 Block 1

1. 42yo M with headache, blurred vision, and confusion for 2 days. No weakness or numbness,
difficulty walking, chest pain, or discomfort, diplopia, or vertico. HTN Rx with propranalol,
doesn't take it regularly. BP 190/20. Neck is supple. Funduscopic examination shows
enlargement of the optic discs with indistinct borders. Blood vessels near the discs are indistinct.
Dx?
- Malignant hypertension

2. 47yo F with difficulty sleeping for 2 months. Has unstable angina pectoris and required
placement of stent 6 months ago, but having chest pain daily. Evaluation shows no organic cause
for her recurring chest pain. Has not enjoyed her work as much as she prevously did. Difficulty
paying attention. No longer prepares meals because she does not enjoy the taste. Physical
normal. Sad and worried mood. Dx?
- Major depressive disorder

3. 37yo M with 3-day history of diarrhea. Six to eight watery stools daily that occasionally
contain streaks of blood. Family does not have similar symptoms. No travel. Two weeks ago, he
completed course of oral ciprofloxacin for acute prostatitis. CBC normal. Stool for leukocytes
and clostridium difficile toxin is positive. Next step?
- Metronidazole

4. 15yo boy with headaches for 3 months, most often in the morning and are associated with
vomiting. Over the past month, he also has had increasing visual difficulty. 4.5-kg weight gain,
school performance declined. Slow puberty. Growth charts are shown. Mild papilledema. Dx?
- Craniopharyngioma

5. 37yoM with 1-week history of pain with swallowing. Diagnosis of AIDS 4 years ago, but
unable to tolerate highly active antiretriviral therapy. Currently takes trimethoprim-
sulfamtheoxazole. VSS. Few white plaques over the pharynx. CD4+ T-lymphocyte count of 50
and plasma HIV viral load of 50,000 copies/mL. Appropriate pharmacotherapy?
- Fluconazole

6. 3mo m infant with tachypnea and tachycardia for 10 days; during this period he has been
feeding poorly. grade 3/6 holosystolic murmur and a grade 2/6, apical mid-diastolic murmur are
heard. X-ray of the chest shows cardiomegaly with increased pulmonary vascular markins.
Echocardiography shows a large ventricular septal defect. Cause?
- Excessive pulmonary blood flow

7. 72yo M with 7-month history of difficulty with memory. Loses his keys and misses
appointments and regular family dinners. Lives alone. No difficulty sleeping, no drugs. Irritable
mood and labile affect. Says he does not have problems with his memory but only recalls two of
five objects after 5 minutes. Pharmacotherapy?
- Donepezil

8. 25yo F with nausea, diarrhea, and anxiety for 2 days. Dizziness and tingling sesnations
shooting down her forearms. 3-year hx of social phobia controlled with paroxetine. Forgot to
pack her medication; her last dose was 3 days ago. BMI 30. Irritable mood with a full range of
affect. No evidence of suicidal ideation or hallucinations. Serum studies show no traces of
paroxetine. Next step?
- Resume paroxetine therapy

9. 37yo F with 3-week history of discomfort in both knees. No hx of joint pain. Eight weeks ago,
she began an exercise program running 0.5 mile four times weekly. Smoked one pack daily for
15 years. BMI 31. How can she decrease her risk for osteoarthritis?
- Weight loss

10. 42yo F with progressive shortness of breath during the past 6 months. Has to rest three or
four times when climbing one flight of stairs. Smoked one pack of cigarettes daily for 26 years.
Chronic nonproductive cough and has hweezing controlled with an albuterol inhaler two to three
times weekly. BMI increased from 45 to 52. Respirations are 24/min and shallow, BP 140/90.
Lungs clear. ABG shows pH 7.37, Po2 48, Po2 62, O2 sat 92%. Her FEV1 is 75% of predicted,
and total lung capacity is 50% of predicted. Dx?
- Restrictive lung disease

11. 47yo F. No hx of rheumatic fever. No meds. P 70.min, BP 150/60. Grade 2/6 decrescendo
murmur that begins after S2 is heard at the left sternal border. Dx?
- Aortic valve insufficiency

12. 10mo infant in ED with labored breathing for 1 hour. She has had cough, coryza, and fever
for 18 hours. T 39 C, P 120/min, respirations 54/min, BP 82/60. Pulse oximetry shows an oxygen
saturation of 92%. Bilateral wheezes and basilar crackles. Pathophys?
- Community-acquired viral disease

13. 7yo boy with facial edema and respiratory distress since eating dinner 2 hours ago. Had
coryza and cough during the past 2 days. T 37.5 C, P 100/min, BP 100/70. Breath sounds are
unequal with decreased aeration and a prolonged expiratory phase. Pathophys?
- Allergen-induced bronchospasm

14. 19yo primigravid at 40 weeks' gestation. External monitoring shows a baseline fetal heart
rate of 140/min with good variability; over a period of 30 minutes, the rate increases twice to
160/min for 25 to 30 seconds. Next step?
- Reassurance

15. 14yo boy has been increasingly irritable, disrespectful, and uncooperative during the past 4
years. Refuses household chores. Rude and threatening to teachers, Suspended three times for
talking back. Failing classes Urine toxicology is positive for nicotine. Explanation?
- Oppositional defiant disorder

16. 52yo M with 14-kg weight loss during the past 6 months. Oily, floating stools during the past
2 months. Diagnosis of acute pancreatitis 2 years go and has had 1- to 3-hour episodes of
abdominal pain since. Smoked one pack daily for 30 years. Had alcoholism. BMI 20. Labs show:
HCT 32%, MCV 83, whc 10k platelets 302k, Alkaline phosphatase 120, AST 23, ALT 29,
Amylase 90, Ferritin 250, Lipase 43 (n=14-280). Next step?
- Pancreatic enzyme replacement therapy

17. Two weeks after induction chemotherapy, 20yo F has onset of fever and chills. Acute
myelogenous leukemia. T 39 C, scattered petechiae over the lower extremities. Labs show Hb 9,
WBC 100 (absolute neutrophil count 0), platelets 22k. In addition to blood cultures, next step?
- Empiric broad-spectrum antibiotic therap

18. 37yo M 12 hours after the onset of vomiting and abdominal cramps and swelling. Had
constipation for the past 4 days. Dx with Crohn disease 7 years ago. Diarrhea and lower quadrant
pain controlled with mesalamine. T 36C, diffusely distended, tympanic abdomen and visible
peristalsis; high-pitched bowel sounds are heard. X-ray of the abdomen shows a small-bowel
obstruction. Cause?
- Small-bowel fibrotic stricture

19. 37yo M with fever, generalized muscle aches, and an ulcer on his neck, began 10 days ago as
a painless, itchy papule that enlarged over a 2-day period, until small, fluid-filled blisters formed
on top of the papule. Painless ulcer covered by a black scap. Emplyed as a postal worker and
works part-time as a horticulturist. No travel. Eschar-covered ulcer surrounded by nonpitting
edema. Dx?
- Cutaneous anthrax

20. Three days after colectomy for colon cancer, 77yoF sudden onset of severe shortness of
breath. Cannot catch her breath. Current medications include subcutaneous heparin and
patientcontrolled morphine. P 140/min, BP 110/60. Pulse oximetry on room air shows an oxygen
saturation of 89%. Breath sounds decreased on the right. ABG: 7.38, PCo2 23, Po2 55. Chest x-
ray shows atelectasis at both lung bases. ECG shows nonspecific ST-T wave changes. In addition
to O2, next step?
- Spiral CT scan of the chest

21. 32yo F G2P1 at 40 weeks' gestation confused for 45 minutes. In labor for 3 days at home,
and she has received her prenatal care from an alternative provider. Patient took a natural product
to chew to induce contractions. Had strong, regular contractions, and after 6 hours, she suddenly
lost consciousness. P 140.min, palpable systolic blood pressure is 40. 25-cm irregular mobile
mass in upper right quadrant. No presenting fetal part can be palpated. Cause?
- Uterine rupture

22. 10mo boy has vomited twice during the past 2 hours. inconsolable crying and has passed one
bloody stool. T 38C, p 110/min. Rectal examination shows bloody mucus in the rectal vault.
Next step in diagnosis?
- Contrast enema

23. 47yo F with 2-year history of venous insufficiency and notes daily swelling of ankles that
worsens in the evening. No meds. P 80/min, BP 160/100. Which antihypertensive drugs would
exacerbate this swelling?
- Nifedipine

24. 10yo boy with rash over his arms and legs for 7 days. BP 150/98. Yellow, crusted, excoriated
rash over the upper and lower extremities. U/A 3+ protein, 30-50 RBC/hpf, and 5-10 WBC/hpf.
Dx?
- Acute glomerulonephritis

25. 17yo boy with mental redardation with low-grade fever and abdominal pain for 6 days. T
37.8 C, P 110/min, BP 120/70. Splinter hemorrhages under the nails. Grade 2/6 systolic murmur
is heard best at the upper left sternal border. Systolic ejection clic. S1 and S2 are normal.
Splenomegaly. Labs show: hb 9.1, wbc 30k, platelets 928k, ESR 110, Urine: blood 2+, protein
1+. Next step?
- Blood cultures

26. 24yo M comatose after head-on MVC. Intubated and mechanically ventilated. T 35.6, P
52/min, BP 160/94. Spontaneous roving eye movements. Pupillary and corneal reflexes are
intact. Spontaneous flexion of the upper extremities and extension of the lower extremities. DTR
3+. Babinski sign is present bilaterally. Over the next hour, receives 80 mL of 0.45% saline and
has urine output of 900 mL. Serum: Na 147, Glucose 124, osmolality 294, urine sp gravity 1.001.
CT heat shows scattered contusions and a subarachnoid hemorrhage. Cause of increased Uop?
- Diabetes insipidus

27. 15yo girl with 1-week history of vaginal discharge and 2-day history of sore throat and white
spots in her mouth. Recurrent candidal infections. Type 1DM and autoimmunte thyroiditis.
Thick white vaginal discharge, budding yeast. Mechanism?
- Impaired cell-mediated immunity

28. 57yo M with impotence for 1 year. Bronze-colored skin. Serum ferritin concentration is
4050. Risk for?
- Hepatocellular carcinoma

29. 72yo M with 6-month history of difficulty walking, cognitive decline, and urinary
incontinence. No dysuria or nocturia. Intermittent confusion. Broad-based, short-stepped gait.
Explanation of urinary incontinence?
- Failure to inhibit the voiding reflex

30. 23yo F with 3-week history of difficulty sleeping. Missing classes and deadlines, no
motivation. Three weeks ago, she was rejected from graduate school of her choice. Lies awake at
night thinking about her future. No change in appetite. Enjoys seing her boyfriend. No suicidal
ideation or hallucinations. Dx?
- Adjustment disorder

31. 32yo F with follow-up exam 1 week after a Pap showed high-grade squamous intraepithelial
lesion. Next step?
- Colposcopic-directed biopsy
32. 3mo boy 6 hours after onset of difficulty breathing. Two days ago, had cough and clear nasal
discharge and feeding poorly since. 180/min resp 60/min, BP 80/60 in the arms and 84/64 in the
legs. Grunting, nasal flaring, and intercostal retractions. Skin is pale and mottled. Scattered
crackles and expiratory wheezes are heard on auscultation. Grade 4/6 systeolic murmur heard
across he precordium radiating to the carotid arteries. Liver palpated 5 cm below costal margin.
Cardiomegaly. ECG shows left axis deviation with tall T waves. Cause?
- Aortic stenosis

33. 17yo girl with fatigue, increased thirst, and increased urination over the past 2 weeks. 4.5-kg
weight loss. No dysuria. Had a mild upper respiratory tract infection. Na 132, Cl 96, K 3.7,
CHO3 26, Cr 1.2. LOcation of primary disease process?
- Pancreas

34. 82yo F with 9-month history of progressive urinary incontinence. Strong urge to void, is
unable to reach a bathroom in time. Mild cerebral infarction 2 years ago. Severe arthritis of her
knees and hips, limits her mobility. On lovastatin and aspirin. Explanation for incontinence?
- Detrusor hyperactivity

35. 77yo F 1 hour after sudden onset right-sided weakness and difficulty speaking. Hx of
hypertension and hypercholesterolemia. BP 160/90. Only able to give single-word answers with
many paraphasic errors. Normal visual fields. Weakness of the right side of the mouth. Strength
of the RUE is 2/5. RLE is normal. Sensation to pinprick is decreased over the right upper
extremity. DTR more brisk on the right than left, and Babinski sign is present on the right.
Arteries occluded?
- Left middle cerebral

36. 13yo boy with 2-week history of left hip pain with an associated limp. No redness or
swelling. No hx of trauma. Above 95th percentile for weight. T 37.5. Holds his left lower
extremity in slight external rotation and hip flexion. Internal rotation and abduction of the left hip
are decreased. Underlying cause?
- Disruption of the femoral head epiphyseal plate

37. 23yo F G2P1 at 32 weeks' gestation with urinary urgency and pain with urination for 3 days.
T 37 C. Uterus consistent in size with a 32-week gestation. Mild suprapubic tenderness but not
costovertebral anlge tenderness. U/A shows wbc and rbc and 3+ bacteria. Risk for?
- Pyelonephritis

38. 16yo boy ith 30day history of right knee pain associated with redness and swelling. No hx of
trauma. 50th percentile for height and weight. T 38.6. Erythema, swelling, and tenderness of
right knee. Next step?
- Joint aspiration

39. 13yo boy with 3-month history of left knee pain that is exacerbated by vigorous exercise.
Occasional pain in his right knee. 50th percentile for height and weight. T 37 C. Tenderness at
left tibial tubercle. Nonsteroidal anti-inflammatory drug therapy
40. 2mo boy. Born at term. Breast-feeding six to eight times daily since birth. Smiles and tilts his
head 50th percentile for length, 75th percentile for weight, and 25th percentile for head
circumference. Nutritional recommendation?
- Begin vitman D supplementation

41. 16yo girl with 4-year history of heavy bleeding with menses History of excessive bleeding
after a dental extraction but no spontaneous bleeding. Father has hx of bleeding. Labs: Hb 8,
HCT 25%, wbc 7k, retics 2%, platelets 200k, bleeding time 12 min, prothrombin time 13 sec
(NR=1), partial thromboplastin time 60 sec. Pelvic u/s normal. Mechnaism of bleeding?
- Abnormal structure of von Willebrand factor

42. 25yo F initial prenatal examination at 12 weeks' gestation. Has schizoaffective disorder and
had been taking oral haloperidol sporadically until 2 mo ago. Says she was impregnated by evil
and needs to get rid of the "Devil's baby." Hears voices. Agitated. In additionto admitting the
patient to the hospital, next step?
- Defer the decision about abortion and resume haloperidol

43. Cohort study to assess relationship between OCP and risk of breast cancer. 530 women
between 30 and 40 years of age to complete questionnaire about OCP use. Twenty years later,
40% of the participants are enrolled with the same HMO. Of the 100 who remained and
continued to use an OCP, 12 developed histologically confirmed breast cancer compared with 4
who did not use OCP. What feature affects validity?
- Differential follow-up

44. 67yo M. Three years ago, underwent radical resection of a T3 N0 M0 epidermoid carcinoma
of the flour of his mouth and supraomohydoid dissection of his neck. No meds. Smoked daily but
stopped. VSS. No signs of local recurrence. X-ray of the chest shows a 3-cm mass in the medial
upper lobe of the right lung. Cause?
- Primary squamous cell carcinoma of the lung

45. 37yo F with increasingly severe pain and masses in both breasts over the past 3 months. 12-
year hx of similar episodes. Masses vary with menstrual cycles. Used OCP for 16 years.
Multonodular breasts. No axillary adenopathy. Dx?
- Fibrocystic changes of the breast

46. 27yo F with 3-day hx of visual loss and aching discomfort in her right eye. THree years ago,
she had vertigo, diplopia, and an ataxic gait and was dx with inner ear infx. Reduced visual
acuity on the right; right peripheral visual fields intact. Color vision decreased in right eye. R eye
does not react to direct light but has a normal consensual response. Babinski sign present
bilaterally. Next step?
- MRI of the brain with contrast

Block 2

1. 27yo M with 12-hour history of vomiting and mild, intermittent, nonradiating abdominal pain.
Passed flatus, and his last BM was today. Underwent exploratory lapartomy secondary to a
gunshot sound 6 years ago. T 37 C. Bowel sounds are hyperactive. Leukocyte count 6900. U/A
normal. X-rays of the abdomen show dilated loops of small bowel and air-fluid levels; there is
gas in the ascending colon and rectum. Next step?
- Nasogastric tube decompression

2. 15mo girl with 3-month history of poor weight gain and foul-smelling, greasy, loose stool.
Bacterial pneumonia at age of 1 year. Diet consists of cow's milk and table food. 25th percentile
for length and 10th percentile for weight. Labs: Hct 35%, leukocyte count 11.1k (pmns 55%,
lymphos 40%, monocytes 5%), platelets 325k, Total protein 6 (albumin 3.6), 72-hour fecal fat
1.8 g/24 h (N<1). Mechansim for poor weight gain?
- Decreased pancreatic enzyme secretion

3. 27yo F with 2-month history of severe, intermittent, bifrontal headaches; two episodes were
accompanied by tunnel vision. BMI 32. Bilateral papilledema. Pupils are equal and reactive to
light. Visual acuity is 20/25 bilaterally; visual field normal. MRI brain normal. Dx?
- Idiopathic intracranial hypertension

4. 37yo F with 4-month history of numbness, burning, and tingling of the toes and soles of her
feet. 3-year hx of recurrent mouth sores. Numerous oral apthous ulcers, genital ulcers, and
several 2.5-cm red lesions over the left anterior tibial region. Photophobia. Ankle reflexes are
absent. Proprioception and sensation to pinprick and vibration decreased in lower ext. Dx?
- Behcet syndrome

5. 14mo boy 30 minutes after the onset of wheezing. He was crawling on the floor. Respiratory
distress. Pulse is 125/min, resp 45/min, BP 84/54. Diffuse wheezes are heard bilaterally. Chest x-
ray shows atelectasis of the left upper lobe with a shift of the trachea to the left. Next step?
- Bronchoscopy

6. 72yo F with 3-month history of bilateral knee pain with weight-bearing. Maximum doses of
over-the-counter naproxen ovver the past 6 weeks. Hx of stable exertional angina. HTN, CAD,
CHF, osteoporosis. Jugular venous distention to 2 cm above the sternal angle with the patient
sitting at a 30-degree angle. Crepitus of both knees and bony prominencys at the proximal tibial
bones bilaterally. Potassium of 5.1, BUN 47, Cr 2.2. Which med caused it?
- Naproxen

7. 25yo F with 1-month history of severe headaches. Missed several days of work because of the
pain. 10-year hx of H/A responsive to treatment with naproxen. Major depressive disorder
treated with fluoxetine. BMI 20. Funduscopic examination shows bilateral papilledema. Pupils
are 5 mm and reactive to light. MRI of the brain shown. Cause?
- Obstruction of the ventricular system

8. 87yo F with metastatic ovarian cancer has poorly controlled pain. Cancer unresponsive to
therapy. On long-acting oral morphine, short-acting morphine PRN, and docusate. Daugher says,
"we want my mother to receive hospice care at home, but no one wants her to die at home. Can
she still have hospice services?" Response?
- "Yes. Hospice can provide home-based care and attempt to transfer the patient to another site
before death."

9. 37yo primigravid at 25 weeks' gestation with confusion for 12 hours. Fever and intermittent
nausea and vomiting over the past 2 weeks. No contractions, but decreased fetal movement.
Family Hx of T1DM, seizure disorder. T 38.8, P 168/min, BP 187/84. Mildly enlarged thyroid
gland. Lungs clear. 3/6 systolic ejection murmur. Fetal heart rate 182/min. Labs show: Hb 9.9,
platelets 282k, Serum: Na 134, Cl 94, K 2.9, Thyroid-stimulating hormone 0.01, AST 33, LDH
112, Uric acid 5.4. Dx?
- Thyroid storm

10. 87yo F with fever for 1 day. Urinary catheter was placed 2 weeks ago. Has dementia,
Alzheimer type, and is unable to communicate verbally. T 37.8 C, P 86/min, BP 120/74. Mucous
membranes are moist and pink. Urinalysis shows: Color cloudy brown, Ph 8.8, Blood 2+,
Glucose negative, Protein 2+, RBC numerous, wbc 20-25, Nitrites 3+, leuk esterase 3+, bacteria
many. Gram stain shows gram-negative bacilli. Which would have prevented?
- Use of incontinence briefs instead of the catheter

11. 32yo F with 4-day hx of fever. Swelling and redness of her left leg during this period. Hx of
chronic lymphedema in both legs. BMI 39. T 38.5, LLE is diffusely red and edematous from just
below the knee to the ankle, with a sharp demarcation. Left femoral nodes are enlarged and
painful. Cause?
- Group A streptococcus infection

12. 25yo F with shortness of breath, marked malaise, weakness, and fatigue for 4 hours.
Developed muscle soreness after an unusually streneous physical workout; took ibuprofen 1 hour
prior. Hx of frequent migraines Rx with metoprolol. Facial flushing and mild periorbital edema.
Multiple wheezes throughout lung fields. Avoidance of which to prevent recurrence?
- Aspirin

13. 57yo F with intermittent episodes of pruritic ulcers around both ankles during the past 4
years, wax and wane. Findings shown in the paragraph. Cause?
- Chronic venous stasis

14. 27yo F with bizarre behavior that began after the sudden death of her father 5 weeks ago.
Went on a shopping spree, Loss of appetite and has not slept. Three years ago, she had severe
depressive episode treated with sertraline. Dx?
- Bipolar disorder

15. 52yo F with tremors in her hands for 4 months. Tremor of the outstretched hands bilaterally,
the amplitude of the tremor increases with finger-nose testing. The tremor resolves at rest.
Muscle strength and tone are intact, and her gait is normal. Pharmacotherapy?
- Propranolol

16. 18mo girl has not used her right arm since falling while running hand-in-hand with her older
sister 2 hours ago. Forearm pronated; she is unable to fully supinate or flex her forearm. No
swelling. Initial management?
- Supination of the forearm

17. 27yo primigravid for first prnatal visit. Persistent nausea and vomiting for 3 weeks. LMP 4
months ago. BP 150/90. Fetal heart tones are notheard. Ultrasonography shows multiple
echolucent cysts in the uterus but no viable fetus. Next step?
- Suction curettage

18. One hour after splenectomy, 42yo M has severe shortness of breath. Additional injuries
include left rib and pelvic fractures. T 36.3, P 133/min, BP 80/60. Breath sounds are absent on
the left. Bowel sounds are absent. Next step?
- Needle thoracostomy

19. 77yo F with lesions on her left arm for the past 2 months. Underwent modified radical
mastectomy of the left breast for breast cancer 20 years ago complicated by chronic edema of the
LUE. Two r-mm, raised, hard, purple lesions just above the left elbow. Dx?
- Lymphangiosarcoma

20. 22yo F took some pills and then passed out at a party. No drinking alcohol or acting
depressed. Unresponsive to painful stimuli, p 60/min, respirations are 8/min. Pupils are 1 to 2
mm bilaterally. No nystagmus. Substance?
- Opioid

21. 23yo F with abdominal discomfort, loss of appetite, and nausea for 4 days. Resp 28/min. Na
132, Cl 102, K 6, HCO3 10, Glucose 450. Cause of abnormal potassium?
- Diabetic ketoacidosis

22. 28yo F has had excessive weakness and a 7.3-kg weight loss over the past 7 weeks. Hx of
successfully treated hypothyroidism. Hyperpigmentation of the skin. Laboratory studies show:
Na 130, K 6.4, Osmolality 278, Urina: Na 35, Osmolality 279. Cause of abnormal potassium?
- Addison disease

23. 52yo F with 1-hour history of nausea, vomiting, and epigastric pain with radiation to her left
shoulder. History of similar episodes of pain after eating or with exertion. Has T2DM rx with
metformin. Smoked one pack daily for 30 years. Exam shows jugular venous distention. Lungs
clear. Normal S1 and S2; a grade 2/6 apical systolic murmur is heard. ECG is shown. Dx?
- Myocardial infarction

24. 77yo F with 24-hour history of watery diarrhea and nausea. Unable to eat or drink, and has
had decreased urination. No fever. Visited her grandson, who has similar symptoms. Pulse is
110/min, bp 100/60. Dry mucous membranes. Labs HCT 42%, Na 132, K 8.2, Cl 99, HCO3 18,
BUN 95, Glucose 199, Cr 6.4. ECG shows peaked T waves and a QRS interval of 0.16 msec.
Initial step?
- Administer calcium gluconate

25. 62yo F with hypertension. BP ranged between 160/110 and 180/120. Rx with maximal dose
of ace inhibitor, a diuretic, and a beta blocker. BMI 21. BP is 160/100 in the right arm, 175/105
in the left arm, 155/90 in the right leg. Femoral and dorsalis pedis pulses are 1+ bilaterally.
Potassium concentration of 4.5, BUN 20, Cr 1.2. Cause of hypertension?
- Atherosclerotic renal artery stenosis

26. 55yo M has had paresthesias and progressive weakness of the upper and lower extremities
over the past 3 weeks. Receiving prophylactic antituberculosis therapy since a pos PPD skin test.
x-ray of the chest at that time showed no abnormalities. Which vitamins would have prevented
these symptoms?
- B6

27. 16yo girl with painful genital lesions for 2 days. Sexually active with five male partners. 3 x
3-mm ulcerated lesions on the anterior vaginal vault. Strategy to prevent transmission?
- Consistent condom use

28. 37yo immigrant from Pakistan with fever and pain in the right upper quadrant. T 38.6, Liver
edge palpable 4 cm below costal margin. Hb 10, Serum: total bilirubin 1.4, alkaline phosphatase
120, AST 40. Ultrasonography of the RU shows a single, right ystic mass of the liver. Next step?
- Serum antibody titer for Entamoeba histolytica

29. 37yo M with fever and bilateral flank pain 1 month after returning to the USA from kenya. T
39 C, Spleen tip palpable. Hb 9, reticulocyte count is 5%, serum lactate dehydrogenase activity is
300. Next step?
- Thick and thin blood smears for malaria

30. 32yo M with AIDS with 1-week history of T to 40 C and cough. Current medications include
trimethopim-sulfamethoxazole and three antiretroviral agents. Moist crackles over right lung
base. X-ray of the chest shows an infiltrate in the right lower lobe. Causal org?
- Stretococcus pneumoniae

31. 57yo F with 2-year history of progressive cough productive of 2 to 3 tablespoons of yellow
sputum daily. Cannot walk more than one block w/o becoming SOB. No fever, hemoptysis, night
sweats, or weight loss. Smoked for 40 years. BMI 32, BP 15090. Pulse oximetry on room air
shows an oxygen saturation of 90%. Breath sounds decreased in all lung fields, and rhonchi
heard at the bases. Expiratory phase is prolonged. ECG shows P pulmonale. PFT show FEV 1
>80% predicted and Fev1:FVC ratio of 70% of predicted. Diffusing capacity of the lung for
carbon monoxide greater than 60% of predicted. Dx?
- Chronic bronchitis

32. Six hours after surgical excision of the distal colon for cancer, 77yo M has decreased urine
output. Lost 500 mL, transfusion of 1 unit pRBC. 10-yr Hx of hypertension. Pulse oximetry on
2L/min of oxygen via nasal cannula shows an oxygen saturation of 89%. Hct 24%, Na conc 140,
Cr 2.1. Next step?
- 0.45% Saline

33. 57yo F with 2-week history of progressive jaundice and a 5-kg weight loss. Dark urine and
pale stools. No meds. BP 120/80. Gallbladder palpated in the RUQ. Urine dipstick is positive for
bilirubin. Ultrasonography shows a dilated gallbladder and dilated intrahepatic and extrahepatic
biliary ducts. No calculi. Next step?
- CT scan of the abdomen

34. 13yo girl concerned has never had a menstrual period. At 80th percentile for height and 75th
percentile for weight. Breast and pubic hair development is Tanner stage 2. Next step?
- Reexamination in 1 year

35. 37yo F G2P2 with painful, irregular menses and intermittent vaginal spotting for 3 months.
LMP 1 week ago, not sexually active. Endometrial biopsy 1 month ago showed secretory
endometrium. 10-cm soft, tender uterus. No masses. Saline infusion ultrasonography shows a
diffusely enlarged uterus and no other abnormalities. Dx?
- Adenomyosis

36. 72yo F with 2-week history of increased thirst and frequent urination. Has hypertension. MI
6 years ago. Dry mucous membranes. Labs show: Hct 47%, Na 125, K 3.5, Cl 95, HCO3 24,
BUN 30, Glucose 700, Cr 1.8. Cause of sodium concentration?
- Hyperglycemia

37. 27yo nulligravid F unable to conceive for 2 years. Pain with sexual intercourse over the past
6 months. Menarche at 13, regular intervals. LMP 1 week ago. Right lower quadrant tenderness.
5-cm, tender, right adnexal mass. Urine pregnancy test negative. Ultrasonography shows a 5-cm,
right adnexal mass containing low-level, homogenous, internal echos. Biopsy will show?
- Endometrial glands and stroma

38. One day after cholecystectomy, 37yo M becomes increasingly tremulous and anxious. Moves
around restlessly in bed. No meds, does not smoke. T 37.4, P 120/min, BP 160/100. Next step?
- Oral diazepam

39. 14yo girl with 2-day history of fever and pain and swelling of the right knee. Injuring the
knee while playing soccer last week, but she was able to finish the game. Sister has IBD. T 39 C.
Edema, tenderness, warmth, and erythema; ROM limited. Causal organism?
- Staphylococcus aureus

40. 22yo F with acute myelogenous leukemia undergoes evaluation prior to discharge. Has
received induction chemotherapy and transfusions via a subcutaneous central venous catheter for
the past 4 weeks. Two days ago, CBC and bone marrow biopsy were normal. Most appropriate
recommndation to avoid complications?
- Hand washing with an antibacterial soap prior to contact with the catheter

41. 17yo boy. Informed by his school counselor that he wants to commit suicide. Last week, he
broke up with his girlfriend of 2 years, and today he learned that he did not get accepted to
university. States that he does not want to hurt himself because of religious beliefs. In addition to
recommending outpatient therapy, best recommendation to parents?
- "Make sure he does not have access to guns."
42. 37yo F with left leg pain for 2 days. Medications include an oral contraceptive and calcium
supplementation. Subcutaneous, palpable, hard, cord-like structure within a 6 x 1-cm, warm,
erythematous area just proximal to the ankle. Scatterred varicose veins. Next step?
- Use of compression stockings

43. 67yo M with alcoholism. 15-year history of poorly controlled hypertension; takes
hydrochlorothiazide, not compliant. BP 170/102. Funduscopic examination shows arteriovenous
nicking and tortuosity of the arteries. Risk for?
- Subarachnoid hemorrhage

44. 62yo M with alcoholism and nonhealing ulcer on his tongue for the past 6 months. smoked
daily. No lymphadenopathy. Lesion removed surgically, and a pathology report describes
pleiomorphic cells with many mitotic figures infiltrating deeply into the tongue muscle. Dx?
- Squamous cell carcinoma

45. 24yo F with mouth sores for 3 dyas. 2-year hx of hypertension and 6-mo hx of anemia.
Symmetric swelling of the proximal interphalangeal and meatarpophalangeal joints of both
hands without ulnar deviation. Hct 29%, WBC 3.1k, platelets 99k, Urine: protein 3+, blood 3+.
Serum antinuclear antibody titer is 1:512, and anti-double-stranted DNA assay is positive. Dx?
- Systemic lupus erythematosus

46. 37yo F G2P2 for contraceptive advice. No hx of illness, no meds. Smoked daily and drinks
socially. BMI 31. T 37.3, BP 137/87. Which contraceptive is contraindicated?
- Combination oral contraceptive

Block 3

1. 4yo girl with 3-hour history of sore throat and T to 39 C. Two months ago, patient brought to
USA from China. Leaning forward but is drooling, appears ill, and responds poorly to stimuli. T
39.8 C,p 160/min, resp 42/min,. Oxygen saturation of 82%. Respiratory distress and poor air
entry. In addition to supplemental oxygen, next step?
- Endotracheal intubation

2. 19yo F at 32 weeks' gestation with 1-month history of a generalized rash that has not
expanded or changed. No pruritis or fever. No prenatal care. Macular rash involving the palms,
chest, back, abdomen, extremities, and soles. Causal oragnism?
- Treponema pallidum

3. 62yo F with 6-month history of pain in her left leg with exertion. Cramping sensation in her
left calf and thigh after walking three level blocks or uphill for one block. Femoral and popliteal
pulses are decreased on the left and normal on the right. Next step?
- Measurement of ankle brachial indices

4. 37yo M after his motorcycle ran into the back of a truck. Neck is immobilized and IV fluids
given. Appeared to be intoxicated. P 130/min, BP 100/60. Lungs clear. Blood at the urethral
meatus. Ultrosonography shows blood in the abdomen. X-ray of the pelvis shows fractures of the
pubic rami and ischial and ilial fractures on the right. Next step?
- Retrograde urethrography

5. 52yo F routine examination. One year ago, started on daily hormone replacement thearpy
(estradiol and medroxyprogesterone) to traet severe vasomotor symptoms. But has been taking
the mexroxy intermittently because of severe depression and mood changes when taking it. Has
had vaginal spotting two to three times monthly. Next step?
- Endometrial biopsy

6. 32yo F ith 2-day history of fever and an area of swelling and redness on her right forearm. No
travel, no hx of trauma. Epitrochlear lymph nodes are enlarged. Distal radial aspect of the right
upper extremity shows an 8 x 12-cm warm, erythematous area of edema that is tender to
palpation; warm, tender red streak extending from this area to the elbow. Causal organism?
- Beta-Hemolytic streptococcus

7. 57yo writer for a routine health mainenance exam. Increasingly preoccupied wih ensuring that
no one will steal her manuscripts. She hides pieces of her work on computer diskettes around her
home and car. Labels each with a coded name. Fired seven housekeepers because she has
suspected them of stealing. Appears well groomed and stylishly dressed. Dx?
- Delusional disorder, paranoid type

8. 62yo M 4 hours after sudden onset of vomiting and sever abdominal pain. Has had mild,
intermittent epigastric pain, relieved with antacid use. No hx of serious illness. Smoked daily for
35 years. Appears diaphoretic and is in acute distress. T 38.4 C, P 100/min, BP 115/75. Bowel
sounds are absent. Next step?
- X-rays of the chest and abdomen

9. 37 year old woman, sudden onset fever 7 days after splenectomy for immune
thrombocytopenic purpura (ITP). Abdominal pain and left shoulder pain for 2 days. T 102.4,
mild distension and diffuse tenderness, no rebound, rigidity or guarding. Bowel sounds are
absent. Labs hg 9.8 Leuks 21,300 Platelet 105, 000, amylase 124. chest xray shows left pleural
effusion. what is the most likely cause of the findings?
- Subphrenic abscess

10. 67yo F with 2-month history of an intermittent mild burning sensaiton in her epigastrium.
Occurs after she walks one block of climbs one flight of stairs. Smoked daily for 40 years. T
37C, P 98/min, BP 150/90. Labs, cardiac enzyme activities are within reference range. ECG
normal. Next step?
- Cardiac stress scintigraphy

11. 4 y/o boy with increasing scalp lesions in last week. He want nature walking 10 days ago.
Scattered papules with some scaly areas on the scalp, surrounding hair is broken near the base
with mild alopecia. What would have prevented condition?
- Avoidance of sharing hats
12. 52yo M with fever and muscular rigidity for 24 hours. Taking chlorpromazine for 4 days for
agitation and insomnia. Well until 2 days ago when he began to sweat profusely and feel
agitated. T 39.2 C, P 120/min, BP 150/100. Clammy skin and rigid extremities. Hoffman and
Babinski signs are absent. Visual hallucinations. Next step?
- Discontinue chlorpromazine

13. 47 yo M at follow-up after being diagnosed with stage I HTN 5 months ago. Started on
hydrochlorothiazide. Over the last month, he has felt fatigued. Exam is normal. Which is causing
his symptoms?
- Hypokalemia

14. 37yo F from Guatemala with joint pain, swelling, and stiffness of her wrists and hands for 2
years. Ibupforen ineffective. No fever, cough, or weight lossl. Received all immunizations. BMI
20. Spleen tip is nontender and is palpated 4 cm below left costal margin. Grip strength is
decreased. Labs: Hb 10, Leukocyte count 2.5k, Platelets 125k. Cause of the leukopenia?
- Felty syndrome

15. 57yo F 6 hours after the onset of progressive confusion. Unable to provide history. Smoked
two packs daily for 40 years. X-ray of the chest shows a 2-cm mass in the right upper lobe of the
lung. A CT scan of the head is normal. Mechanism of confusion?
- Decreased serum sodium concentration

16. 67yo M with 6-month history of aching in his thighs and buttocks after he walks 200 feet. T
37C, BP 140/90. Femoral and distal pulses are absent bilaterally. BUN 30, Cr 1.5 Undergoes
aortic arteriography. Three days later, his serum Cr is 2.8. Administration of which prior would
have prevented renal insufficiency?
- Infusion of 0.9% saline

17. 32yo M 20 minutes after falling 18 feet from a scaffold. Moaning and responds only to
painful stimuli. P 130/min, Resp 16/min, BP 85/40. No evidence of external bleeding.
Ecchymoses over the forehead, left lower chest, and upper abdomen. Intubated, and two large-
bore IV inserted. Next step?
- Intravenous administration of lactated Ringer solution

18. Thirty-six hours after c-section, 27yo G1P1 has the sudden onset of moderate left-sided chest
pain and shortness of breath. No Hx of serious illness. T 37.2, P 120/min, resp 26/min, BP
100/40. Pulse oximetry on room air shows an oxygen saturation of 84%. Breath sounds
decreased over both lung bases. Dx?
- Pulmonary embolism

19. 72yo M with dementia is brought to the ED 2 days after the onset of fever, confusion, and
generalized weakness. Sx began following irrigation of his urinary catheter, which was not
draining well. T 36.2, P 110/min, BP 90/50. Supple neck. Heberden nodes on the hands. Breath
sounds decreased throughout the lungs. Labs show: Hct 50%, Leukocyte count 15.4k, Na 134, K,
4.2, Cl 86, HCO3 24, BUN 12, Cr 1.1. ECG shows sinus tachycardia with some flattening of ST-
T segments. explanation of hypotension?
- Decreased systemic vascular resistance

20. 3yo girl with fever and ear pain for 1 day. Has had cler nasal discharge and cough for 3 days.
History of several ear infections and one episode of streptococcal pharyngitis over the past 12
months. Father smokes in the house, family has two cats. Swims frequently. T 38.5, P 110/min,
BP 80/50. Clear nasal discharge, erythema and bulging of the right tympanic membrane, and
erythema of the throat without exude. Recommendation to prevent recurrence?
- Avoidance of passive smoke exposure

21. 72yo F for exam in the fall. No meds. Bone density normal, 1 year ago, a pap smear,
mammography, and sigmoidoscopy normal. Serum cholesterol 190, glucose was 80. Does not
smoke. BMI 23. BP 140/85. Next step?
- Influenze virus vaccination

22. 52yo F G2P2 with increasingly frequent loss of urine during the past 2 years. Feels an
overwhelming urge to void and completely saturates an absorbent pad before reaching the
bathroom. Awakens three to four times nightly to void. No loss of urine with coughing or
sneezing. Has hypertension rx with a diuretic. VSS. No loss of urine with Valsalva. Postvoid
residual volume is 50 mL. Dx?
- Overactive bladder with incontinence

23. 27yo M with 3-month history of episodes of palpitations, light-headedness, and tightness in
his chest and throat. Feels an impending sense of doom and fears that he might die or "go crazy."
Worried constantly that there is something wrong with his heart. Dx?
- Panic disorder

24. 2yo girl 60 minutes after she had a 2-minute episode of generalized shaking. During the
episode, she was unresponsive, and her eyes were rolled back in her head. Awake and
cooperative. T 39.8 C, P 130/min, BP 90/70. Erythematous, bulging right tympanic membrane.
Next step?
- Oral antibiotic therapy

25. 57yo M with type 2 diabetes mellitus unable to bend his right foot since awakening 4 hours
ago. Numbness over the dorsum of his right foot during this period. Has a 2-year history of
intermittent mild low back pain. DTR 2+ bilaterally. Unable to dorsiflex his right ankle or toes
and evert his right ankle. Straight-leg test negative. Dx?
- Peroneal neuropathy

26. 30yo F routine exam. 10-year history of type 1 diabetes mellitus. Microalbuminuria, her
hemoglobin A1c is 7%, and serum Cr is 1.8. Intervention?
- Administration of an angiotensin-converting enzyme (ACE) inhibitor

27. 92yo F concerned she has become increasingly forgetful. Difficulty remembering names of
new acquaintances. Lives alone, upset that she forgot to pay her bills. Concerned that she is
beginning to have dementia. Drives and does her own shopping and cooking. Recalls two of
three words after 5 minutes. Mini mental state examination score is 27/30. Next step?
- Reassurance

28. 19yo M has sudden onset confusion 36 hours after admission for injuries sustained in a
motorcycle collision. Underwent cast immobilization of a fracture of the right medial malleolus
and opern reduction and internal fixation of a fracture of the left femur. On morphone. T 39.1 C,
P 110/min, rr 26/min, BP 100/50. Pulse oximetry on room air shows an oxygen saturation of
84%. Petechiae over the shoulders, chest, and axillae. Explanation?
- Fat embolism

29. 1-week-old newborn with poor feeding and increasing irritability. Delivered vaginally at
home. Umbilical cord was severed with a kitchen utility knife. He has trismus and rigidity of the
extremities and drunk. Causal organism?
- Clostridium tetani

30. 2yo boy with delayed speech. Born at term, pregnancy and delivery were uncomplicated. 4yo
bother has mental retardation. Pt has high forehead, prominent ears, and a long hypotonic face.
Psychomotor hyperactivity. Explanation?
- Fragile site on the X chromosome

31. 37yo M with 6-week history of the rash shown. Similar rash over the past 5 years resolved
with Rx. Sun exposure, the rash becomes ligher than his tanned skin. Pharmacotherapy?
- Selenium sulfide shampoo

32. 57yo F for routine exam. Smoked one pack of cigarettes daily for 40 years. Takes vitamin D
daily. HCT 42%, Ca 11, Phosphorus 2.8, BUN 15, Cr 1, Parathyroid hormone wnl. X-ray of the
chest shows a 2-cm nodule in the right upper lobe of the lung. A CT scan shows the same nodule
with no evidence of metastases. Cause of increased serum calcium?
- Paraneoplastic syndrome

33. 30yo F with abrupt onset of easy bruising 2 weeks ago and heavy blood loss during menses 1
week ago. Required blood transfusion after MVC 5 years ago. No Hx of bleeding disorder.
Petechiae and ecchymoses. Labs: Hb 13, WBC 7.2k platelets 4k, PT 12 sec, PTT 25 sec. Dx?
- Immune thrombocytopenic purpura

34. 37yo F with 19-year history of hypertension difficulty to control. No meds. BMI 20. BP
160/94. Na 141, K 3.2, Cl 103, HCO3 30, BUN 15, Aldosterone:renin ration 42. Urine
aldosterone 34 (N=3-20). MRI abdomen normal. Next step is to add which?
- Spironolactone

35. 67yo AA woman for annual health exam. Menopause occurred at age 44. Has
hypothyroidism treated with thyroid replacement therapy. Smoked daily. BMI 21. Which
decreases risk for osteoporosis?
- African American race

36. 22yo F with asthma. Treated for six acute episodes of wheezing and nonproductive cough
during the past year. Last episode 1 mo ago. Sx exacerbated when outside during the spring and
fall. On albuterol inhaler. Smoked daily for 5 years. X-ray of the chest normal. Which will
reduce frequency of exacerbations?
- Fluticasone inhaler therapy

37. 62yo M with fatigue for 9 weeks. Drinks moonshine. HCT 29%, MCV 78, and mean
corpuscular hemoglobin concentration is 25%. Blood smear shows hypochromic, microcytic
erythrocytes and normochromic, normocytic erythrocytes. Bone marrow shows greater than 10%
normoblasts containing iron-laden mitochondria that surround the nucleus and appear as rings on
Prussian blue staining. Iron and transferrin saturation increased. Cause?
- Sideroblastic anemia

38. 42yo F has had fatigue for 6 months. CHronic renal failure requiring hemodialysis. HCT
26%, CV 67, reticulocyte count is 0.1%. Iron and transferrin saturation wnl, ferritin
concentration is increased. Cause?
- Erythropoetin deficiency

39. 62yo man has had fatigue and bone pain for 12 weeks. Splenomegaly. Hb 14.9, WBC 24.3k,
Platelets 672k. Leukocyte alkaline phosphatase activity is decreased. Bone marrow examination
shows hypercellularity and many immature leukocyte forms. Cytogenic analysis shows
Philadelphia chromosome (Phl). Cause?
- Chronic Myelogenous leukemia

40. 82yo M with shortness of breath at rest, increasing malaise, generalized weakness, and
depressed mood for 6 weeks. Bruises easily and has bleeding and inflammation of the gums.
Hypertrophic, lichenified patches over the upper extremities. No memory loss. Dx?
- Vitamin C deficiency

41. 6 month old boy, chronic constipation since the age of 1 week. Current Rx with rectal
stimulation, glycerin suppositories, and 4 ounces of prune juice produces string-like stool every 4
days. No vomiting. Growth and development are appropriate for age. Abdominal exam shows
distension, no tenderness. Rectal exam, no palpable stool in ampulla. What is next step in
mangement?
- Rectal manometry

42. Study conducted to compare accuracy of fine-needle aspiration (FNA) with same-site biopsy
for diagnosis of breast cancer. 200 women enrolled, 100 with bx of cancer, 100 without. 90 FNA
+ BX +, 10 FNA - Bx +, 5 FNA + Bx -, 95 FNA - Bx -. Sensitivity?
- 90%

43. 20yo M with sudden onset of confusion and hypotension 5 minutes after Intravenous
nafcillin and gentamycin for staphylococcal endocarditis. Hx of heroin use. T 38.7 C, P 130/min,
RR 32/min, BP 80/60. Wheezing is heard bilaterally. S1 normal. S2 decreased. 1/6 systolic
ejection murmur heard at the base of the heart, and grade 2/6, blowing diastolic murmur heard at
the right sternal border. Pulmonary artery cath shows decreased cardiac output, PCWP, and
SVR. Cardiomegaly. ECG shows sinus tachycardia, t wave inversion in leads I, avL, V1-V6.
Cause?
- Anaphylaxis

44. 52yo F with 8-month hx of intermittent nonproductive cough. No meds. Smoked daily for 25
years. Sinusitis over 18 months. Pale nasal mucosa and cobblestoning of the posterior pharynx.
Lungs clear. No clubbing or cyanosis. Cause?
- Allergic rhinitis

45. 32 year old woman with 1 month of diarrhea, 8lb weight loss, three to four semiliquid stools
daily. No fever, abdo pain or rectal bleeding. Just returned from scuba diving in Mexico 6 weeks
ago. Boyfriend is symptom free. Abdo and rectal exam are normal. What is organism?
- Giardia lamblia

46. 7 yo girl, 2 wk hx of fever, intermittent rash, and joint pain and swelling. Has had three
similar episodes during the past 2 years. T102.9, P 108, rr 20, bp 100/70. Generalized pink
macular rash over the trunk and upper and lower extremities. Warm, swollen interphalangeal
joints, dec ROM. What is in synovium?
- Leukocytes

Block 4

1. 57yo F with 1-month history of increased difficulty sleeping and increasing fatigue and
irritability. Awakens with a headache, poor sleep. Snores throughout the night. Gained 14 kg in 6
months. BMI 28. Polysomnography shows 19 episodes of breathing-related arousals per hour.
TSH is 1.5. Dx?
- Mood disorder due to a general medical condition

2. 27yo F with 12-hour history of severe shortness of breath. 15-year hx of asthma rx with
inhaled corticosteroids twice daily. Had a cold. Awake most of last night due to wheezing and
respiratory distress. Using accessory muscles. P 130/min, RR 36/min. Pulse oximetry on room
air shows an o2 saturation of 90%. ABG: pH 7.52, pco2 30. Twenty minutes after Rx. ABG: pH
7.4, Pco2 42. Next step?
- Intubation

3. 67yo F has a 24-hour hsitory of nausea and abdominal distension. Vomited three times. Had
one bowel movement. Underwent surgical repair of a suprarenal abdominal aortic aneurysm 6
days ago. T 38.1 C, P 95/min, BP 120/80. Lungs clear. Epigastric tenderness. CT abdomen
shows a thickened, indurated pancreas with a loss of surrounding soft tissue planes. Next step?
- Nasogastric decompression

4. 42yo F in ED 30 minutes after found unconscious in her bed. 6-year history of systemic lupus
erythematosus treated with prednisone. Been on a drinking binge and not eating. Three days ago,
had rhinitis, conjunctivitis, and a nonproductive cough. T 38.9 P 110/min, palpable SBP is 80.
Initial step?
- Corticosteroid therapy
5. 57yo F brought in by daughter because she has become lost while driving home from the
store. Bright affect. mmSE is 24/30. Recalls zero of three words after 5 minutes. Oriented to
person and place but is not sure of the month of the year. Dysregulation of which
neurotransmitters is the cause of symptoms?
- Acetylcholine

6. 37 yo man restrained driver in a car with no airbags. Steering wheel was deformed. En route,
his hemodynamic status and respirations were stable. He has severe anterior chest pain. P110,
RR 24, BP 90/60. Exam shows jugular venous distention (JVD), tenderness of the sternum to
palpation. Breath sounds are equal. Heart sounds are decreased. Upper and lower extremities are
normal. After 2L 0.9% saline, pulse decreases to 100/min, BP increases to 100/70. In the next 10
min, BP drops to 80/50. Which explains changes in BP?
- Pericardial tamponade

7. 5yo boy with 1-week history of a sore throat and a 1-day hx of dark urine. Positive rapid
streptococcal test 4 days ago and has received penicillin since. T 37. Urine: glucose negative,
protein 3+, ketones negative, RBC too numerous. Substance that is most likely decreased?
- C3

8. 14yo girl 6 hours after onset of severe abdominal pain. Hx of similar episodes and swelling of
her arms and legs since early childhood. Associated with swelling of the lips and eyes and have
not responded to rx with hydroxyzine. VSS. Rigid and diffusely tender abdomen. Bowel sounds
are increased. Substance that is most likely decreased?
- C1 esterase inhibitor

9. 23yo M with 2-day history of abdominal pain. Initially, pain was diffuse and colicky, but has
become sharp and localized to the right lower quadrant; he has had nausea and has vomited three
times. Last bowel movement 2 days ago. T 38.1 C, 95/min, BP 130/75. Lungs clear. Underlying
mechanism of the shift in location of this patient's pain?
- Inflammation to the parietal peritoneum

10. 47yo M with 2-year history of increasing left knee pain. Over the past 6 months, he has been
awakening at night with pain. Pain exacerbated with walking and prolonged standing. Stoped
participating in spots. At age 16, he sustained fractures of the left proximal tibia while playing
football and undeerwent ORIF. No locking or catching. Varus deformity of the left knee.
Explanation?
- Post-traumatic arthritis

11. 19yo primigravid at 39 weeks' gestation with decreased fetal activity uring the past 2 days.
Has T1DM, postprandial blood glucose ranged b/w 95 and 105. Fundal height is 42 cm.
Nonstress test shows no fetal accelerations, and a contraction stress test shows late decelerations.
Cause of the fetal heart rate findings?
- Placental insufficiency

12. 47yo F 1 week after noticing a lump in her left breast. LMP 3 weeks ago. 2-cm mobile mass
in upper outer quadrant of the left breast. Lymph nodes are not enlarged. Mammography shows
the mass to have irregular borders with no calcifications. Next step?
- Fine-needle aspiration biopsy of the mass

13. 27yo M with 4-day history of pain and fullness in his left testicle and a 2-day history of mild
pain with urination. Sexually active with one female. Mild left testicular and scrotal tenderness
with no redness or edema. Urinalysis shows 3-5 WBC/hpf, no orgs. Causal organism?
- Chlamydia trachomatis

14. 37yo African American man. No hx of illness and no meds. No smoking. Excercises. Mother
and 4-yo brother have HTN. BMI is 23. P 82/min, BP 144/92. Next step?
- Second measurement of blood pressure in 2 weeks

15. Two weeks after bowel resection, 62yo M cannot be weaned from the ventilator. VSS. Serum
thyroxine (T4) concentration of 6, a triiodothyronine (T3) concentration of 90, and a thyroid-
stimualting hormone concentration of 2.8. Cause?
- Euthyroid sick syndrome

16. 4yo boy with increasing left ear pain for 2 weeks. T 38.5. Erythematous, bulging tympanic
membrane an an edematous auditory canal with a small amount of mucopurulent dischage. Ear
displaced laterally. 1-cm, freely moile, nontender mass palpated over the left anterior neck. Next
step?
- NOT Oral amoxicillin therapy
- I think it must then be: CT scan of the temporal bone

17. 18yo primigravid African American at 18 weeks' gestation with 2-day history of fever and a
12-hour history of severe left-sided back pain. No prenatal care. T 39.1. Left costovertebral angle
tenderness. Labs show: Hb 7.9, Hb electrophoresis: A1 14%, A2 4%, F 7%, S 75%; MCV 90,
Platelets 159k, Urine: bacteria 3+ WBC 3+. In addition to antibiotic, most appropriate
pharmacotherapy?
- Folic acid

18. 37yo F G2P2 with 3-month history of shortness of breath with exertion. Hx of rheumatic
fever during childhood. Has a murmur. No meds. BMI 19. Examination shows malar flushing.
Jugular venous distention. Lungs clear. Grade 2/6, late diastolic murmur is heard at the apex.
Loud S1. Cause of dyspnea?
- Increased pulmonary venous pressure

19. 35yo F 20 minutes after sustaining a stab wound to the left side of the chest. Alert and
oriented. Difficulty breathing. P 100/min, rr 30/min, BP 110/70. 1-cm stab wound in the fifth
intercostal space at the midclavicular line. Left hemithorax is hyperresonant to percussion, and
breath sounds decreased. Neck veins distended, trachea deviated to the right. SBP 70. Dx?
- Tension pneumothorax

20. 57yo M takes an angiotensin-converting enzyme (ACE) inhibitor for hypertension and has
been advised to lose weight. Works as pharmacist. BP 152/94. Serum thyroid studies show TSH
of 2, thyroxine (T4) of 18, and triiodothyronine (T3) concentration of 220.Radioactive thyroid
scan shows decreased uptake and a small gland. Cause?
- Exogenous administration of thyroid hormone

21. 24yo F with 6-month history of intermittent weakness of her arms. Arms get tired when she
combs her hair. Had episodes of double vision and drooping of her right eye. No meds. Mild
right ptosis. Ocular movements are full. On prolonged upgase, the eyes drift downward and right
ptosis increases. Pupils equal and reactive to light. DTR 2+. Babinski sign is absent. SILT.
Location of the abnormality?
- Neuromuscular junction

22. 57yo F with 6-month history of moderate periumbilical pain that occurs within 1 hour after
eating. Had 11-kg weight loss as a result of the pain. 5-year hx of HTN and claudication. On BP
meds. BMI 18. P 75/min BP 145/90. Femoral pulses are palpable bilaterally, and popliteal and
distal pulses are absent bilaterally. Next step?
- Arteriography

23. 42yo F with decreased energy, apathy, and difficulty sleeping since being fired from her job
3 weeks ago. Crying spells, weight loss, tearful. Speech is soft and goal directed. Not thought
abot suicide and does not want to die. Labs normal. Next step?
- Citalopram therapy

24. 42yo M with 3-month history of fatigue, generalized weakness, and depressed mood. Cold
intolerance, muscle aches, and constpiation. Follows a strict vegetarian diet. Wife has
hypothyroidism rx with levothyroxine. Dry skin, testes are small. TSH if 0.1. T4 is 2.3.
Mechanism?
- Deficient pituitary production of TSH

25. 27yo M and wife unable to conceive over the past 4 years. Left testicle drags. Both testes are
well descended. Left scrotum hangs lower than the right, and there is a soft tissue mass near the
top of the left testes that feels like a bag of worms. In the supine position, the mass mostly
dissapears. Dx?
- Varicocele

26. 82yo F 30 minutes after collapsing at a shopping center. Intubated at the scene. Comatose
and requires mechanical ventilation Granddaughter comes to the hospital and shows an advance
directive requesting no intubation. Next step?
- Extubate the patient and provide supportive care only

27. 47yo F 2 hours after onset of pain in her right leg. Exacerbated when she elevates her legs.
No meds. Grade 2/6, systolic ejectin murmur is heard at the left sternal border. Right lower
extreemity is cool, and pedal capillary refill is poor. Undergoes emergency femoral
embolectomy, and histology shows a myxoma. Next ste[p?
- Echocardiography

28. 47yo F with intermittent palpitations over the past 3 weeks. No smoke and no meds.
Consumes two caffeinated beverages daily and does not drink alcohol. X-ray of the chest shows
bilateral hilar adenopathy and clear lung fields. ECG shows first-degree atrioventricular block.
Dx?
- Sarcoidosis?

29. 56yo M with sweating, generalized itching, and headaches for 6 weeks; 5-kg weight loss.
Plethora and splenomegaly. Labs: HCT 56%, platelest 568k. Cause?
- Increased production of erythrocytes

30. 37yo M diagnosed with HIV infection 3 weeks ago. Erythematous scaling at the hairline and
nasolabial folds. CD4+ T-lymphocyte count is 160. Viral load is 25k copies. Pharmacotherapy?
- Three-drug antiretroviral thearpy and P. jiroveci prophylaxis

31. 2yo girl with shortness of breath for the past 2 hours. 3-day history of runny nose, sneezing,
and nasal congestion. T 38.5 C, p 130/min, rr 48/min. Dyspnea. Stridor and moderate retractions
with inspiration. Lungs clear. Barking cough. Causal organism?
- Parainfluenza virus

32. 72yo M vomited blood three times during the past 12 hours. Dizziness. 5-year history of
arthritis rx with daily ibuprofen. Has increased his daily dose of ibuprofen for worsening joint
pain. p 110/min, BP 90/60. Dried blood near the mouth. Stool is black, and test for occult blood
is positive. HCT 22%. Upper endoscopy shows hemorrhagic gastritis with no active sit of
bleeding. 30 min after resuscitation with crystalloid solution, patient has shortness of breath.
Diffuse rhonci and crackles heard bilaterally. Cause of dyspnea?
- Gluid overload

33. 23yo M with schizophrenia 28 hours after onset of progressive confusion and agitation. Had
increased thirst. On haloperidol and benztropine. T 38, p 100/min, dry mucous membranes.
Pupils are 4 m and reactive to light. Cause?
- Anticholinergic delirium

34. 25yo F with AIDS comes with 10-day history of fever, shortness of breath, night sweats, and
a nonproductive cough. T 38.6. CXR with bilateral interstitial infiltrates. Silver stain positive for
cysts and organisms. pharm?
- Trimethoprim-sulfamethoxazole

35. Double-blind study for effectiveness of combination hormone replacement therapy (HRT) on
the incidence of cancer in postemenopausal women. Total of 16,408 patients. Results shown.
Most accurate conclusion regarding effect of combination HRT on the incidence of cancer?
- HRT increases the incidence of ovarian cancer

36. 47yo M with shortness of breath during ambulation and at rest for 24 hours. No chest pain.
Chemotherapy including doxorubicin for non-Hodgkin lymphoma 4 months ago. Echo shows
left ventricular ejection fraction of 40%. ECG shows sinus tachy. Explanation?
- Congestive heart failure
37. 67yo F with lesion on her right eyelid for 3 months. No hx of similar lesions. 2 x 1.5-cm
lesion on the lower lid of the right eye. Biopsy shows basal cell carcinoma. Next step?
- Mohs micrographic surgery

38. 27yo F 25 minutes after MVC. Restrained driver. Upper abdominal and left-sided chest pain.
P 120/min, rr 18, BP 80/50. Tenderness over the left costal margin and LUQ of abdomen. X-ray
of the chest shows multiple fractures of the rips. BP stabilizes after 2 L lactated Ringer solution.
Next step?
- CT scan of the abdomen

39. 82yo M with 1-month history of sudden forgetfulness. Had difficulty managing his
checkbook. His deficits have become more severe during the past month and reports occasionally
getting lost and having to ask for directions. He has hypertension treated with
hydrochlorothiazide. No alcohol. BMI 29. BP 145/95. Babinski sign is present on the left. Long-
term memory intact. Mini-Mental State exam is 23/30. Dx?
- Multi-infarct (vascular) dementia

40. 62yo F with vaginal bleeding for 4 days. Menopause was 13 years ago. 8-cm, left adnexal
mass that is freely mobile. Ultrasonography shows a thickened endometrial stripe and a 7-cm,
left ovarian mass. Endometrial biopsy shows complex hyerplasia. Cause?
- Granulosa cell tumor

41. 47yo M 2 hours after onset of severe neck pain while he was lifting a heavy tool at his job.
Pain exacerbated when he turns his neck left or coughs and now radiates over his right shoulder
and arm. Has 3-yr hx of neck pain. DTR decreased in the right biceps and brachioradialis
muscles. Cause?
- Herniated disc at C5-6

42. 22yo F requesting contraceptive advice. as been sexually active with new male partner, do
not use contraception. Pelvic examination shows normal external genitalia. Normal vaginal
mucosa and a mucopurulent exudate at the cervical os. Bimanual examination shows a normal-
sized uterus w/o tenderness. Cause?
- Chlamydia trachomatis

43. 6yo girl with right eye tearing and irritation over the past 2 days. Eye does not itch. VSS.
Right conjunctiva is erythematous with clear discharge and crusting. Left eye normal. Nasal
congestion and erythematous mucosa. Dx?
- Viral conjunctivitis

44. 6yo boy with bilateral eye itching and mild nasal congestion over the past 3 weeks. VSS.
Bilateral conjunctival erythema and tearing. Cobblestone appearance of the tarsal conjunctivae
bilateral. Nasal mucosa is pale and boggy. Dx?
- Allergic conjunctivitis

45. 16yo girl has the rash shown for 3 months. Cause?
- Propionibacterium acnes

46. 23yo primigravid at 10 weeks' gesteration for first prenatal visit. Vegetarian diet and eats no
meat or fish. Intends to breast-feed her newborn. Which additional supplemental vitamin during
pregnancy and lactation?
-D