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2014

Step 2 CK

Content Description
and General Information
A Joint Program of the Federation of State Medical Boards of the United States, Inc.,
and the National Board of Medical Examiners®

Copyright © 2000–2013 by the Federation of State Medical Boards of the United States, Inc. and the National
Board of Medical Examiners® (NBME®). All rights reserved. Printed in the United States of America.
The USMLE® is a joint program of the Federation of State Medical Boards of the United States, Inc. and the
National Board of Medical Examiners.

CONTENTS

Introduction ......................................................................................................................... 3
Preparing for the Test, Applying for the Test, Scheduling Test Dates, and Testing........... 3
Examination Content .......................................................................................................... 3
Test Question Formats ........................................................................................................ 5
Single One Best Answer Questions ....................................................................... 5
Sequential Item Sets…………………….………………………………………..5
Matching Sets ........................................................................................................ 6
Content Outline ................................................................................................................... 7
Sample Step 2 CK ............................................................................................................. 20
Laboratory Values Table...................................................................................... 21
Answer Sheet for Sample Questions.................................................................... 23
Sample Step 2 CK Questions ............................................................................... 24
Answer Key for Sample Questions ...................................................................... 73

The tutorial provided at the beginning of the Step 2 examination has fewer screens and less detailed information than the tutorial available as part of the Step 2 practice materials on the USMLE website. and an item in the abstract format 3 . a sequential item set. or in 2014. the screens describing some of the navigation features of the test delivery software have been consolidated into fewer screens.Introduction This booklet is intended to help you prepare for the Step 2 Clinical Knowledge (Step 2 CK) component of the United States Medical Licensing Examination® (USMLE®) if you are an applicant with an eligibility period that has an ending date in mid to late fall of 2013. Examination Content Step 2 CK consists of multiple-choice questions prepared by examination committees composed of faculty members. and to access updated practice materials. This table will be available as an online reference when you take the examination. and test item formats may vary within each block. This number will vary among blocks. Test questions focus on the principles of clinical science that are deemed important for the practice of medicine under supervision in postgraduate training. you should review the sections that appear in the Bulletin: Preparing for the Test. You will have one hour to complete each block. with which you must become familiar to apply for the examination. and other informational materials are available at the USMLE website (http://www. The Step 2 CK examination consists of questions ("test items") presented in standard multiple-choice formats. Eligibility periods are explained in the 2014 USMLE Bulletin of Information. You should become familiar with test items that have audio and video components and sequential item sets as these formats may be used in the actual examination. and Testing In addition to the information in this booklet. The practice materials on the website include an additional block of items with associated audio or video findings. is reproduced on pages 21 and 22 of this booklet. you should run the practice Step 2 CK test materials and tutorials provided at the USMLE website. In the exam-day tutorial. Information regarding any changes in the USMLE program will also be posted at the USMLE website. You may want to study the descriptions of test item formats that follow before you run the sample test items. Applying for the Test. In addition to reading the Bulletin.usmle. Applying for the Test and Scheduling Your Test Date. Please note that values shown in the actual examination may differ slightly from those printed in this booklet. Preparing for the Test. Committee members are selected to provide broad representation from the academic. The sample test materials in this booklet are provided in computer format at the USMLE website. A Normal Laboratory Values Table. and clinicians with recognized prominence in their respective fields. In advance of testing. including Standard International conversions. practice. The number of items in a block will be displayed at the beginning of each block. You must obtain the most recent information to ensure an accurate understanding of current USMLE rules.org). The block of items with associated audio or video and a sequential item set does not appear in this booklet. investigators. The total number of items on the overall examination form will not exceed 355 items. teachers. regardless of the number of items. The information in this booklet. accompanied by two or more questions). The test items are divided into "blocks" (see Test Lengths and Formats in the Bulletin).usmle. but will not exceed 45 items. USMLE practice test materials and software tutorials.org) announcements section to check for changes in test delivery software. Please monitor the USMLE website (http://www. as described on pages 5-6 of this booklet. Scheduling Test Dates. The examination is constructed from an integrated content outline that organizes clinical science material along two dimensions. (a summary of an experiment or clinical investigation. you should review the longer tutorial available in the Step 2 practice materials. and licensing communities across the United States and Canada. and Testing. as shown in Table 1. a pharmaceutical advertisement item. You must run the tutorial and practice test items to become familiar with test software prior to your test date.

The categorizations and content coverage are subject to change. Applying Principles of Management. Normal Conditions and Disease categories (Dimension 1) form the main axis for organizing the outline. The first section deals with normal growth and development.Table 1: USMLE Step 2 CK Specifications* Normal Conditions and Disease Categories □ Normal growth and development and general principles of care □ Individual organ systems or types of disorders  immunologic disorders  diseases of the blood and blood-forming organs  mental disorders  diseases of the nervous system and special senses  cardiovascular disorders  diseases of the respiratory system  nutritional and digestive disorders  gynecologic disorders  renal. less common problems where early detection or treatability are important considerations. imaging. A full content outline for the USMLE Step 2 CK examination is provided on pages 7-19. The content outline is not intended as a curriculum development or study guide. Understanding Mechanisms of Disease. Promoting Preventive Medicine and Health Maintenance. The remaining sections deal with individual disorders. Questions in this category will focus on the same topics covered in the diagnosis sections. The second set of tasks. and other studies to determine the most likely diagnosis or the most appropriate next step in diagnosis. and shifts in emphases. encompasses the assessment of risk factors. and the puerperium  disorders of the skin and subcutaneous tissue  diseases of the musculoskeletal system and connective tissue  endocrine and metabolic disorders Physician Task 15%–20% 20%–35% 25%–40% 15%–25% Promoting preventive medicine and health maintenance Understanding mechanisms of disease Establishing a diagnosis Applying principles of management * Percentages are subject to change at any time. 4 Sections focusing on individual disorders are subdivided according to Physician Task (Dimension 2). The first set of physician tasks. basic concepts. . See the USMLE website for the most up-to-date information. and the application of primary and secondary preventive measures. To facilitate review. appreciation of epidemiologic data. encompasses etiology. and male reproductive systems  disorders of pregnancy. The third set of tasks. childbirth. with the subcategories in regular type. Questions are generally. and noteworthy exemplars of pathophysiology. They reflect the development of a “High-Impact Disease List” that includes common problems. urinary. but not exclusively. and general principles. and effects of treatment modalities in the broadest sense. In addition. emerging content domains. the major categories are indicated in bold type. not all listed topics are included on each examination. Broadly based learning that establishes a strong general foundation of understanding of concepts and principles in the clinical sciences is the best preparation for the examination. It provides a flexible structure for test construction that can readily accommodate new topics. It describes the scope of the examination in detail. pathophysiology. pertains to interpretation of history and physical findings and the results of laboratory. focused on the listed disorders. The fourth set of tasks. Establishing a Diagnosis. The diseases noted in the outline do not represent an all-inclusive registry of disorders about which questions may be asked. concerns the approach to care of patients with chronic and acute conditions in ambulatory and inpatient settings.

Her hemoglobin concentration is 9 g/dL. Each question is linked to the initial patient vignette but is testing a different point. It is important to understand what is being asked. Examination shows no abnormalities. D. Strategies for Answering Single One-Best-Answer Test Questions • • • • • Read each question carefully. read each option carefully. (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) Acute blood loss Chronic lymphocytic leukemia Erythrocyte enzyme deficiency Erythropoietin deficiency Immunohemolysis Microangiopathic hemolysis Polycythemia vera Sickle cell disease Sideroblastic anemia β-Thalassemia trait (Answer: D) Sequential Item Sets A single patient-centered vignette may be associated with two or three consecutive questions about the information presented. A blood smear shows normochromic. A. most frequently used multiplechoice format. and mean corpuscular volume is 94 μm3. Each pharmaceutical ad or abstract appears as a 2. B. 5 . Questions are designed to be answered in sequential order. hematocrit is 28%. examinees will see no more than 5 of these item sets in their examination. It consists of a statement or question followed by three to twenty-six options that are in alphabetical or logical order. you will not be able to add or change an answer to the displayed (previous) item. but there is only ONE BEST answer. Items with an associated pharmaceutical ad or abstract were introduced into the examination in August 2011.or 3-item set. If unsure about an answer. Which of the following is the most likely cause? This is the traditional. normocytic cells. Try to generate an answer and then look for it in the option list. Other options may be partially correct.Test Question Formats Example Item 1 Single One-Best-Answer Questions 1. but there is only ONE BEST answer. E). Alternatively. exam blocks that include a pharmaceutical ad or abstract item set contain fewer items. You are required to select the one best answer to each question. Of the remaining options. Other options may be partially correct. eliminating those that are clearly incorrect. You must click “Proceed to Next Item” to view the next item in the set. A 32-year-old woman with type 1 diabetes mellitus has had progressive renal failure over the past 2 years. once you click on this button. She is not yet on dialysis. C. The response options in this format are lettered (eg. You are required to select the best answer to the question. it is better to guess. Because item sets with an associated pharmaceutical ad or abstract may require more time to answer than other multiple-choice items. A screen at the beginning of each block that includes a pharmaceutical ad or abstract item set alerts examinees so that they can monitor their time accordingly. select the one that is most correct. since unanswered questions are automatically counted as wrong answers.

and at least two questions. pruritus. A 41-year-old woman comes to the physician for a follow-up examination. Read each question carefully. For matching sets with large numbers of options. and an enlarging lump above his left clavicle for 3 weeks. Example Items 2-3: Matching set (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) Chronic lymphocytic leukemia Drug reaction Hodgkin disease Infectious mononucleosis Metastatic carcinoma Sarcoidosis Systemic lupus erythematosus Toxoplasmosis Tuberculosis Tularemia For each patient with lymphadenopathy. a list of lettered response options. nontender axillary lymph nodes. select the most likely diagnosis. while other options may not be used at all. (Answer: C) 3. All matching sets contain set-specific instructions. This is more efficient than considering each option individually. with instructions and response options repeated for each subsequent question. Examination shows a 3-cm.Matching Sets This format consists of a series of questions related to a common topic. Within a set. You are directed to select one answer for each question in the set. some options may be used several times. 3-cm. Select one answer for each item in the set. A lymph node biopsy shows hyperplasia. A previously healthy 30-year-old man has had fever. Each set is preceded by a box that indicates the number of questions in the set associated with the response options that follow. supraclavicular lymph node. rubbery. She has taken aspirin for chronic headaches and phenytoin for a seizure disorder for 2 years. Respond to each question independently. There will be between four and twenty-six response options. 2. The response options for the next 2 items are the same. An x-ray of the chest shows mediastinal lymphadenopathy. nontender. Examination shows mild epigastric tenderness and bilateral. night sweats. try to generate an answer to the question and then locate the answer in the option list. Strategies for Answering Matching Sets • • • • Begin each set by reading through the option list to become familiar with the available responses. (Answer: B) 6 . Questions will be presented one at a time.

........ Infectious and Parasitic Diseases...................................... 19 18........................ 19 20... 11 8.............................................................................................. Disorders of Pregnancy..............................Step 2 CK Content Outline TABLE OF CONTENTS 1........... Urinary........... 16 14................................................................................................. Neoplasms .... Diseases of the Nervous System and Special Senses ... Disorders of the Skin and Subcutaneous Tissues ............................... Diseases of the Respiratory System .......................................................... Nutritional and Digestive Disorders ..................................................... 8 4............................................... 19 7 ...................... 19 19................................................................................................... 8 3......................... and the Puerperium .............................. Cardiovascular Disorders ......................................................................................................... Symptoms.. General Principles ...................................................................................................................... Childbirth........................................................................ Endocrine and Metabolic Disorders .. Diseases of the Musculoskeletal System and Connective Tissue .................................................................................. 13 10.......... Signs................................................................................ 18 17............ Mental Disorders ........ 8 5..................... Immunologic Disorders ........................................................ Congenital Anomalies ... Injury and Poisoning ................... 15 13...................................... and Male Reproductive Systems............................ 18 16..................... 12 9........................ Diseases of the Blood and Blood-forming Organs ..................................................................... Gynecologic Disorders ........................ 9 6....................................................................................................................... Renal......................... 10 7................................................ and Ill-defined Conditions .................. 8 Infancy and Childhood Adolescence Senescence Medical Ethics and Jurisprudence Applied Biostatistics and Clinical Epidemiology Systems-Based Practice and Patient Safety 2................................................................................................................... Conditions Originating in the Perinatal Period ............. 15 12............................................. 14 11....................................................................................................................................... 17 15.........................................................

alternate therapies. health care proxy) and research issues (eg. reducing deviance) • Patient safety. organ donation. maternal-fetal conflict) • Death and dying (eg. life support. physical changes of puberty Senescence • Normal physical and mental changes associated with aging Medical Ethics and Jurisprudence • Consent and informed consent to treatment (eg. problem identification. Neoplasms (Topic covered under each organ system) 4. vulnerable populations) • Physician-patient relationship (eg. abortion. advance directives. full disclosure. General Principles Infancy and Childhood • Normal growth and development Adolescence • Sexuality. hospice. patients having compromised immune systems) 8 . psychosocial and spiritual issues. root cause analysis) 2. family counseling. adults. public reporting) and birth-related issues (eg. medical errors and near misses (sentinel events. diagnosing death. placebos. confidentiality. children. physician-assisted suicide) and palliative care (eg. autonomy. risks and benefits. Immunologic Disorders Health and Health Maintenance • Anaphylaxis and other allergic reactions • HIV infection/AIDS • Immunization against infectious agents (including infants. consent. pain management. truth telling. Infectious and Parasitic Diseases (Topic covered under each organ system) 3. euthanasia.1. standardization of processes. separation from parents/autonomy. conflict of interest. prenatal diagnosis. the elderly. privacy. fear and loneliness) Applied Biostatistics and Clinical Epidemiology • Understanding statistical concepts of measurement in medical practice • Interpretation of the medical literature Systems-Based Practice and Patient Safety • System-based practice and quality improvement (microsystems and teams including hand-offs.

4. thrombocytopenia (eg. malaria. qualitative and quantitative platelet deficiencies. agranulocytosis • Infection (eg. Hodgkin disease. disorders of red cells. drug-induced. aplastic anemia. sepsis. thalassemia. blood loss. immune thrombocytopenic purpura. anemia associated with chronic disease. pernicious anemia. other megaloblastic anemias. acute leukemia in children. mycosis fungoides. mononucleosis) 9 . Diseases of the Blood and Blood-forming Organs Health and Health Maintenance • Anemia (iron deficiency. hemophilia. iron deficiency anemia. vitamin-related. sickle cell disease. acute leukemia in adults. coagulopathies. multiple myeloma) • Eosinophilia and reactions to transfusion of blood components (including complications) and leukopenic disorders. mixed connective tissue disease and systemic lupus erythematosus) • HIV infection/AIDS. hypofibrinogenemia. chronic leukemic states. disseminated intravascular coagulation. nutritional deficiencies. non-Hodgkin lymphoma. hemochromatosis) • Bleeding disorders. hemoglobin. polycythemia vera. sickle cell) • Infection (systemic) Mechanisms of Disease • Red cell disorders • Coagulation disorders • White cell disorders. hemolytic anemia. and iron metabolism (eg. von Willebrand disease. hemolytic uremic syndrome) • Neoplastic disorders (eg. deficiencies of cell-mediated immunity • Deficiencies of humoral immunity. including leukopenia. agranulocytosis. combined immune deficiency Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 5. Immunologic Disorders (continued) Mechanisms of Disease • Abnormalities of cell-mediated immunity • Abnormalities of humoral immunity Diagnosis • Anaphylactic reactions and shock • Connective tissue disorders (eg. and neoplasms Diagnosis • Anemia. pancytopenia.

family involvement in schizophrenia) Mechanisms of Disease • Biologic markers of mental disorders and mental retardation syndromes • Intended/unintended effects of therapeutic interventions. generalized anxiety disorder.5. attention-deficit/hyperactivity disorder. child. mental retardation. elder abuse. posttraumatic stress disorder. somatization disorder. communication disorders. personality disorders. disruptive disorders. phobia. Diseases of the Blood and Blood-forming Organs (continued) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 6. mood disorder due to a general medical condition. separation anxiety disorder. adjustment disorders. conversion disorder. factitious disorder. psychological factors affecting medical conditions) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 10 . dysthymic disorder. spouse. childhood. medication-induced mood disorder) • Anxiety disorders (eg. hypochondriasis) • Other disorders/conditions (eg. pain disorder. including effects of drugs on neurotransmitters Diagnosis • Mental disorders usually first diagnosed in infancy. Mental Disorders Health and Health Maintenance • Early identification and intervention (eg. alcohol/substance abuse. elimination disorders) • Substance-related disorders (eg. dissociative disorders. or adolescence (eg. sexual and gender identity disorders. pervasive developmental disorders. eating disorders. alcohol and other substances) • Schizophrenia and other psychotic disorders • Mood disorders (eg. major unipolar depressive disorders. depression. obsessive-compulsive disorder. bipolar disorders. panic disorder. anxiety due to a general medical condition. substance-induced anxiety disorder) • Somatoform disorders (eg. acute stress disorder. suicide potential. tic disorders.

abscess. toxic injury. spinal stenosis) . papilledema.spinal cord . viral. metastatic. narcolepsy. including Alzheimer disease and multiple sclerosis Mechanisms of Disease • Localizing anatomy: . including lead. retinal disorders.neuromuscular disorders. amyotrophic lateral sclerosis. dementia) . carbon monoxide. idiopathic hypersomnolence. neck pain.traumatic. vertigo. diabetic retinopathy. headache. traumatic. acoustic neuroma.brain stem . bacterial. parkinsonism. peripheral neuropathy. vitamin B12 [cobalamin] deficiency. Diseases of the Nervous System and Special Senses Health and Health Maintenance • Cerebrovascular disease. aneurysm. and occupational disorders including lead. or ears • Degenerative and demyelinating disorders. carbon monoxide. Huntington disease. Alzheimer disease. and organophosphate poisoning • Infection involving the nervous system. lumbosacral radiculopathy.metabolic disorders (eg. intracerebral hemorrhage. infection. deafness. optic atrophy. diplopia. confusion. multiple sclerosis. blindness. opportunistic infection in immunocompromised patients. dyslexia) .paroxysmal disorders (eg. toxic injuries. myasthenia gravis. cataract.neuromuscular system • Anatomy of cerebral circulation • Increased intracranial pressure and altered state of consciousness • Infection • Degenerative/developmental and metabolic disorders Diagnosis • Disorders of the eye (eg. mastoiditis.infections (eg. trigeminal neuralgia. iridocyclitis. toxoplasmosis) • Disorders of the ear. cervical radiculopathy.7. neoplasms. coma.neoplasms (eg. metabolic encephalopathy. delirium. ischemic disorders. gait abnormalities. and disorders relating to the spine and spinal nerve roots (eg. syncope) . neurosyphilis. cerebral infarction • Nutritional deficiencies. Tay-Sachs disease. sleep apnea) 11 . cerebral palsy. REM sleep behavior disorder. Lyme disease. traumatic. Guillain-Barré syndrome) . olfaction. vitamin B1 [thiamine] deficiency. otitis. restless legs syndrome. muscular dystrophy.brain and special senses . primary. uveitis.cerebrovascular disease (eg. cavernous sinus thrombosis) . vascular disorders. glaucoma.degenerative and developmental disorders (eg. seizure disorders. and taste (eg. hearing loss. circadian rhythm sleep disorder. neurofibromatosis) . toxic injury) • Disorders of the nervous system: . fungal. toxic injury. eyes. tinnitus. Meniere disease. and organophosphate poisoning . subarachnoid hemorrhage.sleep disorders (eg.

thromboembolic disease. pericardial effusion. cardiac arrest) • Heart failure (congestive. fatigue. syncope (eg. varicose veins. aortoiliac disease) • Peripheral arterial vascular diseases. arteriovenous fistula) • Diseases of the veins. vasculitis (eg. polyarteritis. cor pulmonale) • Ischemic heart disease. bacterial endocarditis Mechanisms of Disease • Cardiac output. temporal arteritis. infective endocarditis) • Congenital cardiovascular disease (eg.7. hypovolemia. hyperlipidemia • Prevention of rheumatic heart disease. ventricular fibrillation. central venous pressure • Valvular stenosis. dissecting aortic aneurysm. acute rheumatic fever. ruptured aneurysm. ventricular septal defect. chest pain of cardiac origin (eg. paroxysmal tachycardias. coronary insufficiency. thrombophlebitis. diastolic. mitral and aortic valve disorders. systolic dysfunction). myocardial infarction) • Diseases of the myocardium (eg. resistance. Diseases of the Nervous System and Special Senses (continued) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 8. cyanosis • Arterial hypertension (eg. cardiogenic shock. dyspnea. patent ductus arteriosus. secondary) • Atherosclerosis . bradycardias. essential. angina pectoris. chronic heart failure. Cardiovascular Disorders Health and Health Maintenance • Arterial hypertension • Atherosclerosis and coronary artery disease. acute pericarditis. deep venous thrombosis) • Traumatic injury 12 . chronic constrictive pericardiopathy. incompetence • Congenital heart disease • Regulation of blood pressure • Disorders of the arteries and veins Diagnosis • Dysrhythmias.lipoproteins • Disorders of the great vessels (eg. premature beats. atrial septal defect. peripheral edema (eg. endocardial cushion defect. pulmonary emboli. hypertrophic. peripheral edema of cardiac origin (eg. palpitations. coarctation of the aorta) • Systemic hypotension. atrial flutter and fibrillation. tetralogy of Fallot. pericardial tamponade) • Valvular heart disease (eg. myocarditis) • Diseases of the pericardium (eg.

pharynx. chronic bronchitis. epiglottitis. Cardiovascular Disorders (continued) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 9. bronchospasm. acute laryngotracheitis. pulmonary aspiration. fibrosing or restrictive pulmonary disorders (eg. pleurisy. cystic fibrosis. tuberculosis Mechanisms of Disease • Ventilatory dysfunction (eg. pneumonia. asbestosis. and trachea (eg. traumatic injury to the lungs and disorders involving the pleura (eg. hypercapnia. bronchiectasis. wheezing. cystic fibrosis) • Atelectasis. pulmonary edema) • Neoplastic disorders of the lungs and pleura (eg. drowning) • Pulmonary vascular disorders (eg. tracheoesophageal fistula) • Infections of the lung (eg. asthma. carcinoma of the larynx. sinusitis. 1-antitrypsin deficiency. asthma. trauma. laryngeal/pharyngeal obstruction. hypoxia. emphysema) • Respiratory failure. bronchiectasis. emphysema. including oxygenation failure (eg. sarcoidosis) • Respiratory failure. paranasal sinuses. atelectasis. larynx. peritonsillar abscess. carcinoma of the lung. obstructive disorders: asthma. pulmonary embolism. respiratory distress syndrome of the newborn. silicosis. pulmonary edema. interstitial pneumonitis. primary tumors. metastatic tumors) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 13 . acute respiratory distress syndrome. pulmonary aspiration • Pneumothorax. carcinoma of the larynx. hemothorax. acute respiratory distress syndrome. thrush. acute bronchiolitis. tonsillitis. emphysema. dyspnea (eg. pulmonary hypertension. Diseases of the Respiratory System Health and Health Maintenance • Chronic bronchitis. rhinitis. pharyngitis. pleural effusion) • Pneumoconiosis. chronic obstructive pulmonary disease. acute and chronic.8. bronchitis. ventilation failure) • Circulatory dysfunction • Neoplastic disorders Diagnosis • Disorders of the nose. tuberculosis) • Obstructive airways disease (eg. acute and chronic respiratory failure.

hepatic abscess. carcinoma of the esophagus) • Disorders of the stomach. hiatal hernia. anal fistula. carcinoma of the stomach. salivary glands.10. jaundice. bowel obstruction. hepatitis. carcinoma of the pancreas) • Disorders of the liver and biliary system (eg. portal hypertension. gastritis. motility disorders of the esophagus. esophageal reflux. disorders of the salivary glands. colon. hernia. and rectum. perianal/perirectal abscess) • Disorders of the pancreas (eg. cirrhosis. appendicitis. pseudocyst. and rectum/anus (eg. colonic polyps. cholelithiasis. pancreatitis. neoplasms of the biliary tract) • Traumatic injury and poisoning (including drain cleaner ingestion) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 14 . infection. oropharynx. colon. anal fissures. ulcerative colitis. Nutritional and Digestive Disorders Health and Health Maintenance • Screening (eg. ascites. volvulus. hepatic encephalopathy. hemorrhoids. cholecystitis. esophageal varices. necrotizing enterocolitis. intussusception. diverticula. neoplasms of the liver. small intestine. malabsorption. ischemic colitis. dental disorders. cancer) • Viral hepatitis and alcohol-related hepatopathy Mechanisms of Disease • Malabsorption/malnutrition • Jaundice • Infections/parasites • Obstruction/mechanical Diagnosis • Disorders of the mouth. peritonitis. storage diseases. antibiotic-associated colitis. hepatic failure. congenital disorders. irritable bowel syndrome. dysphagia. subphrenic abscess. and esophagus (eg. granulomatous enterocolitis. peptic ulcer disease.

pelvic inflammatory disease. abnormal uterine bleeding. amenorrhea [including undiagnosed pregnancy]. cervical dysplasia. rectocele. virilization. ovarian neoplasms. endometrial cancer. dysmenorrhea. uterovaginal prolapse. urethritis. vulvovaginitis. abscess of the breast. premenstrual syndrome. sexually transmitted disease. cancer. menopausal. leiomyomata uteri. urinary tract infection. endometritis. infertility Diagnosis • Pelvic relaxation and urinary incontinence (eg.11. testicular. postmenopausal disorders [osteoporosis]. Renal. prostatic) Mechanisms of Disease • Disorders of the male reproductive system • Urinary incontinence and obstruction. hirsutism. urinary tract. Gynecologic Disorders Health and Health Maintenance • Postmenarchal/reproductive • Peri/postmenopausal Mechanisms of Disease • Infections (eg. mastitis) • Urinary incontinence and obstruction • Menstrual and endocrinologic disorders. Bartholin gland abscess. toxic shock. neoplastic disorders of the breast. ovarian disorders [ovarian failure. polycystic ovarian syndrome]) • Sexual abuse and rape Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 12. enuresis • Renal insufficiency/failure • Electrolyte and water metabolism and acid-base balance 15 . urethrocele) • Neoplasms (eg. sexually transmitted diseases [male]) • Acute and chronic renal failure including risk factors and prevention and methods of limiting progression • Male health maintenance examination (eg. cystocele. Urinary. and Male Reproductive Systems Health and Health Maintenance • Infections (eg. vulvar neoplasms) • Benign conditions of the breast • Menstrual and endocrinologic disorders (eg.

neoplasms of the testis. prenatal diagnosis. risk of preterm labor • Intrapartum care. nutrition. oliguria. infections. cystitis. placental dysfunction • Pregnancy and labor. urinary incontinence. azotemia. Renal. undescended testicle. diabetes mellitus. signs of fetal compromise • Contraception. benign prostatic hyperplasia. Urinary.12. sterilization. pyuria. ureteral reflux. urolithiasis. neurogenic bladder. renal osteodystrophy. streptococcal infections) • Assessment of the at-risk pregnancy. hematuria. dysuria. urethral stricture. impotence. including infection • Fetus and newborn 16 . uremia. prevention of iron deficiency. Rh immunoglobulin prophylaxis. renal insufficiency and failure. including infection • Postpartum disorders. teratology. anuria. prevention of vitamin deficiency. pyelitis. urinary tract infection. enuresis. carcinoma of the prostate. varicocele. hypospadias. carcinoma of the bladder. prevention of pregnancy after rape Mechanisms of Disease • Placenta. inherited disorders) • Traumatic injury Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 13. genital herpes. and Male Reproductive Systems (continued) Diagnosis • Disorders of the male reproductive system (eg. premature ejaculation) • Disorders of the urinary bladder and urinary collecting system (eg. glomerulonephritis. lupus nephritis. rubella. -fetoprotein. hydronephrosis) • Disorders of the kidneys (eg. pyelonephritis. hypertensive renal disease. and the Puerperium Health and Health Maintenance • Prenatal care (eg. interstitial nephropathy. Disorders of Pregnancy. torsion of the testis. obstruction. Childbirth. hydrocele.

major medical complications and preexisting medical conditions. postpartum sepsis. gangrene. third-trimester bleeding. abscess. decubitus ulcers) • Neoplasms (eg. multiple gestation. intrapartum fetal distress/fetal death. and the Puerperium (continued) Diagnosis • Pregnancy and labor. surgical complications. gestational trophoblastic disease) • Nonobstetric complications of pregnancy (eg. industrial. Childbirth. maternal mortality. problems with breast-feeding. Disorders of the Skin and Subcutaneous Tissues Health and Health Maintenance • Epidemiology and prevention of skin disorders secondary to exposure to the sun. herpes zoster.13. including cancer. including obstetric complications (eg. hyperemesis gravidarum) • Complications of the puerperium (eg. hemangiomas) • Other skin disorders (eg. normal labor. and inflammatory disorders Diagnosis • Infections (eg. melanoma. hypertension. and atopic dermatitis. contact dermatitis and drug reactions. preterm labor. infections. decubitus ulcers. dermatophytoses. postpartum hemorrhage. hydramnios. squamous cell carcinoma. postpartum depression. psoriasis. congenital abnormalities. pilonidal cyst. chickenpox. mastitis. basal cell carcinoma. spontaneous abortion/septic abortion. psychosis. carbuncle. viral warts. occupational. dermatophytic skin disorders Mechanisms of Disease • Skin disorders. fetal growth and development abnormalities. cellulitis. pigmented nevi. acne) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 17 . herpes simplex. premature rupture of the membranes. venous thromboembolism) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 14. Disorders of Pregnancy. actinic keratosis. ectopic pregnancy. seborrhea.

myofascial pain. Paget disease) • Neoplasms (eg. bursitis. pulmonary osteoarthropathy) • Traumatic injury and nerve compression and injury (eg. congenital hip dysplasia. low back pain) Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 16. rheumatoid arthritis.15. and prevention of degenerative joint and disc disease • Prevention of disability due to musculoskeletal disorders or infection (eg. scoliosis. or developmental disorders (eg. and nutritional disorders • Inherited. fractures. polymyositis-dermatomyositis. metabolic. septic arthritis. cauda equina syndrome. shoulder-hand syndrome. cancer) Mechanisms of Disease • Thyroid function • Diabetes mellitus and carbohydrate metabolism • Parathyroid and calcium metabolism • Pituitary and hypothalamic function • Adrenal function 18 . and other disorders (eg. osteosarcoma. gonococcal tenosynovitis) • Degenerative. congenital. Dupuytren contracture. osteochondritis. Lyme disease. phocomelia. and nutritional disorders (eg. osteomyelitis. impact. gout. dislocated hip in infantile spinal muscular atrophy) • Inflammatory. fibromyalgia. slipped capital femoral epiphysis. immunologic. septic arthritis. syringomyelia. Lyme disease. polymyalgia rheumatica. lupus arthritis. rickets) • Inherited. congenital. degenerative disc disease. including prevention of morbidity and mortality due to complications • Screening (eg. osteomyelitis. metastases to bone. Diseases of the Musculoskeletal System and Connective Tissue Health and Health Maintenance • Epidemiology. dislocations. metabolic. tendinitis. Endocrine and Metabolic Disorders Health and Health Maintenance • Diabetes mellitus. gonococcal tenosynovitis) Mechanisms of Disease • Infections • Nerve compressions and degenerative. sprains. or developmental disorders • Inflammatory or immunologic disorders Diagnosis • Infections (eg. degenerative joint disease. ankylosing spondylitis. carpal tunnel syndrome.

acromegaly) • Adrenal disorders (eg.16. inappropriate ADH secretion. Conditions Originating in the Perinatal Period (Topic covered under Disorders of Pregnancy. Childbirth. acquired hypothyroidism. adrenogenital syndrome. Symptoms. Congenital Anomalies (Topic covered under each organ system) 18. iatrogenic. goiter) • Diabetes mellitus (eg. ketoacidosis. carcinoma. diabetes insipidus. type 1. hyperparathyroidism. type 2. nodule. corticoadrenal insufficiency. hypoparathyroidism). Signs. and Ill-defined Conditions (Topic covered under each organ system) 20. panhypopituitarism. Cushing syndrome. and hypoglycemia and hyperinsulinism (eg. Endocrine and Metabolic Disorders (continued) Diagnosis • Thyroid disorders (eg. congenital hypothyroidism. and the Puerperium [category 13]) 19. hyperosmolar coma. hyperaldosteronism. chronic complications) • Parathyroid and calcium disorders (eg. Injury and Poisoning (Topic covered under each organ system) 19 . pheochromocytoma) • Heat-related illness Principles of Management (With emphasis on topics covered in Diagnosis) • Pharmacotherapy only • Management decision (treatment/diagnosis steps) • Treatment only 17. insulinoma) • Pituitary and hypothalamic disorders (eg. thyrotoxicosis. thyroiditis.

you should allow a maximum of one hour for each block. Photographs. you will have the capability to adjust the brightness and contrast of pictorials on the computer screen. These sample questions are illustrative of the types of questions used in the Step 2 CK examination. In addition.Sample Step 2 CK Questions The following pages include 131 sample test questions. they will not be grouped according to type or specific content. Most of these questions are the same as those you will see when you download the practice software program from the USMLE website. In the actual examination. Please be aware that most examinees perceive the time pressure to be greater during an actual examination. You should run the Step 2 CK tutorial and practice test items that are provided on the USMLE website well before your test date. Please note that reviewing the sample questions in this booklet is not a substitute for acquainting yourself with the test software. no answer form will be provided. 20 . An answer key is provided on page 73. Although the questions exemplify content on the examination. questions may appear randomly in the examination. items with associated audio or video findings. for a total of three hours. To take the following sample test questions as they would be timed in the actual examination. In the actual examination. You should become familiar with these formats as they will be used in the actual examination. In the actual examination. The sample materials on the USMLE website include additional items that do not appear in this booklet: pharmaceutical ads and abstracts. Questions of the same format are grouped together in this booklet. they may not reflect the content coverage on individual examinations. and x-rays referred to in this booklet are not of the same quality as the pictorials used in the actual examination. including use of exhibit buttons (separate windows) for the Normal Laboratory Values Table (included here on pages 21-22) and some pictorials. An answer form for recording answers is provided on page 23. charts. and sequential item sets. answers will be selected on the screen. the questions will be presented one at a time in a format designed for easy on-screen reading.

..4-5.... 0....... 25-125 U/L ................. <5.............................1-2.................. Fasting: 70-110 mg/dL ...... Fasting: < 5 ng/mL ................. 0...8 g/dL ............1-1.................................................................................. 6-23 U/L Female: follicular phase 5-30 mIU/mL ................................................................ serum/plasma ........................................................................................... serum . SERUM * Alanine aminotransferase (ALT)..3 mg/dL ....................... serum Sodium (Na+) .................. 3....... serum .........................................................................0 mmol/L Chloride (Cl–) ... Male: 6-23 mIU/mL .......................... 15-200 μg/L Female: 12-150 ng/mL .. 104-590 nmol/L // 208-970 nmol/L 28-32 wks // 36-40 wks ................. PLASMA............................ 64-155 nmol/L Triglycerides...........75-1...................................................... 95-105 mmol/L Bicarbonate (HCO3–) .............. 0-380 kIU/L IgG ........0-14...................45 g/L Iron ..... 6..... serum (adult) Total // Direct.........0 mg/dL // 0........... 7.....................................0 kPa * Glucose....... 4.... 0..35 * Urea nitrogen................. serum ................................ 3..2-3..................... > 7 μg/L Immunoglobulins. serum........... arterial blood (room air) pH ............................................................ 75-105 mm Hg ....5-5........ 9-30 μmol/L Lactate dehydrogenase........................................................... 25%-35% ... 2........................................arginine stimulation .. [H+] 36-44 nmol/L PCO2 .... 60-78 g/L Albumin ....... 8-20 U/L .......9 kPa PO2 ......0-1............................................ 0............ 25-90 U/L Female: 10-70 U/L ................................ 35-160 mg/dL ....... 275-295 mOsmol/kg H2O Parathyroid hormone............ 136-145 mmol/L * Potassium (K+) ................................... serum ...9 nmol/L Triiodothyronine (T3) resin uptake ............5 g/dL ....... 115-190 ng/dL ............................................................. serum ....................0-4........ serum ................................................ 0....... 8-20 U/L .....0 mEq/L ...............................................0 μU/mL ......... 7-18 mg/dL .......... 0....................................... Rec:<200 mg/dL ........................30/24 h Thyroxine (T4).............................................................. 0............................................................................................................................................................... 33-45 mm Hg ............ 3......5-5................................................................. serum .....2 mg/dL ...................25-0..................... 40-345 mg/dL ......0-8...................................... 35-55 g/L Globulin ................. 8-20 U/L Bilirubin...........................0-7................................................................................................................................................. 140-760 nmol/L // 280-1210 nmol/L Ferritin.... Fraction of 0800 h: < 0............. serum ......4-1..... 45-90 U/L Luteinizing hormone.. 8-20 U/L Amylase............................USMLE Step 2 CK Laboratory Values * Included in the Biochemical Profile (SMA-12) REFERENCE RANGE SI REFERENCE INTERVALS BLOOD.... 10..................... < 6................ 10-70 U/L * Creatinine.......5-2........................... 0..................................................................................................... 8%-30% of administered dose/24 h..45 .................................6 mmol/L Growth hormone .............. 22-28 mmol/L Magnesium (Mg2+) ... serum IgA .....................................................................................................0 mmol/L * Uric acid.......... serum...................5-5................................... 1.. 8..............................8 mmol/L * Cholesterol................50 Creatine kinase.......................1 mmol/L 2-h postprandial: < 120 mg/dL ... 3...................... total........ 20-70 U/L .... 0........ 6...................... 136-145 mEq/L ................. 23-35 g/L Thyroid-stimulating hormone..........2 mg/dL ............................................................................................. 12-150 μg/L Follicle-stimulating hormone..... 95-105 mEq/L ....... 230-630 pg/mL .3-3.81 mmol/L Triiodothyronine (T3). 3.................... 76-390 mg/dL . serum ..........0 mmol/L Estriol...............................2 mmol/L Cortisol........... serum .. 75-150 U/L postmenopause 30-200 mIU/mL .............. 650-1500 mg/dL ..............0 mU/L Thyroidal iodine (123I) uptake ............. serum ................................ 20-70 U/L * Phosphorus (inorganic)..... 4-25 U/L Female: premenopause 4-30 mIU/mL ................................. 3.......8-6.................. 0..........................5-15 g/L IgM ...... 10-90 U/L postmenopause 40-250 mIU/mL ....................... < 20 ng/mL ................................ 4-30 U/L midcycle peak 10-90 mIU/mL ........................ serum ........................... < 5 μg/L provocative stimuli: > 7 ng/mL .................. 1........8-2.. serum ....... serum .. serum ...................................... serum (p-NPP at 30C) .............08-0.......... serum (Ca2+) ......... 0................ 275-295 mOsmol/kg H2O ..... 2.............................................4-3.......... Male: 25-90 U/L ............................. 22-28 mEq/L .................................. 0800 h: 5-23 μg/dL // 1600 h: 3-15 μg/dL 138-635 nmol/L // 82-413 nmol/L 2000 h: < 50% of 0800 h ..........................................6-1...... 50-170 μg/dL ..........90 g/L IgE .... serum Total (recumbent) ............................................................................. 230-630 ng/L * Phosphatase (alkaline).............. N-terminal ............0 mEq/L ............................................. 53-106 μmol/L Electrolytes...........................5 mg/dL ................ 1...... 25-125 U/L * Aspartate aminotransferase (AST)............... 5-30 U/L midcycle 75-150 mIU/mL ........35-7.................. 45-90 U/L ...........................0-0......... 1............................... 30-200 U/L Osmolality......................5 mmol/L Prolactin.. serum or plasma ...............................18-0. 40-220 ng/mL // 80-350 ng/mL ....48 mmol/L 21 ............... serum/plasma ...4-10........................... 30-170 ng/mL // 60-280 ng/mL ............. serum (in pregnancy) 24-28 wks // 32-36 wks .....................5-5........... 2-17 μmol/L // 0-5 μmol/L * Calcium............. < 20 μg/L * Proteins.......76-3.....................2 mg/dL .......... Male: 15-200 ng/mL .. serum (RIA) ...........................5 g/dL ....................................... 40-250 U/L Gases............5-5............................... Male: 4-25 mIU/mL ............................................ 5-12 μg/dL ......... 0-380 IU/mL ................. serum (hPRL) .

USMLE Step 2 CK Laboratory Values (continued)
REFERENCE RANGE
SI REFERENCE INTERVALS
BODY MASS INDEX (BMI)
Body mass index ...................................................... Adult: 19-25 kg/m2
CEREBROSPINAL FLUID
Cell count ................................................................. 0-5/mm3 ............................................................ 0-5 x 106/L
Chloride ................................................................... 118-132 mEq/L................................................. 118-132 mmol/L
Gamma globulin ....................................................... 3%-12% total proteins ...................................... 0.03-0.12
Glucose .................................................................... 40-70 mg/dL .................................................... 2.2-3.9 mmol/L
Pressure ................................................................... 70-180 mm H2O .............................................. 70-180 mm H2O
Proteins, total ........................................................... <40 mg/dL ...................................................... <0.40 g/L
HEMATOLOGIC
Bleeding time (template) ......................................... 2-7 minutes ....................................................... 2-7 minutes
Erythrocyte count ..................................................... Male: 4.3-5.9 million/mm3 ............................... 4.3-5.9 x 1012/L
Female: 3.5-5.5 million/mm3 ............................ 3.5-5.5 x 1012/L
Erythrocyte sedimentation rate (Westergren) ........... Male: 0-15 mm/h ............................................. 0-15 mm/h
Female: 0-20 mm/h........................................... 0-20 mm/h
Hematocrit ............................................................... Male: 41%-53% ............................................... 0.41-0.53
Female: 36%-46% ............................................ 0.36-0.46
Hemoglobin A1c ....................................................... < 6% ................................................................. < 0.06
Hemoglobin, blood ................................................... Male: 13.5-17.5 g/dL ....................................... 2.09-2.71 mmol/L
Female: 12.0-16.0 g/dL .................................... 1.86-2.48 mmol/L
Hemoglobin, plasma ................................................ 1-4 mg/dL ......................................................... 0.16-0.62 mmol/L
Leukocyte count and differential
Leukocyte count ..................................................... 4500-11,000/mm3 ............................................. 4.5-11.0 x 109/L
Segmented neutrophils ......................................... 54%-62% ......................................................... 0.54-0.62
Bands .................................................................... 3%-5% ............................................................. 0.03-0.05
Eosinophils .......................................................... 1%-3% ............................................................. 0.01-0.03
Basophils .............................................................. 0%-0.75% ......................................................... 0-0.0075
Lymphocytes ....................................................... 25%-33% .......................................................... 0.25-0.33
Monocytes ........................................................... 3%-7% ............................................................. 0.03-0.07
Mean corpuscular hemoglobin ................................. 25.4-34.6 pg/cell .............................................. 0.39-0.54 fmol/cell
Mean corpuscular hemoglobin concentration ......... 31%-36% Hb/cell ............................................ 4.81-5.58 mmol Hb/L
Mean corpuscular volume ....................................... 80-100 μm3 ....................................................... 80-100 fL
Partial thromboplastin time (activated) ................... 25-40 seconds ................................................... 25-40 seconds
Platelet count ............................................................ 150,000-400,000/mm3 ...................................... 150-400 x 109/L
Prothrombin time ..................................................... 11-15 seconds ................................................... 11-15 seconds
Reticulocyte count .................................................... 0.5%-1.5% ........................................................ 0.005-0.015
Thrombin time .......................................................... <2 seconds deviation from control .................. <2 seconds deviation from control
Volume
Plasma ................................................................... Male: 25-43 mL/kg ........................................... 0.025-0.043 L/kg
Female: 28-45 mL/kg ....................................... 0.028-0.045 L/kg
Red cell .................................................................. Male: 20-36 mL/kg .......................................... 0.020-0.036 L/kg
Female: 19-31 mL/kg ...................................... 0.019-0.031 L/kg
SWEAT
Chloride .................................................................... 0-35 mmol/L .................................................... 0-35 mmol/L
URINE
Calcium ................................................................... 100-300 mg/24 h .............................................. 2.5-7.5 mmol/24 h
Chloride .................................................................... Varies with intake ............................................. Varies with intake
Creatinine clearance ................................................. Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)
30 wks .................................................................... 6-18 mg/24 h .................................................... 21-62 μmol/24 h
35 wks .................................................................... 9-28 mg/24 h .................................................... 31-97 μmol/24 h
40 wks .................................................................... 13-42 mg/24 h .................................................. 45-146 μmol/24 h
17-Hydroxycorticosteroids ...................................... Male: 3.0-10.0 mg/24 h .................................... 8.2-27.6 μmol/24 h
Female: 2.0-8.0 mg/24 h ................................... 5.5-22.0 μmol/24 h
17-Ketosteroids, total ............................................... Male: 8-20 mg/24 h .......................................... 28-70 μmol/24 h
Female: 6-15 mg/24 h ....................................... 21-52 μmol/24 h
Osmolality ............................................................... 50-1400 mOsmol/kg H2O
Oxalate ..................................................................... 8-40 μg/mL ...................................................... 90-445 μmol/L
Potassium ................................................................ Varies with diet ................................................ Varies with diet
Proteins, total ........................................................... <150 mg/24 h ................................................... <0.15 g/24 h
Sodium .................................................................... Varies with diet ................................................ Varies with diet
Uric acid ................................................................... Varies with diet ................................................ Varies with diet

22

Answer Sheet for Step 2 CK Sample Questions
Block 1 (Questions 1-41)
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Block 3 (Questions 87-131)
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23

Sample Questions
Block 1 (Questions 1-41)

1.

Six hours after delivery, a 1200-g (2-lb 11-oz) newborn develops respiratory distress. She was born at 32 weeks'
gestation. Her pulse is 136/min, respirations are 60/min, and blood pressure is 60/30 mm Hg. Examination shows
grunting and moderate intercostal and subcostal retractions. The lungs are clear to auscultation. Umbilical artery blood
gas analysis on 60% oxygen shows:
pH
PCO2
PO2

7.32
32 mm Hg
60 mm Hg

An x-ray of the chest shows diffuse reticulogranular densities with an air bronchogram. Which of the following is the
most likely underlying mechanism?
(A)
(B)
(C)
(D)
(E)
(F)

2.

A previously healthy 15-year-old boy is brought to the emergency department in August 1 hour after the onset of
headache, dizziness, nausea, and one episode of vomiting. His symptoms began during the first hour of full-contact
football practice in full uniform. He reported feeling weak and faint but did not lose consciousness. He vomited once
after drinking water. On arrival, he is diaphoretic. He is not oriented to person, place, or time. His temperature is
39.5°C (103.1°F), pulse is 120/min, respirations are 40/min, and blood pressure is 90/65 mm Hg. Examination,
including neurologic examination, shows no other abnormalities. Which of the following is the most appropriate next
step in management?
(A)
(B)
(C)
(D)
(E)

3.

Obtain a CT scan of the head
Administer sodium chloride tablets
Administer intravenous fluids
Immerse the patient in an ice water bath
Obtain a lumbar puncture

An 18-year-old man is brought to the emergency department 45 minutes after his car slid off an icy road into a
telephone pole at approximately 35 miles per hour. He was the restrained driver, and the air bag inflated. Examination
shows multiple contusions over the chest bilaterally; there is tenderness to palpation over the right lower chest wall.
The abdomen is flat, soft, and nontender. A complete blood count and serum concentrations of electrolytes, urea
nitrogen, and creatinine are within the reference range. Toxicology screening is negative. His urine is pink; urinalysis
shows 80 RBC/hpf but no WBCs. Which of the following is the most appropriate next step in management?
(A)
(B)
(C)
(D)
(E)

24

Abnormality of mucociliary function
Aspiration of meconium into the lungs
Blockage of airways with mucus
Increased pulmonary capillary permeability
Infection with group B streptococcus
Pulmonary surfactant deficiency

CT scan of the abdomen and pelvis with contrast
Magnetic resonance arteriography of the renal arteries
Intravenous administration of antibiotics
Exploratory laparotomy
No further studies are indicated

On admission. Physical and neurologic examinations show no other abnormalities. Abdominal examination shows severe. Laboratory studies show: Hematocrit Leukocyte count Platelet count Prothrombin time Partial thromboplastin time Fibrin split products Serum Urea nitrogen Creatinine Bilirubin Total Direct Lactate dehydrogenase 32% with fragmented and nucleated erythrocytes 12. para 2. pulse is 110/min. at 25 weeks' gestation is admitted to the hospital 30 minutes after spontaneous rupture of membranes.5 mg/dL 1000 U/L Blood and urine cultures are negative. Examination shows jaundice of the skin and conjunctivae. Her pregnancy had been uncomplicated. A CT scan of the head shows no abnormalities. She began to vomit. and blood pressure is 135/88 mm Hg. There is anhydramnios. She reports that after walking a 5-km course 24 hours ago. diffuse tenderness throughout the lower quadrants. gravida 3. Her temperature is 39. Ultrasonography shows the fetus in a vertex presentation.3°C (102. A previously healthy 34-year-old woman is brought to the physician because of fever and headache for 1 week.0 mg/dL 3. Speculum examination confirms rupture of membranes. Disseminated intravascular coagulation Immune thrombocytopenic purpura Meningococcal meningitis Sarcoidosis Systemic lupus erythematosus Thrombotic thrombocytopenic purpura A 27-year-old woman.500/mm3 20.9°C (102°F). She takes no medications. pulse is 104/min. Her temperature prior to going to bed last night was 38. She has not been exposed to any disease.0 mg/dL 0. Pelvic examination shows exquisite cervical motion and uterine tenderness.4.8°F). she began to have muscle aches and chills. she appears ill. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) 5.1°C (102. She took 800 mg of ibuprofen and awoke 8 hours later with severe abdominal pain and shaking chills. then noted a gush of blood-tinged fluid from her vagina. There are a few scattered petechiae over the trunk and back. respirations are 24/min.3°F). There is no lymphadenopathy. Test of the stool for occult blood is positive.000/mm3 10 sec 30 sec Negative 35 mg/dL 3. She is confused and oriented only to person. and blood pressure is 110/60 mm Hg. Which of the following is the greatest predisposing factor for this patient's premature rupture of membranes? (A) (B) (C) (D) (E) Emesis Exercise Ibuprofen use Intra-amniotic infection Multiparity 25 . respirations are 18/min. Her temperature is 39.

His temperature is 36.6. pulse is 80/min. para 2. She has a history of fibrocystic breast disease. She underwent the screening after eating dinner. comes to the physician after a screening at a health fair showed a serum total cholesterol concentration of 280 mg/dL. place. Range of motion of the neck is decreased due to pain. and blood pressure is 160/90 mm Hg. She is 173 cm (5 ft 8 in) tall and weighs 63 kg (139 lb). Examination shows no abnormalities. Her temperature is 37°C (98.6°F). and a triglyceride concentration of 1420 mg/dL. Laboratory studies show: Hemoglobin Mean corpuscular volume Leukocyte count Platelet count Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) (G) (H) 26 Acute leukemia Anemia of chronic disease Folic acid deficiency Iron deficiency Lyme disease Microangiopathic hemolytic anemia Pernicious anemia Sleep apnea 8 g/dL 70 μm3 9000/mm3 500. pulse is 100/min. pulse is 62/min.1°F). gravida 2. He has not had any other symptoms and has no history of severe headache. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 7. She had an extensive abdominal operation 5 years ago for Crohn disease. respirations are 14/min. She has had progressively severe dyspnea on exertion for 6 weeks. She does not take any medications. and time.6°F). Her father has a history of coronary artery disease. heart. A 47-year-old woman. Current medications include hydrochlorothiazide and ranitidine. He has hypertension and gastroesophageal reflux disease. A 47-year-old man comes to the physician 12 hours after the sudden onset of a severe occipital headache and stiff neck. Test of the stool for occult blood is negative.7°C (98. Neurologic examination shows no focal findings. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 8.000/mm3 . Her temperature is 37°C (98. Cluster headache Meningitis Migraine Subarachnoid hemorrhage Tension-type headache Therapeutic lifestyle diet Fasting serum lipid studies Atorvastatin therapy Gemfibrozil therapy Niacin therapy A 32-year-old woman comes to the physician because of fatigue for 6 months. He is oriented to person. BMI is 21 kg/m2. lungs. and blood pressure is 110/65 mm Hg. She takes no medications. HDL-cholesterol concentration of 78 mg/dL. and extremities shows no abnormalities. and blood pressure is 110/70 mm Hg. abdomen. respirations are 18/min. Examination of the thyroid gland.

pulse is 80/min. A 57-year-old woman comes to the physician because of a worsening cough productive of yellow sputum over the past 3 days. which prompted his wife to call an ambulance and have him admitted to the hospital. His fasting serum glucose concentration is 120 mg/dL. pulse is 68/min. Her temperature is 37°C (98. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) Adhere to the patient's wishes and discuss home-care options Adhere to the patient's wishes on the condition that he agree to home nursing care Schedule neuropsychological testing Seek a court order to appoint a legal guardian Involuntarily hold the patient in the hospital 27 . During the past week. and blood pressure is 150/85 mm Hg.6°F). She has a 20-year history of hypertension. and blood pressure is 112/64 mm Hg. She has smoked one-half pack of cigarettes daily for 37 years. The remainder of the examination shows no abnormalities. He did not get out of bed for 2 days.6°F).9. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 10. irritability. He reports that he has had a 3-month history of fatigue. He says that he has been noncompliant with his diabetic regimen. He is 168 cm (5 ft 6 in) tall and weighs 100 kg (220 lb). She is 163 cm (5 ft 4 in) tall and weighs 59 kg (130 lb).6°F). Her temperature is 37°C (98. BMI is 22 kg/m2. Despite his poor control. Cognition is intact. respirations are 16/min." He has been avoiding his family and friends because he is not in the mood to see them but admits that he is lonely. he demands that he be discharged. She also flies to Asia at least once monthly. Physical examination shows no abnormalities.8-kg (4-lb) weight loss. and blood pressure is 120/76 mm Hg. Her CD4+ T-lymphocyte count is 400/mm3 (Normal≥500). and an S4 is heard. he is tired and has a restricted affect. He does not drink alcohol. the point of maximal impulse is subxiphoid. She is currently receiving triple antiretroviral therapy. she has had six large watery stools daily. There is no evidence of suicidal ideation. Examination shows an increased anteroposterior diameter. On mental status examination. S 1 and S2 are normal. "Sometimes I forget. Prior to admission to the hospital. Occasional expiratory wheezes are heard. adding. and feelings of hopelessness. Perform incentive spirometry Begin oral antibiotic therapy Begin oral theophylline therapy Increase hydrochlorothiazide dosage Switch from hydrochlorothiazide to furosemide therapy Cryptosporidium parvum Cytomegalovirus Mycobacterium avium-intracellulare complex Salmonella enteritidis Strongyloides stercoralis A 37-year-old man with type 1 diabetes mellitus is admitted to the hospital because of inadequate control of his glucose concentrations for the past 2 months. BMI is 36 kg/m2. although he often missed doses. A 37-year-old woman with AIDS comes to the physician because of a 1-month history of progressive diarrhea and a 1. She has a 2-year history of shortness of breath with exertion and chronic cough productive of white sputum daily but has no history of pneumonia or other pulmonary problems. An x-ray of the chest shows flat diaphragms and a midline cardiac silhouette. Current medications include hydrochlorothiazide (25 mg daily) and an ipratropium inhaler (four puffs four times daily). his only medication was insulin. Which of the following is the most likely causal organism? (A) (B) (C) (D) (E) 11. The abdomen is scaphoid. pulse is 88/min. His temperature is 37°C (98. She is employed as a flight attendant and works regularly on domestic flights throughout the USA. respirations are 18/min.

000/mm3. Scattered expiratory wheezing and rhonchi are heard throughout both lung fields.8°C (100°F). He and his wife have been unable to conceive because of his low sperm count. Which of the following is the most appropriate pharmacotherapy? (A) (B) (C) (D) (E) 13. Spirometry shows a decreased FEV 1:FVC ratio. respirations are 22/min. and platelet count is 345.12. and her last menstrual period was 2 weeks ago. He has daily purulent sputum and has noted decreased exercise tolerance over the past 2 years. cervical motion tenderness. An x-ray of the chest shows hyperinflation.5 g/dL. A urine pregnancy test is negative. and blood pressure is 110/70 mm Hg. Abdominal examination shows severe lower quadrant tenderness bilaterally. and bilateral adnexal tenderness. Her temperature is 37. She is sexually active with one male partner and uses a combination contraceptive patch. and malodorous vaginal discharge. Pelvic examination shows a purulent cervical discharge. A previously healthy 17-year-old girl comes to the emergency department because of a 5-day history of progressive lower abdominal pain. pulse is 90/min. fever. leukocyte count is 13. Which of the following is most likely to confirm the diagnosis? (A) (B) (C) (D) (E) 28 Oral azithromycin Vaginal clindamycin Intravenous penicillin and vancomycin Intramuscular ceftriaxone and oral doxycycline Intravenous oxacillin and metronidazole Arterial blood gas analysis Examination of sputum for eosinophils Sweat chloride test Sputum cytology Bronchoscopy . A 20-year-old man has had frequent upper respiratory tract infections over the past 4 years. Her hemoglobin concentration is 10.000/mm3. Menarche was at the age of 12 years.

III. respirations are 12/min. Which of the following is the most likely diagnosis? (A) Acute pericarditis (B) Aortic dissection (C) Gastroesophageal reflux disease 29 . pulse is 90/min. She has not had shortness of breath. upwardly concave ST-segment elevation and PR-segment depression in leads II.2 mg/dL 1:256 negative positive 3+ 3+ 15–17/hpf 1–2/hpf rare Which of the following is the most likely underlying mechanism of this patient's renal failure? (A) (B) (C) (D) (E) (F) 15. and hypertension. The pain is worse with inspiration. palpitations. He has hypercholesterolemia. The joints are diffusely tender with no warmth or erythema. or nausea. and blood pressure is 122/70 mm Hg. Atheroembolic disease Cold agglutinins Interstitial nephritis Lyme disease Septic arthritis Vasculitis A 37-year-old woman is brought to the emergency department because of intermittent chest pain for 3 days. and blood pressure is 132/76 mm Hg. The lungs are clear to auscultation.14. He has not had fever. range of motion is full. His pulse is 84/min. Over the past 3 weeks. or diarrhea. and aVF.9°F). Her temperature is 37.2°C (98. a 3-week history of cough. isosorbide.000/mm3 28 mg/dL 3. and aspirin. S 1 and S2 are normal. a 2-month history of sinus congestion. There is no peripheral edema. A 62-year-old man comes to the physician because of a 3-month history of progressive fatigue and joint pain. and a 1-week history of blood-tinged sputum. She had an upper respiratory tract infection 10 days ago and took an over-the-counter cough suppressant and decongestant and acetaminophen. he has been taking overthe-counter ibuprofen as needed for the joint pain. labetalol. Examination shows clear nasal discharge with no nasal or oral lesions. vomiting.000/mm3 74% 1% 14% 11% 275. and she feels she cannot take deep breaths. Laboratory studies show: Hematocrit Mean corpuscular volume Leukocyte count Segmented neutrophils Eosinophils Lymphocytes Monocytes Platelet count Serum Urea nitrogen Creatinine Antinuclear antibodies Rheumatoid factor Antineutrophil cytoplasmic antibodies Urine Blood Protein RBC WBC RBC casts 36% 83 μm3 14. stable angina pectoris. An ECG shows normal sinus rhythm and diffuse. Medications include atorvastatin. A rub is heard during systole. nausea.

600/mm 3. In addition to analgesia. His neck is supple. pulse is 124/min. but she is not sure what it is.1°C (102. A 37-year-old man comes to the physician because of nonradiating low back pain for 3 days.3 96 24 (E) 148 4. His leukocyte count is 15. Range of motion is limited by pain. 30 Bed rest Regular activity X-rays of the spine MRI of the spine Lumbar spine traction A 27-year-old man is brought to the emergency department by his sister because of increasing confusion for 10 hours.2 100 24 (C) 130 4. The pain began after he worked in his yard. Examination of the back shows bilateral paravertebral muscle spasm. a 37-year-old woman has had epigastric pain 2 to 3 hours after eating and at night. For 2 days. she has a feeling of fullness and bloating even when she eats small amounts. She says that he has a history of excessive drinking. and blood pressure is 160/102 mm Hg.3°F). Mental status examination shows psychomotor agitation alternating with lethargy. Straight-leg raising is negative. and she discontinued the medication due to the quantity of pills she had to take. Which of the following is the most likely explanation for this patient's symptoms? (A) (B) (C) (D) (E) 18. He has not had any change in bowel movements or urination. her symptoms were alleviated. Vital signs are within normal limits. Placement of a Foley catheter yields no urine. After 2 weeks of treatment. He appears acutely ill. and she thinks that he has also experimented with illicit drugs. which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 17. He had one similar episode 3 years ago that resolved spontaneously.8 88 32 (B) 130 4. He is unable to answer questions. The abdomen is soft and nontender. Examination shows profuse diaphoresis and muscle rigidity. Six months ago. This patient is most likely to have which of the following electrolyte profiles? Na+ K+ Cl− HCO3− (mEq/L) (mEq/L) (mEq/L) (mEq/L) (A) 130 2.(D) (E) (F) (G) 16. His temperature is 39. he was prescribed a medication. she has been unable to keep any food "down" and has had repetitive vomiting between meals. she was diagnosed with a peptic ulcer and was treated with a proton pump inhibitor and antibiotics. and serum creatine kinase activity is 943 U/L. His sister states that he recently saw a psychiatrist for the first time because of hearing voices.8 110 24 .4 100 14 (D) 148 2. Myocardial infarction Peptic ulcer disease Pulmonary embolism Unstable angina pectoris Amphetamine intoxication Bacterial meningitis Delirium tremens Neuroleptic malignant syndrome Sepsis During the past month.

She has asthma treated with theophylline and inhaled β-adrenergic agonists and corticosteroids. He does not smoke or drink alcohol.4 g/dL 1. Examination shows a 2-cm. The lesion abuts the posterior chest wall without clear invasion. sore throat. precarinal. An x-ray of the chest shows a large right lower lobe density.5-cm mass in the right adrenal gland. A biopsy specimen of the lung mass is most likely to show which of the following? (A) (B) (C) (D) B-cell lymphoma Lung abscess Mesothelioma Metastatic adenocarcinoma of the breast 31 . His pulse is 84/min.5 x 7. and a cough productive of a small amount of white phlegm. nontender lymph node in the right supraclavicular area. Over the past week. He is 185 cm (6 ft 1 in) tall and weighs 82 kg (180 lb). she has had nausea related to excess coughing. There is mild tenderness over the second and third metacarpophalangeal joints bilaterally without synovial thickening. she has had a 3. Laboratory studies show: Hemoglobin Leukocyte count Platelet count Serum Glucose Albumin Total bilirubin Alkaline phosphatase AST ALT Hepatitis B surface antigen Hepatitis C antibody Rheumatoid factor 16 g/dL 7700/mm3 332. A CT scan of the chest shows a 7. His last visit to a physician was 10 years ago.000/mm3 182 mg/dL 3. An S3 is heard at the apex. right hilar. and blood pressure is 136/82 mm Hg. Examination shows dark brown skin. and subcarinal lymph nodes. Over the past year. There are right lower peritracheal. There is a 1. Examination shows no other abnormalities. She has smoked one pack of cigarettes daily for 44 years and drinks one alcoholic beverage daily.19. He has a 1-year history of fatigue and increased urination. He has no history of serious illness and takes no medications. She appears thin. The stiffness is worse at the end of the day. Heberden nodes are present over the distal interphalangeal joints of the index and ring fingers bilaterally. BMI is 24 kg/m 2. S 1 and S2 are normal. A 62-year-old white man comes to the physician because of an 8-month history of progressive pain and stiffness of his hands.5 x 6-cm right lower lobe mass with some scattered calcifications.2-kg (7-lb) weight loss. Calcium supplementation Enalapril therapy Metformin therapy Methotrexate therapy Phlebotomy A 64-year-old woman comes to the physician because of a 5-month history of increasing shortness of breath.1 mg/dL 52 U/L 55 U/L 68 U/L negative negative negative Which of the following is most likely to have prevented this patient's condition? (A) (B) (C) (D) (E) 20.

Physical examination shows no abnormalities. or dairy products and wishes to decrease the risks of her diet on her baby. She is 165 cm (5 ft 5 in) tall and weighs 104 kg (230 lb). She is recently married and would like to conceive within the next year. The pain extends from the epigastrium to the right upper quadrant and is sometimes felt in the right scapula. She takes no medications. Menses occur at regular 28-day intervals and last 5 days. uterus. it lasts about 30 minutes and is not relieved by antacids. BMI is 38 kg/m2. Pelvic examination shows a normal appearing vagina. Which of the following is most likely to decrease the risk of fetal anomalies in this patient? (A) (B) (C) (D) (E) 22. fish. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) (F) 32 Multiple endocrine neoplasia Non-small cell lung carcinoma Sarcoidosis Tuberculosis Abdominal ultrasonography of the right upper quadrant Upper gastrointestinal series with small bowel follow-through CT scan of the abdomen Endoscopic retrograde cholangiopancreatography Elective cholecystectomy Immediate cholecystectomy . She has not had vomiting. She is currently asymptomatic. Examination shows no other abnormalities. She does not eat meat. cervix. The last episode occurred after she ate a hamburger and french fries. She is 157 cm (5 ft 2 in) tall and weighs 50 kg (110 lb). and adnexa. BMI is 20 kg/m 2. Adjusting diet to include more sources of protein during the first trimester Beginning folic acid supplementation prior to conception Calcium supplementation during the first trimester Iron supplementation during the first trimester Soy protein shakes throughout pregnancy and lactation A 42-year-old woman comes to the physician because of an 8-week history of intermittent nausea and abdominal pain that occurs 20 to 30 minutes after eating.(E) (F) (G) (H) 21. A 21-year-old woman comes to the physician for preconceptional advice. She does not smoke or drink alcohol.

thumbs that may be extended to touch the forearms. range of motion is limited by pain. She usually has pain or swelling of her knees or ankles after practice. Her 16-year-old brother has required two operations for a severe rotator cuff injury he sustained while taking a shower. A midsystolic click is heard at the apex. or corticosteroid cream. Muscle strength is 3/5 in the proximal upper and lower extremities. including 25 degrees of genu recurvatum. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 24. The left ankle is swollen and tender. She has had increasingly frequent chest pain with exertion since starting a soccer program 3 months ago. and she has a maternal cousin who died of a ruptured aortic aneurysm at the age of 26 years. A photograph of the hands is shown. the patient walks with a limp. The joints of the upper and lower extremities are hypermobile. and flexibility at the waist. Her parents say that she started walking at the age of 14 months and since then has always seemed clumsier and had more injuries than other children. Vital signs are within normal limits. Dermatomyositis Myasthenia gravis Psoriasis Systemic lupus erythematosus Systemic sclerosis (scleroderma) A 5-year-old girl is brought to the physician by her parents for evaluation of recurrent injuries. with palms easily touching the floor with straight knees.23. Today. She has a 1-month history of progressive weakness. antibiotic ointments. She has difficulty rising from a chair or reaching over her head. Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) Skeletal survey Echocardiography Bone scan MRI of the shoulder Aortic angiography 33 . She is at the 99th percentile for height and 50th percentile for weight. She has not had any pain. She has been wearing glasses for 2 years. A 62-year-old woman comes to the physician because of a 3-day history of a rash over her face and hands that has not improved with the use of skin moisturizers.

Capillary refill time is less than 3 seconds. Examination of the right upper extremity shows erythema and moderate edema. The alpha and beta values for calculating probability are 0. pulse is 92/min. respirations are 18/min. and blood pressure is 120/80 mm Hg. respirations are 12/min. She is sexually active and uses condoms inconsistently. He appears malnourished. The symptoms are moderately exacerbated by exertion. Chance of a type I error Chance of a type II error Power of the study Sensitivity of the study Specificity of the study Axillary-subclavian venous thrombosis Deep venous valvular insufficiency Superficial thrombophlebitis of the basilic vein Superior vena cava syndrome Thoracic outlet syndrome . Examination of the heart. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 27. and extremities shows no abnormalities. Frequent turning Use of wet to dry dressings Whirlpool therapy Broad-spectrum antibiotic therapy Surgical debridement A 32-year-old man who is a jackhammer operator comes to the physician because of pain and swelling of his right arm for 3 days. fluctuant mass medial to the left labium majus compromising the introital opening.20. abdomen. A total of 1000 patients with type 2 diabetes mellitus are enrolled. Test of the stool for occult blood is negative. If this study had been performed in a population of only 500 patients. lymph nodes. Patients are randomly assigned to receive the new drug or standard treatment. A study is conducted to assess the effectiveness of a new drug for the treatment of type 2 diabetes mellitus. tender. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 34 Administration of intravenous metronidazole Administration of intravenous penicillin G Ultrasound-guided needle aspiration of the mass Incision and drainage Vulvectomy A 65-year-old man who is quadriplegic as a result of multiple sclerosis is hospitalized for treatment of left lower lobe pneumonia. which of the following would have been most likely to increase? (A) (B) (C) (D) (E) 26. Neurologic examination shows quadriparesis. There is a 1-cm area of erythema over the sacrum with intact skin and no induration.25. and blood pressure is 115/75 mm Hg.2°C (99°F).5°F). Results show that the new drug is significantly better than standard treatment. Her temperature is 37.1°C (100. Pelvic examination shows a 4 x 3-cm. Which of the following is the most effective intervention for this patient's skin lesion? (A) (B) (C) (D) (E) 28. pulse is 95/min. His temperature is 38. Rhonchi are heard at the left lower lobe of the lung on auscultation. respectively. A previously healthy 27-year-old nulligravid woman comes to the emergency department because of a 2-day history of moderate-to-severe pain and swelling of the left labia.05 and 0.

000 None gram-positive cocci 35 .29. respirations are 12/min. Coal tar therapy Oral antibiotic therapy Topical antibiotic therapy Topical corticosteroid therapy Vitamin supplementation Two days after admission to the hospital for congestive heart failure. He is in moderate distress. lisinopril. Current medications include atenolol. Examination of the lower extremities shows pitting pedal edema. Analysis of joint fluid aspirate is most likely to show which of the following? WBC Microscopic Examination (/mm3) for Crystals Gram Stain (A) 100 needle-shaped no organisms (B) 100 None gram-positive cocci (C) 100 None no organisms (D) 100 Rhomboid no organisms (E) 20. She was born at term and has been healthy except for an episode of bronchiolitis 6 months ago treated with albuterol.4°F). He does not smoke or drink alcohol. and edema of the left great toe. pulse is 68/min and regular. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 30. erythema. throbbing pain in his left foot. furosemide. arthrocentesis of the joint is performed. He has no history of similar episodes or recent trauma. and aspirin. There is tenderness. Jugular venous pulsations are present 3 cm above the sternal angle. He also has coronary artery disease and hypertension. A grade 2/6 systolic murmur is heard best at the left sternal border and second intercostal space. A 6-year-old girl is brought to the physician because of a 1-month history of a recurrent pruritic rash on her arms.000 needle-shaped no organisms (F) 20. His temperature is 38°C (100. an 82-year-old man is unable to walk because of severe. Active and passive range of motion of the first metacarpophalangeal joint produces pain. and blood pressure is 138/88 mm Hg. Crackles are heard at both lung bases. A photograph of the rash is shown.

A CT scan of the head shows no abnormalities. respirations are 24/min. Adverse effect of medication Alcohol withdrawal Fat emboli Sepsis Subdural hematoma A 16-year-old girl is brought to the physician because of intermittent pain and swelling of both ankles over the past month. Four days after undergoing open reduction and internal fixation of a fracture of the right femur sustained in a motor vehicle collision. it is so severe that she is unable to walk. pulse is 80/min. Which of the following is the most likely cause of these findings? (A) (B) (C) (D) (E) 32. His temperature is 37. a 47-year-old man continues to have agitation and confusion despite treatment with haloperidol.2°C (99°F). and blood pressure is 168/98 mm Hg.31. He has mild hypertension. There is no associated fever or chills.000/mm3 100 mm/h 1:320 Positive 1:16 Negative 3+ Negative None 10–20/hpf X-rays of the ankles show no abnormalities other than tissue swelling. She is sexually active and has had one sexual partner for 12 months. he is uncooperative and refuses to answer questions.6°F). Other medications include acetaminophen. When the pain occurs. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 36 Disseminated gonococcal disease Polyarticular arthritis Reactive arthritis Secondary syphilis Systemic lupus erythematosus . Her temperature is 37°C (98. He is oriented to person but not to place or time. and blood pressure is 145/87 mm Hg. The lungs are clear to auscultation. Laboratory studies show: Leukocyte count Segmented neutrophils Eosinophils Lymphocytes Monocytes Platelet count Erythrocyte sedimentation rate Serum Antinuclear antibodies Anti-DNA antibodies Rapid plasma reagin Rheumatoid factor Urine Protein RBC casts RBC WBC 4000/mm3 65% 3% 25% 7% 60. pulse is 98/min. Cardiac examination shows no abnormalities. She is currently not in pain. There is a nonpainful ulcer on the oral buccal mucosa. Neurologic examination shows tremulousness and no focal findings. and prophylactic subcutaneous heparin. Examination shows no abnormalities or tenderness of the ankle joints. atenolol. During the examination.

and blood pressure is 150/80 mm Hg. and test for occult blood is negative. She has a 3-year history of hypertension. Her hemoglobin concentration is 14. The stool is brown. and there is tenderness to palpation of the left lower quadrant with guarding but no rebound.5 mEq/L 26 mEq/L 16 mg/dL 95 mg/dL 0. Laboratory studies show: Hemoglobin Leukocyte count Serum Na+ Cl− K+ HCO3− Urea nitrogen Glucose Creatinine 12. The pupils are equal and reactive to light. Cardiac examination shows no abnormalities. She has had intermittent constipation for the past 12 years. She underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy 5 years ago because of leiomyomata uteri.000/mm3. and blood pressure is 130/70 mm Hg. and platelet count is 280. On arrival. urinary symptoms. and corneal reflexes are brisk. there is spontaneous medial and lateral gaze.5 g/dL. pulse is 75/min. Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) (F) Examination of the stool for ova and parasites Test of the stool for Clostridium difficile toxin Endoscopic retrograde cholangiopancreatography Pelvic ultrasonography CT scan of the abdomen with contrast Colonoscopy 37 . leukocyte count is 15. Bowel sounds are normal. serum studies and urinalysis show no abnormalities. She has not had nausea. she has become progressively confused.2 g/dL 6000/mm3 118 mEq/L 98 mEq/L 4. Her temperature is 37°C (98. During the past week.000/mm3. Her temperature is 38. BMI is 32 kg/m2.6°F). respirations are 12/min. pulse is 80/min. or bloody stools. vomiting. She is 165 cm (5 ft 5 in) tall and weighs 86 kg (190 lb). A 72-year-old woman with unresectable small cell carcinoma of the lung is brought to the emergency department after her family found her unresponsive. she does not respond to command but withdraws all extremities to pain.1°C (100.6°F). She began a course of amoxicillinclavulanate and metronidazole 2 days ago but has had no relief of her symptoms.33. Adrenal insufficiency Inadequate renal blood flow Injury to the renal tubules Nonphysiologic ADH (vasopressin) secretion Nonphysiologic aldosterone secretion Physiologic ADH (vasopressin) secretion Physiologic aldosterone secretion A 52-year-old woman comes to the emergency department because of a 1-week history of low-grade fever and increasing abdominal cramps that are exacerbated by bowel movements. The lungs are clear to auscultation.8 mg/dL Which of the following is the most likely mechanism of these findings? (A) (B) (C) (D) (E) (F) (G) 34. The abdomen is soft.

shortness of breath. Bowel sounds are normal. A previously healthy 18-year-old man is brought to the emergency department because of abdominal pain and nausea for 6 hours. select the most likely diagnosis. A 33-year-old woman comes to the emergency department 30 minutes after the sudden onset of chest pain.30. Her pulse is 90/min. She has no history of medical problems. and excessive sweating for 3 weeks. pulse is 120/min. She drinks two beers daily and six beers on the weekend. Examination shows warm and moist skin. His temperature is 37. He drinks one to two beers daily and occasionally more on weekends. emotional lability. 36. He takes no medications. numbness and tingling in both arms. respirations are 12/min. Physical examination. respirations are 18/min.5-kg (10-lb) weight loss during this period. He has had decreased appetite for the past week. 38 . she has had a 4. He does not use illicit drugs. a fine tremor of the fingers and tongue. and blood pressure is 105/60 mm Hg. palpitations. and blood pressure is 130/90 mm Hg. (E) Lactic acidosis (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) Alcohol withdrawal Coronary insufficiency Hyperthyroidism Hypoglycemia Major depressive disorder Panic disorder Paroxysmal atrial tachycardia Pheochromocytoma Post-traumatic stress disorder Pulmonary embolus Somatization disorder For each patient with anxiety.8°C (100°F). laboratory studies.8 mEq/L 16 mEq/L 360 mg/dL present present Arterial blood gas analysis on room air shows a pH of 7. Her mother and sisters have a history of anxiety. Which of the following is the most likely diagnosis? (A) (B) (C) (D) Acute appendicitis Acute pancreatitis Alcoholic ketoacidosis Diabetic ketoacidosis The response options for the next 2 items are the same. respirations are 24/min. and blood pressure is 120/80 mm Hg. Abdominal examination shows diffuse tenderness with no guarding or rebound. and hyperreflexia. Laboratory studies show: Serum Na+ Cl− K+ HCO3− Glucose Ketones Urine ketones 135 mEq/L 98 mEq/L 3.35. She uses an oral contraceptive. and fear of going crazy. tremors. She has no personal or family history of psychiatric disorders. and an ECG show no abnormalities. She has visited local emergency departments several times over the past 3 months for similar symptoms that resolved within 1 hour. Her pulse is 95/min. A 35-year-old woman comes to the physician because of nervousness. Select one answer for each item in the set. 37.

He also has had memory loss and difficulty sleeping. (A) (B) (C) (D) (E) (F) (G) (H) Increased intracranial pressure Migraine Occipital neuralgia Post-traumatic headache Subarachnoid hemorrhage Subdural hematoma Temporomandibular joint syndrome Tension-type headache For each patient with headache. She appears mildly depressed. Neurologic examination shows no abnormalities.The response options for the next 2 items are the same. he struck his head on the windshield but did not lose consciousness. bilateral. diffuse headaches that last "all day. 39. 38. Neurologic examination and an MRI of the brain show no abnormalities. The headaches are generalized with a constant pressure-like pain. A 27-year-old man comes to the physician because of persistent headaches since a motor vehicle collision 2 weeks ago. or aura. every day. select the most likely diagnosis. In the collision. She has not had nausea. 39 . Select one answer for each item in the set." They are not responsive to over-the-counter medications. A 32-year-old woman comes to the physician because of an 8-month history of moderately severe. vomiting.

or rebound. or blood. Urine dipstick shows no leukocyte esterase. A previously healthy 32-year-old woman comes to the physician because of a 2-week history of episodic burning with urination without urinary hesitancy or urgency. 2+ blood. pulse is 78/min. and testing for Neisseria gonorrhoeae and Chlamydia trachomatis are negative. (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) (L) (M) (N) (O) Acute bacterial urethritis Acute cystitis Atrophic vaginitis Bacterial vaginosis Candidal vaginitis Carcinoma of the bladder Chemical urethritis Chlamydial urethritis Distal ureteral calculus Gonorrheal urethritis Herpes urethritis Interstitial cystitis Pyelonephritis. Urine dipstick shows 1+ leukocyte esterase. subclinical Trichomonal vaginitis For each patient with pain or burning with urination. 40 . She is in a monogamous relationship.8°F). A previously healthy 37-year-old woman comes to the physician because of a 2-day history of urinary frequency and urgency and burning with urination. select the most likely diagnosis. and her partner has no similar symptoms. wet mount preparation. 41. Select one answer for each item in the set. Abdominal examination shows no abnormalities. and no nitrites. pulse is 78/min. guarding. and she has no abnormal vaginal discharge.6°C (97. Examination shows suprapubic tenderness to palpation without masses. Her temperature is 37.2°C (99°F). Her last menstrual period was 3 weeks ago. she noticed some blood in her urine. Her temperature is 36. respirations are 12/min. and blood pressure is 118/60 mm Hg. and blood pressure is 120/82 mm Hg. This morning. There is no costovertebral angle tenderness. 40. Pelvic examination shows vaginal erythema and scant mucoid discharge. nitrites. There is no cervical motion tenderness or adnexal masses. KOH preparation. She discontinued an oral contraceptive 4 months ago because of weight gain and now uses condoms and spermicidal jelly. acute Pyelonephritis. She is in a monogamous relationship.The response options for the next 2 items are the same. There is no costovertebral angle tenderness.

and diffuse osteopenia.2°C (102.49 30 mm Hg 64 mm Hg 91% An x-ray of the chest shows no abnormalities.Sample Questions Block 2 (Questions 42-86) 42. He also has had persistent pain in the thoracic spine for 1 month. His pulse is 100/min. A 70-year-old man comes to the physician because of fever. His temperature is 39. Over the past 2 years. The remainder of the examination shows no abnormalities. pulse is 94/min. Laboratory studies show: Hematocrit Leukocyte count Segmented neutrophils Bands Lymphocytes Serum calcium 34% 15. Arterial blood gas analysis on room air shows: pH PCO2 PO2 O2 saturation 7.9 mg/dL X-rays of the chest show consolidation of the right lower lobe. respirations are 22/min. Which of the following is the most likely mechanism of these findings? (A) (B) (C) (D) (E) (F) (G) Carbon monoxide poisoning Congenital heart disease Depressed alveolar ventilation Interstitial edema Interstitial fibrosis Low oxygen-carrying capacity of the blood Ventilation-perfusion mismatch 41 . lytic lesions at T8 and T10. HIV infection Multiple myeloma Prostate cancer Staphylococcal osteomyelitis Tuberculosis osteomyelitis A previously healthy 42-year-old man is brought to the emergency department 1 day after the sudden onset of shortness of breath and chest pain at rest. productive cough. he has had two similar episodes. and blood pressure is 140/90 mm Hg. and pleuritic chest pain for 1 day. Examination shows tenderness of the midthoracic spine.000/mm3 81% 4% 15% 10. the pain is exacerbated by deep inspiration. Which of the following is the most likely diagnosis of this patient's back condition? (A) (B) (C) (D) (E) 43. and blood pressure is 110/60 mm Hg. Breath sounds are normal. There is dullness to percussion and decreased breath sounds over the right base. respirations are 22/min.6°F).

or use illicit drugs. She plays field hockey and has noticed she coughs when running up and down the field. and sensitivity to light. Her temperature is 39. pulse is 112/min. Her thought process is organized." Since childhood. She received all appropriate immunizations during childhood but has not received any since then. Cardiopulmonary examination shows no abnormalities. She had chickenpox at the age of 7 years. drink alcohol. stiff neck. A previously healthy 19-year-old college student comes to student health services 24 hours after the onset of headache. respirations are 20/min. Examination shows diffuse petechiae. Ceftriaxone Clindamycin Erythromycin Metronidazole Vancomycin A previously healthy 17-year-old girl comes to the physician because of a 2-month history of exercise-induced cough and nasal congestion. and blood pressure is 100/68 mm Hg. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 45. There is no family history of serious illness. she is calm with a euthymic mood and full range of affect. The cough is nonproductive and resolves with rest. She does not smoke. She explains that she has always felt "more like a boy than a girl. The patient appears well. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 42 Body dysmorphic disorder Delusional disorder Female orgasmic disorder Gender identity disorder Transvestic fetishism Asthma Chronic bronchitis Gastroesophageal reflux disease Postnasal drip syndrome Variable endothoracic upper airway obstruction . A 27-year-old woman comes to the physician because she wants to begin a sex change process.44. Pulse oximetry on room air shows an oxygen saturation of 99%.1°C (102. A lumbar puncture is performed. She says that she is sexually attracted to men despite her masculine tendencies. Which of the following is the most appropriate pharmacotherapy? (A) (B) (C) (D) (E) 46. Her most recent examination 1 year ago included PPD skin testing and showed no abnormalities. She appears lethargic. She takes a daily multivitamin and an herbal weight-loss preparation. The remainder of the examination shows no abnormalities. She takes no medications and does not smoke. She has not had chest pain or palpitations. Kernig and Brudzinski signs are present. Spirometry shows an FEV 1:FVC ratio of 90% and an FEV1 of 90% of predicted. An x-ray of the chest shows no abnormalities. she has dressed in masculine clothes and has preferred to participate in traditionally male-dominated activities.4°F). She does not recall any sick contacts. Her sister has asthma. On mental status examination. and blood pressure is 100/75 mm Hg. A Gram stain of the CSF shows gram-negative cocci. Physical examination shows no abnormalities. respirations are 16/min. Her pulse is 68/min. Cerebrospinal fluid (CSF) analysis shows numerous segmented neutrophils and a decreased glucose concentration.

6°C (97. Sensation to vibration and position is absent over the upper and lower extremities. Her temperature is 37°C (98. A 4-year-old boy with a displaced supracondylar fracture of the humerus without neurovascular complication is placed in skeletal traction.47. Amyotrophic lateral sclerosis Diabetes mellitus History of gastrectomy Meniere disease Multiple sclerosis Vertebrobasilar deficiency Increased weight on the traction apparatus Administration of analgesic medication Exploration of the fracture and fasciotomy of the flexor compartment of the forearm Closed reduction with the patient under anesthesia Open reduction and internal fixation of the fracture A 42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to 5 days every 2 weeks. respirations are 20/min. and they use condoms inconsistently. Which of the following is the most appropriate next step in diagnosis? (A) Barium enema (B) Progesterone challenge test 43 .3 g/dL 105 μm3 4800/mm3 100. tingling sensations in her fingers and toes. Laboratory studies show: Hemoglobin Mean corpuscular volume Leukocyte count Platelet count Serum Bilirubin. She has no history of serious illness and takes no medications. Menses previously occurred at regular 25. She appears pale. A 57-year-old woman is brought to the emergency department 45 minutes after she fell after an episode of lightheadedness. and blood pressure is 100/60 mm Hg. The flow varies from light to heavy with passage of clots. She has type 2 diabetes mellitus. Her only medication is insulin. and blood pressure is 124/76 mm Hg. he has severe pain in the forearm and increased pain on passive extension of the wrist and fingers.to 29day intervals and lasted for 5 days with normal flow. BMI is 29 kg/m2.1 mg/dL 0. The abdomen is soft with a well-healed surgical scar. and loss of balance. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 49. total Direct Lactate dehydrogenase 8. Six hours later.6°F). and her maternal grandmother died of breast cancer. Her temperature is 36. The uterus is normal sized. Her mother died of colon cancer.8°F). Test of the stool for occult blood is negative.000/mm3 2. She is sexually active with one male partner. She has smoked one pack of cigarettes daily for 40 years. She underwent a partial gastrectomy for peptic ulcer disease 10 years ago. pulse is 90/min.2 mg/dL 320 U/L Which of the following is the most likely explanation for these findings? (A) (B) (C) (D) (E) (F) 48. She has a 6-month history of progressive fatigue. She is 163 cm (5 ft 4 in) tall and weighs 77 kg (170 lb). The remainder of the examination shows no abnormalities. The ovaries cannot be palpated. respirations are 12/min. She has a broad-based gait. pulse is 105/min.

The physician determines that surgical intervention is not indicated because of the patient's poor prognosis. The physician meets with the patient's family and informs them about the patient's prognosis. the patient develops decerebrate posturing and becomes hemodynamically unstable. Which of the following is the most appropriate next step with respect to organ donation? (A) (B) (C) (D) 51. and they are devastated. Arrange for the regional organ procurement organization to address the issue with the patient's family Delay further consideration of the issue until after 24 hours of aggressive care Delay further consideration of the issue until the family seems ready Initiate organ donation at this time An 18-year-old man with a 12-year history of type 1 diabetes mellitus comes to the physician for a follow-up examination. The patient's driver's license indicates that he wishes to be an organ donor. A CT scan of the head shows a large evolving cerebral infarction on the left.(C) Colposcopy (D) Cystoscopy (E) Endometrial biopsy 50. respirations are 20/min.2 mEq/L 101 mEq/L 23 mEq/L 325 mg/dL 1. and blood pressure is 145/95 mm Hg. On arrival. Laboratory studies show: Hemoglobin A1c Serum Na+ K+ Cl− HCO3− Glucose Creatinine Cholesterol Urine Blood Glucose Protein Ketones Which of the following is the most likely renal diagnosis? (A) (B) (C) (D) (E) 44 Cholesterol renal emboli Diabetic nephropathy Hypertensive glomerulosclerosis Hypokalemic nephropathy Sodium-losing nephropathy 13% 130 mEq/L 3. Carotid duplex ultrasonography shows dissection of the left carotid artery. Vasopressor therapy is begun. A previously healthy 32-year-old man is brought to the emergency department after being found unconscious on the floor at his workplace. During the meeting.5% 12 weeks ago. After receiving intensive medical care for 6 hours. Medications include 25 U of NPH insulin and 10 U of regular insulin in the morning and 10 U of NPH insulin and 10 U of regular insulin before dinner. A second CT scan of the head shows a massive left hemispheric cerebral infarction with severe edema and herniation. they say that they were unaware of his willingness to be an organ donor and agree that he should not receive cardiopulmonary resuscitation. Examination shows scattered retinal microaneurysms bilaterally. He is intubated and mechanical ventilation is begun.5 mg/dL 350 mg/dL Negative 4+ 1+ Negative . The remainder of the examination shows no other abnormalities. Examination shows flaccid paralysis on the right. His current pulse is 80/min. His hemoglobin A1c was 14. he is obtunded.

The most likely cause of these findings is entrapment of which of the following on the right? (A) (B) (C) (D) (E) 54. A 25-year-old woman comes to the physician because of a 2-month history of numbness in her right hand. sleeps approximately 9 hours nightly. His pulse is 120/min. Three years ago she needed only 7 hours of sleep nightly to feel rested." Results of laboratory studies are within the reference range. Examination shows full muscle strength. and blood pressure is 70/40 mm Hg. She is 173 cm (5 ft 8 in) tall and weighs 75 kg (165 lb). she has been tired most of the time. Which of the following is the most appropriate next step in management? (A) Upright x-ray of the chest (B) CT scan of the chest 45 . Palpation of the right elbow produces a jolt of severe pain in the right ring and small fingers. and occasionally naps on weekends. Sensation to pinprick and light touch is decreased over the medial half of the right ring finger and the entire small finger. respirations are 28/min. She describes her mood as low. Breath sounds are normal on the right and decreased on the left. My life isn't worth very much anyway. During this period. She has two women friends at work whom she sees occasionally. she stopped several months ago because it seemed like too much work to get to the pool. and nothing is going to change. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) 53. There is an exit wound laterally in the left axillary line at the 4th rib. Intravenous fluid resuscitation is begun. She played as a pitcher in a softball league for 5 years until she stopped 2 years ago. Abdominal examination shows an entrance wound in the left upper quadrant at the midclavicular line below the left costal margin. A 37-year-old woman comes to the physician for a routine health maintenance examination for insurance purposes. She says she does not have suicidal ideation but adds. On mental status examination. she appears withdrawn but is cooperative. She is employed as a cashier and uses a computer at home. She has had a 9-kg (20-lb) weight gain during the past 2 years with no change in her diet. Avoidant personality disorder Dysthymic disorder Primary hypersomnia Schizoid personality disorder Social phobia Substance-induced mood disorder Brachial plexus at the axilla Median nerve at the wrist Musculocutaneous nerve at the forearm Radial nerve at the forearm Ulnar nerve at the elbow A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot wound to the abdomen. they dated in college but drifted apart once he moved away after graduation. BMI is 25 kg/m2. During the past 2 years. "It doesn't matter. The patient has had one serious boyfriend. She does not drink alcohol or use illicit drugs. Vital signs are within normal limits. she has taken an oral contraceptive to regulate her menstrual cycle. She takes no other medications.52. She has no history of serious illness and takes no medications. She works as a grade school secretary and has received negative performance assessments during the past year for the number of clerical errors in her work. Physical examination shows no abnormalities. She used to swim two to three times weekly. For 15 years. she has had tingling in the right ring and small fingers most of the time. She lives with her mother who has had Parkinson disease for 5 years. There is no evidence of visual or auditory hallucinations. Vital signs are within normal limits.

Examination shows anterior cervical lymphadenopathy. Her temperature is 38. A 37-year-old woman is brought to the emergency department 45 minutes after she was found unconscious on her apartment floor. Otoscopic examination shows a red. respirations are 20/min. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 56. Which of the following is the most likely explanation for these findings? . Her pulse is 96/min. and blood pressure is 80/60 mm Hg. an erythematous truncal rash. She has been treated with amoxicillin for the past 5 days for left otitis media.3°F). On arrival.(C) Intubation and mechanical ventilation (D) Peritoneal lavage (E) Left tube thoracostomy 55. dull. A 3-year-old girl is brought to the physician because of fever and left ear pain for 3 days. and posterior thighs. Urine toxicology screening is positive for opiates and cocaine.9°F) for 8 days. buttocks. Her serum creatine kinase activity is 10. Microscopic examination of the urine shows pigmented granular casts and rare erythrocytes. nonexudative conjunctivitis bilaterally. Acoustic neuroma Labyrinthitis Lateral sinus thrombosis Mastoiditis Rhabdomyosarcoma Intravenous immune globulin Intravenous penicillin Intravenous prednisone Oral isoniazid Oral rifampin A 4-year-old boy is brought for a follow-up examination. Examination shows erythema. There is edema and tenderness behind the left ear. respirations are 12/min. Her coworkers became concerned when she did not arrive for work. pulse is 100/min. and blood pressure is 124/58 mm Hg. left tympanic membrane that does not move. This patient is at increased risk for which of the following conditions over the next 24 hours? (A) (B) (C) (D) (E) 57. His vital signs are within normal limits. 46 Acute respiratory distress syndrome Acute tubular necrosis Cerebral edema Cerebral hemorrhage Cocaine-induced cardiomyopathy A 4-year-old boy is brought to the physician because of temperatures to 39.4°C (102. Urine dipstick is strongly positive for blood. He has a history of chronic recurrent otitis media and recently completed a 10-day course of antibiotics. Examination shows clear ear canals and intact tympanic membranes. irregular mass is visualized behind the tympanic membrane. Which of the following is the most appropriate pharmacotherapy to prevent complications of this illness? (A) (B) (C) (D) (E) 58. she is unable to provide a history. a brown.300 U/L. a strawberry tongue. and edema of the hands and feet. and induration of the upper back. warmth.5°C (101. Examination shows the left ear displaced forward and laterally from the head.

Epithelial tissue proliferation Lingual papillae loss Middle ear effusion Midface hypoplasia Nerve entrapment Olfactory hair cell degeneration Semicircular canal edema Tympanic membrane rupture Observation Topical application of fluorouracil Sentinel lymph node biopsy Cryosurgery Excision of the lesion A 30-year-old woman comes to the physician because of intermittent throbbing headaches. but it has grown in size over the past week. Serum studies show: Na+ Cl− K+ HCO3− Urea nitrogen Creatinine 140 mEq/L 110 mEq/L 4. It bleeds when she picks at it. Examination of the dorsum of the left hand shows a 2. She has no history of serious illness. A 67-year-old woman comes to the physician 1 month after noticing a nontender nodule on the back of her left hand. and pallor over the past 3 months. She has had several blood pressure measurements that fluctuate from 110/80 mm Hg to 160/108 mm Hg. sweating. Her pulse is 100/min. She initially thought it was an insect bite. She lives in a retirement community in Florida and frequently plays golf and tennis. Photographs of the lesion are shown. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 60. and blood pressure now is 138/88 mm Hg.5 mEq/L 26 mEq/L 14 mg/dL 1 mg/dL Which of the following is the most likely location of the abnormality? (A) (B) (C) (D) (E) Adrenal cortex Adrenal medulla Aorta Renal arterioles Renal glomeruli 47 .5-cm lesion.(A) (B) (C) (D) (E) (F) (G) (H) 59.

night sweats.8-kg (15-lb) weight loss over the past 6 months. respiratory compensation Metabolic acidosis.6°F). He takes no medications.(F) Thyroid gland 61. Examination shows jugular venous distention and pitting edema below the knees. Cardiac examination shows no murmurs. respirations are 26/min and slightly labored. Her pulse is 88/min and regular. rubs. The abdomen is soft with no organomegaly. He has smoked one pack of cigarettes daily for 20 years. Examination shows pale conjunctivae. Laboratory studies show: Hemoglobin Mean corpuscular volume Platelet count Red cell distribution width 11 g/dL 72 μm3 300. he has noticed that his stools have changed in size and consistency. He appears healthy and well nourished.30 28 mm Hg 88 mm Hg 14 mEq/L Which of the following is the most likely acid-base status of this patient? (A) (B) (C) (D) 48 Metabolic acidosis. A previously healthy 47-year-old man comes to the physician because of a 6. Diffuse crackles are heard. pulse is 105/min. He has not had fever. respirations are 16/min.000/mm3 16% (N=13%–15%) Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) 62. respiratory compensation Metabolic alkalosis. His temperature is 37°C (98. or change in appetite. Test of the stool for occult blood is positive. He spent 2 weeks in Mexico 3 months ago. or gallops. Rectal examination shows a normal prostate with no masses. and blood pressure is 176/110 mm Hg. and blood pressure is 130/78 mm Hg. Laboratory studies show: Serum Na+ Cl− 138 mEq/L 100 mEq/L Arterial blood gas analysis on room air: pH PCO2 PO2 HCO3− 7. uncompensated Metabolic alkalosis. Since returning. uncompensated . Second complete blood count in 3 months CT scan of the abdomen Colonoscopy Esophagogastroduodenoscopy Sigmoidoscopy A 47-year-old woman with end-stage renal disease comes to the physician because of increased shortness of breath since her last hemodialysis 2 days ago.

he has had episodes of choking or gasping for breath while sleeping. uncompensated Normal acid-base balance 24-Hour ambulatory ECG monitoring Multiple sleep latency test Polysomnography CT scan of the head Laryngoscopy A 19-year-old college student comes to the physician because of progressive hair growth over her face and body since the age of 16 years. The remainder of the examination. She also has acne and oily skin. His wife says that he has always snored loudly. He has a 40-year history of alcoholism and drinks eight 49 . but his wife is concerned because he sometimes falls asleep on the sofa early in the evening when guests are present. respirations are 14/min. Respiratory acidosis. pulse is 72/min. including pelvic examination. He also once fell asleep while driving at night and drove off the road.2 nmol/L (N<3. renal compensation Respiratory alkalosis.4) 8 mIU/mL 160 ng/dL (N=20–300) 10 mIU/mL 4. respirations are 16/min. He has type 2 diabetes mellitus and hypertension. Bromocriptine Clomiphene Combination oral contraceptive Dexamethasone Gonadotropin-releasing hormone agonist A 67-year-old man with chronic cough comes to the emergency department after he coughed up 1 cup of bright red blood this morning. uncompensated Respiratory alkalosis. and along the midline of the lower abdomen.2°C (99°F). renal compensation Respiratory acidosis. A 52-year-old man comes to the physician with his wife because of a 1-year history of excessive daytime sleepiness.(E) (F) (G) (H) (I) 63. Physical examination shows coarse. He is 178 cm (5 ft 10 in) tall and weighs 105 kg (231 lb). shows no abnormalities. Which of the following is most likely to confirm the diagnosis? (A) (B) (C) (D) (E) 64.to 90-day intervals since menarche at the age of 14 years. around both nipples. and over the past year. and blood pressure is 120/80 mm Hg. pigmented hair over the chin and upper lip. He has not had chest pain. narrowly avoiding injury. His pulse is 76/min. She has no history of serious illness and takes no medications.5) Which of the following is the most appropriate pharmacotherapy? (A) (B) (C) (D) (E) 65. He has a 3-week history of increasingly severe cough productive of whitish yellow sputum and a 1-week history of fever.5–5.5 μU/mL (N=11–240) 3 μg/mL (N=0. the sputum has contained small amounts of blood. and blood pressure is 150/76 mm Hg. Physical and neurologic examinations show no other abnormalities. Her temperature is 37. BMI is 31 kg/m2. She is 168 cm (5 ft 6 in) tall and weighs 88 kg (193 lb). BMI is 33 kg/m2. Serum studies show: Fasting glucose Fasting insulin Dehydroepiandrosterone sulfate Follicle-stimulating hormone 17α-Hydroxyprogesterone Luteinizing hormone Testosterone 95 mg/dL 7. Menses have occurred at 30. Over the past 3 days. He does not think the symptoms are problematic.

Which of the following is the most likely diagnosis? (A) (B) (C) (D) 50 Reduction of systolic blood pressure to less than 120 mm Hg Annual ophthalmologic examination Annual exercise stress test Add metformin to the regimen Switch from lisinopril to atenolol An 18-year-old man is brought to the emergency department 10 minutes after he sustained a stab wound to his chest. Bimanual examination shows a normal-sized uterus and no palpable adnexal masses. A CT scan of the chest shows a soft tissue mass within the cavity. He is 173 cm (5 ft 8 in) tall and weighs 68 kg (150 lb). Scattered rhonchi are heard that move with coughing.8°C (100°F).alcoholic beverages daily. Breath sounds are normal. respirations are 8/min and shallow. The trachea is at the midline. His temperature is 37. BMI is 23 kg/m 2. and hydrochlorothiazide. A 42-year-old man comes to the physician for a routine follow-up examination. On arrival. Examination of the lower extremities shows hair loss over the shins. Chest x-ray Echocardiography Bronchoscopy Pericardiocentesis Placement of a right chest tube A 36-year-old nulligravid woman with primary infertility comes for a follow-up examination. and infusion of 0. Which of the following is most appropriate to reduce diabetic complications in this patient? (A) (B) (C) (D) (E) 67. pulse is 108/min. His hemoglobin A1c is 6. An x-ray of the chest shows a single cavitary lesion. Cardiac examination shows a normal rhythm and no murmurs or gallops. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 66. He has a 15-year history of type 1 diabetes mellitus and an 8-year history of hypertension. Heart sounds are not audible. There is jugular venous distention. Pelvic examination shows a normal vagina and cervix.3%.9% saline is begun. He is intubated and mechanically ventilated. She has been unable to conceive for 10 years. There is trace pedal edema bilaterally. His pulse is 130/min. his pulse is 130/min. and blood pressure is 70/40 mm Hg. His pulse is 80/min. and blood pressure is 130/84 mm Hg. Examination shows a 2-cm wound at the left sixth intercostal space at the midclavicular line. analysis of her husband's semen during this period has shown normal sperm counts. he is unresponsive to painful stimuli. Aspergilloma Bacterial lung abscess Bronchogenic carcinoma Histoplasmosis Tuberculosis Anovulation Endometriosis Intrauterine synechiae Male factor . Hysterosalpingography 1 year ago showed normal findings. Menses occur at regular 28-day intervals and last 5 to 6 days. An endometrial biopsy specimen 5 days before menses shows secretory endometrium. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 68. lisinopril. After 5 minutes. and blood pressure is 124/74 mm Hg. She is asymptomatic except for severe dysmenorrhea. there are no wheezes. He had tuberculosis 15 years ago treated for 1 year with isoniazid and rifampin. Current medications include insulin. respirations are 22/min. and palpable systolic blood pressure is 60 mm Hg. No other abnormalities are noted. Rectal examination is unremarkable.

4 days. compared with a mean time of 6. Examination of the right eye shows an afferent papillary defect.04). Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) 71. His temperature is 38°C (100. A 32-year-old man is brought to the emergency department 30 minutes after he drove his motorcycle into a guardrail at a high speed. An x-ray of the pelvis shows a widened pubic symphysis. Examination shows a deep perineal laceration. The mean time for resolution of symptoms for patients receiving the new drug was 6. He was riding without a helmet. double-blind. He voids 25 mL of bloody urine. Age-related macular degeneration Background diabetic retinopathy Central artery occlusion Central vein occlusion Proliferative diabetic retinopathy Measurement of urine hemoglobin concentration Cystography Urethrography Placement of a urinary catheter Intravenous pyelography A 5-year-old boy is brought to the physician by his mother because of a 2-day history of a low-grade fever. Visual acuity is limited to light perception on the right. Which of the following is the most appropriate interpretation of these study results? (A) (B) (C) (D) The findings are clinically and statistically significant The findings are clinically insignificant but statistically significant The findings are clinically significant but statistically insignificant The findings are neither clinically nor statistically significant 51 . cough.7 days for patients receiving the placebo (p=0. his pulse is 100/min. placebo-controlled clinical trial that evaluated the effectiveness of a new drug for the treatment of the common cold. Examination findings are consistent with a diagnosis of a common cold. A 72-year-old woman is brought to the emergency department 2 hours after the sudden onset of visual loss in her right eye. The physician refers to a randomized. Funduscopic findings of the right eye are shown. respirations are 14/min. and runny nose. On arrival. There is mild suprapubic tenderness.4°F).(E) Tubal obstruction 69. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 70. and blood pressure is 120/80 mm Hg. The anterior structures of both eyes appear normal.

flesh-colored lesions on the shaft of the penis that are 10 mm in diameter. After 10 minutes of pushing. Examination shows no other abnormalities. talking excessively. rapidly develops cyanosis. A previously healthy 27-year-old man comes to the physician 4 weeks after noticing three nontender lesions on his penis. and ecchymoses in various stages of healing over the knees. he fractured his right tibia after falling off a trampoline and sustained a concussion after falling off his bicycle. He is sexually active with multiple male and female partners and uses condoms inconsistently. Physical examination shows a dislocated left shoulder. Five minutes later.72. Mental status examination shows a neutral affect. 52 CT scan of abdomen Repeat test of the stool for occult blood after 3 days on a meat-free diet Measurement of serum carcinoembryonic antigen (CEA) concentration Colonoscopy with polypectomy Total colectomy A 6-year-old boy is brought to the emergency department 2 hours after injuring his arm when he fell out of a tree. the cervix is 100% effaced and 10 cm dilated. At the beginning of the second stage of labor. He says that he likes to run and climb trees. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 74. at 41 weeks' gestation is admitted to the hospital in active labor. An upper gastrointestinal series shows no abnormalities. He takes no medications. there is bleeding from the nose. para 2.5-cm polyp in the descending colon. He drinks two to five beers on social occasions. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 73. He says they have not changed in size. mouth. Which of the following is the most likely diagnosis? . During the past year. the lesions turn white. His father has a history of illicit drug use. There is no family history of cancer. Examination shows three sessile. Test of the stool for occult blood is positive. he often forgets to turn in his homework. Topical ganciclovir therapy Oral acyclovir therapy Oral doxycycline therapy Intramuscular penicillin therapy Cryotherapy Attention-deficit/hyperactivity disorder Conduct disorder Learning disorder Seizure disorder Age-appropriate behavior A 32-year-old woman. Pregnancy has been complicated by mild asthma treated with inhaled bronchodilators. healing abrasions over the elbows. Immediate resuscitation is started. He occasionally smokes marijuana.4°F). His pulse is 80/min. His hematocrit is 38%. There is no lymphadenopathy. and getting out of his seat. gravida 3. His parents are currently divorcing. The patient has the acute onset of shortness of breath. The patient is at the 50th percentile for height and weight. She says that his teachers reprimand him frequently for running wildly in the classroom. His temperature is 36. On application of a dilute solution of acetic acid. and intravenous sites.9°C (98. there is a prolonged deceleration to 60/min. the vertex is at -1 station. and becomes unresponsive. Her pulse and blood pressure cannot be detected. and blood pressure is 100/80 mm Hg. Which of the following is the most likely explanation for these findings? (A) (B) (C) (D) (E) 75. The remainder of the examination shows no abnormalities. A 46-year-old man comes to the physician because of intermittent lower abdominal pain over the past 3 months. His mother says that he is extremely active and likes to climb. The fetal heart rate is reactive with no decelerations. Colon contrast studies show a 1.

gravida 2. respirations are 16/min. especially at the waistline. Deep tendon reflexes are 2+ bilaterally. The mucous membranes of the mouth are erythematous and exfoliated. She has no history of skin problems or associated symptoms. Her sister with whom she shares a room had similar symptoms during the previous week. She takes no medications. para 1.(A) (B) (C) (D) (E) 76. There are multiple 2. He has no history of similar symptoms. There is diffuse exfoliation of the skin with oozing of serous fluid. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 79. This patient is at increased risk for which of the following complications? (A) (B) (C) (D) (E) Abruptio placentae Fetal chromosome abnormality Hyperthyroidism Preterm labor and delivery Twin transfusion syndrome 53 .to 5-mm erythematous papules over the trunk. He has been taking allopurinol and probenecid for 2 weeks because of gouty arthritis. and atrial fibrillation. and aspirin. Amniotic fluid embolism Intracerebral hemorrhage Myocardial infarction Status asmaticus Toxic shock syndrome Bullous pemphigoid Erythema multiforme Pemphigus erythematosus Staphylococcal scalded-skin syndrome Toxic epidermal necrolysis A 32-year-old woman. at 8 weeks' gestation comes to the physician for her first prenatal visit. Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) 78.8°C (98. and blood pressure is 170/90 mm Hg. She has no other history of serious illness. lisinopril. Current medications include metformin. Her blood pressure is 100/70 mm Hg. Epstein-Barr virus Group A streptococcus Measles virus Sarcoptes scabiei Varicella-zoster virus A 77-year-old man is brought to the physician because of a 12-hour history of word-finding difficulty and weakness and sensory loss of the right arm and leg. She delivered her first child spontaneously at 34 weeks' gestation. and fingers. Carotid duplex ultrasonography CT scan of the head EEG Lumbar puncture Cerebral angiography A 60-year-old man has had painful skin with exfoliation of the skin and mucous membranes for 1 day. Ultrasonography shows a dichorionic-diamniotic twin intrauterine pregnancy consistent in size with an 8-week gestation. Examination shows no abnormalities. He follows commands but has nonfluent aphasia. The patient's temperature is 36. There is no lymphadenopathy or hepatosplenomegaly. pregnancy was complicated by iron deficiency anemia. There are no target lesions. Which of the following is the most likely causal organism? (A) (B) (C) (D) (E) 77. He is alert.2°F). There is moderate weakness and decreased sensation of the right upper and lower extremities. His pulse is 80/min and irregular. Babinski sign is present on the right. and over the forearms. He has type 2 diabetes mellitus. A previously healthy 17-year-old girl comes to the physician because of a 1-week history of itching and progressive rash. His serum glucose concentration is 162 mg/dL. hands. hypertension.

Abdominal examination shows distention with epigastric tenderness.80. 54 Acute portal vein thrombosis Hemorrhagic pancreatitis Perforated posterior gastric ulcer Ruptured gastric varices Splenic artery rupture A 57-year-old man comes to the emergency department because of cramping in his hands and feet and numbness and tingling around his lips and in his fingers. Chvostek and Trousseau signs are present. vomiting. He has been hospitalized twice for severe abdominal pain 4 and 6 years ago.5 g/dL 15. and blood pressure is 80/60 mm Hg. He also has had a 13-kg (30-lb) weight loss and bulky. and blood pressure is 105/65 mm Hg.500/mm3 7.5 mg/dL 750 U/L A CT scan of the abdomen is shown. He has a 10-year history of drinking 8 to 10 beers daily. His serum calcium concentration is 6. Laboratory studies show: Hemoglobin Leukocyte count Serum Ca2+ Amylase 5. pulse is 120/min. He appears extremely dehydrated and is short of breath. Bowel sounds are decreased. The abdomen is nontender. foul-smelling stools that do not flush easily.8°C (100°F). A 52-year-old man with alcoholism is brought to the emergency department because of a 2-day history of nausea. His pulse is 80/min. and increasingly severe abdominal pain that radiates to his left shoulder and back. He appears cachectic and chronically ill. Test of the stool for occult blood is negative. respirations are 18/min. Which of the following is the most likely diagnosis? . these symptoms occurred intermittently for 6 months but have been progressively severe during the past 2 weeks.5 mg/dL. His temperature is 37. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) 81. Deep tendon reflexes are 4+ bilaterally. Rectal examination shows no abnormalities.

hyperpigmented. He often falls asleep during class. Physical and pelvic examinations show no abnormalities. He urinates four to five times nightly and often has difficulty falling asleep again. Vital signs are within normal limits. Menarche began at the age of 15 years. The remainder of the examination shows no abnormalities. which of the following is the most appropriate initial treatment? (A) (B) (C) (D) (E) Exercise program Increased fluid intake Cyclosporine therapy Insulin therapy Oral hypoglycemic agent The response options for the next 2 items are the same. He has no history of serious illness and takes no medications. Additional laboratory studies show: Serum glucose Urine pH Specific gravity Glucose Ketones 134 mg/dL 5. He also has had a 2-week history of pain in his extremities. He appears pale.000/mm3. Her mother and older sister have similar symptoms. leukocyte count is 8000/mm3.028 1+ Negative In addition to dietary counseling. she has heavy bleeding on all but the last day. Examination shows a velvety. 84. His temperature is 38. A 5-year-old boy is brought to the physician because of a 1-week history of excessive bruising and bleeding from minor cuts. (A) Hypomagnesemia (B) Hypoparathyroidism (C) Osteomalacia (D) Vitamin D deficiency A 15-year-old boy is brought to the physician because of fatigue since starting his freshman year of high school 3 months ago. Results of a complete blood count and serum electrolyte concentrations show no abnormalities.82. (A) (B) (C) (D) (E) (F) (G) (H) Factor VIII deficiency Factor IX deficiency Fibrinogen deficiency Protein C deficiency Protein S deficiency Thrombocytopenia Vitamin K deficiency von Willebrand factor deficiency For each patient with excessive bleeding. and platelet count is 300.5 1. There is generalized lymphadenopathy and splenomegaly. She has a history of frequent nosebleeds. 55 .9°F). Select one answer for each item in the set. He is at the 20th percentile for height and above the 95th percentile for weight and BMI. her hemoglobin concentration is 9 g/dL. 83. A 17-year-old girl comes to the physician 5 days after she was found to have a hemoglobin concentration of 9 g/dL during a school blood drive. Examination shows bleeding gums and scattered petechiae and purpura over the trunk and extremities. select the most likely cause. and her menses have occurred at regular 28-day intervals and last 9 to 10 days.3°C (100. macular rash over the neck and axillae. Today.

Her pulse is 110/min. Bilateral basilar crackles are heard. The next day. There is an S 4 gallop. (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) (K) Coronary artery thrombosis Coronary artery vasospasm Costochondritis Dissecting aortic aneurysm Esophageal spasm Pericarditis Pleuritis Pneumonia Pneumothorax Postmyocardial infarction syndrome Pulmonary infarction For each patient with chest pain. 56 . and a follow-up visit is scheduled in 1 week. 86. and blood pressure is 170/100 mm Hg. There is an S 4 gallop. Antihypertensive therapy with hydrochlorothiazide is initiated. Bilateral basilar crackles are heard. she had smoked crack cocaine.The response options for the next 2 items are the same. Select one answer for each item in the set. 85. At a recent health fair. pulse is 110/min. respirations are 16/min. A previously healthy 25-year-old woman comes to the physician because of substernal chest tightness and shortness of breath for 2 hours. His pulse is 85/min. Twenty minutes before the onset of the pain. A nonradiating.6°F). grade 2/6. He takes no medications. he was told that his blood pressure and cholesterol were high. He has diaphoresis and dyspnea. A previously healthy 57-year-old man comes to the physician because of shortness of breath for 5 days. The lungs are clear to auscultation. and blood pressure is 175/100 mm Hg. he comes to the emergency department because of severe substernal chest pain radiating to the jaw. systolic ejection murmur is heard at the upper right sternal border. select the most likely cause. His temperature is 37°C (98. and blood pressure is 200/110 mm Hg. respirations are 20/min.

A 5-year-old boy is brought to the physician because of a 2-day history of fever and painful swelling of the left ankle. A bone scan shows increased uptake in the left lower tibial metaphysis. He is dressed casually in baggy pants and a T-shirt. erythematous. His speech is slow. His temperature is 37. Her hemoglobin A1c is 6. She has a 2-year history of type 1 diabetes mellitus controlled with insulin. Begin running for exercise Dietary modification for weight loss Human papillomavirus testing Mammography Influenza virus vaccine Supplementation with vitamins C and D Adenosine deaminase deficiency Consumption of complement Defective opsonization Destruction of CD4+ T lymphocytes Developmental arrest of maturation of B lymphocytes Dysmorphogenesis of the third and fourth pharyngeal pouches Impaired chemotaxis Impaired phagocytic oxidative metabolism A 19-year-old man is brought to the emergency department by a friend because of strange behavior during the past 2 hours at a party. She feels well. but it seemed to take several hours. he has a mildly anxious affect. Culture of bone aspirate grows Serratia marcescens.2°C (99°F). Deep tendon reflexes are decreased. She is 168 cm (5 ft 6 in) tall and weighs 57 kg (125 lb). There is ataxia on finger-nose testing. BMI is 20 kg/m2. pulse is 107/min. Which of the following health maintenance recommendations is most appropriate at this time? (A) (B) (C) (D) (E) (F) 88. A 22-year-old woman comes to the physician in October for a follow-up examination.2%. He says that he is angry because his friend had promised that the ride to the hospital would only take 5 minutes. respirations are 12/min. Examination shows injected conjunctivae.4°F). He has had recurrent cervical lymphadenitis and pneumonia since infancy. and his thought process is disorganized. On mental status examination. Examination shows a tender. He looks out the door of the examination room frequently during the examination. Nitroblue tetrazolium test shows no color change. Which of the following is the most likely mechanism for these findings? (A) (B) (C) (D) (E) (F) (G) (H) 89. His temperature is 38°C (100. Two years ago. Her 67-year-old grandmother has breast cancer. Which of the following is the most likely cause of these findings? (A) Alcohol (B) Heroin 57 .Sample Questions Block 3 (Questions 87-131) 87. he is alert but confused. there is point tenderness over the medial malleolus. and fingerstick blood glucose concentration is 118 mg/dL. She had a normal Pap smear 3 months ago and saw her ophthalmologist 6 months ago. edematous left ankle. and blood pressure is 120/85 mm Hg. He states that he has been hungry all evening. and he asks if there is anywhere he can get something to eat. On arrival. a culture from an abscess in the cervical region grew Staphylococcus aureus. The patient has seemed confused and has been insisting that someone is following him.

and blood pressure is 152/91 mm Hg. There is no personal or family history of serious illness. brittle hair. His temperature is 37°C (98. swelling of his legs. There is mild edema of the ankles bilaterally.6°F). and blood pressure is 150/90 mm Hg. generalized fatigue. and cold intolerance for 1 year. Her pulse is 55/min. Inhalant LSD Marijuana Methamphetamine PCP (phencyclidine) A 19-year-old man comes to the physician because of a 3-week history of malaise.9 mEq/L 101 mEq/L 19 mEq/L 68 mg/dL 4. A renal biopsy specimen shows a crescent formation in the glomeruli and immune complex deposition along the basement membrane. She appears lethargic. The relaxation phase of the Achilles reflex is greatly prolonged.000/mm3 135 mEq/L 4. swelling of the ankles. Examination shows dry skin and a nontender thyroid gland that is enlarged to two times its normal size. The remainder of the examination shows no abnormalities. A 67-year-old woman has had fatigue.4 g/dL 5000/mm3 250. Laboratory studies show: Hemoglobin Leukocyte count Platelet count Serum Na+ K+ Cl− HCO3− Urea nitrogen Creatinine Urine Blood Protein RBC RBC casts 10. He has no known sick contacts. dry skin. He takes no medications.6 mg/dL 3+ 3+ 5–7/hpf with dysmorphic features Numerous Serum complement concentrations are within the reference ranges. and dark urine. The most appropriate next step in management is administration of which of the following? (A) (B) (C) (D) (E) 91. pulse is 82/min.(C) (D) (E) (F) (G) 90. respirations are 14/min. Renal ultrasonography shows no abnormalities. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) (G) (H) 58 Oral azathioprine Oral lisinopril Intravenous fluids Intravenous furosemide Intravenous methylprednisolone Chronic lymphocytic thyroiditis (Hashimoto disease) Defect in thyroxine (T4) biosynthesis Graves disease Multinodular goiter Riedel thyroiditis Thyroid cyst Thyroid lymphoma Thyroiditis . Examination shows 2+ pretibial edema bilaterally. she has gained 9 kg (20 lb) during this period.

luteal N>3–5) Pelvic ultrasonography shows no abnormalities. After the seizure. Her temperature is 37°C (98. respirations are 20/min. she is confused and has short-term memory deficits. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) 94.6°F). A previously healthy 22-year-old college student is brought to the emergency department by her parents 20 minutes after they observed her having a seizure. His symptoms began 15 minutes after he was stung by a bee and lasted approximately 60 minutes. She has difficulty naming objects and makes literal paraphasic errors.to 45-day intervals and last 3 to 7 days. Which of the following is the most appropriate recommendation to prevent future morbidity and mortality from this condition? (A) (B) (C) (D) (E) 93. She is sexually active and does not use contraception. She has had a headache. Serum studies show: Thyroid-stimulating hormone Follicle-stimulating hormone Prolactin Progesterone 3 μU/mL 5 mIU/mL 18 ng/mL 0. Neurologic examination shows diffuse hyperreflexia. He has been stung by bees three times over the past year. and each reaction has been more severe. Avoid areas known to have bees Avoid wearing colorful clothing outside Carrying diphenhydramine tablets Carrying self-injectable epinephrine Seek immediate medical attention following any future sting Bacterial meningitis Dextromethorphan intoxication Herpes simplex encephalitis HIV encephalopathy Reye syndrome Syphilis A 27-year-old nulligravid woman comes to the physician because of a 1-year history of irregular heavy menstrual bleeding. and fever for 3 days treated with acetaminophen and dextromethorphan. She has been otherwise healthy. Her temperature is 38. On mental status examination. and blood pressure is 120/80 mm Hg. A 10-year-old boy is brought for a follow-up examination 2 days after he was seen in the emergency department because of hives. pulse is 80/min.9°C (102°F). Menses occur at irregular 15. and a protein concentration of 78 mg/dL. and light-headedness.92. menses had previously occurred at regular 28-day intervals with moderate flow. cough. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Adenomyosis Anovulation Endometrial polyp Leiomyoma uteri Pregnancy 59 . Physical examination shows no abnormalities. An MRI of the brain shows bitemporal hyperintensities. Examination shows no abnormalities. Her last menstrual period was 4 weeks ago. they resolved before he was treated. hoarseness. cerebrospinal fluid analysis shows an erythrocyte count of 340/mm3. she was confused and had difficulty thinking of some words.5 ng/mL (menstrual cycle day 30: follicular N<3. A lumbar puncture is done. a leukocyte count of 121/mm3 (88% monocytes). Pelvic examination shows clear cervical mucus.

There are jugular venous pulsations 5 cm above the sternal angle. She has never smoked.4°C (103°F). 60 24-Hour monitoring of esophageal pH Echocardiography CT scan of the chest Inhaled corticosteroid therapy Nitroglycerin therapy A 22-year-old man with a seizure disorder has had increasing cough and shortness of breath for 3 days and fever for 1 day. and blood pressure is 130/75 mm Hg. A 27-year-old woman comes to the physician for a follow-up examination. An x-ray of the chest shows a right upper-lobe infiltrate of the lung. Crackles are heard at both lung bases. On mental status examination. She has no history of serious illness. He had a generalized tonic-clonic seizure 1 week ago. she is alert and cooperative. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 97. She accurately describes her medical history and understands the . She otherwise feels well. She has not had loss of appetite or change in exercise tolerance. Her temperature is 37°C (98. She has no family and most of her friends are sick or deceased. and blood pressure is 110/76 mm Hg. she is nearly blind and will likely require bilateral leg amputations. an 87-year-old woman refuses insulin injections. Empiric treatment with an oral decongestant and albuterol inhaler has not improved her symptoms. Cardiopulmonary examination and an x-ray of the chest show no abnormalities. respirations are 20/min. There is edema from the midtibia to the ankle bilaterally. A 62-year-old man comes to the physician because of a 2-month history of progressive fatigue and ankle swelling. He had an anterior myocardial infarction 3 years ago and has had shortness of breath with mild exertion since then. She reports that she has always been an active person and does not see how her life will be of value anymore. He has smoked one-half pack of cigarettes daily for 30 years.6°F). He has foul-smelling sputum. respirations are 12/min. Her FEV1 is normal. His temperature is 39. Decreased pulmonary capillary wedge pressure Impaired contractility of the left ventricle Prolapse of the mitral valve Thrombosis of the superior vena cava Ventricular septal defect Chemical pneumonitis Pneumonia secondary to anaerobes Pneumonia secondary to gram-negative aerobes Pneumonia secondary to gram-positive aerobes Pneumonia secondary to Mycoplasma pneumoniae Three days after hospitalization for diabetic ketoacidosis. Current medications include labetalol and daily aspirin.95. Further evaluation of this patient is most likely to show which of the following findings? (A) (B) (C) (D) (E) 96. She has a 10-week history of persistent nonproductive cough that is worse at night and a 1-month history of a hoarse voice. Cardiac examination shows an S3 gallop. Which of the following is the most likely cause? (A) (B) (C) (D) (E) 98. pulse is 68/min. Crackles are heard on auscultation of the chest. His pulse is 100/min and regular. She says that her medical condition has declined so much that she no longer wishes to go on living.

and platelet count is 35. Laboratory findings are within the reference range. On mental status examination." Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 99. A 67-year-old woman comes to the physician because of easy bruising for 4 months. place. Her hemoglobin concentration is 13 g/dL. Discharge the patient after she has signed an "against medical advice" form Seek a court order to appoint a legal guardian Offer insulin but allow the patient to refuse it Admit to the psychiatric unit Administer insulin against the patient's wishes A 72-year-old woman with advanced ovarian cancer metastatic to the liver is brought to the physician by her son because she cries all the time and will not get out of bed. A 19-year-old college student comes to the physician because of vaginal irritation and pain with urination for 5 days. pulse is 110/min. distended abdomen with moderate tenderness over the liver. Her last menstrual period was 1 week ago. and blood pressure is 90/60 mm Hg. saying that the physician is too young to understand her situation. Today. During a visit 1 month ago for an uncomplicated upper respiratory tract infection. An ECG shows borderline left ventricular hypertrophy.6°F). his blood pressure was 172/96 mm Hg. she rates the pain as a 1 to 2. Current medications also include oxycodone (10 mg twice daily). she is oriented to person. She has a 2-year history of hypertension treated with a thiazide diuretic and an angiotensin-converting enzyme (ACE) inhibitor. On a 10-point scale. shows no abnormalities except for multiple ecchymoses. and time.consequences of refusing insulin. and this is what I want. including neurologic examination. "I know I will die. Two weeks ago. She dismisses any attempts by the physician to change her mind. Examination shows no other abnormalities. Her temperature is 37°C (98. Examination shows a firm. She is 165 cm (5 ft 5 in) tall and weighs 66 kg (145 lb). She also has hypertension and major depressive disorder. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) Reassurance Assess for suicidal ideation Begin dextroamphetamine therapy Increase oxycodone dosage Restart chemotherapy 100. she uses condoms for contraception. his pulse is 76/min. During a visit 2 months ago. BMI is 24 kg/m2. She has been sexually active with two partners over the past year. She has a history of lung cancer treated with radiation therapy 6 months ago. She has good eye contact but appears sad and cries easily. Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) Bone scan CT scan of the abdomen CT scan of the chest Bronchoscopy Bone marrow aspiration 101. Examination. and fluoxetine (20 mg/d). Her temperature is 37. His only medication is allopurinol. She says. A serum antiplatelet antibody assay is negative. He has had several episodes of gout over the past 6 years. respirations are 12/min. Pelvic examination shows erythema of the vulva 61 . leukocyte count is 5000/mm3. hydrochlorothiazide (25 mg/d). and blood pressure is 166/98 mm Hg. she had streptococcal pharyngitis treated with amoxicillin. and blood pressure is 120/80 mm Hg.000/mm3. his blood pressure was 170/94 mm Hg. She has received chemotherapy for 2 years. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) Repeat blood pressure measurement in 3 months Order renal Doppler ultrasonography Add atenolol to the regimen Add hydrochlorothiazide to the regimen Discontinue allopurinol therapy 102.2°C (99°F). An asymptomatic 72-year-old man comes to the physician for a routine examination. There is no evidence of depression.

respirations are 18/min. An x-ray of the chest shows bilateral hilar adenopathy.3°F). Examination shows a 6-cm. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) (G) (H) Cat-scratch disease Chronic lymphocytic leukemia Hodgkin disease Rubella Sarcoidosis Syphilis Systemic lupus erythematosus Tuberculosis 104. soft. He has had a painless left scrotal mass since childhood. A 22-year-old man comes to the physician for a routine health maintenance examination. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) 62 Acute cerebral infarction Arteriovenous malformation Astrocytoma Bacterial abscess Carotid cavernous fistula Epidural abscess Epidural hematoma Fungal abscess Glioblastoma multiforme Intracerebral hemorrhage . he moves the left extremities semipurposely but not the right extremities. Which of the following is the most likely cause of the mass? (A) (B) (C) (D) (E) Accumulation of scrotal adipose tissue Cryptorchidism of the left testis Dilation of the pampiniform plexus of veins around the testis Persistence of a patent processus vaginalis Torsion of the left testis 105. there are no bowel sounds in the mass. The pH of the discharge is 4. A 67-year-old man is brought to the emergency department because of headache and decreased level of consciousness over the past hour.4°C (99. A CT scan of the head shows a large hyperintense mass in the left basal ganglia with compression of the left lateral ventricle and shift of the midline structures. nontender left scrotal mass that transilluminates. Babinski sign is present on the right. A 37-year-old woman comes to the physician because of shortness of breath for 3 months. Her symptoms increase with exertion. pulse is 90/min. She also has had difficulty walking because of ankle pain. Examination of the testis shows no abnormalities. She takes acetaminophen for aches and pains. Which of the following is the most likely cause of these findings? (A) (B) (C) (D) (E) (F) Bacterial vaginosis Candidiasis Chlamydia trachomatis infection Escherichia coli infection Neisseria gonorrhoeae infection Trichomoniasis 103. and cardiac examination shows no abnormalities. She has not had a sore throat. Two months ago. The lungs are clear to auscultation. He is unresponsive to verbal stimuli. With painful stimulation. and blood pressure is 140/90 mm Hg.and vagina and a thick white vaginal discharge. He feels well. The left pupil is larger than the right and reacts sluggishly to light. she had painful red spots on her legs for several weeks. Her temperature is 37. He has a 20-year history of poorly controlled hypertension.

pulse is 130/min and irregularly irregular. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Chronic granulomatous disease of childhood Severe combined immunodeficiency Thymic-parathyroid dysplasia (DiGeorge syndrome) Transient hypogammaglobulinemia of infancy X-linked agammaglobulinemia 107. Bilateral crackles are heard at the lung bases. Examination shows a soft abdomen. He is not in acute distress.(K) (L) (M) (N) (O) (P) (Q) Medulloblastoma Meningioma Metastatic carcinoma Mycobacterium avium-intracellulare granuloma Sturge-Weber syndrome Subarachnoid hemorrhage Subdural hematoma 106. He is an only child. pneumoniae pneumonia at 7 months of age. A 67-year-old man is brought to the emergency department because of a 1-week history of nausea.3 mEq/L 18 mEq/L 40 mg/dL 1. spironolactone. Laboratory studies show: Hematocrit Leukocyte count Serum Na+ K+ HCO3− Urea nitrogen Creatinine AST 36% 10.000/mm3 140 mEq/L 7. Haemophilus influenzae meningitis at 5½ months of age. He has had frequent infections since the age of 4 months. There is 2+ edema in the lower extremities.7°C (98°F). A 52-year-old woman has had dyspnea and hemoptysis for 1 month. Her temperature is 36. Jugular venous pressure is not increased. and S. His immunizations are up-to-date. and there is no family history of frequent infections. isosorbide. He had Streptococcus pneumoniae bacteremia at 4 months of age. His temperature is 37. respirations are 20/min. hypertension. and metoprolol. and coronary artery disease. She has a history of rheumatic fever as a child and has had a cardiac murmur since early adulthood. He is at the 20th percentile for length and 3rd percentile for weight. Examination shows no abnormalities other than a purulent drainage from the left ear canal. digoxin. Which of the following is the most likely explanation for this patient's hyperkalemia? (A) (B) (C) (D) (E) Adverse effect of medications Laboratory error Metabolic acidosis Renal failure Rhabdomyolysis 108. and malaise. He has congestive heart failure. pulse is 88/min.2°C (99°F). He also has had two episodes of otitis media during this period. A 9-month-old boy is brought to the physician because of discharge from the left ear for 1 day. and blood pressure is 98/60 mm Hg. There is an opening snap followed by a low-pitched diastolic murmur at 63 . generalized weakness. Current medications include lisinopril. and blood pressure is 140/90 mm Hg.8 mg/dL 20 U/L Urinalysis shows no abnormalities.

Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) 64 CT scan of the abdomen CT scan of the chest Thoracoscopy Laparotomy Thoracotomy . Her pulse is 135/min. Pregnancy and delivery of her first child were uncomplicated.0 μU/mL. Which of the following is the most likely explanation for these findings? (A) (B) (C) (D) (E) Aortic valve insufficiency Aortic valve stenosis Mitral valve insufficiency Mitral valve stenosis Tricuspid valve insufficiency 109. Urine dipstick shows leukocyte esterase. at 12 weeks' gestation comes to the physician for a prenatal visit. She feels well.2°C (99°F). gravida 2. abdominal discomfort. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Acute stress disorder Agoraphobia Generalized anxiety disorder Hypothyroidism Panic disorder 111. Her temperature is 37. she was robbed at knifepoint in a parking lot 3 weeks ago. An x-ray of the chest shows opacification of the left lower lung field with loss of the diaphragmatic shadow. and serum thyroid-stimulating hormone concentration is 5. Medications include folic acid and a multivitamin. and difficulty concentrating. glancing around quickly when a loud noise is heard outside the office. and blood pressure is 108/60 mm Hg. urinalysis shows WBCs and rare gramnegative rods. Breath sounds are decreased at the left lung base. A 45-year-old woman has a 2-week history of increased anxiety. Pelvic examination shows a uterus consistent in size with a 12-week gestation. Her blood pressure is 140/80 mm Hg. On arrival. para 1. respirations are 30/min. Placement of a chest tube yields a small amount of air followed by greenish fluid. Examination shows dry skin and hair. An ECG shows sinus tachycardia. a straight left cardiac border. and pulmonary venous engorgement. She is cooperative but appears anxious. and blood pressure is 80/40 mm Hg. Which of the following is the most appropriate next step in management? (A) (B) (C) (D) (E) (F) Recommend drinking 8 oz of cranberry juice daily Oral amoxicillin therapy Oral metronidazole therapy Intravenous cefazolin therapy Intravenous pyelography Cystoscopy 110. she has shortness of breath and abdominal pain.the third left intercostal space. Leukocyte count is 12. An x-ray of the chest shows left atrial enlargement. A 42-year-old woman is brought to the emergency department 10 minutes after being involved in a high-speed motor vehicle collision in which she was a restrained passenger.000/mm 3. She takes levothyroxine for hypothyroidism and uses an over-the-counter inhaler as needed for exercise-induced asthma. and pulse is 100/min. irritability. A 27-year-old woman.

Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Herpes zoster Impetigo Pyoderma gangrenosum Syphilis Systemic lupus erythematosus 114. He underwent chemotherapy for non-Hodgkin lymphoma 1 year ago. There is blood on the vulva. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) Abruptio placentae Amniotic fluid embolism Latent phase of labor Placenta previa Ruptured uterus Ruptured vasa previa 113. Two weeks ago. para 4. and blood pressure is 138/76 mm Hg. and blood pressure is 134/76 mm Hg. She has had no prenatal care.112. A 56-year-old man has had the painful weeping rash shown for 2 days. Examination shows no other abnormalities. The abdomen is nontender. and no contractions are felt. and on the medial aspect of each thigh. The fetal heart rate is 144/min. she had a 3-day episode of flu-like symptoms that resolved without treatment.7°C (98°F). Her pulse is 92/min. her other three children were delivered vaginally. A 37-year-old woman. His temperature is 36. respirations are 18/min. Her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. gravida 5. pulse is 80/min. The fetus is in a transverse lie presentation. at 34 weeks' gestation comes to the emergency department because of vaginal bleeding for 2 hours. the introitus. She has a 65 . A 27-year-old woman comes to the physician because she has been unable to move the left side of her face for the past 2 days.

2 mg/dL 14 U/L 15 U/L Serologic testing for hepatitis A and B is negative. He says he feels well and has not had any problems. He occasionally drinks a beer or a glass of wine. She is sexually active with one male partner and uses an oral contraceptive. The patient does not smoke. diarrhea. pulse is 72/min. or constipation. total Direct AST ALT 44% 5000/mm3 11 sec (INR=1) 141 mEq/L 4. BMI is 31 kg/m2. Examination of the face shows thick. The remainder of the examination shows no abnormalities.history of impaired glucose tolerance. The fingertips are tapered and covered with ischemic ulcerations. She lives in Minnesota and hikes a wooded path with her dog daily to go swimming in a lake. A 27-year-old man comes to the physician for a routine health maintenance examination.0 mg/dL 0. Laboratory studies show: Hematocrit Leukocyte count Prothrombin time Serum Na+ K+ Cl− HCO3− Urea nitrogen Creatinine Bilirubin. There is no family history of liver disease. He has been in a monogamous relationship for the past 3 years.8 mg/dL 3. abdominal pain. they do not use condoms. A previously healthy 42-year-old woman comes to the physician because of a 6-month history of difficulty swallowing and regurgitation of undigested food. She is 157 cm (5 ft 2 in) tall and weighs 77 kg (170 lb). His temperature is 37°C (98.2 mEq/L 104 mEq/L 24 mEq/L 14 mg/dL 0. Examination shows no abnormalities except for mild scleral icterus. There are telangiectasias diffusely distributed over the trunk and upper extremities. and blood pressure is 118/70 mm Hg. He has no history of serious illness. His brother had kidney failure at the age of 32 years. She says she sometimes eats too much and occasionally consumes raw shellfish.6°F). tightly bound skin. He has had 10 lifetime male sexual partners and uses condoms consistently. Which of the following is the most likely cause of these findings? (A) (B) (C) (D) (E) Decreased conjugation of bilirubin Decreased excretion of bilirubin by hepatocytes Decreased intracellular storage of bilirubin Delayed uptake of bilirubin Hemolysis 116. Funduscopic examination shows retinal 66 . He occasionally takes acetaminophen for headaches. She has not had nausea. Examination shows an inability to wrinkle the left side of the forehead and an asymmetric smile. He has never used intravenous illicit drugs. Abdominal ultrasonography shows no abnormalities. She also has had color changes and pain in her fingertips when they are exposed to cold temperatures. Which of the following is the strongest predisposing factor for this patient's condition? (A) (B) (C) (D) (E) (F) Hiking Oral contraceptive use Overeating Shellfish ingestion Swimming in a lake Unprotected sexual intercourse 115.

hemorrhages bilaterally. and pain in the genital area. Internal examination is not possible due to patient discomfort. severe burning with urination. Laboratory studies show: Hematocrit Leukocyte count Serum Ca2+ Urea nitrogen Creatinine Albumin 40% 13. simvastatin. The lesions extend into the vagina. fatigue. Abdominal examination shows a large. Examination of the knee shows a large effusion. He holds the knee in 30 degrees of flexion. A previously healthy 20-year-old college student comes to the emergency department because she has been unable to urinate for 8 hours. lisinopril. She appears uncomfortable.7°C (101. He was admitted to the hospital 2 days ago for an acute myocardial infarction. She is sexually active and uses a diaphragm for contraception. and he underwent placement of a stent. clopidogrel. and heparin. She has a 2-day history of fever. She takes no medications. Which of the following is the most appropriate pharmacotherapy for this patient's pain and ulcerations? (A) (B) (C) (D) (E) Enalapril Methotrexate Nifedipine Prednisone Propranolol 117. midline pelvic mass. A hospitalized 57-year-old man has had severe progressive pain in his left knee since awakening 2 hours ago. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) (F) Deep venous thrombosis Gonorrhea Gout Hemarthrosis Pseudogout Septic arthritis 118. The knee is hot to touch and erythematous. Current medications include aspirin. Her temperature is 38. The groin nodes are enlarged and tender. metoprolol. Which of the following is the most appropriate initial step in management? (A) (B) (C) (D) Measurement of serum urea nitrogen concentration Vaginal cultures Intravenous pyelography Renal ultrasonography 67 .6 g/dL An x-ray of the left knee shows calcification of the synovium.0 mg/dL 3. Vital signs are within normal limits.7°F). and blood pressure is 110/70 mm Hg.2 mg/dL 15 mg/dL 1. Pelvic examination shows erythematous external genitalia with extensive ulceration. cystic. pulse is 110/min. Cardiac catheterization showed occlusion of the left anterior descending artery.000/mm3 9. the pain is exacerbated with further flexion or extension.

No wheezes are heard. The skin is cold to the touch. and blood pressure is 50/20 mm Hg. He responds to voice. A chest x-ray is shown. He appears pale and gasps and moans as he attempts to breathe. Ten minutes ago.(E) Placement of a Foley catheter 119. His temperature is 36°C (96.8°F). especially on the left. A 4-year-old boy with asthma becomes limp during treatment with inhaled albuterol in the emergency department. Which of the following is the most likely underlying cause of this patient's hypotension? (A) (B) (C) (D) (E) 68 Adverse effect of albuterol Adverse effect of methylprednisolone Atelectasis of the left lung Decrease in cardiac output Severe bronchospasm . Pulmonary examination shows poor air movement. The point of maximal impulse is 2 cm to the left of the midclavicular line in the sixth intercostal space. and he was alert and oriented at that time. He received the diagnosis of asthma 2 years ago and has been admitted to the hospital for acute exacerbations eight times since then. he received intravenous methylprednisolone for an acute exacerbation. respirations are 18/min. Current medications include albuterol and montelukast. pulse is 160/min and thready.

Vital signs are within normal limits. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Anomalous coronary vessels Atrial septal defect Endocardial fibroelastosis Tetralogy of Fallot Total anomalous pulmonary venous return 122. An x-ray of the chest shows a small boot-shaped heart and decreased pulmonary vascular markings. His temperature is 37. A 67-year-old woman comes to the physician for a follow-up examination. respirations are 44/min. BMI is 31 kg/m2. Her only medication is warfarin. Examination of the skin shows no abnormalities. She had a hematoma that was resolving on discharge from the hospital 2 weeks ago. She is 157 cm (5 ft 2 in) tall and weighs 77 kg (170 lb).120. She receives estrogen replacement therapy. Which of the following is the most likely cause of this patient's decreased sensation? (A) (B) (C) (D) (E) (F) Cerebral infarction during the hospitalization Complication of the IVC filter placement Compression of the lateral femoral cutaneous nerve Hematoma of the left thigh Spinal cord infarct Vitamin B12 (cobalamin) deficiency 121. she says she has had a persistent sensation of tingling and numbness of her left thigh that she did not report in the hospital because she thought it would go away. anticoagulant therapy was temporarily discontinued. and a 9-kg (20-lb) weight gain during the past year. and blood pressure is 75/45 mm Hg. Serum lipid studies were within the reference range 5 years ago. pulse is 170/min. A grade 3/6 harsh systolic ejection murmur is heard at the left upper sternal border. He was born at 38 weeks' gestation and weighed 2466 g (5 lb 7 oz). she has had fatigue.8°C (100°F). Muscle strength is normal. the sensation has improved somewhat during the past week. Today. A 62-year-old woman comes to the physician for a routine health maintenance examination. On questioning. Sensation to light touch is decreased over a 5 x 5-cm area on the lateral aspect of the left anterior thigh. and she underwent placement of an inferior vena cava (IVC) filter. She had a retroperitoneal hemorrhage. Serum lipid studies today show: Total cholesterol HDL-cholesterol LDL-cholesterol Triglycerides 269 mg/dL 48 mg/dL 185 mg/dL 180 mg/dL Which of the following is the most likely cause? (A) (B) (C) (D) (E) (F) Alcohol Diabetes mellitus Estrogen deficiency Estrogen replacement therapy Hypothyroidism Thiazide diuretic therapy 69 . he also sweats during feeding. She had a pulmonary embolism and required treatment in the hospital for 3 weeks. Physical examination shows no other abnormalities. A 2-week-old newborn is brought to the physician because his lips have turned blue on three occasions during feeding. constipation. he currently weighs 2778 g (6 lb 2 oz).

Her hemoglobin concentration is 11 g/dL. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Acute myocardial infarction Aortic dissection Esophageal rupture Mitral valve prolapse Pulmonary embolism 124. She has been drinking two alcoholic beverages daily for the past month. Examination 70 . respirations are 24/min. A 57-year-old woman comes to the physician because of an 8-week history of difficulty sleeping. Which of the following is the most appropriate initial step in treatment? (A) (B) (C) (D) (E) (F) Acupuncture Diazepam therapy Donepezil therapy Ferrous sulfate therapy Ginkgo biloba extract therapy Paroxetine therapy 125. she also has had memory lapses. and serum ferritin concentration is 140 ng/mL. severe chest pain. A 47-year-old man is brought to the emergency department 2 hours after the sudden onset of shortness of breath. Mental status examination shows a depressed mood and constricted affect. He has smoked one pack of cigarettes daily for 30 years. fatigue. before this time. Physical examination shows no abnormalities. A grade 3/6. He has no history of similar symptoms. she seldom drank alcohol. dizziness. Over the past 2 weeks. Which of the following is the most appropriate diagnostic test for this syndrome in this patient at this time? (A) (B) (C) (D) (E) Measurement of fetal nuchal fold Measurement of maternal serum α-fetoprotein concentration Chorionic villus sampling Amniocentesis Cordocentesis 126. gravida 2. She says that she is no longer interested in activities that she used to enjoy. The symptoms improve following ingestion of orange juice or soft drinks. diastolic blowing murmur is heard over the left sternal border and radiates to the right sternal border. A 27-year-old woman. She would like to be tested as soon as possible. She says that she has had a great deal of stress. Femoral pulses are decreased bilaterally. An ECG shows left ventricular hypertrophy. She is concerned about the risk for Down syndrome in her fetus because her first child has Down syndrome. She has had similar episodes over the past 6 months.123. difficulty concentrating. and sweating. and blood pressure is 110/50 mm Hg. During this period. A 27-year-old nurse comes to the emergency department because of nervousness. she has had three episodes of palpitations and shortness of breath that have awakened her from sleep. There is no personal or other family history of serious illness. and blood pressure is 110/90 mm Hg. and excess perspiration for the past 3 hours. He has hypertension treated with hydrochlorothiazide. at 10 weeks' gestation comes to the physician for a routine prenatal visit. She has suicidal ideation without a plan. Examination shows a uterus consistent in size with a 10-week gestation. His pulse is 110/min. palpitations. Her pulse is 80/min. para 1. and muscle tension. and has been reprimanded at work for arriving late.

Examination shows large dense breasts. Complete blood count. 71 . Intravenous glucose is administered. and pregnancy was complicated by an erythematous rash during the first trimester. 129. The infant is alert. Her mother died of metastatic breast cancer at the age of 40 years. mobile mass is palpated in the upper outer quadrant of the left breast. firm. He was born to a 21-year-old primigravid woman following an uncomplicated labor and delivery. (A) (B) (C) (D) (E) (F) (G) (H) (I) (J) Clostridium tetani Cytomegalovirus Escherichia coli Group B streptococcus Herpes simplex virus Listeria monocytogenes Parvovirus B19 Rubella virus Toxoplasma gondii Treponema pallidum For each newborn with an infection. She has had five sexual partners during the past year. A full-term newborn is brought to the emergency department at 5 days of age because of abnormal extremity movements for 6 hours. Her serum glucose concentration is 30 mg/dL. afebrile. and the patient's symptoms improve.shows no abnormalities. hypertonic. serum electrolyte concentrations. select the most likely pathogen. and there is no palpable axillary adenopathy. Which of the following is the most likely diagnosis? (A) (B) (C) (D) (E) Fibroadenoma Fibrocystic changes of the breast Infiltrating ductal carcinoma Intraductal papilloma Lobular carcinoma The response options for the next 2 items are the same. A 19-year-old woman noticed a mass in her left breast 2 weeks ago while doing monthly breast self-examination. 128. A 2500-g (5-lb 9-oz) full-term newborn has opacities obscuring the fundi and a continuous murmur heard over the left hemithorax. and cerebrospinal fluid analysis are within normal limits. and hyperreflexic. Select one answer for each item in the set. a 2-cm. The mother received no prenatal care. There are no changes in the skin or nipple. Which of the following is the most appropriate next step in diagnosis? (A) (B) (C) (D) (E) Liver tests Measurement of serum proinsulin and insulin antibodies Measurement of serum cortisol and ACTH concentrations Measurement of serum growth hormone and plasma somatomedin-C concentrations Measurement of serum insulin and C-peptide concentrations 127. The newborn was delivered at home to a 21-year-old primigravid woman who received no prenatal care.

weight.1°F). respirations are 40/min. vomiting. One week ago. 72 . Examination shows pale yellow skin and mild scleral icterus.3°C (99. He was born at term following an uncomplicated pregnancy and delivery. 130. She has received her complete hepatitis B immunization series. A 3-year-old girl is brought to the physician because of a 3-day history of dark urine and a 1-day history of yellow skin and pale stools. and diarrhea that have now resolved. During this period. His temperature is 37. Several other children at the day care she attends had similar symptoms 2 weeks ago. and head circumference. 131. There is mild tenderness of the liver to palpation. His skin is diffusely pale yellow. Abdominal examination shows mild distention and a subhepatic mass. He is at the 50th percentile for length. she had mild abdominal pain. (A) (B) (C) (D) (E) (F) (G) Autoimmune disorder Bacterial infection Metabolic process Obstruction Physiologic process Toxin exposure Viral infection For each patient with jaundice. select the most likely mechanism. and blood pressure is 70/30 mm Hg. A previously healthy 3-week-old newborn is brought to the emergency department because of a 2-day history of irritability and yellow skin. he has had dark urine and pale stools.The response options for the next 2 items are the same. pulse is 120/min. His mother was immunized against hepatitis B prior to conception. Select one answer for each item in the set. She is at the 50th percentile for height and weight.

35. 80. 76. 130. 47. 48. 45. 39. 49. A D B A 117. 99. 54. 108. 83. 15. B E D E D F C D H B 41. 23. 81. B C B E 107. 86. A D C F A B D A E F 21. 28. 70. 58. 56. 36. 16. A H F B A 127. E E D C 73 . 22.Answer Key for Step 2 CK Sample Questions Block 1 (Questions 1-41) 1. 37. E H E E 97. 8. 64. 32. 98. G 82. 69. 118. B G D A A C C E A B 52. 88. 89. 77. 119. 4. 3. F C A F D D B D B A 11. 65. 120. 2. 50. 68. 129. 75. 43. 61. 79. B A A B B D A A D E 31. 19. 29. 66. 38. 85. 30. 27. 10. 109. 24. 26. 78. 60. 73. 100. 17. 90. 33. 63. 46. 14. 25. 84. A H A G Block 2 (Questions 42-86) 42. 128. 13. A C C A B D B C C B 72. 12. 6. 9. 71. 44. 34. 110. B E E D B A A E B C 62. 40. 51. 67. 5. 18. E D A A D B E D B D Block 3 (Questions 87-131) 87. 74. 55. 7. 59. 20. 57. 53.

116. 94. 123. 126. 115. 112. 103. 74 A D C B B A 101. 92. 95. 102. 114. D . 113. 93. 96. 122. 124. D D A A A C 121. 106. 125. 104.91. C B E D J E 111. 105. D E B F C E 131.