,
50 yr old man with severe back ache-stable obs- pic of xray-which i thought showed a calcified abdo aorta..so put it as AAA.
-q's on stress fracture of 1st metatarsal Rx,
A pt hd a puncture wound to his lt little finger 3 days ago, came with swollen finger upto 1st metacarpophalangeal jt and flexion causing pain-cause-osteomylitis,septicarthritis,tenosnovitis,midpalmarinfection,
2 q's on tesnion pneumothorax,
confusion in elderly-alzeimers,psedodementia,
stress,urge,incontinance etiology,
midpelvic contraction mx,
herpis encephalitis,
23 yr old female with resistant htn with impaired renal function and briut-pathology in renal arteries,
man had a RTA-blood at urethral meatus,high riding prostate,stable obs-next step in mx,
lady with elevated periosteum,stable obs- etiology,
asymptomatic oldman with elveted IgG 2000..whts the dx- i put as MGUS,
man with loss of vision + loss afferent optic reflex -site of lesion,
man with loss of taste,hearing loss and loss of stepedial reflex,-etio
q's on benign postural vertigo, and meneiers disease,
2 ecg's-one is a man with high K+ who is in VF,stbilised, next step- rx with ca gluconate,
next one is 27 yr old loss of consiousness,bradycardic ecg in 2 hb- mx- pacing,
Q's on HOCM,
man with extensive mets in liver and 1 in pancreas came with itching , bili is >15, whts the
next step in mx- i put as stent??
Aymptomatic lady came to request to get investigate , as she has a strog family hx of thyroid ca in family, which Ix u do- ??
Pregnant lady with hyperthyriodism mx?
q's on epidural hematoma,
2 q's on temporal arteritis,
q's on histoplasmosis,
ulnar neuropathy, compartment synd,
adenocarcinnoma of lung- predisposing factor,
esophageal ca,
diverticuosis-abscess- mx,
man wt severe abdo pain,septic,-ct scan of abdo- pancreas distended with grey matter,etio- i put pancreas necrosis,
femoral hernia,
man sht in thigh, a femoral anurysm developed, loss of puses distally and pale limb next step in mx,
man stabbed with butcher knife in left flank, 3cm deep, slight bleeding next step in mx,
q's on PNH, Vonwillibrands, Heamophila a,


pls put some explanation.
1) newborn for hiv+ women.
next step
a-AZT during 12h, for 6 w.
b-AZT after 2 w.
c- 3 drugstherapy .
d- = = = = only if cd4<200.

2) u put acast for a pt, 2 days later he wants u to pull it up,the pts is agitated with alcohol smell in his mouth.when u asked him if he drives the car to u, he got anger and said:"if don't pull the cast i will hurt u" and he broke the chair.
next step ?
a- call the security
b- pull the cast
c- arrest him

3)a newborn for dm mother weights 4500g,good status,apgar 1,5 is 8 ,8 .
next step?
a- ca level
b- glucose level
c- mg level
d- observation

4) 24 woman ,amenorrhea for 8 w , sexally active ,pain and tenderness in the RLQ, bp:110/80.
next step ?
a- laparoscopy
b- laparotomy
c- observation
d- they don't give me BHCG in the choices?

5) 36 woman,c-section 9month ago with tubular ligation during the operation,now come with menorrhagia and heavey sensation in the lower abdomen ,pE:uterin =8 weeks.
next step ?
a-endometrial biopsy
b- sono
c- hysteroscopy

6)20 woman,sexualy active, rarely use condom, come with RLQ pain with tenderness.
ns?
a-abdominal sono
b-B-HCG
c- laparoscopy
d-exploratory laparotomy

7) acute mi in ICU with cardiogenic shoke,u give him fluid and vasopressor but the CI:0.2 ,pcwp:22.
ns?
a-aortic baloon
b-echo
c-catheralization

8) 24 woman, 3 male sexual partner last year, pap 6 month ago is NL,BMI=35.
what is the contraindicated contraception?
a-IUd
b-ocp
c-tubular ligation
d- implant
(what if she doesn't have multiple sexual partner? same choices).

9) newborn 500g,during resuscitation his pulse dropped lower than 30.
ns?
a- intubation
b- catheter
c-stop resuscitaion

10) woman waked up with bell's palsy!,there is a mass behind her ear .
ns?
a-MRI
b-lp
c-corticosteroid
d-protective glasses for eyes

11)erderly man,CXR 2 days after surgery shows collapse in the left upper lobe,and the trachea is deviated to the left.
ns?
a-exercises to improve breathing.
b-observation + ABx
c- bronchoscopy

12) 57 man,2centimeter central nodule in left lung.
ns in Dx?
a-bronchoscopy
b-chest ct
c- oprn lung biopsy

13) after ERCP for a stone in the common duct,there is hi amylase + abdominal distention.
Dx?
a-pancreatitis due to ERCP .
b- duodenal perforation
c- gastric perforation
d- cholangitis

14) woman with coma (due to trauma ), her friend brought her to ER with a paper says that the pts doesn't want heroic efforts in treating her.but the durable power attorney is with pt's sister.
what will u do now?
a-treat
b- don't treat due to paper
c- call pt's sister
(what if her freind told u that the pt wrote a paper for not to give heroic effort in treating her ,nd the paper with pt's sister)

15)65 man with ALS tells u not to tell his family(children) about that.
what do u do ?
a-tell them
b-don't tell them (keeping the confidently)
c- u should tell them and look for ALS gene.

16) 4 yrs with croup,stridor.
ns in Tx?
a-albuterol
b-iv hydrocortison
c-nebulized examethason

17) 56 woman wary about colon cancer,u did colonoscopy and it is NL.
ns?
a-colonoscopy after 10 yrs
b- sigmoidoscopy after 3yrs
c- == = 5 yrs

18)aweek after birth, newborn come with jaundice,bil=16,direct =10.
ns?
a-phototherapy
b-liver biopsy

19)45 woman BMI=21,smoker .what is the more important risk factor in developing osteoporosis?
a-smoking
b- being thin

20)woman with chronic constipation,pain during defecation,and sometimes blood on stool.
ns?
a-sitz bath,high fiber regimen
b-excisional biopsy

21)child with recurrent sore throat,recurrent pneumonia,LAB:lo IgG.his father has this problem in the past.
Dx?
a-cyclic neutropenia
b-Tcell problem
c-i don't remember other choices.

22)mi,6 weeks later he got colon resection, the day after surgery he felt compressive chest pain.
explanation?

23)child with upper tibial mass,nontender,immobile,not erythematous, no tenderness.X-ray:the bone is NL,
AND THE MASS OCCUPYING the tissue near the bone.
Dx?
a-osteosarcoma
b-osteochondroma
c-sarcoma of soft tissue

24)16 boy with generalized lymphadenopathy,buccal painful ulcer,his father daid 2 yrs ago due
to pneumonia .
what is the mechanism?
a-T cell deficiency
b-B = =
C-ANTIBODIES deficiency
d-problem in burst
e- = = chemotoxins
pls check my answers:
1-a
2-a
3-d
4-c
5-b
6-b
7-a
8-a,d
9-a
10-d
11-a
12-a
13-b
14-a
15-b
16-c
17-c
18-b
19-b
20-a
21-a
22-reinfarction
23-c
24-c

1)screen: lady 62y/o, normal pap&cholesterol, heart and lungs for years, what to scren for? (mamography)

2)lady menopause, no HRT, back pain, screen for osteoporosis with DEXA/CT/MRI

3)lady menopause, nio HRT, kyphoscoliosis...do: DEXA/ pet scan/ bone scan

4) man, 32, fam history of CAD, what to screen for?-cholesterol

5) female, 32, fam hist of colon cancer, when to start screening: colonoscopy now/at 40/at 50or sygmoidoscopy at 50

6) history of allergy to bees stings: where long sleeved clothes, avoid bushes, carry epinephrine ( someone else posted this before, i had the same q)

7) positive pred value-calculate from 2x2 chart

8) cluster headache- prophylaxis

9) trigeminal neuralgia-tx with carbamazepine

10) elective splenectomy for TTP, what vaccine to give before surgery? (except pneumo)

11) splenectomy at 9y/o, now 23 y/o, had pneumo, what other vaccine is needed? (i only had hep A< hep B , meningoccocal (does it exist?) and influenza to chose from)

12) splenectomy 10 y ago, now pulm inf with gram pozitive, what is the pathophys

13) REM sleep disorder ( same as the q in UW)

14) reactive attachement dz,4y/o girl who had probl only with dad, teacher and doctor where ok

15)cyclothymia- man, depressed/maniac for 3 y

16) major depressive dz vs grief...2y after wife died

17) oppositional defiant dz- kid who argued with everybody, but had good grades

18) chronic schizo, get halloperidol and NMS after..what to treat with

19) media clip: murmur in kid of diabetic mom

20) thyramine crisis, lady at restaurant, takes MAO inhib

21) risk for fetus if mom gets in contact with epople with parvovirus B19

22) only urethral pain on urination, no frequency/urgency/fever etc...what is it? (non gonoccocal urethritis?)

23) SOB, cyanosis 30 min postpartum, BP 60/30, dies despite resuscitation, why?

24) placenta previa-bleeding, no pain, fetus transverse lie

25) female depressive adolescent, 2 suicide attempts, but says she won't do it again, admit to psych unit or treat with fluoxetine?

26) HIV, 37y/o married with attorney, doesn't want mechanical ventilation for pneumonia, husband ask you to do it anyway..

27) diabetic with foot ulcer, what causes it (derma picture)

28) HIV, CD count 150, what to give prophilaxis for

29) sickle cell female, pain on hip, normal XRay, what does she have? (Xray shown)

30) female, pain on hip, very ugly xray (shown) with necrosis, on femoral neck and intertrohanterian, but not on fem head

31) sigle liver mass- measure alphaFP levels

32) study surgery vs stent for carotid stenosis, gave 3 results from 3 studies, asks to interpret (confusing)

33) ekg: third degree block, pulse rate of 38/min

34) ekg: looked like WPW, but the history was like HOCM...confusing (athlete on bascketball

35) kawasaki-tx

36) osgood-schlatter in teenager athelete

37) slipped cap fem epyphisis- chubby 14 y/o

38) female, very high thyroxine level, very low TSH, all the signs for hyper thyroidism, lived with sister who took levo thyroxine for hypothyroidism- exogen adm??

39) pigmented lesion, grew over 2 mo, and after other appeared around it, also pigmented (derma picture)-melanoma

40) 9y/o girl, developed breasts and pubic hair, dresses like her mom, pretends to be older, mom takes OCP- what is the cause: mom's OCP/estrogen lotions/Puberty/pituitary adenoma

41) male, around 50y/o, has developed gynecomastia and and small firm testes
low TSH, LOW T3 T4, what is the cause

42) varicella after splenectomy, what is the cause (derma picture)

43) female, marrathon runner, pain on knee, normal XRAY (shown) no tenderness over tibial tubercule, full range of motion, what is it?



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