NBME Test 1

8lock 1
1) A 30yearold man wlLh a 20year hlsLory of Lype

2 dlabeLes melllLus has had sensory neuropaLhy for 2 weeks
ulses are decreased aL Lhe ankle 1here ls no perlpheral edema Pls serum
glucose levels have been beLween 130 mg/dL and 200 mg/dL over Lhe pasL 6
monLhs Whlch of Lhe followlng ls Lhe mosL effecLlve measure Lo prevenL
serlous fooL lnfecLlons?

A) use of supporL hose
8) use of wellflLLed shoes
C) rophylacLlc anLlbloLlcs
u) ually asplrln and dlpyrldamole
L) Decrease |n serum g|ucose |eve|

2) A 63yearold woman comes Lo Lhe emergency
deparLmenL because of palplLaLlons for 1 hour She was dlagnosed wlLh
hyperLhyroldlsm 2 monLhs ago buL has noL recelved LreaLmenL 1hree
hours before arrlval she drank Lwo boLLles of beer wlLh dlnner Per blood
pressure ls 90/60 mm Pg and pulse ls 83/mln and lrregularly lrregular
LxamlnaLlon shows a varlaLlon ln lnLenslLy of S1 1here ls an absence of
waves ln Lhe venous pulse An LCC ls shown Whlch of Lhe followlng ls
Lhe mosL llkely cardlac rhyLhm dlsLurbance?

A) Atr|a| f|br|||at|on
8) ALrlal fluLLer
C) MulLlfocal aLrlal Lachycardla
u) aroxysmal aLrlal Lachycardla
L) Seconddegree aLrlovenLrlcular block Wenckebach Lype
l) Slck slnus syndrome
C) SlnoaLrlal exlL block Lype ll
P) 1orsades de polnLes
l) Wanderlng pacemaker
!) WolffarklnsonWhlLe syndrome

3) A 3yearold glrl ls broughL Lo Lhe physlclan 30 mlnuLes afLer
belng blLLen on Lhe forearm by her caL LxamlnaLlon shows a small
puncLure wound covered wlLh drled blood She ls aL lncreased rlsk of
lnfecLlon for whlch of Lhe followlng reasons?

A) Arm wounds are more suscepLlble Lo lnfecLlon
) Sa||vary enzymes |n cats augment |nfect|on
C) lL ls dlfflculL Lo cleanse paLhogens from Lhls wound
u) 1he SLaphylococcus specles lnvolved ls parLlcularly vlrulenL
L) ?oung chlldren are less able Lo reslsL lnfecLlon Lhan adulLs

4) A 4yearold glrl ls broughL Lo Lhe physlclan because of pallor
and [aundlce for 2 days She had prevlously been well alLhough she was
LreaLed for [aundlce wlLh phoLoLherapy for 2 weeks whlle a newborn
Per moLher and Lwo addlLlonal maLernal relaLlves underwenL splenecLomy
durlng chlldhood for unknown reasons LxamlnaLlon of Lhe paLlenL shows
[aundlce 1he spleen Llp ls palpaLed 4 cm below Lhe lefL cosLal margln
Whlch of Lhe followlng blood smear flndlngs ls mosL llkely Lo explaln Lhls
famllys condlLlon?

A) LlllpLocyLes
8) Powell!olly bodles
C) SchlsLocyLes
u) Slckle cells
L) Spherocytes

3) A sexually acLlve 20yearold woman has had fever chllls malalse and paln of Lhe
vulva for 2 days LxamlnaLlon shows a vulvar pusLule LhaL has ulceraLed and
formed mulLlple saLelllLe leslons nodes are palpaLed ln Lhe lngulnal and
femoral areas A smear of fluld from Lhe leslons esLabllshes Lhe dlagnosls
Whlch of Lhe followlng ls Lhe mosL llkely causal organlsm?

A) Chlamydla LrachomaLls
) naemoph||us ducrey|
C) nelsserla gonorrhoeae
u) SLrepLococcus pyogenes (group A)
L) 1reponema pallldum

6) A 3yearold boy ls broughL Lo Lhe physlclan 1 hour afLer urlnaLlng
brlghL red blood Pe has been Laklng lbuprofen slnce ln[urlng hls
rlghL flank whlle wresLllng wlLh frlends yesLerday he also has been
Laklng penlclllln for 3 days for sLrepLococcal pharynglLls Pls
LemperaLure ls 367 C (98 l) blood pressure ls 90/48mm Pg pulse ls
108/mln and resplraLlons are 18/mln LxamlnaLlon shows purple
ecchymoses over Lhe shlns and rlghL flank Lhere ls Lenderness of Lhe
rlghL cosLoverLebral area 1he abdomen ls nonLender CenlLal
examlnaLlon shows no abnormallLles 1here ls no edema urlnalysls
shows gross blood mlcroscoplc examlnaLlon shows 310 leukocyLes/hpf
and eryLhrocyLes LhaL are Loo numerous Lo counL Whlch of Lhe followlng
ls Lhe mosL llkely explanaLlon for Lhls paLlenLs hemaLurla?

A) AcuLe pyelonephrlLls
) Ibuprofen|nduced acute pap|||ary necros|s
C) osLsLrepLococcal glomerulonephrlLls
u) 8habdomyolysls
L) 1raumaLlc ln[ury Lo Lhe kldney

7) A 16yearold glrl comes Lo Lhe physlclan for her flrsL prenaLal
vlslL aL 12 weeks gesLaLlon She has noL had any lmmunlzaLlons slnce
Lhe age of 3 years She has recelved Lhe followlng lmmunlzaLlons aL Lhe
recommended ages

3 ulphLherlaLeLanusperLussls
3 PepaLlLls 8
1 Measlesmumpsrubella
4 Cral pollovlrus
LxamlnaLlon shows no abnormallLles Whlch of Lhe followlng ls Lhe mosL
approprlaLe lmmunlzaLlon Lo admlnlsLer aL Lhls vlslL?

A) ulphLherlaLeLanusperLussls
) D|phther|a(ch||d)tetanus toxo|d
C) ulphLherla (adulL)LeLanus Loxold
u) Paemophllus lnfluenzae Lype b
L) PepaLlLls 8
l) lnacLlvaLed pollovlrus

8) A 12yearold boy ls broughL Lo Lhe physlclan because of
LemperaLures Lo 402 C (1044 l) leLhargy and a sLlff neck for 2 days A
dlagnosls of pneumococcal menlnglLls ls made and Lhe chlld ls admlLLed Lo
Lhe hosplLal for anLlbloLlc Lherapy Serum sLudles 24 hours afLer
admlsslon show

na+ 117 mLq/L
Cl 89 mLq/L
PCC3 23 mLq/L

Whlch of Lhe followlng ls Lhe mosL llkely explanaLlon for Lhese flndlngs?

A) Lxcesslve corLlsol release
8) PyperaldosLeronlsm
) Inappropr|ate secret|on of ADn (vasopress|n)
u) lncreased producLlon of leukoLrlene C4

9) An asympLomaLlc 37yearold man wlLh a 3year hlsLory of Lype 2
dlabeLes melllLus comes for a rouLlne followup vlslL LxamlnaLlon shows no
abnormallLles Serum sLudles show
AsparLaLe amlnoLransferase (AS1 CC1) 76 u/L
Alanlne amlnoLransferase (AL1 C1) 86 u/L
lron 260 g/dL 1oLal lronblndlng capaclLy 300 g/dL (n230430)
lerrlLln 1200 ng/mL AnLlnuclear anLlbody negaLlve
Serologlc LesLlng for hepaLlLls ls negaLlve Whlch of Lhe followlng ls
Lhe mosL approprlaLe nexL sLep ln managemenL?

A) CorLlcosLerold Lherapy
8) lnLerferon Lherapy
) en|c|||am|ne therapy
u) Chronlc phleboLomy
L) no Lherapy lndlcaLed

10) A 26yearold man has had anxleLy and lnsomnla slnce he losL hls
[ob 1 monLh ago Pe also has had palplLaLlons dally headaches and
flaLulence Pe has no hlsLory of psychlaLrlc dlsorders Pls moLher has
a hlsLory of blpolar dlsorder mlxed and hls faLher has alcohollsm
hls younger slsLer had a hlsLory of drug abuse buL has been absLlnenL
from drugs for 3 years Whlch of Lhe followlng ls Lhe mosL llkely
dlagnosls?

A) Ad[ustment d|sorder
8) 8lpolar dlsorder depressed
C) Cenerallzed anxleLy dlsorder
u) Ma[or depresslve dlsorder
L) osLLraumaLlc sLress dlsorder

11) A prevlously healLhy 32yearold man comes Lo Lhe emergency
deparLmenL because of a 12hour hlsLory of faLlgue and shorLness of breaLh
aL resL Pe Lakes no medlcaLlons Pls LemperaLure ls 37 C (986 l) blood pressure ls
96/38 mm Pg pulse ls 110/mln and resplraLlons are 22/mln LxamlnaLlon shows
scleral lcLerus and con[uncLlval pallor 1here ls no hepaLosplenomegaly LaboraLory
SLudles show
Pemoglobln 62 g/dL
Serum LeukocyLe counL 8800/mm3
8lllrubln LoLal 83 mg/dL
8eLlculocyLe counL 16
ulrecL 13 mg/dL
laLeleL counL 243000/mm3
LacLaLe dehydrogenase 1260 u/L

A) AcuLe Loxlc hepaLlLls
8) Alcohollc hepaLlLls
C) Cholanglocarclnoma
u) Chronlc ldlopaLhlc clrrhosls
L) Common blle ducL calculus
l) CongesLlve hepaLlLls
C) CallsLone pancreaLlLls
P) CllberLs syndrome
l) lnfecLlous hepaLlLls
I) Intravascu|ar hemo|ys|s
k) rlmary blllary clrrhosls

12) A 24yearold Lhlrdyear medlcal sLudenL comes Lo Lhe sLudenL healLh cllnlc for
evaluaLlon of [aundlce whlch he noLlced Lhls mornlng Pe has had no abdomlnal
paln lLchlng or welghL change Pe Lakes no medlcaLlons Pe descrlbes recenL
anxleLy over anLlclpaLlon of Lhe upcomlng SLep 2 examlnaLlon Pls LemperaLure ls
37 C (986 l) blood pressure ls 120/80 mm Pg pulse ls 76/mln and resplraLlons
are 12/mln LxamlnaLlon shows no abnormallLles excepL for scleral lcLerus

LaboraLory sLudles show

Pemoglobln 13 g/dL Serum
LeukocyLe counL 7000/mm3
Alkallne phosphaLase 90u/L
AsparLaLe amlnoLransferase Serum (AS1 CC1) 23 u/L
Alanlne amlnoLransferase ulrecL 07 mg/dL (AL1 C1) 27 u/L

A) AcuLe Loxlc hepaLlLls
8) Alcohollc hepaLlLls
C) Cholanglocarclnoma
u) Chronlc ldlopaLhlc clrrhosls
L) Common blle ducL calculus
l) CongesLlve hepaLlLls
C) CallsLone pancreaLlLls
n) G||berts syndrome
l) lnfecLlous hepaLlLls
!) lnLravascular hemolysls
k) rlmary blllary clrrhosls

13) A 37yearold woman wlLh a 2year hlsLory of hyperLenslon comes for a followup
examlnaLlon her hyperLenslon has worsened desplLe LreaLmenL wlLh a lowsodlum
dleL and a adrenerglc blocklng agenL She has a hlsLory of rheumaLlc fever and
Craves dlsease LreaLed wlLh 131l Per blood pressure ls 160/106 mm Pg and
pulse ls 80/mln Serum sLudles show

na+ 133 mLq/L
Cl 100 mLq/L
k+ 34 mLq/L
PCC3 26 mLq/L
urea nlLrogen (8un) 12 mg/dL
CreaLlnlne 08 mg/dL

urlnalysls ls wlLhln normal llmlLs 8enal ulLrasonography shows a lefL kldney wlLh a
markedly lrregular conLour lL ls 28 cm smaller Lhan Lhe rlghL

A) Adrenal corLex
8) Adrenal medulla
C) AorLa
D) kena| arter|es
L) 8enal glomerull
l) 1hyrold gland

14) A 27yearold woman comes Lo Lhe physlclan because of muscle weakness and
cramps for 2 weeks She has been Laklng a adrenerglc blocklng agenL for
hyperLenslon for 2 years She had chronlc lymphocyLlc LhyroldlLls (PashlmoLos
dlsease) 1 year ago Per blood pressure ls 160/108 mm Pg and pulse ls 60/mln
Serum sLudles show

na+ 140 mLq/L
Cl 110 mLq/L
k+ 22 mLq/L
PCC3 30 mLq/L
CreaLlnlne 1 mg/dL

MagneLlc resonance anglography of Lhe abdomen shows normal flndlngs

A) Adrena| cortex
8) Adrenal medulla
C) AorLa
u) 8enal arLerles
L) 8enal glomerull
l) 1hyrold gland

13) A 24yearold man ls hosplLallzed for LreaLmenL of a posLerlor dlslocaLlon of Lhe
rlghL knee susLalned ln a moLorcycle colllslon Slx hours afLer closed reducLlon
prevlously presenL dlsLal pulses ln hls fooL are absenL buL Lhe fooL has remalned
warm Whlch of Lhe followlng ls Lhe mosL approprlaLe nexL sLep ln managemenL?

A) LlevaLlon of Lhe llmb and observaLlon for 24hours
8) nlLroprusslde Lherapy
C) SympaLheLlc block
D) Iemora| arter|ography
L) LmbolecLomy wlLh a logarLy caLheLer Lhrough aproxlmal arLerloLomy
l) lnflammaLlon of Lhe orlgln of Lhe planLar fascla

16) A healLhy 4yearold glrl ls broughL for a wellchlld examlnaLlon A grade 2/6
sysLollc e[ecLlon murmur ls heard along Lhe upper lefL sLernal border S2 ls wldely
spllL and does noL vary wlLh resplraLlon A sofL mlddlasLollc murmur ls heard along
Lhe lower lefL sLernal border LxamlnaLlon shows no oLher abnormallLles Whlch of
Lhe followlng ls Lhe mosL llkely dlagnosls?

A) AorLlc sLenosls
) Atr|a| septa| defect
C) CoarcLaLlon of Lhe aorLa
u) MlLral valve prolapse
L) aLenL ducLus arLerlosus
l) ulmonary sLenosls
C) 1eLralogy of lalloL
P) 1ransposlLlon of Lhe greaL arLerles
l) venLrlcular sepLal defecL
!) normal hearL

18) A prevlously healLhy 37yearold woman comes Lo Lhe physlclan because of Lhree
eplsodes of blurred vlslon ln Lhe rlghL eye over Lhe pasL 3 weeks each eplsode
lasLs approxlmaLely 3mlnuLes 8eLlnal examlnaLlon shows a small refracLlle body aL
1he blfurcaLlon of a reLlnal arLery 1he remalnder of Lhe examlnaLlon shows no
abnormallLles Whlch of Lhe followlng ls Lhe mosL approprlaLe nexL sLep ln
dlagnosls?

A) Cerebral anglography
8) Lchocardlography
C) LlecLroencephalography
D) Dup|ex scan of the carot|d arter|es
L) M8l of Lhe braln

19) A 67yearold woman comes Lo Lhe physlclan for her flrsL lnfluenza vlrus
vacclnaLlon She has a hlsLory of unLreaLed hyperLenslon Per blood pressure ls
160/100 mm Pg and pulse ls 100/mln ShorLly afLer admlnlsLraLlon of Lhe
lnfluenza vlrus vacclne she develops shorLness of breaLh hlves and angloedema
Whlch of Lhe followlng ls mosL llkely Lo have prevenLed Lhls reacLlon?

A) Inqu|ry about an egg a||ergy
8) PeLerophlle aggluLlnaLlon LesL
C) Skln LesL wlLh hlsLamlne reagenL
u) Adrenerglc blocklng agenL Lherapy
L) AmanLadlne Lherapy
l) lnsulln Lherapy
C) 8lmanLadlne Lherapy

20) A 7yearold glrl ls broughL Lo Lhe physlclan because of a 2day hlsLory of fever
headache sore LhroaL and swollen glands She does noL have a runny nose
congesLlon or cough She has no allergles Lo medlcaLlons Per LemperaLure ls
386C (1014 l) blood pressure ls 100/60 mm Pg pulse ls 120/mln and
resplraLlons are 16/mln LxamlnaLlon shows a swollen eryLhemaLous oropharynx
WlLh Lonslllar exudaLes 1he anLerlor cervlcal lymph nodes are enlarged and
Lender no oLher abnormallLles are noLed Whlch of Lhe followlng ls Lhe mosL llkely
causal organlsm?

A) Adenovlrus
8) CorynebacLerlum dlphLherlae
) Group A streptococcus
u) Paemophllus lnfluenzae
L) Mycoplasma pneumonlae

21) A 70yearold nurslng home resldenL ls admlLLed Lo Lhe hosplLal because of
progresslve obLundaLlon over Lhe pasL 2 days Pe has Lachycardla Lachypnea and
hypoLenslon 8llaLeral basllar crackles and an S3 gallop are heard on ausculLaLlon
LxamlnaLlon shows [ugular venous dlsLenLlon and perlpheral edema SwanCanz
caLheLerlzaLlon shows a cardlac lndex of 18 L/mln/m2 (n2342) a mean
ulmonary caplllary wedge pressure of 23 mm Pg (n110) and markedly
lncreased sysLemlc vascular reslsLance Whlch of Lhe followlng ls Lhe mosL llkely
dlagnosls?

A) ard|ogen|c shock
8) Pypovolemlc shock
C) neurogenlc shock
u) SepLlc shock

22) A 42yearold man wlLh alcohollsm ls broughL Lo Lhe emergency deparLmenL by a
frlend because of fever and progresslve shorLness of breaLh for 12 hours Pls
frlend reporLs LhaL Lhey were eaLlng lefLover chlcken and drlnklng beer earller ln
Lhe day when Lhe paLlenL suddenly choked and vomlLed Slx hours laLer he
developed sweaLlng chllls and shorLness of breaLh Pe has noL had any
subsequenL nausea vomlLlng hemaLemesls or abdomlnal paln Pe has smoked
1wo packs of clgareLLes dally for 22 years and drlnks 12 Lo 18 beers dally Pe ls ln
moderaLe resplraLory dlsLress Pls LemperaLure ls 393 C (1028 l) blood pressure
ls 90/60 mm Pg pulse ls 120/mln and resplraLlons are 24/mln LxamlnaLlon
shows no [ugular venous dlsLenLlon 8reaLh sounds are decreased halfway up Lhe
lefL lung wlLh lncreased dullness Cardlac examlnaLlon shows a normal S1 and S2
no murmurs are heard 1here ls no abdomlnal Lenderness 8owel sounds are
hypoacLlve xray fllms of Lhe chesL show a lefL pleural effuslon and alr ln Lhe
medlasLlnum 1horacenLesls ls performed
SegmenLed neuLrophlls 83
8ands 10
LymphocyLes 3
Serum roLeln 6 g/dL
leural fluld LeukocyLe counL 8000/mm3
MonocyLes 2
roLeln 42 g/dL
Amylase 140 u/L
Crams sLaln
W8C presenL
Crganlsms none

Whlch of Lhe followlng ls Lhe mosL llkely dlagnosls?

A) CongesLlve hearL fallure
) Lsophagea| rupture
C) ancreaLlLls
u) erlcardlLls
L) 1uberculosls

23) A 2yearold glrl wlLh Lrlcuspld aLresla has lncreaslng resplraLory dlsLress for 2
days She has been recoverlng unevenLfully from an operaLlon 10 days ago Lo [oln
sysLemlc venous reLurn wlLh pulmonary arLerlal clrculaLlon Cver Lhe pasL 4 days
she has been weaned off mechanlcal venLllaLlon sLarLed on oral feedlngs and
ls recelvlng chesL physloLherapy for aLelecLasls Per LemperaLure ls 374 C (993 l)
blood pressure ls 98/64 mm Pg pulse ls 120/mln and resplraLlons are 46/mln
LxamlnaLlon shows nasal flarlng grunLlng and lnLercosLal reLracLlons An xray
fllm of Lhe chesL shows large bllaLeral pleural effuslons 1horacenLesls ylelds 300
mL of whlLlshyellow fluld 1he supernaLanL remalns unlformly opaque on
cenLrlfugaLlon Whlch of Lhe followlng ls Lhe mosL llkely cause of Lhe pleural
effuslons?

A) hy|othorax
8) CongesLlve hearL fallure
C) Lmpyema
u) ulmonary embollsm
L) Superlor vena cava obsLrucLlon

24) A 23yearold man ls broughL Lo Lhe physlclan by hls moLher because he has heard
a volce over Lhe pasL monLh Lelllng hlm Lo hurL hlmself Pls moLher says LhaL her
son has no frlends and ls a llfelong loner slnce graduaLlng from hlgh school he
has been unable Lo hold a [ob Pe admlLs Lo smoklng marl[uana occaslonally and
drlnklng slx beers weekly LxamlnaLlon shows a poorly groomed man wlLh poor
eye conLacL Pe has a flaL affecL and llmlLed faclal expresslon Pe says he has no
lnLenLlon of harmlng hlmself or oLhers Whlch of Lhe followlng ls Lhe mosL
approprlaLe nexL sLep ln managemenL?

A) Schedule a followup vlslL ln 4 weeks
) rescr|be ora| r|sper|done and schedu|e a fo||owup v|s|t |n 2 weeks
C) AdmlL hlm Lo Lhe parLlal hosplLal program and prescrlbe oral llLhlum carbonaLe
u) AdmlL hlm Lo Lhe psychlaLrlc unlL for deLoxlflcaLlon
L) AdmlL hlm Lo Lhe psychlaLrlc unlL and prescrlbe oral lmlpramlne

23) A 23yearold man ls broughL Lo Lhe physlclan by hls moLher because he has heard
a volce over Lhe pasL monLh Lelllng hlm Lo hurL hlmself Pls moLher says LhaL her
son has no frlends and ls a llfelong loner slnce graduaLlng from hlgh school he
has been unable Lo hold a [ob Pe admlLs Lo smoklng marl[uana occaslonally and
urlnklng slx beers weekly LxamlnaLlon shows a poorly groomed man wlLh poor
Lye conLacL Pe has a flaL affecL and llmlLed faclal expresslon Pe says he
has no lnLenLlon of harmlng hlmself or oLhers Whlch of Lhe followlng ls Lhe mosL

A) Schedule a followup vlslL ln 4 weeks

8) rescrlbe oral rlsperldone and schedule a followup vlslL ln 2 weeks

C) AdmlL hlm Lo Lhe parLlal hosplLal program and prescrlbe oral llLhlum carbonaLe

u) AdmlL hlm Lo Lhe psychlaLrlc unlL for deLoxlflcaLlon

L) AdmlL hlm Lo Lhe psychlaLrlc unlL and prescrlbe oral lmlpramlne

26) An 18monLhold boy ls broughL for a wellchlld examlnaLlon Pe was born aL 37
weeks gesLaLlon and welghed 2800 g (6 lb 3oz) 1here were no prenaLal or
perlnaLal compllcaLlons uevelopmenLal hlsLory lndlcaLes LhaL he ls able Lo run and
walk up sLalrs whlle holdlng hls moLhers hand Pe can hold a crayon buL does noL
Scrlbble sponLaneously Pe ls aL Lhe 40Lh percenLlle for lengLh and 30Lh percenLlle
for welghL LxamlnaLlon shows a crude plncer grasp Whlch of Lhe followlng ls Lhe
mosL approprlaLe assessmenL of flne and gross moLor developmenL?

llne MoLor Cross MoLor
uevelopmenL uevelopmenL

A) De|ayed norma|

8) normal delayed

C) uelayed delayed

u) normal normal

27) llve monLhs afLer beglnnlng fluoxeLlne Lo LreaL obsesslvecompulslve dlsorder a
19yearold man sLaLes LhaL he dlsconLlnued hls medlcaLlon 2 monLhs ago because
he had begun Lo worry abouL Laklng hls medlcaLlon every day Pls lnlLlal response
Lo Lhe medlcaLlon was good Pls sympLoms have now reLurned and hls mornlng
rlLual of cleanlng and groomlng consumes so much Llme LhaL hls [ob ls ln [eopardy
ln addlLlon Lo educaLlon abouL Lhe naLure of hls dlsorder and lLs LreaLmenL whlch
of Lhe followlng ls Lhe mosL approprlaLe nexL sLep ln managemenL?

A) 1ell Lhe paLlenL Lo schedule a reLurn vlslL as needed

8) Cffer Lo change Lhe medlcaLlon

C) 8equesL LhaL Lhe paLlenLs parenLs supervlseadmlnlsLraLlon of medlcaLlon

u) MonlLor Lhe paLlenLs compllance by weekly blood LesLs

L) 8egln a Lrlal of cognlLlvebehavlor Lherapy

28) A 32yearold woman comes Lo Lhe physlclan because of a 3monLh hlsLory of
lncreaslng paln and sLlffness ln her wrlsLs hands and ankles uurlng Lhls perlod
she also has had progresslve faLlgue and mornlng sLlffness lasLlng 2 hours She has
a 1year hlsLory of rheumaLold arLhrlLls LreaLed wlLh naproxen LxamlnaLlon shows
redness swelllng and warmLh over Lhe wrlsL hand and ankle [olnLs bllaLerally
1here are nonLender subcuLaneous nodules over Lhe exLensor surfaces of boLh
elbows xray fllms of Lhe hands show dlffuse osLeopenla and eroslons over several
of Lhe dlsLal meLacarpal bones Whlch of Lhe followlng ls Lhe mosL approprlaLe
pharmacoLherapy?

A) Add oral cyclophosphamlde

8) Add oral gold

C) Add oral meLhoLrexaLe

u) Add oral penlclllamlne

L ) SwlLch Lo oral lbuprofen

28) A prevlously healLhy 62yearold man comes Lo Lhe physlclan because of a 2monLh
hlsLory of progresslve shorLness of breaLh and a mlld nonproducLlve cough Pe
does noL smoke Pe worked ln a foundry mosL of hls adulL llfe before reLlrlng 2
years ago vlLal slgns are wlLhln normal llmlLs Crackles are heard aL boLh lung
8ases wlLh no wheezes Cardlac examlnaLlon shows an accenLuaLed 2 1he
remalnder of Lhe examlnaLlon shows no abnormallLles An xray fllm of Lhe chesL
shows promlnenL lnLersLlLlal marklngs aL Lhe lung bases Lchocardlography shows
an e[ecLlon fracLlon of 33 ulmonary funcLlon LesLlng ls mosL llkely Lo show
whlch of Lhe followlng?

A) uecreased lLv1lvC raLlo

8) uecreased maxlmal lnsplraLory efforL

) Decreased tota| |ung capac|ty

u) lncreased forced vlLal capaclLy

L) normal carbon monoxlde dlffuslon capaclLy

29) A 33yearold man ls admlLLed Lo Lhe hosplLal because of progresslve shorLness of
breaLh for 10 days Pe has a hlsLory of chronlc venous sLasls and deep venous
Lhrombosls Pe has been LreaLed wlLh warfarln slnce he had several pulmonary
emboll 2 years ago he Lakes no oLher medlcaLlon Pe has smoked Lwo packs of
ClgareLLes dally for 30 years Pe welghs 109 kg (240 lb) and ls 163 cm (63 ln) Lall
LxamlnaLlon shows [ugular venous dlsLenLlon Lchocardlography ls mosL llkely Lo
show whlch of Lhe followlng?

A) LefL venLrlcular dllaLlon
8) MlLral sLenosls
C) erlcardlal Lhlckenlng and Lamponade
D) k|ght ventr|cu|ar hypertrophy and d||at|on
L) 1rlcuspld sLenosls

30) A 32yearold woman comes Lo Lhe physlclan because of weakness of Lhe lower
exLremlLles for 2 days 1hree years ago she had paln and parLlal loss of vlslon of
Lhe rlghL eye Lhe vlslon reLurned Lo normal afLer 6 weeks 1here ls mlld pallor of
Lhe rlghL opLlc dlsc She has lmpalred Landem galL 8ablnskls slgn ls presenL
bllaLerally 1here ls mlld spasLlclLy of Lhe lower exLremlLles and mlld weakness of
Lhe lllopsoas and hamsLrlng muscles Serum creaLlne klnase acLlvlLy ls 30 u/L

A) AmyoLrophlc laLeral sclerosls
8) 8eckers muscular dysLrophy
C) ulffuse sensorlmoLor perlpheral neuropaLhy
u) uuchennes muscular dysLrophy
L) Pyperkalemlc perlodlc paralysls
l) Pypokalemlc perlodlc paralysls
G) Mu|t|p|e sc|eros|s
P) MyasLhenla gravls
l) MyasLhenlc (LamberLLaLon) syndrome
!) MyoLonlc muscular dysLrophy
k) olymyoslLls
L) onLlne asLrocyLoma
M) onLlne lnfarcLlon
n) Splnal cord Lumor
C) 1ransverse myellLls

31) A healLhy 42yearold man comes Lo Lhe physlclan for a llfe lnsurance evaluaLlon
Pe smoked onehalf pack of clgareLLes dally for 20 years buL qulL 10 years ago Pls
faLher dled of a myocardlal lnfarcLlon aL Lhe age of 63 years 1he paLlenL welghs 93
kg (203lb) and ls 178 cm (70 ln) Lall Pls blood pressure ls 160/110 mm Pg
pulse ls 96/mln and resplraLlons are 16/mln hyslcal examlnaLlon LCC and an x
ray fllm of Lhe chesL show no abnormallLles LaboraLory sLudles are wlLhln normal
llmlLs excepL for a serum cholesLerol level of 206 mg/dL Whlch of Lhe followlng ls
Lhe greaLesL rlsk facLor for cerebral lnfarcLlon ln Lhls paLlenL?

A) CeneLlc proflle
8) PlsLory of smoklng
C) PypercholesLerolemla
D) nypertens|on
L) CbeslLy

32) A prevlously healLhy 36yearold woman comes Lo Lhe physlclan because of
[aundlce and dark urlne for 3 weeks She has a 1year hlsLory of generallzed
prurlLus She Lakes no medlcaLlons LxamlnaLlon shows [aundlce and several
ecchymoses over Lhe forearms and Lhlghs 1he llver and spleen are enlarged and
nonLender LaboraLory sLudles show

roLhrombln Llme 18 sec
Serum roLeln 1oLal 83 g/dL
Albumln 38 g/dL
8lllrubln 1oLal 3 mg/dL
ulrecL 2 mg/dL
Alkallne phosphaLase 130 u/L
AnLlmlLochondrlal anLlbody assay ls sLrongly poslLlve

A C1 scan of Lhe abdomen shows hepaLosplenomegaly
Lndoscoplc reLrograde cholanglopancreaLography shows no abnormallLles

8ecause of her condlLlon Lhls paLlenL ls aL greaLesL rlsk for whlch of Lhe followlng
deflclencles?

A) nlacln
) V|tam|n A
C) vlLamln 82 (rlboflavln)
u) vlLamln 812 (cyanocobalamln)
L) vlLamln C

33) An asympLomaLlc 32yearold man comes for a followup examlnaLlon 1 monLh afLer he
passed renal calcull Pe has a hlsLory of renal calcull 2 years ago Serum urlc acld and
calclum levels and urlnary oxalaLe excreLlon are wlLhln normal llmlLs urlnary calclum
excreLlon ls lncreased ln order Lo avold recurrence of renal calcull whlch of Lhe followlng ls
Lhe mosL approprlaLe pharmacoLherapy for Lhls paLlenL?

A) 8lcarbonaLe
8) Calclum lacLaLe
C) MeLhenamlne mandelaLe
u) robenecld
L) 1h|az|de d|uret|c

34) A 37yearold woman ls broughL Lo Lhe emergency deparLmenL because of
abdomlnal paln for 12 hours Cver Lhe pasL 3 hours Lhe paln has become
severe and generallzed Cver Lhe pasL monLh she has had mlld upper
abdomlnal dlscomforL LhaL ls relleved by eaLlng She has a hlsLory of
recurrenL mlgralnes LreaLed wlLh sumaLrlpLan as needed Per LemperaLure
ls 382 C (1008 l) blood pressure ls 170/93 mm Pg and pulse ls 110/mln
Abdomlnal examlnaLlon shows mlld dlsLenLlon Lhere ls marked rlgldlLy wlLh
dlffuse Lenderness 8owel sounds are absenL 8ecLal examlnaLlon
shows no abnormallLles LesL of Lhe sLool for occulL blood ls negaLlve

PemaLocrlL 36
Serum
na+ 143 mLq/L
Cl 106 mLq/L
k+ 38 mLq/L
PCC3 19 mLq/L

Whlch of Lhe followlng ls Lhe mosL approprlaLe nexL sLep ln dlagnosls?

A) kray f||ms of the abdomen wh||e sup|ne and stand|ng
8) Abdomlnal ulLrasonography
C) upper gasLrolnLesLlnal serles wlLh conLrasL
u) PluA scan
L) llberopLlc endoscopy of Lhe upper gasLrolnLesLlnal LracL

33 An 18yearold man comes Lo Lhe physlclan because of lLchy leslons on hls penls for 2
weeks and lLchlng around hls wrlsLs and ankles for 1 week Pe ls sexually acLlve and does
noL conslsLenLly use condoms LxamlnaLlon shows scaLLered crusLed leslons on Lhe
penls and no slgnlflcanL lngulnal lymphadenopaLhy 1here are excorlaLed papules on Lhe
wrlsLs and ankles a few papules beLween Lhe flngers and excorlaLlons
along Lhe belL llne Whlch of Lhe followlng ls Lhe mosL llkely dlagnosls?

A) ulssemlnaLed prlmary herpes slmplex
8) Lczema
) Scab|es
u) Secondary syphllls
L) vascullLls

36 An asympLomaLlc 62yearold man comes for a followup vlslL
Cne monLh ago he had acuLe cysLlLls LreaLed wlLh clprofloxacln AL hls
lnlLlal vlslL a urlne culLure grew klebslella pneumonlae Pe has a
2year hlsLory of chronlc prosLaLlLls and has had four eplsodes of
cysLlLls over Lhe pasL year Pls LemperaLure ls 369C (984 l)
LxamlnaLlon lncludlng prosLaLe examlnaLlon shows no abnormallLles
Whlch of Lhe followlng ls Lhe mosL approprlaLe measure Lo prevenL
recurrenL eplsodes of cysLlLls ln Lhls paLlenL?

A) 1r|methopr|msu|famethoxazo|e prophy|ax|s
8) lnserLlon of a loley caLheLer
C) 1oLal prosLaLecLomy
u) 1ransureLhral prosLaLecLomy
L) no LreaLmenL ls avallable

37 A 32yearold woman comes for a rouLlne healLh malnLenance examlnaLlon
LxamlnaLlon shows a bloody dlscharge from Lhe nlpple of her lefL breasL
1here ls no palpable mass Cn quesLlonlng she says LhaL she never noLed Lhe
dlscharge and does noL perform breasL selfexamlnaLlons Whlch of Lhe followlng
ls Lhe mosL llkely dlagnosls?

A) 8reasL abscess
8) 8reasL cysL
C) 8reasL hemaLoma
u) llbroadenoma
L) llbrocysLlc changes of Lhe breasL
I) Intraducta| adenoma
38 A 33yearold woman ls broughL Lo Lhe physlclan by her husband
because of lncreaslng memory loss and lnvolunLary danclng movemenLs
over Lhe pasL 6 weeks She has had dlfflculLy rememberlng Lhlngs
parLlcularly recenL evenLs She has had no dlsLurbances ln sleep or appeLlLe
Per medlcal hlsLory ls unremarkable She does noL remember her moLher
who dled 23 years ago buL her faLher Lold her LhaL her moLher had
slmllar sympLoms several years before her deaLh
neurologlc examlnaLlon shows lnvolunLary chorelform movemenLs
She has a chlldllke affecL She descrlbes her mood as good Cn recall LesLlng she
can remember one ouL of Lhree ob[ecLs afLer 3 mlnuLes wlLh dlsLracLlon she
cannoL remember Lhe oLher ob[ecLs wlLh prompLlng She cannoL remember
Lhe daLe of her marrlage or her prevlous address 1he mosL llkely
cause of Lhese sympLoms ls a leslon aL whlch of Lhe followlng locaLlons?

A) audate nuc|eus
8) arleLal lobe
C) refronLal lobe
u) uLamen
L) 1emporal lobe

39 A 67yearold man comes Lo Lhe physlclan because of lnsomnla for
2 years Pe goes Lo bed aL 1100 M afLer Laklng a baLh buL does noL
fall asleep unLll mldnlghL Pe usually wakes up Lwlce each nlghL once
around 300 AM Lo vold and agaln aL 600 AM Pe sLays ln bed unLll hls
alarm goes off aL 7 AM Pe ls concerned because he used Lo sleep 8
hours dally Pe recenLly reLlred from hls [ob as an aLLorney Pe Lakes
no medlcaLlons Pe drlnks one beer wlLh lunch 3 days each week and
one glass of wlne wlLh dlnner each evenlng Pe walks 1 mlle dally afLer
dlnner hyslcal examlnaLlon shows no abnormallLles
Pls mood ls neuLral and cognlLlon ls lnLacL urlne Loxlcology
screenlng ls negaLlve Whlch of Lhe followlng ls Lhe mosL llkely cause of
Lhls paLlenLs sympLoms?

A) Advanced sleep phase syndrome
8) Alcohol abuse
C) uelayed sleep phase syndrome
u) Ma[or depresslve dlsorder
L) MelaLonln deflclency
l) oor sleep hyglene
G) Norma| ag|ng

40 An asympLomaLlc 37yearold woman comes for a followup examlnaLlon 1 year afLer
recelvlng a renal LransplanL CurrenL medlcaLlons lnclude felodlplne enalaprll cyclosporlne
pravasLaLln and penlclllln C She appears well Per LemperaLure ls 368 C (982l) blood
pressure ls 160/93 mm Pg pulse ls 80/mln and resplraLlons are 12/mln
LxamlnaLlon shows no oLher abnormallLles Whlch of Lhe followlng
medlcaLlons ls Lhe mosL llkely cause of Lhls paLlenLs hyperLenslon?

A) yc|ospor|ne
8) Lnalaprll
C) lelodlplne
u) enlclllln C
L) ravasLaLln

41 A 4080g (9lb) male newborn ls dellvered aL Lerm Lo a 32yearold woman gravlda 2
para 1 Apgar scores are 8 and 9 aL 1 and 3 mlnuLes respecLlvely LxamlnaLlon ln Lhe
dellvery room shows fracLure of Lhe rlghL clavlcle Whlch of Lhe followlng ls Lhe
mosL llkely sequela of Lhls condlLlon?

A) CorrecLlon only wlLh casLlng
8) CorrecLlon only wlLh physlcal Lherapy
C) LefLhand domlnance
u) ermanenL nerve damage
L) SponLaneous heallng wlLhouL LreaLmenL

42 A 22yearold man wlLh schlzoaffecLlve dlsorder ls broughL Lo
Lhe emergency deparLmenL 2 hours afLer Lhe sudden
onseL of neck and back
paln 1he sympLoms began afLer Laklng one of hls
medlcaLlons for hls
psychlaLrlc dlsorder 1he dosage was lncreased
yesLerday buL he does
noL recall Lhe names of elLher of hls medlcaLlons Pe
has no oLher
hlsLory of serlous lllness hyslcal examlnaLlon
shows rlgld conLracLlon
of Lhe neck and back muscles wlLh archlng Cn menLal
sLaLus
examlnaLlon he ls alerL and cooperaLlve and hears a
falnL volce LhaL Lells hlm Lo
wash wlndows Pe ls orlenLed Lo person place and
Llme Whlch of Lhe
followlng medlcaLlons ls mosL llkely responslble for
Lhls paLlenLs
sympLoms?

A
) Clozaplne

8
) Paloperldol

C
) LlLhlum carbonaLe

u
) 1razodone

L
) valprolc acld

43 A 32yearold woman gravlda 3 para 3 comes
Lo Lhe physlclan
because of lrregular vaglnal bleedlng over Lhe pasL 2
monLhs She has
hyperLenslon LreaLed wlLh enalaprll and Lype 2
dlabeLes melllLus well
conLrolled wlLh dleL Menopause occurred 2 years ago
Per maLernal aunL
had breasL cancer aL Lhe age of 70 years 1he paLlenL
welghs 88 kg
(193 lb) and ls 160 cm (63 ln) Lall LxamlnaLlon
shows no oLher
abnormallLles An endomeLrlal blopsy speclmen shows
adenocarclnoma Whlch of
Lhe followlng ls Lhe mosL slgnlflcanL predlsposlng
facLor for Lhls
paLlenLs endomeLrlal cancer?

A
) PeredlLy

8
) PyperLenslon

C
) arlLy

u
) 1ype 2 dlabeLes melllLus

L
) WelghL

44 A 67yearold man ls broughL Lo Lhe emergency
deparLmenL 2 hours
afLer Lhe onseL of weakness and double vlslon Pe has
hyperLenslon and
hyperllpldemla LreaLed wlLh meLoprolol capLoprll and
aLorvasLaLln
Pls blood pressure ls 190/106 mm Pg neurologlc
examlnaLlon shows
lefLslded faclal weakness lncludlng Lhe forehead
1here ls palsy of lefL
con[ugaLe gaze and Lhe lefL eye falls Lo adducL on
rlghL gaze
verLlcal eye movemenLs are lnLacL Muscle sLrengLh ls
3/3 ln Lhe rlghL upper
and lower exLremlLles ueep Lendon reflexes are
brlsk and 8ablnskls
slgn ls presenL on Lhe rlghL Whlch of Lhe followlng
ls Lhe mosL
llkely locaLlon of Lhls paLlenLs leslon?

A
) 8llaLeral Lhalamlc

8
) LefL fronLal

C
) LefL ponLlne

u
) 8lghL caudaLe

L
) 8lghL mldbraln

43 Slx weeks afLer sponLaneous dralnage of an anal
abscess a
32yearold man has perslsLenL bloodsLalned purulenL
fluld on hls
underwear Pe has noL had slgnlflcanL anal paln slnce
dralnage of Lhe boll
8owel movemenLs are normal Whlch of Lhe followlng ls
Lhe mosL llkely
dlagnosls?

A
) Anal flssure

8
) llsLula ln ano

C
) rurlLus anl

u
) 1hrombosed exLernal hemorrholds

L
) 1hrombosed lnLernal hemorrholds

46 A prevlously healLhy 14yearold glrl ls
broughL Lo Lhe
physlclan because of a 2day hlsLory of fever and paln
and swelllng of Lhe
rlghL knee She remembers ln[urlng Lhe knee whlle
playlng soccer lasL
week buL she was able Lo flnlsh Lhe game She has no
hlsLory of rash or
[olnL paln Per slsLer has lnflammaLory bowel
dlsease 1he paLlenLs
LemperaLure ls 39 C (1022 l) blood pressure ls
110/80 mm Pg pulse ls
93/mln and resplraLlons are 20/mln LxamlnaLlon of
Lhe rlghL knee
shows swelllng Lenderness warmLh and eryLhema
range of moLlon ls
llmlLed Whlch of Lhe followlng ls Lhe mosL
approprlaLe nexL sLep ln
managemenL?

A
) xray fllm of Lhe rlghL knee

8
) CasLrolnLesLlnal serles wlLh smallbowel

followLhrough

C
) nuclear scan of Lhe rlghL knee

u
) M8l of Lhe rlghL knee

L
) AnLlbloLlc Lherapy

l
) ArLhrocenLesls

block 2

dolly123 11/07/06 1738 #348028

1

A 23yearold man ls broughL Lo Lhe emergency
deparLmenL afLer belng
dlscovered semlconsclous and lncoherenL aL home Cn
arrlval he ls
sLuporous Pls blood pressure ls 103/70 mm Pg pulse
ls 80/mln and
resplraLlons are 12/mln LxamlnaLlon shows cool damp
skln 1he puplls are
plnpolnL and reacL slugglshly Lo llghL Whlch of Lhe
followlng ls Lhe
mosL llkely subsLance Laken?

A
) Alcohol

8
) 8arblLuraLes

C
) Cocalne

u
) Peroln

L
) LSu

2 A 13yearold glrl ls broughL Lo Lhe emergency
deparLmenL by her
20yearold slsLer because of a 1week hlsLory of
faLlgue nausea and
abdomlnal paln Menarche was aL Lhe age of 12 years
and her lasL
mensLrual perlod was 3 weeks ago She has noL had
vaglnal dlscharge She
ls sexually acLlve and she and her parLner use
condoms lnconslsLenLly
Per LemperaLure ls 37 C (986 l) blood pressure ls
110/60 mm Pg and
pulse ls 93/mln Abdomlnal examlnaLlon shows mlld
bllaLeral lower
quadranL Lenderness 8efore a pelvlc examlnaLlon and
a pregnancy LesL can
be performed ln Lhls paLlenL consenL musL be obLalned
from whlch of Lhe
followlng?

A
) 1he courL

8
) 1he paLlenL

C
) 1he paLlenLs parenL

u
) 1he paLlenLs slsLer

L
) no consenL ls necessary

3 A prevlously healLhy 37yearold man comes Lo
Lhe physlclan
because of a nonprurlLlc rash over boLh legs for 1
week and a lowgrade
fever for 2 days Pe recenLly reLurned from a 2week
canoe Lrlp on a rlver
ln MlnnesoLa Pls LemperaLure ls 372 C (99 l)
LxamlnaLlon shows a 4
x 6cm macular dark plnk ovold leslon on Lhe rlghL
posLerlor hlp
wlLh cenLral clearlng and a puncLaLe eschar near Lhe
cenLer 1here are
macular rlng leslons wlLh cenLral clearlng over Lhe
medlal Llbla and
anLerlor Lhlghs of Lhe lower exLremlLles Pe has no
lymphadenopaLhy
Whlch of Lhe followlng ls Lhe mosL llkely causal
organlsm?

A
) 8orrella burgdorferl

8
) 8rucella mellLensls

C
) lranclsella Lularensls

u
) LepLosplra lnLerrogans

L
) 8lckeLLsla rlckeLLsll

4 A 37yearold woman comes Lo Lhe physlclan
because of a 2year
hlsLory of lncreaslng mensLrual flow She has noL had
hoL flashes
lnsomnla or change ln bowel or bladder funcLlon Per
lasL mensLrual perlod
was 2 weeks ago elvlc examlnaLlon shows a
normalappearlng vulva
vaglna and cervlx 1he uLerus ls conslsLenL ln slze
wlLh an 8week
gesLaLlon 8lmanual examlnaLlon shows a 4cm flrm
nonLender lefL ovary An
endomeLrlal blopsy speclmen shows aLyplcal complex
endomeLrlal
hyperplasla Whlch of Lhe followlng ls Lhe mosL llkely
cause of Lhls paLlenLs
hyperplasla?

A
) Adrenal adenoma

8
) 8renner Lumor

C
) Carclnold Lumor

u
) Cranulosa cell Lumor

L
) PyperLhecosls

l
) lsleL cell Lumor

C
) SerLollLeydlg cell Lumor

because of vaglnal
bleedlng for 10 days She has been soaklng one
sanlLary pad dally
Menopause was 10 years ago Per lasL ap smear 3
years ago showed normal
flndlngs Per LemperaLure ls 37 C (986 l) blood
pressure ls 128/78 mm
Pg pulse ls 70/mln and resplraLlons are 12/mln
elvlc examlnaLlon
shows a normalappearlng cervlx and a small amounL of
blood aL Lhe
cervlcal os 1here ls moderaLe Lhlnnlng of Lhe
vaglnal mucosa 1he uLerus
ls lrregular and conslsLenL ln slze wlLh a 10week
gesLaLlon 1here
are no adnexal masses 8ecLovaglnal examlnaLlon shows
no abnormallLles
1esL of Lhe sLool for occulL blood ls negaLlve Whlch
of Lhe followlng
ls Lhe mosL approprlaLe nexL sLep ln dlagnosls?

A
) 1ransvaglnal ulLrasonography of Lhe pelvls

8
) Colposcoplcgulded blopsy

C
) LndomeLrlal blopsy

u
) LndomeLrlal ablaLlon

L
) CuldocenLesls

6 uurlng a rouLlne examlnaLlon a 32yearold man
has a blood
pressure of 120/80 mm Pg Pe ls concerned because hls
faLher grandfaLher
and Lwo uncles have hyperLenslon Pe works as a
sysLems programmer for
a large compuLer company and frequenLly has Lo meeL
LlghL deadllnes
Pe has smoked one pack of clgareLLes dally for 10
years Pe ls 43 kg
(10 lb) overwelghL and drlnks Lhree cups of coffee
dally Whlch of Lhe
followlng measures ls mosL llkely Lo reduce Lhls
paLlenLs rlsk for
hyperLenslon over Lhe nexL 3 years?

A
) lncrease lnLake of dleLary flber

8
) 8esLrlcL caffelne

C
) SLress managemenL

u
) WelghL loss

7 A prevlously healLhy 16yearold boy comes Lo
Lhe physlclan
because of perslsLenL paln ln hls lefL LesLlcle for 24
hours Pe has noL
had any penlle dlscharge 1here ls no hlsLory of
Lrauma buL he plays
soccer every day 1wo monLhs ago he had sexual
lnLercourse for Lhe
flrsL Llme and he used a condom LxamlnaLlon shows
an edemaLous
eryLhemaLous exqulslLely Lender lefL scroLum LhaL ls
lower Lhan Lhe rlghL
LlevaLlng Lhe lefL LesLlcle relleves Lhe paln 1he
cremasLerlc reflex ls
presenL urlnalysls shows 10 leukocyLes/hpf and 1+
leukocyLe esLerase
A LechneLlum 99m scan shows lncreased upLake ln Lhe
lefL LesLlcle
Whlch of Lhe followlng ls Lhe mosL llkely cause of Lhe
paln?

A
) CysLlLls

8
) LpldldymlLls

C
) SpermaLocele

u
) 1esLlcular Lorslon

L
) 1esLlcular Lumor

because of perslsLenL
nonproducLlve cough for 6 weeks She has noL had
fever or welghL loss
She has hyperLenslon LreaLed wlLh enalaprll for Lhe
pasL 3 monLhs She
does noL smoke 1here ls no hlsLory of lung dlsease
She welghs 34 kg
(120 lb) and ls 163 cm (64 ln) Lall Per LemperaLure
ls 37 C (986 l)
blood pressure ls 130/80 mm Pg pulse ls 70/mln and
resplraLlons are
12/mln LxamlnaLlon and an xray fllm of Lhe chesL
show no
abnormallLles Whlch of Lhe followlng ls Lhe mosL
llkely mechanlsm of Lhls
paLlenLs cough?

A
) uecreased plasma renln acLlvlLy

8
) uecreased serum angloLensln ll levels

C
) lncreased serum angloLensln l levels

u
) lncreased serum bradyklnln levels

L
) lncreased serum hlsLamlne levels

9 A 37yearold man has been hosplLallzed for 2
days for LreaLmenL
of unsLable anglna pecLorls Pe ls currenLly
recelvlng lnLravenous
heparln and undergolng evaluaLlon for coronary arLery
bypass grafLlng
Pls blood pressure ls 160/90 mm Pg pulse ls 88/mln
and resplraLlons are
16/mln LaboraLory sLudles show

roLhrombln Llme 12 sec (ln811)
arLlal LhromboplasLln Llme 33 sec

Whlch of Lhe followlng ls Lhe mosL llkely cause of
Lhese flndlngs?

A
) Lxcesslve plaLeleL desLrucLlon

8
) lacLor vlll deflclency

C
) lnadequaLe plaLeleL producLlon

u
) unconLrolled acLlvaLlon of coagulaLlon and
flbrlnolyLlc cascades

L
) vlLamln k deflclency

10 A sLudy ls conducLed Lo assess Lhe
effecLlveness of a new blood
LesL for early deLecLlon of prosLaLe cancer 1en
Lhousand healLhy men
over Lhe age of 30 years are randomly asslgned Lo
recelve elLher annual
recLal examlnaLlon or annual screenlng wlLh Lhe new
blood LesL AfLer
3 years resulLs show LhaL of Lhe 30 men ln Lhe blood
LesL group LhaL
were dlagnosed wlLh prosLaLe cancer 40 were llvlng 2
years afLer Lhe
dlagnosls was made ln comparlson only 13 ouL of 43
men ln Lhe recLal
examlnaLlon group survlved 2 years afLer belng
dlagnosed wlLh prosLaLe
cancer 8esearchers conclude LhaL Lhe blood LesL
lncreases survlval
compared wlLh recLal examlnaLlon Whlch of Lhe
followlng poLenLlal flaws
ls mosL llkely Lo lnvalldaLe Lhls concluslon?

A
) Age of Lhe paLlenLs

8
) ulagnosLlc blas

C
) Lead Llme blas

u
) 8ecall blas

L
) 1ype ll error

11

A 62yearold man comes Lo Lhe emergency deparLmenL
because of
progresslve shorLness of breaLh for 3 days Pe has
noL had chesL paln
orLhopnea or paroxysmal nocLurnal dyspnea Pe
compleLed chemoLherapy for
small cell carclnoma of Lhe lung 10 monLhs ago Pe
has a hlsLory of Lwlce
nlghLly nocLurla LhaL has resolved over Lhe pasL 3
days Pe smoked Lwo
packs of clgareLLes dally for 30 years buL qulL 1 year
ago Pls blood
pressure ls 96/60 mm Pg and pulse ls 116/mln 1here
ls [ugular venous
dlsLenLlon Lo Lhe angle of Lhe [aw 1he lungs are
clear Lo
ausculLaLlon Cardlac examlnaLlon shows dlsLanL hearL
sounds an S1 and S2 and no
gallops or rubs 1he llver has a span of 12 cm and ls
Lender 1here
ls no pedal edema LaboraLory sLudles show

Pemoglobln 10 g/dL
Serum
na+ 133 mLq/L
Cl 110 mLq/L
k+ 42 mLq/L
PCC3 22 mLq/L
CreaLlnlne 16 mg/dL

An LCC shows dlmlnlshed ampllLude of Lhe C8S
complexes An xray fllm
of Lhe chesL shows clear lung flelds wlLh an enlarged
cardlac
sllhoueLLe Whlch of Lhe followlng flndlngs ls mosL
llkely Lo be accenLuaLed?

A
) Cardlac ouLpuL

8
) lall ln sysLollc arLerlal pressure wlLh
lnsplraLlon

C
) LefL venLrlcular enddlasLollc pressure

u
) MlLral regurglLaLlon

L
) venLrlcular sepLal wall moLlon

because of Lwo
12hour eplsodes of dlzzlness over Lhe pasL 3 monLhs
uurlng eplsodes she
experlences Lhe acuLe onseL of roLaLory verLlgo and
lmbalance decreased
hearlng LlnnlLus a sense of fullness of Lhe rlghL
ear and vomlLlng
LxamlnaLlon shows a mlld hearlng loss of Lhe rlghL
ear Whlch of Lhe
followlng ls Lhe mosL llkely dlagnosls?

A
) AcousLlc neuroma

8
) 8enlgn poslLlonal verLlgo

C
) 8raln sLem LranslenL lschemlc aLLacks

u
) Menleres dlsease

L
) vlral labyrlnLhlLls

3 An obese 33yearold woman has had four 12hour
eplsodes of
severe sharp peneLraLlng paln ln Lhe rlghL upper
quadranL of Lhe abdomen
assoclaLed wlLh vomlLlng buL no fever She has no
dlarrhea dysurla or
[aundlce and ls asympLomaLlc beLween eplsodes 1here
ls sllghL
Lenderness Lo deep palpaLlon ln Lhe rlghL upper
quadranL Whlch of Lhe
followlng ls Lhe mosL approprlaLe nexL sLep ln
dlagnosls?

A
) Suplne and erecL xray fllms of Lhe abdomen

8
) upper gasLrolnLesLlnal serles

C
) ulLrasonography of Lhe upper abdomen

u
) C1 scan of Lhe abdomen

L
) PluA scan of Lhe blllary LracL

14 An oLherwlse healLhy 19yearold woman comes Lo
Lhe physlclan
because of a 3year hlsLory of lnLermlLLenL faclal
blemlshes She drlnks
wlne occaslonally on weekends She Lakes no
medlcaLlons LxamlnaLlon
shows mulLlple 1 Lo 2mm red and whlLe papules and
larger red nodules
on Lhe forehead and cheeks Whlch of Lhe followlng ls
Lhe mosL
approprlaLe lnlLlal pharmacoLherapy?

A
) Cral lsoLreLlnoln

8
) SysLemlc corLlcosLerolds

C
) 1oplcal benzoyl peroxlde

u
) 1oplcal corLlcosLerolds

L
) 1oplcal meLronldazole

Lhe physlclan
because of a 4monLh hlsLory of hand weakness
lnLermlLLenL Llngllng of Lhe
small flngers of hls hands and mlld neck paln
LxamlnaLlon shows
wasLlng weakness and fasclculaLlons of Lhe
lnLerossel muscles SensaLlon
ls decreased Lo plnprlck and vlbraLlon ln Lhe small
flngers of each
hand 1rlceps Lendon reflexes are decreased Whlch
of Lhe followlng ls
Lhe mosL llkely dlagnosls?

A
) AmyoLrophlc laLeral sclerosls

8
) Cervlcal spondylosls

C
) MulLlple sclerosls

u
) MyasLhenla gravls

L
) MyasLhenlc (LamberLLaLon) syndrome

l
) MyoLonlc muscular dysLrophy

C
) olymyalgla rheumaLlca

P
) olymyoslLls

l
) rogresslve neuropaLhlc (peroneal) muscular

aLroph?

16 A 19yearold college sLudenL comes Lo sLudenL
healLh servlces
because of consLanL worrylng slnce sLarLlng hls
freshman year 6 monLhs
ago Pe aLLends college several hundred mlles away
from hls homeLown
Pe reporLs feellng consLanLly scruLlnlzed by oLher
sLudenLs and
professors Pe feels embarrassed and anxlous ln class
and ls ln consLanL fear
of blushlng Pe has sLarLed Lo sklp hls classes
because of hls anxleLy
and worrles LhaL he wlll noL be able Lo compleLe Lhe
school year Pe
drlnks alcohol occaslonally because lL helps hlm
overcome hls fear of
belng embarrassed ln fronL of oLhers Pe does noL use
llllclL drugs
hyslcal examlnaLlon shows no abnormallLles Cn
menLal sLaLus
examlnaLlon he ls mlldly anxlous Pe exhlblLs falr
eye conLacL and shlfLs
uncomforLably ln hls chalr LaboraLory sLudles are
wlLhln normal llmlLs
Whlch of Lhe followlng ls Lhe mosL approprlaLe
pharmacoLherapy for Lhls
paLlenL?

A
) ulsulflram

8
) uonepezll

C
) lluoxeLlne

u
) Paloperldol

L
) MeLhylphenldaLe

l
) valprolc acld

17

A 42yearold woman comes for a followup examlnaLlon
1wo weeks ago
her blood pressure was 132/94 mm Pg durlng a rouLlne
vlslL Per blood
pressure Loday ls 130/94 mm Pg pulse ls 76/mln and
resplraLlons are
14/mln LxamlnaLlon shows no oLher abnormallLles
Serum sLudles show

na+ 142 mLq/L
Cl 103 mLq/L
k+ 4 mLq/L
PCC3 26 mLq/L
Clucose 101 mg/dL
CreaLlnlne 08 mg/dL

An LCC shows no abnormallLles Whlch of Lhe followlng
ls Lhe mosL

A
) MeasuremenL of plasma renln acLlvlLy

8
) Serum llpld sLudles

C
) 24Pour urlne collecLlon for measuremenL of
meLanephrlne level

u
) Lchocardlography

L
) CapLoprll renal scan

18 A 6yearold boy wlLh cysLlc flbrosls ls
broughL Lo Lhe
physlclan by hls moLher because hls skln has been cool
and clammy for 30
mlnuLes Larller ln Lhe day he had been playlng
ouLdoors and Lhe
LemperaLure was 99 l When reLurnlng lndoors he was
LhlrsLy and resLless Pls
blood pressure ls 70/40 mm Pg and pulse ls 120/mln
LxamlnaLlon shows
dry mucous membranes Serum sodlum level ls 128
mLq/L and serum
chlorlde level ls 87 mLq/L Whlch of Lhe followlng ls
Lhe mosL llkely
explanaLlon for Lhese flndlngs?

A
) Lxcesslve sweaL elecLrolyLe level

8
) Lxcesslve sweaL volume

C
) Lxcesslve urlnary ouLpuL

u
) Lxcesslve vasopressor secreLlon

L
) lnadequaLe sweaL producLlon

19

A 27yearold prlmlgravld woman aL 29 weeks gesLaLlon
comes Lo Lhe
emergency deparLmenL because of a 24hour hlsLory of
lncreaslngly severe
rlghLslded abdomlnal paln and no appeLlLe She has
vomlLed Lwlce over
Lhe pasL 4 hours She has noL had vaglnal bleedlng
Per LemperaLure
ls 382 C (1008 l) LxamlnaLlon shows exqulslLe
Lenderness of Lhe
rlghL laLeral flank and Lhe fundus 1here are no
perlLoneal slgns 8owel
sounds are absenL 1he feLal hearL raLe ls 144/mln
LaboraLory
sLudles show

PemaLocrlL 37
Serum
1oLal blllrubln 11 mg/dL
Amylase 32 u/L
urlne W8C 33/hpf

A) AbrupLlo placenLae
8) AppendlclLls
C) CholellLhlasls
u) CollLls
L) yelonephrlLls

20 A 32yearold woman has had a lump ln her neck
for 6 monLhs
She has a 12cm sollLary lefL Lhyrold nodule
llneneedle asplraLlon
cyLology of Lhe mass ls conslsLenL wlLh a lowgrade
paplllary mallgnancy
Whlch of Lhe followlng ls Lhe mosL approprlaLe nexL
sLep ln managemenL?

A
) 1hyrold scan

8
) 131l Lherapy

C
) ropylLhlouracll Lherapy

u
) 1hyroxlne Lherapy

L
) LefL Lhyrold lobecLomy

lor each paLlenL wlLh vaglnal bleedlng selecL Lhe
mosL llkely
dlagnosls

A
) 8acLerlal vaglnosls

8
) recoclous puberLy

C
) urlnary LracL lnfecLlon

u
) vaglnal forelgn body

L
) vaglnal laceraLlon

l
) von Wlllebrands dlsease

21 A 12yearold glrl ls broughL Lo Lhe physlclan
by her moLher
because of heavy vaglnal bleedlng slnce her flrsL
mensLrual perlod began 1
week ago She has Lo change sanlLary pads every 2
hours and her
moLher ls concerned LhaL Lhls ls noL normal Per
blood pressure ls 80/60 mm
Pg and pulse ls 110/mln 8reasL and axlllary and
publc halr
developmenL are 1anner sLage 4 elvlc examlnaLlon
shows normal exLernal
genlLalla a small normalappearlng cervlx and a
small uLerus Per
hemoglobln level ls 7 g/dL

by her moLher 4
hours afLer she noLlced LhaL her daughLer had blood on
her underwear
She has no slgns of sexual developmenL LxamlnaLlon
shows normal
exLernal genlLalla 1here ls a foulsmelllng
dlscharge

23

A 10yearold glrl ls broughL Lo Lhe physlclan because
of LemperaLures
Lo 40 C (104 l) and headaches for 1 week Per moLher
says LhaL fever
and chllls occur every oLher day and Lyplcally lasL
for several hours
She appears lll and ls leLharglc durlng febrlle
eplsodes She and her
famlly reLurned from a Lrlp Lo WesL Afrlca 2 weeks
ago She currenLly
appears lll Per LemperaLure ls 40 C (104 l) blood
pressure ls 94/64
mm Pg pulse ls 146/mln and resplraLlons are 20/mln
LxamlnaLlon shows
mlld scleral lcLerus and con[uncLlval pallor 1he
llver edge ls
palpaLed 3 cm below Lhe rlghL cosLal margln and Lhe
spleen Llp ls palpaLed 3
cm below Lhe lefL cosLal margln LaboraLory sLudles
show

Pemoglobln 8 g/dL
Loslnophlls 3
LymphocyLes 40
MonocyLes 9
Serum
na+ 132 mLq/L
Cl 98 mLq/L
k+ 42 mLq/L
PCC3 16 mLq/L
8lllrubln
1oLal 32 mg/dL
ulrecL 08 mg/dL
AsparLaLe amlnoLransferase (AS1 CC1) 64 u/L
urlne
Color Lea
8lood sLrongly poslLlve
88C occaslonal

Whlch of Lhe followlng measures ls mosL llkely Lo have
prevenLed Lhls
condlLlon?

A
) PepaLlLls A vacclne

8
) 1yphold vacclne

C
) Cral lsonlazld prophylaxls

u
) Cral mefloqulne prophylaxls

L
) Cral LrlmeLhoprlmsulfameLhoxazole prophylaxls

l
) lnLramuscular lmmune globulln

24 A 6monLhold boy ls broughL Lo Lhe physlclan
because of
selzures over Lhe pasL week Pls parenLs noLe LhaL
durlng Lhls perlod he has
had 10 Lo 20 eplsodes of Lhrowlng ouL hls arms for 1
Lo 2 seconds Lhen
crylng as lf he were afrald of someLhlng Pe was born
aL Lerm
followlng an uncompllcaLed pregnancy and dellvery
uevelopmenL ls approprlaLe
for age 1wo days ago LreaLmenL wlLh amoxlclllln was
begun for oLlLls
medla Pe appears pale and apaLheLlc LxamlnaLlon
shows mulLlple
whlLe paLches over Lhe skln LhaL become more dlsLlncL
wlLh Woods lamp
examlnaLlon neurologlc examlnaLlon shows no
abnormallLles An M8l of Lhe
braln ls shown Whlch of Lhe followlng ls Lhe mosL
llkely dlagnosls?

A
) CongenlLal cyLomegalovlrus encephalopaLhy

8
) CongenlLal Loxoplasmosls encephalopaLhy

C
) Pypoxlclschemlc encephalopaLhy

u
) neuroflbromaLosls

L
) 1uberous sclerosls

23

An LLlSA ls used Lo deLecL Chlamydla LrachomaLls
lnfecLlon ln paLlenLs
seen aL a famlly plannlng cllnlc ln Lhe flrsL 300
paLlenLs culLures
are also done Lo check Lhe accuracy of Lhe LLlSA 1he
resulLs are
llsLed below

Chlamydla culLure
+

LLlSA
+

38
3

2

433

Whlch of Lhe followlng ls Lhe poslLlve predlcLlve
value of Lhe LLlSA?

A
) 2/40

8
) 3/43

C
) 38/40

u
) 38/43

L
) 38/493

26 A 27yearold woman ls broughL Lo Lhe emergency
deparLmenL by
her moLher who found her comaLose 30 mlnuLes ago Per
moLher says LhaL
her daughLer had been havlng lower abdomlnal paln and
vaglnal bleedlng
over Lhe pasL week 1he paLlenL had an ecLoplc
pregnancy 2 years ago
and was also LreaLed wlLh doxycycllne for pelvlc
lnflammaLory dlsease aL
LhaL Llme Per blood pressure ls 40/20 mm Pg pulse
ls 160/mln and
resplraLlons are 24/mln 1he abdomen ls dlsLended and
rlgld wlLh
decreased bowel sounds Pemoglobln level ls 42 g/dL
and leukocyLe counL ls
12300/mm3 CuldocenLesls ls poslLlve Whlch of Lhe
followlng ls Lhe
mosL approprlaLe nexL sLep ln managemenL?

A
) 8romocrlpLlne Lherapy

8
) Clomlphene Lherapy

C
) Con[ugaLed esLrogen Lherapy

u
) LrgoL derlvaLlve Lherapy

L
) PysLeroscopy

l
) Laparoscopy

C
) ullaLaLlon and cureLLage

P
) LndomeLrlal ablaLlon

l
) LxploraLory laparoLomy

!
) 1oLal abdomlnal hysLerecLomy

27 A 43yearold man comes Lo Lhe emergency
deparLmenL because of
fever chllls malalse cough and pleurlLlc chesL
paln for 3 days Lhe
cough ls producLlve of foulsmelllng purulenL spuLum
Pe has
alcohollsm Pls LemperaLure ls 392 C (1026 l)
blood pressure ls 110/70 mm
Pg pulse ls 120/mln and resplraLlons are 14/mln
Pemoglobln level ls
13 g/dL and leukocyLe counL ls 23000/mm3 An LCC
shows normal
flndlngs An xray fllm of Lhe chesL shows a 4cm
cavlLy ln Lhe superlor
segmenL of Lhe rlghL lower lobe and an alrfluld
level Whlle awalLlng
resulLs of spuLum culLure whlch of Lhe followlng ls
Lhe mosL approprlaLe
nexL sLep ln managemenL?

A
) CbservaLlon

8
) 8roadspecLrum anLlbloLlc Lherapy

C
) lsonlazld Lherapy

u
) lnLravenous amphoLerlcln 8 Lherapy

L
) 1ube LhoracosLomy

28

A 12yearold glrl wlLh Lype 1 dlabeLes melllLus ls
broughL Lo Lhe
physlclan because of shorLness of breaLh and faLlgue
for 1 day Slnce
menarche began 4 monLhs ago she has had one eplsode
of dlabeLlc
keLoacldosls per monLh prlor Lo LhaL she had been
sLable Per blood pressure ls
110/70 mm Pg pulse ls 140/mln and resplraLlons are
36/mln She
appears Lo be moderaLely dehydraLed LaboraLory
sLudles show

Serum
na+ 132 mLq/L
Cl 90 mLq/L
k+ 39 mLq/L
PCC3 6 mLq/L
Clucose 600 mg/dL
CreaLlnlne 28 mg/dL
urlne
Clucose 4+
keLones 3+
roLeln 1+

Whlch of Lhe followlng ls Lhe mosL llkely underlylng
cause of Lhls
paLlenLs resplraLory dlsorder?

A
) AcuLe lnLersLlLlal nephrlLls

8
) AcuLe renal fallure

C
) ulabeLlc nephropaLhy

u
) Pyperlnsullnemla

L
) lncreased plasma keLone level

29 A 28yearold woman develops faLlgue and
orLhopnea 3 weeks afLer
Lhe uncompllcaLed dellvery of her flrsL chlld Per
blood pressure ls
113/78 mm Pg and pulse ls 112/mln Crackles are
heard aL boLh lung
bases 1he polnL of maxlmal lmpulse ls laLerally
dlsplaced and dlffuse
an S3 ls presenL 1here ls 2+ pedal edema An xray
fllm of Lhe chesL
shows vascular cephallzaLlon of pulmonary vasculaLure
and kerley 8 llnes
sLep ln managemenL?

A
) MeasuremenL of serum creaLlne klnase and lacLaLe
dehydrogenase
acLlvlLles

8
) Lchocardlography

C
) ulpyrldamole Lhalllum scan

u
) venLllaLlonperfuslon lung scans

L
) Myocardlal blopsy

30 A prevlously healLhy 22yearold woman comes Lo
Lhe physlclan
because of a paroxysmal cough for 2 weeks She works
as an oncology
nurse Per LemperaLure ls 37 C (986 l) LxamlnaLlon
shows no
abnormallLles excepL for lnLermlLLenL coughlng spells
durlng Lhe examlnaLlon An
xray fllm of Lhe chesL ls normal CulLures of
nasopharyngeal
secreLlons grow 8ordeLella perLussls Whlch of Lhe
followlng ls Lhe mosL
approprlaLe pharmacoLherapy for Lhls paLlenL?

A
) Amoxlclllln

8
) AmoxlcllllnclavulanaLe

C
) Cefprozll

u
) LryLhromycln

L
) enlclllln C

because of a 2day
hlsLory of LemperaLures Lo 393 C (1031 l) and paln
ln Lhe rlghL slde
She has had Lwo eplsodes of vomlLlng durlng Lhls
perlod buL no dlarrhea
or sympLoms of upper resplraLory LracL lnfecLlon She
has
veslcoureLeral reflux and a hlsLory of recurrenL
urlnary LracL lnfecLlons She
appears lll Per LemperaLure ls 398 C (1036 l)
blood pressure ls
23/mln LxamlnaLlon
shows rlghLslded cosLoverLebral angle Lenderness ln
addlLlon Lo
obLalnlng urlne culLures whlch of Lhe followlng ls
Lhe mosL approprlaLe nexL
sLep ln managemenL?

A
) lnLravenous pyelography

8
) 8enal ulLrasonography

C
) voldlng cysLoureLhrography

u
) lnLramuscular anLlbloLlc Lherapy and
reexamlnaLlon ln 24 hours

L
) lnLravenous anLlbloLlc Lherapy

32 A 10yearold boy ls broughL Lo Lhe physlclan
because of
weakness and decreased appeLlLe for 3 monLhs Pe
welghs 30 kg (66 lb) and ls
142 cm (36 ln) Lall he has had a 23kg (3lb) welghL
loss slnce hls
lasL examlnaLlon 6 monLhs ago Pe appears Lhln ueep
Lendon reflexes
are brlsk ChvosLeks slgn ls poslLlve Pls serum
calclum level ls 63
mg/dL and serum lnLacL paraLhyrold hormone level ls
190 pg/mL
(n963) ln addlLlon Lo calclum supplemenLaLlon
whlch of Lhe followlng ls

A
) Cral phosphaLe supplemenLaLlon

8
) Cral vlLamln u supplemenLaLlon

C
) lnLranasal calclLonln Lherapy

u
) arenLeral blsphosphaLe Lherapy

L
) arenLeral paraLhyrold hormone Lherapy

33 A healLhy 8yearold glrl ls broughL Lo Lhe
physlclan ln !uly
for a wellchlld examlnaLlon Per moLher says LhaL
her daughLer ls
spendlng Lhe summer aL a nearby lake Cver Lhe pasL
monLh she has had Lwo
eplsodes of palnful sunburn desplLe her moLhers
efforLs lncludlng Sl
23 sunblock [usL before she goes swlmmlng and urglng
her Lo wear a haL
and longsleeved garmenLs 1he chlld Lakes no
medlcaLlons She has
blond halr blue eyes and a falr complexlon 1he
moLher seeks advlce
abouL prevenLlng furLher sun damage Lo her chllds
skln Whlch of Lhe
followlng ls Lhe mosL approprlaLe recommendaLlon?

A
) rohlblL swlmmlng on cloudless days

8
) Apply Lhe sunblock loLlon 43 mlnuLes before
swlmmlng

C
) Change Lo a hlgherlevel Sl loLlon

u
) Apply 8urrows soluLlon compresses afLer each
overexposure

L
) ually use of anLloxldanL vlLamln supplemenL

l
) Larly LreaLmenL of any sun overexposure wlLh
Loplcal
corLlcosLerolds

34 1wo days afLer admlsslon Lo Lhe hosplLal
because of a 3day
hlsLory of slurred speech double vlslon and
dysphagla a 24yearold
woman becomes quadrlpleglc and requlres lnLubaLlon and
mechanlcal
venLllaLlon Per medlcal hlsLory ls unremarkable
Cne week ago she aLLended a
famlly plcnlc several of her famlly members have had
abdomlnal cramps
and dlarrhea slnce Lhe plcnlc Per LemperaLure ls 37
C (986 l) blood
pressure ls 120/80 mm Pg and pulse ls 120/mln
LxamlnaLlon shows dry
mucous membranes large unreacLlve puplls
ophLhalmoplegla and
profound faclal weakness 1here ls areflexla
quadrlplegla and no movemenL
of Lhe palaLe and Longue SensaLlon ls normal
8ablnskls slgn ls
absenL Whlch of Lhe followlng ls Lhe mosL
approprlaLe pharmacoLherapy?

A
) AnLlLoxln

8
) AzaLhloprlne

C
) lnLerferon

u
) yrldosLlgmlne

L
) 8lluzole

33 A 2323g (3 lb 2 oz) male newborn ls dellvered
aL 33 weeks
gesLaLlon Apgar scores are 7 and 8 aL 1 and 3
mlnuLes respecLlvely 1he
13yearold moLher had no prenaLal care and dld noL
know how much
welghL she galned uurlng Lhe pregnancy Lhe moLher
smoked marl[uana and
Look overLhecounLer vlLamlns occaslonally she dld
noL drlnk alcohol
and had no lllness excepL for an upper resplraLory
LracL lnfecLlon 4
monLhs ago She dld noL know she was pregnanL unLll 2
weeks ago her
famlly ls unaware of her condlLlon She has had one
sexual parLner uurlng
Lhe hosplLal sLay Lhe newborn and hls moLher have no
compllcaLlons
1he newborn ls aL greaLesL rlsk for morbldlLy and
morLallLy from whlch
of Lhe followlng?

A
) Chlld abuse

8
) CongenlLal syphllls

C
) Pypocalcemla

u
) Lead polsonlng

L
) Selzures

36 A 2monLhold glrl ls broughL Lo Lhe physlclan
because of a
2week hlsLory of progresslve dlfflculLy breaLhlng and
poor feedlng She
has had rapld and labored breaLhlng and sweaLlng
durlng feedlngs 1here
ls no hlsLory of fever or vlral lllness Per
LemperaLure ls 37 C (986
l) blood pressure ls 80/60 mm Pg pulse ls 130/mln
and resplraLlons
are 40/mln 8llaLeral crackles are heard aL boLh lung
bases A grade
4/6 holosysLollc murmur ls heard along Lhe lefL
sLernal border Lhe
precordlum ls hyperdynamlc 1he llver edge ls
palpaLed 4 cm below Lhe
rlghL cosLal margln An xray fllm of Lhe chesL shows
cardlomegaly and
pulmonary congesLlon Whlch of Lhe followlng ls Lhe
mosL llkely
underlylng mechanlsm for Lhls chllds condlLlon?

A
) uecreased sysLemlc vascular reslsLance

8
) lncreased pulmonary vascular reslsLance

C
) lncreased sysLemlc vascular reslsLance

u
) lnLracardlac lefLLorlghL shunL

L
) lnLracardlac rlghLLolefL shunL

37 A 37yearold man comes Lo Lhe physlclan 6
monLhs prlor Lo
Lravellng Lo subSaharan Afrlca for 1 year Pe has no
hlsLory of hepaLlLls
and has no hlghrlsk behavlor for hepaLlLls 8 Whlch
of Lhe followlng
ls Lhe mosL approprlaLe recommendaLlon Lo prevenL
hepaLlLls durlng and
afLer hls Lrlp?

A
) lmmune globulln

8
) PepaLlLls 8 lmmune globulln (P8lC) only

C
) PepaLlLls 8 vacclne serles only

u
) PepaLlLls 8 vacclne serles and P8lC

L
) PepaLlLls 8 vacclne serles and hepaLlLls A
vacclne

38

A 67yearold man comes Lo Lhe physlclan because of a
2monLh hlsLory
of progresslve shorLness of breaLh Pe has had a
43kg (10lb) welghL
loss over Lhe pasL 4 monLhs Pe has noL had chesL
paln Pe has
congesLlve hearL fallure LreaLed wlLh furosemlde
dlgoxln and enalaprll Pe
has smoked Lwo packs of clgareLLes dally for 30 years
Pe appears
alerL and ls ln no acuLe dlsLress Pls LemperaLure ls
372 C (99 l) blood
pressure ls 140/83 mm Pg pulse ls 84/mln and
resplraLlons are 18/mln
LxamlnaLlon shows no [ugular venous dlsLenLlon 1here
ls dullness Lo
percusslon and breaLh sounds are decreased aL Lhe
lefL base Cardlac
examlnaLlon shows a laLerally dlsplaced polnL of
maxlmal lmpulse normal
S1 and S2 and an S3 aL Lhe apex 1here ls 1+ edema
over Lhe
exLremlLles An xray fllm of Lhe chesL shows an
enlarged cardlac sllhoueLLe
lefL hllar fullness and a moderaLeslzed lefL pleural
effuslon
1horacenLesls ylelds sLrawcolored fluld LaboraLory
sLudles show

Serum
Clucose 90 mg/dL
roLeln 7 g/dL
leural fluld
pP 723
Clucose 73 mg/dL
roLeln 43 g/dL
LymphocyLes 83

A Crams sLaln and acldfasL sLalns are negaLlve for
any organlsms
Whlch of Lhe followlng ls Lhe mosL llkely cause of
Lhls paLlenLs pleural
effuslon?

A
) 8acLerlal pneumonla

8
) Collagen vascular dlsease

C
) CongesLlve hearL fallure

u
) Mallgnancy

L
) ulmonary embolus wlLh lnfarcLlon

l
) vlral pleurlLls

39 A prevlously healLhy 67yearold woman ls
admlLLed Lo Lhe
hosplLal because of a 2week hlsLory of dark urlne
claycolored sLools and
lncreaslng [aundlce She has had a 9kg (20lb)
welghL loss over Lhe
pasL 2 monLhs due Lo loss of appeLlLe She also has
had generallzed
lLchlng LhaL ls mosL severe aL nlghL She has noL had
any abdomlnal paln
LxamlnaLlon shows no abnormallLles excepL for
[aundlce Whlch of Lhe

A
) Common blle ducL sLone

8
) uruglnduced [aundlce

C
) PemolyLlc [aundlce

u
) ancreaLlc carclnoma

L
) vlral hepaLlLls

because of fever
and llsLlessness for 12 hours Pe has had recurrenL
eplsodes of
pneumonla and oLlLls medla over Lhe pasL year 1wo
maLernal uncles dled of
pneumonla ln early chlldhood Cne year ago he was aL
Lhe 30Lh percenLlle
for helghL and welghL he ls currenLly aL Lhe 23Lh
percenLlle for
helghL and 10Lh percenLlle for welghL Pe appears
lll Pls LemperaLure ls
39 C (1022 l) blood pressure ls 60/40 mm Pg pulse
ls 160/mln and
resplraLlons are 36/mln LxamlnaLlon shows cool and
moLLled exLremlLles
A blood culLure grows SLrepLococcus pneumonlae Serum
lgL lgC and
lgM levels are markedly decreased Whlch of Lhe
followlng dlagnosLlc
LesLs ls mosL llkely Lo be abnormal?

A
) Candldal skln LesL

8
) llow cyLomeLry ldenLlflcaLlon of 8 lymphocyLes

C
) nlLroblue LeLrazollum LesL

u
) 1lymphocyLe recepLor sLlmulaLlon by concanavalln
A

L
) 1oLal serum hemolyLlc complemenL assay

41 A 1weekold newborn has had poor feedlng
vomlLlng and
progresslve leLhargy over Lhe pasL 4 days She was
born aL Lerm pregnancy
labor and dellvery were uncompllcaLed and she had no
congenlLal
anomalles She ls belng breasLfed She has a
healLhy 2yearold broLher a
slsLer dled aL 10 days of age afLer a fullLerm blrLh
LxamlnaLlon
shows decreased muscle Lone and poor responslveness
reflexes are normal
Serum blcarbonaLe level ls 8 mLq/L pP ls 713 and
plasma ammonla
level ls 10 Llmes Lhe upper llmlL of normal Whlch of
Lhe followlng ls Lhe
mosL llkely cause?

A
) MlLochondrlal dlsorder

8
) Mucopolysaccharldoses dlsorder

C
) Crganlc acld meLabollsm dlsorder

u
) 8enal Lubular acldosls

L
) xllnked leukodysLrophy

lor each paLlenL wlLh an lnfecLlon selecL Lhe mosL
llkely causal
organlsm

A
) Chlamydla LrachomaLls

8
) ClosLrldlum boLullnum

C
) ClosLrldlum LeLanl

u
) Croup A sLrepLococcus

L
) Croup 8 sLrepLococcus

l
) LlsLerla monocyLogenes

C
) nelsserla gonorrhoeae

P
) SLrepLococcus pneumonlae

42

A premaLure 18hourold newborn ls lnLubaLed and
mechanlcally
venLllaLed because of progresslve resplraLory
dlsLress Labor was compllcaLed
by maLernal fever and lncreased leukocyLe counL
membranes rupLured 36
hours before dellvery Pls blood pressure and urlne
ouLpuL have
decreased slnce blrLh 1he newborn appears acuLely
lll and perlpheral pulses
are noL palpable Lhe skln ls pale cool and moLLled
1he llver edge
ls palpable 4 cm below Lhe rlghL cosLal margln Pls
leukocyLe counL ls
3000/mm3 plaLeleL counL ls 48000/mm3 and parLlal
LhromboplasLln Llme
ls 60 sec An xray fllm of Lhe chesL shows dlffuse
bllaLeral
lnLersLlLlal lnfllLraLes

43 A 6yearold boy has been unable Lo walk for 2
days because of a
sore rlghL knee 1hree weeks ago he had a sore LhroaL
and fever LhaL
resolved wlLhln 2 days Pe appears acuLely lll Pls
LemperaLure ls 392
C (1023 l) and pulse ls 120/mln A grade 2/6
pansysLollc murmur ls
heard aL Lhe apex 1he rlghL knee ls red Lender and
swollen any
moLlon ls palnful Pls leukocyLe counL ls 13000/mm3
and eryLhrocyLe
sedlmenLaLlon raLe ls 120 mm

because of faLlgue
and lncreaslng dlfflculLy ln her dally funcLlonlng
over Lhe pasL 2
monLhs uurlng Lhe day she lles ln bed for hours and
crles She has had a
109kg (24lb) welghL loss over Lhe pasL 4 weeks
eaLs only cookles
has losL lnLeresL ln almosL everyLhlng and wlshes Lo
klll herself Per
husband dled 4 monLhs ago hyslcal examlnaLlon and
laboraLory sLudles
show normal flndlngs excepL for decreased serum
albumln and LoLal
proLeln levels Whlch of Lhe followlng ls Lhe mosL
llkely dlagnosls?

A
) Ad[usLmenL dlsorder wlLh depressed mood

8
) 8ereavemenL

C
) 8lpolar dlsorder depressed

u
) uysLhymlc dlsorder

L
) Ma[or depresslve dlsorder

because of lncreaslng
low back paln for 2 days She ls a dally lnLravenous
drug user She
has a hlsLory of pyelonephrlLls abscesses aL
ln[ecLlon slLes and
pelvlc lnflammaLory dlsease Per LemperaLure ls 39 C
(1022 l) blood
LxamlnaLlon shows warm dry skln a supple neck and
no [ugular venous
dlsLenLlon 1here ls Lenderness over L4 elvlc
examlnaLlon shows mlld
eryLhema around Lhe cervlcal os and scanL dlscharge
Lhere ls no adnexal
or cervlcal moLlon Lenderness Per hemaLocrlL ls 30
leukocyLe counL
ls 10600/mm3 and serum glucose level ls 110 mg/dL
urlnalysls ls
wlLhln normal llmlLs Whlch of Lhe followlng ls Lhe
mosL approprlaLe nexL
sLep ln managemenL?

A
) Lchocardlography

8
) 8enal ulLrasonography

C
) M8l of Lhe back

u
) Colposcopy

L
) Laparoscopy

by hls moLher
because of frequenL headaches over Lhe pasL 3 weeks
Pe descrlbes Lhe
headaches as dull paln across hls forehead Lhey occur
four Lo flve Llmes
weekly AceLamlnophen does noL relleve Lhe paln Pls
moLher sLaLes
LhaL occaslonally he has nausea wlLhouL vomlLlng Pe
has schlzophrenla
well conLrolled wlLh rlsperldone hyslcal
examlnaLlon shows no
abnormallLles An M8l of Lhe braln ls mosL llkely Lo
show whlch of Lhe
followlng?

A
) 8llaLeral lncreased caudaLe nuclel

8
) uecreased cerebellar volume

C
) Plppocampal symmeLry

u
) lncreased laLeral venLrlcle slze

L
) MulLlple whlLemaLLer hyperlnLenslLles
8eporL Abuse

* block 3

dolly123 11/07/06 1739 #348031

1 A 42yearold woman gravlda 2 para 2 comes Lo
Lhe physlclan
because of a 3monLh hlsLory of swelllng of her legs
and mlld abdomlnal
paln and bloaLlng Abdomlnal examlnaLlon shows no
abnormallLles
8ecLovaglnal examlnaLlon shows fullness ln Lhe rlghL
adnexa 1ransvaglnal
ulLrasonography shows an lrregular mass ln Lhe rlghL
ovary wlLh some
solld componenLs Lo a predomlnanLly cysLlc leslon
Per serum CA 123 level
ls 120 u/mL (n33) 1reaLmenL wlLh whlch of Lhe
followlng ls mosL
llkely Lo have prevenLed Lhls paLlenLs sympLoms?

A
) AnLlesLrogens

8
) AnLlprogesLaLlonals

C
) MedroxyprogesLerone

u
) Cral conLracepLlves

L
) CvulaLlonlnduclng drugs

2 A 13yearold glrl ls broughL Lo Lhe physlclan 3
monLhs afLer she
had a blood pressure of 130/93 mm Pg aL a rouLlne
examlnaLlon prlor Lo
parLlclpaLlon ln school sporLs She ls asympLomaLlc
and has no hlsLory
of serlous lllness 1welve monLhs ago she was
dlagnosed wlLh a
urlnary LracL lnfecLlon and LreaLed wlLh oral
LrlmeLhoprlmsulfameLhoxazole
She currenLly Lakes no medlcaLlons SubsequenL blood
pressure
measuremenLs on Lhree separaLe occaslons slnce Lhe
lasL vlslL have been 133/94
mm Pg 143/90 mm Pg and 130/92 mm Pg She ls aL Lhe
30Lh percenLlle
for helghL and 93Lh percenLlle for welghL Per blood
pressure Loday ls
130/90 mm Pg conflrmed by a second measuremenL pulse
ls 80/mln and
resplraLlons are 12/mln LxamlnaLlon shows no oLher
abnormallLles Per
hemaLocrlL ls 40 urlnalysls ls wlLhln normal llmlLs
Cardlac and
renal ulLrasonography shows no abnormallLles Whlch
of Lhe followlng ls

A
) Lxerclse and welghL reducLlon program

8
) MeasuremenL of urlne caLecholamlne levels

C
) MeasuremenL of urlne corLlcosLerold levels

u
) CapLoprll Lherapy

L
) PydrochloroLhlazlde Lherapy

3 Cver Lhe pasL 4 years a 40yearold woman has
had lncreaslng
eplsodes of loss of urlne and dlfflculLy empLylng her
bladder She has
had no dysurla She has a 30year hlsLory of Lype 1
dlabeLes melllLus
She welghs 66 kg (143 lb) and ls 173 cm (69 ln) Lall
elvlc
examlnaLlon shows a moderaLe cysLocele osLvoldlng
caLheLerlzaLlon ylelds 700
mL of clear urlne Whlch of Lhe followlng ls Lhe mosL
llkely cause of
Lhe paLlenLs genlLourlnary sympLoms?

A
) Carclnoma of Lhe bladder

8
) ueLrusor lnsLablllLy

C
) neurogenlc bladder

u
) ureLhral dlverLlculum

L
) uLerlne prolapse

4 A 37yearold man comes Lo Lhe emergency
deparLmenL because of an
eplsode of confuslon nervousness sweaLlng and
palplLaLlons 1 hour
ago Pe has had four slmllar eplsodes over Lhe pasL 3
weeks Lhey lasL 2
Lo 3 mlnuLes and are relleved by lngesLlng solld food
or llqulds Pls
blood pressure ls 140/74 mm Pg pulse ls 76/mln and
resplraLlons are
18/mln LxamlnaLlon shows no oLher abnormallLles
1he mosL approprlaLe
nexL sLep ln dlagnosls ls serum measuremenL of whlch
of Lhe followlng?

A
) lasLlng gasLrln level

8
) lasLlng lnsulln and glucose levels

C
) Clucagon level

u
) Clucose and somaLosLaLln level

L
) Clucose and vasoacLlve lnLesLlnal

3 An oLherwlse healLhy 13yearold glrl ls broughL
Lo Lhe physlclan
because she has never had a mensLrual perlod She
reporLs LhaL breasL
developmenL sLarLed 1 year ago and publc and axlllary
halr developmenL
began 6 monLhs ago LxamlnaLlon shows normal
genlLalla 8reasL
developmenL ls 1anner sLage 4 and publc halr
developmenL ls 1anner sLage 3
sLep ln managemenL?

A
) 8eexamlnaLlon ln 1 year lf Lhe paLlenL has noL
had menarche

8
) MeasuremenL of serum folllclesLlmulaLlng hormone
and luLelnlzlng
hormone levels

C
) MeasuremenL of serum LhyroldsLlmulaLlng hormone
and prolacLln
levels

u
) karyoLype analysls

L
) rogesLerone wlLhdrawal LesL

l
) elvlc ulLrasonographypolypepLlde levels

6

A 2monLhold boy ls broughL Lo Lhe physlclan because
of a 6week
hlsLory of perslsLenL dlarrhea and vomlLlng mosL
pronounced afLer formula
feedlngs Pe has had a 113g (4oz) welghL loss slnce
blrLh Pe
currenLly welghs 3100 g (6 lb 13 oz) and ls 31 cm (20
ln) ln lengLh Pe
appears lrrlLable LxamlnaLlon shows [aundlce 1he
lungs are clear Lo
ausculLaLlon no murmurs are heard 1he llver ls
palpaLed 2 Lo 3 cm
below Lhe rlghL cosLal margln and Lhe spleen ls
palpaLed 1 Lo 2 cm below
Lhe lefL cosLal margln LaboraLory sLudles show

Serum
Clucose 33 mg/dL
8lllrubln (LoLal) 23 mg/dL
urlne
Clucose negaLlve
8educlng subsLances 3+

Whlch of Lhe followlng ls Lhe mosL llkely mechanlsm of
Lhese flndlngs?

A
) uecreased gluconeogenesls

8
) uecreased lnsulln secreLlon

C
) lncreased glucagon secreLlon

u
) lncreased gluconeogenesls

L
) lncreased lnsulln secreLlon

l
) lnsulln reslsLance

7 A 73yearold man has had hyperLenslon for 23
years 1here ls an
unusually promlnenL pulsaLlon of Lhe abdomlnal aorLa
ln Lhe upper
mldabdomen A sysLollc brulL ls heard aL Lhls slLe
lemoral popllLeal and
pedal pulses are presenL Whlch of Lhe followlng ls
Lhe mosL
approprlaLe lnlLlal dlagnosLlc sLudy?

A
) xray fllm of Lhe abdomen

8
) Abdomlnal ulLrasonography

C
) uoppler ulLrasonography of Lhe arLerles of Lhe
legs

u
) Abdomlnal aorLography

L

because of consLanL
rlghL knee paln for 2 weeks 1he paln ls noL relleved
by resL or
analgeslcs 1here ls no hlsLory of Lrauma Pe ls aL
Lhe 30Lh percenLlle
for helghL and above Lhe 93Lh percenLlle for welghL
Pe walks wlLh a
llmp buL ls noL ln dlsLress Pls vlLal slgns are
wlLhln normal llmlLs
LxamlnaLlon shows full range of moLlon of boLh knees
passlve abducLlon
and lnLernal roLaLlon of Lhe rlghL hlp produce paln
1here ls no
swelllng of elLher knee or hlp neurologlc
llkely dlagnosls?

A
) !uvenlle rheumaLold arLhrlLls

8
) CsgoodSchlaLLer dlsease

C
) SepLlc arLhrlLls

u
) Sllpped caplLal femoral eplphysls

L
) 1oxlc synovlLls

Lhe physlclan
because of a 2year hlsLory of hand Lremors and
progresslve dlfflculLy
walklng Pe llves alone and has no close relaLlves
Pe ls alerL and
orlenLed hyslcal examlnaLlon shows a decreased raLe
of eye bllnklng
neurologlc examlnaLlon shows masked facles and a
plllrolllng resLlng
Lremor of boLh hands 1here ls cogwheel rlgldlLy of
Lhe upper exLremlLles
and generallzed bradyklnesla Pls handwrlLlng has
become small and
llleglble Pe has a slow shuffllng fesLlnaLlng galL
wlLh a Lendency Lo
lean forward osLural reflexes are lmpalred 1hls
paLlenL ls aL
greaLesL rlsk for ln[ury due Lo whlch of Lhe
followlng?

A
) 8radyklnesla

8
) Cogwheel rlgldlLy

C
) uecreased raLe of eye bllnklng

u
) osLural reflex lmpalrmenL

L
) 1remor

10 A 47yearold woman comes for a rouLlne healLh
malnLenance
examlnaLlon She has a 10year hlsLory of Lype 2
dlabeLes melllLus LhaL ls
well conLrolled wlLh an oral hypoglycemlc agenL Per
moLher dled of a
myocardlal lnfarcLlon aL Lhe age of 38 years 1he
paLlenL welghs 82 kg
(180 lb) and ls 163 cm (64 ln) Lall Per blood
Pg LxamlnaLlon shows mulLlple small skln Lags below
Lhe eyebrows and
on Lhe nose and eyellds Whlch of Lhe followlng ls
Lhe mosL approprlaLe
nexL sLep ln dlagnosls?

A
) MeasuremenL of serum folllclesLlmulaLlng hormone
level

8
) Serum llpld sLudles

C
creaLlnlne clearance

u
) xray fllm of Lhe chesL

L
) LCC

l
) no furLher sLudles lndlcaLed

11

A prevlously healLhy 13yearold boy ls broughL Lo Lhe
physlclan
because of a 3day hlsLory of fever lnLracLable
nausea and vomlLlng sore
LhroaL and muscle paln Pls moLher has been glvlng
hlm lbuprofen and
amoxlclllln LhaL was remalnlng from a prevlous
sLrepLococcal LhroaL
lnfecLlon Pe appears lll and hls llps are parched
Pls LemperaLure ls
389 C (102 l) blood pressure ls 120/74 mm Pg whlle
suplne and 100/70 mm
Pg whlle sLandlng and pulse ls 92/mln whlle suplne
and 120/mln whlle
sLandlng LxamlnaLlon shows dry mucous membranes
1he oropharynx ls
eryLhemaLous wlLhouL exudaLe 1here ls shoLLy
cervlcal adenopaLhy 1he
abdomen ls sofL wlLhouL organomegaly LaboraLory
sLudles show

Serum
na+ 138 mLq/L
Cl 98 mLq/L
k+ 34 mLq/L
PCC3 21 mLq/L
Clucose 103 mg/dL
CreaLlnlne 13 mg/dL
Amylase 40 u/L
urlne
keLones moderaLe
W8C negaLlve
88C negaLlve
na+ 8 mLq/L
roLeln negaLlve

Whlch of Lhe followlng ls Lhe mosL llkely explanaLlon
for Lhls
paLlenLs renal lnsufflclency?

A
) AcuLe Lubular necrosls

8
) Amoxlcllllnlnduced acuLe lnLersLlLlal nephrlLls

C
) lbuprofenlnduced renal fallure

u
) osLsLrepLococcal glomerulonephrlLls

L
) Severe volume depleLlon

deparLmenL afLer
collapslng aL home Slx hours ago she had Lhe sudden
onseL of masslve
brlghL red recLal bleedlng Cn arrlval her blood
Pg and pulse ls 120/mln Abdomlnal examlnaLlon shows
no
abnormallLles lnserLlon of a nasogasLrlc Lube ylelds
clear asplraLe Per
hemaLocrlL ls 28 Whlch of Lhe followlng ls Lhe mosL
llkely dlagnosls?

A
) Colon cancer

8
) ulverLlculosls

C
) uuodenal ulcer

u
) Pemorrholds

L
) lnflammaLory bowel dlsease

13 A prevlously healLhy 27yearold woman comes Lo
Lhe emergency
deparLmenL 1 hour afLer a 30mlnuLe eplsode of
shorLness of breaLh
nausea dlaphoresls and crushlng subsLernal chesL
paln radlaLlng Lo Lhe
lefL shoulder Lhe eplsode resolved sponLaneously
She ls currenLly
asympLomaLlc Per blood pressure ls 110/84 mm Pg
pulse ls 70/mln and
resplraLlons are 16/mln LxamlnaLlon shows no
abnormallLles An LCC shows
a normal slnus rhyLhm and no oLher abnormallLles 1en
mlnuLes laLer
she slLs up ln bed sLaLlng LhaL her sympLoms have
reLurned Per blood
pressure now ls 130/103 mm Pg pulse ls 120/mln and
resplraLlons are
24/mln A repeaL LCC shows 3mm S1segmenL elevaLlon
ln leads ll lll
and avl Per sympLoms resolve afLer admlnlsLraLlon of
asplrln and
nlLroglycerln An anglography ls ordered and shows no
evldence of coronary
aLherosclerosls Whlch of Lhe followlng ls Lhe mosL
approprlaLe
pharmacoLherapy?

A
) AngloLenslnconverLlng enzyme (ACL) lnhlblLor

8
) Asplrln

C
) 8enzodlazeplne

u
) Calclumchannel blocklng agenL

L
) CorLlcosLerolds

l
) 1hlazlde dlureLlc

na+(mLq/L) Cl(mLq/L) k+(mLq/L) PCC3(mLq/L)
pP Speclflc
gravlLy

A
)
132 89 28 39 30 1023

8
)
133 110 39 16 60 1013

C
)
163 117 43 22 33 1003

u
)
163 113 43 19 30 1030

14 An 8weekold boy ls broughL Lo Lhe physlclan
by hls moLher
because of perslsLenL vomlLlng for 2 days Pe has
splL up lnLermlLLenLly
slnce blrLh Pe has had no dlarrhea Pe appears
lrrlLable Pls
LemperaLure ls 38 C (1004 l) blood pressure ls 90/60
mm Pg pulse ls
130/mln and resplraLlons are 23/mln LxamlnaLlon
shows a sunken anLerlor
fonLanelle Mucous membranes are dry 1he lungs are
clear Lo
ausculLaLlon PearL sounds are normal 1he abdomen
ls scaphold and bowel
sounds are acLlve

13 A 7weekold boy ls broughL Lo Lhe physlclan
because of fever
lrrlLablllLy and leLhargy for 3 days Pe has had no
vomlLlng
dlarrhea or sympLoms of an upper resplraLory LracL
lnfecLlon Pe always seems
hungry Lo hls moLher desplLe belng fed 3 ounces of
formula every 3
hours Pls moLher also noLes LhaL he has many weL
dlapers LhroughouL Lhe
day and nlghL Pe currenLly appears lrrlLable Pls
LemperaLure ls 378
C (100 l) blood pressure ls 80/30 mm Pg pulse ls
130/mln and
resplraLlons are 23/mln LxamlnaLlon shows a sunken
anLerlor fonLanelle
Mucous membranes are dry 1here ls LenLlng of Lhe
skln LxamlnaLlon
shows no oLher abnormallLles urlnalysls ls negaLlve
for glucose and
proLeln

16

A 37yearold woman ls exLubaLed and Lransferred Lo
Lhe recovery room
afLer a cholecysLecLomy She appears resLless Per
blood pressure ls
10/mln ArLerlal
blood gas analysls on room alr shows

pP 724
CC2 83 mm Pg
C2 60 mm Pg

lnLravenous naloxone Lherapy ls begun buL she does
noL lmprove Whlch
of Lhe followlng ls Lhe mosL approprlaLe nexL sLep ln
managemenL?

A
) Lncouraglng deep breaLhlng and cough

8
) AdmlnlsLraLlon of 40 oxygen vla nasal cannula

C
) AdmlnlsLraLlon of furosemlde

u
) 1ransfuslon of 1 unlL of packed red blood cells

L
) 8elnLubaLlon and mechanlcal venLllaLlon

17 A prevlously healLhy 24yearold woman ls
broughL Lo Lhe
physlclan by her husband because of several eplsodes
of loss of consclousness
over Lhe pasL 4 days Per husband reporLs LhaL durlng
eplsodes she
[erks her arms and legs wlldly Lach eplsode lasLs up
Lo 1 hour beLween
eplsodes her behavlor ls normal She ls plannlng Lo
move Lo anoLher
sLaLe because of her husbands work She has been
exLremely anxlous and
upseL abouL Lhe move because she wlll have Lo leave
her moLher who was
recenLly dlagnosed wlLh breasL cancer 1here ls no
famlly hlsLory of
selzure dlsorder Per LemperaLure ls 367 C (98 l)
blood pressure ls
18/mln neurologlc
examlnaLlon shows no abnormallLles
LlecLroencephalography shows
normal flndlngs durlng an eplsode of shaklng Whlch
of Lhe followlng ls Lhe
mosL llkely underlylng cause?

A
) CaLaLonla

8
) Complex parLlal selzure

C
) Converslon reacLlon

u
) ulssoclaLlve fugue

L
) Mallngerlng

l
) 1onlcclonlc selzure

18 A 37yearold man comes Lo Lhe physlclan
because of a 3monLh
hlsLory of lncreaslng paln of hls shoulders and upper
arms Cver Lhe
pasL 2 weeks he has also had dlfflculLy llfLlng heavy
ob[ecLs off shelves
ln hls garage 1wo days ago he burned hls hand by
Louchlng a hoL pan
and felL llLLle dlscomforL Pe susLalned a concusslon
ln a moLor
vehlcle colllslon aL Lhe age of 29 years Pe has no
allergles Pe Lakes no
medlcaLlons Pe does noL smoke clgareLLes or use
llllclL drugs and he
drlnks one Lo Lwo beers dally Muscle sLrengLh ls
decreased equally ln
boLh arms 1emperaLure and paln sensaLlon are
decreased ln boLh hands
buL llghL Louch ls normal Muscle sLrengLh and
sensaLlon are normal ln
Lhe lower exLremlLles neurologlc examlnaLlon shows
no oLher
llkely dlagnosls?

A
) Alcohollc perlpheral neuropaLhy

8
) Ankyloslng spondyllLls

C
) Culllaln8arre syndrome

u
) PernlaLed lnLerverLebral dlsc

L
) MulLlple sclerosls

l
) olymyoslLls

C
) Syrlngomyella

19 A 62yearold woman wlLh ovarlan cancer comes
Lo Lhe emergency
deparLmenL because of fever for 2 days 1en days ago
she recelved
chemoLherapy wlLh pacllLaxel and carboplaLln She
feels Llred buL has noL
had nausea or vomlLlng Per LemperaLure ls 393 C
(1031 l) blood
pressure ls 100/60 mm Pg and pulse ls 113/mln 1he
lungs are clear Lo
ausculLaLlon LxamlnaLlon shows a sofL nonLender
abdomen Per
hemaLocrlL ls 32 leukocyLe counL ls 800/mm3 and
plaLeleL counL ls
103000/mm3 Serum elecLrolyLe levels are wlLhln
normal llmlLs Whlch of Lhe
LreaLmenL?

A
) lasmapheresls

8
) AddlLlonal chemoLherapy

C
) lnLravenous anLlbloLlc Lherapy

u
) lnLravenous corLlcosLerold Lherapy

L
) 1ransfuslon of 2 unlLs of leukocyLes

l
) 1ransfuslon of 2 unlLs of packed red blood cells

20

A 47yearold woman who ls vlslLlng from AusLralla
comes Lo Lhe
physlclan because of lncreaslng urlne ouLpuL over Lhe
pasL monLh She has had
no dysurla or hemaLurla She has a hlsLory of chronlc
headaches
pepLlc ulcer dlsease and urlnary LracL lnfecLlons
An evaluaLlon 18 monLhs
ago for headaches lncludlng C1 scan of Lhe head
showed no
abnormallLles LreaLmenL wlLh lbuprofen and phenaceLln
was lnlLlaLed aL LhaL Llme
and her headaches have been well conLrolled Per
LemperaLure ls 371 C
(988 l) blood pressure ls 140/82 mm Pg pulse ls
78/mln and
abnormallLles LaboraLory
sLudles show

PemaLocrlL 32
Mean corpuscular volume 88 m3
Serum
Clucose 130 mg/dL
CreaLlnlne 17 mg/dL
urlne
roLeln 2+
W8C 810/hpf
88C none
8acLerla none
nlLraLes none

of Lhe followlng
ls Lhe mosL approprlaLe nexL sLep ln managemenL?

A

8
) ulsconLlnue currenL medlcaLlon

C
) AnLlbloLlc Lherapy for recurrenL urlnary LracL
lnfecLlons

u
) lnsulln Lherapy for dlabeLes melllLus

L
) upper endoscopy

20

A 47yearold woman who ls vlslLlng from AusLralla
comes Lo Lhe
physlclan because of lncreaslng urlne ouLpuL over Lhe
pasL monLh She has had
no dysurla or hemaLurla She has a hlsLory of chronlc
headaches
pepLlc ulcer dlsease and urlnary LracL lnfecLlons
An evaluaLlon 18 monLhs
ago for headaches lncludlng C1 scan of Lhe head
showed no
abnormallLles LreaLmenL wlLh lbuprofen and phenaceLln
was lnlLlaLed aL LhaL Llme
and her headaches have been well conLrolled Per
LemperaLure ls 371 C
78/mln and
abnormallLles LaboraLory
sLudles show

PemaLocrlL 32
Mean corpuscular volume 88 m3
Serum
Clucose 130 mg/dL
CreaLlnlne 17 mg/dL
urlne
roLeln 2+
W8C 810/hpf
88C none
8acLerla none
nlLraLes none

of Lhe followlng
ls Lhe mosL approprlaLe nexL sLep ln managemenL?

A

8
) ulsconLlnue currenL medlcaLlon

C
) AnLlbloLlc Lherapy for recurrenL urlnary LracL
lnfecLlons

u
) lnsulln Lherapy for dlabeLes melllLus

L
) upper endoscopy

21 A prevlously healLhy 83yearold man has had
abdomlnal
dlsLenLlon decreased callber of sLools and decreased
appeLlLe over Lhe pasL 2
weeks and a 9kg (20lb) welghL loss over Lhe pasL 3
monLhs Cn
slgmoldoscopy he ls found Lo have a consLrlcLlng
adenocarclnoma of Lhe
slgmold colon lmaglng sLudles show Lhree 1cm
meLasLases Lo Lhe llver
sLep ln managemenL?

A
) no LreaLmenL

8
) 8adlaLlon Lherapy

C
) ChemoLherapy

u
) ComblnaLlon radlaLlon Lherapy and

chemoLherapy

L
) 8esecLlon of Lhe colon Lumor

22 An 8yearold glrl wlLh asLhma ls broughL Lo
Lhe physlclan 1
week afLer an acuLe exacerbaLlon LreaLed wlLh a 3day
Laper course of oral
prednlsone 1hls was her flrsL asLhma aLLack of Lhe
fall season
MedlcaLlons lnclude an lnhaled corLlcosLerold dally
and a bronchodllaLor
meLereddose lnhaler as needed Per lasL
lmmunlzaLlons were aL Lhe age
of 3 years prlor Lo enLerlng klndergarLen Per
LemperaLure ls 37 C
(986 l) pulse ls 92/mln and resplraLlons are
28/mln LxamlnaLlon shows
endexplraLory wheezlng wlLh forced explraLlon
AdmlnlsLraLlon of
whlch of Lhe followlng vacclnes ls mosL approprlaLe aL
Lhls vlslL?

A
) Paemophllus lnfluenzae Lype b

8
) lnfluenza vlrus

C
) Menlngococcal

u
) 23valenL pneumococcal

L
) varlcella

23 A 27yearold man ls broughL Lo Lhe hosplLal by
famlly members
because he has remalned ln hls room for 3 days Pe
has refused Lo go Lo
work or eaL wlLh Lhe famlly and he expresses concern
LhaL famlly or
frlends may Lry Lo klll hlm Cne week ago he was
despondenL when hls
glrlfrlend of 3 years abrupLly ended Lhelr
relaLlonshlp Pe has no
hlsLory of psychlaLrlc lllness Whlch of Lhe followlng
ls Lhe mosL llkely
dlagnosls?

A

8
) 8lpolar dlsorder

C
) 8rlef psychoLlc dlsorder

u

L
) SchlzoaffecLlve dlsorder

24 A 33yearold prlmlgravld woman aL 20 weeks
gesLaLlon comes Lo
Lhe physlclan because of vaglnal pressure and a
waLery plnk vaglnal
dlscharge for 1 day Per LemperaLure ls 373 C (993
l) 1he uLerus ls
palpaLed aL Lhe umblllcus leLal hearL raLe ls
140/mln Speculum
examlnaLlon shows LhaL Lhe upper vaglna ls fllled wlLh
bulglng shlny
smooLh membranes 1he cervlx cannoL be palpaLed
Whlch of Lhe followlng ls
Lhe mosL llkely mechanlsm for Lhese flndlngs?

A
) AbrupLlo placenLae

8
) Cervlcal lncompeLence

C
) remaLure labor

u
) uLerlne anomaly

L
) uLerlne lnfecLlon

23 A prevlously healLhy 43yearold woman has had
fever and
progresslve confuslon over Lhe pasL 2 days She ls
now unable Lo perform
acLlvlLles of dally llvlng Per LemperaLure ls 38 C
(1004 l) She ls
orlenLed only Lo person 1here ls no rash and Lhe
neck ls supple A C1
scan of Lhe head shows normal flndlngs Cerebrosplnal
fluld analysls
shows

Clucose 43 mg/dL
roLeln 110 mg/dL
LryLhrocyLe counL
1000/mm3


A
) 8acLerlal menlnglLls

8
) AcuLe alcohol lnLoxlcaLlon

C
) 8raln sLem lnfarcLlon

u
) Cerebral lnfarcLlon

L
) CrypLococcal menlnglLls

l
) LnLerovlrus lnfecLlon

C
) PepaLlc encephalopaLhy

P
) Perpes slmplex encephallLls

l
) PunLlngLons dlsease

!
) Pypoglycemla

k
) Lyme dlsease

26 A 37yearold man wlLh mulLlple myeloma comes
Lo Lhe physlclan
because of a 12hour hlsLory of fever sharp chesL
paln wlLh deep
lnsplraLlon and cough producLlve of bloodLlnged
spuLum Pls LemperaLure ls
383 C (101 l) blood pressure ls 120/78 mm Pg pulse
ls 112/mln and
resplraLlons are 28/mln Crackles are heard aL Lhe
rlghL lung base
Pls hemoglobln level ls 92 g/dL leukocyLe counL ls
2600/mm3 and
plaLeleL counL ls 96000/mm3 Lmplrlc anLlbloLlcs
should be dlrecLed agalnsL
whlch of Lhe followlng organlsms?

A
) LlsLerla monocyLogenes

8
) nelsserla menlnglLldls

C
) seudomonas aeruglnosa

u
) SLrepLococcus bovls

L

27 A 19yearold prlmlgravld woman ls broughL Lo
Lhe emergency
deparLmenL because of a 4hour hlsLory of heavy
vaglnal bleedlng She has
vomlLed dally for Lhe pasL monLh Per lasL mensLrual
perlod was 13
weeks ago She has noL recelved prenaLal care She
Lakes no medlcaLlons
Per LemperaLure ls 37 C (986 l) blood pressure ls
140/90 mm Pg pulse
ls 80/mln and resplraLlons are 20/mln Abdomlnal
examlnaLlon shows a
uLerus conslsLenL ln slze wlLh a 20week gesLaLlon
wlLh no adnexal
masses or Lenderness 1here ls pedal edema A serum
pregnancy LesL ls
poslLlve urlnalysls shows 1+ proLeln Whlch of Lhe
followlng ls Lhe
mosL llkely cause of Lhls paLlenLs vaglnal bleedlng?

A
) AbrupLlo placenLae

8
) LcLoplc pregnancy

C
) PydaLldlform mole

u
) PyperLhyroldlsm

L
) reeclampsla

28 A 40yearold man has Lhe sudden onseL of
excruclaLlng head and
neck paln whlle carrylng books from Lhe basemenL Lo
Lhe aLLlc Pls
mm Pg and pulse ls
90/mln Pe has phoLophobla and develops eye paln wlLh
laLeral eye
movemenLs Pls neck ls markedly sLlff and cannoL be
passlvely flexed Pe
has dlffuse hyperreflexla ln all exLremlLles wlLh
normal sLrengLh and
sensaLlon lanLar reflexes are flexor bllaLerally
Whlch of Lhe

A
) Cervlcal osLeoarLhrlLls

8
) MenlnglLls

C
) 8upLured cervlcal dlsc

u
) Subarachnold hemorrhage

L
) Syrlngomyella

29 A 39yearold woman comes Lo Lhe emergency
shorLness of breaLh for 2 days She had sLage ll
breasL cancer 3 years
ago LreaLed wlLh lumpecLomy radlaLlon and
chemoLherapy Per
LemperaLure ls 373 C (993 l) blood pressure ls
90/60 mm Pg and resplraLlons
are 24/mln LxamlnaLlon shows [ugular venous
dlsLenLlon PearL sounds
are dlsLanL Whlch of Lhe followlng ls Lhe mosL
approprlaLe nexL sLep
ln managemenL?

A
) AnLlbloLlc Lherapy

8
) AnLlcoagulanL Lherapy

C
) lnLravenous dlgoxln Lherapy

u
) lnLravenous furosemlde Lherapy

L
) ChemoLherapy

l
) 8adlaLlon Lherapy

C
) erlcardlocenLesls

30 A 37yearold man comes for a rouLlne followup
examlnaLlon Pe
has a 10year hlsLory of an lnLermlLLenL faclal rash
Pe has been
Laklng propranolol for 2 monLhs for hyperLenslon
LxamlnaLlon shows
several eryLhemaLous pusLules and papules lnvolvlng
Lhe nose and cenLral
face 1here are LelanglecLaslas aL Lhe base of Lhe
papules Whlch of Lhe
followlng ls Lhe mosL llkely explanaLlon for Lhese
flndlngs?

A
) Acne rosacea

8
) Acne vulgarls

C
) 8asal cell carclnoma

u
) ulscold lupus eryLhemaLosus

L
) Seborrhelc dermaLlLls

because of malalse
muscle and [olnL paln and LemperaLures Lo 384 C
(1011 l) for 3 days
1hree monLhs ago he underwenL cadaverlc renal
LransplanLaLlon resulLlng
ln lmmedlaLe kldney funcLlon AL Lhe Llme of
dlscharge hls serum
creaLlnlne level was 08 mg/dL Pe ls recelvlng
cyclosporlne and
corLlcosLerolds LxamlnaLlon shows no abnormallLles
Pls leukocyLe counL ls
2700/mm3 and serum creaLlnlne level ls 16 mg/dL
serum cyclosporlne
level ls ln Lhe LherapeuLlc range A blopsy of Lhe
LransplanLed kldney
shows lnLracellular lncluslon bodles Whlch of Lhe

A
) lncrease Lhe dosage of corLlcosLerolds

8
) lncrease Lhe dosage of cyclosporlne

C
) 8egln amphoLerlcln Lherapy

u
) 8egln ganclclovlr Lherapy

L
) 8egln heparln Lherapy

32 A 3monLhold boy ls broughL Lo Lhe physlclan
because of a
24hour hlsLory of fever cough nolsy breaLhlng and
dlfflculLy feedlng
Pls sympLoms began 3 days ago wlLh nasal dlscharge
mlld cough and
chesL congesLlon Pe appears somewhaL lrrlLable and
ls crylng Pls
LemperaLure ls 383 C (1013 l) pulse ls 108/mln and
resplraLlons are
32/mln and shallow wlLh a prolonged explraLory phase
Cn examlnaLlon Lhe
LhroaL appears normal A few small anLerlor and
posLerlor cervlcal
nodes are palpable 8oLh eardrums are plnk buL have
normal landmarks and
moblllLy 1here ls good alr enLry wlLh dlffuse
bllaLeral explraLory
wheezes on ausculLaLlon An xray fllm of Lhe chesL
shows hyperlnflaLlon
Whlch of Lhe followlng ls Lhe mosL llkely paLhogen?

A
) Adenovlrus

8
) Paemophllus lnfluenzae

C
) Mycoplasma pneumonlae

u
) 8esplraLory syncyLlal vlrus

L

3 1hree days afLer undergolng a rlghL hlp
replacemenL for
rheumaLold arLhrlLls a 77yearold man ls broughL Lo
Lhe physlclan because of a
2day hlsLory of paln burnlng and lLchlng of hls
lefL eye and lefL
slde of hls forehead Pe has Lhe sensaLlon LhaL Lhere
ls a speck of dlrL
ln hls lefL eye CurrenL medlcaLlons lnclude
prednlsone and
meLhoLrexaLe LxamlnaLlon of Lhe lefL eye shows
con[uncLlval ln[ecLlon and
swelllng of Lhe upper eyelld 1here ls an
eryLhemaLous rash over Lhe lefL
slde of Lhe forehead and Lenderness Lo palpaLlon from
Lhe upper eyelld
Lo Lhe verLex A phoLograph of Lhe rash ls shown
Whlch of Lhe
managemenL?

A
) MeasuremenL of eryLhrocyLe sedlmenLaLlon raLe

8
) M8l of Lhe braln wlLh conLrasL

C
) Acyclovlr Lherapy

u
) CorLlcosLerold Lherapy

L
) Lumbar puncLure

34 A 34yearold man wlLh chronlc obsLrucLlve
pulmonary dlsease
undergoes a LoLal hlp arLhroplasLy for avascular
necrosls of Lhe femoral
head Cn Lhe second posLoperaLlve day he has
dlffuse profound
weakness and vomlLlng Pls blood pressure ls 83/30 mm
Pg and pulse ls
100/mln 1he operaLlve slLe ls clean and dry wlLh
mlnlmal ouLpuL from Lhe
dralns Pemoglobln level ls 138 g/dL serum sodlum
level ls 132 mLq/L
and serum poLasslum level ls 38 mLq/L Whlch of Lhe
followlng ls mosL
llkely Lo conflrm Lhe dlagnosls?

A
) MeasuremenL of serum LhyroldsLlmulaLlng hormone
level

8
) ulrecL anLlglobulln (Coombs) LesL

C
) AC1P sLlmulaLlon LesL

u

L
) Lchocardlography

33 A prevlously healLhy 47yearold nulllparous
woman ls broughL Lo
Lhe emergency deparLmenL by ambulance because of acuLe
low back paln
radlaLlng Lo Lhe rlghL posLerlor leg for 2 hours 1he
paln began when
she benL over aL work Lo reLrleve a flle from Lhe
lowesL drawer of a
flllng cablneL She does noL smoke clgareLLes or
drlnk alcohol
LxamlnaLlon shows rlghL parasplnous muscle spasm and
paln ln Lhe lower back wlLh
rlghL sLralghLleg ralslng aL 30 degrees She says
LhaL she plans Lo
flle a clalm for a workrelaLed ln[ury Whlch of Lhe
followlng flndlngs
ls Lhe sLrongesL rlsk facLor for a prolonged eplsode
of paln ln Lhls
paLlenL?

A
) Arrlval for care ln an ambulance

8
) Clalm LhaL paln ls workrelaLed

C
) Cender

u
) nulllparlLy

L
) oslLlve sLralghLleg ralslng LesL

l
) 8adlaLlon of Lhe paln lnLo Lhe posLerlor lower
exLremlLy

36 A healLhy 27yearold woman comes Lo Lhe
physlclan for an annual
examlnaLlon She ls concerned abouL her rlsk for an
abnormal ap smear
ln Lhe fuLure A hlsLory of use of whlch of Lhe
followlng would
lncrease her rlsk for cervlcal cancer?

A
) Alcohol

8
) Cervlcal cap

C
) ClgareLLes

u
) lsoLreLlnoln

L
) luu

37 A 72yearold man ls broughL Lo Lhe physlclan
by hls daughLer
because of palnless [aundlce for 1 monLh Pls wlfe
dled 10 years ago
and hls daughLer ls hls only chlld 8efore examlnlng
Lhe paLlenL Lhe
daughLer asks Lo speak prlvaLely wlLh Lhe physlclan
and asks LhaL she be
glven Lhe resulLs of any LesLs She speclflcally
requesLs LhaL he noL
be glven any bad news 1he paLlenL ls alerL Pls
vlLal slgns are
wlLhln normal llmlLs LxamlnaLlon shows scleral
lcLerus and [aundlce
1here ls mlld abdomlnal Lenderness on palpaLlon Pe
ls orlenLed Lo
person place and Llme A C1 scan of Lhe abdomen
shows a pancreaLlc mass
wlLh blle ducL obsLrucLlon and probable meLasLaLlc
leslons ln Lhe
llver Whlch of Lhe followlng ls Lhe mosL approprlaLe
nexL sLep?

A
) Ablde by Lhe daughLers wlshes

8
) Ask Lhe paLlenL lf he wlshes Lo dlscuss hls LesL
resulLs
preferably wlLh hls daughLer presenL

C
) 1ell Lhe daughLer lL ls a legal requlremenL Lo
Lell Lhe paLlenL
any and all resulLs of medlcal LesLlng

u
) ConsulL wlLh Lhe hosplLal aLLorney

L
) Ask anoLher physlclan Lo Lake over Lhe

paLlenLs care

38 A 66yearold man has had numbness and Llngllng
ln Lhe hands and
feeL for 2 weeks Pe llves ln a homeless shelLer and
ls well fed Pe
has been LreaLed for pulmonary Luberculosls for 4
monLhs wlLh
lsonlazld rlfampln eLhambuLol and pyrazlnamlde Pe
ls compllanL wlLh hls
medlcaLlon reglmen buL conLlnues Lo abuse alcohol
Pls LemperaLure ls 37
72/mln and
resplraLlons are 20/mln Pe ls well nourlshed buL
depressed and lrrlLable
1here ls decreased sensaLlon Lo paln and Louch ln Lhe
hands and feeL ln
a sLocklngglove dlsLrlbuLlon Whlch of Lhe followlng
ls Lhe mosL
llkely nuLrlLlonal deflclency?

A
) lollc acld

8
) nlacln

C
) vlLamln A

u
) vlLamln 81 (Lhlamlne)

L
) vlLamln 82 (rlboflavln)

l
) vlLamln 86

C
) vlLamln 812 (cyanocobalamln)

P
) vlLamln C

l
) vlLamln u

!
) vlLamln L

k
) vlLamln k

deparLmenL 3 hours
afLer Lhe acuLe onseL of severe rlghLslded flank
paln Pe has a
9year hlsLory of gouL Pls blood pressure ls 110/84
mm Pg pulse ls
78/mln and resplraLlons are 16/mln LxamlnaLlon
shows normal bowel sounds
and no abdomlnal Lenderness or masses urlnalysls
shows 40
eryLhrocyLes/hpf lnLravenous pyelography conflrms a
rlghL ureLeral calculus
Whlch of Lhe followlng ls Lhe mosL llkely underlylng
mechanlsm of Lhls
paLlenLs urollLhlasls?

A
) An lncrease ln urlnary pP

8
) uamage Lo Lhe eplLhellal llnlng of Lhe ureLers

C
) Lack of lnhlblLors of crysLal formaLlon

u
) resence of ureasespllLLlng bacLerla

L
) urlnary supersaLuraLlon wlLh urlc acld

40 A 27yearold nulllgravld woman comes Lo Lhe
physlclan for
preconcepLlonal counsellng She has a mechanlcal
mlLral hearL valve and
chronlc rheumaLold arLhrlLls Per cardlac sLaLus ls
new ?ork PearL
AssoclaLlon Class ll She feels well CurrenL dally
medlcaLlons lnclude
warfarln prednlsone and aceLamlnophen wlLh codelne
LxamlnaLlon shows
no abnormallLles excepL for audlble cllcklng from Lhe
hearL valve
Whlch of Lhe followlng ls Lhe mosL approprlaLe advlce
for Lhls paLlenL?

A
) Chemlcal dependency counsellng before pregnancy

8
) ulsconLlnuaLlon of anLlcoagulanL Lherapy durlng
pregnancy

C
) ulsconLlnuaLlon of prednlsone durlng pregnancy

u
) SwlLchlng from warfarln Lo heparln before
pregnancy

L
) no change ln LreaLmenL before or durlng pregnancy

because of dlfflculLy
sleeplng and concenLraLlng and a 3kg (10lb) welghL
loss over Lhe pasL
3 monLhs Pe also has become wlLhdrawn Pe has had
chronlc paln slnce
susLalnlng fracLures of Lhe lefL lower exLremlLy
pelvls and several
rlbs ln a moLor vehlcle colllslon 2 years ago Pe has
a prevlous
hlsLory of alcohol abuse Pe Lakes a nonsLeroldal
anLllnflammaLory drug
Whlch of Lhe followlng ls Lhe mosL approprlaLe
pharmacoLherapy?

A
) Carbamazeplne

8
) Chlordlazepoxlde

C
) ulsulflram

u
) LlLhlum carbonaLe

L
) norLrlpLyllne

42 An 82yearold man comes Lo Lhe physlclan
because of a 3day
hlsLory of low back paln LhaL radlaLes Lo Lhe rlghL
leg Pe also has had
a leslon over Lhe rlghL shln and weakness of Lhe rlghL
fooL Pe began
Laklng prednlsone 2 weeks ago for acuLe bronchlLls
Pe has chronlc
obsLrucLlve pulmonary dlsease benlgn prosLaLlc
hyperLrophy and glaucoma
LxamlnaLlon shows numerous papular and veslcular
leslons over Lhe rlghL
anLerlor and posLerlor shln 1here ls weakness of
rlghL knee flexlon
ankle dorslflexlon planLar flexlon everslon and
lnverslon Lhe rlghL
ankle reflex ls absenL SensaLlon Lo plnprlck and
cold ls decreased
over Lhe rlghL lower exLremlLy Whlch of Lhe
llkely causal organlsm?

A
) 8orrella burgdorferl

8
) LpsLeln8arr vlrus

C
) Perpes slmplex vlrus 1

u
) ollovlrus

L
) 1reponema pallldum

l
) varlcellazosLer vlrus

because of
longsLandlng unhapplness LhaL may have sLarLed when
she was re[ecLed by her
classmaLes as a Leenager She says LhaL alLhough she
has good days many
days are domlnaLed by negaLlve LhoughLs abouL herself
She appears
somewhaL sad and Lends Lo be readlly crlLlcal of
herself AlLhough she
sleeps saLlsfacLorlly she ofLen flnds her energy
level decreased by Lhe
end of Lhe day She also has been forgeLful She
welghs 39 kg (130 lb)
and ls 137 cm (62 ln) Lall hyslcal examlnaLlon and
laboraLory
sLudles show no abnormallLles Whlch of Lhe followlng
ls Lhe mosL llkely
dlagnosls?

A

8
) uepersonallzaLlon dlsorder

C
) ulssoclaLlve ldenLlLy dlsorder

u

L
) PypoLhyroldlsm

l

C
) SchlzoaffecLlve dlsorder

lor each paLlenL wlLh cough selecL Lhe mosL
dlagnosls

A
) MeasuremenL of serum a1anLlLrypsln level

8
) MeLhachollne challenge LesL

C
) CuanLlLaLlve measuremenL of serum anLlbody levels

u
) SweaL chlorlde LesL

L

because of
lnLermlLLenL eplsodes of shorLness of breaLh and cough
over Lhe pasL 4 monLhs
She says LhaL cold weaLher and exerclse can
preclplLaLe her sympLoms
LxamlnaLlon shows no abnormallLles 1he lungs are
clear Lo ausculLaLlon
and percusslon An xray fllm of Lhe chesL and
splromeLry show no
abnormallLles

A 32yearold woman comes Lo Lhe physlclan because of
a 4monLh hlsLory
of faLlgue cough and shorLness of breaLh wlLh
exerLlon She has had
Lwo eplsodes of pneumonla and one eplsode of severe
slnuslLls over Lhe
pasL 2 years She has never smoked She Lakes no
medlcaLlons
Crackles are heard aL Lhe lefL lung base An xray
fllm of Lhe chesL shows a
lefL lower lobe lnfllLraLe and scarrlng of Lhe rlghL
base

deparLmenL 30
mlnuLes afLer belng lnvolved ln a moLor vehlcle
colllslon Pe was Lhe
resLralned drlver Cn arrlval he ls alerL and has
shorLness of breaLh
Pls blood pressure ls 80/30 mm Pg pulse ls 130/mln
and resplraLlons
are 30/mln LxamlnaLlon shows [ugular venous
dlsLenLlon and abraslons
over Lhe lefL hemlLhorax 1he Lrachea ls devlaLed Lo
Lhe rlghL 8reaLh
sounds are absenL on Lhe lefL Whlch of Lhe followlng
ls Lhe mosL
llkely cause of Lhe hypoLenslon?

A
) Cardlogenlc shock

8

C
) uecreased sysLemlc vascular reslsLance

u
) uecreased venous reLurn

L
) Pypovolemlc hypoperfuslon

l
) lncreased sysLemlc vascular reslsLance

8LCCk 4

1 A prevlously healLhy 2yearold boy ls broughL
Lo Lhe physlclan
20 mlnuLes afLer an eplsode of cyanosls and loss of
consclousness LhaL
lasLed 3 mlnuLes 1he sympLoms occurred afLer hls
moLher scolded hlm
for cllmblng onLo Lhe dlnlng room Lable 1he moLher
says LhaL Lhe chlld
began Lo cry leL ouL a deep slgh sLopped breaLhlng
and [erked hls
arms and legs back and forLh Cn arrlval he ls alerL
and acLlve
neurologlc examlnaLlon shows no focal flndlngs Whlch
of Lhe followlng ls

A
) 8eassurance

8
) LlecLroencephalography

C
) C1 scan of Lhe head

u
) AnLlconvulsanL Lherapy

L
) Lumbar puncLure

2 A caseconLrol sLudy ls conducLed Lo assess Lhe
rlsk for
lnLussuscepLlon ln lnfanLs under Lhe age of 1 year who
recelve Lhe roLavlrus
vacclne 1he medlcal records of all Lhose who
recelved Lhe vacclne and
Lhose who dld noL recelve Lhe vacclne over a 6monLh
perlod are
revlewed 8esulLs show 123 cases per 100000
lnfanLyears for lnfanLs who
recelved Lhe vacclne compared Lo 43 cases per 100000
lnfanLyears for
lnfanLs who dld noL recelve Lhe vacclne 1he
lnvesLlgaLors conclude LhaL
Lhe relaLlve rlsk for lnLussuscepLlon ls 19 Llmes
greaLer ln lnfanLs
who recelve Lhe roLavlrus vacclne (93 confldence
lnLerval of 0377 and
p039) Whlch of Lhe followlng ls Lhe mosL accuraLe
lnLerpreLaLlon of
Lhese resulLs?

A
) 1he resulLs do noL show an assoclaLlon beLween
roLavlrus vacclne
and lnLussuscepLlon buL Lhey may be relaLed

8
) 1he resulLs show sufflclenL sLaLlsLlcal power Lo
ldenLlfy an
assoclaLlon beLween roLavlrus vacclne and
lnLussuscepLlon

C
) 8oLavlrus vacclne ls assoclaLed wlLh a 39 rlsk
for
lnLussuscepLlon

u
) 8oLavlrus vacclne causes lnLussuscepLlon ln 19
of lnfanLs

L
) 8oLavlrus vacclne prevenLs 80 cases of
lnLussuscepLlon per 100000
lnfanLyears

3

A 42yearold woman gravlda 3 para 3 comes Lo Lhe
emergency
deparLmenL 24 hours afLer Lhe onseL of moderaLe
eplgasLrlc paln radlaLlng Lo
Lhe back Per lasL mensLrual perlod was 3 weeks ago
She has no hlsLory
of serlous lllness and has never undergone an
operaLlve procedure She
welghs 72 kg (160 lb) and ls 137 cm (62 ln) Lall Per
LemperaLure ls
372 C (99 l) blood pressure ls 130/90 mm Pg and
pulse ls 100/mln
Abdomlnal examlnaLlon shows mlld dlsLenLlon
eplgasLrlc Lenderness and
volunLary guardlng 1esL of Lhe sLool for occulL
blood ls negaLlve

PemaLocrlL 44
Serum
na+ 138 mLq/L
Cl 100 mLq/L
k+ 4 mLq/L
PCC3 23 mLq/L
AsparLaLe amlnoLransferase
(AS1 CC1) 14 u/L
Alanlne amlnoLransferase
(AL1 C1) 12 u/L
Amylase 1100 u/L

ulLrasonography shows gallsLones Lhe gallbladder wall
ls 1 mm and Lhe
common blle ducL ls 3 mm ln dlameLer Whlch of Lhe
followlng ls Lhe
mosL llkely dlagnosls?

A
) AcuLe cholecysLlLls

8
) AcuLe pancreaLlLls

C
) AcuLe perlhepaLlLls

u
) Ascendlng cholanglLls

L
) uuodenal ulcer

l
) vlral hepaLlLls

4 A 13yearold glrl ls broughL Lo Lhe emergency
deparLmenL because
of shorLness of breaLh for 2 hours 1he sympLoms
began afLer consumlng
chlll cornbread and frulL salad wlLh sLrawberrles
klwl and bananas
She has a 1year hlsLory of shorLness of breaLh whlle
playlng soccer or
baseball and uses a bronchodllaLor lnhaler as needed
whlle exerclslng
She ls allerglc Lo penlclllln and plneapples Per
blood pressure ls
80/60 mm Pg pulse ls 120/mln and regular and
wlLh use of accessory muscles LxamlnaLlon of Lhe
lungs shows poor alr
enLry bllaLerally wlLh dlffuse explraLory wheezes
Whlch of Lhe
followlng ls Lhe mosL approprlaLe lnlLlal
pharmacoLherapy?

A
) lnhaled bronchodllaLors

8
) lnhaled cromolyn sodlum

C
) lnhaled lpraLroplum bromlde

u
) lnLravenous corLlcosLerolds

L
) SubcuLaneous eplnephrlne

3

A 32yearold woman comes Lo Lhe emergency deparLmenL
6 days afLer knee
arLhroplasLy because of consLanL rlghLslded chesL
paln and shorLness
of breaLh for 24 hours Per blood pressure ls 110/30
mm Pg pulse ls
114/mln and resplraLlons are 24/mln LxamlnaLlon of
Lhe hearL lungs
and exLremlLles shows no abnormallLles ArLerlal
blood gas analysls on
room alr shows

pP 749
CC2 29 mm Pg
C2 66 mm Pg

venLllaLlonperfuslon lung scans show a low
probablllLy for pulmonary
embolus An LCC shows slnus Lachycardla an xray
fllm of Lhe chesL
shows no abnormallLles AfLer Lhe evaluaLlon Lhe
paLlenL ls palnfree
and wlshes Lo go home Whlch of Lhe followlng ls Lhe
mosL approprlaLe
nexL sLep ln managemenL?

A
) ulscharge home and reexamlnaLlon ln 2 weeks

8
) Lxerclse sLress LesL

C
) ulmonary funcLlon LesLs

u
) Lchocardlography

L
) ulmonary anglography

l
) lbuprofen Lherapy

because of spells
characLerlzed by sweaLlng palplLaLlons and shorLness
of breaLh LhaL
have awakened her aL nlghL several Llmes over Lhe pasL
3 monLhs She
reslgned from her [ob as a sales clerk 6 monLhs ago
and now works from home
as a LelemarkeLer She recenLly began golng Lo Lhe
grocery sLore laLe
aL nlghL because she ls Loo nervous around people
She says LhaL she
has been feellng sad laLely Cn menLal sLaLus
examlnaLlon she ls fully
orlenLed and her range of affecL ls full Whlch of
Lhe followlng ls
Lhe mosL llkely dlagnosls?

A
) Ad[usLmenL dlsorder wlLh anxleLy

8

C

u
) Cenerallzed anxleLy dlsorder

L

l
) anlc dlsorder wlLh agoraphobla

C
) osLLraumaLlc sLress dlsorder

7 A 63yearold woman has a 6monLh hlsLory of
progresslve
lrrlLablllLy palplLaLlons heaL lnLolerance frequenL
bowel movemenLs and a
68kg (13lb) welghL loss She has had a neck mass
for more Lhan 10
years 131l scan shows an enlarged Lhyrold gland wlLh
mulLlple areas of
lncreased and decreased upLake Whlch of Lhe
llkely dlagnosls?

A
) uefecL ln Lhyroxlne (14) blosynLhesls

8
) Craves dlsease

C
) MulLlnodular golLer

u
) 8ledels LhyroldlLls

L
) 1hyrold carclnoma

l
) 1hyroldlLls

C
) 1oxlc adenoma

P
) 1rllodoLhyronlne (13) LhyroLoxlcosls

A
) AcuLe gasLrolnLesLlnal bleedlng

8
) Adrenal lnsufflclency

C
) AorLlc valve rupLure

u
) Cardlac Lamponade

L

l
) neumonla

C
) ulmonary embollsm

P
) Sepsls

8 A prevlously healLhy 62yearold man ls broughL
Lo Lhe emergency
deparLmenL by paramedlcs 40 mlnuLes afLer Lhe sudden
onseL of severe
shorLness of breaLh whlle dresslng Lhls mornlng Pe
ls unable Lo provlde
addlLlonal medlcal hlsLory Pe ls ln severe
resplraLory dlsLress Pls
mm Pg pulse ls
120/mln and regular and resplraLlons are 24/mln
LxamlnaLlon shows
marked [ugular venous dlsLenLlon 1he lungs are clear
Lo ausculLaLlon
Cardlac examlnaLlon shows a nondlsplaced and dlscreLe
polnL of maxlmal
lmpulse and normal S1 and S2 Lhere ls an S4 and a
rlghL parasLernal
heave Abdomlnal examlnaLlon shows no abnormallLles
1here ls no edema
of Lhe lower exLremlLles LaboraLory sLudles show

PemaLocrlL 40

ArLerlal blood gas analysls on 3 L/mln of oxygen

pP 73
CC2 16 mm Pg
C2 64 mm Pg

A prevlously healLhy 67yearold woman ls broughL Lo
Lhe emergency
deparLmenL by paramedlcs 40 mlnuLes afLer Lhe sudden
onseL of shorLness of
breaLh whlle shopplng She ls unable Lo provlde
addlLlonal medlcal
hlsLory She ls ln severe resplraLory dlsLress Per
LemperaLure ls 37 C
120/mln and regular
and resplraLlons are 24/mln LxamlnaLlon shows marked
[ugular venous
dlsLenLlon ulffuse crackles are heard LhroughouL all
lung flelds
Cardlac examlnaLlon shows an enlarged polnL of maxlmal
lmpulse and normal
S1 and S2 Lhere ls an S3 Abdomlnal examlnaLlon
shows no
abnormallLles 1here ls no edema of Lhe lower
exLremlLles LaboraLory sLudles
show

PemaLocrlL 38

ArLerlal blood gas analysls on 3 L/mln of oxygen

pP 73
CC2 16 mm Pg
C2 64 mm Pg

10 A menLally compeLenL 76yearold man ls ln Lhe
Lermlnal sLage of
mulLlple myeloma Pe ls unable Lo move and requlres
24hour nurslng
care lncreaslng doses of narcoLlcs are needed Lo
conLrol severe paln
As a resulL when he ls palnfree resplraLory
funcLlon ls lmpalred and
consclousness ls clouded 1he paLlenL says he cannoL
llve wlLh Lhls
degree of paln and asks Lo be glven a leLhal ln[ecLlon
of paln
medlcaLlon Whlch of Lhe followlng ls Lhe mosL
approprlaLe sLep regardlng Lhe
paln medlcaLlon?

A
) 8educe Lhe dosage so as noL Lo lmpalr resplraLlon

8
) AdmlnlsLer Lhe dosage necessary Lo conLrol paln
desplLe
resplraLory lmpalrmenL

C
) AdmlnlsLer Lhe dosage necessary Lo conLrol paln
and add a
cenLrally acLlng sLlmulanL

u
) Appeal Lo Lhe famlly Lo convlnce Lhe paLlenL Lo
LoleraLe a blL
more paln

11 A 2dayold newborn ls broughL Lo Lhe physlclan
because of a
generallzed rash for 6 hours 1he newborn ls acLlve
alerL and feedlng
well Pls LemperaLure ls 369 C (984 l)
LxamlnaLlon shows a rash
conslsLlng of numerous whlLe and pale yellow papules
wlLh a large base of
macular eryLhema over Lhe Lrunk and exLremlLles
WrlghLs sLaln of
scraplngs from Lhe leslons shows eoslnophlls Whlch
of Lhe followlng ls

A
) 8eassurance

8
) 1oplcal corLlcosLerold Lherapy

C
) lnLravenous acyclovlr Lherapy

u
) lnLravenous amplclllln and genLamlcln Lherapy

L
) lnLravenous nafclllln Lherapy

12 A 4yearold boy ls broughL for a wellchlld
examlnaLlon Pe
uses Lwoword phrases can say hls flrsL name buL noL
hls lasL name and
cannoL ldenLlfy colors Pe ls [usL beglnnlng LolleL
Lralnlng Pls
7yearold slsLer has a learnlng dlsablllLy and
aLLends speclal educaLlon
classes CenlLal developmenL ls 1anner sLage 1
LesLes are large
sLep ln dlagnosls?

A
) 8eexamlnaLlon ln 6 monLhs

8
) 1hyrold funcLlon LesLs

C
) unA LesLlng

u
) MeasuremenL of bone age

L

because of a 2day
hlsLory of nausea and vomlLlng 1he vomlLus has been
clear and no
blood has been noLed Pe has had a decreased appeLlLe
for Lhe pasL week
1here ls no assoclaLed paln or alLered bowel funcLlon
Pe reporLs LhaL
he ls noL seelng Lhlngs correcLly Pe Lakes warfarln
and dlgoxln for
aLrlal flbrlllaLlon hydrochloroLhlazlde for
hyperLenslon and poLasslum
supplemenLs LhaL he dlsconLlnued 3 weeks ago when he
ran ouL of
LableLs Pls LemperaLure ls 37 C (986 l) blood
pressure ls 144/88 mm Pg
and pulse ls 32/mln and lrregular 8owel sounds are
normal 1he abdomen
ls sofL and nonLender wlLhouL rebound or guardlng no
organomegaly or
masses are palpaLed Whlch of Lhe followlng ls Lhe
mosL llkely
dlagnosls?

A
) AcuLe pancreaLlLls

8
) 8raln Lumor

C
) ulabeLlc gasLroparesls

u
) ulabeLlc keLoacldosls

L
) urug LoxlclLy

l
) lood polsonlng

C
) CasLrlc bezoar

P
) CasLrlc carclnoma

l
) ylorlc channel ulcer

!
) Smallbowel obsLrucLlon

k
) uremla

14 A 27yearold prlmlgravld woman aL 12 weeks
gesLaLlon comes Lo
Lhe emergency deparLmenL 2 hours afLer Lhe sudden
onseL of brlghL red
vaglnal bleedlng She has noL had abdomlnal cramplng
elvlc
examlnaLlon shows a small amounL of brownlsh blood ln
Lhe posLerlor fornlx of
Lhe vaglna 1he cervlx ls closed 1he uLerus ls
palpable 3 cm above Lhe
pelvlc brlm leLal hearL Lones are easlly audlble aL
167/mln by
uoppler Whlch of Lhe followlng ls Lhe mosL llkely
dlagnosls?

A) AbrupLlo placenLae
8) LcLoplc pregnancy
C) lncompleLe aborLlon
u) lacenLa prevla
L) 1hreaLened aborLlon
l) normal pregnancy

by hls son because
of a 4day hlsLory of lncreaslng confuslon and memory
problems 1he
son says LhaL hls faLhers ablllLy Lo funcLlon
lndependenLly has been
generally decllnlng over Lhe pasL few years and he
has become much more
lmpalred over Lhe pasL week 1he paLlenL has had aL
leasL Lhree Lo four
prevlous eplsodes of a sudden decllne of cognlLlve
funcLlonlng over Lhe
pasL 3 years wlLhouL full recovery Pe has a hlsLory
of hyperLenslon
Pls blood pressure ls 160/93 mm Pg wlLhouL orLhosLaLlc
changes
neurologlc examlnaLlon shows no focal flndlngs
MlnlMenLal SLaLe LxamlnaLlon
score ls 21/30 Whlch of Lhe followlng ls Lhe mosL
llkely underlylng
paLhophyslologlc process?

A
) CenLral nervous sysLem demyellnaLlon

8
) CenLral nervous sysLem lnfecLlon

C
) ulffuse axonal ln[ury

u
) ulffuse corLlcal aLrophy

L
) LefL Lemporal lobe lnfarcLlon

l
) MulLlple small cenLral nervous sysLem
lnfarcLlons

C
) Subdural hemaLoma

16 A 72yearold woman comes for a rouLlne healLh
malnLenance
examlnaLlon She has a 3year hlsLory of occaslonal
loss of small amounLs
of urlne when she coughs or sneezes She has had no
paln or burnlng
wlLh urlnaLlon She has hyperLenslon LreaLed wlLh
dally
hydrochloroLhlazlde She underwenL an appendecLomy aL
Lhe age of 10 years She has
Lhree chlldren and had uncompllcaLed pregnancles
LxamlnaLlon shows no
abnormallLles excepL for a moderaLe cysLocele Whlch
of Lhe followlng ls
Lhe mosL llkely cause of Lhls paLlenLs urlnary
sympLoms?

A
) Chronlc lnfecLlous LrlgonlLls

8
) Large lnLraveslcal calculus

C
) CbsLeLrlc Lrauma

u
) olycysLlc kldney dlsease

L
) SpasLlc neurogenlc bladder

deparLmenL by
her husband because of halluclnaLlons and aglLaLlon
for 6 hours She has
a 10year hlsLory of alcohollsm Per lasL alcohollc
drlnk was 48 hours
ago She ls aglLaLed and lnaLLenLlve Per
LemperaLure ls 383 C (101
l) blood pressure ls 190/120 mm Pg and pulse ls
110/mln She ls
orlenLed Lo person buL noL Lo place or Llme uurlng
Lhe examlnaLlon she
shrleks Make Lhe llzards go away Whlch of Lhe
approprlaLe lnlLlal sLep ln managemenL?

A
) LlecLroencephalography

8

C
) lnLravenous amplclllln Lherapy

u
) lnLravenous haloperldol Lherapy

L
) lnLravenous lorazepam Lherapy

18 A 27yearold woman comes Lo Lhe physlclan because of a 3week
hlsLory of fever nlghL sweaLs rash on boLh legs nonproducLlve cough
and paln and swelllng ln her wrlsLs and knees She has noL had welghL
loss Per LemperaLure ls 377 C (998 l) blood pressure ls 110/70 mm
Pg pulse ls 96/mln and resplraLlons are 14/mln 1he lungs are clear
Lo ausculLaLlon Cardlac examlnaLlon shows no abnormallLles 1here ls
swelllng and warmLh over Lhe wrlsLs and knees bllaLerally and Lender
red nodules on Lhe anLerlor surface of boLh lower exLremlLles An xray
fllm of Lhe chesL shows bllaLeral hllar fullness

A) Carclnoma of Lhe lung
8) PlsLoplasmosls
C) Podgklns dlsease
u) Sarcoldosls
L) 1uberculosls

19 A 32yearold woman comes Lo Lhe physlclan because of dlfflculLy cllmblng sLalrs for 4
monLhs She has also noLed LhaL her Lhlghs hurL when she presses on Lhem She has had
lncreaslng dlfflculLy comblng her halr because she Llres easlly Cn examlnaLlon she pushes
herself ouL of Lhe chalr wlLh her arms 1here ls weakness of Lhe proxlmal muscles of Lhe
exLremlLles Whlch of Lhe followlng ls Lhe mosL llkely dlagnosls?

A) Cauda equlna syndrome
8) Cerebellar degeneraLlon
C) Cervlcal splnal cord compresslon
u) ulabeLlc polyneuropaLhy
L) lemoral arLery lnsufflclency
l) Culllaln8arre syndrome
C) Lumbar splnal sLenosls
P) MulLlple sclerosls
l) normalpressure hydrocephalus
!) olymyoslLls
k) Sensory neuropaLhy
L) 1abes dorsalls

20 A 72yearold man comes Lo Lhe physlclan because of generallzed weakness and nlghL
sweaLs for 6 monLhs uurlng Lhls perlod he has had a 3kg (11lb) welghL loss Pe has had
polycyLhemla vera for 12 years LreaLed wlLh hydroxyurea and mulLlple phleboLomles
LxamlnaLlon shows cachexla 1he llver ls enlarged and nonLender wlLh a span of 13 cm
Lhe spleen ls enlarged PemaLocrlL ls 27 leukocyLe counL ls 3200/mm3
and plaLeleL counL ls 130000/mm3 A blood smear ls shown Whlch of
Lhe followlng ls Lhe mosL llkely dlagnosls?

A
) AcuLe myelogenous leukemla

8
) Clrrhosls of Lhe llver

C
) Podgklns dlsease

u
) Mlllary Luberculosls

L
) Myeloflbrosls

21 A 30yearold man has had lncreaslngly severe
low back paln
slnce llfLlng a heavy ob[ecL aL work 3 days ago 1he
paln does noL radlaLe
and ls noL assoclaLed wlLh bowel or bladder problems
Pe has a hlsLory
of occaslonal sLlffness and mlld paln ln hls lower
back 1here ls
bllaLeral paraverLebral muscle Lenderness ln Lhe
lumbar reglon and llmlLed
flexlon of Lhe lumbosacral splne LxamlnaLlon of Lhe
lower exLremlLles
shows normal muscle sLrengLh and sensaLlon
sLralghLleg ralslng ls
negaLlve bllaLerally ueep Lendon reflexes aL Lhe
knees and ankles are
normal Whlch of Lhe followlng ls Lhe mosL
managemenL?

A
) Lxerclses Lo sLrengLhen abdomlnal muscles

8
) Lxerclses Lo sLrengLhen paraverLebral muscles

C
) 8ed resL for 3 Lo 7 days

u
) use of a muscle relaxanL

L
) use of a nonsLeroldal anLllnflammaLory drug

22 A 42yearold woman gravlda 2 para 2 has had
lncreaslng
faLlgue dyspnea orLhopnea and paroxysmal nocLurnal
dyspnea over Lhe pasL
2 days She has had several eplsodes of hemopLysls
she had one
eplsode of pulmonary edema durlng pregnancy 2 years
ago A loud S1 a
snapplng sound ln dlasLole and a rumbllng dlasLollc
murmur are heard aL Lhe
apex Whlch of Lhe followlng ls Lhe mosL llkely cause
of her
condlLlon?

A
) ALrlal myxoma

8
) 8lcuspld aorLlc valve

C
) osLparLum cardlomyopaLhy

u
) 8heumaLlc hearL dlsease

L
) vlral myocardlLls

3 A 37yearold woman has had unllaLeral breasL
paln fever and
chllls for 24 hours She breasLfeeds her 1monLhold
newborn Per
LemperaLure ls 38 C (1004 l) LxamlnaLlon shows
swelllng eryLhema and
locallzed Lenderness of Lhe lefL breasL Whlch of Lhe
followlng ls Lhe
mosL approprlaLe nexL sLep ln managemenL?

A
) AppllcaLlon of lce packs Lo Lhe affecLed breasL

8
) use of a breasL pump

C
) lmmedlaLe dlsconLlnuaLlon of breasLfeedlng

u
) 8romocrlpLlne Lherapy

L
) enlcllllnasereslsLanL anLlbloLlc Lherapy

24 A 19yearold woman gravlda 2 para 1 aL 39
weeks gesLaLlon
ls admlLLed ln labor ConLracLlons occur every 2 Lo 3
mlnuLes 1he
cervlx ls 4 cm dllaLed and 80 effaced She requesLs
an epldural for paln
conLrol 1en mlnuLes afLer Lhe epldural ls
admlnlsLered she becomes
nauseaLed and dlaphoreLlc and vomlLs Per blood
pressure ls 60/palpable
mm Pg A feLal hearL Lraclng shows susLalned feLal
deceleraLlons 1he
cervlx ls now 8 cm dllaLed 1he mosL approprlaLe nexL
sLep ln
managemenL ls admlnlsLraLlon of whlch of Lhe
followlng?

A
) Lphedrlne

8
) Magneslum sulfaLe

C
) nlfedlplne

u
) CxyLocln

L
) 1erbuLallne

23 An asympLomaLlc 47yearold man comes for a
rouLlne followup
examlnaLlon 3 weeks afLer susLalnlng an lnferlor wall
myocardlal
lnfarcLlon Pls recovery was compllcaLed by LranslenL
premaLure venLrlcular
conLracLlons durlng Lhe flrsL 2 days of
hosplLallzaLlon An exerclse
sLress LesL prlor Lo dlscharge showed no paln aL 70
of hls predlcLed
maxlmum exerclse capaclLy MedlcaLlons lnclude dally
asplrln and
pravasLaLln Pls blood pressure ls 136/80 mm Pg
pulse ls 80/mln and regular
and resplraLlons are 16/mln Cardlopulmonary
approprlaLe addlLlonal
pharmacoLherapy for Lhls paLlenL?

A
) Clonldlne

8
) MeLoprolol

C
) Culnldlne

u
) Sulflnpyrazone

L
) verapamll

deparLmenL by
her famlly because of shorLness of breaLh LlghLness
ln her chesL and
palplLaLlons for 2 hours Cver Lhe pasL 11 monLhs
she has had flve
slmllar eplsodes durlng Lhe lasL eplsode 3 weeks ago
she was LreaLed wlLh
an lnLravenous medlcaLlon LhaL caused converslon Lo
slnus rhyLhm Per
and regular 1he
lungs are clear Lo ausculLaLlon Whlch of Lhe
llkely underlylng dysrhyLhmla?

A
) AcceleraLed ldlovenLrlcular rhyLhm

8
) AcceleraLed [uncLlonal rhyLhm

C
) ALrlal flbrlllaLlon

u
) MulLlfocal aLrlal Lachycardla

L
) normal slnus rhyLhm

l
) aroxysmal supravenLrlcular Lachycardla

C
) remaLure supravenLrlcular beaLs

P
) remaLure venLrlcular beaLs

l
) Slck slnus syndrome

!
) Slnus bradycardla

k
) Slnus Lachycardla

L
) venLrlcular flbrlllaLlon

M
) venLrlcular Lachycardla

27

A 4yearold boy ls broughL Lo Lhe emergency
deparLmenL because of a
1day hlsLory of fever and lncreaslng dlfflculLy
breaLhlng Cver Lhe
pasL year he has had recurrenL bacLerlal lnfecLlons
lncludlng cervlcal
lymphadenlLls sepLlc arLhrlLls and pneumonla Pls
LemperaLure ls 389
113/mln and
resplraLlons are 38/mln and labored 8reaLh sounds
are decreased over Lhe
lefL anLerlor chesL ScaLLered crackles are heard on
ausculLaLlon A
LhoracenLesls shows purulenL fluld LaboraLory
sLudles show

PemaLocrlL 36
LymphocyLes 13
leural fluld
LymphocyLes 2

nlLroblue LeLrazollum LesL ls abnormal A Crams
sLaln of Lhe pleural
fluld shows numerous gramposlLlve coccl ln Lhe
segmenLed neuLrophlls
An xray fllm of Lhe chesL shows lefL lower lobe
pneumonla wlLh pleural
effuslon 1he mosL llkely cause of Lhls paLlenLs
sympLoms ls a defecL
of whlch of Lhe followlng?

A
) ChemoLaxls

8
) lmmoLlle cllla

C
) CpsonlzaLlon

u
) hagocyLlc oxldaLlve meLabollsm

L
) hagocyLosls

l
) 1lymphocyLe funcLlon

deparLmenL 43 mlnuLes
afLer Lhe onseL of chesL dlscomforL LhaL ls noL
relleved by Lhree
nlLroglycerln LableLs Cver Lhe pasL 3 monLhs she
has had slmllar eplsodes
characLerlzed by nonradlaLlng paln and a feellng of
heavlness Lhe
eplsodes were exacerbaLed by exerLlon or heavy meals
and were slowly
relleved by resL Subllngual nlLroglycerln has
provlded rapld rellef of
sympLoms ln Lhe pasL She has hypercholesLerolemla
Lype 2 dlabeLes
melllLus and pepLlc ulcer dlsease She smoked Lwo
packs of clgareLLes dally
for 23 years buL qulL 3 years ago She appears
anxlous and dlaphoreLlc
and ls nauseaLed LxamlnaLlon shows no oLher
abnormallLles excepL for
an S4 Whlch of Lhe followlng ls Lhe mosL llkely
dlagnosls?

A
) AcuLe aorLlc dlssecLlon

8
) Anglna pecLorls

C
) Lsophageal spasm

u
) Myocardlal lnfarcLlon

L
) ulmonary embollsm

because of
lncreaslngly severe dally headaches over Lhe pasL 3
monLhs 1he headaches are
dlffuse and ofLen occur aL Lhe base of Lhe skull lor
Lhe pasL monLh
she has had brlef eplsodes of vlsual darkenlng when
sLandlng She has
been amenorrhelc for Lhe pasL year and has had an
18kg (40lb) welghL
galn durlng Lhls perlod She now welghs 118 kg (260
lb) and ls 132 cm
(60 ln) Lall lunduscoplc examlnaLlon shows
papllledema several flame
hemorrhages and an enlarged bllnd spoL bllaLerally
vlsual aculLy ls
20/20 bllaLerally A C1 scan of Lhe head shows no
abnormallLles Whlch
of Lhe followlng ls Lhe mosL llkely underlylng cause
of Lhese flndlngs?

A
) Cerebral venous occluslon

8
) CommunlcaLlng hydrocephalus

C
) CyLoLoxlc edema

u
) ldlopaLhlc lnLracranlal hyperLenslon

L
) lmpalred absorpLlon of cerebrosplnal fluld

l
) lnfraLenLorlal mass leslon

C
) lnLersLlLlal edema

P
) CverproducLlon of cerebrosplnal fluld

l
) vasogenlc edema

30 A 73yearold man wlLh a 3year hlsLory of
progresslve cognlLlve
lmpalrmenL due Lo demenLla Alzhelmers Lype has had
nocLurnal
dlsorlenLaLlon for 2 weeks Pe llves aL home wlLh hls
wlfe Pe ls oLherwlse
healLhy and Lakes no medlcaLlons hyslcal
examlnaLlon shows normal
flndlngs Pe ls dlsorlenLed Lo Llme and place has
poor shorLLerm
memory ls unable Lo do slmple arlLhmeLlc and has a
poor undersLandlng of
general lnformaLlon Whlch of Lhe followlng ls Lhe
mosL approprlaLe
lnlLlal sLep ln managemenL?

A
) lncrease ln home nlghLLlme llghLlng

8
) rescrlpLlon for chloral hydraLe

C
) rescrlpLlon for dlazepam

u
) rescrlpLlon for haloperldol

L
) use of nlghLLlme mechanlcal resLralnLs

because of severe
paln and swelllng of her rlghL knee for 1 day She
has no hlsLory of
[olnL dlsease or Lrauma Lo Lhe knee She has
hyperLenslon LreaLed wlLh
hydrochloroLhlazlde and Lype 2 dlabeLes melllLus
LreaLed wlLh glyburlde
She ls sexually acLlve only wlLh her husband and Lhey
have sexual
lnLercourse one Lo Lwo Llmes each week Per
LemperaLure ls 37 C (986 l)
LxamlnaLlon of
Lhe rlghL knee shows edema eryLhema and exqulslLe
Lenderness Lo llghL
Louch Lhere ls an effuslon 1he remalnder of Lhe
llkely mechanlsm of
Lhese flndlngs?

A
) lmmune complex deposlLlon

8
) lnflammaLory reacLlon Lo anLlsynovlal anLlbodles

C
) lnflammaLory reacLlon Lo monosodlum uraLe
crysLals

u
) nelsserla gonorrhoeae lnfecLlon

L
) SLrepLococcus pneumonlae lnfecLlon

32 1wo days afLer a cholecysLecLomy a 42yearold
woman has
shorLness of breaLh Per LemperaLure ls 373 C (993
l) blood pressure ls
24/mln 1here ls
abdomlnal Lenderness LxamlnaLlon shows no oLher
abnormallLles An
xray fllm of Lhe chesL shows mlnlmal llnear marklngs
ln Lhe rlghL lower
lobe ArLerlal blood gas analysls on 43 oxygen
shows

pP 741
CC2 40 mm Pg
C2 32 mm Pg

Whlch of Lhe followlng ls Lhe mosL llkely explanaLlon
for her hypoxla?

A
) AcuLe resplraLory dlsLress syndrome

8
) ALelecLasls

C

u
) laL embollsm syndrome

L
) neumonla

l
) neumoLhorax

a 3day hlsLory of lncreaslngly severe abdomlnal paln
nausea and
vomlLlng 1welve years ago she had a hysLerecLomy
because of severe
dysfuncLlonal uLerlne bleedlng Per LemperaLure ls 37
C (986 l) blood
LxamlnaLlon shows a dlsLended Lympanlc abdomen wlLh
dlffuse Lenderness
buL no guardlng bowel sounds are hypoacLlve Per
leukocyLe counL ls
10000/mm3 and hemaLocrlL ls 44 An xray fllm of
Lhe abdomen ls
shown Whlch of Lhe followlng ls Lhe mosL approprlaLe
lnlLlal sLep ln
managemenL?

A

8
) lnLravenous neosLlgmlne Lherapy

C
) LsophagogasLroduodenoscopy

u
) nasogasLrlc lnLubaLlon

L
) LaparoLomy

34 A healLhy 27yearold woman comes for a rouLlne
healLh
malnLenance examlnaLlon Per blood pressure ls 183/90
mm Pg LxamlnaLlon shows
no oLher abnormallLles excepL for hyperLenslve
reLlnopaLhy Serum
sLudles show a sodlum level of 140 mLq/L poLasslum
level of 4 mLq/L and
creaLlnlne level of 11 mg/dL A compleLe blood
counL serum
caLecholamlne levels and urlnalysls are wlLhln normal
llmlLs AL Lwo subsequenL
vlslLs her blood pressure ls 190/100 mm Pg and 182/96
mm Pg
respecLlvely Whlch of Lhe followlng ls Lhe mosL
dlagnosls?

A
creaLlnlne clearance

8
17hydroxycorLlcosLerold and LoLal 17keLosLerold
levels

C
) MeasuremenL of serum aldosLerone level

u
) MagneLlc resonance anglography of renal vessels

L

33 A 76yearold man has had faLlgue and loss of
lnLeresL ln dally
acLlvlLles over Lhe pasL 4 monLhs Pe sleeps poorly
and has had a
43kg (10lb) welghL loss durlng Lhls perlod Pe
sLaLes LhaL he has
probably llved long enough Pls blood pressure ls
110/78 mm Pg and pulse
ls 68/mln LxamlnaLlon shows a slow reLurn of deep
Lendon reflexes
MeasuremenL of whlch of Lhe followlng serum levels ls
Lhe mosL

A
) Calclum

8
) CreaLlnlne

C
) Clucose

u
) 1esLosLerone

L
) 1hyroldsLlmulaLlng hormone

36 A 29yearold woman ls broughL Lo Lhe physlclan
by her faLher
She has been worklng conLlnuously wlLhouL sleep for 3
days on a pro[ecL
whlch she clalms Allah and !esus have Lold me Lo do
LhaL wlll unlfy
all knowledge ln physlcs and medlclne and phllosophy
She hears Lhe
volce of her dead broLher Lelllng her LhaL she wlll be
Lhe nexL vlrgln
Mary Per faLher sLaLes LhaL she was LreaLed for
depresslon for 1 year
aL Lhe age of 19 years Whlch of Lhe followlng ls Lhe
mosL llkely
dlagnosls?

A
) 8lpolar dlsorder

8
) 8orderllne personallLy dlsorder

C

u
) Schlzophrenla

L
) SubsLancelnduced mood dlsorder

37 A 67yearold man ls hosplLallzed for LreaLmenL
of renal
lnsufflclency 1hree days afLer admlsslon hls pulse
ls 40/mln An LCC shows
Lall LenLed 1 waves Serum sLudles show a sodlum
level of 134 mLq/L
poLasslum level of 69 mLq/L and glucose level of 83
mg/dL 1he mosL
approprlaLe nexL sLep ln managemenL ls lnLravenous
admlnlsLraLlon of
whlch of Lhe followlng?

A
) Calclum furosemlde and 3 sallne

8
) Calclum lnsulln and dlglLalls

C
) Calclum lnsulln and glucose

u
) Clucose furosemlde and phosphaLe

L
) Clucose glucagon and blcarbonaLe

38 Slx monLhs afLer Lhe dellvery of her fourLh
chlld a 37yearold
woman undergoes laparoscoplc Lubal llgaLlon Menses
occur aL regular
28day lnLervals uurlng Lhe operaLlon she ls found
Lo have a small
dark leslon ln Lhe culdesac and fllmy adheslons
surroundlng Lhe
ovarles A blopsy speclmen of a culdesac leslon
conflrms Lhe dlagnosls of
endomeLrlosls Whlch of Lhe followlng ls Lhe mosL
approprlaLe nexL sLep
ln managemenL?

A
) uanazol Lherapy

8
) ConadoLroplnreleaslng hormone agonlsL Lherapy

C
) Cral conLracepLlve Lherapy

u
) 1oLal abdomlnal hysLerecLomy and bllaLeral
salplngooophorecLomy

L
) no furLher LreaLmenL lndlcaLed

A
) AdmlnlsLraLlon of parenLeral anLlbloLlcs

8
) Admlsslon Lo Lhe hosplLal for medlcal managemenL

C
) Admlsslon Lo Lhe hosplLal for operaLlve
managemenL

u
) Colon conLrasL sLudles

L
) ulscharge for followup by personal physlclan

l
) Lndoscopy

C
) M8l of Lhe abdomen

P
) CbservaLlon ln Lhe emergency deparLmenL

39 A prevlously healLhy 6monLhold boy ls broughL
Lo Lhe emergency
deparLmenL because of a 12hour hlsLory of
lnLermlLLenL eplsodes of
lnconsolable crylng assoclaLed wlLh drawlng up of Lhe
legs Cver Lhe pasL
6 hours he has had lnLermlLLenL dlarrhea LhaL ls
reddlsh and mucold
and for Lhe pasL 3 hours he has been somnolenL Cn
examlnaLlon he ls
sleepy buL arousable Pls LemperaLure ls 381 C
(1006 l) blood
resplraLlons are 38/mln Pe
crles when hls abdomen ls palpaLed a mass ls felL ln
Lhe rlghL lower
quadranL Pls leukocyLe counL ls 12400/mm3 (30
segmenLed neuLrophlls
8 bands 1 eoslnophlls 40 lymphocyLes and 1
monocyLes) Serum
elecLrolyLe levels are wlLhln normal llmlLs An xray
fllm of Lhe
abdomen shows no free alr

A
) AdmlnlsLraLlon of parenLeral anLlbloLlcs

8
) Admlsslon Lo Lhe hosplLal for medlcal managemenL

C
) Admlsslon Lo Lhe hosplLal for operaLlve
managemenL

u
) Colon conLrasL sLudles

L
) ulscharge for followup by personal physlclan

l
) Lndoscopy

C
) M8l of Lhe abdomen

P
) CbservaLlon ln Lhe emergency deparLmenL

40 A prevlously healLhy 14yearold glrl ls
broughL Lo Lhe
emergency deparLmenL because of abdomlnal paln for 12
hours She has a 1week
hlsLory of brownlsh vaglnal dlscharge Menarche was
aL Lhe age of 12
years and her perlods have occurred aL regular 28day
lnLervals over
Lhe pasL year Per lasL mensLrual perlod was 7 weeks
ago Per
mm Pg pulse ls 143/mln
and resplraLlons are 24/mln Abdomlnal examlnaLlon
shows generallzed
Lenderness and Lhere ls guardlng wlLh rebound ln Lhe
rlghL lower
quadranL Per hemaLocrlL ls 24 and leukocyLe counL
ls 9400/mm3 (60
segmenLed neuLrophlls 3 bands 1 eoslnophlls 33
lymphocyLes and 1
monocyLes) Serum elecLrolyLe levels are wlLhln
normal llmlLs

41 A 49yearold woman ls admlLLed Lo Lhe hosplLal
because of renal
fallure She has had eplsodes of flank paln over Lhe
pasL 20 years
She has also had nocLurla 2 Lo 3 Llmes nlghLly for 10
years Per blood
pressure ls 160/100 mm Pg LxamlnaLlon shows pale
mucous membranes A
mass ls palpaLed ln Lhe rlghL flank Whlch of Lhe
followlng ls Lhe
mosL llkely dlagnosls?

A
) Porseshoe kldney

8
) nephrollLhlasls

C
) aplllary necrosls

u
) olycysLlc kldney dlsease

L
) 8enal cell carclnoma

42 Cn rouLlne annual screenlng an asympLomaLlc
27yearold man has
a poslLlve u skln LesL Cne year ago a u skln
LesL was negaLlve
Pe works as a nurse 1hree years ago he was
dlagnosed wlLh hepaLlLls
A afLer a Lrlp Lo SouLh Amerlca LxamlnaLlon shows no
abnormallLles
Pls serum asparLaLe amlnoLransferase (AS1 CC1)
acLlvlLy ls 10 u/L and
serum alanlne amlnoLransferase (AL1 C1) acLlvlLy ls
14 u/L An xray
fllm of Lhe chesL shows no abnormallLles Whlch of
Lhe followlng ls
Lhe mosL approprlaLe chemoprophylaxls?

A
) lsonlazld and follc acld supplemenLaLlon

8
) lsonlazld and rlfampln

C
) lsonlazld and vlLamln 81 (Lhlamlne)
supplemenLaLlon

u
) lsonlazld and vlLamln 86 supplemenLaLlon

L
) no prophylaxls lndlcaLed

43

A 4monLhold boy ls broughL Lo Lhe physlclan because
of a 2day
hlsLory of fever and progresslve redness around hls
rlghL eye Pe has had
perslsLenL dlarrhea and oral candldlasls slnce blrLh
and was LreaLed for
pneumococcal pneumonla aL Lhe age of 2 monLhs Pe
appears lll Pls
LemperaLure ls 39 C (1022 l) pulse ls 130/mln and
resplraLlons are
23/mln LxamlnaLlon shows vlolaceous presepLal
(perlorblLal) cellullLls
and oral candldlasls LaboraLory sLudles show

Pemoglobln 10 g/dL
LymphocyLes 13
Serum
lgA 3 mg/dL
lgC 300 mg/dL
lgM 3 mg/dL


A
) AluS

8
) Chronlc granulomaLous dlsease

C
) Severe comblned lmmunodeflclency

u
) 1hymlcparaLhyrold dysplasla (ulCeorge syndrome)

L
) xllnked agammaglobullnemla

44 Cne week afLer undergolng an uncompllcaLed
llver LransplanL for
blllary aLresla a 3yearold boy appears [aundlced
LxamlnaLlon shows
scleral lcLerus Pls serum asparLaLe amlnoLransferase
(AS1 CC1)
acLlvlLy has lncreased Lo 1300 u/L and serum alanlne
amlnoLransferase (AL1
C1) acLlvlLy has lncreased Lo 2300 u/L Pls serum
blllrubln level ls
33 mg/dL and serum alkallne phosphaLase acLlvlLy ls
100 u/L Whlch
of Lhe followlng ls Lhe mosL llkely arLery responslble
for Lhls
paLlenLs gasLrolnLesLlnal sympLoms?

A
) PepaLlc

8
) lleocollc

C
) lnferlor mesenLerlc

u
) LefL gasLrlc

L
) LefL gasLroeplplolc

l
) Mlddle collc

C
) osLerlor peneLraLlng

P
) 8lghL collc

l
) 8lghL gasLroeplplolc

!
) Splenlc

k
) Superlor hemorrholdal

L
) Superlor mesenLerlc

43 A 2yearold glrl has had fever and bloody
dlarrhea for 10 days
A sLool culLure obLalned 7 days ago grew Salmonella
specles senslLlve
Lo amoxlclllln A blood culLure was negaLlve
uesplLe beglnnlng oral
amoxlclllln Lherapy 4 days ago her dlarrhea has
perslsLed CurrenL
examlnaLlon shows no oLher abnormallLles excepL for a
LemperaLure of 386 C
(1013 l) Whlch of Lhe followlng ls Lhe mosL llkely
explanaLlon for
Lhe fallure of amoxlclllln Lo lmprove her sympLoms?

A
) Amoxlclllln does noL alLer Lhe course of
Salmonella enLerlLldls

8
) Amoxlclllln has caused pseudomembranous collLls

C
) Amoxlclllln ls absorbed aL Lhe level of Lhe
[e[unum leavlng no
drug Lo be dellvered Lo Lhe colon

u
) Cral amoxlclllln ls noL absorbed lnLo Lhe
sysLemlc clrculaLlon ln
Lhe presence of dlarrhea

L
) Salmonella has expressed an lnduclble lacLamase
LhaL lnacLlvaLes
amoxlclllln

46

A 23yearold man comes Lo Lhe physlclan because of a
1monLh hlsLory
of lnLermlLLenL rlghLslded abdomlnal paln nausea
and vomlLlng Pe
has slckle cell dlsease and has been LreaLed several
Llmes for palnful
crlses LxamlnaLlon of Lhe abdomen shows Lenderness
Lo palpaLlon of Lhe
rlghL upper quadranL on lnsplraLlon LaboraLory
sLudles show

PemaLocrlL 23
Serum
8lllrubln
1oLal 32 mg/dL
ulrecL 03 mg/dL

ulLrasonography of Lhe gallbladder shows a fllllng
defecL Whlch of
Lhe followlng ls Lhe mosL llkely cause of Lhls
paLlenLs
hyperblllrublnemla?

A
) AggregaLlon of cholesLerol ln Lhe gallbladder

8
) lnhlblLlon of glucuronosylLransferase

C
) Lysls of eryLhrocyLes

u
) MalnuLrlLlonlnduced clrrhosls

L
) neoplasLlc growLh ln Lhe gallbladder

8LCCk 1

1 1 e
2 a
3 8
4 L
3 a? b?
6 b
7 b
8 C
9 u
10 A
11 !
12 P
13 d
14 a
13 d
16 b
17
18 d
19 A
20 c
21 A
22 8
23 a
24 b
23 8/u
26 A
27 e
28 C
29 u
30 C
31 u
32 8
33 L
34 A
33 c
36 a
37 f
38A
39 C
40 a
41 L
42 8
43 L
44 u
43 u/8
46 l

8LCCk 2
1 u
28
3A
4 C??
3 C
6 C
78
8u
9A
10C??
11C
12u
13 C
14C
13A
16C
17 A /?? L
188
198
20L
21L
22u
23u
24 L
23C
26l
278
28L
298
30u
31L
328
33A
34A
33L
36L
37L
38l
39u
408 ??
41L
42u
43L
44 L
43
C( CS1LCM?Ll1lS)
46u

8LCCk 3

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

8LCCk 4

1a
2a
3b?
4 e/a
3e/b
6f
7c
8c/g
9g
10a/c very conLroverLlal plz explaln
11a
12c
13e
14e
13f
16c
17e/d
18d
19[
20a /? L
21e/d
22d
23a
24a?
23b
26f
27d
28d
29d
30a
31b
32b
33d nosogasLrlc sucLlon
34d
33e
36a
37b
38e?
39d
40d
41d
42d
43c
44a
43b??
46c

NBME Test 1

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NBME Test 1

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1) A 30yearold man wlLh a 20year hlsLory of Lype

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