NBME Form 1 Step 2 Section 1:-1.

A 70-year-old woman has had increasing abdominal pain over the past 2 days. She has renal failure and has been receiving peritoneal dialysis for 18 months; her last treatment was 2 hours ago. She appears toxic. Her temperature is 39 C (102.2 F), and blood pressure is 140/90 mm Hg. Her abdomen is distended and diffusely tender to deep palpation with rebound tenderness. Leukocyte count is 18,000/mm3. Which of the following is the most appropriate next step? A ) X-ray films of the abdomen B ) Comparison of abdominal fluid amylase with serum amylase activity C ) Gram's stain of abdominal fluid D ) Ultrasonography of the abdomen E ) CT scan of the abdomen and pelvis 2. A 5-year-old girl is brought to the physician because of temperatures to 40 C (104 F), tachypnea, and a nonproductive cough for 12 hours. Four days ago she was treated with an oral antibiotic for suspected pneumococcal pneumonia. Examination shows diminished breath sounds over the lower right lung fields and dullness to percussion at the right costophrenic angle. Which of the following is the most likely diagnosis? A ) Bronchopleural fistula B ) Empyema C ) Lung abscess D ) Pleurodynia E ) Pneumothorax 3. A 40-year-old man is brought to the emergency department 1 hour after a high-speed motor vehicle collision. On arrival, he is awake and alert but has severe pain over the sternum. His systolic blood pressure is 80 mm Hg, pulse is 80/min, and respirations are 10/min. An ECG shows multifocal premature ventricular contractions but no ST-segment changes. His PO2 is 100 mm Hg. After 1 L of lactated Ringer's solution is administered, his PO2 decreases to 60 mm Hg while breathing 4 L/min of oxygen by nasal cannula. Pulmonary capillary wedge pressure has increased from 14 mm Hg to 24 mm Hg (N=1–10). Which of the following is the most likely explanation for the patient's poor response to fluid resuscitation? A ) Inadequate administration of fluids B ) Myocardial contusion C ) Myocardial infarction D ) Pulmonary contusion E ) Traumatic rupture of the aorta 4. A 21-year-old African American college student has had increasing fatigue over the past 3 weeks. Since an episode of cystitis treated with trimethoprim-sulfamethoxazole 3 weeks ago, he has been unable to keep up with his physical education classes. For 6 months, he has been following a vegetarian diet that has been supervised by student health services. Examination shows no abnormalities. His hemoglobin level is 10 g/dL, mean corpuscular volume is 85 μm3, and reticulocyte count is 15%. Which of the following is the most likely cause of anemia in this patient?

A ) Anemia secondary to infection B ) Antibiotic therapy C ) Gastrointestinal blood loss D ) Sickle cell disease E ) Vegetarian diet 5. An 87-year-old nursing home resident with dementia, Alzheimer's type, is admitted to the hospital because of progressive lethargy and decreased appetite for 3 days. She had a flu-like illness followed by a deep cough 1 week ago. Over the past 10 months, she has been hospitalized once for bacterial pneumonia. She is responsive only to painful stimuli. Her temperature is 38.6 C (101.5 F), blood pressure is 110/60 mm Hg, pulse is 123/min and regular, and respirations are 28/min. Examination shows dry mucous membranes. There is no adenopathy. Crackles are heard in the right lung base. An x-ray film of the chest shows an infiltrate at the right lung base. The remainder of the examination shows no abnormalities. Which of the following is the most likely predisposing factor for this patient's pneumonia? A ) Decreased airway elasticity B ) Decreased baroreflex C ) Decreased gag reflex D ) Decreased thyroid function E ) Diastolic cardiac dysfunction F ) Impaired cardiac response to exercise G ) Impaired T-lymphocyte function H ) Impaired thirst I ) Increased lung compliance J ) Renal salt wasting 6. A 27-year-old woman comes to the physician because of feelings of anxiety about attending her 10-year high school reunion. She has a 2-year history of profound anxiety, palpitations, and sweating associated with an uneasiness around people; she avoids family gatherings and visiting friends because she is afraid of being embarrassed. She acknowledges that this fear is unreasonable. She does not use illicit drugs but says that alcohol makes her more comfortable around people. Her blood pressure is 130/90 mm Hg, and pulse is 88/min. On physical examination, she appears healthy and well nourished. Occasional wheezing is heard over the left lung field. The remainder of the examination shows no abnormalities. On mental status examination, she appears worried. Her leukocyte count is 9000/mm3 with a normal differential. Which of the following is the most likely diagnosis? A ) Alcohol abuse B ) Anxiety disorder due to a general medical condition C ) Asthma D ) Generalized anxiety disorder E ) Panic disorder with agoraphobia

F ) Social phobia The response options for the next two items are the same. You will be required to select one answer for each item in the set. For each patient with urinary incontinence, select the most likely cause. A ) Detrusor instability B ) Interstitial cystitis C ) Overflow incontinence D ) Stress incontinence E ) Urethra diverticulum F ) Urinary fistula 7. A previously healthy 44-year-old woman, gravida 4, para 4, comes to the physician because of a 9-month history of progressive loss of small amounts of urine while running; she now has to wear an absorbent pad. Examination shows a second-degree cystourethrocele. For each patient with urinary incontinence, select the most likely cause. A ) Detrusor instability B ) Interstitial cystitis C ) Overflow incontinence D ) Stress incontinence E ) Urethra diverticulum F ) Urinary fistula 8. One day after an uncomplicated spontaneous vaginal delivery, a 23-year-old woman, gravida 1, para 1, has the onset of loss of small amounts of urine. She received epidural anesthesia during labor and delivery. Examination shows an episiotomy without evidence of hematoma. She is voiding 50 to 75 mL of urine at a time. Postvoid residual volume is 300 mL. The response options for the next two items are the same. You will be required to select one answer for each item in the set. For each patient with cognitive impairment, select the most likely diagnosis. A ) Acute stress disorder B ) Dementia, Alzheimer's type C ) Dissociative amnesia D ) General paresis E ) Head trauma F ) Hepatolenticular degeneration (Wilson's disease)

She appears unkempt and has poor personal hygiene. blood pressure is 110/70 mm Hg. A ) Acute stress disorder B ) Dementia.7 mg/dL. Alzheimer's type C ) Dissociative amnesia D ) General paresis E ) Head trauma F ) Hepatolenticular degeneration (Wilson's disease) G ) HIV encephalitis H ) Huntington's disease I ) Major depressive disorder J ) Multi-infarct (vascular) dementia K ) Niacin deficiency L ) Normal-pressure hydrocephalus M ) Parkinson's disease . and pulse is 80/min and regular. and serum creatinine level is 1. she has difficulty remembering past events and seems unconcerned about her memory lapses. Her temperature is 37 C (98. She is a retired schoolteacher and lives independently. Her serum urea nitrogen (BUN) level is 25 mg/dL. An 82-year-old woman is brought to the physician by her granddaughter because of a 6-week history of increasing forgetfulness. and trouble repeating three numbers in sequence. a flat affect.6 F). She is unable to recall the names of recent presidents. She has a history of similar symptoms 2 and 5 years ago that were successfully treated with medication.G ) HIV encephalitis H ) Huntington's disease I ) Major depressive disorder J ) Multi-infarct (vascular) dementia K ) Niacin deficiency L ) Normal-pressure hydrocephalus M ) Parkinson's disease N ) Pick's disease O ) Schizophrenia. The patient describes trouble sleeping through the night and has had a decreased appetite resulting in a 4. During conversations with her granddaughter.5-kg (10-lb) weight loss over the past month. Mental status examination shows psychomotor retardation. For each patient with cognitive impairment. select the most likely diagnosis. impaired ability to recall past events. Her granddaughter is concerned because on several occasions she has left the stove on when she went to bed. catatonic type P ) Normal aging 9.

6 2 months . but there is restricted movement of the elbow. A 5-month-old boy is brought for a follow-up examination. who reports insidious changes in his wife's personality and behavior. She was born with a lumbosacral myelomeningocele which was successfully repaired at 2 days of age. and the posterior fontanelle is 3 x 4 cm and bulging. She has severe motor and sensory deficits involving both lower extremities. On examination. and her family history is unknown. Physical examination shows vermicular movements of the tongue and bilateral writhing motions of the upper extremities. His diet consists of 32 ounces of iron-fortified cow's milkbased formula daily. and her symptoms have developed since that time. There is no tenderness of the left lower extremity. The anterior fontanelle is 6 x 8 cm and bulging. catatonic type P ) Normal aging 10. He reports that she believes that aliens have been speaking to her and tampering with their heating and air-conditioning systems. A 6-month-old girl is brought to the physician for a routine health maintenance examination. He says that she was upset when she turned 40 years old. A 42-year-old computer science professor is brought to the physician by her husband. On examination.N ) Pick's disease O ) Schizophrenia.2 1 month 36. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite treatment with nebulized and oral bronchodilators and oral corticosteroids. She was adopted. Which of the following is the most appropriate initial step in management? A ) Passive hypersupination of the forearm B ) Application of figure-of-8 strap C ) Administration of analgesics and application of ice D ) Aspiration of the elbow joint E ) In-place splint immobilization of the elbow 13. He appears well nourished and happy. An 18-month-old boy is brought to the emergency department because he has not used his left arm since he fell while walking and holding hands with his 8-year-old sister 2 hours ago. The remainder of the examination shows no abnormalities. 11. Which of the following is the most likely mechanism of this infant's wheezing? A ) Allergic reaction to cow's milk B ) Aspiration of a foreign body C ) Compression of the airway by a vascular ring D ) Concurrent upper respiratory tract infection E ) Persistent immaturity of lungs 12. he holds his left upper extremity at his side with his forearm pronated. there is moderate relief of wheezing with extension of the neck. A head growth chart shows the following values: Age Head circumference (cm) Birth 34. Mental status examination shows indifference to her condition and mild to moderate difficulty with memory and calculations.

He takes no medications. and erythrocyte sedimentation rate are within normal limits. Which of the following is the most appropriate next step in management? A ) Repeat measurement of MSAFP level B ) Triple screening for MSAFP. and his court hearing is scheduled in 12 hours. Abdominal examination shows no rebound. Maternal serum αfetoprotein (MSAFP) level is increased to 3 multiples of the median. A 28-year-old man is brought to the emergency department by police because of severe pain in the right lower quadrant of the abdomen for 36 hours. He has been incarcerated in the county jail. Which of the following is the most likely diagnosis? A ) Adjustment disorder B ) Conversion disorder C ) Depressive disorder not otherwise specified D ) Factitious disorder E ) Hypochondriasis F ) Malingering G ) Somatization disorder 16. and serum estriol levels C ) Ultrasonography D ) Amniocentesis for measurement of α-fetoprotein level E ) Amniocentesis for chromosomal analysis 15. An x-ray film of the abdomen shows a normal gas pattern. A 6-year-old girl is brought to the physician because of a 4-week history of headache.38 4 months 44 6 months 47 Which of the following is the most likely cause of increased intracranial pressure? A ) Acute cerebral edema B ) Decreased absorption of cerebrospinal fluid C ) Dilation of cerebral arteries D ) Intracranial mass lesion E ) Obstruction of lateral sinus F ) Obstruction of superior vena cava G ) Obstruction of cerebrospinal fluid flow H ) Overproduction of cerebrospinal fluid 14. liver tests. serum β-hCG. She is not sure about the date of her last menstrual period but says that the pregnancy probably occurred immediately after she stopped taking oral contraceptives 5 months ago. fatigue. . Test of the stool for occult blood is negative. Complete blood count. An 18-year-old primigravid woman comes for her initial prenatal visit at 16 weeks' gestation.

A previously healthy 62-year-old man comes to the emergency department because of abdominal pain for 48 hours. Which of the following is the most appropriate next step in diagnosis? A ) Barium enema B ) CT scan of the abdomen C ) Colonoscopy D ) Cystoscopy E ) Exploratory laparotomy 18. Examination shows grunting. Abdominal examination shows diffuse left lower quadrant tenderness with no peritoneal signs. nasal flaring. Which of the following is the most likely mechanism of these findings? . During this period. pulse is 110/min. A previously healthy 3-month-old girl is brought to the emergency department because of a 3day history of grunting and increasing difficulty breathing. His leukocyte count is 14.6 C (101. Which of the following is most likely to limit progression of this patient's renal failure? A ) Increased potassium and sodium bicarbonate intake B ) Decreased sodium and daily calorie intake C ) Low-protein diet D ) Strict fluid restriction E ) Dialysis 17.5 F). She appears ill. pulse is 160/min.7 C (98 F).6 mg/dL Phosphorus 11 mg/dL Alkaline phosphatase 250 U/L Capillary blood gas analysis on 100% oxygen: pH 7. diffuse interstitial infiltrates and absence of the thymic shadow. she has had nausea and vomiting. and respirations are 76/min. blood pressure is 130/80 mm Hg. Rectal examination shows no abnormalities. and respirations are 15/min. At the age of 4 years. test of the stool for occult blood is negative.36 PCO2 38 mm Hg PO2 46 mm Hg An x-ray film of the chest shows bilateral. Her serum urea nitrogen (BUN) level is 50 mg/dL. she was diagnosed with poststreptococcal glomerulonephritis. Her temperature is 36. Serum studies show: Ca2+ 5. Bronchial breath sounds and occasional bilateral crackles are heard on auscultation.700/mm3. and marked intercostal retractions. Examination shows no abnormalities.and decreased appetite. She is at the 15th percentile for height and the 10th percentile for weight. His temperature is 38. Bronchoalveolar lavage is positive for numerous Pneumocystis carinii.

He drinks 4 oz of alcohol daily. Reflexes are absent. He has peptic ulcer disease and emphysema. He has a barrelshaped chest. Which of the following is the most likely diagnosis? A ) Acute respiratory distress syndrome B ) Aspiration pneumonia C ) Fat embolism D ) Hemothorax E ) Pulmonary contusion 20.38 PCO2 34 mm Hg PO2 66 mm Hg An x-ray film of the chest obtained 4 hours later shows diffuse infiltrates on the right side.4-kg (23-lb) weight loss over the past 4 months despite no change in appetite. theophylline. Arterial blood gas analysis while breathing 40% oxygen shows: pH 7. He also has had a 10. Examination shows multiple bruises over the chest. Breath sounds are distant. and low-dose prednisone. An x-ray film shows a hyperinflated chest and a 3 x 4-cm mass in the right hilum. He has difficulty rising from a chair. A 4-year-old boy is brought to the emergency department 20 minutes after being involved in a motor vehicle collision. and respirations are 32/min with grunting and retractions. Examination shows mild ptosis. Medications include cimetidine. His neurologic findings are most likely due to a lesion involving which of the following? A ) Muscle membrane B ) Parasympathetic nervous system . He was an unrestrained passenger. pulse is 100/min. There is moderate weakness of the proximal muscles of the lower extremities. Sensory examination shows no abnormalities. On arrival. his blood pressure is 110/70 mm Hg. A 72-year-old man comes to the physician because of a 7-month history of leg weakness and dry eyes and mouth. He has smoked one and a half packs of cigarettes daily for 50 years.A ) Adenosine deaminase deficiency B ) Consumption of complement C ) Defective opsonization D ) Destruction of CD4+ T lymphocytes E ) Developmental arrest of maturation of B lymphocytes F ) Dysmorphogenesis of the third and fourth pharyngeal pouches G ) Impaired chemotaxis H ) Impaired phagocytic oxidative metabolism 19.

He takes nitroglycerin as needed and one aspirin . A 42-year-old man comes to the emergency department because of a 2-week history of increasingly severe headaches and a 2-day history of nausea. and unsteadiness. neck stiffness. and a leukocyte count of 59/mm3 (1% segmented neutrophils and 99% lymphocytes). A 55-year-old man has had crushing substernal chest pain on exertion over the past 6 weeks. labial. He is able to recall two out of three objects after 5 minutes and makes several errors on serial sevens.5 F). peri-introital. Neurologic examination shows mild meningismus and diffusely brisk deep tendon reflexes. Which of the following is the most appropriate next step in management? A ) Psychiatric assessment of the mother B ) DNA typing of the mother's palmar wart for papillomavirus C ) Treatment of the mother's palmar wart D ) Vaginal. Which of the following is the most appropriate pharmacotherapy for this patient? A ) Acyclovir B ) Amphotericin B C ) Itraconazole D ) Penicillin E ) Vancomycin 22. a protein level of 108 mg/dL. and throat cultures for Chlamydia trachomatis and Neisseria gonorrhoeae in the child E ) Laser therapy of the condylomata acuminata in the child 23. Some of the pedunculated condylomata appear to have caused the bleeding. A 3-year-old girl is brought to the physician after her mother noted blood on her underpants. Examination shows genital condylomata acuminata in the perineal. a cryptococcal antigen assay is positive.1 C (100. He has type 2 diabetes mellitus treated with glyburide. He walks with a moderately broadbased gait. Cerebrospinal fluid analysis shows a glucose level of 18 mg/dL. A CT scan of the head shows no abnormalities. Her mother has a palmar wart on her hand but no history of condylomata acuminata. anal. She has no visible intravaginal condylomata or vaginal or anal tears. and anal areas.C ) Peripheral nerve D ) Presynaptic neuromuscular junction E ) Sympathetic nervous system 21. They live with the mother's 27-year-old brother who only baby-sits the children when they are asleep. His temperature is 38. He had a myocardial infarction 2 months ago. Her mother has a boyfriend who does not live with them and who has never been left alone with the girl. vomiting. Funduscopic examination shows bilateral papilledema.

She has not had fever or weight loss. Examination shows a painless red papule on the hand with several nontender subcutaneous nodular lesions above it. She had an appendectomy at the age of 12 years and a cesarean delivery 4 years ago. She also has intermittent constipation. She is currently pain-free and has not had diarrhea for 2 days. Which of the following is the most likely diagnosis? .daily. She resides in southeastern USA where she owns a nursery and garden shop. She returned from a trip to Mexico 3 months ago. Examination shows normal heart sounds and no carotid or femoral bruits. A 27-year-old woman comes to the physician because of a 2-year history of intermittent diarrhea and severe cramping abdominal pain. He has smoked two packs of cigarettes daily for 30 years. and there is a sharp sound after S2. The cardiac apex is not palpable. S1 is loud. A previously healthy 52-year-old woman comes to the physician because she has had a large pimple on her right hand for 2 weeks that has failed to heal. A 28-year-old woman at 28 weeks' gestation reports excessive fatigability and dyspnea. Which of the following is the most likely diagnosis? A ) Blastomycosis B ) Candidiasis C ) Coccidioidomycosis D ) Histoplasmosis E ) Sporotrichosis 25. A low-frequency diastolic murmur is heard at the apex that increases in intensity before S1. occasionally foul-smelling. Her blood pressure is 118/74 mm Hg. and nonbloody. Which of the following is the most likely diagnosis? A ) Aortic regurgitation B ) Ebstein's anomaly C ) Mitral regurgitation D ) Mitral stenosis E ) Tricuspid regurgitation 26. Examination shows no abnormalities. and lungs are clear to auscultation. pulse is 110/min and regular. Treatment with a β-adrenergic blocking agent is most likely to improve his symptoms due to which of the following mechanisms? A ) Decreasing diastolic relaxation B ) Decreasing myocardial contractility C ) Dilating the coronary arteries D ) Peripheral vasodilation E ) Preventing fibrin and platelet plugs 24. The stools are watery.

A 16-year-old girl is brought to the physician because of episodes of palpitations over the past 6 months. She is otherwise asymptomatic. A grade 4/6. Which of the following is the most likely cause of these findings? A ) Aortic incompetence B ) Aortic stenosis C ) Mitral incompetence D ) Mitral stenosis E ) Pulmonary incompetence F ) Pulmonary stenosis G . and the upper segment to lower segment ratio is 0.A ) Bacterial gastroenteritis B ) Crohn's disease C ) Intermittent small-bowel obstruction D ) Irritable bowel syndrome E ) Laxative abuse 27. early diastolic murmur is heard along the upper and middle left sternal border with radiation to the apex. pulse is 78/min. and respirations are 18/min. She weighs 55 kg (121 lb) and is 180 cm (71 in) tall. Her arm span is 188 cm (74 in). Her fingers appear long and are hyperextensible. The episodes occur when she runs or plays basketball. Which of the following is the most likely diagnosis? A ) Benign cystic teratoma B ) Corpus luteum cyst C ) Dysgerminoma D ) Endometrioma E ) Mucinous cystoadenoma 28.85. Her blood pressure is 124/46 mm Hg. She uses oral contraceptives. A photograph of the mass is shown. An asymptomatic 21-year-old woman is found to have an adnexal mass on pelvic examination. Peripheral pulses are bounding.

7 F). Prior to transplantation. A grade 2/6 systolic murmur is heard over the precordium. she had been receiving hemodialysis for 3 years. One month after undergoing an uneventful renal transplant for chronic renal failure secondary to glomerulonephritis. Over the past 48 hours. Both renal biopsy and a radionuclide scan confirm the diagnosis of acute rejection. posterior tibial. pulse is 92/min. urine output has remained stable. anterior chest. The labia minora are absent.1 C (98.) Tricuspid incompetence H ) Tricuspid stenosis 29. The upper extremities appear to be more muscular than the lower extremities. thin vulva. A previously healthy 87-year-old woman comes to the physician because of a 4-month history of vulvar itching. Which of the following is the most likely diagnosis? A ) Escherichia coli infection B ) Lichen sclerosus C ) Squamous cell carcinoma D ) Trichomoniasis E ) Vulvar melanoma F ) Vulvar vestibulitis 30. Which of the following is the most appropriate next step in management? A ) Limiting physical activity B ) Repeat blood pressure measurement in 1 month . a 38-year-old woman is hospitalized because of increased serum urea nitrogen (BUN) and creatinine levels. and respirations are 12/min. Examination shows no abnormalities. Examination shows excoriated areas from scratching and a white. An 18-year-old man comes to the physician 1 week after he had a blood pressure of 140/110 mm Hg during a routine precollege examination. and dorsalis pedis pulses are decreased. Radial pulses are normal. The remainder of the examination shows no abnormalities. blood pressure is 140/100 mm Hg. His temperature is 37. and there are small fissures at the introitus. Which of the following is the most effective treatment? A ) Immediate discontinuation of cyclosporine B ) Increased dosage of corticosteroids C ) Diuresis and alkalinization of the urine D ) Renal dialysis for 1–2 weeks E ) Transplant nephrectomy 31. An ECG shows left ventricular hypertrophy. and back. Current medications include cyclosporine and prednisone. femoral.

and respirations are 24/min. preoperative hematocrit was 35%. and time. pulse is 112/min. Abdominal examination shows distention and tenderness. No murmurs are heard. a 37-yearold woman. and blood loss is estimated to be 800 mL. decreased from 120/72 mm Hg intraoperatively. gravida 2. Bowel sounds are absent. Four hours after undergoing a cesarean delivery at term followed by tubal ligation. place. Her hematocrit is 23%. Breath sounds are decreased bilaterally. A 77-year-old woman comes to the physician because of a 2-day history of cramping abdominal pain and distention accompanied by nausea and vomiting. para 2.4 F). increased from 96/min intraoperatively. Her blood pressure now is 80/40 mm Hg. The operation was uncomplicated. and pulse is 152/min. Cardiopulmonary examination shows no abnormalities. Her temperature is 37. Which of the following is the most likely diagnosis? A ) Adhesive small-bowel obstruction B ) Cecal cancer C ) Gallstone ileus D ) Intussusception E ) Mesenteric infarction F ) Ruptured appendicitis G ) Small bowel lymphoma 33. Patient-controlled epidural analgesia has been moderately effective for pain. She is otherwise healthy and has no history of abdominal operations. Which of the following is the most likely cause of the hemodynamic changes? A ) Epidural-related hypotension B ) Insufficient intraoperative fluid replacement C ) Postoperative intra-abdominal hemorrhage D ) Supine hypotensive syndrome E ) Underestimated intraoperative blood loss . Examination of the abdomen shows distention and mild diffuse tenderness. bowel sounds are high-pitched. there is no gas in the colon or free air. blood pressure is 110/86 mm Hg.C ) Initiate a low-sodium diet and exercise program D ) Pharmacologic management E ) Operative treatment 32. The incision is intact with no drainage. An x-ray film of the abdomen shows air-fluid levels throughout the small bowel and air in the liver.4 C (99. has dizziness and confusion. She is disoriented to person.

her blood pressure has ranged between 150–170/105–115 mm Hg.34. Which of the following is the most appropriate next step in management? A ) Acetaminophen with codeine therapy B ) Arthrocentesis C ) Bone marrow aspiration D ) Bone scan E ) Immobilization and traction F ) Lyme titer . She cries when the right knee is moved.5 F). pulse is 68/min.2 mg/dL Which of the following is the most likely underlying cause of this patient's hypertension? A ) Autonomous production of aldosterone B ) Catecholamine-producing tumor C ) Decreased arterial distensibility caused by atherosclerosis D ) Excess production of atrial natriuretic peptide E ) Juxtaglomerular cell hypertrophy and sclerosis 35. pulse is 120/min. In addition. There is no edema. Her blood pressure today is 168/115 mm Hg.9 mEq/L HCO3– 32 mEq/L Urea nitrogen (BUN) 20 mg/dL Creatinine 1. Funduscopic examination shows mild arteriovenous nicking. At her last two office visits during the past 3 months. The point of maximal impulse is not displaced. A 42-year-old woman comes to the physician for evaluation of persistently increased blood pressures. She holds her right knee in flexion and resists any attempted movement of her right leg. and respirations are 22/min.6 C (101. she has had occasional headaches. The right knee is erythematous and swollen. A previously healthy 4-year-old girl is brought to the physician because of fever and refusal to walk for 1 day. she has had an increased urine output over the past 6 weeks that she attributes to a diet high in sodium. abdominal bruits. During this period. or masses. She is otherwise healthy and takes no medications. and respirations are 14/min. Her temperature is 38. She appears mildly ill. Serum studies show: Na+ 144 mEq/L Cl– 90 mEq/L K+ 2.

An 18-year-old man comes for an examination prior to participation in school sports. but now his academic performance has deteriorated to the point that he is failing ninth grade. Which of the following is the most likely diagnosis? A ) Attention-deficit/hyperactivity disorder B ) Autistic disorder C ) Down syndrome D ) Fetal alcohol syndrome E ) Fragile X syndrome F . hard. Which of the following is the most likely cause? A ) Cystic dilations of the efferent ductules B ) Dilated pampiniform venous plexus C ) Fluid accumulation within the tunica vaginalis testis D ) Germinal cell tumor E ) Vascular trauma 37. examination shows macroorchidism. His parents say that he has always been hyperactive and distractible. He exhibits poor eye contact during the examination. nontender mass in the right testicle. A 14-year-old boy is brought to the physician by his parents because of a 2-year history of increasing academic problems. The mass does not transilluminate or change in size when the patient is placed in the supine position. He states that he has had a dull ache in the scrotum since being hit in that area during a basketball game 2 months ago. Psychoeducational testing shows an IQ of 70. protruding ears.G ) MRI of the spine H ) Physical therapy I ) Reassurance J ) Serum rheumatoid factor assay K ) Systemic antibiotic therapy 36. He has a high forehead and long. Sexual development is Tanner stage 5. Examination shows a 2-cm. which was not shown on previous examinations. He weighs 54 kg (120 lb) and is 152 cm (60 in) tall. His teachers say that his hyperactivity is disrupting the classroom.

She has fallen frequently because of muscle weakness. and gastroparesis. Neurologic . Which of the following is the most appropriate next step in management? A ) Application of a soft cervical collar B ) Physical therapy C ) Mithramycin therapy D ) Tamoxifen therapy E ) Spinal cord decompression and cervical stabilization 40. She has not used illicit drugs or alcohol. Her last Pap smear was 6 years ago when she was sexually active with a male partner. He appears well. There is tenderness over the cervical spine. Examination shows hyperreflexia of all extremities. A 57-year-old man comes to the physician because of intermittent urinary incontinence over the past 6 months. He has loss of small amounts of urine when he coughs or sneezes. X-ray films show metastases to the cervical spine. She has been sexually active with one female partner for 5 years. He has not had pain or blood with urination. Rectal examination shows a normal-sized prostate. Examination shows a grayish vaginal discharge with a pH greater than 4. not otherwise specified H ) Prader-Willi syndrome I ) Rett's disorder J ) Seminiferous tubule dysgenesis (Klinefelter's syndrome) 38. retinopathy. A 57-year-old woman with breast cancer comes to the physician because of increasing neck pain over the past 3 days. He has a 15-year history of type 2 diabetes mellitus with peripheral neuropathy. She has not been treated with antibiotics over the past 2 years. A wet mount preparation of the vaginal discharge is most likely to show which of the following? A ) Budding yeast B ) Clue cells C ) Ferning D ) Leukocytes in sheets E ) Trichomonas vaginalis 39. Vital signs are within normal limits.5.) Lesch-Nyhan syndrome G ) Pervasive developmental disorder. Current medications include metoclopramide and glyburide. A 32-year-old woman comes to the physician because of vaginal discharge for 2 weeks. Serum calcium level is 11 mg/dL.

Achilles tendon reflexes are absent bilaterally. After 1 hour. Which of the following is the most likely mechanism of this patient's incontinence? A ) Central nervous system disorder B ) Functional incontinence C ) Intrinsic sphincter deficiency D ) Overflow incontinence from acontractile bladder E ) Overflow incontinence from bladder outlet obstruction F ) Pelvic floor muscle weakness G ) Retroperitoneal fibrosis H ) Retroperitoneal lymphadenopathy I ) Urinary tract infection 41. Which of the following is the most likely diagnosis? A .examination shows decreased sensation in a stocking-glove distribution. and a routine prenatal visit 2 days ago showed no abnormalities. His postvoid residual volume is 500 mL. The placenta and membranes appear normal. On admission. Which of the following is the most appropriate immediate course of action? A ) Notify the hospital liability department B ) Obtain consent for fetal organ donation from the parents C ) Recommend autopsy of the infant D ) Tell the mother not to worry since she can get pregnant again E ) Tell the parents that there is a 1 in 4 chance of recurrence in future pregnancies 42. There are clusters of painful umbilicated vesicles at sites of active skin inflammation. fetal heart tones cannot be heard. A previously healthy 16-year-old high school wrestler comes to the physician because of a rash on his forearms and the back of his legs for 1 week. Ultrasonography shows little amniotic fluid. fetal edema. A 27-year-old primigravid woman at 38 weeks' gestation is admitted in labor. He is allergic to pollen and dust. she delivers a 3175-g (7-lb) stillborn infant. Her pregnancy has been uncomplicated. and no evidence of a fetal heartbeat. Urinalysis shows 2+ protein with no leukocytes or erythrocytes. Test of the stool for occult blood is negative. Examination shows patches of erythema with mild lichenification over the antecubital and popliteal fossae. examination of the infant shows no obvious abnormalities except for mild edema.

He appears to vomit more liquid than he drank. Examination shows no abnormalities. A 28-year-old woman is hospitalized after taking a massive overdose of acetaminophen tablets in a suicide attempt. Despite appropriate therapy. Which of the following is the most likely explanation for his vomiting? A ) Duodenal atresia B ) Gastroesophageal reflux C ) Hypertrophic pyloric stenosis D ) Lactose intolerance E ) Protein malabsorption F ) Rotavirus infection 44. Switching from a cow's milk-based formula to a soy-based formula and one bottle of an electrolyte solution has not decreased his vomiting. sizeappropriate donor liver is available. A 5-week-old boy is brought to the physician because of vomiting for 3 days. On the 6th day of hospitalization.) Eczema herpeticum B ) Herpes zoster C ) Keratosis pilaris D ) Lichen planus E ) Pityriasis rosea 43. but it is forceful and occurs immediately after he has had 1 to 2 ounces of liquid. She has type 1 diabetes mellitus and major depressive disorder refractory to tricyclic antidepressant therapy. Which of the following is the most appropriate course of action regarding transplantation? A ) Do not proceed with the transplantation because diabetes mellitus is a contraindication B ) Do not proceed with the transplantation because hepatic function is likely to return over the next week C ) Do not proceed with the transplantation because major depressive disorder places the patient at risk for another suicide attempt D ) Do not proceed with the transplantation because the onset of encephalopathy and CT findings suggest bacterial meningitis . she is comatose. An appropriately crossmatched. His mother says that there is no yellow color to the vomitus. she develops rapidly progressive hepatic failure and becomes progressively encephalopathic. A CT scan of the brain shows mild diffuse swelling. He has one mustard-colored seedy stool daily.

he is confused and disoriented. and pulse is 155/min. Neurologic examination shows no focal findings. Which of the following is the most likely mechanism of this patient's condition? A ) Depletion of total body potassium B ) Depletion of total body sodium C ) High-output cardiac failure D ) Inadequate dissipation of body heat E ) Release of creatine kinase from muscle cells _______________________________________________________________________________ ___ Form 1--Section 2:-1. A 3-year-old boy who is HIV positive is brought for a routine examination.E ) Proceed with the transplantation 45. Laboratory studies show: Hemoglobin 8. nausea. His skin is warm and dry. A 77-year-old woman is brought to the physician by her son for a routine health maintenance . His diet is appropriate for age. A 20-year-old man is brought to the emergency department on a summer day 20 minutes after developing headache. blood pressure is 100/60 mm Hg. On arrival. His temperature is 40 C (104 F).6 g/dL Mean corpuscular hemoglobin 38 pg/cell Mean corpuscular hemoglobin concentration 30% Hb/cell Mean corpuscular volume 101 μm3 Leukocyte count 5600/mm3 Segmented neutrophils 60% (many hypersegmented) Bands 3% Lymphocytes 37% Red cell distribution width 21% (N=10–16) Which of the following is most likely to have prevented this patient's anemia? A ) Folic acid supplementation B ) Iron supplementation C ) Thyroid supplementation D ) Vitamin B12 (cyanocobalamin) supplementation E ) Monthly intravenous immune globulin therapy 46. and unsteady gait while running the last 2 miles of a marathon. His medications include three antiretroviral drugs and trimethoprimsulfamethoxazole for Pneumocystis carinii prophylaxis.

3 mEq/L HCO3– 6 mEq/L Glucose 710 mg/dL Which of the following laboratory findings is most likely to be increased? A ) Arterial pH B ) Serum C-peptide level C ) Serum magnesium level D ) Serum osmolality E ) Serum phosphorus level 3.examination. pulse is 95/min. Menses occur at regular 28-day intervals and last 5 to 6 days. Serum studies show: Na+ 142 mEq/L K+ 5. A 10-year-old girl is brought to the emergency department because of diffuse. and conversant. Her last menstrual period was 3 weeks ago. she got lost while driving home from the local supermarket. Two weeks ago. A healthy 24-year-old woman comes for a routine health maintenance examination. aching abdominal pain. On mental status examination. Her gait is normal. Which of the following is the most appropriate next step in management? A ) Repeat examination in 2 weeks B ) Measurement of serum CA 125 level C . Sensation to vibration is mildly decreased over the toes. Bimanual examination shows a 5-cm. Her son reports that 1 month ago. and respirations are 20/min and deep. She appears lethargic but is easily arousable. Neurologic examination shows mild fine tremors of the hands when the arms are outstretched. and time and recalls one out of three objects after 10 minutes. She says that she feels well. She takes no medications. Her visual acuity corrected with glasses is 20/25 in both eyes. mildly tender left adnexa. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her language function is normal. She is oriented to person. and recurrent vomiting over the past 5 hours. she is awake. She has an 8-year history of type 1 diabetes mellitus treated with 20 U of NPH and 6 U of regular insulin in the morning and 14 U of NPH and 5 U of regular insulin in the evening. A pregnancy test is negative. she forgot to turn off the stove after cooking dinner. Which of the following findings in this patient warrants further evaluation? A ) Decreased deep tendon reflexes at the ankles B ) Decreased sensation to vibration over the toes C ) High-frequency hearing loss D ) Memory loss E ) Tremor of the outstretched hands 2. Muscle strength is 5/5 in all extremities. There is an obvious odor of ketones on her breath. Her blood pressure is 100/70 mm Hg. the tremor is not present at rest. nausea. place. alert. Deep tendon reflexes are decreased at the ankles and 2+ elsewhere.

Examination shows erythematous. Which of the following measures is most likely to decrease the risk for hepatitis B infection in her newborn? A ) Recommendation of bottle-feeding rather than breast-feeding B ) Maternal administration of hepatitis B immune globulin (HBIG) now C ) Neonatal administration of HBIG after delivery and hepatitis B vaccine at 3 months of age D ) Neonatal administration of HBIG and hepatitis B vaccine immediately after delivery E ) Cesarean delivery 6. she tested positive for hepatitis B surface antigen. Her only medication is hydrochlorothiazide. Examination shows a uterus consistent in size with a 38-week gestation. some of the nodules have a violaceous hue. and bed rest. and she was able to deliver the baby at term. Cardiac examination shows an obvious opening snap in S2.) Measurement of serum α-fetoprotein level D ) CT scan of the pelvis E ) Diagnostic laparoscopy 4. A 37-year-old woman comes to the physician because of progressive shortness of breath over the past 5 years. tender nodules over the anterior surface of both lower extremities. Her temperature is 37 C (98. During routine screening at 28 weeks' gestation. low-sodium diet. blood pressure is 110/80 mm Hg.6 F). late diastolic murmur is heard at the apex. Pregnancy has been otherwise uncomplicated. Fetal heart tones are audible by Doppler. pulse is 100/min and regular. Which of the following is most likely . Which of the following is the most likely diagnosis? A ) Amebiasis B ) Diverticulitis C ) Hyperperistaltic diarrhea D ) Inflammatory bowel disease E ) Viral gastroenteritis 5. Her pregnancy has been otherwise uncomplicated. She was treated with diuretics. She has had increased bowel movements over the past 9 weeks. A 24-year-old primigravid woman at 18 weeks' gestation comes for a routine prenatal visit. The uterus is consistent in size with an 18-week gestation. she now has fatigue and shortness of breath with mild exertion. She has never traveled outside the USA. Rectal examination shows no hemorrhoids or fissures. A grade 3/6. the stools are sometimes covered with mucus and blood. She has a history of mitral stenosis secondary to rheumatic fever at the age of 15 years. Use of over-the-counter antidiarrheal drugs has not relieved her symptoms. A 32-year-old woman at 38 weeks' gestation comes for a routine prenatal visit. and respirations are 26/min. She was asymptomatic until 5 years ago when she developed severe shortness of breath during pregnancy. A right ventricular lift is palpated along the left sternal border.

An 8-year-old girl with type 1 diabetes mellitus is brought to the emergency department 10 minutes after being involved in a motor vehicle collision. A 5-year-old girl with ventricular septal defect is scheduled for tonsillectomy in 2 weeks.6 F). pulse is 148/min. on arrival. Her blood pressure is 40/palpable mm Hg. She was in the back seat of a small automobile that was rear-ended. She has no known drug allergies. she responds to noxious stimuli with brief grimaces and no withdrawal. Initially. but then she stopped talking. she was alert during transport and reported bilateral thigh pain. The abdomen is soft. Her hematocrit is 37%. Which of the following is the most appropriate prophylaxis prior to tonsillectomy? A ) Amoxicillin B ) Ciprofloxacin C ) Rifampin D ) Tetracycline E ) Trimethoprim-sulfamethoxazole F ) No prophylaxis indicated 8. closed her eyes.increased in this patient? A ) Blood flow to the lower lung fields B ) Diastolic filling time C ) Left-to-right shunt of blood D ) Left ventricular end-diastolic pressure E ) Pulmonary artery pressure 7. There is swelling of the upper portions of both thighs. Examination shows no abnormalities. Her temperature is 37 C (98. No cardiac murmur is heard. and respirations are 28/min. Which of the following is the most appropriate next step in management? A ) Measurement of arterial blood gases B ) X-ray film of the chest C ) CT scan of the head D ) Administration of 50% dextrose in water E . The pupils are equal and react to light. and became unresponsive to voice. Air entry is symmetric.

) Infusion of 0.9% saline 9. A previously healthy 16-year-old boy is brought to the emergency department 20 minutes after an episode of left arm shaking that lasted approximately 3 minutes. Over the past 2 days, he has had fever and emotional lability. On arrival, his temperature is 38.9 C (102 F). He is somnolent and disoriented to person, place, and time. He responds poorly to pain. Neurologic examination shows no other abnormalities. Laboratory studies show: Hematocrit 34% Leukocyte count 6000/mm3 Segmented neutrophils 50% Lymphocytes 50% Platelet count 280,000/mm3

Analysis of cerebrospinal fluid shows: Leukocyte count 120/mm3 Segmented neutrophils 20% Lymphocytes 80% Erythrocyte count 300/mm3 Glucose 60 mg/dL Protein 400 mg/dL Which of the following is the most likely cause of this patient's neurologic findings? A ) Bacterial infection B ) Congenital malformation C ) Fungal infection D ) Hemorrhage E ) Immune-mediated demyelination F ) Parasitic infection G ) Viral infection 10. A 72-year-old man with hypertension has had increasingly severe back pain over the past 2 months. He had a myocardial infarction 4 years ago. He has marked tenderness over T11, T12, L1, and L2. An x-ray film of the lumbosacral spine shows osteoblastic lesions in these vertebrae. Which of the following is the most likely diagnosis? A ) Abdominal aneurysm B ) Fibrosarcoma C ) Metastatic prostate carcinoma

D ) Multiple myeloma E ) Osteosarcoma 11. A 64-year-old woman has moderately severe postoperative pain 1 day after a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Which of the following is the most appropriate analgesic pharmacotherapy? A ) Oral aspirin-codeine compound B ) Oral diazepam C ) Oral ibuprofen D ) Intermittent intravenous naloxone E ) Patient-controlled intravenous morphine F ) Transcutaneous administration of fentanyl 12. A 37-year-old woman comes to the physician because of a 1-day history of throbbing facial pain. She describes the pain as 7 out of 10 in intensity. Over the past 9 days, she has had nasal congestion, purulent nasal discharge, sore throat, and a nonproductive cough. She does not smoke. Her husband and children have had no recent illness. Her temperature is 38.5 C (101.3 F). Examination shows congested nasal mucosa and purulent discharge on the left. There is tenderness to palpation over the left cheek and no transillumination over the left maxillary sinus. The tympanic membranes are normal, and there is no erythema of the throat. Examination shows no cervical adenopathy. The lungs are clear to auscultation. Which of the following is the most likely causal organism? A ) Haemophilus influenzae type b B ) Moraxella catarrhalis C ) Staphylococcus aureus D ) Streptococcus pneumoniae E ) Streptococcus pyogenes (group A) 13. A 42-year-old woman comes to the physician for an annual pelvic examination and Pap smear. Over the past year, she has had increasing fatigue and difficulty sleeping. She has two children who both attend college. She is currently looking for part-time work outside the home. Her husband has been busy in a new start-up business. Examination shows no abnormalities. Laboratory studies show: Hemoglobin 15 g/dL Mean corpuscular volume 95 μm3

Leukocyte count 6000/mm3 with a normal differential Serum Na+ 145 mEq/L Cl– 102 mEq/L K+ 4.5 mEq/L HCO3– 25 mEq/L Urea nitrogen (BUN) 18 mg/dL Creatinine 1.0 mg/dL Alkaline phosphatase 70 U/L Aspartate aminotransferase (AST, GOT) 22 U/L Alanine aminotransferase (ALT, GPT) 19 U/L γ-Glutamyltransferase (GGT) 83 U/L (N=5–50 U/L) Which of the following is the most likely explanation for this patient's laboratory abnormalities? A ) Acetaminophen B ) Alcohol C ) Diphenhydramine D ) Estrogen effect E ) Ibuprofen 14. Five weeks after vaginal delivery of a healthy full-term newborn, a 22-year-old woman, gravida 1, para 1, is brought to the physician by her mother because of depressed mood for 2 weeks. Her mother is concerned that her daughter is not able to take care of her infant. Physical examination shows no abnormalities. She is quiet and tearful and does not engage in conversation easily. She states that she lives alone with her infant and has had thoughts of suicide and infanticide. Which of the following is the most appropriate next step in management? A ) Reassurance B ) Long-term outpatient counseling C ) Antipsychotic therapy D ) Selective serotonin reuptake inhibitor therapy E ) Admission to the hospital for treatment 15. A 72-year-old man comes for a routine follow-up examination. He has chronic obstructive pulmonary disease treated with β-adrenergic agonists and ipratropium by metered-dose inhaler and mild arterial insufficiency of the lower extremities treated with aspirin. His blood pressure is 160/60 mm Hg, pulse is 70/min, and respirations are 12/min. Funduscopic examination shows arteriovenous nicking. Pedal pulses are decreased bilaterally. Which of the following antihypertensive drugs is most likely to cause adverse effects in this patient?

and respirations are 15/min. pulse is 70/min and regular. The lungs are clear to auscultation. For each patient with loss of consciousness. He weighs 82 kg (180 lb) and is 191 cm (75 in) tall.A) α2-Adrenergic agonist B) α-Adrenergic blocking agent C) β-Adrenergic blocking agent D) Angiotensin-converting enzyme (ACE) inhibitor E) Calcium-channel blocking agent F) Loop diuretic G) Thiazide diuretic H) Vasodilator The response options for the next two items are the same. the murmur becomes louder when he stands. For each patient with loss of consciousness. select the most likely diagnosis. His blood pressure is 110/70 mm Hg. A) Aortic stenosis B) Carotid sinus hypersensitivity C) Conversion reaction D) Hypertrophic obstructive cardiomyopathy . A grade 2/6 systolic murmur is heard at the left sternal border with minimal radiation to the neck. A 15-year-old boy is brought to the emergency department 30 minutes after a 2-minute episode of loss of consciousness after completing a 400-meter race. You will be required to select one answer for each item in the set. On awakening. select the most likely diagnosis. he says that he feels fine except for shortness of breath. A) Aortic stenosis B) Carotid sinus hypersensitivity C) Conversion reaction D) Hypertrophic obstructive cardiomyopathy E) Hypoglycemia F) Mitral valve prolapse G) Orthostatic hypotension H) Pulmonary embolus I) Seizure J) Vasovagal syncope K) Vertebrobasilar insufficiency 16.

and pulse is 150/min and regular. A grade 2/6 systolic murmur is heard at the second right intercostal space with no radiation.2 C (99 F). He also had pneumonia at the age of 12 months that required chest tube placement for drainage. tender.000/mm3 . She is dyspneic and diaphoretic. 18. A 3-year-old boy is brought to the physician because of a 7-day history of fever and a painful swollen lymph node in his groin. A 50-year-old woman has had progressive dyspnea over the past 2 weeks and constant. and respirations are 28/min.000/mm3 Segmented neutrophils 65% Bands 10% Lymphocytes 25% Platelet count 350. her blood pressure is 82/60 mm Hg. Her temperature is 37. sharp chest pain for 4 days. nontender abdomen.3 F). An ECG shows sinus tachycardia with nonspecific ST-segment changes diffusely. Test of the stool for occult blood is positive. She has smoked one pack of cigarettes daily for 30 years and drinks two ounces of alcohol daily. pulse is 110/min. Which of the following is the most appropriate next step in management? A ) Echocardiography B ) CT scan of the abdomen C ) Ventilation-perfusion lung scans D ) Bronchoscopy E ) Paracentesis 19. erythematous lymph node in the right inguinal area. A 62-year-old woman is brought to the emergency department 1 hour after a 1-minute episode of loss of consciousness. the previous episodes resolved after drainage and prolonged antibiotic therapy. Examination shows a warm.50. There is 1+ edema of the right lower extremity with no tenderness. This is his sixth episode of lymph node swelling. Examination shows a soft. PCO2 of 30 mm Hg. His temperature is 38. The patient is at the 5th percentile for height and weight. Arterial blood gas analysis on room air shows a pH of 7. The liver span is 14 cm with 4 cm of shifting abdominal dullness. She has a history of hypothyroidism treated with thyroid replacement therapy. Examination shows jugular venous distention to the angle of the mandible. A maternal uncle died during childhood of recurrent infections. An x-ray film of the chest shows an enlarged cardiac silhouette with a globular configuration. She has been receiving warfarin therapy for deep venous thrombosis for 2 weeks. She underwent a right. The lungs are clear to auscultation. watery stool. On arrival. There are several healed incisions over the inguinal area and neck from old drainage sites. and PO2 of 70 mm Hg. The pain is localized to the center of the chest and is worse while supine.E) Hypoglycemia F) Mitral valve prolapse G) Orthostatic hypotension H) Pulmonary embolus I) Seizure J) Vasovagal syncope K) Vertebrobasilar insufficiency 17. blood pressure is 90/70 mm Hg with a pulsus paradoxus of 20 mm Hg. her symptoms began when she stood up after she passed a dark.5 C (101. modified radical mastectomy and adjuvant chemotherapy for breast cancer 3 years ago. Laboratory studies show: Hematocrit 35% Leukocyte count 17. She is unable to stand. She has had diarrhea and dark stools for 2 days.

Her preoperative functional vital capacity was 40% of predicted. She is awake and alert. The ventilator settings are a synchronized intermittent mandatory ventilation of 8/min. Arterial blood gas analysis shows: pH 7. Which of the following is the most likely mechanism for these findings? A) Adenosine deaminase deficiency B) Consumption of complement C) Defective opsonization D) Destruction of CD4+ T lymphocytes E) Developmental arrest of maturation of B lymphocytes F) Dysmorphogenesis of the third and fourth pharyngeal pouches G) Impaired chemotaxis H) Impaired phagocytic oxidative metabolism 20. A 67-year-old woman has been intubated for 1 week after undergoing a left lobectomy for lung cancer. cultures grow Staphylococcus aureus. Her blood pressure is 130/75 mm Hg.A Gram's stain of the lymph node aspirate shows numerous segmented neutrophils filled with bacteria. FIO2 of 40%. She has chronic obstructive pulmonary disease. and pulse is 72/min.42 PCO2 47 mm Hg PO2 90 mm Hg O2 saturation 96% Which of the following is the most appropriate next step in management? A) Antibiotic therapy B) Bronchodilator therapy C) Chest physiotherapy D) Decrease inotropes E) Diuretic therapy F) Fiberoptic bronchoscopy G) Heparin therapy H) Incentive spirometry I) Increase FIO2 J) Increase inotropes K) Increase respiratory rate L) Placement of thoracostomy tube M) Tracheostomy N) Wean from the ventilator . and positive-end expiratory pressure of 5 cm H2O.

A 67-year-old woman is brought to the emergency department because of severe chest pain 4 hours after undergoing outpatient endoscopy and dilatation of an esophageal stricture caused by reflux.4 F). Rh-negative O. and reticulocyte count is 18%. A direct antiglobulin (Coombs') test is positive. Cord blood hemoglobin is 4 g/dL. Rh-negative O. and respirations are 22/min. including serum vitamin B12 (cyanocobalamin). Which of the following sets of blood groups is most likely in the mother and her newborn? Mother Newborn A)A. Laboratory studies. and breath sounds are equal bilaterally. A CT scan of the head shows mild volume loss. Three hours later. Her son says that she repeats herself frequently and has been forgetting to take her routine medications. Rh-positive . and scattered petechiae. The newborn's pulse is 60/min. At discharge. gravida 2. An 87-year-old woman is brought to the physician by her son because of progressive memory loss over the past 2 years. MiniMental State Examination score is 23/30. She takes hydrochlorothiazide for mild systolic hypertension and levothyroxine for hypothyroidism. Rh-negative E) O. hepatosplenomegaly.A newborn is in severe respiratory distress immediately following delivery. Rh-positive O. pulse is 125/min.21. are within normal limits. Her blood pressure is 138/78 mm Hg. She was born at 35 weeks' gestation to a 35-year-old woman. anasarca. Rh-positive O. Examination shows pallor with perioral cyanosis. who did not receive prenatal care. she reported no chest pain. Rh-positive B)A. She is pale. and respirations are irregular and labored. Rh-negative C)A. Rh-positive O. and thyroid-stimulating hormone levels. Rectal examination shows no masses. Her temperature is 38 C (100. Which of the following is the most likely cause of these symptoms? A ) Bleeding from erosive esophagitis B ) Esophageal perforation C ) Mallory-Weiss syndrome D ) Myocardial infarction E ) Perforated gastric ulcer 22. she vomited a small amount of blood and had severe pain. para 1. Rh-negative D)O. She had vulvar cancer 10 years ago treated with wide excision. blood pressure is 140/85 mm Hg. The lungs are clear to auscultation. thyroxine (T4). Examination shows crepitus in the neck and moderate epigastric tenderness. Physical examination is within normal limits for her age. Which of the following is the most appropriate pharmacotherapy? A) β-Adrenergic agonist B) Cholinesterase inhibitor C) Dopamine agonist D) Prednisone E) Selective serotonin reuptake inhibitor 23. aborta 1. test of the stool for occult blood is positive.

He does not smoke and drinks only on social occasions. Which of the following is the most appropriate next step in management? A) Measurement of serum aspartate aminotransferase (AST. and the 2 hours in the recovery room. Mental status examination shows an anxious mood and slight motor restlessness.45% saline and morphine. a 62-year-old man has not had any urine output since the Foley catheter was removed 12 hours ago. Which of the following immunizations should be administered? A) Hepatitis A vaccine B) Influenza virus vaccine C) Measles-mumps-rubella vaccine D) Pneumococcal vaccine E) Diphtheria-tetanus toxoid 26. GOT) activity B) Measurement of serum bupropion level C) Platelet count D) Discontinuation of lithium carbonate therapy E) Discontinuation of valproic acid therapy . the patient does not produce any urine. Since that time. Examination shows no abnormalities. Preoperative serum studies showed: Na+ 137 mEq/L K+ 4. and valproic acid level of 77 μg/mL (therapeutic range=40–100). A 19-year-old man comes to the physician because of frequent nosebleeds over the past 3 weeks. He is awake and alert and has a moderate amount of abdominal pain.3 mEq/L (therapeutic range=0. After an uncomplicated laparoscopic cholecystectomy.6–1.24. he has been receiving intravenous 5% dextrose in water with 0.2 mg/dL One hour after receiving an intravenous bolus of 0. He has bipolar disorder currently well controlled with lithium carbonate. Physical examination shows no abnormalities except for dried blood in the nares.2). During the hour before the operation. the 40 minutes of operating room time.9% saline.5 L and urine output was 1 L. His last visit to a physician was over 10 years ago. his fluid input was 2. Which of the following is the most appropriate next step in management? A ) Increase in the dose of morphine B ) Intravenous administration of an additional bolus of 0. bupropion.9% saline C ) Intravenous administration of doxazosin D ) Intravenous administration of furosemide E ) Reinsertion of a Foley catheter 25. and valproic acid. A healthy 55-year-old man comes for an initial health maintenance examination. Serum studies show a lithium carbonate level of 1.2 mEq/L Urea nitrogen (BUN) 18 mg/dL Creatinine 1.

2 mg/dL An x-ray film of the chest shows a small amount of free air under the left diaphragm. Examination shows a rigid abdomen. Administration of antibiotics and fluids is begun. She takes captopril for hypertension and glyburide for type 2 diabetes mellitus.000/mm3 Serum Urea nitrogen (BUN) 34 mg/dL Creatinine 1. His temperature is 37.27. bowel sounds are absent. He has no history of similar symptoms. The lungs are clear to auscultation. and he has vomited once since that time. His temperature is 37 C (98. The lungs are clear to percussion and auscultation. Any movement exacerbates the pain. His symptoms awoke him from sleep. and he does not take any medications or use alcohol or illicit drugs.8 C (100 F). Laboratory studies show: Hemoglobin 14 g/dL Leukocyte count 18. blood pressure is 108/68 mm Hg. She drinks a pint of vodka daily.6 F). He had an anaphylactic reaction to a blood transfusion following a motor vehicle collision 3 years ago. Fasting serum studies show: Total cholesterol 252 mg/dL HDL-cholesterol 80 mg/dL Triglycerides 300 mg/dL .200/mm3 Platelet count 150. She also has intermittent episodes of gout.A 37-year-old man is brought to the emergency department 6 hours after the onset of constant. pulse is 112/min. increasingly severe abdominal pain and nausea. He has a 10-year history of frequent sinus and pulmonary infections. He is in acute distress and lying in the fetal position. and respirations are 24/min. Family history is noncontributory. A complete blood count and serum protein electrophoresis are within normal limits. A 52-year-old woman with alcoholism comes to the physician after a serum cholesterol level of 290 mg/dL was found on a routine screening. An asymptomatic 32-year-old man comes for a routine health maintenance examination. Which of the following is the most appropriate next step in management? A) Barium swallow B) CT scan of the abdomen C) Intravenous administration of an H2-receptor blocking agent D) Upper endoscopy E) Laparotomy 29. Examination shows mild erythema in the posterior pharynx.9 mg/dL Total bilirubin 1. Which of the following is the most likely cause of the frequent infections? A) Colonization with Streptococcus pneumoniae B) Common variable immunodeficiency C) HIV infection D) Selective IgA deficiency E) X-linked agammaglobulinemia 28.

A previously healthy 24-year-old woman comes to the physician because of a low-grade fever and a nonproductive cough for 7 days. He will not work for a toy that is out of his reach. A 2-month-old boy is brought to the physician for a well-child examination. Her temperature is 37. Which of the following is the most likely cause of this condition? A) Hypercoagulable state of pregnancy B) Hyperuricemia C) Peripheral artery aneurysm D) Platelet embolus E) Prolonged pressure on the vena cava during delivery 31. Examination shows no other abnormalities. A few scattered inspiratory crackles are heard in the thorax. A complete blood count and serum electrolyte levels are within normal limits. The right foot is swollen.Glucose 118 mg/dL Thyroid-stimulating hormone 4. He smiles spontaneously and vocalizes without crying. but he does not appear to laugh or squeal. An xray film of the chest shows patchy infiltrates in both lungs. and there is marked tenderness with dorsiflexion and palpation of the right calf. A 23-year-old woman has pain. Which of the following is the most appropriate initial pharmacotherapy? A ) Amoxicillin .7 C (99. and swelling of the right calf 3 days after an uncomplicated labor and delivery.5 μU/mL Which of the following is the most appropriate next step in management? A) Alcohol cessation B) Better control of diabetes C) Switch from captopril to calcium-channel blocking agent therapy D) Gemfibrozil therapy E) Thyroid replacement therapy 30.9 F). cramping. Which of the following is the most appropriate assessment of language and psychosocial development? Language Psychosocial development development A)Normal normal B)Normal delayed C)Delayed normal D)Delayed delayed 32. She has been able to continue her daily activities.

Sublingual nitroglycerin therapy does not relieve her symptoms and gives her a headache. and diaphoretic. dizziness. His blood pressure is 165/95 mm Hg. She had three similar episodes last week when she was vacationing at the Grand Canyon. has little spontaneous speech. Her blood pressure is 130/90 mm Hg. and mild numbness and tingling around the lips for 2 hours. He appears catatonic but abruptly becomes assaultive two times and needs to be restrained. His temperature is 37. and since returning. Last night he was out with friends. She says that she feels like she is going to die. the first episode occurred while crossing a narrow bridge on a donkey. She takes a hypoglycemic drug for type 2 diabetes mellitus. and is disoriented to place and time. A 17-year-old boy is brought to the emergency department by his parents because of bizarre behavior for 6 hours. A 67-year-old man is bro ught to the emergency department 4 hours after the onset of severe midlumbar back pain. Examination shows no other abnormalities.8 F). chest pain. verapamil for hypertension. and respirations are 28/min. Which of the following is the most likely diagnosis? A) Aortoiliac occlusion B) Herniated nucleus pulposus C) Lumbar discitis D) Lumbar strain E) Pyelonephritis F) Ruptured aortic aneurysm G) Spinal stenosis 35. pale. Serum glucose level is 120 mg/dL. he has been confused and has "trashed" his room. He is hypervigilant. The most appropriate next step in management is administration of which of the following? A) Haloperidol B) Lorazepam C) Oxygen D) Sumatriptan E) Verapamil 34. pulse is 120/min. A 45-year-old woman comes to the emergency department because of shortness of breath. He is anxious.B ) Cefaclor C ) Ciprofloxacin D ) Erythromycin E ) Trimethoprim-sulfamethoxazole 33. An ECG shows sinus tachycardia.1 C (98. Which of the following is the most likely substance taken? A) Cocaine . She is mildly diaphoretic and appears pale. and pulse is 120/min. X-ray films of the lumbar spine show degenerative disc disease with calcifications anterior to the vertebral bodies. and sumatriptan as needed for migraine. blood pressure is 105/65 mm Hg.

select the most likely diagnosis. A) Herniated disc B) Lumbar spinal stenosis C) Metastatic cancer D) Muscle strain E) Osteoporotic compression fracture F) Sacroiliitis G) Spinal epidural abscess H) Spondylolisthesis 37. You will be required to select one answer for each item in the set. dull. and pulse is 64/min. The pain began when she was lifting her grandson. Bilateral straight-leg raising to 80 degrees does not increase the pain. select the most likely diagnosis. The pain began after he . A 57-year-old woman is brought to the physician 2 days after the sudden onset of severe low back pain. Examination shows deformities of the interphalangeal joints of the hands and exquisite tenderness to percussion over the lumbar spine. A) Herniated disc B) Lumbar spinal stenosis C) Metastatic cancer D) Muscle strain E) Osteoporotic compression fracture F) Sacroiliitis G) Spinal epidural abscess H) Spondylolisthesis 36. For each patient with back pain. Deep tendon reflexes are 2+ bilaterally. blood pressure is 130/60 mm Hg. the pain does not radiate to the lower extremities. For each patient with back pain. She has a 10-year history of rheumatoid arthritis treated with prednisone. Babinski's sign is absent bilaterally.6 F). Muscle strength and sensation are intact in the lower extremities. low back pain that does not radiate to the extremities.B) Ecstasy C) LSD D) Methaqualone E) PCP The response options for the next two items are the same. She does not have weakness or sensory loss in the legs and has had no urinary incontinence. Her temperature is 37 C (98. A previously healthy 32-year-old plumber comes to the physician because of a 3-week history of constant.

a 24-year-old man had the sudden onset of pain in the right side of his chest that has become increasingly severe. Which of the following is most likely to have prevented progression of this patient's renal disease? A) Intermittent Foley catheterization B) Intravenous mannitol therapy C) Oral cyclophosphamide and prednisone therapy D) Oral enalapril therapy E) Oral finasteride therapy F) Oral prednisone therapy only G) Oral terazosin therapy 39. Babinski's sign is absent bilaterally. An x-ray film of the chest is shown. His postvoid residual volume is 10 mL. Serum studies show a urea nitrogen (BUN) level of 45 mg/dL and creatinine level of 3. There is mild enlargement of the prostate with no palpable nodules. She is concerned about her appearance and plans to be in a wedding in 3 weeks. Deep tendon reflexes are 2+ bilaterally. 38. The pain increases with forward or lateral movements of the spine. Abdominal examination shows no suprapubic fullness or tenderness. Cardiopulmonary examination shows no abnormalities. Urine dipstick shows 3+ protein. His blood pressure is 135/86 mm Hg. Muscle strength and sensation are intact in the lower extremities. His temperature. She has had similar episodes that have resolved completely without treatment. His father was diagnosed with prostate cancer at the age of 70 years. A 21-year-old college student comes to the physician because of acne that developed 4 days ago while she was taking her medical college admission test. Examination shows acute acne over the face with a predominance of comedones and pustules. blood pressure.unloaded heavy equipment from his van. Which of the following is the most appropriate next step in management? A) Bed rest and sedative therapy B) Antibiotic therapy C) Anticoagulant therapy D) Tube thoracostomy E) Immediate thoracotomy 40. and his sister died of complications from systemic lupus erythematosus. There is no evidence of chronic scarring. He has a 15-year history of type 2 diabetes mellitus now moderately well controlled with glyburide. Bilateral straight-leg raising to 80 degrees does not increase the pain.8 mg/dL. It increases with activity and is temporarily relieved by bed rest and ibuprofen. Two hours ago. Which of the following is the most appropriate initial step in treatment? A) Dietary restriction of chocolates and simple sugars B) Dietary restriction of milk products C) Topical acyclovir D) Topical hydrocortisone cream . A 72-year-old man comes to the physician because of a 2-month history of urination twice nightly and occasional urinary frequency and urgency. He is now having difficulty breathing. Examination shows tenderness to palpation over the lumbar paraspinal region bilaterally. and pulse are normal.

Laboratory studies are within normal limits. and the abdomen is swollen with a fluid wave. She exercises regularly. shoulders. Which of the following is the most appropriate pharmacotherapy? . her serum cholesterol level was 180 mg/dL. Two years ago. She is not sexually active. A 24-year-old woman comes to the physician because of constant. a Pap smear and mammography showed normal findings. Cardiac examination shows a lifting systolic motion of the sternum and no palpable point of maximal impulse. Examination shows multiple tender spots over the neck. Today. flexible sigmoidoscopy showed no abnormalities. Which of the following is the most likely cause of the murmur? A) Aortic stenosis B) Mitral regurgitation C) Mitral stenosis D) Tricuspid regurgitation E) Ventricular septal defect 43. Range of motion of all joints is full.E) Topical retinoic acid 41. Which of the following is the most appropriate screening test for this patient? A) Pap smear B) Measurement of serum cholesterol level C) Measurement of serum glucose level D) Mammography E) Flexible sigmoidoscopy 42. Fluorescent serum antinuclear antibody and rheumatoid factor assays are negative. Which of the following is the most likely diagnosis? A) Ankylosing spondylitis B) Fibromyalgia C) Polymyalgia rheumatica D) Polymyositis E) Seronegative rheumatoid arthritis 44. and lumbar spine. Her blood pressure is 120/80 mm Hg. There is no peripheral edema. Cardiac examination shows an S4 gallop. There is no evidence of synovitis. An ECG shows no acute changes. A grade 3/6. Use of over-the-counter ibuprofen and aspirin has not relieved her symptoms. He had a myocardial infarction 2 years ago and has had an ejection fraction of 35% since then. A 72-year-old man comes to the physician because of a 6-month history of mild to moderate shortness of breath when climbing stairs. There is striking jugular venous distention with a large wave occurring with S2. The carotid upstroke is normal. she weighs 63 kg (140 lb) and is 165 cm (65 in) tall. There is marked ankle edema. She has a history of irritable bowel syndrome. shoulders. His only medication is a β-adrenergic blocking agent. severe pain in her neck. A 62-year-old man has had the gradual onset of fatigue and shortness of breath over the past 3 years. holosystolic. Examination shows no abnormalities. plateau-shaped murmur that is loudest on inspiration is heard at the lower left sternal border. The lungs are clear to auscultation. and fasting serum glucose level was 80 mg/dL. The liver is enlarged and tender. and back for 3 months. She has been unable to enjoy her usual activities because of the pain. At her last visit 1 year ago. A 67-year-old woman comes for a routine health maintenance examination.

5 F). He has renal failure but has missed his last two dialysis treatments. His renal function did not improve. She drinks two to three cups of coffee each morning. Bowel sounds are normal. Upon awakening. Which of the following is the most likely diagnosis? A) Acute stress disorder B) Nightmare disorder C) Panic disorder D) Sleep apnea E) Sleep terror disorder 46. Laboratory studies show: Serum Na+ 135 mEq/L Cl– 102 mEq/L K+ 7. Examination shows a soft abdomen.1 mEq/L HCO3– 12 mEq/L Arterial blood gas analysis on 4 L/min of oxygen by nasal cannula: pH 7.5 C (99. She does not know why she is having this particular dream because she has never been the victim of an assault. A 42-year-old woman comes to the physician because of a 3-month history of a recurrent vivid dream that several men are assaulting her and her children. his temperature is 37.9% saline . A 57-year-old man is brought to the emergency department 30 minutes after he was found on the floor of his house. Physical examination shows no abnormalities. On arrival. she is anxious and distressed by the frightening images. pulse is 95/min and regular. Crackles are heard in the lung bases. She does not use illicit drugs. Which of the following is the most appropriate next step in management? A) Observation until dialysis is initiated B) Intravenous calcium gluconate C) Intravenous glucose and insulin D) Intravenous 0. Medications include amlodipine and doxazosin. His breathing is rapid and deep. She realizes that it is just a dream but is afraid to go back to sleep.A) α-Adrenergic blocking agent B) Angiotensin-converting enzyme (ACE) inhibitor C) Angiotensin2-receptor blocking agent D) Nitrates E) Thiazide diuretic 45. blood pressure is 150/100 mm Hg. His renal failure was caused by inadvertent ingestion of ethylene glycol. The left lower extremity is externally rotated. and respirations are 24/min. he has left hip pain and shortness of breath. There is no evidence of depressed mood or hallucinations. Laboratory studies are within normal limits.22 PCO2 31 mm Hg PO2 61 mm Hg An ECG shows peaked T-waves. It will be at least 45 minutes before dialysis can be started. and he is currently on the transplantation list.

she also has had a flu-like illness for 3 days. The lungs are clear to auscultation. her serum thyroid-stimulating hormone level was 3 μU/mL. A 26-year-old woman is brought to the emergency department because of marked confusion for 2 hours. An ECG shows sinus tachycardia with peaked T waves. Abdominal examination shows diffuse mild tenderness and no rebound. He has been healthy except for a "bad cold" 1 month ago that resolved spontaneously after 10 days. An ECG shows no abnormalities. There is a normal S1 and S2 and an S3. 1 week ago. Over the past 6 weeks. Examination shows cool. She appears confused and lethargic. paroxysmal nocturnal dyspnea. Her temperature is 38 C (100.E) Intravenous sodium bicarbonate F) Rectal sodium polystyrene sulfonate (Kayexalate) _______________________________________________________________________________ ___________________________________________________ Section 3:-1. and nausea. blood pressure is 90/60 mm Hg. mottled skin. He has not had chest pain or palpitations. A 27-year-old man comes to the physician because of a 1-week history of shortness of breath with exertion. pulse is 120/min. Cardiac examination shows a diffuse. laterally displaced point of maximal impulse.6 F). She recently started thyroid hormone replacement therapy for autoimmune thyroiditis. His temperature is 37 C (98. and pulse is 140/min. Examination shows jugular venous distention to 8 cm. Echocardiography is most likely to show which of the following? A ) Asymmetric septal hypertrophy . especially involving the palmar creases. she has had increased fatigue.4 mEq/L HCO3– 16 mEq/L An x-ray film of the chest and urinalysis show normal findings. weakness. and swelling of his feet.4 F). Laboratory studies show: Hemoglobin 10 g/dL Leukocyte count 9000/mm3 Segmented neutrophils 55% Eosinophils 20% Lymphocytes 25% Serum Na+ 124 mEq/L Cl– 92 mEq/L K+ 6. Bilateral basilar crackles are heard. Examination shows 2+ pretibial edema bilaterally. Which of the following is most likely to confirm the primary cause of this patient's condition? A) Measurement of pulmonary artery pressure B) Measurement of right atrial pressure C) Measurement of serum antithyroglobulin antibody level D) Measurement of serum lactate dehydrogenase activity E) Measurement of serum thyroid-stimulating hormone level F) ACTH stimulation test G) Dexamethasone suppression test H) Blood cultures I) Echocardiography 2. and respirations are 24/min. blood pressure is 80/40 mm Hg. There is generalized hyperpigmentation.

5 25 E)160 135 5. Which of the following are the most likely serum electrolyte findings? Na+ Cl– K+ HCO3– (mEq/L) (mEq/L) (mEq/L) (mEq/L) A)115 80 4. A 35-year-old man is brought to the emergency department because of intractable nausea and vomiting of nonbilious fluid over the past 48 hours. Which of the following is the most appropriate next step in diagnosis? A ) Bone scan B ) CT scan of the head C ) Tympanometry D ) Lumbar puncture E ) Tympanocentesis 5. His temperature is 38. heart sounds are normal. Examination shows mild epigastric tenderness. He has a history of duodenal ulcer disease treated with H2-receptor blocking agents. Which of the following is the most appropriate next step in diagnosis? .5 40 C)145 100 5. pulse is 130/min. He has smoked two packs of cigarettes daily for 25 years. He just completed a 10-day course of amoxicillin that has not resolved his right ear pain.0 25 4. He appears irritable. He appears chronically ill. he has had an 11. his neck is supple.9 C (102 F). An x-ray film of the chest shows a large left-sided pleural effusion.0 15 D)150 105 2. blood pressure is 90/60 mm Hg. His temperature is 37 C (98.0 25 B) 140 80 2. A 67-year-old man has had shortness of breath on exertion for 3 months.B ) Bicuspid aortic valve with stenosis C ) Diffuse hypokinesia and dilation of the ventricles D ) Dyskinesia of the left ventricular apex E ) Mitral valve prolapse 3. Examination shows decreased breath sounds on the left.6 F). and respirations are 10/min. Examination shows downward and lateral displacement of the right auricle with tenderness to palpation of the posterior auricular area. A 3-year-old boy is brought for a follow-up examination.3-kg (25-lb) weight loss during this period.

Knee jerk and ankle reflexes are 2+ bilaterally. She has hypertension controlled with a calcium-channel blocking agent and type 2 diabetes mellitus controlled with diet. Babinski's sign is absent bilaterally. and few bacteria. A 77-year-old woman comes to the physician because of low back pain for 3 months. 2–5 leukocytes/hpf.A) Bronchoscopy B) Thoracoscopy C) Closed pleural biopsy D) Open pleural biopsy E) Thoracentesis 6. straight-leg raising produces pain in the low back at the L2–4 range. Which of the following is the most appropriate pharmacotherapy? A ) Acetaminophen B ) Gold C ) Methotrexate D) Prednisone E) Probenecid 8. Urinalysis shows 5–10 epithelial cells/hpf. Her health maintenance regimen should include immunization against which of the following pathogens? A) Haemophilus influenzae type b B) Hepatitis A C) Influenza virus D) Neisseria meningitidis E) Streptococcus pyogenes (group A) . which of the following measures involving the disease is most effective in monitoring the program? A ) Case fatality B ) Hospitalization C ) Incidence D ) Mortality E ) Prevalence 7. Her vital signs are within normal limits. A 32-year-old woman who is HIV positive has a CD4+ lymphocyte count of 800/mm3 (Normal ≥ 500). Examination shows no spinal or costovertebral angle tenderness. Assuming that diagnostic procedures and detection remain the same. A program for the primary prevention of coronary artery disease is implemented in a community in the USA.

and her medication was discontinued. She has had progressively severe dysmenorrhea over the past 6 months adequately controlled by nonsteroidal anti-inflammatory agents. she began treatment with warfarin.9. her INR was 6. there is no change in the size of the adnexal mass. she has had mild constipation with no change in the caliber of the stool. A 32-year-old woman comes to the physician because of bright red rectal bleeding and severe stabbing pain with each bowel movement over the past 2 weeks. blood pressure is 100/78 mm Hg. Transvaginal ultrasonography shows a 7-cm septated adnexal mass. and respirations are 20/min. Over the past 2 months. An ECG shows a normal sinus rhythm. Test of the stool for occult blood is negative. but no abnormalities are detected except for a small amount of bright red blood from the fissure. A 28-year-old nulligravid woman comes for a routine health maintenance examination. Four weeks later. and there is nodularity of the cul-de-sac. Which of the following is the most likely explanation for this patient's abdominal symptoms? A) Internal small-bowel herniation B) Intestinal ischemia from a cardiac embolus C) Intramural hematoma of the proximal small bowel D) Intussusception of the small bowel . Her hemoglobin level has decreased from 13 g/dL yesterday to 7. Yesterday at a followup visit. The uterus is retroverted and fixed. She takes no other medications. Pelvic examination shows a normal vagina and cervix. The abdomen is distended and moderately tender. or obvious hernias.6 F). A 6-cm left adnexal mass is palpated. and there is blood on the toilet paper. Examination shows a small anal fissure at the posterior midline. there is voluntary guarding in the epigastrium. Rectal examination is painful.8 g/dL today. she was hospitalized for treatment of atrial fibrillation. Two weeks ago. A 67-year-old woman is hospitalized because of abdominal pain and persistent copious vomiting for 24 hours. Which of the following is the most appropriate diagnostic test? A) Measurement of serum CA 125 level B) Barium enema C) CT scan of the pelvis D) MRI of the pelvis E) Laparoscopy 11. after cardioversion to a normal sinus rhythm. Her temperature is 37 C (98. Which of the following is the most appropriate next step in management? A ) Anesthetic ointment and stool softeners B ) Anal dilatation under anesthesia C ) Debridement and closure of the fissure under anesthesia D ) Surgical flaps E ) Lateral internal sphincterotomy 10. There are no masses. pulse is 120/min and regular. organomegaly. Rectal examination shows no abnormalities. She has blood-streaked stools.

Over the past 3 years. pulse is 120/min. Which of the following is the most likely cause of her condition? A) Anovulation B) Asherman's syndrome C) Hypopituitarism D) Menopause E) Premature ovarian failure 14. and respirations are 18/min. pulse is 110/min. A 32-year-old man with alcoholism is brought to the emergency department by friends because he has been unable to stand without support and has had "funny eye movements"." The most likely cause of these findings is a deficiency of which of the following? A) Folic acid B) Magnesium C) Vitamin B1 (thiamine) D) Vitamin B12 (cyanocobalamin) E) Zinc 13. bowel sounds are decreased. There is a family history of coronary artery disease and hypertension. She does not smoke and drinks one to two glasses of wine each evening.5 mg/dL Alkaline phosphatase 120 U/L Aspartate aminotransferase (AST. and an asymmetric horizontal-gaze evoked nystagmus. Her temperature is 37 C (98. para 2. vomiting. A previously healthy 47-year-old woman comes to the emergency department because of a 36-hour history of nausea. they report that he has been drinking approximately 18 beers daily over the past month and has been increasingly confused over the past 5 days. and his breath smells of alcohol. Laboratory studies show: Hematocrit 45% Leukocyte count 9000/mm3 with a normal differential Serum Total bilirubin 1. gravida 2. When helped up and told to walk. Neurologic examination shows no focal weakness or numbness. he has a broad-based. and abdominal pain that radiates to her back. strabismus. he relates that "I drove to this place to visit some friends. blood pressure is 100/60 mm Hg. she has had intermittent episodes of cramping abdominal pain 1 to 2 hours after meals. His speech is slurred. horizontal diplopia. uncertain gait. Abdominal examination shows moderate epigastric and right upper quadrant tenderness with no guarding or rebound. He is awake and confused but is noncombative.E) Malrotation of the small bowel 12. A 32-year-old woman. comes to the physician because she has been amenorrheic for 4 months.2 C (99 F). the pain lasts for several hours and resolves spontaneously. GOT) 78 U/L Amylase 365 U/L Lipase 1223 U/L (N=1–160) Triglycerides 300 mg/dL . and respirations are 20/min. blood pressure is 180/60 mm Hg. A serum pregnancy test is negative. She is given medroxyprogesterone and has the onset of bleeding 3 days later. Physical examination shows sixth cranial nerve palsy. His temperature is 37. When asked how he arrived at the emergency department.6 F). Examination shows a well-estrogenized vagina and no evidence of virilization or other abnormalities.

She weighs 66 kg (145 lb) and is 178 cm (70 in) tall. Two previous ultrasonographies have shown a triplet gestation. Her pelvis is normal-sized. A healthy 37-year-old primigravid woman at 12 weeks' gestation comes for a routine prenatal visit. Laboratory studies show: . Her blood pressure is 116/70 mm Hg.Which of the following is the most likely diagnosis? A) Acute cholecystitis B) Alcoholic hepatitis C) Alcoholic pancreatitis D) Ascending cholangitis E) Gallstone pancreatitis F) Hepatitis A G) Pancreatic cancer H) Peptic ulcer disease I) Triglyceride-induced pancreatitis 15. A grade 3/6. Examination shows a uterus consistent in size with a 16week gestation. or drugs. blood pressure is 110/65 mm Hg. Her blood pressure is 138/62 mm Hg. Babinski's sign is present on the left. Five years ago. alcohol. The lungs are clear to auscultation. The remainder of the examination shows no abnormalities. Neurologic examination shows mild left hemiparesis. A 67-year-old man is brought to the emergency department because of a 3-day history of fever and headache. and respirations are 14/min. and pulse is 72/min. This patient is at greatest risk for which of the following? A) Abruptio placentae B) Hepatitis B C) HIV infection D) Preterm labor E) Uterine rupture 16. systolic ejection murmur is heard. and respirations are 22/min. pulse is 110/min. He appears ill. pulse is 76/min and regular. This patient is at greatest risk for which of the following complications? A) Brain abscess B) Carotid artery occlusion C) Encephalitis D) Hydrocephalus E) Venous sinus thrombosis 17. She is a hematologist and works 10 to 12 hours daily. he underwent placement of a mechanical aortic valve for treatment of sequelae of rheumatic fever. A 67-year-old woman comes for a routine health maintenance examination. The pregnancy was achieved by in vitro fertilization. She does not use tobacco. There is no nuchal rigidity. His temperature is 40 C (104 F). She drinks 1 ounce of alcohol daily.

A) Bacterial meningitis B) Cerebral infarction C) Cryptococcal meningitis D) Glioblastoma multiforme E) Herpes simplex encephalitis F) Hypertensive encephalopathy G) Idiopathic intracranial hypertension H) Intracerebral hemorrhage I) St. You will be required to select one answer for each item in the set. she has had transient episodes of blindness lasting 1 to 2 seconds. Louis encephalitis 18.9 mg/dL Creatinine 0. She has not had nausea or vomiting.5–5. A 25-year-old woman comes to the emergency department because of increasingly severe bifrontal headaches over the past 6 months. A CT scan of the head with and without contrast shows no abnormalities.1) Which of the following is the most appropriate next step in management? A) Measurement of serum alkaline phosphatase activity B) Measurement of serum parathyroid hormone level C) Measurement of serum vitamin D level D) Serum and urine protein electrophoresis E) X-ray film of the chest F) Skeletal survey G) Bone scan The response options for the next two items are the same.8 g/dL Serum Ca2+ 11. Examination of the cerebrospinal fluid shows: Opening pressure 300 mm H2O Glucose 70 mg/dL Protein 25 mg/dL . For each patient with papilledema. She currently weighs 113 kg (250 lb) and is 152 cm (60 in) tall.Hemoglobin 12. The remainder of the neurologic examination shows normal findings. She has a long-standing history of difficulty losing weight.8 mg/dL Total protein 6. Her blood pressure is 120/80 mm Hg.8 mg/dL Phosphorus 2. During this period. select the most likely diagnosis. Visual field testing shows enlarged blind spots.2 g/dL Ionized calcium 5.8 mg/dL (N=4.5 g/dL Albumin 4.

select the most likely diagnosis. Her mother and sister have a history of low back pain and disc herniation. . A CT scan of the head with and without contrast shows moderate ventricular enlargement. and low-grade fever for 2 months. An asymptomatic 32-year-old woman comes for a routine health maintenance examination. There is no scoliosis or excessive kyphosis of the back. The patient is a postal worker. Her blood pressure is 130/78 mm Hg. For each patient with papilledema.WBC 1/mm3 RBC 0/mm3 Gram's stain and cultures are negative. A) Bacterial meningitis B) Cerebral infarction C) Cryptococcal meningitis D) Glioblastoma multiforme E) Herpes simplex encephalitis F) Hypertensive encephalopathy G) Idiopathic intracranial hypertension H) Intracerebral hemorrhage I) St. Which of the following is the most effective strategy to decrease this patient's risk for developing low back pain? A) Change in job B) Limit physical activity C) Stretching exercises D) Weight-loss program E) Nonsteroidal anti-inflammatory drug therapy F) Prophylactic brace 21. and respirations are 16/min. A 25-year-old man with a history of intravenous drug use comes to the emergency department because of a progressive diffuse headache. Mental status examination shows no abnormalities. he has had a poor appetite resulting in a 6.8-kg (15-lb) weight loss. generalized malaise. a 62-yearold woman becomes acutely short of breath and coughs up a small amount of blood-tinged sputum. Three days after being hospitalized for treatment of a hip fracture sustained in a fall. Range of motion of the spine is normal and without pain. His temperature is 38 C (100. Louis encephalitis 19.4 F). Examination shows ¬¬neck stiffness. During this period. Cranial nerve examination shows weakness of the lateral rectus muscle on the right and bilateral papilledema. She weighs 86 kg (190 lb) and is 165 cm (65 in) tall. Examination of cerebrospinal fluid shows: Opening pressure 220 mm H2O Glucose 35 mg/dL Protein 150 mg/dL WBC 100/mm3 Lymphocytes 100% RBC 1/mm 20. pulse is 74/min.

Which of the following is the most likely diagnosis? A . Mental status examination shows a broad range of affect. and respirations are 24/min. makes religious statements. He is initially cyanotic but then begins to cough and breathe spontaneously after a 5-minute resuscitation. Which of the following is the most appropriate next step in management? A) Pulmonary angiography B) Dopamine therapy C) Heparin therapy D) Urokinase therapy E) Intubation 22. Examination of the chest shows dullness to percussion and decreased breath sounds over the right hemithorax. Arterial blood gas analysis on 40% oxygen by face mask shows: pH 7. A 24-year-old man is brought to the emergency department by police 1 hour after his ex-wife found him stumbling around in the yard. Her blood pressure is 110/70 mm Hg. On arrival. During the examination.40 PCO2 38 mm Hg PO2 70 mm Hg Ventilation-perfusion lung scans show multiple segmental areas of mismatch on the right. Over the next 36 hours. there is no evidence of thought disorder except for mild paranoia. After being submerged for 3 minutes. His blood pressure is 80/40 mm Hg. and respirations are 24/min. he is disoriented. and respirations are 16/min. The pupils are equal and reactive to light. the sclerae are injected. he is rescued. A 17-year-old boy sustains a head injury and loses consciousness after diving into a freshwater lake from a platform. He was the unrestrained passenger. pulse is 110/min. His blood pressure is 100/70 mm Hg. Which of the following is the most appropriate next step in management? A) Observation in the emergency department B) Intramuscular administration of naloxone C) Intravenous administration of 50% dextrose D) Intravenous administration of lorazepam E) Oral administration of chlorpromazine 23. There is no jugular venous distention. he laughs without obvious reason. and asks if there is anything to eat or drink. A 15-year-old boy is brought to the emergency department 30 minutes after being involved in a motor vehicle collision.She appears anxious. pulse is 112/min. which of the following complications is most likely? A) Acute respiratory distress syndrome B) Bacteremia C) Bacterial pneumonia D) Hypernatremia E) Metabolic alkalosis 24. pulse is 90/min. Examination shows no other abnormalities.

He takes no medications. is brought to the emergency department in labor. gravida 2. laboratory tests. Her gums are hypertrophied and exude blood with pressure. On mental status examination. Vital signs are normal. The remainder of the examination shows normal findings. When asked about his mood.) Diaphragmatic rupture B ) Flail chest C ) Hemothorax D ) Massive aspiration E ) Pneumothorax 25. and x-ray films. He has brought a large folder containing information about previous medical consultations. he states that the future appears bleak. An episiotomy is performed. A 30-year-old woman. Physical examination shows no other abnormalities. Supplementation with which of the following vitamins is most likely to have prevented this condition? A) A B) B12 (cyanocobalamin) C) C D) D E) E 27. An 80-year-old woman has had bleeding gums for 3 weeks. Her diet has consisted of only tea and toast for 2 years. para 1. She appears thin and weak. Following delivery of the head. He weighs 50 kg (110 lb) and is 173 cm (68 in) tall. the shoulders do not follow with the usual . he is preoccupied with his symptoms. Which of the following is the most appropriate next step in management? A ) Ask about further symptoms of obsessions and compulsions B ) Ask about sexual history including sexual orientation and practices C ) Ask about suicidal feelings D ) Ask about travel history over the past 6 months E ) Obtain a detailed exercise history F ) Measurement of serum Lyme (Borrelia burgdorferi) antibody level G ) Urine toxicology screening 26. and that he is too tired to think about it. There are ecchymoses of the inner thighs and small hemorrhages around the hair follicles. An 18-year-old man comes to the physician for an initial examination because of a 3-year history of fatigue and migrating joint pain.

His temperature is 37. There is no tenderness to palpation of the lower back. The thyroid glands are not enlarged. He has had several similar episodes over the past 3 years. he underwent operative treatment for an optic nerve glioma. and blood pressure is 126/76 mm Hg. He has not had any urethral discharge or recent sexual contacts.traction and maternal pushing. minimally enlarged. Which of the following is the most likely cause of this patient's high blood pressure? A) Catecholamine-producing tumor B) Carcinoma of the thyroid gland . A 16-year-old boy with neurofibromatosis is brought for a follow-up examination. Which of the following is the most appropriate next step in management? A) Flexing the woman's knees toward her shoulders B) More forceful traction and fundal pressure C) Delivering the posterior arm D) Rotating the head 180 degrees E) Symphysiotomy 28.2 C (98. There are no motor or sensory deficits in the lower extremities. His blood pressure is 164/105 mm Hg. and radial pulses are equal. Abdominal examination shows no abnormalities. Six months ago. pulse is 102/min. and pain with urination. No murmurs are heard. Straight-leg raising to 90 degrees is negative.9 F). there is no costovertebral angle tenderness. The lungs are clear to auscultation. tender prostate with no masses.020 Blood negative Glucose negative Ketones negative Leukocyte esterase negative Nitrites negative Which of the following is the most likely diagnosis? A) Benign prostatic hypertrophy B) Cystitis C) Epididymitis D) Prostate cancer E) Prostatitis F) Pyelonephritis G) Urolithiasis 29. A 32-year-old man comes to the physician because of a 3-day history of low back pain. Abdominal examination shows no tenderness or masses. He has a 1-year history of headaches during which his parents say he appears pale. Laboratory studies show: Serum prostate-specific antigen 6 ng/mL (N<4) Urine Specific gravity 1. and respirations are 14/min. Rectal examination shows a diffuse. His uncle also has neurofibromatosis. urinary hesitancy.

4 F). Which of the following is the most appropriate next step in management? A) Step 2 American Heart Association cardiac diet B) Serum lipid studies while fasting C) Exercise stress test D) Oral cholestyramine and niacin therapy E) Oral pravastatin therapy at bedtime 32. She has leiomyomata uteri. bowel sounds are present. Abdominal examination shows right-sided tenderness without guarding or rebound. She is listless except for intermittent episodes of discomfort. Neurologic examination shows no abnormalities. He has never been hospitalized. she is otherwise healthy. and he plays handball once weekly. The amount of cornstarch ingested has increased gradually during this time. and a paternal uncle had heart disease. Examination shows no abnormalities. He is a computer programmer. A 14-month-old girl is brought to the physician because of a 14-hour history of irritability and episodes of drawing her knees toward her chest. His total serum cholesterol level is 225 mg/dL. she has vomited nonbilious fluid twice and had a bowel movement containing a small amount of blood. Rectal examination shows bright red blood and mucus. She had an upper respiratory tract infection 2 weeks ago. An x-ray film of the abdomen shows no abnormalities. She has no compulsive behavior or obsessive thoughts. she weighs 61 kg (135 lb) and is 168 cm (66 in) tall. Her blood pressure is 120/80 mm Hg. An asymptomatic 47-year-old man comes for a preemployment examination. She is embarrassed about her problem. A 25-year-old woman comes to the physician because of a 3-month history of the unexplained urge to eat a few tablespoons of cornstarch daily. Her weight is unchanged from her last visit 1 year ago. An ECG shows sinus tachycardia. The patient's blood pressure is 126/80 mm Hg. During this period. Physical examination shows mild pallor. Which of the following is the most appropriate next step in management? A) X-ray film of the upper gastrointestinal tract with contrast B) Water-soluble contrast enema C) Corticosteroid enemas D) Admission to the hospital for total parenteral nutrition E) Immediate laparotomy 31.C) Essential hypertension D) Overproduction of aldosterone from an adrenal adenoma E) Postsubclavian coarctation of the aorta 30. Which of the following is the most appropriate next step in management? A) Psychiatric assessment B) Complete blood count C) Thyroid function studies D) Urine toxicology screening E) Admission to an eating disorders clinic F) Antipsychotic therapy . and pulse is 100/min. Her temperature is 38 C (100. His maternal grandmother had type 2 diabetes mellitus.

increased spending. He drinks four to five 8-oz bottles of milk daily. and his wife agrees to abide by his wishes.2 mg/dL. When the results are initially discussed. blood pressure is 120/80 mm Hg. and mean corpuscular volume of 72 μm3. He has had a 6. On a routine examination. and his mother has hypertension and type 2 diabetes mellitus.2-kg (7-lb) weight gain. and overtalkativeness. Which of the following serum levels is most likely to be increased in this patient? . a 2-year-old boy has a hemoglobin level of 10. His blood pressure is 160/85 mm Hg in both arms. the patient says that he does not want to hear the report. Examination shows no other abnormalities. A 57-year-old man is brought to the physician by his wife because his skin has appeared yellow for 3 weeks. He maintains a regular diet but does not eat vegetables. His nonfasting serum glucose level is 280 mg/dL. hematocrit of 30%.G) Folic acid supplementation H) Selective serotonin reuptake inhibitor therapy 33. during this period she has had a 3. The most appropriate next step is measurement of which of the following? A) Fasting serum glucose level B) Leukocyte count C) Serum alkaline phosphatase activity D) Serum creatinine level E) Serum thyroid-stimulating hormone level 34. He currently weighs 95 kg (210 lb) and is 178 cm (70 in) tall. His total serum bilirubin level is 8 mg/dL with a direct component of 6. His father has hypertension. Her medication was prescribed soon after the birth of her son to treat racing thoughts. A previously healthy 52-year-old man comes to the physician because of a 3-month history of increased urinary volume and increased urinary frequency at night. and pulse is 70/min. Her temperature is 37 C (98. Her symptoms decreased after 2 weeks of lithium carbonate therapy. Which of the following is the most appropriate course of action? A) Withhold the results as the patient wishes B) Contact the patient's children to discuss the results C) Consult with the hospital ethics committee D) Insist on telling the patient the results E) Refer him to another physician 36. she has had difficulty sleeping for more than 2 hours nightly. Which of the following is the most likely diagnosis? A) Folic acid deficiency B) Iron deficiency C) Sickle cell disease D) Thalassemia E) Vitamin B6 deficiency 35. She continues to take lithium carbonate (300 mg three times daily). A 30-year-old woman comes to the physician for a follow-up examination 4 months after starting treatment with lithium carbonate. A CT scan of the abdomen shows a large lesion in the head of the pancreas.6 F).8-kg (15-lb) weight loss during this period despite no change in appetite. Examination shows normal findings.5 g/dL. Examination shows jaundice and scleral icterus.

5 C (99.000/mm3 Prothrombin time 14 sec (INR=1. a 52-year-old woman has prolonged bleeding from a venipuncture site. Her temperature is 37. pulse is 78/min.500/mm3 Segmented neutrophils 72% Bands 1% Eosinophils 15% Lymphocytes 4% Monocytes 8% Serum Urea nitrogen (BUN) 12 mg/dL Creatinine 0. She had a pulmonary embolus 2 years ago.9 mg/dL Urine . Laboratory studies show: Hemoglobin 10.5 g/dL Platelet count 25.5 F). She is in mild distress. Examination shows a maculopapular erythematous rash over the trunk. She has a history of recurrent urinary tract infections and has been taking trimethoprimsulfamethoxazole prophylaxis for the past year. Three days after hospitalization for heparin treatment of deep venous thrombosis of a left superficial femoral vein. chills. blood pressure is 96/62 mm Hg. chest pain. and respirations are 14/min.3) Partial thromboplastin time 65 sec Plasma fibrinogen 300 mg/dL (N=200–400) Serum creatinine 1. shortness of breath.A) Bicarbonate B) Glucagon C) HDL-cholesterol D) Insulin E) Ketones 37.1 mg/dL Which of the following is the most likely diagnosis? A) Adverse drug reaction B) Disseminated intravascular coagulation C) Excessive blood loss from anticoagulation D) Factor VIII deficiency E) Factor IX deficiency F) Immune thrombocytopenic purpura G) Thrombotic thrombocytopenic purpura 38.5 C (99. Her temperature is 37. or gastrointestinal symptoms. Examination shows multiple ecchymoses at the venipuncture sites with oozing of fresh blood. Laboratory studies show: Leukocyte count 10. She has not had fever. A 37-year-old woman comes to the physician because of an itchy rash over her trunk for 2 weeks.5 F).

Examination shows a uterus consistent in size with a 34-week gestation.WBC 2/hpf RBC 2/hpf Which of the following is the most likely cause of these findings? A) Eczema B) Medication adverse effect C) Staphylococcal skin infection D) Streptococcal skin infection E) Urinary tract infection 39. Examination shows no abnormalities. nodular temporal arteries with decreased pulses. Which of the following is the most appropriate immediate step in management? A) Carotid ultrasonography B) Aspirin therapy . Her pregnancy has been uncomplicated. Over the past month. Menses have occurred every other month since menarche 10 months ago. he has had headache and pain in the jaw with chewing. A 19-year-old primigravid woman at 34 weeks' gestation comes to the physician for a routine prenatal visit. She has no history of serious illness. Sexual development is Tanner stage 3. A 13-year-old girl is brought for a well-child examination. A routine clean-catch urine culture grows greater than 100. A 72-year-old man comes to the emergency department after a 5-minute episode of blindness in the right eye. She is not sexually active. Examination shows tender. Which of the following is the most appropriate pharmacotherapy? A ) Ampicillin B ) Ciprofloxacin C ) Clindamycin D ) Doxycycline E ) Trimethoprim-sulfamethoxazole 40. His temperature is 38.000 colonies/mL of Escherichia coli. His erythrocyte sedimentation rate is 92 mm/h. Which of the following is the most appropriate next step in management? A) Discussion of pregnancy prevention B) Measurement of serum luteinizing and follicle-stimulating hormone levels C) Urine β-hCG test D) Pelvic examination E) Estrogen therapy F) Diagnostic laparoscopy 41.6 F). Her last menstrual period was 1 week ago. She takes no medications and has no known allergies.1 C (100.

She is sexually active with one partner. Her maternal grandmother was diagnosed with breast cancer at the age of 65 years. His blood pressure is 120/80 mm Hg. A 28-month-old boy has a history of cyanosis since birth with episodes of syncope. There is a right ventricular heave. and a grade 3/6 systolic murmur. Her last menstrual period was 2 weeks ago. His weight is appropriate for his height. Examination shows cyanosis and clubbing. and she and her partner use condoms inconsistently for contraception. A healthy 18-year-old woman comes for a routine health maintenance examination. a systolic click. and he does not smoke. and her maternal grandfather died of a myocardial infarction at the age of 66 years.C) Cefotaxime therapy D) Corticosteroid therapy E) Temporal artery biopsy 42. Which of the following is the most appropriate screening test for this patient? A) Complete blood count B) Fasting serum lipid studies C) Test of the stool for occult blood D) Testing for Neisseria gonorrhoeae and Chlamydia trachomatis E) Urinalysis . and triglyceride level of 150 mg/dL. Which of the following is the most appropriate next step in management? A ) Recommend the Step 2 National Cholesterol Education Program diet B ) Measure serum LDL-cholesterol level now C ) Measure total serum cholesterol level in 5 years D ) Prescribe prophylactic aspirin E ) Begin treatment with lovastatin 43. Which of the following is the most likely diagnosis? A) Bicuspid aortic valve B) Coarctation of the aorta C) Mitral stenosis D) Patent ductus arteriosus E) Tetralogy of Fallot 44. The lungs are clear to auscultation. her paternal grandfather was diagnosed with colon cancer at the age of 72 years. A 42-year-old man comes for a routine health maintenance examination. HDL-cholesterol level of 40 mg/dL. Menses occur at regular 28-day intervals. Examination shows no abnormalities. There is no family history of coronary artery disease. a single S2. Serum lipid studies show a total cholesterol level of 190 mg/dL.

_______________________________________________________________________________ ___________________________________________________ . Six months ago. His temperature is 38. An x-ray film of the chest shows a right pleural effusion and hilar adenopathy. he visited his grandparents in Albania for 2 weeks. Her temperature is 38 C (100. A) α1-Antitrypsin deficiency B) Cystic fibrosis C) Pneumothorax D) Pulmonary alveolar proteinosis E) Pulmonary aspergillosis F) Pulmonary hemorrhage G) Pulmonary tuberculosis 45.8 F). For each child with fever and cough. pulse is 76/min. He appears thin and pale. and respirations are 36/min.2 C (100. A previously healthy 16-year-old boy is brought to the physician because of fever and cough with right-sided chest pain for 2 weeks. Examination shows mild clubbing.The response options for the next two items are the same. He weighs 54 kg (120 lb) and is 173 cm (68 in) tall. She has had several similar episodes since the age of 4 months. Wheezing and bilateral crackles are heard at the lung bases. Examination shows shallow respirations with decreased breath sounds at the right lung base. She is at the 25th percentile for length and 5th percentile for weight. You will be required to select one answer for each item in the set. pulse is 150/min. select the most likely diagnosis. For each child with fever and cough. Three months ago.4 F). A 20-month-old girl is brought to the physician because of fever and cough for 2 days. She appears thin and pale. An x-ray film of the chest shows streaky densities bilaterally with mild hyperinflation. she and her family visited her grandmother in Finland for 2 weeks. select the most likely diagnosis. A) α1-Antitrypsin deficiency B) Cystic fibrosis C) Pneumothorax D) Pulmonary alveolar proteinosis E) Pulmonary aspergillosis F) Pulmonary hemorrhage G) Pulmonary tuberculosis 46. and respirations are 40/min.

Babinski's sign is absent. Initially. A previously healthy 52-year-old man comes to the emergency department because of hiccups for 1 week. and difficulty swallowing liquids. He does not drink alcohol. and the gag reflex is reduced. pulse is 70/min. A 67-year-old man comes to the physician because of a 6-month history of double vision. he has had shortness of breath with exertion. his symptoms were intermittent but now occur daily and are worse at the end of the day. A CT scan of the chest is shown.9% Saline therapy N) 3% Saline therapy O) Sodium bicarbonate therapy 2. He has smoked two packs of cigarettes daily for 30 years. blood pressure is 150/95 mm Hg.6 F). He has pernicious anemia treated with monthly vitamin B12 (cyanocobalamin) injections and autoimmune thyroid disease currently treated with thyroid replacement therapy. An xray film of the chest shows a diffuse alveolar and interstitial pattern. An x-ray film of the chest shows a right hilar mass. The tongue is weak. His temperature is 37 C (98.2 F). and respirations are 12/min. Over the past week. There is bilateral facial weakness and hypernasal speech. A 32-year-old man receiving intensive chemotherapy for Hodgkin's disease has a temperature of 39 C (102. He is alert and oriented. slurred speech. His respirations are 40/min. Muscle strength is 4/5 in the proximal muscles of the upper and lower extremities. Which of the following is the most appropriate next step in treatment? A) Bisphosphonate therapy B) Calcitonin therapy C) Calcium therapy D) Dexamethasone therapy E) 5% Dextrose in 0.Section 4:-1.45% saline therapy G) 5% Dextrose in water therapy H) Fluid restriction I) Hydrocortisone therapy J) Lactated Ringer's solution K) Mannitol therapy L) Potassium therapy M) 0. Examination shows bilateral ptosis and disconjugate gaze. Deep tendon reflexes are 2+ diffusely.225% saline therapy F) 5% Dextrose in 0. Sensory examination shows no abnormalities. Physical and neurologic examinations show no abnormalities. Which of the following is the most likely causal organism? A) Aspergillus species B) Candida albicans C) Coccidioides immitis D) Pneumocystis carinii E) Streptococcus pneumoniae . Which of the following is the most likely diagnosis of this patient's intrathoracic lesion? A) Aspiration pneumonia B) Bronchogenic carcinoma C) Lung metastasis D) Sarcoidosis E) Thymoma F) Thyroid carcinoma 3. His serum sodium level is 120 mEq/L. Widespread crackles are heard in all lung fields.

blood pressure is 120/70 mm Hg. The remainder of the eye examination shows no abnormalities. Which of the following is the most likely diagnosis? A) Adjustment disorder with disturbance of conduct B) Conduct disorder C) Conversion disorder D) Factitious disorder E) Hypochondriasis F) Major depressive disorder G) Oppositional defiant disorder H) Somatization disorder 6. night sweats. fatigue. He has had no fever. pulse is 76/min. A 37-year-old woman is brought to the emergency department because she has been unable to see out of her right eye since awakening 2 hours ago. His temperature is 36. He weighs 68 kg (150 lb) and is 168 cm (66 in) tall. A 44-year-old woman comes to the emergency department 2 days after being discharged from the hospital for abdominal pain. The left pupil reacts normally to light. She states that any movement of the eye is painful. indurated laparoscopic wound. Over the past 5 years. Examination shows a reddened. On the second hospital day. His only medication is oxycodone for joint pain. Examination shows no abnormalities. an exploratory laparoscopy showed no abnormalities. she had been admitted to the hospital numerous times for the evaluation of a variety of symptoms.6 F). a nurse witnesses the patient rubbing saliva into her laparoscopy site.7 C (98 F). The right pupil is poorly reactive to direct light. She is admitted to the hospital and given intravenous antibiotics. Which of the following is the most likely site of the lesion? A) Left optic nerve B) Left optic radiation . The optic fundi are normal. Laboratory studies show: Hematocrit 20% Mean corpuscular volume 110 μm3 Leukocyte count 2300/mm3 Reticulocyte count 1. or cough productive of sputum. and generalized weakness. and respirations are 18/min. all work-ups had been negative.8% Which of the following is the most likely mechanism for these findings? A) Adverse drug reaction B) Atrophy of gastric mucosa C) Bacterial overgrowth in the small intestine D) Increased demand for folic acid E) Increased demand for vitamin B12 (cyanocobalamin) F) Malabsorption G) Vitamin B1 (thiamine) deficiency 5. Her temperature is 39.2 C (102. Examination shows visual acuity of 20/200 in the right eye and 20/20 in the left eye.4. A 20-year-old African American man with sickle cell disease comes to the physician because of a 1-week history of shortness of breath on exertion. chills.

select the most likely site of nerve injury. and long finger. Examination shows minimal atrophy of the thenar muscles. Sensation to light touch is decreased at the tip of the thumb. A previously healthy 37-year-old man comes to the physician because of a 2-month history of pain in the forearm and little finger of his dominant hand. For each patient with peripheral nerve dysfunction. X-ray films of the right elbow and wrist show no abnormalities. he has been working as a receptionist for . You will be required to select one answer for each item in the set. A) Axillary nerve B) Cervical nerve root at the cervical foramen C) Long thoracic nerve D) Median nerve above the elbow E) Median nerve at the elbow F) Median nerve at the wrist G) Musculocutaneous nerve above the elbow H) Musculocutaneous nerve at the elbow I) Musculocutaneous nerve at the wrist J) Radial nerve above the elbow K) Radial nerve at the elbow L) Radial nerve at the wrist M) Suprascapular nerve N) Thoracodorsal nerve O) Ulnar nerve above the elbow P) Ulnar nerve at the elbow Q) Ulnar nerve at the wrist 7. A previously healthy 42-year-old carpenter comes to the physician because of a 6-month history of pain and numbness in his dominant hand that awakens him at night.C) Left optic tract D) Left visual cortex E) Optic chiasm F) Retina G) Right optic nerve H) Right optic radiation I) Right optic tract J) Right visual cortex The response options for the next two items are the same. He describes numbness in his long and index fingers after driving for extended periods of time. For each patient with peripheral nerve dysfunction. select the most likely site of nerve injury. There is normal sensation to light touch on the little finger and the palm of the right hand. index finger. A) Axillary nerve B) Cervical nerve root at the cervical foramen C) Long thoracic nerve D) Median nerve above the elbow E) Median nerve at the elbow F) Median nerve at the wrist G) Musculocutaneous nerve above the elbow H) Musculocutaneous nerve at the elbow I) Musculocutaneous nerve at the wrist J) Radial nerve above the elbow K) Radial nerve at the elbow L) Radial nerve at the wrist M) Suprascapular nerve N) Thoracodorsal nerve O) Ulnar nerve above the elbow P) Ulnar nerve at the elbow Q) Ulnar nerve at the wrist 8.

Her blood pressure is 150/100 mm Hg while supine and 149/100 mm Hg while standing. The point of maximal impulse is at the left anterior axillary line. 9. Examination shows a 4-cm laceration in the right upper quadrant in the midclavicular line. A 3-month-old boy is brought for a well-child examination. There is decreased sensation to light touch at the tip of the little finger. He is obtunded. Breath sounds are equal bilaterally. Examination shows no abnormalities except for pallor. and irritability. Which of the following is the most likely location of this patient's lesion? A) Adrenal gland B) Brain C) Heart D) Kidney E) Thyroid gland 11. His blood pressure is 60/palpable mm Hg. a 30-year-old woman has had intermittent episodes of headache. She has been taking hormone replacement therapy with conjugated estrogen since the operation. large stab wound to the right upper quadrant of the abdomen. Which of the following is the most likely diagnosis? A) Congenital muscular dystrophy B) Glycogen storage disease. The liver edge is palpated 4 cm below the right costal margin. rugated vagina. palpitations.6 months. The abdomen is distended. sweating. Over the past 3 months. Paresthesias are elicited with compression of the cubital tunnel. this symptom began 8 months ago. type II (Pompe's disease) C) GM1 gangliosidosis D) Infant botulism E) Ventricular septal defect 10. He describes numbness in his little finger and weakness of his grip. A 52-year-old woman comes to the physician because of decreased libido. Examination shows generalized hypotonia. and pulse is 90/min while supine and 110/min while standing. Which of the following is the most likely cause of these findings? A) Decreased androgens B) Decreased estrogen C) Decreased follicle-stimulating hormone (FSH) D) Decreased luteinizing hormone (LH) E) Decreased progesterone F) Decreased prolactin G) Increased androgens H) Increased estrogen I) Increased FSH . after she underwent a total abdominal hysterectomy and bilateral salpingooophorectomy for leiomyomata uteri and menorrhagia. Which of the following is the most appropriate next step in management? A) X-ray films of the abdomen and pelvis B) Angiography C) Contrast study of the wound tract D) CT scan of the abdomen E) CT scan of the chest F) Laparoscopy G) Peritoneal lavage H) Laparotomy I) Local wound exploration 12. He has poor head control. Examination shows a moist. and pulse is 148/min. The spleen is not palpable. A 19-year-old man is brought to the emergency department 45 minutes after sustaining a single.

Examination shows no abnormalities.5 C) 3. For 8 weeks. He is at the 75th percentile for length and weight. He has smoked two packs of cigarettes daily for 30 years. A 67-year-old man with long-standing signs and symptoms of congestive heart failure is admitted to the hospital because of progressive shortness of breath. After vaccination with hepatitis B. a 52-year-old man with a 5-year history of type 2 diabetes mellitus has had deep burning pain in the ball of his right foot and big toe when the foot is raised above chest level.5 E) 4. There is no family history of excessive bleeding. and a right-sided pleural effusion.J) Increased LH K) Increased progesterone L) Increased prolactin 13.000/mm3 Prothrombin time 20 sec (INR=1. Femoral pulses are palpable. The newborn is breast-feeding well. He was born at home. Laboratory studies show: Hemoglobin 16 g/dL Leukocyte count 6800/mm3 Segmented neutrophils 48% Bands 2% Lymphocytes 50% Platelet count 280.8 D) 4. A 7-day-old newborn is brought for a well-child examination. pedal pulses are absent. he has prolonged bleeding at the injection site. Which of the following sets of pleural fluid findings is most likely in this patient? PROTEIN(g/dl) A) 2. An x-ray film of the chest shows cardiomegaly. His mother has taken acetaminophen for perineal discomfort. Examination shows no other abnormalities. cephalization of blood vessels.5 GLUCOSE(mg/dl) 10 90 40 60 90 CELL COUNT(/mm3) 10000 2000 30000 10000 2000 NEUTROPHILS(%) 50 60 80 20 50 MONOCYTES(%) 50 40 20 80 50 15.5 B) 2. Which of the following is the most likely diagnosis? .6) Partial thromboplastin time 60 sec Which of the following is the most likely mechanism for these findings? A) Autoimmunization B) Bacterial toxic effect C) Factor VIII deficiency D) Factor IX deficiency E) Immunoglobulin deficiency F) Iron deficiency G) Pharmacologic effect H) Viral toxic effect I) Vitamin deficiency J) Zinc deficiency 14. He also has cramping in his right calf when he walks more than 50 feet.

a nonstatistically significant difference (p>0. gravida 2.10). The investigators of the study concluded that the new drug did not cause hair growth. Funduscopic examination shows optic atrophy. month. Babinski's sign is present bilaterally. prenatal tests. A healthy 7-year-old boy is brought to the physician 1 week after he was exposed for several hours to a child with chickenpox. Fetal heart tones are heard by Doppler.A) Aortoiliac stenosis B) Femoral popliteal stenosis C) Mononeuropathy D) Vasculitis E) Venous stasis 16. The patient and his healthy sister have not had chickenpox. or the names of his siblings. Over the past 2 years. All patients completed the trial. writing. A 6-year-old boy is brought to the physician by his mother because of progressive visual loss over the past year. On mental status examination. This effect has also been reported in studies of other similar drugs in the new therapeutic class. Which of the following is the most appropriate management for the patient and his sister at this time? A) Administer acyclovir as prophylaxis B) Administer immune globulin. Deep tendon reflexes are extremely hyperactive. One hundred patients with hypertension are enrolled. His maternal uncle had similar symptoms. Which of the following is the most appropriate next step in management? A) Routine prenatal visit in 1 week B) Maternal hydration C) Nonstress test D) Immediate induction of labor E) Amniocentesis 18. 50 patients are given the new drug and another 50 patients are given hydrochlorothiazide. he is not oriented to place. he has had deterioration of his hearing. year. Visual acuity is 20/200 bilaterally. speech. and fetal growth have been normal. and intellectual performance. Diagnostic studies are most likely to show which of the following? A) Abnormally decreased serum cholesterol level B) Acanthocytes on blood smear C) An excess of very long chain fatty acids D) Normal nerve conduction studies E) Vitamin E deficiency . His hearing is markedly impaired. One noted unexpected effect is increased growth of scalp hair which occurred in those taking the new drug. intravenously C) Administer aspirin therapy if vesicles appear D) Advise the parents to keep the siblings home from school to prevent exposing their classmates E) Inform the parents that a vesicular rash may appear at any time over the next 2 weeks 19. at 38 weeks' gestation has had no fetal movement for 36 hours. Her prenatal course. para 1. A 1-year study of a new drug to treat hypertension is conducted. A 38-year-old woman. They have not received varicella vaccine. Which of the following features of this study is most likely to affect the validity of this conclusion? A) Differential follow-up B) Lead time bias C) Length of the study D) Sample size E) Self-selection 17. An MRI of the brain shows marked symmetric white matter disease involving all lobes. There is weakness and spasticity of all extremities.

A 22-year-old primigravid woman at 16 weeks' gestation is brought to the emergency department because of progressive shortness of breath over the past 48 hours. His temperature is 37. His temperature is 37 C (98.000 mIU/mL. The lungs are clear to auscultation. and its edge is palpated 4 cm below the right costal margin. A 5-year-old boy is brought to the emergency department 30 minutes after he fainted at home after standing up from a sitting position. An x-ray film of the chest shows multiple round densities throughout all lung fields. He has had no urine output for 18 hours. Scattered wheezes are heard. Which of the following is the most likely mechanism of this patient's increased central venous pressure? A ) Constrictive pericarditis B ) Cor pulmonale C ) Left-sided congestive heart failure D ) Mitral stenosis E ) Tricuspid stenosis 22. Bowel sounds are hyperactive. Cardiac examination shows a nondisplaced point of maximal impulse. Pelvic examination shows a uterus that extends to the umbilicus.6 F). Abdominal examination shows mild distention with shifting dullness.20. pulse is 100/min. pulse is 110/min. A 42-year-old man comes to the physician because of progressive swelling of the legs over the past 2 months.000/mm3. He is alert but quiet. Her hematocrit is 32%. and respirations are 24/min. and serum βhCG level is 300. An early diastolic sound is heard at the apex. Examination shows jugular venous distention that increases with inspiration. The remainder of the examination shows no abnormalities. His capillary . blood pressure is 75/45 mm Hg. Fetal heart tones are absent. Examination shows dry lips and tenting of the skin. Which of the following is the most likely diagnosis? A ) Bacterial pneumonia B ) Choriocarcinoma C ) Pulmonary embolism D ) Tuberculosis E ) Viral pneumonia 21. The liver is pulsatile. blood pressure is 102/80 mm Hg. Her temperature is 37 C (98. leukocyte count is 11. and respirations are 22/min. There is 2+ peripheral edema extending up to the knees. Pulse oximetry on room air shows an oxygen saturation of 92%. and respirations are 28/min.5 F). He has a history of stage IIA Hodgkin's disease treated 1 year ago with radiation therapy to the neck and chest. There is no abdominal tenderness. blood pressure is 120/70 mm Hg. His symptoms began 3 days ago with diarrhea and vomiting. pulse is 120/min. heart sounds are distant.6 F).5 C (99.

Bladder catheterization yields 5 mL of urine.refill time is 5 seconds. doxorubicin. asparaginase. A 2-year-old boy is brought to the physician because of fever and cough for 2 days. lamivudine (3TC). Examination shows subcostal retractions on inspiration. pneumoniae bacteremia at the age of 18 months. At her last visit 9 months ago. and methotrexate therapy D) Zidovudine (AZT).000/mm3 Segmented neutrophils 70% Bands 20% Lymphocytes 8% Monocytes 2% Platelet count 240. Intravenous bolus doses of 0. and respirations are 18/min. Laboratory studies show: Hemoglobin 8. vincristine.8 C (100 F).000/mm3 Serum IgA <5 mg/dL IgG 30 mg/dL IgM <5 mg/dL An x-ray film of the chest shows an infiltrate in the left upper lobe.6 F).5 g/dL Leukocyte count 9100/mm3 Segmented neutrophils 55% Lymphocytes 35% . Two maternal uncles died before the age of 2 years from "infection. Which of the following is the most appropriate next step in management? A) Reexamination in 12 weeks B) Prednisone therapy only C) Prednisone. He had Streptococcus pneumoniae meningitis at the age of 1 year. She is now at the 50th percentile for height and the 10th percentile for weight. Urinalysis is most likely to show which of the following? A) Blood B) Erythrocyte casts C) Hyaline casts D) Leukocyte casts E) Oxalate crystals 23. Examination shows no other abnormalities.8 C (103. S. and ritonavir therapy E) Intravenous immunoglobulin infusion F) Bone marrow transplantation G) Thymus transplantation 24. she was at the 50th percentile for height and the 50th percentile for weight. and respirations are 60/min. She has had a 2. Test of the stool for occult blood is positive.3-kg (5-lb) weight loss during this period due to a decreased appetite." His temperature is 39.9% saline are administered. but she drinks up to 1 liter of fruit juice daily. A previously healthy 13-year-old girl is brought to the physician because of a 2-month history of intermittent abdominal pain and loose stools. Her temperature is 37. pulse is 80/min. and pneumonia at the age of 22 months. pulse is 150/min. Laboratory studies show: Hemoglobin 10 g/dL Leukocyte count 36.

and pulse is 82/min.4 mg/dL. and serum creatinine level is 1. raised.2 mEq/L HCO3– 23 mEq/L Urea nitrogen (BUN) 8 mg/dL Glucose 73 mg/dL Creatinine 0. Which of the following is the most likely cause of this patient's bruit? A ) Accumulation of lipids in the arterial wall B ) Hypertrophy of the arterial wall media C ) Infiltration of arterial wall by giant cells D ) Infiltration of round cells in the arterial wall E ) Reflex vasodilation 26. He has smoked one pack of cigarettes daily for 37 years. nontender. Examination shows a 3 x 2-cm. Which of the following is the most appropriate next step in management? A ) Topical corticosteroid therapy B ) Biopsy C ) Laser therapy . An otherwise healthy 4-month-old girl is brought to the physician because of a birthmark on her arm that has increased in size over the past several weeks. compressible patch over the left forearm.2 mg/dL A barium enema shows patches of ulcerations along the proximal colon with reflux of dye into the terminal ileum. An asymptomatic 57-year-old man comes to the physician for a routine health maintenance examination. serum urea nitrogen (BUN) level is 23 mg/dL. Abdominal examination shows a bruit in the right upper quadrant and no masses. bright red. His blood pressure is 180/112 mm Hg. His hematocrit is 42%.receptor blocking agent therapy D) Prednisone and aminosalicylate therapy E) Bowel resection 25. Which of the following is the most appropriate next step in management? A) Eliminate fruit juice from the patient's diet B) Switch to a gluten-free diet C) H2.Monocytes 10% Platelet count 650.000/mm3 Erythrocyte sedimentation rate 75 mm/h Serum Na+ 139 mEq/L Cl– 101 mEq/L K+ 3. soft.

" The episode resolved completely within 10 minutes. he had an episode of sudden visual loss in his left eye that he describes as "a shade coming down. Her temperature is 38. For each patient with weakness. You will be required to select one answer for each item in the set. She is in the third week of second grade. select the most appropriate test to establish the cause of the condition. Examination shows expressive aphasia and right lower facial droop.5 F). A) Brain stem auditory evoked potentials .D ) Excision E ) No intervention is necessary 27. There is no significant cervical lymphadenopathy. A 57-year-old man is brought to the emergency department 6 hours after the onset of weakness of his right face.6 C (101. and leg. He has hypertension and type 2 diabetes mellitus. A) Brain stem auditory evoked potentials B) Carotid ultrasonography C) Chromosomal analysis for trinucleotide repeat D) Electroencephalography E) Electromyography and nerve conduction studies F) MRI of the spine G) Muscle biopsy H) Repetitive nerve stimulation I) Somatosensory evoked potentials J) SPECT scan K) Temporal artery biopsy L) Visual evoked potentials 28. Examination shows an erythematous pharynx and slightly enlarged tonsils without exudate. Three days ago. worse in the upper extremity than the lower extremity. Sensory examination shows no abnormalities. Which of the following is the most appropriate next step in management? A ) Monospot test B ) Throat culture C ) Intramuscular penicillin therapy D ) Oral erythromycin therapy E ) Oral penicillin therapy The response options for the next two items are the same. select the most appropriate test to establish the cause of the condition. There is moderate weakness on the right. Deep tendon reflexes are 3+ in the right extremities and 2+ in the left extremities. both poorly controlled with lisinopril and glyburide. For each patient with weakness. arm. Babinski's sign is present on the right. A 7-year-old girl is brought to the physician in September because of fever and sore throat for 1 day. A rapid test for group A streptococcus is negative.

There are gouty tophi on the dorsal aspect of the left elbow. she tripped and fell several times and was unable to button clothes or hold utensils. The illness is characterized by the onset of nausea and vomiting 3 to 4 hours after attending . and respirations are 16/min. He has smoked one pack of cigarettes daily for 50 years and drinks 10 oz of homemade whiskey daily. blood pressure is 160/98 mm Hg. 30. He has an ataxic gait. Sensation to vibration is slightly decreased at the fingers and toes.8 C (98. cranial nerves are otherwise intact. He takes no medications. Three weeks ago. A previously healthy 27-year-old woman is brought to the emergency department because of a 2-day history of weakness of her arms and legs and numbness of her hands and feet and a 4-hour history of mild shortness of breath while supine. There is areflexia. His temperature is 36. pulse is 74/min.B) Carotid ultrasonography C) Chromosomal analysis for trinucleotide repeat D) Electroencephalography E) Electromyography and nerve conduction studies F) MRI of the spine G) Muscle biopsy H) Repetitive nerve stimulation I) Somatosensory evoked potentials J) SPECT scan K) Temporal artery biopsy L) Visual evoked potentials 29. He has a history of gout. The weakness began in her feet and has progressed to involve the hands. Today. There is mild facial weakness. Muscle strength in the upper and lower extremities is 4/5 proximally and 2/5 distally. Laboratory studies show: Hematocrit 33% Mean corpuscular volume 70 μm3 Serum Urea nitrogen (BUN) 17 mg/dL Glucose 90 mg/dL Creatinine 2 mg/dL Uric acid 14 mg/dL Which of the following is the most appropriate next step in management? A ) Measurement of blood lead level B ) Measurement of serum porphobilinogen level C ) CT scan of the abdomen D ) MRI of the brain E ) Carbidopa-levodopa therapy 31. Neurologic examination shows mild short-term memory loss and decreased sensation to pinprick in the distal extremities. His wife states that he has become more forgetful over the past 6 months. Babinski's sign is absent bilaterally.3 F). A 72-year-old man comes to the physician with his wife because of chronic abdominal pain and headaches for 4 months. she had a mild upper gastrointestinal illness that resolved within 5 days. She describes a sensation of "electrical shocks" extending from the buttocks to the feet. A county health officer investigates an outbreak of illness among persons attending a church picnic. Her respirations are 20/min and shallow.

the picnic. Laboratory studies show: Erythrocyte sedimentation rate 15 mm/h Serum Na+ 136 mEq/L Cl– 100 mEq/L K+ 4. respectively. She has a 20-year history of arthritis of the hands treated with aspirin and acetaminophen. All affected persons recover without specific therapy. This episode is consistent with a foodborne outbreak caused by which of the following? A ) Clostridium perfringens B ) Giardia lamblia C ) Salmonella species D ) Staphylococcus aureus 32. She had two episodes of urinary tract infections 5 and 11 years ago. A 62-year-old woman comes to the physician because of generalized weakness for 2 weeks. Which of the following is most likely to have prevented this condition? A) Periodic PPD skin testing B) Screening for autoimmune causes of glomerulonephritis C) Periodic renal ultrasonography D) Avoidance of analgesics . Examination shows no abnormalities except for Heberden's nodes on the hands. The investigation implicates egg salad as the vehicle of transmission.9 mEq/L HCO3– 20 mEq/L Urea nitrogen (BUN) 41 mg/dL Creatinine 4 mg/dL Urine Protein 1+ WBC 2–4/hpf RBC none Bacteria none Squamous epithelial cells occasional Granular casts occasional Renal ultrasonography shows no abnormalities.

blood pressure is 170/95 mm Hg. Breath sounds are diminished at the right lung base. he has driven a taxi. He has not had chest pain.3 mEq/L Creatinine 1 mg/dL Thyroid-stimulating hormone 4. He has smoked two packs of cigarettes daily for 40 years. A biopsy specimen of the nodule is most likely to show which of the following? A ) Adenocarcinoma B ) Clear cell carcinoma C ) Mesothelioma D ) Small cell carcinoma .6 F). which of the following is most likely to have prevented this patient's condition? A ) Appropriate immunizations B ) Different occupation C ) Different medications D ) Hypertension screening E ) Smoking cessation 34. he worked in a warehouse with exposed bare insulation. and decreased appetite for 7 days. pulse is 98/min. Serum studies show: Na+ 114 mEq/L K+ 4. An x-ray film of the chest shows calcified pleural plaques on the right hemidiaphragm and a 2-cm pleural-based mass.1 μU/mL An x-ray film of the chest shows a 2-cm nodule in the right lower lobe and mediastinal adenopathy. Cardiac examination shows no murmurs. Between the ages of 18 and 30 years.6 F). and respirations are 24/min. confusion. With regard to the findings on the x-ray film. Neurologic examination shows no abnormalities except for lethargy. His temperature is 37 C (98. for the past 15 years. and respirations are 20/min. muscle cramps. Anterior and posterior diffuse wheezes are heard.E) Suppressive antibiotic therapy for treatment of urinary tract infections 33. A 60-year-old man comes to the physician because of increasing shortness of breath for 1 week. Medications include ipratropium bromide and albuterol metered-dose inhalers. His temperature is 37 C (98. There is mild pretibial edema. pulse is 100/min. A previously healthy 67-year-old man is admitted to the hospital because of lethargy. He appears ill. blood pressure is 120/70 mm Hg. it occurs at rest and is exacerbated by exertion.

Vital signs are within normal limits. She has had recurrent respiratory tract infections since birth. Test of the stool for occult blood is negative. Bowel sounds are increased. She has a 3-year history of major depressive disorder treated with fluoxetine.E ) Squamous cell carcinoma 35. Which of the following is the most likely diagnosis? A) Atrial septal defect (ostium primum type) B) Atrial septal defect (ostium secundum type) C) Atrioventricular canal D) Coarctation of the aorta E) Hypoplastic left heart syndrome F) Patent ductus arteriosus G) Tetralogy of Fallot H) Transposition of the great arteries I) Tricuspid atresia . Examination of the breasts shows no abnormalities. A 62-year-old woman comes to the physician because of bloating and cramping abdominal pain and intermittent diarrhea over the past 5 years. Which of the following is the most likely diagnosis? A) Cystosarcoma phyllodes B) Fat necrosis C) Fibroadenoma D) Fibrocystic changes of the breast E) Galactorrhea F) Hyperprolactinemia G) Intraductal papilloma H) Mastitis I) Paget's disease of the breast 37. and a widened pulse pressure. Abdominal examination shows diffuse tenderness to palpation with no rebound tenderness. Her symptoms have increased over the past month since she started a new diet that emphasizes yogurt and cottage cheese as low-fat sources of calcium and protein. No masses are noted on palpation. A 52-year-old woman comes to the physician because of a 3-month history of intermittent bloody discharge from the right breast. Examination shows a toand-fro murmur in the second left intercostal space. Serosanguineous fluid can be expressed from the nipple of the right breast by pressing on the left side of the areola. A 6-month-old girl is brought to the physician because of poor feeding and labored breathing for 2 months. She does not perform regular monthly breast selfexaminations. bounding peripheral pulses. Which of the following is the best explanation for this patient's diarrhea? A ) Impaired intestinal motility B ) Inflammatory process C ) Malabsorption D ) Secretory process 36. there are no masses or organomegaly. a loud S2.

and respirations are 18/min. the positive predictive value is 80% and the negative predictive value is 96%. The screening test has a sensitivity of 95% and a specificity of 90%. His temperature is 37. She stopped breast-feeding 1 month ago. She is unable to fall back asleep after nighttime feedings. Although this disorder is predominantly found in a particular ethnic group. Which of the following is the most likely result of this screening program? A ) Negative predictive value decreases B ) Positive predictive value decreases .1%. Her serum cholesterol level is 265 mg/dL.5 F). Her blood pressure is 122/80 mm Hg. and growth and development are normal for his age. Testicular examination shows no abnormalities. Urinalysis shows many leukocytes and no erythrocytes. The institute proposes to use this screening test on the general population where the prevalence of this disease is 0. A 70-year-old man comes to the physician because of urinary hesitancy and frequency for 9 months. pulse is 58/min. it is also found sporadically throughout the entire population. The genetic disease institute at a university hospital has developed a rapid screening test for a serious but treatable inherited metabolic disorder. She remembers one out of three objects after 5 minutes.5 C (99. Her son is healthy. Examination shows a circumcised penis with no urethral discharge.J) Ventricular septal defect 38. Rectal examination shows an enlarged rubbery prostate that is nontender to palpation. Gram's stain of urine shows gram-negative rods. Which of the following is the most likely cause of this patient's condition? A ) Infection of the epididymis B ) Infection of the prostate C ) Infection of the urethra D ) Neurogenic bladder E ) Outflow obstruction of the bladder 39. When used in an ethnically prescreened population where the prevalence of this disorder is 30%. She worries about her ability to care for him and has had frequent palpitations. A 32-year-old woman comes to the physician because of lethargy and boredom since the birth of her son 5 months ago. Physical examination shows no abnormalities. The most appropriate next step in diagnosis is measurement of which of the following serum levels? A) Cortisol B) Estrogen C) Progesterone D) Prolactin E) Thyroid-stimulating hormone 40.

he required 6 months of rehabilitation. He had a persistent dry cough 3 days ago. A 42-year-old man is brought to the physician by his wife because of a 2-month history of staring spells that last 1 to 2 minutes each. he has had intermittent episodes of smelling burnt rubber that occur approximately every 2 weeks. During episodes. He hears an intense hissing sound during these episodes. Which of the following is the most likely diagnosis? .C ) Sensitivity decreases D ) Specificity decreases 41. and respirations are 78/min. which of the following is the most appropriate next step in management? A) Stool culture for bacterial pathogens B) Urinalysis C) HIV testing D) Quantitative measurement of immunoglobulins E) Nitroblue tetrazolium testing F) Platelet morphology evaluation G) Tympanocentesis 43. he also smacks his lips and picks at his shirt collar. Her job does not require heavy lifting. A 32-year-old woman comes to the physician because of a 1-year history of increasingly severe dull pain in her lower back and buttocks. His temperature is 37 C (98. There is no history of trauma. A 6-month-old boy is brought to the physician because of respiratory distress for 1 day. There are intercostal retractions. and respirations are 16/min. Examination shows white plaques on the mucous membranes of his mouth and diffuse adenopathy. Examination shows no abnormalities. pulse is 140/min. He reports that. Her blood pressure is 110/70 mm Hg. She also has had morning stiffness of the lower back that lasts for 1 to 2 hours. he was comatose for 2 weeks after sustaining a head injury in a motorcycle collision. There is tenderness to palpation over the sacroiliac joints bilaterally and decreased flexion and extension of the lumbar spine. Four years ago. He appears ill and is in respiratory distress. Laboratory studies are most likely to show which of the following findings in this patient? A ) Decreased erythrocyte sedimentation rate B ) Histocompatibility human leukocyte antigen B27 C ) Increased serum antinuclear antibody titer D ) Increased serum carcinoembryonic antigen (CEA) level E ) Positive serum rheumatoid factor 42. He has not had a fever or nasal discharge. and diffuse crackles are heard throughout all lung fields. An x-ray film of the lumbosacral spine shows sclerosis of the sacroiliac joints. pulse is 68/min and regular. Pulse oximetry shows an oxygen saturation of 70% while breathing room air. He is at the 50th percentile for height and 10th percentile for weight. Cardiopulmonary examination shows no abnormalities. In addition to oxygen and antibiotic therapy. but he has had chronic watery stools.6 F). over the past year.

Serum studies show: Na+ 137 mEq/L Cl– 96 mEq/L K+ 3. he has had multiple psychiatric hospitalizations for threatening people who he believed were plotting against him. for years. waiting to hear further messages from God. Examination shows thin forearms.8 mEq/L HCO3– 22 mEq/L Urea nitrogen (BUN) 30 mg/dL Glucose 68 mg/dL Creatinine 1. She has been talking incessantly at a rapid rate and pacing around the house.A 47-year-old woman is admitted to the hospital for evaluation of a 2-week history of increased irritability and racing thoughts. Which of the following is the most appropriate pharmacotherapy to decrease this patient's risk for future hospitalization? A) Clozapine B) Fluphenazine hydrochloride C) Haloperidol decanoate D) Risperidone .A) Absence seizures B) Complex partial seizures C) Transient ischemic attack D) Tourette's disorder E) Limbic encephalopathy 44. She says that. or causing him to hear voices by implanting devices in his head. Her family reports that she argues with anyone who does not agree with her. after discharge. he discontinued the medication and his symptoms worsened. Which of the following is the most likely diagnosis? A) Acute renal failure B) Borderline personality disorder C) Diabetes insipidus D) Narcissistic personality disorder E) Schizoaffective disorder F) Schizoid personality disorder 45. Over the past 20 years. She is too distractible to perform cognitive tests. She is disheveled and dehydrated. Which of the following is the most likely diagnosis? A) Amyotrophic lateral sclerosis B) Cervical spondylosis C) Multiple sclerosis D) Myasthenia gravis E) Myasthenic (Lambert-Eaton) syndrome F) Myotonic muscular dystrophy G) Polymyalgia rheumatica H) Polymyositis I) Progressive neuropathic (peroneal) muscular atrophy 46. His father has cataracts and frontal baldness. She has barely slept for the past week. He has a 15-year history of difficulty relaxing his hands after tightly gripping objects or after shaking hands.2 mg/dL Mental status examination shows disorganized thoughts and flight of ideas. she has been hearing the voice of God telling her that she has been chosen for a special mission. She is agitated and has difficulty staying seated. A 47-year-old man is admitted to the hospital after threatening to harm a radio announcer he believed was broadcasting his thoughts. Past symptoms improved with neuroleptic therapy. A 20-year-old man comes for a routine health maintenance examination. There is moderate weakness of the hands and difficulty releasing after gripping with his hands. Toxicology screening is negative. trying to control his mind.

B 18.F 19.F 16-C 17.G 14 –C 15.E 20 –D 21.B 22-D / C ? 23-B 24-E 25-D 26-D .C 2 -B 3 -B 4.B 5 -C 6 -F 7.D 8 -B 9 -H 10 11-C / B ? 12.A 13.E) Trifluoperazine hydrochloride ___________________________________________________________________ Answers: FORM1 block 1: 1) e 2) b 3) b 4) d 5) c 6) f 7) d 8) a 9) b 10) h 11) d 12) a 13) g? 14) a 15) f 16) c 17) c 18) f 19)e 20) d 21) b 22) d 23) d 24) e 25) d 26) d 27) a 28) a 29) b 30) d 31) e 32) b 33) b 34) a? 35) b 36) d 37) e 38) e 39) e? 40) d 41) c 42) a 43) c 44) e 45) a 46) d FORM 1 block 2 1) b 2) d 3) d 4) d 5) d 6) e 7) a 8) e 9) g 10) d 11) e 12) d 13) b 14) e 15) c 16) d 17) g 18) a 19)h 20) l 21) b 22) b 23) e 24) e 25) e 26) c 27) d 28) e 29) a 30) a 31) b 32) d 33) c 34) g 35) e 36) e 37) d 38) d 39) d 40) e 41) d 42) d 43) b 44) b? 45) b 46) b Form 1 block 3 1) f 2) c? 3) b 4) c 5) e 6) c 7) a 8) a? 9) a 10) d? 11) b 12) c 13) a 14) e 15) d 16) b 17) b 18) g 19)i?? 20) c 21) c 22) d 23) a 24) c 25) c 26) c 27) a? 28) e 29) a? 30) b 31) e 32) g 33) b 34) b 35) a 36) d 37) f 38) b 39) b? 40) a? 41) d 42) e 43) e 44) d 45) b 46) g? Form 1 block 4 1) H/M 2) e 3) d 4) d 5) d 6) g 7) f 8) p 9) b 10) h 11) h 12) h? 13)i 14) b? 15) b 16) d 17) d 18) e 19)c 20) b 21) a? 22) c 23) e 24) d 25) a 26) e 27) a 28) b 29) e 30) a 31) d 32) d 33) b 34) d 35) c 36) g 37) f 38) e 39) e 40) b 41) b 42) c 43) b 44) e 45) f 46) c More answers: NBME FORM 1 ANSWERS BLOCK 1 1.

C 27.A 30.E 37.F 35.27-A 28-A 29-B 30.B 23.B 34.D 39.D 17.E / D 32-C 33-C 34-A 35-B 36-D 37-E 38-B 39-E 40-D 41-C 42-A 43-C 44-E 45-A 46-D block 2 1-b 2-d? 3-a 4-d 5-d 6-e 7-f 8-e / next ? c 9-g?? 10-c 11-e 12-d 13-B/ d?? 14-e 15-c 16.B 31.E 29.C / D 33.G 18.D 40.E 26.E 19.K 21.B 28.D 38.A 31.E 25.H 20.B 22.E 24.E 36.A 32.E .

B 46.D 42.B 45.c 27.)? 39 E 40 B 41 D 42 C 43 E 44 D 45 B 46 G BLOCK 4 1-m 2-e 3-e 4-d 5-d 6-g 7-f .a 23.b?d? 21.a?b? 28.c 25.D / E 43.b?g? 18.a?b? 26.a 24.a?c? 20.a 17.B 44.e 29.b 31 B 32 B 33 E 34 B 35 A 36 D 37 A 38 B (why such a low bp in this patient.g 19.c 22.B BLOCK 3 1F 2C 3B 4B 5E 6C 7A 8 C OR E ( if strept pyogens is the same as strept pneumonia then its E) 9A 10 E 11 C 12 C 13 A 14 E 15 D 16.a 30.41.

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

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