1st set

Question 1

A 74-year-woman consults you because of tremor and difficulty completing her daily tasks on time. She has hypertension and takes hydro-chlorothiazide 25 mg every morning. She does not smoke and uses alcohol infrequently. On examination, her BP is 126/84; her vital signs are otherwise unremarkable. Eye movements are normal as are her reflexes and motor strength. She moves slowly; her timed get-up-and-go test takes 24 seconds (normal 10 seconds). She has a slow resting tremor with a frequency of about 3/second; the tremor is more prominent on the right than the left. The tremor decreases with intentional movement. Her handwriting has deteriorated and is small and crabbed. Which therapy is most likely to improve her functional disabilities?
A. Switching her antihypertensive to propranolol 20 mg po bid
B. Benztropine mesylate 0.5 mg po tid
C. Lorazepam 0.5 mg po tid
D. Ropinirole beginning at a dose of 0.25 mg tid
E. Carbidopa/levodopa beginning at a dose of one-half of a 25 mg/100 mg tablet tid

Answer 1

E. Carbidopa/levodopa beginning at a dose of one-half of a 25 mg/100 mg tablet tid

Question 2

A 48-year-old woman presents with a change in bowel habit and 10-Ib weight loss over the past 2 months despite preservation of appetite. She notices increased abdominal gas, particularly after fatty meals. The stools are malodorous and occur 2 to 3 times per day; no rectal bleeding is noticed. The symptoms are less prominent when she follows a clear liquid diet. Which of the following is the most likely histological abnormality associated with this patient’s symptoms?
A. Signet ring cells on gastric biopsy
B. Mucosal inflammation and crypt abscesses on sigmoidoscopy
C. Villous atrophy and increased lymphocytes in the lamina propria on small bowel biopsy
D. Small, curved gram-negative bacteria in areas of intestinal metaplasia on gastric biopsy
E. Periportal inflammation on liver biopsy

Answer 2

C. Villous atrophy and increased lymphocytes in the lamina propria on small bowel biopsy

Question 3

A 36-year-old female complains of inability to lose weight despite low-calorie diet and daily exercise. She has also noticed that she is cold intolerant. She is wearing a jacket even though it is summer. She also reports constipation and hair loss. These symptoms have been worsening over the past 2 to 3 months. An elevated TSH and low total and free T 4 confirm your suspicion of hypothyroidism. You suspect the etiology of this patient’s hypothyroidism to be autoimmune thyroiditis.
What is the best test to confirm the diagnosis of autoimmune thyroiditis?
A. Thyroid peroxidase antibody (TPOAb)
B. Antinuclear antibody
C. 24-hour radioactive iodine uptake
D. Thyroid ultrasound
E. Thyroid aspiration

Answer 3

A. Thyroid peroxidase antibody (TPOAb)

Question 4

A 47-year-old man who had a splenectomy after a childhood accident develops shaking chills and dies within 8 hours from refractory hypotension and respiratory failure. What is the most likely organism?
F. Streptococcus pneumoniae
G. Staphylococcus aureus
H. Viridans streptococci
I. Providencia stuartii|
J. Actinomyces israelii
K. Haemophilus ducreyi
L. Neisseria meningitidis
M. Listeria monocytogenes

Answer 4

F. Streptococcus pneumoniae

Question 5

Three weeks after an upper respiratory illness, a 25-year-old male develops weakness of his legs over several days. On physical examination he has 4/5 strength in his arms but only 2/5 in the legs bilaterally. There is no sensory deficit, but motor reflexes in the legs cannot be elicited. During a 2-day observation period the weakness ascends, and he begins to notice increasing weakness of the hands. He notices mild tingling, but the sensory examination continues to be normal.
The workup of this patient is most likely to show which of the following?
A. Acellular spinal fluid with high protein
B. Abnormal EMG/NCV showing axonal degeneration
C. Positive edrophonium (Tensilon) test

D. Elevated CK
E. Respiratory alkalosis on arterial blood gas

Answer 5

A. Acellular spinal fluid with high protein

Question 6

A 73-year-old man has had 3 episodes of visual loss in the right eye. The episodes last 20 to 30 minutes and resolve
completely. He describes the sensation as like a window shade being pulled down in front of the eye. He has a history of hypertension and tobacco use. He denies dyspnea, chest pain, palpitations, or unilateral weakness or numbness. On examination the patient appears healthy; his vital signs are normal and the neurological examination is unremarkable. An ECG shows normal sinus rhythm without evidence of ischemia or hypertrophy. Initial laboratory studies are normal. Both noncontrast CT scan of the head and MR scan of the brain are normal. What is the best next step in this patient’s management?
A. Begin anticoagulation with low-molecular-weight heparin and warfarin.
B. Obtain an echocardiogram.
C. Check for antiphospholipid antibodies and homocysteine levels.
D. Order a carotid duplex ultrasonogram and begin antiplatelet therapy.
E. Begin lamotrigine for probable nonconvulsive seizure.
 

Answer 6

D. Order a carotid duplex ultrasonogram and begin antiplatelet therapy.

Question 7

A 32-year-old woman complains of severe seasonal allergies. Every year from April through July she is miserable with sneezing, nasal congestion, and watery itchy eyes. Antihistamines, nasal corticosteroids, nasal saline washes, eye drops, and attempts to avoid potential antigens have proven unsuccessful. She requests referral to an allergist for “allergy shots.” What advice should you give her about immunotherapy (hyposensitization) for her allergic symptoms?
A. Immunotherapy is useful is asthma but not in allergic rhinitis.
B. Immunotherapy can be used in allergic rhinitis because there is no risk.
C. The beneficial effect of immunotherapy goes away as soon as the shots are discontinued.
D. Immunotherapy against respiratory organisms can decrease the incidence of bacterial sinusitis.
E. Immunotherapy requires the identification of specific antigen by dermal or serum testing.

Answer 7

E. Immunotherapy requires the identification of specific antigen by dermal or serum testing.

Question 8

A 73-year-old man has had 3 episodes of visual loss in the right eye. The episodes last 20 to 30 minutes and resolve completely. He describes the sensation as like a window shade being pulled down in front of the eye. He has a history of hypertension and tobacco use. He denies dyspnea, chest pain, palpitations, or unilateral weakness or numbness. On examination the patient appears healthy; his vital signs are normal and the neurological examination is unremarkable. An ECG shows normal sinus rhythm without evidence of ischemia or hypertrophy. Initial laboratory studies are normal. Both noncontrast CT scan of the head and MR scan of the brain are normal. What is the best next step in this patient’s management?
A. Begin anticoagulation with low-molecular-weight heparin and warfarin.
B. Obtain an echocardiogram.
C. Check for antiphospholipid antibodies and homocysteine levels.
D. Order a carotid duplex ultrasonogram and begin antiplatelet therapy.
E. Begin lamotrigine for probable nonconvulsive seizure.

Answer 8

D. Order a carotid duplex ultrasonogram and begin antiplatelet therapy.

Question 9

A 32-year-old woman complains of severe seasonal allergies. Every year from April through July she is miserable with sneezing, nasal congestion, and watery itchy eyes. Antihistamines, nasal corticosteroids, nasal saline washes, eye drops, and attempts to avoid potential antigens have proven unsuccessful. She requests referral to an allergist for “allergy shots.” What advice should you give her about immunotherapy (hyposensitization) for her allergic symptoms?
A. Immunotherapy is useful is asthma but not in allergic rhinitis.
B. Immunotherapy can be used in allergic rhinitis because there is no risk.
C. The beneficial effect of immunotherapy goes away as soon as the shots are discontinued.
D. Immunotherapy against respiratory organisms can decrease the incidence of bacterial sinusitis.
E. Immunotherapy requires the identification of specific antigen by dermal or serum testing.

Answer 9

E. Immunotherapy requires the identification of specific antigen by dermal or serum testing.

Question 10

An 18-year-old male has been seen in the clinic for urethral discharge. He is treated with ceftriaxone, but the discharge has not resolved and the culture has returned as no growth. Which of the following is the most likely etiologic agent to cause this infection?
A. Ceftriaxone-resistant gonococci
B. Chlamydia psittaci
C. Chlamydia trachomatis
D. Herpes simplex
E. Chlamydia pneumoniae

Answer 10

C. Chlamydia trachomatis

Question 11

A 20-year-old female competitive swimmer notes that her arms now ache after swimming one or two laps, and she is unable to continue. She has had night sweats and a 10-lb weight loss. Pulses in the upper extremity are difficult to palpate. Select the most probable diagnosis for this patient.
A. Churg Strauss syndrome
B. Cryoglobulinemic vasculitis
C. Temporal arteritis
D. Wegener granulomatosis
E. Takayasu arteritis
F. Polyarteritis nodosa
G. Henoch-Schönlein purpura

Answer 11

E. Takayasu arteritis

Question 12

A 50-year-old female presents with complaints of more than 10 severe hot flashes per day. Her last menstrual period was 13 months ago. She denies fatigue, constipation, or weight gain. Current medical issues include osteopenia diagnosed by central DXA. Family history is positive for hypertension in her father and osteoporosis in her mother. The patient uses no medications other than calcium and vitamin D supplements.
Physical examination reveals weight 145 Ibs, height 5ft 6 in, BMI 24, BP 126/64, HR 68. Otherwise the examination is normal.
Screening laboratory studies:
Fasting glucose: 98
Cholesterol: 200 mg/dL
LDL: 100 mg/dL
Triglycerides: 150 mg/dL
HDL: 50 mg/dL
TSH: 1.0 mU/L
The patient requests hormone therapy to decrease hot flashes. Which of the following statements is true regarding hormone replacement therapy?
A. Progesterone therapy alone can alleviate hot flashes.
B. Hormone therapy does not affect bone density.
C. Her symptoms do not warrant systemic HT.
D. Oral estrogen therapy does not affect lipid levels.
E. The risk of breast cancer is directly related to duration of estrogen use.

Answer 12

E. The risk of breast cancer is directly related to duration of estrogen use.

Question 13

A 25-year-old PhD candidate recently traveled to Central America for 1 month to gain information regarding thesocioeconomics of that region. While there, he took ciprofloxacin twice a day for 5 days for diarrhea. However, over the 2 to 3 weeks since coming home, he has continued to have occasional loose stools plus vague abdominal discomfort and bloating. There has been no rectal bleeding. Which of the following therapies is most likely to relieve this traveler’s diarrhea?
A. Another course of ciprofloxacin
B. Doxycycline
C. Metronidazole
D. Trimethoprim-sulfamethoxazole
E. Oral glucose-electrolyte solution

Answer 13

C. Metronidazole

Question 14

After being stung by a yellow jacket, a 14-year-old develops the sudden onset of hoarseness and shortness of breath. An urticarial rash is noted. Which of the following is the most important first step in treatment?
A. An antihistamine
B. Epinephrine
C. Venom immunotherapy
D. Corticosteroids
E. Removal of the stinger

Answer 14

B. Epinephrine

Question 15

A 22-year-old man develops the insidious onset of low-back pain improved with exercise and worsened by rest. There is no history of diarrhea, conjunctivitis, urethritis, rash, or nail changes. On examination, the patient has loss of mobility with respect to lumbar flexion and extension. He has a kyphotic posture. A plain film of the spine shows sclerosis of the sacroiliac joints. Calcification is noted in the anterior spinal ligament. Which of the following best characterizes this patient’s disease process?
A. He is most likely to have acute lumbosacral back strain and requires bed rest.
B. The patient has a spondyloarthropathy, most likely ankylosing spondylitis.
C. The patient is likely to die from pulmonary fibrosis and extrathoracic restrictive lung disease.
D. A rheumatoid factor is likely to be positive.
E. A colonoscopy is likely to show Crohn disease

Answer 15

B. The patient has a spondyloarthropathy, most likely ankylosing spondylitis.

Question 16

A 50-year-old female is 5 ft 7 in tall and weighs 185 lb. There is a family history of diabetes mellitus. Fasting blood glucose (FBG) is 160 mg/dL and 155 mg/dL on two occasions. HgA1c is 7.8%. You educate the patient on medical nutrition therapy. She returns for reevaluation in 8 weeks. She states she has followed diet and exercise recommendations but her FBG remains between 130 and 140 and HgA1C is 7.3%. She is asymptomatic, and physical examination shows no abnormalities. Which of the following is the treatment of choice?
A. Thiazolidinediones
B. Encourage compliance with medical nutrition therapy
C. Insulin
D. Metformin
E. Observation with repeat HgA1C in 6 weeks.

Answer 16

D. Metformin

Question 17

A 90-year-old male complains of hip and back pain. He has also developed headaches, hearing loss, and tinnitus. On physical examination the skull appears enlarged, with prominent superficial veins. There is marked kyphosis, and the bones of the leg appear deformed. Serum alkaline phosphatase is elevated. Calcium and phosphorus levels are normal. Skull x-ray shows sharply demarcated lucencies in the frontal, parietal, and occipital bones. X-rays of the hip show thickening of the pelvic brim. Which of the following is the most likely diagnosis?
A. Multiple myeloma
B. Paget disease
C. Vitamin D intoxication
D. Metastatic bone disease
E. Osteitis fibrosa cystica

Answer 17

B. Paget disease

Question 18

A 67-year-old African American man complains of tendency toward urinary retention. Digital rectal examination reveals enlarged prostate. The initial choice of an antihypertensive or the addition of further agents) to the regimen may depend on concomitant factors. Indicate the medication choice that would give the best additional benefit in addition to blood pressure control.
A. Alpha-blocker
B. Beta-blocker
C. Calcium-channel blocker
D. Angiotensin-converting enzyme inhibitor
E. Centrally acting alpha agonist
F. Diuretic

Answer 18

A. Alpha-blocker

Question 19

A 60-year-old woman complains of fever and constant left lower quadrant pain of 2 days duration. She has not had vomiting or rectal bleeding. She has a history of hypertension but is otherwise healthy. She has never had similar abdominal pain, and has had no previous surgeries. Her only regular medication is lisinopril. On examination blood pressure is 150/80, pulse 110, and temperature 38.9°C (102°F). She has normal bowel sounds and left lower quadrant abdominal tenderness with rebound. A complete blood count reveals WBC= 28,000. Serum electrolytes, BUN, creatinine and liver function tests are normal. What is the next best step in evaluating this patient’s problem?
A. Colonoscopy
B. Barium enema
C. Exploratory laparotomy
D. Ultrasound of the abdomen
E. CT scan of the abdomen and pelvis

Answer 19

E. CT scan of the abdomen and pelvis

Question 20

A 40-year-old construction worker has noted increasing shortness of breath and cough over many years. On physical examination bilateral inspiratory crackles are heard. Chest x-ray shows egg shell calcifications in hilar adenopathy and bilateral small nodular interstitial markings in the upper lobes. What is the most likely diagnosis?
A. Small cell carcinoma of the lung
B. Bronchoalveolar carcinoma of the lung
C. Silicosis
D. Pneumonia
E. Cystic fibrosis
F. Hodgkin disease
G. Asbestosis
H. Hypersensitivity pneumonitis

Answer 20

Silicosis

Question 21

A 60-year-old male complains of hematuria and an aching pain in his right flank. Laboratory data show normal BUN, creatinine, and electrolytes. Hemoglobin is elevated at 18 g/dL and serum calcium is 11 mg/dL. A solid renal mass is found by ultrasound. Which of the following is the most likely diagnosis?
A. Polycystic kidney disease
B. Pheochromocytoma
C. Adrenal carcinoma
D. Renal adenomyolipoma
E. Renal carcinoma

Answer 21

E. Renal carcinoma

Question 22

A 20-year-old female develops urticaria that lasts for 6 weeks and then resolves spontaneously. She gives no history of weight loss, fever, rash, or tremulousness. Physical examination shows no abnormalities. Which of the following is the most likely cause of the urticaria?
A. Connective tissue disease
B. Hyperthyroidism
C. Chronic infection
D. Food allergy
E. Not likely to be determined

Answer 22

E. Not likely to be determined

Question 23

A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat. On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver span is 12 cm and the spleen is palpable.
* Throat culture: negative for group A streptococci
* Hgb: 12.5, Hct: 38%
* Reticulocytes: 4%
* WBC: 14, 000/uL
* Segmented: 30%
* Lymphocytes: 60%
* Monocytes: 10%
* Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2)
* Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220)
* Aspartate aminotransferase (AST): 40 U/L (normal 8 to 20 U/L)
* Alanine aminotransferase (ALT): 35 U/L (normal 8 to 20 U/L)
* Alkaline phosphatase: 40 IU/L (normal 35 to 125)

Which of the following is the most important initial test combination to order?
A. Liver biopsy and hepatitis antibody
B. Streptococcal screen and antistreptolysin O (ASO) titer
C. Peripheral blood smear and heterophile antibody
D. Toxoplasma IgG and stool sample
E. Lymph node biopsy and cytomegalovirus serology

Answer 23

C. Peripheral blood smear and heterophile antibody

Question 24

A 16-year-old male has recurrent episodes of nonpruritic, nonerythematous angioedema. There is a family history of angioedema. The patient has also complained of recurring abdominal pain. What is the most likely immunologic deficiency?
A. Wiskott-Aldrich syndrome
B. Ataxia telangiectasia
C. DiGeorge syndrome
D. D Immunoglobulin A deficiency
E. Severe combined immunodeficiency
F. C1 inhibitor deficiency
G. Adenosine deaminase deficiency

Answer 24

F. C1 inhibitor deficiency

Question 25

A 55-year-old woman with long-standing rheumatoid arthritis is on prednisone 5 mg daily and etanercept (Enbrel) 50 mg subcutaneously once a week. Her arthritis is well-controlled. However, she complains of a 2-day history of headaches, chills, and spiking fevers to 39.4°C (103°F). You suspect which of the following?
A. An allergic febrile reaction to etanercept
B. Fever related to her underlying autoimmune disease
C. A serious infection
D. A viral syndrome
E. An occult malignancy

Answer 25

C. A serious infection

Question 26

A 75-year-old African American woman, previously healthy, presents with low-grade fever, diarrhea, and rectal bleeding. Colonoscopy shows continuous erythema from rectum to mid-transverse colon. The cecum is normal. What is the most likely diagnosis?
A. Ulcerative colitis
B. Crohn disease
C. Ischemic colitis
D. Diverticulitis
E. Amebic colitis
F. Tuberculoma of the colon

Answer 26

A. Ulcerative colitis

Question 27

In the ICU, a patient suddenly becomes pulseless and unresponsive, with cardiac monitor indicating ventricular tachycardia.
The crash cart is immediately available. What is the best first therapy?
A. Amiodarone 150-mg IV push
B. Lidocaine 1.5-mg/kg IV push
C. Epinephrine 1-mg IV push
D. Defibrillation at 200 J
E. Defibrillation at 360 J

Answer 27

D. Defibrillation at 200 J

Question 28

A 50-year-old woman with rheumatoid arthritis has been treated with meloxicam (Mobic). You add hydroxychloroquine. Six weeks later her arthritis is mildly improved. The same joints are still involved but she now reports only 1-hour morning stiffness. She has, however, developed epigastric burning and melena for the past 3 days. Stool is strongly positive for occult blood. Which of the following is the most likely cause for the melena in this case?
A. Emotional stress over her illness resulting in acid peptic disease
B. Hydroxychloroquine-induced acid peptic disease
C. Gastric lymphoma associated with autoimmune disease
D. NSAID gastropathy
E. Meckel diverticulum

Answer 28

D. NSAID gastropathy

Question 29

An 82-year-old man is admitted to a long-term care facility after a right hemiplegic stroke. He is unable to walk and has limited ability to move himself in bed. He is frequently incontinent of urine. He has a past history of type 2 diabetes mellitus. On examination you note a 3-cm area of persistent erythema on the right buttock. Which of the following treatments would you recommend at this time?
A. Sharp surgical debridement to remove the area of erythema
B. Application of a hydrocolloid dressing (such as Duoderm) to be left in place for 5 days
C. Placement of a Foley catheter
D. Use of a foam mattress, repositioning at least every 2 hours, and scheduled voidings
E. Admission to the hospital for IV antibiotic

Answer 29

D. Use of a foam mattress, repositioning at least every 2 hours, and scheduled voidings

Question 30

A 70-year-old intensive care unit patient complains of fever and shaking chills. The patient develops hypotension, and blood cultures are positive for gram-negative bacilli. The patient begins bleeding from venipuncture sites and around his Foley catheter. Laboratory studies are as follows:
Hct: 38%
WBC: 15,000/UL
Platelet count: 40,000/uL (normal 150,000-400,000)|
Peripheral blood smear: fragmented RBCs
PT: elevated
PTT: elevated
Plasma fibrinogen: 70 mg/dL (normal 200-400)
Which of the following is the best course of therapy in this patient?
A. Begin heparin.
B. Treat underlying disease.
C. Begin plasmapheresis.
D. Give vitamin K.
E. Begin red blood cell transfusion.

Answer 30

B. Treat underlying disease.

Question 31

A 64-year-old woman who is receiving chemotherapy for metastatic breast cancer has been treating midthoracic pain with acetaminophen. Over the past few days she has become weak and unsteady on her feet. On the day of admission she develops urinary incontinence. Physical examination reveals fist percussion tenderness over T8 and moderate symmetric muscle weakness in the legs. Anal sphincter tone is reduced. Which of the following diagnostic studies is most important to order?
A. Serum calcium
B. Bone scan
C. Plain radiographs of the thoracic spine
D. MRI scan of the spine
E. Electromyogram with nerve conduction studies

Answer 31

D. MRI scan of the spine

Question 32

A 32-year-old runner has been training for her first marathon. She complains of 2 weeks of heel pain which is severe for the first few steps each morning and then goes away. She has no pain at night. What is the appropriate disease?
A. Plantar fasciitis
B. Metatarsal stress fracture
C. Charcot foot
D. Tarsal tunnel syndrome
E. Podagra
F. Hallux valgus
G. Morton neuroma

Answer 32

A. Plantar fasciitis

Question 33

A 42-year-old female with acute pericarditis develops jugular venous distention and hypotension. The ECG shows electrical
alternans. Which of the following is the most likely additional physical finding?
A. Basilar rales halfway up both posterior lung fields
B. S3 gallop
C. Pulsus paradoxus
D. Strong apical beat
E. Epigastric tenderness

Answer 33

C. Pulsus paradoxus

Question 34

An HIV-positive patient develops fever and dysphagia; endoscopic biopsy shows yeast and hyphae. What is the most likely etiologic agent?
A. Candida albicans
B. Aspergillus flavus
C. Coccidioides immitis
D. Herpes simplex type 1
E. Herpes simplex type 2
F. Hantavirus
G. Tropheryma whippelii
H. Coxsackievirus B
I. Histoplasma capsulatum
J. Human parvovirus
K. Cryptococcus neoformans

Answer 34

A. Candida albicans

Question 35

A 50-year-old female is evaluated for hypertension. Her blood pressure is 130/98. She complains of polyuria and mild muscle weakness. She is on no blood pressure medication. On physical examination, the PMI is displaced to the sixth intercostal space. There is no sign of congestive heart failure and no edema. Laboratory values are as follows:
Na + : 147 mEq/dL
K + : 2.3 mEq/dL
Cl - : 112 mEq/dL
HCO 3: 27 mEq/dL
The patient denies the use of diuretics or over-the-counter agents to decrease fluid retention or promote weight loss. She does not eat licorice. Which of the following tests is most useful in establishing a diagnosis?
A. 24-hour urine for cortisol
B. Urinary metanephrine
C. Plasma renin activity
D. Renal angiogram
E. Ratio of serum aldosterone to plasma renin activity

Answer 35

E. Ratio of serum aldosterone to plasma renin activity

Question 36

A 60-year-old woman complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On examination, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. Which of the following is the best next step in evaluation?
A. Lip biopsy
B. Schirmer test and measurement of autoantibodies
C. IgG antibody to mumps virus
D. A therapeutic trial of prednisone for 1 month
E. Administration of a benzodiazepine
 

Answer 36

B. Schirmer test and measurement of autoantibodies

Question 37

A 47-year-old HIV positive man is brought to the emergency room because of weakness. The patient has HIV nephropathy
and adrenal insufficiency. He takes trimethoprim-sulfamethoxazole for PCP prophylaxis and is on triple agent antiretroviral treatment. He was recently started on spironolactone for ascites due to alcoholic liver disease. Physical examination reveals normal vital signs, but his muscles are diffusely weak. Frequent extrasystoles are noted. He has mild ascites and 1+ peripheral edema. Laboratory studies show a serum creatinine of 2.5 with a potassium value of 7.3 mEq/L. An EKG shows peaking of the T waves and QRS duration of 0.14. What is the most important immediate treatment?
A. Sodium polystyrene sulfonate (Kayexalate)
B. Acute hemodialysis
C. IV normal saline
D. IV calcium gluconate
E. IV furosemide 80 mg stat

Answer 37

D. IV calcium gluconate

Question 38

An orthopedic surgeon asks you to help him manage an 82-year-old female who just received a hip replacement as a result of a hip fracture. The patient was watering her flowers when she tripped on the water hose and heard her hip crack as she fell to the ground. She has a history of hypothyroidism, mild CVA, and hypertension. Her mother had lost about 5 inches of height in her older years. She believes that she has lost “a few inches” in comparison to her husband. On review of systems, she admits to chronic diarrhea. Her only home medication is metoprolol. On physical examination, her blood pressure is 158/90; pulse 88 and regular; the hip is tender to palpation. Labs show normal calcium, renal function, and alkaline phosphatase. You send a TSH, celiac panel, and 25-OH vitamin D level. Which of the following medications would be most effective in preventing another fracture?
A. Raloxifene
B. Calcitonin-salmon nasal spray
C. Estradiol
D. Hydrochlorothiazide
E. A bisphosphonate

Answer 38

E. A bisphosphonate

Question 39

You are working in the university student health clinic, seeing adolescents and young adults for urgent care problems, but you remain attuned to the possibility of more serious underlying disease. This tall, thin 19-year-old white female with little previous health care complains primarily of decreased vision. You note a strong pulse, blood pressure of 180/70, and a high-pitched, blowing, diastolic decrescendo murmur. What is the likely associated valvular or related heart disease?
A. Tricuspid stenosis
B. Tricuspid regurgitation
C. Mitral stenosis
D. Mitral regurgitation
E. Aortic regurgitation (insufficiency)
F. Aortic stenosis
G. Hypertrophic cardiomyopathy
H. Pulmonic stenosis
I. Pulmonic regurgitation (insufficiency)

Answer 39

E. Aortic regurgitation (insufficiency)

Question 40

A 19-year-old woman presents for evaluation of a nontender left axillary lymph node. She is asymptomatic and denies weight loss or night sweats. Examination reveals three rubbery firm nontender nodes in the axilla, the largest 3 cm in diameter. No other lymphadenopathy is noted; the spleen is not enlarged. Lymph node biopsy, however, reveals mixed-cellularity Hodgkin lymphoma. Liver function tests are normal. Which of the following is the best next step in evaluation?
A. Bone marrow biopsy
B. Liver biopsy
C. Staging laparotomy
D. Erythrocyte sedimentation rate
E. CT scan of chest, abdomen, and pelvis

Answer 40

E. CT scan of chest, abdomen, and pelvis

Question 41

A 32-year-old Japanese woman has a long history of recurrent aphthous oral ulcers. In the last 2 months she has had recurrent genital ulcers. She now presents with a red painful eye that was diagnosed as anterior uveitis. What is the most likely diagnosis?
A. Herpes simplex
B. HIV infection
C. Behçet disease
D. Diabetes mellitus
E. Systemic lupus erythematosus

Answer 41

C. Behçet disease

Question 42

A 50-year-old obese female is taking oral hypoglycemic agents. While being treated for an upper respiratory infection,
she develops lethargy and is brought to the emergency room. Neurological examination is nonfocal; she does not have neck rigidity. Laboratory results are as follows:
Na: 134 mEq/L
K: 4.0 mEq/L
HCO 3: 25 mEq/L
Glucose: 900 mg/dL
BUN: 84 mg/dL
Creatinine: 3.0 mg/dL
HgA1c: 6.8%
BP: 120/80 lying down, 105/65 sitting
Which of the following is the most likely cause of this patient’s coma?
A. Diabetic ketoacidosis
B. Hyperosmolar coma
C. Inappropriate ADH
D. Noncompliance with medication
E. Bacterial meningitis

Answer 42

B. Hyperosmolar coma

Question 43

A 36-year-old male presents with the sensation of a racing heart. His blood pressure is 110/70, respiratory rate 14/minute, and O 2 saturation 98%. His ECG shows a narrow QRS complex tachycardia with rate 180, which you correctly diagnose as paroxysmal atrial tachycardia. Carotid massage and Valsalva maneuver do not improve the heart rate. Which of the following is the initial therapy of choice?
A. Adenosine 6-mg rapid IV bolus
B. Verapamil 2.5 to 5 mg IV over 1 to 2 min
C. Diltiazem 0.25-mg/kg IV over 2 min
D. Digoxin 0.5 mg IV slowly
E. Electrical cardioversion at 50 J

Answer 43

A. Adenosine 6-mg rapid IV bolus

Question 44

Two weeks after hospital discharge for documented myocardial infarction, a 65-year-old returns to your office concerned about low-grade fever and pleuritic chest pain. There is no associated shortness of breath. Lungs are clear to auscultation and the heart is free of murmur, gallop, or rub. ECG is unchanged from the last one in the hospital. Which therapy is most likely to be effective?
A. Antibiotics
B. Anticoagulation with warfarin (Coumadin)

C. An anti-inflammatory agent
D. An increase in antianginal medication

E. An anxiolytic agent

Answer 44

C. An anti-inflammatory agent

Question 45

A 38-year-old female presents with repeated episodes of sore throat. She is on no medications, does not use ethanol, and has no history of renal disease. Physical examination is normal. On CBC the Hgb is 9.0 g/dL, MCV is 85 fL (normal), white blood cell count is 2,000/uL, and platelet count is 30,000/uL. Which of the following is the best approach to diagnosis?
A. Erythropoietin level
B. Serum B12
C. Bone marrow biopsy
D. Liver spleen scan
E. Therapeutic trial of corticosteroids

Answer 45

C. Bone marrow biopsy

Question 46

Toward the end of her soccer season, a 17-year-old high school student suddenly develops pain in the top of the right foot. The pain is quite severe and she cannot run. Examination reveals point tenderness over the right third metatarsal. Radiographs of the foot are negative for fracture. What is the appropriate disease?
A. Plantar fasciitis
B. Metatarsal stress fracture
C. Charcot foot
D. Tarsal tunnel syndrome
E. Podagra
F. Hallux valgus
G. Morton neuroma

Answer 46

B. Metatarsal stress fracture

Question 47

A diabetic patient is admitted with elevated blood sugar and acidosis. The patient complains of headache and sinus tenderness and has black, necrotic material draining from the nares. What is the fungal agent most likely responsible for the disease process described?
A. Histoplasma capsulatum
B. Blastomyces dermatitidis
C. Coccidioides immitis
D. Cryptococcus neoformans
E. Candida albicans
F. Aspergillus fumigatus
G. Zygomycosis

Answer 47

Zygomycosis

Question 48

A 62-year-old man is admitted with pneumonia and severe sepsis. Vasopressors are required to maintain peripheral perfusion, and mechanical ventilation is needed because of ARDS. Admission creatinine is 1.0 mg/dL but rises by the second hospital day to 2.2 mg/dL. Urine output is 300 cc/24 hours. UA shows renal tubular epithelial cells and some muddy brown casts. The fractional excretion of sodium is 3.45. What is the likely cause of the patient’s renal failure?
A. Prerenal azotemia because of intravascular volume depletion
B. Ischemia-induced acute tubular necrosis
C. Nephrotoxin-induced acute tubular necrosis
D. Acute interstitial nephritis
E. Postrenal azotemia because of obstructive uropathy
F. Postinfectious glomerulonephritis
G. Acute cortical necrosis

Answer 48

B. Ischemia-induced acute tubular necrosis

Question 49

A 35-year-old previously healthy woman complains of a severe, excruciating headache and then has transient loss of consciousness. There are no focal neurologic findings. Which of the following is the best next step in evaluation?
A. CT scan without contrast
B. CT scan with contrast
C. Cerebral angiogram
D. Holter monitor
E. Therapeutic trial of nortriptyline

Answer 49

A. CT scan without contrast

Question 50

A 60-year-old man complains of pain in both knees coming on gradually over the past 2 years. The pain is relieved by rest and worsened by movement. The patient is 5 ft 9 in. tall and weighs 210 lb. There is bony enlargement of the knees with mild warmth and small effusions. Crepitation is noted on motion of the knee joint bilaterally. There are no other findings except for bony enlargement at the distal interphalangeal joint. Which of the following is the best way to prevent disease progression?
A. Weight reduction
B. Calcium supplementation
C. Total knee replacement
D. Long-term nonsteroidal anti-inflammatory drug (NSAID) administration
E. Oral prednisone

Answer 50

A. Weight reduction

Question 51

A 20-year-old white man notes an uneven tan on his upper back and chest. On examination, he has many circular, lighter macules with a barely visible scale that coalesce into larger areas. Which test is most likely to establish the diagnosis?
A. Punch biopsy
B. Potassium hydroxide (KOH) microscopic examination
C. Dermatophyte test medium (DTM) culture for fungus
D. Serological test for syphilis
E. Tzanck smear

Answer 51

B. Potassium hydroxide (KOH) microscopic examination

Question 52

A nonpregnant woman has headaches, bitemporal hemianopsia, irregular menses, and galactorrhea. What is the most likely disease process for this clinical syndrome?
A. Acromegaly
B. Essential hypertension
C. Empty sella syndrome
D. Cushing disease
E. TSH-secreting adenoma
F. Diabetes insipidus
G. Chronic oral glucocorticoid use
H. Prolactin-secreting adenoma

Answer 52

H. Prolactin-secreting adenoma

Question 53

A 67-year-old male is brought by his wife for evaluation of memory loss. Over the last 2 years he has had difficulty recalling the names of friends. On two occasions he has become lost in his own neighborhood. Recently, he has become suspicious that his wife may be trying to put him in a nursing home. He has hypertension. He has never used alcohol. He does not have urinary incontinence. His only medication is hydrochlorothiazide 25 mg daily. His mother was diagnosed with Alzheimer disease at age 60. Blood pressure is 130/76. There are no focal neurologic findings and gait is normal. He is not oriented to date and cannot recall any of three objects at 3 minutes. He cannot speak the name of common objects such as a pen or watch. His clock drawing test is abnormal. A complete blood count, blood chemistries, liver function tests, serologic test for syphilis, thyroid stimulating hormone, and vitamin B 12 levels are all normal. A CT scan of the brain reveals age-related atrophic changes but is otherwise normal. Of the following choices, which is the next best step?
A. Begin treatment with donepezil 5 mg daily.
B. Order APOE gene testing.
C. Refer the patient for neuro cognitive testing.
D. Begin treatment with ginkgo biloba.
E. Begin treatment with an antipsychotic.

Answer 53

A. Begin treatment with donepezil 5 mg daily.

Question 54

A 47-year-old woman complains of fatigue, weight loss, and itching after taking a hot shower. Physical examination shows plethoric facies and an enlarged spleen, which descends 6 cm below the left costal margin. Her white cell count is 17,000 with a normal differential, the platelet count is 560,000, and hemoglobin is 18.7. Liver enzymes and electrolytes are normal; the serum uric acid level is mildly elevated. What is the most likely underlying process?
A. Myelodysplastic syndrome
B. Myeloproliferative syndrome
C. Paraneoplastic syndrome
D. Cushing syndrome
E. Gaisböck syndrome

Answer 54

B. Myeloproliferative syndrome

Question 55

A 40-year-old white male complains of weakness, weight loss, and abdominal pain. On examination, the patient has diffuse hyperpigmentation and a palpable liver edge. Polyarthritis of the wrists and hips is also noted. Fasting blood sugar is 185 mg/dL. Which of the following is the most likely diagnosis?
A. Insulin-dependent diabetes mellitus
B. Pancreatic carcinoma
C. Addison disease
D. Hemochromatosis
E. Metabolic syndrome

Answer 55

D. Hemochromatosis

Question 56

A 60-year-old woman develops deep venous thrombosis after a 14-hour plane flight from New Zealand. The diagnosis is confirmed by a venous Doppler. There is no evidence of pulmonary embolism, and she is started on subcutaneous low-molecular-weight heparin. She has no family history of venous thrombosis, and she is on no medications that would increase her risk of clotting. In addition to routine monitoring of coagulation parameters and a CBC, what diagnostic tests should be ordered next?
A. Functional test for factor V Leiden (Activated protein C resistance)
B. Protein C, protein S, and antithrombin Ill levels
C. Antiphospholipid antibody test
D. Genetic testing for prothrombin G20210A gene mutation
E. No further testing

Answer 56

E. No further testing

Question 57

A recent outbreak of severe diarrhea is currently being investigated. Several adolescents developed bloody diarrhea, and one remains hospitalized with acute renal failure. A preliminary investigation has determined that all the affected ate at the same restaurant. The food they consumed was most likely to be which of the following?
A. Pork chops
B. Hamburger
C. Gefilte fish
D. Sushi
E. Soft-boiled eggs

Answer 57

B. Hamburger

Question 58

A 25-year-old complains of fever and myalgias for 5 days and now has developed a macular rash over his palms and soles with some petechial lesions. The patient recently returned from a summer camping trip in Tennessee. Which of the following is the most likely cause of the rash?
A. Contact dermatitis
B. Sexual exposure
C. Tick exposure.
D. Contaminated water
E. Undercooked pork

Answer 58

C. Tick exposure.

Question 59

A 34-year-old woman is referred by an OB-GYN colleague for the onset of fatigue and dyspnea on exertion 1 month after her second vaginal delivery. Physical examination reveals a laterally displaced PMI, elevated jugular venous pressure and 2+ pitting lower extremity edema. Echocardiogram shows systolic dysfunction with an ejection fraction of 30%. Which statement most accurately describes her condition?
A. This disease may occur unexpectedly years after pregnancy and delivery.
B. About half of similar patients will recover completely.
C. The condition is idiosyncratic; the risk of recurrence with a future pregnancy is no greater than average.
D. This condition will require a different therapeutic approach than the typical dilated cardiomyopathy.
E. This condition will require endomyocardial biopsy for diagnosis.

Answer 59

B. About half of similar patients will recover completely.

Question 60

A 75-year-old man complains of headache. On one occasion he transiently lost vision in his right eye. He also complains of aching in the shoulders and neck. There are no focal neurologic findings. Carotid pulses are normal without bruits. Laboratory data show a mild anemia. Erythrocyte sedimentation rate (ESR) is 85. Which of the following is the best approach to management?
A. Begin glucocorticoid therapy and arrange for temporal artery biopsy.
B. Schedule temporal artery biopsy and begin corticosteroids based on biopsy results and clinical course.
C. Schedule carotid angiography.
D. Follow ESR and consider further studies if it remains elevated.
E. Start aspirin and defer any invasive studies unless further symptoms develop.

Answer 60

A. Begin glucocorticoid therapy and arrange for temporal artery biopsy.

Question 61

A 60-year-old woman with depression and poorly controlled type 2 diabetes mellitus complains of episodic vomiting over the last three months. She has constant nausea and early satiety. She vomits once or twice almost every day. In addition, she reports several months of mild abdominal discomfort that is localized to the upper abdomen and that sometimes awakens her at night. She has lost 5 lb of weight. Her diabetes has been poorly controlled (glycosylated hemoglobin recently was 9.5). Current medications are glyburide, metformin, and amitriptyline. Her physical examination is normal except for mild abdominal distention and evidence of a peripheral sensory neuropathy.
Complete blood count, serum electrolytes, BUN, creatinine, and liver function tests are all normal. Gallbladder sonogram is negative for gallstones. Upper Gl series and CT scan of the abdomen are normal. What is the best next step in the evaluation of this patient’s symptoms?
A. Barium esophagram
B. Scintigraphic gastric emptying study
C. Colonoscopy
D. Liver biopsy
E. Small bowel biopsy

Answer 61

B. Scintigraphic gastric emptying study

Question 62

A 20-year-old presents after recent upper respiratory infection. She complains of neck pain and heat intolerance. The thyroid is tender. Erythrocyte sedimentation rate is elevated; free thyroxine value is modestly elevated. Which of the following is the most likely disease?
A. Subacute thyroiditis
B. Graves disease
C. Factitious hyperthyroidism
D. Struma ovarii
E. Multinodular goiter
F. Thyroid nodule
G. lodide deficiency
H. TSH-secreting pituitary adenoma

Answer 62

A. Subacute thyroiditis

Question 63

A 66-year-old postmenopausal woman presents with a painless breast mass and is found to have a 3 cm infiltrating ductal breast cancer. Sentinel node sampling reveals metastatic cancer in the sentinel node; a formal axillary node dissection shows that 4 of 13 nodes are involved by the malignant process. Both estrogen and progesterone receptor are expressed in the tumor. There is no evidence of metastatic disease outside the axilla. In addition to lumpectomy and radiation therapy to the breast and axilla, what should her treatment include next?
A. No further treatment at this time
B. 
Radiation therapy to the internal mammary nodes
C. 
Platinum-based adjuvant chemotherapy
D. 
Bilateral oophorectomy

E. Adjuvant hormonal therapy (tamoxifen or aromatase inhibitor)

Answer 63

E. Adjuvant hormonal therapy (tamoxifen or aromatase inhibitor)

Question 64

A 52-year-old African American diabetic requires hemodialysis for end-stage renal disease. She has hemoglobin of 9, hematocrit of 27, and normal red cell indices. The iron and iron-binding capacity are normal. Her peripheral blood smear is unremarkable. What is the most likely diagnosis?
A. Sideroblastic anemia
B. Thalassemia
C. Iron-deficiency anemia
D. Anemia of renal disease
E. Anemia of chronic disease
F. Folate deficiency
G. Microangiopathic hemolytic anemia

Answer 64

D. Anemia of renal disease

Question 65

A 67-year-old male presents to your office after community ultrasound screening revealed an aortic aneurysm measuring 3.0 × 3.5 cm. Physical examination confirms a palpable, pulsatile, nontender abdominal mass just above the umbilicus. The patient’s medical conditions include hypertension, hyperlipidemia, and tobacco use. What is the best recommendation for the patient to consider?
A. Watchful waiting is the best course until the first onset of abdominal pain.
B. Surgery is indicated except for the excess operative risk represented by the patient’s risk factors.
C. Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being aneurysmal size greater than 5 to 6 cm.
D. Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being involvement of a renal artery.
E. Unlike stents in coronary artery disease, endovascular stent grafts have proven unsuccessful in the management of AAAs.

Answer 65

C. Serial follow-up with ultrasound, CT, or MRI is indicated, with the major determinant for surgery being aneurysmal size greater than 5 to 6 cm.

Question 66

A 50-year-old male complains of slowly progressive weakness over several months. Walking has become more difficult, as has using his hands. There are no sensory, bowel, or bladder complaints; he denies problems with thinking, speech, or vision. Examination shows distal muscle weakness with muscle wasting and fasciculations. There are also upper motor neuron signs, including extensor plantar reflexes and hyperreflexia in wasted muscle groups. Which of the following tests is most likely to be abnormal in this patient?
A. Cerebrospinal fluid white blood cell count
B. Sensory conduction studies
C. CT scan of the brain
D. Electromyography
E. Thyroid studies and vitamin B12 level

Answer 66

D. Electromyography

Question 67

A 50-year-old man with a history of alcohol and tobacco abuse has complained of difficulty swallowing solid food for the past 2 months. More recently, swallowing fluids has also become a problem. He has noted black, tarry stools on occasion.
The patient has lost 10 lb. Which of the following statements is correct?
A. CT scan of the abdomen and pelvis is the best next test.
B. Barium contrast esophagram will likely establish a diagnosis.
C. The most likely diagnosis is peptic ulcer disease.
D. The patient has achalasia.
E. Herpes simplex virus infection of the esophagus is likely

Answer 67

B. Barium contrast esophagram will likely establish a diagnosis.

Question 68

A 60-year-old obese male complains of excessive daytime sleepiness. He has been in good health except for mild hypertension. He drinks alcohol in moderation. The patient’s wife states that he snores at night and awakens frequently. Examination of the oropharynx is normal. Which of the following studies is most appropriate?
A. EEG to assess sleep patterns
B. Ventilation pattern to detect apnea
C. Arterial O2 saturation
D. Study of muscles of respiration during sleep
E. Polysomnography

Answer 68

Polysomnography

Question 69

A 39-year-old alcoholic presents with massive hematemesis and hypotension. Examination reveals hemorrhoids and ascites. What is the most likely diagnosis?
A. Gastric ulcer
B. Aortoenteric fistula
C. Mallory-Weiss tear
D. Esophageal varices
E. Hereditary hemorrhagic telangiectasia (HHT)
F. Colon polyp
G. Adenocarcinoma of the colon

Answer 69

D. Esophageal varices

Question 70

A 65-year-old male who has not had routine medical care presents for a physical examination and is found to have a blood pressure of 165/80. He has no other risk factors for heart disease. He is not obese and walks 1 mile a day. Physical examination shows no retinopathy, normal cardiac examination including point of maximal impulse, and normal pulses. There is no abdominal bruit, and neurological examination is normal. ECG, electrolytes, blood sugar, and urinalysis are also normal. Repeat visit 2 weeks later shows blood pressure to be unchanged. Which of the following is the best next step in management?
A. Intravenous pyelogram.
B. Begin therapy with a low-dose diuretic.
C. Follow patient; avoid toxicity of antihypertensive agents.
D. Begin therapy with a beta-blocker.
E. Begin therapy with a short-acting calcium-channel blocker.

Answer 70

B. Begin therapy with a low-dose diuretic.

Question 71

A 72-year-old Caucasian male presents with shortness of breath that awakens him at night. At baseline he is able to walk less than a block before stopping to catch his breath. Physical examination findings include bilateral basilar rales and neck vein distention. The patient has a known history of congestive heart failure, and his last echocardiogram revealed an ejection fraction of 25%. The patient is compliant with a medication regimen including an ACE inhibitor, beta-blocker, and loop diuretic. Blood pressure is well controlled. What additional treatment should you begin next?
A. Spironolactone
B. Aspirin
C. Amlodipine
D. Warfarin
E. Hydralazine and isosorbide dinitrate

Answer 71

A. Spironolactone

Question 72

A 58-year-old female presents to your office for a sinus infection. She takes no medications except a “baby aspirin.” When you inquire why she is taking the 81-mg aspirin, she says “to prevent heart attacks.” Her history is negative for hypertension, hyperlipidemia, smoking, diabetes, obesity, or family history of cardiovascular disease. What would you advise this patient about the use of aspirin for heart attack prevention?
A. She should take a full-dose aspirin for primary prevention of heart attacks.
B. She does not need to take aspirin for cardiovascular protection.
C. She should take an 81 mg-dose of aspirin every other day.
D. She should take an aspirin only if she experiences chest pain.
E. A nonsteroidal anti-inflammatory has the same cardiovascular benefits as aspirin.

Answer 72

B. She does not need to take aspirin for cardiovascular protection.

Question 73

A 34-year-old white woman is treated for a UTI with amoxicillin. Initially she improves, but 5 days after beginning treatment, she develops recurrent fever, abdominal bloating, and diarrhea with six to eight loose stools per day. What is the best diagnostic test to confirm your diagnosis?
A. Identification of Clostridium difficile toxin in the stool
B. Isolation of C difficile in stool culture
C. Stool positive for white blood cells (fecal leukocytes)
D. Detection of IgG antibodies against C difficile in the serum
E. Visualization of clue cells on microscopic examination of stool

Answer 73

A. Identification of Clostridium difficile toxin in the stool

Question 74

A 30-year-old male with sickle cell anemia is admitted with cough, rusty sputum, and a single shaking chill. Physical examination reveals increased tactile fremitus and bronchial breath sounds in the left posterior chest. The patient is able to expectorate a purulent sample. Which of the following best describes the role of sputum Gram stain and culture?
A. Sputum Gram stain and culture lack the sensitivity and specificity to be of value in this setting.
B. If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae.
C. Empirical use of antibiotics for pneumonia has made specific diagnosis unnecessary.
D. There is no characteristic Gram stain in a patient with pneumococcal pneumonia.
E. Gram-positive cocci in clusters suggest pneumococcal infection.

Answer 74

B. If the sample is a good one, sputum culture is useful in determining the antibiotic sensitivity pattern of the organism, particularly Streptococcus pneumoniae.

Question 75

A 30-year-old woman has prominent cervical and dorsal fat pads, purple abdominal striae, unexplained hypokalemia, and diabetes mellitus. What is the most likely disease process for this clinical syndrome?
A. Acromegaly
B. Essential hypertension
C. Empty sella syndrome
D. Cushing disease
E. TSH-secreting adenoma
F. Diabetes insipidus
G. Chronic oral glucocorticoid use
H. Prolactin-secreting adenoma

Answer 75

D. Cushing disease

Question 76

A 42-year-old man requires transfusion for blood loss resulting from an automobile accident. During the infusion, he develops urticaria, stridor, and hypotension requiring IV epinephrine. Further history reveals frequent episodes of sinusitis and bronchitis. What is the most likely immunologic deficiency?
A. Wiskott-Aldrich syndrome
B. Ataxia telangiectasia
C. DiGeorge syndrome
D. Immunoglobulin A deficiency
E. Severe combined immunodeficiency
F. C1 inhibitor deficiency
G. Adenosine deaminase deficiency

Answer 76

D. Immunoglobulin A deficiency

Question 77

A 40-year-old female nurse was admitted to the hospital because of fever to 39.4°C (103°F). Despite a thorough workup in the hospital for over 3 weeks, no etiology has been found, and she continues to have temperature spikes greater than 38.9°C (102°F). Which of the following statements about diagnosis is correct?
A. Chronic infection, malignancy, and collagen vascular disease are the most common explanations for this presentation.
B. Influenza may also present in this manner.
C. Lymphoma can be ruled out in the absence of palpable lymphadenopathy.
D. SLE is an increasing cause for this syndrome.
E. Factitious fever should be considered only in the patient with known psychopathology.

Answer 77

A. Chronic infection, malignancy, and collagen vascular disease are the most common explanations for this presentation.

Question 78

The patient recalls having episodes when he smells a pungent odor, becomes sweaty, and loses consciousness. His wife describes a period of motor arrest followed by repetitive picking movements that last about a minute. The patient does not fall or lose muscle control. What is the appropriate diagnosis?
A. Absence (petit mal) seizure
B. Complex partial seizure
C. Simple partial seizure
D. Atonic seizure
E. Myoclonic seizure
F. Nonconvulsive seizure (pseudoseizure)

Answer 78

B. Complex partial seizure

Question 79

A 30-year-old black man plans a trip to India and is advised to take prophylaxis for malaria. Three days after beginning treatment, he develops pallor, fatigue, and jaundice. Hematocrit is 30% (it had been 43%) and reticulocyte count is 7%. He stops taking the medication. The next step in treatment should consist of which of the following?
A. Splenectomy.
B. Administration of methylene blue.
C. Administration of vitamin E.
D. Exchange transfusions.
E. No additional treatment is required.

Answer 79

E. No additional treatment is required.

Question 80

A 78-year-old woman with mild Alzheimer disease falls at home and suffers a left hip fracture. She is admitted to the hospital and undergoes a left total hip replacement. Postoperatively she is given D5W and treated with meperidine for pain, diphenhydramine for sleep, and given prophylactic ranitidine. On the second postoperative day, she pulls out her Foley catheter and her IV. On examination blood pressure is 150/90, pulse rate is 80, and temperature 36.7°C (98°F). Oxygen saturation on room air is 92%. She is markedly confused and appears agitated. She has no focal neurologic findings. Laboratory testing reveals WBC = 7500, hemoglobin = 10.2, Na = 132, potassium = 3.2, BUN = 6, creatinine = 0.9. CXR, ECG, and liver tests are normal. What is the next best step in her management?
A. Order CT scan of the brain.
B. Order ventilation perfusion lung scan.
C. Obtain blood cultures and begin broad-spectrum antibiotics.
D. Restrain the patient and order lorazepam for agitation.
E. Remove Foley catheter, change fluids to NS with KCL, and discontinue meperidine, diphenhydramine, and ranitidine.

Answer 80

E. Remove Foley catheter, change fluids to NS with KCL, and discontinue meperidine, diphenhydramine, and ranitidine.

Question 81

A 60-year-old white female presents for an office visit. Her mother recently broke her hip, and the patient is concerned about her own risk for osteoporosis. She weighs 165 lb and is 5 ft 6 inches tall. She has a 50-pack-year history of tobacco use. Medications include a multivitamin and levothyroxine 50 ug/d. Her exercise regimen includes mowing the lawn and taking care of the garden. She took hormone replacement therapy for 6 years after menopause, which occurred at age 49. Which recommendation for osteoporosis screening is most appropriate for this patient?
A. Nuclear medicine bone scan.
B. Dual x-ray absorptiometry (DXA scan).
C. Quantitative CT bone densitometry.
D. Peripheral bone densitometry.
E. No testing is recommended at this time.

Answer 81

B. Dual x-ray absorptiometry (DXA scan).

Question 82

A 33-year-old female presents to your office with complaints of inability to become pregnant. She and her husband have been having regular intercourse for 10 years without contraception. Her husband has normal sperm count and motility. Her menses are irregular, occurring every 28 to 60 days. She has noticed some facial and upper back acne, as well as increased amount of pubic hair. On examination, her waist circumference is 36 in and she has cystic acne on her neck, forehead, and upper back. She also has acanthosis nigricans in her groin and posterior neck.
* Labs: fasting blood glucose: 106
* Urine glucose: absent
* DHEAS: 360 g/dL (follicular 32.2-308 g/dL) (luteal 29.5-269 g/dL)
* Total testosterone: 1.1 ng/mL (0.1-0.6 ng/mL)
* Pelvic sonogram: normal
What is the best plan for the initial management of this patient?
A. Weight loss through diet and exercise
B. Metformin
C. Isotretinoin
D. OTC appetite suppressants
E. Gastric bypass surgery

Answer 82

A. Weight loss through diet and exercise

Question 83

You are volunteering with a dental colleague in a community indigent clinic. A nurse has prepared a list of patients who are scheduled for a dental procedure and may need antibiotic prophylaxis beforehand. Of the patients listed below, who would be most likely to benefit from antibiotic prophylaxis to prevent infective endocarditis?
A. 17-year-old male with coarctation of the aorta
B. 26-year-old female with a ventricular septal defect repaired in childhood
C. 42-year-old female with mitral valve prolapse
D. 65-year-old male with prosthetic aortic valve
E. 72-year-old female with aortic stenosis

Answer 83

D. 65-year-old male with prosthetic aortic valve

Question 84

A 35-year-old woman is concerned that she may be allergic to certain foods. She believes that she gets a rash several hours after eating small amounts of peanuts. In evaluating this concern, which of the following is correct?
A. At least 30% of the adult population is allergic to some food substance.
B. Symptoms occur hours after ingestion of the food substance.
C. The foods most likely to cause allergic reactions include egg, milk, seafood, nuts, and soybeans.
D. The organ systems most frequently involved in allergic reactions to foods in adults are the respiratory and cardiovascular systems.
E. Immunotherapy is a proven therapy for food allergies.

Answer 84

C. The foods most likely to cause allergic reactions include egg, milk, seafood, nuts, and soybeans.

Question 85

A 50-year-old develops sudden onset of bizarre behavior. CS shows 80 lymphocytes; magnetic resonance imaging shows temporal lobe abnormalities. What is the most likely etiologic agent?
A. Candida albicans
B. Aspergillus flavus
C. Coccidioides immitis
D. Herpes simplex type 1
E. Herpes simplex type 2
F. Hantavirus
G. Tropheryma whippelii
H. Coxsackievirus B
I. Histoplasma capsulatum
J. Human parvovirus
K. Cryptococcus neoformans

Answer 85

D. Herpes simplex type 1

Question 86

A 50-year-old white woman presents with aching and stiffness in the trunk, hip, and shoulders. There is widespread muscle pain after mild exertion. Symptoms are worse in the morning and improve during the day. They are also worsened by stress.
The patient is always tired and exhausted. She has trouble sleeping at night. On examination, joints are normal. ESR is normal, and Lyme antibody and HIV test are negative. A diagnosis is best made by which of the following?
A. Trial of glucocorticoid
B. Muscle biopsy
C. Demonstration of 11 tender points
D. Psychiatric evaluation
E. Trial of an NSAID

Answer 86

C. Demonstration of 11 tender points

Question 87

A 25-year-old male student presents with the chief complaint of rash. He denies headache, fever, or myalgia. A slightly pruritic maculopapular rash is noted over the abdomen, trunk, palms of the hands, and soles of the feet. Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic, flat, wartlike lesions are noted around the anal area. Laboratory studies show the following:
Hct: 40%
Hgb: 14 g/dL
WBC: 13,000/uL
Diff: 50% segmented neutrophils, 50% lymphocytes
Which of the following is the most useful laboratory test in this patient?
A. Weil-Felix titer
B. Venereal Disease Research Laboratory (VDRL) test
C. Chlamydia titer
D. Blood cultures
E. Biopsy of perianal lesions

Answer 87

B. Venereal Disease Research Laboratory (VDRL) test

Question 88

A previously healthy 25-year-old music teacher develops fever and a rash over her face and chest. The rash is itchy and, on examination, involves multiple papules and vesicles in varying stages of development. One week later, she complains of cough and is found to have an infiltrate on x-ray. Which of the following is the most likely etiology of the infection?
A. Streptococcus pneumoniae
B. Mycoplasma pneumoniae
C. Histoplasma capsulatum
D. Varicella-zoster virus
E. Chlamydia psittaci

Answer 88

D. Varicella-zoster virus

Question 89

A 49-year-old sedentary man goes on an 8-mile hike with his son’s scout troop, and awakens that night with severe pain, swelling, and redness of the first metatarsophalangeal joint. What is the appropriate disease?
A. Plantar fasciitis
B. Metatarsal stress fracture
C. Charcot foot
D. Tarsal tunnel syndrome
E. Podagra
F. Hallux valgus
G. Morton neuroma

Answer 89

E. Podagra

Question 90

A patient with bacterial endocarditis develops thrombophlebitis while hospitalized. His course in the hospital is uncomplicated. On discharge he is treated with penicillin, rifampin, and warfarin. Therapeutic prothrombin levels are obtained on 15 mg/d of warfarin. After 2 weeks, the penicillin and rifampin are discontinued. Which of the following is the best next step in management of this patient?
A. Cautiously increase warfarin dosage.
B. Continue warfarin at 15 mg/d for about 6 months.
C. Reduce warfarin dosage.
D. Stop warfarin therapy.
E. Restrict dietary vitamin K.

Answer 90

C. Reduce warfarin dosage.