2nd set

Question 1

A 42-year-old banker sees you as a new patient. He states that he is healthy and takes no regular medications. His examination is normal except for a blood pressure of 150/94. When questioning him about alcohol use, he admits that he goes out drinking with friends about 2 Saturdays each month to relieve stress. At these times he will often have 8 to 10 mixed alcohol drinks. He and his wife have recently had several arguments about this habit, and she has threatened to divorce him if he doesn’t change his ways. Despite this he has been unable to change. On one occasion he was arrested for driving while intoxicated. Nonetheless he has continued to be successfully employed, has never been hospitalized for an alcohol-related problem, and has never had symptoms of alcohol withdrawal. Which of the following statements is true regarding treatment of this patient?
A. Advice from a physician to reduce his alcohol consumption is likely to be successful.
B. The patient should be advised that complete abstinence from alcohol and referral to a mutual aid group is the best strategy in treating his alcohol-related problem.
C. Abstinence from alcohol may necessitate treatment of his blood pressure because he is currently using alcohol to treat stress.
D. Medications for alcohol dependence are not usually helpful.
E. The fact that this patient has had no symptoms of alcohol dependence proves that he does not abuse alcohol.

Answer 1

B. The patient should be advised that complete abstinence from alcohol and referral to a mutual aid group is the best strategy in treating his alcohol-related problem.

Question 2

A 67-year-old male presents to your clinic to establish primary care; he is asymptomatic. He has a history of hypertension for which he takes hydrochlorothiazide. His father had a myocardial infarction at age 62. The patient smoked until 5 years ago, but has been abstinent from tobacco since then. His blood pressure in the office today is 132/78. Aside from being overweight, the remainder of the physical examination is unremarkable. Which of the following preventive health interventions would be most appropriately offered to him today?
A. Carotid ultrasound to evaluate for carotid artery stenosis
B. Abdominal ultrasound to evaluate for aortic aneurysm
C. Lipoprotein(a) assay to evaluate coronary heart disease risk
D. Exercise (treadmill) stress testing to evaluate for coronary artery disease
E. Homocysteine level to evaluate coronary heart disease risk

Answer 2

B. Abdominal ultrasound to evaluate for aortic aneurysm

Question 3

A 65-year-old man presents with painless hematuria. He has a 45-year history of tobacco use. He denies fever, chills, and dysuria. General physical examination is unremarkable. On rectal examination, the prostate is small, non-nodular, and nontender. A urinalysis shows 100 red blood cells per high-power field. No white cells or protein are present. Three months previously, the patient had an abdominal ultrasound for right upper quadrant pain; on review, both kidneys were normal.
Which of the following is the most useful diagnostic test at this time?
A. Urine culture and sensitivity
B. PSA
C. Bladder scan
D. Cystoscopy and retrograde pyelography
E. CT scan of the kidneys

Answer 3

D. Cystoscopy and retrograde pyelography

Question 4

An active 78-year-old female with history of hypertension presents with the new onset of left hemiparesis. Cardiac monitoring reveals atrial fibrillation. She had been in sinus rhythm on checkup 3 months earlier. Optimal management at discharge includes a review of antihypertensive therapy, a ventricular rate control agent, and which of the following?
A. Automated implanted cardioverter-defibrillator (AlCD)/permanent pacemaker to avoid the need for anticoagulation
B. Immediate direct-current cardioversion
C. Antiplatelet therapy such as aspirin, without warfarin
D. Antiplatelet therapy plus warfarin with a target INR of 1.5
E. Warfarin with a target INR of 2.0 to 3.0.

Answer 4

E. Warfarin with a target INR of 2.0 to 3.0.

Question 5

An 80-year-old white male is being evaluated as part of an annual physical examination. Examination reveals a large plaque on the left shoulder that is well demarcated, hyperkeratotic, and oily to palpation. It appears to be “stuck on.” Its surface includes keratin plugs. Which of the following is the most appropriate next step?
A. Biopsy to rule out melanoma
B. Advice about sun exposure and actinic keratosis
C. Reassurance of the benign nature of this seborrheic keratosis
D. Removal of basal cell carcinoma
E. Treatment with topical steroids for psoriasis

Answer 5

C. Reassurance of the benign nature of this seborrheic keratosis

Question 6

A 30-year-old male complains of bilateral leg weakness and clumsiness of fine movements of the right hand. Five years previously he had an episode of transient visual loss. On physical examination, there is hyperreflexia with Babinski sign, and cerebellar dysmetria with poor finger-to-nose movement. When the patient is asked to look to the right, the left eye does not move normally past the midline. Nystagmus is noted in the abducting eye. A more detailed history suggests the patient has had several episodes of gait difficulty that have resolved spontaneously. He appears to be stable between these episodes. He has no systemic symptoms of fever or weight loss. Which of the following is the most appropriate next test to order?
A. Lumbar puncture
B. MR scan with gadolinium infusion
C. Quantitative CSF IgG levels
D. Testing for oligoclonal bands in cerebrospinal fluid
E. CT scan of the head with intravenous contrast

Answer 6

B. MR scan with gadolinium infusion

Question 7

A 20-year-old nursing student complains of asthma while on her surgical rotation. She has developed dermatitis of her hands. Symptoms are worse when she is in the operating room. Which of the following statements is correct?
A. This allergic reaction is always benign.
B. The patient should be evaluated for latex allergy by skin testing.
C. This syndrome is less common now than 10 years ago.
D. Oral corticosteroid is indicated.
E. She will have to change her career since there is no substitute for latex gloves.

Answer 7

B. The patient should be evaluated for latex allergy by skin testing.

Question 8

A 76-year-old white man presents with painless hematemesis and hypotension. He has no previous Gl symptoms but did have resection of an abdominal aortic aneurysm 12 years previously. EGD shows no bleeding source in the stomach or duodenum. 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 8

B. Aortoenteric fistula

Question 9

A 70-year-old patient with chronic obstructive lung disease requires 2 L/min of nasal O 2 to treat his hypoxia, which is sometimes associated with angina. The patient develops pleuritic chest pain, fever, and purulent sputum. While using his oxygen at an increased flow of 5 L/min he becomes stuporous and develops a respiratory acidosis with CO 2 retention and worsening hypoxia. What would be the most appropriate next step in the management of this patient?
A. Stop oxygen.
B. Begin medroxyprogesterone.
C. Intubate and begin mechanical ventilation.
D. Observe patient 24 hours before changing therapy.
E. Begin sodium bicarbonate

Answer 9

C. Intubate and begin mechanical ventilation.

Question 10

A 17-year-old girl noted a 2-cm annular pink, scaly lesion on her back. Over the next 2 weeks she develops several smaller oval pink lesions with a fine collarette of scale. They seem to run in the body folds and mainly involve the trunk, although a few occur on the upper arms and thighs. There is no adenopathy and no oral lesions. Which of the following is the most likely diagnosis?
A. Tinea versicolor
B. Psoriasis
C. Lichen planus
D. Pityriasis rosea
E. Secondary syphilis

Answer 10

D. Pityriasis rosea

Question 11

A 53-year-old woman presents to the emergency room with a minor injury and is found to have a blood pressure of 150/102, possibly elevated as a result of pain. On follow-up at your office, her BP on two occasions is 142/94 despite good dietary habits and reasonable exercise. Her history and physical are normal except that she has had a hysterectomy. Basic laboratory evaluation reveals no significant abnormalities. Based on recent recommendations of the JNC 7 (The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure) which of the following is accurate information to give her?
A. At age >50, high diastolic BP becomes a more important cardiovascular risk factor than high systolic BP.
B. The new classification of prehypertension fits her latest BP readings; continue close follow-up.
C. Thiazide diuretics would be a good initial choice for her.
D. Initiating therapy with two antihypertensives would be preferred based on her current BP.
E. Estrogen-replacement therapy would be helpful in delaying her need for antihypertensives.

Answer 11

C. Thiazide diuretics would be a good initial choice for her.

Question 12

A 72-year-old woman presents with poor coordination and frequent falls. She smokes 1 pack of cigarettes per day and uses alcohol modestly. She takes raloxifene for osteoporosis and a daily multiple vitamin. She has lost 10 pounds of weight over the past 6 weeks and notices some diminution of appetite. Her general physical examination shows evidence of mild temporal muscle wasting and diminished breath sounds over both lung fields. On neurological examination her strength, sensation (including vibratory sensation), and reflexes are normal. She walks with an uncoordinated unsteady gait. On testing of coordination in the upper extremities, she displays past pointing and poor rapid alternating movements. The findings are symmetrical. In the lower extremities, her heel-shin testing also reveals poor coordination symmetrically. What is the most likely cause of her condition?
A. Tumor in the right lobe of the cerebellum
B. Multiple small infarcts in the basal ganglia
C. Paraneoplastic cerebellar degeneration
D. Alcohol abuse
E. Posterior column degeneration as a result of vitamin deficiency

Answer 12

C. Paraneoplastic cerebellar degeneration

Question 13

A 35-year-old alcoholic man is admitted with nausea, vomiting, and abdominal pain that radiates to the back. He has had several previous episodes of pancreatitis presenting with the same symptoms. Which of the following laboratory values suggests a poor prognosis in this patient?
A. Elevated serum lipase
B. Elevated serum amylase
C. Leukocytosis of 20,000/um
D. Diastolic blood pressure greater than 90 mm Hg
E. Heart rate of 100 beats/minute

Answer 13

C. Leukocytosis of 20,000/um

Question 14

A 64-year-old African American man presents for evaluation of a painless “lump” in the left thigh. He first noticed the abnormality about 1 month previously and thinks it has increased in size; there is no prior history of trauma. On examination, you find a 5-cm soft tissue mass, firm to hard in consistency, in the soft tissue above the knee. There is no tenderness or erythema; the mass is deep to the subcutaneous tissue and appears fixed to the underlying musculature. Inguinal lymph nodes are normal. Which of the following is the most appropriate management of this patient?
A. Reexamine the lesion in 3 months, as it is probably a lipoma.
B. Obtain a bone scan.
C. Treat with cephalexin 500 mg po qid for presumed abscess
D. Refer the patient for surgical biopsy.
E. Aspirate the mass as it is probably a hematoma.

Answer 14

D. Refer the patient for surgical biopsy.

Question 15

A 25-year-old female complains of watery rhinorrhea and pruritus of the eyes and nose that occurs around the same season each year. Symptoms are not exacerbated by weather changes, emotion, or irritants. She is on no medications and is not pregnant. Which of the following statements is correct?
A. Her symptoms are likely produced by an IgE antibody against a specific allergen.
B. She has vasomotor rhinitis.
C. The patient’s nasal turbinates are likely to be very red.
D. Avoidance measures alone are almost always effective.
E. Decongestant nasal sprays can suppress her symptoms.

Answer 15

A. Her symptoms are likely produced by an IgE antibody against a specific allergen.

Question 16

A 52-year-old man with cirrhosis resulting from chronic hepatitis C presents with increasing right upper quadrant pain, anorexia, and 15-Ib weight loss. The patient is mildly icteric and has moderate ascites. A friction rub is heard over the liver.
Abdominal paracentesis reveals blood-tinged fluid, and CT scan shows a 4-cm solid mass in the right lobe of the liver. Which of the following is the most important initial diagnostic study?
A. Serum a-fetoprotein level
B. Colonoscopy to search for a primary neoplasm
C. Measurement of hepatitis C viral RNA
D. Upper Gl endoscopy
E. Positron emission tomography scan

Answer 16

A. Serum a-fetoprotein level

Question 17

A 65-year-old male inquires about the pneumonia vaccine. He had a friend who died of pneumonia. The patient is in good health without underlying disease. Which of the following is the most appropriate management of this patient?
A. Recommend the pneumococcal vaccine and check on the status of other immunizations, particularly tetanus vaccination.
B. Inform the patient that he has no risk factors for pneumonia.
C. Report that the present pneumonia vaccine does not work.
D. Emphasize that the influenza vaccine is more important.
E. Give pneumonia vaccine and influenza vaccine 4 weeks apart.

Answer 17

A. Recommend the pneumococcal vaccine and check on the status of other immunizations, particularly tetanus vaccination.

Question 18

A 32-year-old stockbroker sees you because she has felt anxious almost every day for the past 9 months. She feels “keyed up” at work. At times she has difficulty concentrating and has made several minor errors in clients’ accounts. For the past year she has frequently had trouble falling asleep at night despite the fact that she always feels tired. She does not fall asleep during the day at inopportune times. She takes supplemental calcium but no other medications. She denies substance or alcohol abuse. Her vital signs and physical examination are normal. CBC and chemistry panel are normal. What is the most likely diagnosis?
A. Hyperthyroidism
B. Hyperparathyroidism
C. Generalized anxiety disorder
D. Obstructive sleep apnea
E. Frontal lobe dementia

Answer 18

C. Generalized anxiety disorder

Question 19

As part of a review of systems, a 55-year-old male describes an inability to achieve erection. The patient has mild diabetes and is on an ACE inhibitor for hypertension. Which of the following is the most appropriate first step in evaluation?
A. Penile Doppler ultrasound
B. Serum gonadotropin level
C. Information about libido and morning erections
D. Therapeutic trial of sildenafil
E. Nocturnal penile tumescence testing

Answer 19

C. Information about libido and morning erections

Question 20

A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. What is the best diagnostic test?
A. Rheumatoid factor
B. Antinucleolar antibody
C. ECG
D. BUN and creatinine
E. Reproduction of symptoms and findings by immersion of hands in cold water

Answer 20

B. Antinucleolar antibody

Question 21

A 55-year-old type-2 diabetic patient has lost weight and has had good control of his blood glucose on oral metformin, with HgA1c of 6.4%. He has a history of mild hypertension and hyperlipidemia. Which of the following statements is correct regarding routine testing for diabetic patients?
A. Dilated eye examination twice yearly
B. 24-hour urine protein annually
C. Home fasting blood glucose measurement at least once per week
D. Urine microalbumin annually
E. Referral to neurologist for peripheral neuropathy evaluation

Answer 21

D. Urine microalbumin annually

Question 22

A 42-year-old male was admitted to the hospital with pneumonia. On the third day of his hospitalization he becomes agitated and confused. He reports feeling “spiders” crawling on his skin. You note that he has a blood pressure of 172/94 mm Hg, heart rate of 107/minute, and temperature of 38°C (100.4°F). With the exception of agitation and tremor, the remainder of his physical examination is unchanged from earlier in the day. What is the best initial step in management of this patient?
A. Emergent noncontrast CT scan of the brain
B. Emergent administration of intravenous haloperidol
C. Emergent administration of intravenous lorazepam
D. Emergent administration of intravenous labetalol
E. Placement of physical restraints for patient safety

Answer 22

C. Emergent administration of intravenous lorazepam

Question 23

A 60-year-old woman presents with complaints of pain during intercourse. She describes the pain as sharp and constant during sexual activity, and there is a lack of lubrication. This discomfort is very bothersome to her because she wishes to continue an active sex life. She underwent surgical menopause at age 44 due to uterine fibroids and heavy bleeding. She used oral estrogen until age 50; she has used no hormonal therapy since then. On physical examination you note significant urethral and vaginal atrophy. Which of the following is the best treatment option for this patient?
A. Commercial lubricant (K-Y lubricating jelly)
B. Oral estrogen
C. Vaginal estrogen preparation
D. Sildenafil
E. Topical antifungal therapy

Answer 23

C. Vaginal estrogen preparation

Question 24

A 60-year-old white man has just moved to town and needs to establish care. He had a “heart attack” last year. Preferring a “natural” approach, he has been very conscientious about low-fat, low-cholesterol eating habits, and a significant exercise program. He has gradually eliminated a number of prescription medications (he does not recall their names) that he was on at the time of hospital discharge. Past history is negative for hypertension, diabetes, or smoking. The lipid profile you obtain shows the following:
* Total cholesterol: 194 mg/dL
* Triglycerides: 140 mg/dL
* HDL: 42
* ECG shows Q waves in lead II, II, and avE
Which of the following recommendations would most optimally treat his lipid status?
A. Continue current dietary efforts and exercise.
B. Add an HMG-CoA reductase inhibitor (statin drug) to reduce LDL cholesterol to less than 100.
C. Add a fibric acid derivative such as gemfibrozil.
D. Review previous medications and resume an angiotensin-converting enzyme inhibitor.
E. Begin aspirin 81 mg daily.

Answer 24

E. Begin aspirin 81 mg daily.

Question 25

A 57-year-old white female with a past medical history of breast cancer stage 2, ER+, PR+, presents to the emergency room complaining of the sudden onset of chest pain and shortness of breath. The pain is sharp and stabbing in the left posterior lung area. The pain does not increase on exertion but increases with deep breathing. The patient denies any history of cardiovascular or pulmonary disease. Her only medication is tamoxifen for 2 years and OTC vitamins. Pulse is 110, RR 26, BP 150/94; lungs are clear bilaterally; cardiovascular examination shows regular rate and rhythm with fixed splitting of S2. ECG shows S wave in lead I, Q wave in lead III, and inverted T in lead III. Pulse oximetry is 90% on room air. Chest x-ray is unremarkable. Which factor is most likely to be contributing to this patient’s respiratory distress?
A. Myocardial infarction
B. Asthma
C. Tamoxifen use
D. Anxiety
E. Pneumonia

Answer 25

C. Tamoxifen use

Question 26

A 65-year-old who is retiring from work as a plumber has complained of a dry cough. He has also had some shortness of breath on walking. On physical examination there are bilateral crackling rales at both lung bases. Bilateral clubbing is also noted. On chest x-ray, bilateral linear infiltrates are seen at the lung bases. Pleural scarring is noted on CT scan. What is the most likely diagnosis?
A. Tuberculosis
B. Primary lung tumor
C. Pulmonary embolus

D. Metastatic lung cancer
E. Asbestosis
F. Histoplasmosis
G. Idiopathic pulmonary fibrosis

Answer 26

Asbestosis

Question 27

A 32-year-old woman presents to you for evaluation of headache. The headaches began at age 18, were initially unilateral and worse around the time of her menses. Initially the use of triptans 2 or 3 times a month would provide complete relief.
Over the past several years, however, the headaches have become more frequent and severe. Triptans provide only partial relief; the patient requires a combination of acetaminophen, caffeine, and butalbital to achieve some improvement.
Prophylactic medications including beta-blockers, tricyclics, and topiramate have been unsuccessful in preventing the headaches, and she has been to the emergency room three times over the past 2 weeks for a “pain shot.” The general physical examination is unremarkable. Her funduscopic examination shows no evidence of papilledema, and a careful neurological examination is likewise normal. What is the most likely explanation for her headache syndrome?
A. Status migranosus
B. Medication overuse headache
C. Space occupying intracerebral lesion
D. CNS vasculitis
E. Pseudotumor cerebri

Answer 27

B. Medication overuse headache

Question 28

A 58-year-old postmenopausal female presents to your office on suggestion from a urologist. She has passed 3 kidney stones within the past 3 years. She is taking no medications. Her basic laboratory work shows the following:
* Na: 139 mEq/L
* K: 4.2 mEq/L
* HCO 3: 25 mEq/L
* CI: 101 mEq/L
* BUN: 19 mg/dL
* Creatinine: 1.1 mg/dL
* Ca: 11.2 mg/dL
A repeat calcium level is 11.4 mg/dL; PO 4 is 2.3 mmol/L (normal above 2.5). Which of the following tests will confirm the most likely diagnosis?
A. Serum ionized calcium
B. Thyroid function profile
C. Intact parathormone (iPTH) level
D. Liver function tests
E. 24-hour urine calcium.

Answer 28

C. Intact parathormone (iPTH) level

Question 29

A 68-year-old man complains of several blisters arising over the back and trunk for the preceding 2 weeks. He takes no medications and has not noted systemic symptoms such as fever, sore throat, weight loss, or fatigue. The general physical examination is normal. The oral mucosa and the lips are normal. Several 2 to 3 cm bullae are present over the trunk and back. A few excoriations where the blisters have ruptured are present. The remainder of the skin is normal, without erythema or scale. What is the best diagnostic approach at this time?
A. Culture of vesicular fluid for herpes viruses
B. Trial of corticosteroids
C. Biopsy of the edge of a bulla with some surrounding intact skin
D. CT scan of the chest and abdomen looking for occult malignancy
E. Combination of oral H1 and H2 antihistamines

Answer 29

C. Biopsy of the edge of a bulla with some surrounding intact skin

Question 30

A 40-year-old alcoholic male is being treated for tuberculosis, but he has not been compliant with his medications. He complains of increasing weakness, fatigue, weight loss, and nausea over the preceding three weeks. He appears thin, and his blood pressure is 80/50 mm Hg. There is increased pigmentation over the elbows and in the palmar creases. Cardiac examination is normal. Which of the following is the best next step in evaluation?
A. CBC with iron and iron-binding capacity
B. Erythrocyte sedimentation rate
C. Early morning serum cortisol and cosyntropin stimulation
D. Blood cultures
E. Esophagogastroduodenoscopy (EGD)

Answer 30

C. Early morning serum cortisol and cosyntropin stimulation

Question 31

A 76-year-old male presents to the emergency room. He had influenza and now presents with diffuse muscle pain and weakness. His past medical history is remarkable for osteoarthritis for which he takes ibuprofen, and hypercholesterolemia for which he takes lovastatin. Physical examination reveals blood pressure of 130/90 with no orthostatic change. The only other finding is diffuse muscle tenderness. Laboratory data include
* BUN: 30 mg/dL
* Creatinine: 6 mg/dL
* K: 6.0 mEq/L
* Uric acid: 18 mg/dL
* Ca: 6.5 mg/dL
* PO 4: 7.5 mg/dL
* UA: large blood, 2+ protein. Microscopic study shows muddy brown casts and 0 to 2 RBC/HPF (red blood cells/high power field).
Which of the following is the most likely diagnosis?
A. Nonsteroidal anti-inflammatory drug-induced acute renal failure (ARF)
B. Volume depletion
C. Rhabdomyolysis-induced ARF
D. Urinary tract obstruction
E. Hypertensive nephrosclerosis

Answer 31

C. Rhabdomyolysis-induced ARF

Question 32

A 15-year-old girl complains of low-grade fever, malaise, conjunctivitis, runny nose, and cough. After this prodromal phase, a rash of discrete pink macules begins on her face and extends to her hands and feet. She is noted to have small red spots on her palate. What is the most likely cause of her rash?
A. Toxic shock syndrome
B. Gonococcal bacteremia
C. Reiter syndrome
D. Rubeola (measles)
E. Rubella (German measles)

Answer 32

D. Rubeola (measles)

Question 33

A 30-year-old obese female bus driver develops sudden pleuritic left-sided chest pain, hemoptysis, and dyspnea. Which arterial blood gas and pH values are likely?
A. pH 7.50, PO2 75, PCO2 28
B. pH 7.14, PO2 78, PCO2 95
C. pH 7.06, PO2 36, PCO2 95
D. pH 7.06, PO2 108, PCO2 13
E. pH 7.37, PO2 48, PCO2 54’

Answer 33

A. pH 7.50, PO2 75, PCO2 28

Question 34

A 45-year-old man with Parkinson disease has macular areas of erythema and scaling behind the ears and on the scalp, eyebrows, glabella, nasolabial folds, and central chest. Which of the following is the most likely diagnosis?
A. Tinea versicolor
B. Psoriasis
C. Seborrheic dermatitis
D. Atopic dermatitis
E. Dermatophyte infection

Answer 34

C. Seborrheic dermatitis

Question 35

A 22-year-old male has been healthy except for abdominal surgery after an auto accident. He is admitted with clinical signs of pneumonia and meningitis. Cultures of blood, sputum, and cerebrospinal fluid grow gram-positive diplococci.
What is the most likely immunologic deficiency?
A. Complement deficiency C5-C9
B. Selective IgA deficiency
C. Postsplenectomy
D. Neutropenia
E. Interleukin-12 receptor deficit
F. Microbicidal leukocyte defect
G. Phagocyte immune deficit
H. Congenital T-cell deficit

Answer 35

Postsplenectomy

Question 36

A 28-year-old female complains of fatigue and a sense of fullness at the base of her neck. She has no significant past medical history, gave birth to a healthy infant 4 months ago, and is only taking oral contraceptives. On examination, vital signs are pulse 88, blood pressure 110/66, temperature 98.6°F, and respirations 12. Her thyroid gland is homogeneously enlarged and she has a very mild tremor of the outstretched hands. The rest of the examination is within normal limits. Laboratory evaluation reveals the following:
* WBC: 7800/uL
* Hgb: 12.3 g/dL
* Hct: 36%
* Plt: 220,000/uL
* Na: 138 mEq/L
* K: 4.0 mEq/L
* CI: 106 mEq/L
* CO2: 26 mEq/L
* BUN: 12 mg/dL
* Creatinine: 0.7 mg/dL
* TSH: 0.01 mlU/L (normal 0.4-4)
* T 4: 19 nmol/L (normal 5-12)
* Antithyroid antibody test (TPO antibodies): elevated
What is the most likely diagnosis?
A. Thyrotoxicosis factitia
B. Subacute thyroiditis
C. Toxic multinodular goiter
D. Postpartum thyroiditis
E. Struma ovarii

Answer 36

D. Postpartum thyroiditis

Question 37

A 56-year-old man presents with hypertension and peripheral edema. He is otherwise healthy and takes no medications. Family history reveals that his father and a brother have kidney disease. His father was on hemodialysis before his death at age 68 of a stroke. Physical examination reveals BP 174/96 and AV nicking on funduscopic examination. He has a soft S 4 gallop. Bilateral flank masses measuring 16 cm in length are palpable. Urinalysis shows 15 to 20 RBC/HPF and trace protein but is otherwise normal; his serum creatinine is 2.4 mg/dL.
Which is the most likely long-term complication of his condition?
A. End-stage renal disease requiring dialysis or transplantation
B. Malignancy
C. Ruptured cerebral aneurysm
D. Biliary obstruction owing to cystic disease of the pancreas
E. Dementia

Answer 37

A. End-stage renal disease requiring dialysis or transplantation

Question 38

A 62-year-old woman has noted fever to 38.3°C (101°F) every evening for the past 3 weeks, associated with night sweats and a 15-Ib weight loss. Physical examination reveals matted supraclavicular lymph nodes on the right; the largest node is 3.5 cm in diameter. She also has firm rubbery right axillary and bilateral inguinal nodes. Excisional biopsy of one of the nodes shows diffuse replacement of the nodal architecture with large neoplastic cells which stain positively for B cell markers. No Reed-Sternberg cells are seen. Which statement most accurately reflects her prognosis?
A. This is an indolent process which will respond to corticosteroids.
B. This is an aggressive neoplasm which responds poorly to chemotherapy and will likely be fatal in 6 months or less.
C. This is an aggressive neoplasm, but it may be cured with chemotherapy in up to 60% of the cases.
D. 
The neoplasm often responds to chemotherapy but almost always relapses.

E. Radiation therapy is curative.

Answer 38

C. This is an aggressive neoplasm, but it may be cured with chemotherapy in up to 60% of the cases.

Question 39

A 30-year-old female with mitral valve prolapse and mitral regurgitant murmur develops fever, weight loss, and anorexia after undergoing a dental procedure. What is the most likely organism?
A. Streptococcus pneumoniae
B. Staphylococcus aureus
C. Viridans streptococci
D. Providencia stuartii
E. Actinomyces israelii
F. Haemophilus ducreyi
G. Neisseria meningitidis
H. Listeria monocytogenes

Answer 39

C. Viridans streptococci

Question 40

Four months after an unremarkable vaginal delivery, a previously healthy 34-year-old G1P1 develops fatigue, dyspnea on minimal exertion, and paroxysmal nocturnal dyspnea. She is no longer breastfeeding. Physical examination reveals a fatigued appearing woman, with normal heart sounds and minimal bibasilar crackles in her lungs. She has no evidence of lower extremity edema, calf tenderness, or ascites. Echocardiogram shows global systolic dysfunction without hypertrophy and an ejection fraction of 40%. Which of the following statements regarding her condition is correct?
A. Peripartum cardiomyopathy may occur unexpectedly years after pregnancy and delivery.
B. The postpartum state will require a different therapeutic approach than typical treatment for dilated cardiomyopathy.
C. For patients with persistent LV dysfunction, future pregnancy carries no increased risk of cardiac decompensation.

D. Fifty percent of patients will recover with normal ejection fraction.

E. Intravenous immune globulin (IVIG) is the cornerstone of treatment.

Answer 40

D. Fifty percent of patients will recover with normal ejection fraction.


Question 41

A 40-year-old man without a significant past medical history comes to the emergency room with a 3-day history of fever and shaking chills, and a 15-minute episode of rigor. He also reports a nonproductive cough, anorexia, and the development of right-sided pleuritic chest pain. Shortness of breath has been present for the past 12 hours. Chest X-ray reveals a consolidated right middle lobe infiltrate, and CBC shows an elevated neutrophil count with many band forms present. Which of the following statements regarding pneumonia in this patient is correct?
A. If the sputum Gram stain shows multiple squamous epithelial cells and the culture is reported as mixed flora, the patient probably has a viral infection.
B. If the Gram stain reveals numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae is the most likely pathogen.

C. Although S pneumoniae is the agent most likely to be the cause of this patient’s pneumonia, this diagnosis would be unlikely if blood cultures prove negative.

D. The absence of rigors would rule out a diagnosis of pneumococcal pneumonia.

E. 
Penicillin is still the drug of choice in pneumococcal pneumonia.

Answer 41

B. If the Gram stain reveals numerous gram-positive diplococci, numerous white blood cells, and few epithelial cells, Streptococcus pneumoniae is the most likely pathogen.


Question 42

A 64-year-old woman presents to the emergency room with flank pain and fever. She noted dysuria over the past 3 days. Blood and urine cultures are obtained, and she is started on intravenous ciprofloxacin. Six hours after admission, she becomes tachycardic and her blood pressure drops. Her intravenous fluid is NS at 100 mL/h. Her current blood pressure is 79/43 mm Hg, heart rate is 128/minute, respiratory rate is 26/minute and temperature is 39.2°C (102.5°F). She seems drowsy yet uncomfortable. Extremities are warm with trace edema. What is the best next course of action?
A. Administer IV hydrocortisone at stress dose.
B. Begin norepinephrine infusion and titrate to mean arterial pressure greater than 65 mm Hg.
C. Add vancomycin to her antibiotic regimen for improved gram positive coverage.
D. Administer a bolus of normal saline.
E. Place a central venous line to monitor central venous oxygen saturation.

Answer 42

D. Administer a bolus of normal saline.

Question 43

A 60-year-old male develops acute shortness of breath, tachypnea, and tachycardia while hospitalized for congestive heart failure. On physical examination there is no jugular venous distention and the lungs are clear to auscultation and percussion. There is a loud P 2 sound. Examination of the lower extremities shows no edema or tenderness. Which of the following is the most important diagnostic step?
A. Pulmonary angiogram
B. Thin cut chest CT pulmonary angiogram with contrast
C. D-dimer assay
D. D Venous ultrasound
E. High resolution chest CT without contrast

Answer 43

B. Thin cut chest CT pulmonary angiogram with contrast

Question 44

A 40-year-old white man with hypertension has three episodes over the past 2 years of debilitating acute arthritis involving ankle or foot joints. The choice of an antihypertensive agent may involve trying to avoid an adverse effect on a comorbid condition. Indicate the medication choice that needs to be avoided above all others.
A. Angiotensin-converting enzyme inhibitor
B. Beta-blocker, noncardioselective
C. Calcium-channel blocker
D. Diuretic

E. Hydralazine

Answer 44

D. Diuretic


Question 45

A 52-year-old man complains of impotence. On physical examination, he has an elevated jugular venous pressure, S 3 gallop, and hepatomegaly. He also appears tanned, with pigmentation along joint folds. His left knee is swollen and tender.
The plasma glucose is 250 mg/dL, and liver enzymes are elevated. Which of the following studies will help establish the diagnosis?
A. Detection of nocturnal penile tumescence
B. Determination of iron saturation
C. Determination of serum copper
D. Detection of hepatitis B surface antigen
E. Echocardiography

Answer 45

B. Determination of iron saturation

Question 46

A 60-year-old male has had a chronic cough with clear sputum production for over 5 years. He has smoked one pack of cigarettes per day for 20 years and continues to do so. X-ray of the chest shows hyperinflation without infiltrates. Arterial blood gases show a pH of 7.38, PCO 2 of 40 mm Hg, and PO 2 of 65 mm Hg. Spirometry shows an FEV , /FVC of 45% without bronchodilator response. Which of the following is the most important treatment modality for this patient?
A. Oral corticosteroids
B. Home oxygen
C. Broad-spectrum antibiotics
D. Smoking cessation program
E. Oral theophylline

Answer 46

D. Smoking cessation program

Question 47

A 50-year-old man has recurrent stones that cannot be seen on plain film of the abdomen but are readily apparent on CT scan (renal stone protocol). The urinalysis is clear but the urine pH is 4.88 on a 24-hour urine specimen. What is the most likely type of stone that occurs in this clinical situation?
A. Calcium phosphate
B. Calcium oxalate
C. Cystine
D. Struvite
E. Uric acid
F. Xanthine
G. Bilirubin

Answer 47

E. Uric acid

Question 48

A 32-year-old diabetic woman who takes an estrogen-containing oral contraceptive and drinks three beers per day is found to have a triglyceride level greater than 1000 mg/dL. She is at greatest risk for which of the following complications?
A. Acute pancreatitis
B. Sudden cardiac death
C. Acute peripheral arterial occlusion
D. Acute renal insufficiency
E. Myositis

Answer 48

A. Acute pancreatitis

Question 49

A 38-year-old female present to your office with complaints of fatigue and generalized weakness for 6 weeks. She experiences stiffness in her hands and wrists for an hour after waking, and has taken nonsteroidal anti-inflammatory medication with some relief. Two weeks ago, she noticed that her knuckles were red and tender. Her past medical history is unremarkable, and she takes no medications. On examination, her temperature is 100°F. Erythema with edema is present at most MCP joints. She has minimally decreased muscle strength. Her labs include
* WBC: 12,000
* Hemoglobin: 10.6 g/dL
* Rheumatoid factor: negative
* Antibodies to citrulline-containing proteins (anti-CCP): positive
* ESR: 62
* Hand x-ray: juxtaarticular osteopenia of the MCP joints
Scheduled nonsteroidal anti-inflammatories are started with appropriate monitoring. After one month her pain is unchanged. What is the most appropriate next step in her treatment?
A. Physical therapy.
B. Referral to a rheumatologist.
C. Begin IV TNF monoclonal antibodies.
D. Begin allopurinol.
E. Begin doxycycline 100mg twice daily for 30 days.

Answer 49

B. Referral to a rheumatologist.

Question 50

A 22-year-old woman seeks advice for the treatment of headaches. The first of these headaches began at age 16, but their frequency has increased to 2 to 3 per month over the past year. The headaches are not preceded by an aura. The headaches are usually bilateral, are throbbing, and are so intense that she has to go home from work. Loud noise and physical activity make the pain more severe. Each headache lasts until the evening; she will awaken the next morning without pain or nausea, and will be able to return to work. She takes acetaminophen at the onset of the headache but without benefit. She is on no other medications including oral contraceptives. Neurological examination is benign. What is the best step in the management of these headaches?
A. Topiramate starting at a dose of 25 mg twice daily
B. An oral triptan such as sumatriptan at the onset of pain
C. Combination acetaminophen/hydrocodone at the onset of pain
D. Long acting propranolol 40 mg daily, increasing until the headaches are completely prevented
E. Gabapentin 300 mg daily at bedtime, increasing until the headaches are controlled

Answer 50

B. An oral triptan such as sumatriptan at the onset of pain

Question 51

A 45-year-old woman presents to her physician with an 8-month history of gradually increasing limb weakness. She first noticed difficulty climbing stairs, then problems rising from a chair, and, finally, lifting her arms above shoulder level. Aside from some difficulty swallowing, she has no ocular, bulbar, or sphincter problems and no sensory complaints. Family history is negative for neurological disease. Examination reveals significant proximal limb and neck muscle weakness with minimal atrophy, normal sensory findings, and normal deep tendon reflexes. Which of the following is the most likely diagnosis in this patient?
A. Polymyositis
B. Cervical myelopathy
C. Myasthenia gravis
D. Mononeuritis multiplex
E. Limb-girdle muscular dystrophy

Answer 51

A. Polymyositis

Question 51

A 58-year-old man has a history of hypertension and asks about reducing his risk for myocardial infarction. A lipid profile shows low HDL cholesterol at 32 mg/dL. Which of the following is an important recommendation in attempting to raise the HDL?
A. Aspirin, one tablet each day
B. Low cholesterol diet
C. Vitamin E, 400 U each day
D. DHEA (dehydroepiandrosterone) supplementation
E. Exercise

Answer 51

Exercise

Question 52

A 70-year-old patient with long-standing type 2 diabetes mellitus presents with complaints of pain in the left ear with purulent drainage. On physical examination, the patient is afebrile. The pinna of the left ear is tender, and the external auditory canal is swollen and edematous. The white blood cell count is normal. Which of the following organisms is most likely to grow from the purulent drainage?
A. Pseudomonas aeruginosa
B. Streptococcus pneumoniae
C. Candida albicans
D. Haemophilus influenzae
E. Moraxella catarrhalis

Answer 52

A. Pseudomonas aeruginosa

Question 53

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. An 18-year-old male is sent over from his physical education class owing to his symptoms of dizziness and palpitations after exercise. The instructor thinks he may be faking this to get out of future activities. Vital signs are within normal limits. A rapidly rising carotid pulse is noted. On auscultation an S 4 is heard along with a harsh systolic crescendo-decrescendo murmur, beginning well after S 1, best noted at the lower left sternal border. 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 53

G. Hypertrophic cardiomyopathy

Question 54

A 42-year-old male is evaluated for fever, night sweats, and pruritus. There is a 2-cm firm rubbery supraclavicular node on physical examination as well as bilateral axillary nodes. Chest x-ray shows mediastinal lymphadenopathy. 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 54

F. Hodgkin disease

Question 55

What is the most appropriate screening test for a 70-year-old woman admitted to a nursing home?
A. A DNA or RNA amplification tests for chlamydia obtained from the cervix
B. Intermediate strength tuberculin skin test
C. Abdominal ultrasonograpny
D. Chest x-ray
E. Rapid plasma reagin (RPR)

Answer 55

B. Intermediate strength tuberculin skin test

Question 56

A 25-year-old woman complains of persistent bleeding for 5 days after a dental extraction. She has noticed easy bruisability since childhood, and was given a blood transfusion at age 17 because of prolonged bleeding after an apparently minor cut. She denies ecchymoses or bleeding into joints. Her father has noticed similar symptoms but has not sought medical care. Physical examination is normal except for mild oozing from the dental site. She does not have splenomegaly or enlarged lymph nodes. Her CBC is normal, with a platelet count of 230,000. Her prothrombin time is normal but the partial thromboplastin time is mildly prolonged. The bleeding time is 12 minutes (normal 3-9 minutes). What is most appropriate way to control her bleeding?
A. Factor VIll concentrate
B. Fresh frozen plasma
C. Desmopressin (DDAVP)
D. Whole blood transfusion
E. Single donor platelets

Answer 56

C. Desmopressin (DDAVP)

Question 57

An 85-year-old male has a history of long-standing diabetes mellitus and prostatic hypertrophy. He complains of dribbling urine. There is a sense of incomplete voiding and of a decrease in urinary stream. Postvoiding residual is 300 mL. What is the most likely type of urinary incontinence?
A. Stress incontinence
B. Urge incontinence
C. Overflow incontinence.
D. Functional incontinence
E. Mixed incontinence
F. Normal physiologic functioning of old age

Answer 57

C. Overflow incontinence.

Question 58

A 25-year-old woman is admitted for hypertensive crisis. The patient’s urine drug screen is negative. In the hospital, blood pressure is labile and responds poorly to antihypertensive therapy. The patient complains of palpitations and apprehension. Her past medical history shows that she developed hypertension during an operation for appendicitis at age 23.
* Hct: 49% (37-48)
* WBC: 11 × 10 3 mm (4.3-10.8)
* Plasma glucose: 160 mg/dL (75-115)
* Plasma calcium: 11 mg/dL (9-10.5)
Which of the following is the most likely diagnosis?
A. Anxiety attack
B. Renal artery stenosis
C. Essential hypertension
D. Type 1 diabetes mellitus
E. Pheochromocytoma

Answer 58

E. Pheochromocytoma

Question 59

A 30-year-old female presents with a chief complaint of palpitations. A 24-hour Holter monitor shows occasional unifocal premature ventricular contractions and premature atrial contractions. Which of the following is the best management for this patient?
A. Anxiolytic therapy
B. Beta-blocker therapy
C. Digoxin
D. Quinidine
E. Reassurance, no medication

Answer 59

E. Reassurance, no medication

Question 60

An 84-year-old woman develops confusion and agitation after surgery for hip fracture. Her family reports that prior to her hospitalization she functioned independently at home, although requiring help with balancing her checkbook and paying bills. Her current medications include intravenous fentanyl for pain control, lorazepam for control of her agitation, and DVT prophylaxis. She has also been started on ciprofloxacin for pyuria (culture pending). In addition to frequent reorientation of the patient, which of the following series of actions would best manage this patient’s delirium?
A. Increase lorazepam to more effective dose, repeat urinalysis.
B. Discontinue lorazepam, remove Foley catheter, add haloperidol for severe agitation, and change to nonfluoroquinolone antibiotic.
C. Continue lorazepam at current dose, discontinue fentanyl, add soft restraints.

D. Continue lorazepam at current dose, add alprazolam 0.25 mg for severe agitation, repeat urinalysis, restrain patient to prevent self harm.

E. Discontinue lorazepam, remove Foley catheter, add alprazolam 0.25 mg for severe agitation, place the patient on telemetry.

Answer 60

B. Discontinue lorazepam, remove Foley catheter, add haloperidol for severe agitation, and change to nonfluoroquinolone antibiotic.

Question 61

A 38-year-old obese female with history of chronic venous insufficiency and peripheral edema was admitted to the hospital the previous night for cellulitis involving both lower legs. She has had recurrent such episodes, treated successfully in the past with various antibiotics, including cefazolin, nafcillin, ampicillin/sulbactam, and levofloxacin. Intravenous levofloxacin was again chosen due to the perceived ease in transitioning to a once-daily oral outpatient dose. Normal saline at 50 mL/h is administered. Past history is otherwise significant only for hypertension, which is being treated at home with HCTZ 25 mg, lisinopril 40 mg, and atenolol 100 mg, all once each morning. Admission BP was 144/92 and the orders were written to continue each of these antihypertensives at one tablet po qd. The only other inhospital medication is daily prophylactic enoxaparin. As you round at 6 PM on the day following admission, the nurse contacts you emergently stating that she has just finished giving evening medicines and the patient’s BP is unexpectedly 90/50. Pulse rate is 92. There is no chest pain, dyspnea, or tachypnea. What is most likely cause of her hypertension?
A. An allergic reaction either to the antibiotic or to one of the antihypertensives
B. A vasovagal reaction secondary to pain
C. Hypovolemia due to the cellulitis
D. Acute pulmonary embolism
E. Medication error

Answer 61

E. Medication error

Question 62

A 40-year-old woman complains of headache associated with visual disturbance. Which of the following histories suggests migraine headache as the likely diagnosis?
A. Numbness or tingling of the left face, lips, and hand lasting for 5 to 15 minutes, followed by throbbing headache
B. An increasingly throbbing headache associated with unilateral visual loss and generalized muscle aches
C. A continuous headache associated with sleepiness, nausea, ataxia, and incoordination of the right upper limb
D. An intense left retro-orbital headache associated with transient left-sided ptosis and rhinorrhea
E. A visual field defect that persists following cessation of a unilateral headache

Answer 62

A. Numbness or tingling of the left face, lips, and hand lasting for 5 to 15 minutes, followed by throbbing headache

Question 63

A 50-year-old male with emphysema develops the sudden onset of shortness of breath and left-sided pleuritic chest pain. Pneumothorax is suspected. Which of the following physical examination findings would be consistent with the diagnosis?
A. Localized wheezes at the left base
B. Hyper-resonance, decreased breath sounds in the left chest with trachea deviation to right

C. Increased tactile fremitus on the left side
D. Decreased breath sounds on the left side with deviation of the trachea to the left
E. 
Rales at the left base

Answer 63

B. Hyper-resonance, decreased breath sounds in the left chest with trachea deviation to right


Question 64

A 25-year-old man is referred to you because of hematuria. He noticed brief reddening of the urine with a recent respiratory infection. The gross hematuria resolved, but his physician found microscopic hematuria on two subsequent first-voided morning urine specimens. The patient is otherwise healthy; he does not smoke. His blood pressure is 114/72 and the physical examination is normal. The urinalysis shows 2+ protein and 10 to 15 RBC/HPF, with some dysmorphic erythrocytes. No WBC or casts are seen. What is the most likely cause of his hematuria?
A. Kidney stone
B. Renal cell carcinoma
C. Acute poststreptococcal glomerulonephritis
D. Chronic prostatitis
E. IgA nephropathy (Berger disease)

Answer 64

E. IgA nephropathy (Berger disease)

Question 65

A 67-year-old male presents with hemoptysis 1 week in duration. He has smoked 1-2 packs of cigarettes per day for 50 years and has been unable to quit smoking despite nicotine replacement therapy and bupropion. He has mild COPD for which he uses an ipratropium inhaler. Chest x-ray reveals a 3-cm right perihilar mass. Which of the following is the most likely cause of this patient’s hemoptysis?
A. Adenocarcinoma of the lung
B. Squamous cell carcinoma of the lung
C. Bronchoalveolar cell carcinoma
D. Bronchial adenoma
E. Sarcoidosis

Answer 65

B. Squamous cell carcinoma of the lung

Question 66

A 53-year-old female presents to the clinic with an erythematous lesion on the dorsum of her right hand. The lesion has been present for the past 7 months and has not responded to corticosteroid treatment. She is concerned because the lesion occasionally bleeds and has grown in size during the past few months. On physical examination you notice an 11-mm erythematous plaque with a small central ulceration. The skin is also indurated with mild crusting on the surface.
Which of the following is true about this process?
A. It is a malignant neoplasm of the keratinocytes with the potential to metastasize.
B. It is an allergic reaction resulting from elevation of serum IgE.
C. It is a chronic inflammatory condition, which can be complicated by arthritis of small and medium-sized joints.
D. It is a malignant neoplasm of the melanocytes with the potential to metastasize.
E. It is the most common skin cancer.

Answer 66

A. It is a malignant neoplasm of the keratinocytes with the potential to metastasize.

Question 67

A businessman traveling around the world asks about prevention of malaria. He will travel to India and the Middle East and plans to visit several small towns. What is the most appropriate advice for the traveler?
A. Common sense measures to avoid malaria such as use of insect repellants, bed nets, and suitable clothing have not really worked in preventing malaria.
B. The decision to use drugs effective against resistant Plasmodium falciparum malaria will depend upon the knowledge of local patterns of resistance and the patient’s very specific travel plans.

C. Prophylaxis should be started the day of travel.

D. Chemoprophylaxis has been proven to be entirely reliable.
E. He should stay inside at the noon as this is the mosquito’s peak feeding time.

Answer 67

B. The decision to use drugs effective against resistant Plasmodium falciparum malaria will depend upon the knowledge of local patterns of resistance and the patient’s very specific travel plans.


Question 68

A 72-year-old woman is found unconscious at home by her daughter. In the emergency room the patient does not respond to verbal or noxious stimuli. Which of the following is the most likely cause of her condition?
A. Hypoglycemia
B. Left posterior cerebral artery occlusion
C. Lacunar infarct in the right internal capsule
D. Middle cerebral artery occlusion
E. Anterior cerebral artery occlusion

Answer 68

A. Hypoglycemia

Question 69

A patient with a previous history of tuberculosis now complains of hemoptysis. There is an upper lobe mass with a cavity and a crescent-shaped air-fluid level. What is the most likely etiologic agent?
A. Candida albicans
B. Aspergillus flavus
C. Coccidioides immitis
D. Herpes simplex type 1

Answer 69

B. Aspergillus flavus

Question 70

A 55-year-old diabetic woman suddenly develops weakness of the left side of her face as well as of her right arm and leg. She also has diplopia on left lateral gaze. Where is the responsible lesion?
A. Right cerebral hemisphere
B. Left cerebral hemisphere
C. Right side of the brainstem
D. Left side of the brainstem
E. Right median longitudinal fasciculus

Answer 70

D. Left side of the brainstem

Question 71

A 22-year-old male complains of fever and shortness of breath. There is no pleuritic chest pain or rigors and no sputum production. A chest x-ray shows diffuse perihilar infiltrates. The patient worsens while on erythromycin. A methenamine silver stain shows cystlike structures. Which of the following is correct?
A. Definitive diagnosis can be made by serology.
B. The organism will grow after 48 h.
C. History will likely provide important clues to the diagnosis.
D. Cavitary disease is likely to develop.
E. The infection will not recur.

Answer 71

C. History will likely provide important clues to the diagnosis.

Question 72

A 70-year-old man with with hypertension and COPD quit smoking 5 years ago, but is now beginning to experience cramps in his calf muscles upon walking one block. Diminished popliteal and pedal pulses are noted on examination. The choice of an antihypertensive agent may involve trying to avoid an adverse effect on a comorbid condition. Indicate the medication choice that needs to be avoided above all others.
A. Angiotensin-converting enzyme inhibitor
B. Beta-blocker, noncardioselective
C. Calcium-channel blocker
D. Diuretic
E. Hydralazine

Answer 72

B. Beta-blocker, noncardioselective

Question 73

A 46-year-old woman presents for her annual examination. Her main complaint is frequent sweating episodes with a sensation of intense heat starting at her upper chest and spreading up to her head. These have been intermittent for the past 6 to 9 months but are gradually worsening. She has three to four flushing/sweating episodes during the day and two to three at night. She occasio-nally feels her heart race for about a second, but when she checks her pulse it is normal. She reports feeling more tired and has difficulty with sleep due to sweating. She denies major life stressors. She also denies weight loss, weight gain, or change in bowel habits. Her last menstrual cycle was 3 months ago. Physical examination is normal. Which treatments is the most effective choice to alleviate this woman’s symptoms?
A. Levothyroxine
B. Estrogen
C. Estrogen plus progesterone
D. Fluoxetine
E. Gabapentin

Answer 73

C. Estrogen plus progesterone

Question 74

A 73-year-old woman is admitted for deep venous thrombosis and concern for pulmonary embolism. She has a history of type 2 diabetes mellitus, hypertension, and coronary artery disease. She had been admitted for a 3-vessel coronary artery bypass graft 2 weeks prior to this admission. She did well and was dismissed 5 days after the procedure. Pain and swelling of the right leg began 2 days before this admission; she has noticed mild dyspnea but no chest pain. The clinical suspicion of DVT is confirmed by a venous Doppler, and the patient is started on unfractionated heparin. Her initial laboratory studies, including CBC, are normal. The next day her pain has improved, and helical CT scan of the chest reveals no evidence of pulmonary embolism. She is instructed in the use of low-molecular-weight heparin and warfarin; she is eager to go home. Her serum creatinine is normal. Her predischarge CBC shows no anemia, but the platelet count has dropped to 74,000. An assay for antibodies to heparin-platelet factor 4 complexes is ordered. What is the best next step in her management?
A. Dismiss the patient on low-molecular heparin, warfarin, and close outpatient followup.
B. Obtain a liver-spleen scan to look for platelet sequestration.
C. Discontinue all forms heparin, continue warfarin, and add aspirin 162 mg daily until INR becomes therapeutic.
D. Keep the patient in the hospital, discontinue unfractionated heparin, add low-molecular-weight heparin, and monitor the platelet count daily.
E. Keep the patient in the hospital, discontinue all forms of heparin, and start the patient on lepirudin by intravenous infusion.

Answer 74

E. Keep the patient in the hospital, discontinue all forms of heparin, and start the patient on lepirudin by intravenous infusion.

Question 75

A 27-year-old female presents to the emergency room with a panic attack. She appears healthy except for tachycardia and a respiratory rate of 30. Electrolytes include calcium 10.0 mg/dL, albumin 4.0 g/dL, phosphorus 0.8 mg/dL, and magnesium 1.5 mg/dL. Arterial blood gases include pH of 7.56, PCO 221 mm Hg, PO 2 99 mm Hg. Which of the following is the most important cause of the hypophosphatemia?
A. Hypomagnesemia
B. Hyperparathyroidism
C. Respiratory alkalosis with intracellular shift
D. Poor dietary intake
E. Vitamin D deficiency

Answer 75

C. Respiratory alkalosis with intracellular shift

Question 76

A frail 80-year-old nursing home resident has had several episodes of syncope, all of which have occurred while she was returning to her room after breakfast. She complains of light-headedness and states she feels cold and weak. She takes nitroglycerin in the morning for a history of chest pain, but denies recent chest pain or shortness of breath. Which of the following is the best initial test?
A. Cardiac catheterization
B. Postprandial blood pressure monitoring
C. Holter monitoring
D. CT scan
E. EEG

Answer 76

B. Postprandial blood pressure monitoring

Question 77

A 34-year-old homosexual male with a history of HIV presents to the clinic complaining of a wheezing and multiple violaceous plaques and nodules on his trunk and extremities. Physical examination of the oral mucosa reveals similar findings on his palate, gingiva, and tongue. Chest x-ray is also significant for pulmonary infiltrates. What is the most likely pathogenesis of this process?
A. Proliferation of neoplastic T cells
B. Infection with human herpesvirus 6
C. Infection with Mycobacterium avium due to decreasing CD4 count
D. Angioproliferative disease caused by infection with human herpesvirus 8
E. Disseminated HSV infection

Answer 77

D. Angioproliferative disease caused by infection with human herpesvirus 8

Question 78

While on call in the hospital, you become involved in an emergent situation. A 72-year-old male presents with a 2-hour history of chest pain, acute ST segment elevation in leads II, Ill, and a VF, and sinus bradycardia at a rate of 40. His blood pressure is 80/40 mm Hg. Choose the best next step in antiarrhythmic management.
A. Amiodarone
B. Atropine
C. Digoxin
D. D Ditiazem
E. Isoproterenol
F. Lidocaine
G. Metoprolol
H. Quinidine

Answer 78

B. Atropine

Question 79

A 64-year-old woman is found to have a right-sided pleural effusion on chest x-ray. Analysis of the pleural fluid reveals pleural fluid to serum protein ratio of 0.38, a lactate dehydrogenase (LDH) level of 110 IU (normal 100-190), and pleural fluid to serum LDH ratio of 0.46. Which of the following disorders is most likely in this patient?
A. Bronchogenic carcinoma
B. Congestive heart fallure
C. Pulmonary embolism
D. Sarcoidosis
E. Systemic lupus erythematosus

Answer 79

B. Congestive heart fallure

Question 80

A 24-year-old white male presents with a persistent headache for the past few months. The headache has been gradually worsening and not responding to over-the-counter medicines. He reports trouble with his peripheral vision which he noticed while driving. He takes no medications. He denies illicit drug use but has smoked one pack of cigarettes per day since the age of 18. Past history is significant for an episode of kidney stones last year. He tells you no treatment was needed as he passed the stones, and he was told to increase his fluid intake.
Family history is positive for diabetes in his mother and a brother (age 20) who has had kidney stones from too much calcium and a “low sugar problem.” His father died of some type of tumor at age 40. Physical examination reveals a deficit in temporal fields of vision and a few subcutaneous lipomas. Laboratory results are as follows:
* Calcium: 11.8 mg/dL (normal 8.5-10.5)
* Cr: 1.1 mg/dL
* Bun: 17 mg/dL
* Glucose: 70 mg/dL
* Prolactin: 220 pg/L (normal 0-20)
* Intact parathormone: 90 pg/mL (normal 8-51)
You suspect a pituitary tumor and order an MRI which reveals a 0.7 cm pituitary mass. Based on this patient’s presentation, which of the following is the most probable diagnosis?
A. Tension headache
B. Multiple endocrine neoplasia Type 1 (MEN 1)
C. Primary hyperparathyroidism
D. Multiple endocrine neoplasia Type 2A (MEN 2A)
E. Prolactinoma

Answer 80

B. Multiple endocrine neoplasia Type 1 (MEN 1)

Question 81

A 58-year-old cigarette smoker develops a cough, weakness, and mental confusion. Chest CT shows a 2-cm perihilar density with hilar and mediastinal lymphadenopathy. Sputum cytology shows malignant squamous cells. What paraneoplastic syndrome would you associate with this scenario?
A. Humoral hypercalcemia of malignancy
B. Hyponatremia caused by inappropriate ADH secretion
C. Hypoglycemia due to IGF-2
D. Migratory thrombophlebitis associated with procoagulant cytokines
E. Skin infiltration with T lymphocytes
F. Erythrocytosis due to erythropoietin overproduction

Answer 81

A. Humoral hypercalcemia of malignancy

Question 82

A 60-year-old man with known hepatitis C and a previous liver biopsy showing cirrhosis requests evaluation for possible liver transplantation. He has never received treatment for hepatitis C. Though previously a heavy user of alcohol, he has been abstinent for over 2 years. He has had 2 episodes of bleeding esophageal varices. He was hospitalized 6 months ago with acute hepatic encephalopathy. He has a 1 year history of ascites that has required repeated paracentesis despite treatment with diuretics. Medications are aldactone 100 mg daily and lactulose 30 cc 3 times daily.
On examination he appears thin, with obvious scleral icterus, spider angiomas, palmar erythema, gynecomastia, a large amount ascites, and small testicles. There is no asterixis. Recent laboratory testing revealed the following: hemoglobin=12.0 mg/dL (normal 13.5-15.0), MCV=103 fL (normal 80-100), creatinine=2.0 mg/dL (normal 0.7-1.2), bilirubin=6.5 mg/dL (normal 0.1-1.2), AST=25 U/L (normal<40), ALT=45 U/L (normal<40), INR=3.0 (normal 0.8-1.2).
What is the next best step?
A. Repeat liver biopsy.
B. Start treatment with interferon and ribavirin.
C. Refer the patient for hospice care
D. Continue to optimize medical treatment for his ascites and hepatic encephalopathy and tell the patient he is not eligible for liver transplantation because of his previous history of alcohol abuse.
E. Refer the patient to a liver transplantation center.

Answer 82

E. Refer the patient to a liver transplantation center.

Question 83

What is the most appropriate screening test for a 67-year-old male smoker?
A. DNA or RNA amplification tests for chlamydia obtained from the cervix
B. Intermediate strength tuberculin skin test
C. Abdominal ultrasonograpny
D. Chest x-ray
E. Rapid plasma reagin (RPR)

Answer 83

C. Abdominal ultrasonograpny

Question 84

You are a physician in charge of patients who reside in a nursing home. Several of the patients have developed influenza-like symptoms, and the community is in the midst of influenza A outbreak. None of the nursing home residents have received the influenza vaccine. Which course of action is most appropriate?
A. A Give the influenza vaccine to all residents who do not have a contraindication to the vaccine (ie, allergy to eggs).
B. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give oseltamivir for 2 weeks to all residents.
C. Give amantadine alone to all residents.
D. Give azithromycin to all residents to prevent influenza-associated pneumonia.
E. Do not give any prophylactic regimen

Answer 84

B. Give the influenza vaccine to all residents who do not have a contraindication to the vaccine; also give oseltamivir for 2 weeks to all residents.

Question 85

A 60-year-old male is brought in by ambulance and is unable to speak. The EMS personnel tell you that a neighbor informed them he has had a stroke in the past. There are no family members present. His serum sodium is 118 mEq/L.
Which of the following is the most helpful first step in the assessment of this patient’s hyponatremia?
A. Order a chest x-ray
B. Place a Foley catheter to measure 24 hour urine protein
C. Clinical assessment of extracellular fluid volume status
D. CT scan of head
E. Serum AVP (arginine vasopressin) level

Answer 85

C. Clinical assessment of extracellular fluid volume status

Question 86

A 33-year-old fair-skinned woman has telangiectasias of the cheeks and nose along with red papules and occasional pustules. She also appears to have conjunctivitis with dilated scleral vessels. She reports frequent flushing and blushing.
Drinking red wine produces a severe flushing of the face. There is a family history of this condition. Which of the following is the most likely diagnosis?
A. Carcinoid syndrome
B. Porphyria cutanea tarda
C. Lupus vulgaris
D. Rosacea
E. Seborrheic dermatitis

Answer 86

Rosacea

Question 87

A 21-year-old female presents with an annular pruritic rash on her neck. She explains that the rash has been present for the past 3 weeks and that her roommate had a similar rash not long ago. Physical examination is remarkable for a 20-mm scaling, erythematous plaque with a serpiginous border. Which of the following is the most appropriate initial treatment for this condition?
A. Griseofulvin
B. Oral cephalexin
C. Topical mupirocin ointment
D. Topical ketoconazole
E. Hydrocortisone cream

Answer 87

D. Topical ketoconazole

Question 88

A young, previously healthy male presents with verrucous skin lesions, bone pain, fever, cough, and weight loss. Chest x-ray shows nodular infiltrates. 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 88

B. Blastomyces dermatitidis

Question 89

A 90-year-old male complains of weakness, some shortness of breath on exertion, and poor sleep. In evaluating this patient, which of the following physiologic parameters does not change with age?
A. Creatinine clearance
B. Forced expiratory volume
C. Hematocrit
D. Heart rate response to stress
E. Hours of REM sleep

Answer 89

C. Hematocrit