The most common cause of acute mesenteric ischemia is:
(A) Thrombosis in the superior mesenteric artery (SMA).
(B) Mesenteric vein thrombosis.
(C) Nonocclusive mesenteric vascular disease.
(D) SMA embolism.
(E) Abdominal aortic aneurysm involving the SMA.

2. A 3-year-old girl swallows a button battery. Plain radiographs demonstrate that the battery is lodged in the esophagus.
Which of the following is the most appropriate
next step in management?
(A) Expectant management
(B) Endoscopic removal
(C) Ipecac for therapeutic emesis
(D) Activated charcoal
(E) Whole bowel irrigation

3. A 42-year-old woman presented to the emergency department (ED) with acute-onset epigastric abdominal pain and nausea
without vomiting. Her workup revealed acute pancreatitis and she was admitted. After receiving appropriate analgesics and
antiemetics, she is now hungry and wants something to eat. Which of the following is true?
(A) She should undergo a period of bowel rest for 48 hours regardless of her laboratory results.
(B) She requires ongoing nasogastric (NG) suctioning until pancreatic enzyme abnormalities resolve.
(C) She should receive total parenteral nutrition for 72 hours.
(D) She should be allowed to eat if abdominal computed tomography (CT) reveals resolution of the signs of pancreatitis.
(E) She may eat a low calorie, carbohydrate-rich diet.

4. A 6-year-old girl presents with abdominal pain. She has had moderate, constant periumbilical pain for several hours with
associated nausea. Her parents noted a rash on her legs and buttocks for several days, which they attributed to poison ivy.
Physical examination demonstrates an afebrile, uncomfortable patient, diffuse abdominal tenderness without true rebound or
guarding, a maculopapular rash on the legs and buttocks, and diffuse joint tenderness. Which of the following is the most
important next step in evaluation?
(A) Urinalysis
(B) CT scan of the abdomen/pelvis
(C) Anti-streptolysin O antibodies (ASO) titer
(D) Blood cultures
(E) Meckel scan

5. What is the most common cause of lower gastrointestinal (GI) bleeding (LGIB) in children?
(A) Anal fissure
(B) Hemorrhoids
(C) Henoch–Schönlein purpura
(D) Food allergy
(E) Meckel’s diverticulum

6. Which of the following is true regarding acute mesenteric ischemia (AMI)?
(A) Most patients have a lactic acidosis early in the course of their illness.
(B) The mortality rate of AMI is roughly 70%.
(C) In the absence of angiography, intravenous heparin infusion is the standard of management.
(D) Tenderness on physical examination is most often worse than a patient’s subjective complaint of pain.
(E) The most common CT finding is gas in the portal venous system.

7. A 32-year-old pregnant woman in her third trimester presents with dysuria. She has a penicillin allergy. Urinalysis
demonstrates bacteria, but no white blood cells, leukocyte esterase, or nitrites. Physical examination is normal. Which of the
following is the most appropriate next step in management?
(A) Close outpatient observation
(B) Trimethoprim–sulfamethoxazole
(C) Ciprofloxacin
(D) Nitrofurantoin
(E) Amoxicillin

8. Which of the following is the most important factor in determining the chance of spontaneous passage of a kidney stone?
(A) Composition of the stone
(B) Size of the stone
(C) Degree of pain
(D) Degree of nausea
(E) Age of the patient

9. A 27-year-old man presents to the ED with pruritus ani, tenesmus, and yellowish mucoid discharge from his rectum. Upon
further questioning, he acknowledges recent unprotected anal intercourse. The recommended regimen for treating this
patient is:
(A) Topical podophyllin b.i.d. × 7 days
(B) Ceftriaxone 125 mg IM plus doxycycline 100 mg PO b.i.d. × 7 days
(C) Valacyclovir 1 g PO daily × 5 days
(D) Benzathine penicillin G 2.4 million units IM × 1 dose
(E) Lopinavir

10. An 18-year-old primigravida at 35 weeks of gestation presents with abdominal pain, vaginal discharge, and a low-grade
fever. She states that she was well until two days ago when, after coughing, she experienced a small stream of fluid running
down her leg which she thought was urine. Her temperature is 102°F and her pulse is 108. Her examination reveals a
yellowish discharge in the vaginal vault with a tender uterus. What is the most likely cause of her symptoms?
(A) Abruptio placentae
(B) Pelvic inflammatory disease
(C) Bacterial vaginitis
(D) Pyelonephritis
(E) Chorioamnionitis

11. A nasogastric tube (NGT) should be:
(A) Placed in all patients with a complaint of gastrointestinal (GI) bleeding
(B) Avoided in all patients with a complaint of GI bleeding
(C) Placed only in patients who have ongoing hematemesis
(D) Placed in patients who have rectal bleeding of uncertain origin
(E) Avoided in patients with esophageal varices

12. Which of the following statements about Yersinia enterocolitica infection is true?
(A) Y. enterocolitica gastroenteritis may mimic appendicitis.
(B) Unlike other causes of gastroenteritis, Y. enterocolitis may last for 2 weeks or longer.
(C) Some adults recovering from Y. enterocolitis may develop polyarthritis or erythema nodosum.
(D) Y. enterocolitica infections are most common in childhood.
(E) All of the above

13. Which of the following laboratory abnormalities is most commonly associated with hyperemesis gravidarum?
(A) Hyperkalemia
(B) Elevated liver enzymes
(C) Thrombocytopenia
(D) Hyperglycemia
(E) Elevated erythrocyte sedimentation rate

14. Patients with inflammatory bowel disease (IBD) may develop which of the following extraintestinal complications?
(A) Arthralgias
(B) Episcleritis
(C) Cholelithiasis
(D) Pyoderma gangrenosum
(E) All of the above

15. A 62-year-old man with a history of chronic alcoholism presents with acute-onset epigastric abdominal pain. Initial labs
reveal a white blood cell (WBC) count of 19,000 per mm3, a normal chemistry with a glucose of 168 mg per dL, a lactate
dehydrogenase (LDH) of 400 IU per L, liver enzymes demonstrating an aspartate aminotransferase (AST) of 137 SF units and
an alanine aminotransferase (ALT) of 94 SF units, and a lipase level that is five times the lab’s upper limit of normal. You admit
him with a diagnosis of acute pancreatitis. Which of the following is true?
(A) He has 0 Ranson’s criteria upon admission.
(B) He has 1 Ranson’s criteria upon admission.
(C) He has 2 Ranson’s criteria upon admission.
(D) He has 3 Ranson’s criteria upon admission.
(E) His elevated WBC count suggests an infectious etiology

16. An 18-year-old woman presents to the emergency department (ED) with acute onset severe right lower quadrant pain.
Initially, she was doubled over with pain and had immediate nausea and vomiting just prior to her ED evaluation. The pain
resolved almost completely after 15 minutes, and then she had a second episode while in the ED waiting room. The patient is
currently pain-free. Her last menstrual period was 2 weeks ago. She has a family history of kidney stones. Her vital signs are
normal. Physical examination is unremarkable except for mild fullness and tenderness in the right adnexa. Her CBC, chemistry,
and urinalysis are normal and her urine pregnancy is negative. Which of the following is the most appropriate next step in
(A) Computed tomography (CT) abdomen/pelvis with oral and IV contrast
(B) CT abdomen/pelvis with IV contrast only
(C) CT abdomen/pelvis with rectal contrast
(D) Pelvic ultrasound
(E) Emergent urologic consultation

17. The most common complication of peptic ulcer disease (PUD) is:
(A) Perforation
(B) Gastric adenocarcinoma
(C) Gastrointestinal bleeding
(D) Obstruction
(E) Penetration into an adjacent organ

18. A 26-year-old is brought to the ED by EMS three hours after ingesting an overdose of his mother’s digoxin. Which of the
following is true?
(A) Whole bowel irrigation is an effective means of decontamination.
(B) Activated charcoal should be given.
(C) A digoxin level may overestimate the amount of digoxin ingested.
(D) His underlying heart rhythm is likely sinus tachycardia.
(E) Ten vials of Digibind (Fab fragments) should be given to prevent cardiac toxicity.

19. A 25-year-old woman presents to the ED with worsening left-sided pelvic pain and vaginal discharge. She states that she
was seen in the office by her primary care doctor 3 days ago for similar problems, received an injection of an antibiotic and
was given a prescription that she has not had a chance to fill. In the ED, she has a fever, purulent vaginal discharge, cervical
motion tenderness, and a palpable, tender left-sided adnexal mass. Which of the following is true?
(A) She has Fitz–Hugh–Curtis syndrome.
(B) Aspiration and culture of the mass is likely to reveal Neisseria gonorrhoeae.
(C) If untreated, rupture of the mass and secondary peritonitis may occur.
(D) The patient should be kept NPO for emergent surgery.
(E) The patient most likely has a hemorrhagic ovarian cyst.

20. A 47-year-old man without significant past medical history presents with a chief complaint of burning epigastric
abdominal pain. It does not radiate and occasionally wakes him up in the middle of the night. He takes no medicines and
denies drinking alcohol. You suspect he may have peptic ulcer disease and want to test for Helicobacter pylori. Which of the
following is the best initial screening method?
(A) Serologic testing (IgG antibody testing)
(B) 13C or 14C urea breath testing
(C) Referral for endoscopy and biopsy
(D) Stool antigen test
(E) Rapid urease test

21. Which of the following is the most common cause of large bowel obstruction?
(A) Malignancy
(B) Sigmoid volvulus
(C) Adhesions
(D) Diverticular disease
(E) Fecal impaction

22. Which of the following is a risk factor for cholelithiasis?
(A) Pregnancy
(B) Obesity
(C) Female gender
(D) Oral contraceptive use
(E) All of the above

23. Which of the following is true regarding lipase and amylase in the setting of acute pancreatitis?
(A) Lipase is more specific than amylase.
(B) Amylase is more sensitive than lipase.
(C) Amylase peaks earlier and remains elevated for a longer period than lipase.
(D) The degree of elevation of either amylase or lipase correlates with disease severity.
(E) The amylase to lipase ratio may be useful in determining the etiology of pancreatitis.

24. A 20-year-old previously healthy female college student presents to the ED with diarrhea. She went on a camping trip 2
weeks ago but denies any other travel. She notes seven to eight watery, foul-smelling stools per day and generalized
abdominal cramping. A test for fecal leukocytes, ordered in triage after the patient had a large diarrheal stool, is negative.
Which of the following is the best management?
(A) Azithromycin 500 mg daily for 3 days
(B) Metronidazole 250 mg t.i.d. for 7 days
(C) Ciprofloxacin 500 mg b.i.d. for 3 days
(D) Supportive care with IV hydration and antimotility agents
(E) Vancomycin 125 mg q.i.d. for 10 days

25. Which of the following is the most common cause of dysuria?
(A) Bacterial infection
(B) Viral infection
(C) Fungal infection
(D) Parasitic infection
(E) Allergic urethritis

26. Which of the following is true about gastric volvulus?
(A) It is usually associated with a large umbilical hernia.
(B) It most commonly results from twisting about its short axis.
(C) It most commonly occurs in infants younger than 1 year.
(D) In most cases, a nasogastric tube cannot be passed into the stomach.
(E) Gastric infarction and death occur in 80% of patients if not rapidly diagnosed and treated.

27. A 47-year-old man with a history of alcoholism presents with a chief complaint of jaundice, right upper quadrant pain, and
a low-grade fever. He had his last drink earlier in the day. Which of the following is true?
(A) His AST and ALT levels will be more than 10 times normal.
(B) He should be transferred for immediate liver transplantation.
(C) The patient’s fever suggests an infectious cause of his symptoms is most likely.
(D) Reactive leukopenia is the most common cellular laboratory abnormality.
(E) Hepatomegaly is the most common physical examination finding.

28. A 60-year-old man presents with acute urinary retention. He has been unable to urinate for the last 10 hours and has
extreme discomfort in his lower abdomen. His physical examination is normal except for a distended suprapubic region and
nontender prostatic hypertrophy. He appears very uncomfortable. Which of the following is the most appropriate next step in
(A) Magnetic resonance imaging (MRI) of the abdomen
(B) CT scan abdomen with and without IV contrast
(C) Renal ultrasonography
(D) Complete blood count, chemistry panel
(E) Foley catheter placement

29. Which of the following is true regarding appendicitis?
(A) Nearly all patients with appendicitis younger than 3 years have evidence of perforation at the time of appendectomy.
(B) Most patients younger than 2 years have diffuse abdominal tenderness.
(C) An appendicolith is only seen in approximately 15% of cases.
(D) CT scan has better sensitivity and specificity than ultrasound.
(E) All of the above