Block 1

1. 22yo Primi admitted in labor. Pregnancy was complicated by 3 UTIs, the last one at 22 weeks
gestation. She’s now taking daily nitrofurantoin. Pt is otherwise healthy. What’s causing the recurrent
UTIs?

- Urinary Stasis

2. 4yo boy with 3-day hx of cough, fever, runny nose. No wheezing, vomiting, or diarrhea. 75th %ile
for height, and 10th %ile for weight. T 37.5. Cap refill is 2 sec. Exam shows clear rhinorrhea. Breath
sounds normal. There is a media tab to view the cardiac exam. Dx?

- URI

3. 42yo woman with generalized weakness, lethargy, and double vision for 2 weeks. Chest X-ray
shows upper anterior mediastinal mass. Dx?

- Thymoma

4. 4mo old brought to ER after an apparent seizure. Pt has vomiting 6 times over the last 2 days,
feeding poorly, and sleeping more than usual. Pt is lethargic and afebrile. Anterior fontanel is tense,
bilateral retinal hemorrhages. Dx?

- Child abuse

5. 52yo man with excruciating pain/swelling of his great toe since undergoing appendectomy 10
days ago. Celecoxib has provided no relief. Temp is 37.6. Exam shows red/swelling great toe and tender
MTP joint. Most appropriate next step?

- Indomethacin

6. During a sports physical, a healthy 14-yo boy has a BP of 150/90. Previous BP checks have been
normal. 6 ft 2 in and weights 180 lb. BMI is 24. Exam is normal otherwise. Most appropriate next step?

- Repeat BP check in 4 weeks

 7. 19yo man brought to ER by police after found standing in his neighbor’s living room in the middle
of the night. He is conscious but remains mute during questioning. Temp 37C, respirations 18/min, BP
160/95. Exam shows bilateral nystagmus, constricted pupils, hypertonia, and decreased sensation to
pinprick. Substance?

- PCP

8. Officer investigates an outbreak of illness at a picnic. Onset of nausea and vomiting 3 to 4 hours
after attending the picnic. All those affected recover without Rx. Egg salad was the vehicle of
transmission. What is the factor most commonly contributing to an outbreak of this type?

- Inadequate refrigeration of implicated food

9. 2 days after beginning ACTH therapy for MS, a 47yo woman exhibits bizarre behavior. She is easily
angered and thinks the nurses are terrorists. She’s been pulling out her IV and walking down the halls at
night. Muscle strength in lower extremities is 2/5. On mental status exam, she is fidgety, labile affect, and
is easily distracted. Oriented to person, but not place or time. Most appropriate Rx?

- Haloperidol

10. 50yo F with 5-year Hx of metastatic breast cancer has SOB for 8 hours. Pulse 116/min, resp
32/min, BP 90/60. End-inspiratory crackles heard at base of both lungs. JVD present. Distant heart
sounds. ABG shows: pH 7.50; Pco2 28; Po2 78. XR shows cardiomegaly, ECG shows alternating QRS
amplitude patterns. Echo shows paradoximal motion of the interventricular septum and a pericardial
effusion. Most appropriate next step?

- Pericardial window.

11. 14 month boy brought in for well-child exam. Mother is worried because he is not yet walking on
his own. He will stand for several seconds before falling. He can empty raisins from a cup and tries to eat
with a spoon. 25th %ile for length and 30th %ile for weight. Exam shows no abnormalities. Most
appropriate next step?

- Reassurance

12. Asymptomatic 23yo M in for preemplyoment evaluation. Exam shows normal findings. PPD
shows 16 mm of induration & erythema. He has had no previous PPD tests and hasn’t been exposed to
anyone with active TB. XR shows no abnormalities. Sputum contains no acid fast bacilli. Most
appropriate next step?

- Treat latent TB now

13. Previously healthy 26yo M in ER with SOB for 3 weeks and painful bumps on his legs for 1 week.
T 38.2, P 80/min, BP 140/85. Exam shows 2- to 3-cm tender, red nodules on anterior shins. CXR shows
bilateral hilar fullness. Which serum abnormalities is most likely in this patient?

- Increased calcium

14. 47yo F with fever, nausea, vomiting, and severe headache for 24 hours. T 39. Exam shows
weakness of right upper extremity and nystagmus, optic fundi cannot be visualized. Kernig sign is
present. Most appropriate next step in diagnosis?

- CT of head

15. 47yo F brought to ER 30 minutes after a MVC, unrestrained driver. Severe neck pain and mild
chest and abdominal pain. P 95/min, Respirations 20/min, and BP 120/80. Exam shows severe
tenderness of the cervical spine at C5. Bruise and mild tenderness over lower sternum and upper
abdomen. Neuro exam is normal. CXR is normal except for slightly widened mediastinum. Cervical spine
XR shows C5 facet fracture. Abdominal XR is normal. Most likely location of the life-threatening
cardiovascular injury?

- Thoracic aorta

16. 18yo primi at 37 weeks’ gestation admitted in labor. Regular contractions every 3 minutes.
Pregnancy complicated by several episodes of genital herpes, most recent episode 6 weeks ago. No
lesions or prodromal symptoms since last episode. Vaginal exam shows no lesions. Membranes are
intact. Fetal movement has been appropriate. Cervix 100% effaced, 5cm dilated, vertex at -1 station.
Most appropriate next step?

- Amniotomy and vaginal delivery

17. 4yo girl with 5lb weight loss during the last 2 months. No Hx of illness, on no medications,
immunizations up to date. 50th %ile for height, 25th %ile for weight. Occasional crackles over right
middle lung field. Intradermal testing with PPD, tetanus, and antigens for candida and trichophyton is
nonreactive at 72 hours. WBC count is 5100. Nucleic acid hybridization testing of gastric aspirates shows
TB. Most likely explanation?

- T lymphocyte dysfunction

18. 27yo F with 5 day history of headache, severe, diffuse abdominal pain, nausea, vomiting. Pain is
exacerbated by eating and relieved by vomiting. Vomitus originally had semisolid content with green
fluid, and now only contains clear yellow fluid. Hx of Crohn dz treated with prednisone, tapered over the
last 2 weeks, mesalamine, and azathioprine. LMP 7 weeks ago. Sex w/ 1 partner, use condoms
inconsistently. Temp 38.4, P 120/min, Resp 22/min, BP 90/50. Dry oral mucosa, pale conjunctiva,
distended abdomen, diffusely tender and tympanic. Decreased bowel sounds. Pelvic exam is normal.
Labs: HCT 31% WBC 15k, amylase 300, lipase 9. Dx?

- SBO

19. 37yo F with malaise, muscle aches, painful vulvar blisters, vaginal discharge, and dysuria for 3
days. Had sex with new partner 7 days ago. T 38. Exam shows bilateral painful inguinal lymphadenopathy
and numerous 1-3 mm vesicles and ulcers on labia majora and minora, perineum, vulva, mons pubis.
Next step in diagnosing these lesions?

- Cx for herpes

20. 52yo F with personality change since death of close friend 2 weeks ago. Irritable, less sleep,
speaks rapidly, jumping from topic to topic. She’s had past episodes excessive sleeping, decreased
energy, and loss of interest, but never thought these symptoms were severe enough to seek medical
attention. Mental status exam shows loud, rapid speech, and flight of ideas. She says she is not sad, but
rather uplifted by her friend’s death. She hears her friend’s voice and communicates with her. Dx?

- Bipolar d/o

21. 6 hours after CABG, 62yo experiences drop in BP from 120/80 to 100/85. Urine output decreases
from 60 to 10 mL/h, and cardiac output decreases from 6 to 3 L/min. Pulmonary artery diastolic pressure
has decreased . CXR shows widened mediastinum. Most appropriate next step?

- Surgical exploration of mediastinum

22. Homeless 66yo M with jaundice for 1 week. Eats irregularly, 20lb weight loss, over the past year.
20-year Hx of alcoholism. Icteric sclerae, palmar erythema, and spider angiomata. Serum Mg is 0.8.
Serum studies most likely to show?

- Decreased Calcium

23. 24yo F with amenorrhea for 7 days. 8-year Hx of anorexia. Compared to other women her age,
she has an increased risk for?

- Osteoporosis

24. 24. 62yo F with 3-mon Hx of difficulty swallowing solids and liquids, occasionally regurgitates
undigested food. Exam shows foul-smelling breath. Most appropriate next step in diagnosis?

- Barium Swallow

25. 24yo M with shortness of breath 2 days after ORIF of a midshaft femoral fracture. Abrasions over
left anterior chest wall. Initial CXR is normal. P 96/min, resp 24/min, BP 130/74. Exam shows petechial
hemorrhages of the conjunctivae and petechiae over the chest and upper extremities. ABG shows pH
7.48; Pco2 30; pO2 56; HCO3 23. CXR now shows fluffy infiltrates in both lung fields. Dx?

- Fat embolism syndrome

26. 160yo F brought in by her mom requesting birth control. Mom wants to talk to doc alone
because daughter is staying out late, receiving many calls from several different boys, and wear tight
clothing and excessive makeup. Daughter confides many details of the dates to her. Father is furious and
berates daughter, so mother doesn’t want to tell father about what is going on. On interview, she says
she doesn’t know why she is doing this, but would like to understand. Most appropriate next step in
management?

- Family therapy

27. 82yo F with metastatic breast cancer with low back pain and left thigh pain for 5 days despite
taking 5 mg of morphine syrup q4 hours. She says morphine wears off after 2-3 hours. She is otherwise
tolerating morphine without side effects. Most appropriate next step in management?

- Increase the frequency of the dose to every 3 hours

28. 17yo F with 4-month history of persistent rash over face and upper back (photo). Which
structure is primarily involved in the development of this rash?

- Pilosebaceous follicles

29. 42M in ER, 6 hours after onset of severe flank pain. T 37C P 110/min, resp 12/min, BP 130/90.
Tenderness over RLQ of abdomen and costovertebral angle. UA shows 50-100 RBC and 3-5 wbc. 2 hours
after morphine, symptoms subside. In addition to analgesics, most appropriate next step in
management?

- Discharge and encourage fluid intake

30. 72yo M with 3 month Hx of difficulty climbing stairs, arising from chair, and combing hair. 4-year
Hx of hypercholesterolemia treated with simvastatin. Cranial nerves intact. Tenderness to palpation over
UE and thighs. Strength 4+/5 in deltoid, biceps, triceps, hip flexor, and quads. DTR and sensation are
normal. Most likely location of the abnormality?

- Muscle

31. 72yo F with indigestion while walking uphill or briskly, relieved with rest. Sx are not related to
eating and not relieved by antacids. Most appropriate next step in management?

- Exercise stress test

32. 67yo M with 1 mo Hx of recatal bleeding. Passes bright red blood with bowel movements. No
other Sx. Hx of HTN and osteoarthritis. Current meds: losartan, metoprolol, amlodipine, and naproxen.
Father had colon cancer at age 70 and died at 74. 89yo mother had breast cancer 20 years ago and has
survived. 183cm tall, weighs 91kg; BMI 27. Vitals are wnl. Mass palpated in rectum, remainder of exam is
wnl. Colonoscopy shows ulcerating rectal mass, bx shows rectal cancer. Review of which clinical study is
most useful in developing treatment plan?

- RCTs

33. 6mo boy with diaper rash for 3 days. Otherwise healthy. Breast-feeds 6x a day. T 37.4C, P
100/min, resp 25/min. On exam, 2-cm crusted, popular, honey-colored lesion with clear discharge in left
groin. Most appropriate next step in management is topical application of?

- Mupirocin
 34. 27yo M and wife unable to conceive for past 10 mo. Wife conceived from previous marriage,
husband with no children. Wife’s menses and are normal, and her exam is wnl. Exam of husband shows
ill-defined soft masses palpated bilaterally, high in scrotum. Most likely cause of these masses?

- Bilateral varicoceles

35. 9yo boy with low back pain for 4 months, present throughout the day, but most severe when he
awakens and after physical activities. Pain described as dull ache. Walks with a stooped gait, but appears
well. Exam shows tenderness of right SI joint, paravertebral muscle spasm, decreased flexion at waist.
Skin exam normal, CK normal, ESR is increased. XR of spine shown. Dx?

- Ankylosing spondylitis

36. 15yo girl with low back pain for 2 mo, dull ache present all day and night, making it difficult to
find comfortable sleeping position. Hx of asthma for 2 years treated with prolonged courses of oral
prednisone. Cushingoid and hirsute appearance. Tenderness from T11 to L2 and paravertebral muscle
spasm. CK and ESR wnl. XR shown. Dx?

- Compression fracture

37. 6yo boy with cramping abdominal pain & right-sided scrotal pain for 4 hours. Vomited once,
Exam shows distended abdomen. BS decreased, and deiffuse tenderness to palpation with involuntary
guarding. Right hemiscrotum discolored with swelling & tenderness superiorly. Left hemiscrotum is wnl.
Most appropriate next step in management?

- Operative procedure

38. 62yo F with SOB for 12 hours. 15y Hx of type 2 DM and 3y hx of chronic renal insufficiency. Meds
include insulin and captopril. T 38.2C, P 88/min, respt 16/min, BP 144/70. Exam shows no adenopathy.
Inspiratory crackles greater on right than left. Cardiac exam: discrete PMI, S1/S2 wnl, intermittent S4.
Trace pedal edema. Pulse ox on room air shows o2 sat of 90%. 13,000 leukocytes, creatinine is 2.2. CXR
shows patchy infiltrate in right midlung. Rx ith IV ceftriaxone and heparin is begun. She has poor oral
intake, and temp ranges from 37 – 38.4C, and BP range from 112/60 to 146/84. Glucose range from 140-
320 despite insulin control. 4 days later, Cr is 3.6. What could have prevented renal deterioration?

- IV fluids
 39. 24yo W with intermittent double vision and drooping of the eyelids for 3 weeks and difficulty
chewing and swallowing for 1 week. Sx worse late in day. Eyelid ptosis worse on the right, weakness of
abduction of right eye, adduction of left eye, and eye closure. Weakness of forehead and mouth. Speech
is nasal. DTR and sensation are normal. Dx?

- decreased acetylcholine receptors

40. 37yo M with progressive weakness over the past 5 days, started at ankles and spread to proximal
muscles of lower extremities, hands, forearms, and face. Mild tingling of feet and fingers. Had URI 2
weeks ago. Exam shows moderate weakness of facial muscles and muscles of extremities and marked
weakness of distal muscles of extremities. DTR absent, hypotonia of knees/ankles. SLT and vibration
mildly decreased over feet. Dx?

- Demyelination of axons? Could be incorrect. Answer is NOT E, loss of motor neurons

41. 32yo F abdominal pain, N/V for 6 hours. Cholesystectomy 2 years ago. Menses wnl, LMP 2 weeks
ago. No smoking/drinking. Appears acutely ill. T 37.4 resp 14/min, P 110/min BP 130/70 while supine, p
135 BP 90/60 when standing. Exam: guarding with rebound, BS decreased.

Labs: NA 146, K 3.3, Ca 8.9, T bili 1, alk phos: 120, AST 64 Amylase 1022.

Most appropriate next step to determine cause is measurement of?

- Triglycerides

42. 4yo boy with fatigue since viral illness 3 weeks ago. Pale for 1 week, gums bled yesterday when
brushing. Cervical, axillary, and inguinal adenopathy and hepatomegaly. Hb is 8, leukocytes 3000,
platelets 30k. Most appropriate next step in management?

- Bone marrow aspiration

43. 1 day after removal of large meningioma, 42yo F is comatose, intubated. Groans/moves
extremities to painful stimuli. T 37.2, p 96/min, resp 14/min, BP 110/72. Neuro exam shows no focal
findings. Labs: Na 155, Cl 120, K 3.6, HCO3 24, urea nitrogen 16, Cr 0.8, Urine specific gravity 1.004. In
last 24h, she’s received 2L IV 0.9% saline and had urine output of 6 L. Explanation for the hypernatremia?

- Diabetes insipidus
 44. 82yo F with visual loss in left eye since awakening. HTN treated with Lisinopril, and takes daily
aspirin. Pupils are 2 mm bilaterally and reactive to light. Visual acuity is 20/30 on R and 20/400 on L.
Fundoscopic exam of L eye shows dilated retinal veins and widespread retinal hemorrhages intermixed
with patches of white exudate. R optic fundus wnl. Dx?

- central retinal vein occlusion

45. 47yo F with fatigue for 1 week. 10y Hx of type 2 DM Rx with short-acting insulin before each
meal needed and 12 U of intermediate acting insulin at bedtime. Over past week, glucose levels >250.
BMI 27. T is 38.5C, P 90/min BP 110/70 when supine, P 120/min bp 90/40 when standing. Urine is pos
for glucose, neg for protein and ketones. UA shows 6-10 wbc and no RBC casts. Cause of postural
hypotension?

- intravascular volume depletion

46. 18yo F with 3-day hx of fatigue and yellow eyes. Hx of anemia, but otherwise healthy. 16yo
brother also has anemia. T 36.7C, p 82/min, resp 14/min, BP 105/69. Scleral icterus, exam shows mildly
tender 1-cm cervical lymph nodes. Spleen tip palpated 3 cm below costal margin. Hb 8.6, MCHC 38%,
retics 8%, Serum T Billi 3. Negative coombs. Blood smear shown. What would have prevented
symptoms?

- Splenectomy

Block 2

1. 37yo M with end-stage Duchenne muscular dystrophy. Life expectancy less than 6 months. Patient
tells physician that he is “tired of living like this” and requests a DNR with no further antibiotics. He has
considered this decision for 3 weeks, but has not discussed it with family. On mental status exam, he
shows sadness about his health, but has a normal thought process. He expresses no ambivalence about
his decision. Most appropriate next step in management?

- Determine if patient wants to discuss his decision with anyone else

2. 36yo G1P1 with heavy vaginal bleeding since delivery of placenta 15 minutes ago. Had vaginal
delivery of full term 4200g baby after 3-hour second stage of labor. P 110/min, BP 90/60. Fundus
palpated 3 cm above umbilicus. No evidence of genital tract injury. Placenta appears complete but torn.
Dx?

- Uterine atony

3. 57yo F with factor XI and IgA deficiencies is scheduled to undergo resection for colon cancer.
Preop HCT is 24% and requires transfusion with 2 unites of PBRC. 3 minutes after beginning the first unit,
patient develops severe shortness of breath and urticarial with swelling of tongue and throat. She
appears anxious. BP 90/60. Dx?

-Anaphylactic transfusion reaction

4.

Q. Three days after hospitalization for treatment of severe muscle weakness secondary to Guillain-
Barre syndrome, a 21-year old woman has a temperature of 39C (102.2F). Arterial blood gas analysis on
2 L/min of oxygen via nasal cannula shows pH 7.33, pCO2 32 mmHg, PO2 50 mmHg. An x-ray of the chest
shows infiltrates in the middle and lower lobes. Bronchoscopy is performed; Gram stain of material
obtained from the right main-stem bronchus shows numerous segmented neutrophils, gram-positive
cocci, and gram-negative cocci and bacilli. Which of the following is most likely to have prevented her
acute pulmonary symptoms?

A) Elevation of the head of the bed

B) Nasogastric suction

C) Administration of intravenous cephalosporin

D) Administration of intravenous cimetidine

E) Administration of subcutaneous heparin

5. 32yo nulligravid with PCOS trying to conceive for 3 years. Menses occur at irregular intervals. She
is 165 cm tall and weighs 100 kg. BMI is 37. Most appropriate Rx?

- Clomiphene

6. 25yo primigravid at 27 weeks gestation with severe contractions for 6 hours that have not
resolved despite changing positions and increasing fluid intake. Small amount of vaginal spotting the last
time she voided. External fetal monitoring shows contractions every 2 – 3 minutes and a fHR of 130/min
with no decels. Cervix is 1 cm dilated and 10% effaced. Fetal presenting part is high. During the next
hour, she receives oral hydration. Temp 37.2C, P 110/min, resp 16/min, BP 110/70. Lungs are clear,
fundal height is 27 cm. Cervix is now 1 – 2 cm dilated and 70% effaced; vertex at -2 station. Positive GBS
culture. Most appropriate next step in management?

-IM betamethasone

7. 37yo M with 6-month Hx of SOB and fatigue. SOB after walking 2 blocks. Sleeps 6 hours nightly
but doesn’t feel well-rested. No smoking/drinking. Worked as teacher for 15 years. BMI is 59. P 86/min,
resp 14/min, BP 146/92. Lungs clear, breath sounds are decreased. Normal cardiac exam. ABG shows pH
7.32, Pco2 56, Po2 70. CXR is normal. Most likely cause of hypoxemia?

- Alveolar hypoventilation

8. 27yo asymptomatic HIV positive F requesting advice for immunization. All childhood
immunizations up to date. MMR 4 years ago, last tetanus vaccine 6 years ago. Hep B antibody was
positive 3 weeks ago. CD4 count was 450 3 weeks ago. Which immunization is most appropriate?

-Pneumococcal vaccine

9. Afebrile 32yo F with cramping abdominal pain and watery stools for 4 days. Exam is normal. Her
Hb is 12.5, and leukocyte count is 8500. Exam of stool shows no neutrophils. Organism?

- Enterotoxic E. Coli? Answer is NOT S. Aureus

10. 67yo M with uncontrollable nosebleed for 6 hours. No Hx of HTN and takes no meds. Smokes 1-2
packs for 45 years. BP is 220/120. Exam shows lesion in left naris controlled with cauterization. Bilateral
bruits over flank. Rental arteriography shows 13 cm kidneys with single renal arteries. Ostial lesions of
both kidneys that occlude 85% of vessel orifice. After ACE inhibitor, BP drops to 140/80. Mechanism of
response?

-No cleaving of C-terminal peptides on angiotensin I

11. 62yo F in for resection of ovarian tumor. 25 lb weight loss over past 2 months. Exam shows
adnexal mass, and no other abnormalities. Preop labs: Serum - BUN 80; Cr 5.7; Urine – Glucose none;
protein trace; WBC 0-2; RBC 0-2; Casts none; crystals none; bacteria none. Most appropriate next step to
determine cause of renal failure?
 -Renal U/S

12. 57yo F with pain over left groin and anterior thigh for past year. Active range of motion of hip
joint reproduces pain. 20-degree hip flexion contracture. ESR is 20; pelvic XR shown; Dx?

- Osteoarthritis

13. 32yo F with headache, joint pain, fatigue, fever for 2 weeks. 3 weeks ago, she had a bright red
rash on right calf for 7 days. No Hx of illness, no meds. T 37.7C. Physical normal except for pain on
hyperextension of knees. Neuro exam normal. Positive IgM antibody assay to Borrelia burgdoferi.
Administration of which of the following is most appropriate next step to prevent long-term
complications of this disease?

-Amoxicillin

14. 17yo girl in MVC as unrestrained driver. Arrives on a backboard with C-collar. During attempts to
administer 100% O2, patient is combative. Facial trauma and open facial fractures. Chest severely
bruised. Makes gurgling sounds when she breathes. Most appropriate initial step in management?

-Cricothyrotomy

15. 52yo F with 5-day Hx of abdominal pain, nausea, decreased appetite. Nine days ago, underwent
lap cholecystectomy for stones. Discharged 7 days ago. T 38.2, P 108/min, resp 20/min, BP 102/64. Exam
shows jaundice, RUQ tenderness. Bowel sounds present. Labs: Hb 12.2, HCT 36%, Leukocytes 17,200
BUN, 48; Glucose 186; Cr 1.5; T bili 7.2; alk phos 251; AST 84. U/S is normal; Most appropriate next step
in management?

-ERCP

16. 32yo M with 3-month Hx of burning substernal chest pain and sour taste in his mouth.
Sometimes awakens at night with acidic liquid in his mouth. Nonproductive cough for 2 months. Smoked
1 pack daily for 14 years. Drinks 6 beers every week. BMI 31. Exam is otherwise normal. Most
appropriate next step in management?

- Trial of omeprazole therapy

 17. 47yo M with 6-month Hx of progressive weakness that began in his right leg and gradually
spread to his other extremities. Mild difficulty swallowing solids and liquids. Exam shows atrophy of right
quads and both deltoid muscles and fasciculations in both quad muscles. Babinski sign present
bilaterally. EMG and nerve conduction studies are most likely to show?

- Fibrillation potentials in multiple muscles of multiple extremities

18. 22yo M exposed to unknown gas, now vomiting and has diarrhea. Pulse 96/min, resp 20/min, BP
115/65. Exam shows miosis, copious oral secretions, rhinorrhea, and muscular fasciculations. Diffuse
wheezing bilaterally. Clothing is removed. While being washed, he has a generalized tonic-clonic seizure.
Most appropriate Rx?

- Atropine

19. 2 hours after repair of perforated gastric ulcer, 75yo W has multifocal PVCs. Hx of CHF treated
with Digoxin and diuretics. Most likely abnormal serum concentration?

- Decreased potassium

20. 55yo F with metastatic breast cancer admitted for confusion progressing to obtundation over
past 24 hours. Barely arousable. Most likely abnormal serum concentration?

- Increased calcium (by way of PTHrP)

21. 57yo F with HTN in ER for 8-hour Hx of nausea, vomiting, diarrhea, abdominal pain, and
weakness. Slight blurred vision, double vision, dry mouth, and tingling and numbness of her legs. 32
hours ago, consumed pork, shrimp, rice, and home-canned preserves. 1 week ago, had URI that resolved
without treatment. Current meds: Lisinopril and 81-mg aspirin. No smoking or drugs. T 36.9C, Pulse
64/min, resp 16/min, BP 124/72. Pulse ox shows O2 saturation of 94%. Pupils slightly dilated, sluggishly
reactive. Mucous membranes are dry. Normal cardiopulmonary exam. Weakness of oculomotor and
facial nerves. Muscle strength 4/5 in lower extremities. DTR 2+. Dx?

- Botulism

22. 75yo M with confusion and lethargy for 2 days. Was gardening on a 100F day before symptoms.
15-year Hx of DM treated with glyburide and 25-y Hx of HTN treated with HCTZ. Underwent lap chole 6
weeks ago. Smokes 1 pack daily and 2 drinks nightly. Traveled to Hawaii 2 months ago. T 41.5C, pulse
120/min, BP 90/60. Skin is hot and dry but not erythematous. Muscle tone decreased Serum CK is 8000,
AST is 400. Cause?

-Heat stroke

23. 4yo boy in ER for not using his left arm. No known injury to arm. Comfortable, but resists
attempts to move arm due to pain. Holds left UE with elbow flexed and forearm in pronation. No
evidence of injury, radial pulses normal. Sensation is full. Most appropriate next step in management?

- Supination of forearm with elbow in slight flexion

24. 37yo F with alcoholism in ICU for pancreatitis. During first 12 hours, vitals: Pulse 100-130/min;
resp 28-36/min; SBP 90-110. 14 liters of crystalloid solution infused to maintain urine output of 30 mL/h.
She is intubated for low O2 saturation. Lungs are clear. Pulmonary cath shows: Cardiac index 4.2L/min;
CVP 11; PCWP 10. ABG on FiO2 of 60% and PEEP of 10: pH 7.32; Pco2 38; Po2 78. CXR shows bilateral,
diffuse, hazy densities with cephalization of the pulmonary vasculature and perihilar fullness. Dx?

- ARDS

25. 43yo M with 3-day Hx of Temp 38.4C, left-sided chest pain, malaise, loss of appetite, and a cough
productive of yellow phlegm and SOB. Smoked 2 packs/day for 25y. He appears ill. Pulse 112/min, resp
22/min, BP 118/72. Crackles and wheezes at left base, breath sounds decreased. Increased tactile
fremitus and dullness to percussion at left base. CXR shown. Gram neg bacilli and leukocytes on stain.
Dx?

- H. influenza

26. 32yo F at 16 weeks’ gestation with 6-hours of fever and waxing/waning consciousness. Only
meds is multivitamin with iron. T 38.3C. Neuro exam shows waxing/waning consciousness. HCT is 11%,
platelets 52K, Cr is 3.5. Blood smear shows schistocytes. Dx?

- TTP

27. 4 days after right hemicolectomy, 67yo F has leakage of serosanguineous fluid b/w incision
staples; the dressing is soaked. Meds include corticosteroids for COPD, T 37.5C, pulse 73/min, BP 140/90
Abdominal exam shows distension with minimal incisional tenderness and no erythema. Dx?

- Wound dehiscence

28. Sexually active 24yo M with painful sores on his penis for the past 5 days. There’s
lymphadenopathy. No fever/chills. Lesions are shown. Dx?

-Genital herpes

29. 22yo F nulligravid for routine exam. Concerned about risk for ovarian cancer because her mother
was diagnosed at age 42. Doesn’t know of anyone else in her family who has had acancer. No Hx of
serious illness, no meds, Menses normal, no smoking, occasional alcohol. Sexually active at 16. Uses
condoms for contraception. Plays tennis 2-3X a week. BMI is 21. Temp 37C, P 60/min, resp 20/min, BP
100/60. Physical is normal. Most appropriate recommendation?

- Oral contraceptive therapy

30. 72yo M with SOB for 3 days. Hx of HTN and CAD. Receiving 2 L/min of O2 via nasal canula. Temp
37C, P 110/min, resp 20/min, BP 150/80. Bilateral crackles and wheezes. HCT is 28%, leukocyte count is
8000. Pulmonary artery cath shows cardiac index of 2 L/min (N = 2.5 – 4.2) and a pulmonary artery
occlusion pressure of 28. ABG shows pH 7.49; Pco2 30; Po2 58. Most appropriate next step in
management?

- Diuretic therapy

31. Over the past 2 years, 67yo M with gradually progressive difficulty walking. Good health, no
meds. Smoked 1.5 packs per day X 50 years and 3 drinks per night. Wide-based gait and tends to reel
from one side to the other. Cannot walk more than three steps heel-to-toe in a straight line. Which
would have prevented this condition?

-Abstinence from alcohol

32. 15yo boy brought by mother for changes in behavior since he was transferred to new school 4
months ago. He has become withdrawn, poor sleep, daytime fatigue, 10-lb weight loss, declining
academic performance. His maternal uncle and grandmother treated for depression. Denies alcohol or
illicit drugs. Physical is normal. Cooperative, but flat affect. Dx?
 - Major depressive disorder

33. 11yo girl brought by parents for noticeable body odor. 3-month Hx of arguing and acting
secretive at home. Exam is normal except for mild facial acne. Sexual development is Tanner stage 2.
Mental status exam is normal. Most appropriate next step in management?

- Education about puberty for the child and parents

34. 50yo F with Hx of hypothyroidism has tingling in hands and feet and difficulty maintaining her
balance over last 2 months. Pale complexion, easy fatigability, and SOB. Labs show megaloblastic anemia.
Anormal Schilling test corrected by oral intrinsic factor. What’s causing her anemia?

-Atrophic gastritis

35. 12mo boy with 4-hour Hx of temp to 40.6C and irritability. Two previous infections during past 8
months: pneumococcal bacteremia at age of 4 mo and periorbital cellulitis caused by H influenze type b
at 7mo. All immunizations were given. LP shows CSF with leukocytes of 500, 95% neutrophils. Gram stain
shows gram positive diplococci. Cell type involved in Dx?

- B lymphocyte

36. 12mo boy with persistent S. aureus abscess despite 2 weeks of cephalexin. 3rd infection since
birth, including inguinal abscess with S. aureus, pneumonia and empyema. Cell type involved in Dx?

- Neutrophil

37. 6 hours after undergoing left thoracotomy for coarctation of aorta, 10-day-old newborn is fussy
and irritable. Sedated and mechanically ventilated. Temp is 37.2C, pulse 160/min, resp 30/min, BP
110/70. Most appropriate next step in management?

-Analgesic therapy

38. 42yo F with intermittent loss of urine over past 3 weeks. Sx only after voiding. Pelvic exam shows
3-cm, midline, cystic, tender mass in the midthird of vagina. U/A is normal. Posvoid residual volume is 50
mL. Dx?
 - Urethral diverticulum? Answer is NOT interstitial cystitis

39. 17yo boy unresponsive after using heroin at a party. He is obtunded. Temp is 35.9C, pulse
75/min, resp 6/min, BP 100/60. Administration of which of the following is most appropriate initial step?

-Naloxone

40. 27yo male stuck with needle while drawing blood from patient positive for hepatitis B antigen.
Physician was vaccinated against hep B 2 years ago. Labs show adequate antihepB antibodies. Most
appropriate management to prevent hep B infection in the physician?

- No treatment necessary

41. 32yo M with depression has sensation of insects crawling under his skin for 2 weeks. Initially
treated for scabies, but then told he had herpes zoster. Using acyclovir and topical scabies preparation,
but Sx have worsened, and he now sees tiny worms crawling out from his skin. Appears anxious but
healthy. Scattered excoriations over his face, head, abdomen, and upper and lower extremities. Lesions
are punched-out sores on a clean base. Tox screen most likely to show?

- Methamphetamine

42. 57yo M with mild left flank pain and intermittent blood in his urine for 3 days. No meds. He
appears to be in mild distress. Temp 37.2C, pulse 88/min, resp 12/min, BP 146/94. Mild left
costovertebral angle tenderness. Serum Ca is 10.9, phosphorus 2.3, intact parathyroid hormone is 1020
(N=10-65). Ct shows renal calculi bilaterally. Cause of calculi?

- Increased urinary excretion of calcium

43. 27yo M brought to ER 30 minutes after a 10minute episode of loss of consciousness; during
episode, pulse 45/min, occurred while viewing body of his brother at the morgue. LOC was preceded by
sweating and light-headedness. Pulse is 100/min and regular, resp 12/min, BP 140/80. He hasn’t eatin in
14 hours. Dx?

- Vasovagal syncope
 44. 32yo M brought to ER after syncope while jogging. On arrival, he is alert and conversant. BP is
140/84. Grade 3/6 systolic murmur at LSB, intensity increases when he stands from a squatting position.
Explanation?

- Hypertrophic obstructive cardiomyopathy

45. 54yo M with weakness and numbness of the left upper and lower extremities for 1 week; he is
now asymptomatic. BP is 150/80. Carotid duplex shows 90% stenosis of right internal carotid. Serum
cholesterol is 200. Most appropriate management to prevent subsequent stroke?

- Carotid endarterectomy

46. 8-hour-old newborn develops jaundice and respiratory distress. Born at 39 weeks’ following
uncomplicated pregnancy and delivery. He is pale and edematous. Hepatosplenomegaly and scattered
petechiae. Labs show Hb of 4, total bilirubin of 15, with a direct component of 0.3. Dx?

- Rh incompatibility

Block 3

1. 15yo girl with finger pain and swelling for 6 months. Appears well nourished, erythema over the
cheeks. Minimal redness, tenderness, and swelling around proximal interphalangeal joints of the hands.
Labs show Hb 10.3; leukocytes 2500; C3 27 (N=72-120); ANA positive 1:60; RF negative; Urine blood 1+,
protein 4+, RBC 30-50. Dx?

- SLE

2. 14yo boy with 6-month Hx of left knee pain exacerbated by activity. No Hx of injury. He has grown
3 inches over the past 6 months. His older brother had similar Sx at the age of 13 years. Normal gait,
ROM is normal. Tenderness over left tibial tubercle. No joint effusion, knee joint is stable. Mechanism?

- Repeated microfracture at the tendon insertion

3. For 12 hours, 25yo F G2P1 at 20 weeks’ has severe epigastric pain that radiates to the back.
Vomited once. Temp 37.8C, pulse 92/min, BP 120/80. Fundus is nontender, fundal height is 21 cm. FHR is
138/min. HCT is 42%, leukocyte 9000, platelets 220k. Most appropriate next step in management?

- Measurement of serum amylase activity

 4. 21yo primi at 37 weeks’ with mild epigastric pain and moderate headache for 24 hours. Temp
37C, BP 150/98. Fundus nontender, fundal height is 36 cm. FHR is 130/min. DTR are 3+, urine protein is
3+. Most appropriate next step in management?

- Measurement of platelet count

5. 3 days after total hip replacement, 50yo M is unable to move his legs and has urinary
incontinence. Sx began immediately following removal of epidural catheter inserted for pain control. His
meds include ketorolac, enoxaparin, and morphine. Dx?

- epidural hematoma

6. 47yo M with 9-mo Hx of constipation and 2-mo hx of blood in stool. Sx partially relieved by stool
softeners and laxatives. Has hypercholesterolemia rx with atorvastatin, and had appendectomy at age
26. Vitals normal. Cardiopulmonary, abdomen exam normal. Rectal exam shows external hemorrrhoids.
Positive occult blood test. HCT is 35%. Most appropriate next step in management?

- Colonoscopy

7. 67yo M with fatigability & generalized weakness for 3 mo and chest pain for 1 mo, which is worse
on deep inspiration. He appears slightly pale. Tenderness over left 8th and 9th ribs. HCT 28%. SPEP and
UPEP show monoclonal spike. BM biopsy shows greater than 50% plasma cells. CXR shows 1.5cm areas
of radiolucency in 8th/9th ribs. He's most susceptible to infection with?

- S. Pneumoniae

8. 4 CAGE questions are used to screen for alcoholism. If the number of "yes" responses needed for
test to be positive is decreased to one, how will it effect sensitivity and specificity?

- Increase sensitivity, decrease specificity

9. 32yo F with asthma and 3-mo Hx of progressive cough. Initially, nonproductive cough every 2-3
days. For the past month, cough occurred daily and has been productive of thick yellow sputum/tinged
w/ blood. 1-mo Hx of SOB after walking two blocks. Meds include albuterol and budesonide inhalers,
used more frequently over the past month. No smoking. Today, in mild resp. distress. T 37C, P 88/min,
resp 17/min, BP 110/65. Pulse ox: O2 sat 93%. Scattered end-expiratory wheezes bilaterally with corase
rhonchi at bases. Labs: HCT 42%, WBC 10k (67% PMNs, 8% eosinophils, 25% lymphos). platelets 160k,
serum IgE 1250. CXR shows linear atelectasis at bases and thickened airways with irregular cystic
opacities. Dx?

- Allergic bronchopulmonary aspergillosis

10. 62yo M with intermittent painless rectal bleeding for 3 weeks. Hx of angina and taking inhaled
corticosteroids for COPD. Smoked 1.5 packs daily for 45 years. Vitals normal. Crackles and wheezes
bilaterally. Heart sounds normal. Rectal exam shows palpable mass 2-3 cm inside anal verge. Anoscopy
shows 5-cm ulcerated mass, bx shows adenocarcinoma. Most appropriate next step in management?

- Colonoscopy to the cecum

11. 62yo M brought in 30 min after onset of severe chest pain. Tearing sensation in midchest
radiating to his back. P 104/min, resp 24/min, BP 200/120 in RUE and 180/100 in LUE. Decreased left
brachial pulse. Grade 2/6 diastolic decrescendo murmur at RSB. CXR shows widened mediastinum. Most
appropriate initial pharmacotherapy?

- IV labetalol

12. 37yo F G3P3. Exam shows 3-cm, nontender, fluctuant mass involving left posterior vulva
underlying the mucosa of the vestibule and external to the hymenal ring. Dx?

- Bartholin duct cyst

13. 18yo F with fever, mild nonproductive cough, sore throat, general malaise, and anorexia for 5
weeks. Exudative pharyngitis with a whitish membrane, cervical LAD, and splenomegaly. Dx?

- EBV

14. 42yo M scheduled to undergo MRI for hemoptysis and abnormal CXR. During MRI, he yells to get
out, and appears pale. No chest pain or SOB, but had tunnel vision and tingling in his fingers while in the
machine. Hx of hypothryroidism Rx with levothyroxine and occasional heartburn rx with rantidine. P
104/min, resp 22/min and shallow, BP 140/09. No evidence of paranoia. Most appropriate next step in
management?
 - Lorazepam therapy

15. 72yo M hospitalized because of dyspnea for 6 weeks. Hx of type 1 DM and angina. Meds include
insulin and warfarin. During past 4 months, was hospitalized once for DVT and another time for PE. Exam
shows JVD, ascites, pitting pretibial edema. CXR shows mild cardiomegaly and no pulmonary edema.
Cause?

- Cor pulmonale

16. 24yo F primi at 38 weeks' gestation admitted in labor. Spontaneous ROM 2 hrs ago. Contractions
are moderate and occur every 5-6 min. Was treated at 20 wks with ampicilin for GBS UTI. Temp 37C, p
82/min, resp 18/min, BP 122/74. Cervix 2 cm dilated and 80% effaced; vertex at -1 station. Most
appropriate rx to prevent GBS infection in the newborn?

- IV Penicillin G

17. 27yo M with 2-month history of a rash on his face, neck, and torso. Rash began with couple tiny
spots, and now there are more than 100. Exam shows 2-8 mm flesh-colored papules with central
umbilication over face, neck, back, and chest. Dx with molluscum contagiousum is made. In addition to
Rx, most appropriate intervention?

- HIV antibody testing

18. 14yo boy with sickle cell trait with 1-day hx of severe pain in left thigh and knee. Unable to bear
weight. No swelling, locking, or catching. 6 days ago, twisted his knee playing basketball. Knee XR was
taken (shown), and he was was given NSAIDS, ice, and crutches. His sx had improved for 3 days. BMI 32.
Temp 37C, BP 110/70. Joint line tenderness of the knee, no effusion. ROM of left hip limited by pain.
WBC 8k, ESR 10. Most appropriate next step in management?

- XR of the left hip

19. 70yo F with peeling, scaling, and cracking of the right nipple for 2 months. Breast exam shows no
masses, and mammography shows no masses or calcifications. Dx?

- ?? Not eczema, so I'm assuming it's Paget disease of the breast

 20. 40yo F with few drops of yellow discharge from her left nipple while performing a breast self-
examination 4 days ago. No spontaneous discharge, only when squeezing. No masses, and
mammography shows no masses or calcifications. Dx?

- Physiologic discharge

21. 3 hours after repair of leaking AAA, 72yo F has following hemodynamic findings by pulmonary
artery cath:

Cardiac index: 1.2L/min

MAP: 55 (N = 80-90)

PCWP: 30 (N=5-16)

CVP: 28 (N=5-8)

Pulmonary arterial pressure: 55/35

IV dopamine begun intraoperatively. Surgery complicated by hypotension, metabolic acidosis, and

oliguria. ECG shows supraventricular and ventricular arrhythmias, each causing hypotension. Cause of
these hemodynamic findings?

- Cardiogenic shock

22. 67yo M with aching in the calves while walking during the past 2 months, relieved by rest.
Decreased pedal pulses. Symptoms due to narrowing of?

- femoropopliteal arteries

23. 16yo girl comatose next to a suicide note. Unresponsive. Temp 37.2C, p 100/min, resp 28/min,
BP 100/66. Pupils reactive to light; doll's eye reflex present. Labs: Na 140, Cl 104, K 3.5, HCO3 6. ABG: pH
7.32, Pco2: 12; Po2: 92. What substance had she used in her suicide attempt?

- Aspirin

24. 72yo M with decreased UOP 2 days after Rx for cholecystitis. UOP has been 15 mL/h for 3 hours.
On admission, results showed gram neg bacteremia and DIC. CUrrently receiving IV fluids, cefoxitin, and
gentamicin. Temp 38.5C, Pulse 110/min, resp 24/min, BP 90/64. Mild RUQ tenderness. Serum Cr
increased from 1.5 2 days ago to 3. Urinalysis findings?
 - ?? It's NOT A, but could be D: Blood 1+, Protein 1+, RBC 0-5, WBC 0-5, Casts pigmented granular,
Other microscopic findings renal tubular epithelial cells

25. 27yo primi F at 39 weeks' admitted in labor. spontaneous ROM 1 hour ago. Cervix was 3 cm
dilated and vertex at -1 station. Point A on labor curve shown, FHR tracing shows recurrent late decels
and decreased variability. Most appropriate next step in management?

- Cesarean delivery

26. 24yo F with pain in th eleft hemithorax for 2 days; the pain began after she moved heavy
furniture. The pain is worse with inspiration. She has used an oral contraceptive for 16 years and smoked
1 pack daily for 18 yrs. Pulse 110/min, resp 24/min, BP 110/70. Lungs clear, tenderness to palpation
lateral to the sternum on the left. Cardiac exam normal. Dx?

- Costochondritis

27. Missing this question

28. 37yo F with 1-year hx of irregular menses, occurring at irregular 3-month intervals and lasted for
10 days with moderately heavy flow. No hx of illness and no meds. BMI 24, Temp 37.1C, pulse 70/min,
resp 12/min, BP 90/50. Visual field test shows outer field deficits bilaterally. Milky white discharge from
both breasts. Stool for occult blood is neg. Prolactin concentration is 40 ng/mL. MRI of the brain shows
pituitary microadenoma. Most appropriate next step in management?

- Bromocriptine therapy

29. Five days after open splenectomy for ITP, 57yo F has SOB. Only med is morphine. Temp 37.3C, p
80/min, resp 20/min, BP 120/80. Surgical wound appears normal. BS decreased at left lung base. WBC
15.6K, platelets 112k, amylase is 90U/L. Most appropriate next step in management?

- CXR

30. 19yo African American man with 9-month Hx of watery diarrhea associated with abdominal
cramps and bloating. Has occasionally had diarrhea after meals since age of 12, but has been worse since
he started college 1 year ago. Exam shows no abnormalities. Cause of diarrhea?
 - ?? Answer is NOT "immunologic damage to the microvilli of the bowl," so I'm assuming it's "
Digestive enzym deficiency"

31. 42yo F left eye is red since she awoke 4 hours ago. NO changes in vision and no trauma. NO
meds. BP 110/70. Left eye is shown. Visual acuity 20/20 in both eyes, pupils equal and reactive. Most
appropriate next step in management?

- Reassurance

32. 72yo M for follow-up exam 4 weeks after 10-day quinolone Rx for UTI. Has been drinking 12 to
15 glasses of water daily to prevent another infection. 30-year hx of schizoaffective d/o. On
Reisperidone. Oriented to person but not to place or time. P 80/min, BP 128/60, with no orthostatic
changes. Exam shows dry oral mucosa and no JVD. Lungs clear. No peripherla edema. Muscle strength
5/5, sensation intact. Reflexes 1+ bilaterally. Labs: Na 122, K 4, Cl 94, HCO3 22, BUN 16, Cr 1.1; Urine:
blood neg, glucose neg, protein neg, sodium 20, osmolality 200. Cause of hyponatremia?

- Psychogenic polydipsia

41. Previously healthy 82 yo woman comes because she is concerned she has Parkinson Disease.
Over 6 months, she has had occ difficulty finding word that she wants to use, her ability to distinguish
smells has decreased. She reports that her reaction time to shifts in posture seems slow, and she needs
to use a handrail to steady herself while walking on stairs. She loves alond, able to manage her own
finances. Pupils 3 mm, mild reduction of upward gaze andbrisk rotatory nystagmus on left lateral gaze.
Audio- high frequency hearing loss. No tremor or rigidity. Gait is normal. MMSE 29/30. Which of
following warrants further evaluation?

- Brisk rotatory nystagmus on left lateral gaze

43. 37 yo M persistent numbness in hands/feet for 10 months, weakness in L wrist for 3 weeks. He
renovates old houses. he has abdominal pain and diagnosed with gastritis. BP is 135/95. mucous mb
pale. Neuro exam shows weakness with dorsiflexion of L wrist and loss of sensation in stocking glove
distribution. He has low hematocrit and BUN is 35. Blood smear shows microcytic hypochromic
erythrocytes. Early tx with what would have prevented him?

- Calcium disodium edetate (CA EDTA)

 46. An 18 yo woman has had fever 12 hrs and obtundation 4 hrs. She had been attending a summer
camp with 120 other students and was well until yesterday, when she developed a sore throat and
nonproductive cough; this morning she couldn't be aroused. T= 101.5, P= 120, RR= 30, BP= 80/50.
Extremities cool. Skin lesion shown over her extremities, chest and abdomen. Hsct 41%, leuko 21200
with shift to left. Dx?

- Meningococcemia

Block 4

1. 10 yo girl fever and joint pain 5 days. T= 103, P = 120, RR= 24, BP= 110/70. Precordial heave.
Gallop and grade 3/6 holosystolic murmur in 4th IC space at midclavucular line. Elbow and knee tender.
GAS, ASO increased. Explanation for the cardiac findings?

- Mitral valve incompetence

2.

3. A previously health 67 yo man has an aching burning sensation in the distal lower extremities for
3 weeks, worse with walking and relieved by elevating his feet. Metatarsophalangeal joints and ankles
are warm, swollen, tender, and erythematous. There is clubbing of finger and toes. Dx?

- Bronchogenic carcinoma

10. 20 yo man, brought to physician by his parents b/c of auditory hallucinations and bizarre
behavior over 1 year. Dropped out of college, moved home, and not attempted to find job. He says he
has been feeling strange, like in a dram and talks to his great great grandfather who died 50 yrs ago. He
was diagnosed with HepA 2 yrs ago after an episode of jaundice, and has been treated with thyroxine for
hypthyroidism for past 6mths. P68, rr 10, bp 100/70. Physical exam: hyperreflexia of lower extremities,
milk resting tremor of upper extremities. On mental exam, his voice is monotonous, face is immobile,
seems very anxious. He stares at physician and barely answers any questions. Serum studies: T.bili 1 TSH
1 AST 21 ALT 20. Urine Tox Screen is Negative. What is most likely dx?

- Schizophrenia
 11. 47 yo man comes to ED for 3 day H/O N/V, burning nonradiating epigastric pain. He notes that
the vomitus was initially yellowish, but last 2 episodes were darker. He consumed 1 pint of whiskey 4
days ago. Takes no medications. On arrival, he is awake and confused. T= 99.3, P= 128, RR- 12, BP- 90/50.
Skin is cool and clammy. Cardiopulmonary exam shows no abn. Ab exam- diffuse tenderness w/o
rebound. Neuro- no focal or sensorimotor abn. FOBT-ve. CXR- fine. ECG- sinus tachy. Cause of abn vital
signs?

- Hypovolemia

13. Previously healthy 18 yr old woman, lump in her neck she first noticed 1 month ago. Otherwise
asymptomatic. Exam shows 3cam left supraclavicular lymph node that is firm and rubber. Spleen is 3cm
below left costal margin. Remaining exam is normal. Labs will most likely show which?

- D, increased serum lactate dehydrogenase activity

16. 57yo M with generalized weakness and purple rash on his legs for 3 days. He has a hx of several
blood transfusions. Exam shows 1.5-cm, raised, nonblanching purple lesions over the legs. Positive
cyroglobulins diagnosed with essential mixed cryoglobulinemia. Negative hepatitis C. Rx?

- Interferon-alpha

18. 52 yo woman 2 wk H/O progressive SOB. SOB when walking across room. 8 yrs ago, Dx of breast
cancer, underwent mastectomy followed by chemo. Annual exam- no recurrence. T= 98.6, P= 90, RR- 24,
NP- 130/80. Exam shows no JvD. Dullness to percussion over lower half of Right lung. Left lung is clear to
auscultation. Heart sounds normal. No peripheral edema. Which of the following is like cause of
dyspnea?

- Pleural metastases

19. A 32 yo man brought to ED by a firend because of sudden onset of confusion and agitation. He
has long-standing H/O schizoaffective disorder, depressed type. 5 days ago, a new med was added to his
regimen because of auditory hallucinations, but he is not sure what it is. He rarely drinks alcohol and
does not use illicit drugs. He is confused and does not know why he is at ED. His T 103.1, P 110, RR 28, BP
160/100. Neuro exam shows muscle rigidity. His leukocyte count in 15000 CK 950. Which of the following
NT is most likely responsible for this pt's condition?

- Dopamine
 22. 25 y/o woman, at the doctors for tremulousness and fatigue for 1 month. T 99F, P 120. She
appears nervous. Ophthalmologic exam no abnormalities. Thyroid gland is barely detectable by
palpation and non tender. Iodine uptake is decreased. Dx?

- F, surreptitious administration of thyroxine. You know she's hyperthryoid, which EXCLUDES COLD
NODULE (usually not hyperthyroid). No eye problems (which would indicate Grave's), and then you
should have your answer

25. New vaccine for HIV, tested on prisoners, Early parole. Concern?

- Coercion of vulnerable population

26. 6 wk old forceps delivery, Head is rotated to the left with chin deviated to the right (torticollis). 2
cm hard, nontender, oval mass is palpated in right side of neck. Most likely cause?

B. Fibrosis of the sternomastoid muscle

27. 22 yo college student is brought by friend for 1 month H/O difficulty sleeping and increasing
paranoia. His friend reports that the pt has become suspicious of his roommates and has expresse
concerns about effects of dorm food on his health. He often stays awake until 3 am watching for
strangers in the vicinity of his building. His school performance has deteriorated, and he has become
socially withdrawn. He admits to occ use of marijuana. He appears tense and restless. P/E- no abn.
Mental status exam- anxious mood and audtory hallucinations. Urine toxicology screening is negative.
Next step in Mx?

- Olanzapine

31. 32 yo W brought to ER, 2 day hx of vomiting, diarrhea and right sided pelvic pain. Last mentrual
period was 3 wks ago. Temp 102.2, RR20, P100, BP 120/70. Abdo exam shows right lower quadrant
tenderness with rebound. Decreased bowel sounds. Pelvic exam shows right adnexal tenderness.
Negative serum pregnancy test. Labs: Hg 12 Leukocytes 15,000 Seg PMNs 80% Bands10% Lymphs5%
Monos 5%. Ultrasound shows no adnexal masses. Most likely dx?

- It's NOT H tubo-overian abscess. I think it might be B, appendicitis. Can anyone confirm this?
 30. 70 yo W brought to ER 3hrs after onset of substernal chest pain, weakness and dsypnea. She had
MI 6 months ago and has had recurrent chest paon on exertion treated with nitroglycerin. T98.8, rr 22,
bp 60/40. Exam is normal. EKG is shown. Dx?

- I, Ventricular tachycardia

34. A 67 yo man has had an ulcer on ant surface of leg just above ankle for 2 wks. He had MV
replacement 15 yrs ago because of Rheumatic valvular disease. Takes furosemide for CHF and oral
hypoglycemic for DM II. Exam- 5 cm ulcer with 3 mm red border. There is moderate edema from toes to
midcalf bilaterally; his feet are warm, pulses weakly palpable. Scattered crackles are heard at lung bases
B/L. Dx?

- Stasis dermatitis with ulcer

37. 82 year old man with CHF comes to doc for f/u exam. one month ago, he had worsening dyspnea
while lying in bed at night and walking up stairs, and his dose of furosemide was increased. his only
other medication is lisinopril. he was dx with chef 5 years ago after MI. he had coronary angiography and
stent at that time. no CP since them. also has a 10 year hx of well controlled CKD. creatinine conc have
ranged from 1.3- 1.5 and urinalyses have shown no protein. today his pulse is 90/min, rest are 14/min
and BP is 130/86/ cardiopulmonary shows no abnormalities. there is trace edema of ankles, which has
decreased since examination 1 month ago. serum studies show:

1 month ago: na-138, K 4, cl 101, HCo3- 26, bun-15, cr-1.8

today: NA-140, k-4.2, cl-103, hco3-28, bun-24, cr-2.3

urinalysis shows no abnormalities. which of the following is the most likely explanation for the
change in lab values during the past month?

- Decreased renal blood flow

40. 72 yo woman has hypoNa 3 days after admission to hospital after cerebral infarction. She has
been receiving 5% Dex in 0.45% saline since admission. Current meds are phenytoin and atenolol. She
has expressive aphasia. P= 86, RR- 16, BP 130/86, Exam shows right dense hemiparesis. Lab: Na: 120,
Os:255. Urine Na: 50, Osm 358.

- SIADH
 41. 4 yo boy develops chickenpox 8 hrs after visiting his NB sister in nursery. Six other full term NB
were also exposed, all of the mothers have a H/O chickenpox prior to pregnancy. Which of the following
is most appropriate recommendation to prevent chickenpox in NB?

- No intervention is necessary.

42. Newborn with B/L clubfoot deformity. Born at term following uncomplicated preg and delivery.
Did not more his lower extremities immediately after birth, did not cry when he receied a needlestick in
his feet. On exam, he is vigorous and moves his upper extremirites but not his lower extremities. Bladder
is palpable and full, Dx?

- Spinal dysraphism