NBME 3 BLOCK 1

1. A 12-year-old girl with chronic renal

failure has had persistent epistaxis for
15 days. Laboratory studies show:
Hemoglobin 7.2 g/dL
Platelet count 175,000/mm3
Bleeding time 12 min
Prothrombin time 12 sec
Partial thromboplastin time (activated)
30 sec
Serum urea nitrogen (BUN) 125 mg/dL
Which of the following is the most
likely cause of the epistaxis?
O A) Acquired platelet dysfunction
O B) Circulating immune complexes
O C) Erythropoietin deficiency
O D) Factor III deficiency
O E) Hypocalcemia
A
2. A 57-year-old woman comes to the
physician because of depressed mood
and daily crying episodes since the
death of her father 6 weeks ago. She
has had difficulty concentrating,
decreased libido, and a 3.2-kg (7-Ib)
weight loss during this period. She is
less interested in her usual activities
but continues to work productively.
She sleeps for about 8 to 10 hours
every night. Over the past 2 weeks,
she has been smoking and drinking
more frequently, she now smokes onehalf pack of cigarettes daily and drinks
two to three glasses of wine every
other day. She has no history of
serious illness and takes no
medications. She is 163 cm (5 ft 4 in)
tall and weighs 80 kg (176 Ib), BMI is
30 kg/m2. Her temperature is 37C
(98.6F), pulse is 641min, and blood
pressure is 108160 mm Hg. The
remainder of the examination shows
no abnormalities. Mental status

examination shows a sad mood and

restricted affect. Her speech is normal
in rate and rhythm. There is no
evidence of suicidal ideation or
hallucinations. She can recall three of
three objects after 5 minutes. Longterm memory is intact. Which of the
following is the most likely diagnosis?
O
O
O
O
O
O
O

A) Alcohol dependence
B) Bereavement
C) Bipolar disorder
D) Cyclothymic disorder
E) Dysthymic disorder
F) Major depressive disorder
G) Malingering

B
3. An 80-year-old man is brought to
the emergency department on an 80degree day 2 hours after a syncopal
episode while playing golf. He plays
golf twice weekly. An ECG obtained at
his last examination 6 months ago
showed occasional premature
ventricular contractions (PVCs). On
arrival, his temperature is 38C
(100.4F), blood pressure is 150/90
mm Hg, pulse is 80/min and regular,
and respirations are 22/min. Cardiac
examination shows a grade 3/6, latepeaking systolic ejection murmur. No
bruits are heard over the carotid
arteries, but the upstrokes are
delayed. Which of the following is the
most likely cause of the syncope?
O A) Aortic stenosis
O B) Heat stroke
O C) Hypertensive cardiomyopathy
O D) Platelet emboli
0 E) PVCs
A
4. Five days after sustaining a 6-cm
laceration through the skin and

subcutaneous tissue of the left upper

extremity with a clean knife, a 52year-old man has increasing
tenderness in the area of the
laceration. Treatment at the time of
injury included cleansing and dressing
of the wound. The wound is now
erythematous, and yellow pus is
expressed when pressure is applied.
Which of the following is the most
likely mechanism for the accumulation
of pus?
O A) Chemotaxis
O B) Dysplasia
O C) Hyperoxia
O D) Metaplasia
0 E) Vasoconstriction
A
5. Twenty-four hours after
splenectomy for blunt trauma
sustained in a motor vehicle collision, a
previously healthy 25-year-old man
has oliguria and pain at the incision
site. Intraoperative complications
included a 30-minute period of
hypotension and a total blood loss of
2.5 L requiring 4 units of packed red
blood cells. Currently, his temperature
is 38C (100.4F), blood pressure is
120180 mm Hg, pulse is 1001min, and
respirations are 14/min. Central
venous pressure is 8 cm H 2O (N=58). The lungs are clear to auscultation,
and breath sounds are heard
bilaterally. Abdominal examination
shows no distention, bowel sounds are
absent. A Foley catheter is in place,
and over the past 3 hours, his urine
output has been 20 mL/h. Laboratory
studies show a hematocrit of 28%, a
serum urea nitrogen (BUN) level of 30
mg1dL, and a serum creatinine level of
2.5 mgfdL, serum electrolyte levels are
within normal limits. Which of the
following is the most likely explanation
for these findings?

O A) Acute tubular necrosis

O B) Foley catheter malfunction
O C) Hypervolemia
O D) Transfusion reaction
0 E) Ureteral injury
A
6. A 32-year-old man comes to the
physician for a second opinion
regarding an enlarged cervical lymph
node that he noted 6 weeks ago. He
has not had pain or tenderness but has
been unable to return to work despite
normal findings on a biopsy of the
node 4 weeks ago. He had a mild
upper respiratory tract infection 1
month ago. His maternal uncle
recently died of lymphoma. He states
that cancer runs in his family, and that
for the past several years he has
thought that he will have some kind of
cancer eventually. Which of the
following is the most likely diagnosis?
O A) Asthma
O B) Conversion disorder
O C) Factitious disorder
O D) Hypochondriasis
O E) Malingering
O F) Pulmonary embolus
0 G) Somatization disorder
D
7. A 32-year-old woman, gravida 3,
para 2, at 40 weeks' gestation is
admitted to the hospital in labor.
Vaginal and anal cultures at 36 weeks'
gestation were positive for group B
streptococcus. She has no known drug
allergies. Which of the following is the
most appropriate pharmacotherapy for
this patient before delivery?
O A) Intravenous azithromycin
O B) Intravenous clindamycin
O C) Intravenous penicillin
O D) Oral amoxicillin and clavulanate
O E) Oral erythromycin

O F) No treatment until after delivery

C
8. A 38-year-old woman comes to the
physician because of a low-grade fever
and generalized rash for 4 days. She is
currently receiving cefazolin therapy
for chronic osteomyelitis. Her
temperature is 38.2C (100.8F),
blood pressure is 1501108 mm Hg,
and pulse is 1001min. There is a faint
diffuse maculopapular rash.
Examination of the back shows no
costovertebral angle tenderness.
Cardiac and pulmonary examinations
show no abnormalities. Laboratory
studies show:
Leukocyte count 10,8001mm3
Segmented neutrophils 60%
Bands 8%
Eosinophils 4%
Lymphocytes 20%
Monocytes 8%
Serum
Urea nitrogen (BUN) 20 mg/dL
Creatinine 1.6 mg/dL
Urine
WBC 121hpf
RBC 81hpf
RBC casts none
WBC casts rare
Eosinophils are found in the urine
sediment. Which of the following is the
most likely explanation for these
findings?
O
O
O
O
O
O
C

A) Acute tubular necrosis

B) Fibromuscular dysplasia
C) Interstitial nephropathy
D) Polyarteritis nodosa
E) Pyelonephritis
F) Wegener's granulomatosis

9. A healthy 60-year-old woman comes

to the physician for a routine
examination. She has no history of
illness over the past year and has
never had an operation. She takes no
medications. Menopause occurred 6
years ago. She weighs 57 kg (125 lb)
and is 160 cm (63 in) tall. Pelvic
examination shows atrophic external
genitalia and a small, midpositioned
uterus. The left ovary is 3 x 3 cm, the
right ovary is not palpable. Which of
the following is the most appropriate
next step in management?
O A) Reexamination in 1 month
O B) Reexamination in 1 year
O C) Obtain patient's medical records
O D) Measurement of serum
progesterone level
O E) Pelvic ultrasonography
E
Normally, on physical examination, the
ovaries are 2-3 cm in young women
and not palpable in postmenopausal
women.
10. On the fifth day of a 7-day cruise
in the western Caribbean, a 37-yearold woman develops headaches, fever,
chills, abdominal discomfort, and
watery diarrhea over a 12-hour period.
Many other passengers and crew
members have had similar symptoms.
Her temperature is 37C (98.6F).
Abdominal examination shows diffuse
tenderness without rebound, bowel
sounds are hyperactive. Her leukocyte
count is 11,000/mm3. Gram's stain of
a stool specimen shows a small
number of neutrophils. A stool culture
grows Salmonella enteritidis. Two days
after treatment with bismuth
subsalicylate and oral rehydration, her
symptoms subside. Which of the
following is the most appropriate

immediate measure to prevent further

spread of this pathogen?
O A) Cancellation of shore leave for all
crew members
O B) Elimination of seafood and
shellfish from the ship's menu
O C) Exclusive use of pasteurized eggs
O D) Hyperchlorination of the ship's
drinking water
O E) Reassignment of all food-handling
personnel to other duties
O F) Treatment of all affected persons
with doxycycline
E
11. A 57-year-old man with a 10-year
history of type 2 diabetes mellitus
comes to the physician fora routine
examination. His last office visit was 6
months ago. He feels well. Current
medications include enalapril and
glyburide. He is 168 cm (5 ft 6 in) tall
and weighs 84 kg (185 Ib), BMI is 30
kg/mZ. His pulse is 60/min, and blood
pressure is 100/70 mm Hg.
Funduscopic examination shows soft
and hard exudates. Laboratory studies
show
Hemoglobin Al. 12%
Serum
Urea nitrogen (BUN) 23 mg/dL
Creatinine 1.4 mg/dL
Urine protein 1+
Which of the following is the most
appropriate additional
pharmacotherapy?
O A) Atenolol
O B) Captopril
O C) Hydrochlorothiazide
O D) Metformin
0 E) Verapamil
D
12. An 82-year-old man is brought to

the physician by his neighbors because

he looks ill." They say that he subsists
primarily on hot dogs and canned
meats and that his slovenly habits
have attracted rats to the
neighborhood. He does not drink
alcohol but is forgetful. Examination
shows a pleasant, dirty, confused man
who appears thin. He has diffuse
purpura on his legs and perifollicular
inflammation. Which of the following is
the most likely cause of these findings?
O A) Aplastic anemia
O B) Leukemia
O C) Rat-bite fever
O D) Scurvy
O E) Warfarin ingestion
D
13. A 6-month-old girl is brought to
the physician because of fever, cough,
and coryza for 1 day. Her pulse is
1001min, and respirations are 501min.
Her cough is harsh and sounds like a
dog's bark. There is inspiratory stridor
and intercostal retractions. Which of
the following is the most likely
diagnosis?
O A) Asthma
O B) Bacterial tracheitis
O C) Bronchiolitis
O D) Foreign body in the small airways
O E) Foreign body in the trachea
O F) Laryngotracheobronchitis
O G) Pneumonia
O H) Pneumothorax
0 I) Pulmonary edema
F
14. An 80-year-old man has had poor
balance for 6 months. He has a history
of hypertension treated with
hydrochlorothiazide. His blood
pressure is 136/86 mm Hg. Neurologic
examination shows mild tremor of the

hands when his arms are outstretched

and decreased
vibratory sensation at the knees. Deep
tendon reflexes of the quadriceps and
gastrocnemius-soleus muscles are
hyperactive. Babinski's sign is present
bilaterally. He is unable to stand with
his eyes closed. Which of the following
is most consistent with normal
age-related changes?
O A) Babinski's sign
O B) Hyperactive deep tendon reflexes
of the gastrocnemius-soleus muscles
O C) Inability to stand with the eyes
closed
O D) Reduced vibratory sensation at
the knees
0 E) Tremor of the outstretched hands
E
15. A previously healthy 6-month-old
boy is brought to the physician
because of a 12-hour history of
vomiting and diarrhea. He vomits after
all feedings, the vomitus does not
contain blood or bile. His mother says
that he has had fewer wet diapers than
usual during this period. He appears
dehydrated and is crying without tears.
He is at the 50th percentile for length
and 30th percentile for weight. He
appears lethargic. His temperature is
38C (100.4F), pulse is 180/min,
and blood pressure is 60/40 mm Hg.
Examination shows sunken eyes, dry
mucous membranes, and a sunken
anterior fontanel. Arterial blood gas
analysis on room air shows:
pH 7.2
PCO2 38 mm Hg
PO2 90 mm Hg
Which of the following is the most
likely explanation for this patient's
arterial blood gas findings?
O A) Excessive metabolic acid

formation
O B) Impaired ventilation
O C) Increased chloride loss
( increase HCO3 which is not the case
here)
O D) Increased CO2 concentration in
the extracellular fluid
0 E) Increased metabolic acid
produced by the gastrointestinal tract
A
16. A 42-year-old man is brought to
the emergency department because of
a 2-day history of muscle spasms and
jaw stiffness. He is sexually active with
three partners and uses condoms
inconsistently. He has a 5-year history
of intravenous heroin use. He appears
irritable. His temperature is 38.8C
(101.8F), pulse is 120/min, and
blood pressure is 152/96 mm Hg.
Physical examination shows facial and
paraspinal muscle spasms and rigidity;
stimulation of the muscles results in
paroxysmal spasms. Mobility of the
jaw is decreased. Neurologic
examination shows hyperreflexia.
Which of the following is most likely to
have prevented this condition?
O A) Consistent condom use
O B) Botulism antitoxin therapy
O C) Prednisone therapy
O D) Rifampin therapy
O E) Tetanus toxoid vaccination
0 F) Vitamin B1 (thiamine)
supplementation
E
17. A 72-year-old woman comes to the
physician because of increasing
episodes of urinary incontinence over
the past 6 months. Her incontinence
usually occurs at night, she feels no
sensation to urinate prior to the
episodes. The episodes are less
frequent if she schedules her trips to

the bathroom and restricts liquid

intake several hours prior to bedtime.
She has a 20-year history of type 2
diabetes mellitus. Current medications
include metformin and glyburide.
Funduscopic examination shows mild
retinopathy. Pelvic examination shows
normal vaginal mucosa. Sensation to
pinprick is decreased in a stockingglove distribution. Urinalysis shows 1
+ protein and no leukocyte esterase or
nitrites. Which of the following is the
most likely cause of this patient's
urinary symptoms?
O A) Functional incontinence
O B) Hypersensitivity of the detrusor
muscle
O C) Overflow of urine from large
residual volumes
O D) Urethral atrophywith loss of
urethrovesical angle
O E) Normal aging
C
18. An afebrile 2-year-old boy has had
right ear pain for 3 days. He has been
swimming everyday for the past week.
Purulent fluid is draining from the right
external ear canal, and manipulation of
the pinna is painful. No abnormalities
are noted on visualization of tympanic
membranes. Which of the following is
the most likely causal organism?
O A) Haemophilus influenzae type b
O B) Moraxella catarrhalis
O C) Pasteurella multocida
O D) Pseudomonas aeruginosa
O E) Streptococcus pneumoniae
D
19. Over the past 2 weeks, a 60-yearold man has had shortness of breath
on exertion. He also has paroxysmal
nocturnal dyspnea with two-pillow
orthopnea. He has taken aspirin daily

since a myocardial infarction 3 years

ago. He has a history of atrial
fibrillation well controlled with digoxin
and type 2 diabetes mellitus treated
with diet. His blood pressure is 136188
mm Hg, pulse is 98/min and irregular,
and respirations are 20/min. Jugularvenous pressure is increased. Breath
sounds are decreased over the right
lung base.. there is dullness to
percussion. Cardiac examination shows
an S. gallop. There is 2+ edema of the
lower extremities. Pulse oximetry
shows an oxygen saturation of 90%.
Which of the following is the most
appropriate next step in diagnosis?
O A) X-ray film of the chest
O B) Ambulatory ECG monitoring
O C) Thallium stress test
O D) Echocardiography
O E) Ventilation-perfusion lung scans
A
20. A 47-year-old woman comes to the
emergency department because of
severe abdominal pain for 3 hours. The
pain began after a 2-week drinking
binge. She has a 15-year history of
alcoholism. She has no history of
jaundice or hepatitis. Current
medications include multivitamins and
iron. Her temperature is 38C
(100.4F), blood pressure is 110/80
mm Hg, and pulse is 110/min.
Examination shows mild jaundice and
diffuse spider angiomata over the
trunk and abdomen. The liver is tender
to palpation. A complete blood count
shows mild anemia with normal red
cell indices. Ultrasonography of the
abdomen shows normal-sized hepatic
ducts. Which of the following is the
most likely set of laboratory findings?
Total Indirect Alkaline
Bilirubin Bilirubin Phosphatase
Reticulocyte

(mg/dL) (mg/dL) (U/L) (ALT, GPT)

(U/L) Count (%)
O A) 2 0.9 80 30 1.2
O B) 3 2.8 70 30 1.0
O C) 3 2.8 80 20 3.0
O D) 4 2.0 800 200 1.5
O E) 4 1.0 150 400 1.0
E
21. A 3-month-old boy is brought to
the physician in January because of
difficulty breathing, clear nasal
discharge, and cough for 24 hours. His
temperature is 37.6C (99.6F),
blood pressure is 88/54 mm Hg, pulse
is 168/min, and respirations are
60/min. Bilateral wheezing, prolonged
expiration, and a grade 2/6 systolic
murmur along the left sternal border
are heard. The liver is palpated 3 cm
below the right costal margin. An x-ray
film of the chest shows bilateral
hyperinflation and no cardiomegaly.
Which of the following is the most
likely diagnosis?
O A) Adenovirus pneumonia
O B) Congestive heart failure
O C) Influenza A virus pneumonia
O D) Respiratory syncytial viral
bronchiolitis
O E) Staphylococcal pneumonia
0 F) Status asthmaticus
D
22. A 22-year-old woman comes to the
physician because of diffuse constant
headaches and vision problems for 3
months, the headaches are worse in
the morning when she awakens from
sleep. She also has had brief episodes
of loss of vision in both eyes. She has
had an 18-kg (40-Ib) weight gain over
the past year. She now weighs 100 kg
(220 lb) and is 163 cm (64 in) tall.
Visual acuity is 20/30 bilaterally. Visual
fields are full, but the blind spots are

enlarged bilaterally. Funduscopic

examination shows marked blurring of
the optic disc margins bilaterally. The
remainder of the neurologic
examination shows no abnormalities.
Which of the following is the most
likely diagnosis?
O A) Amaurosis fugax
O B) Central retinal vein occlusion
O C) Glaucoma
O D) Macular degeneration
O E) Migraine
O F) Nutritional optic neuropathy
O G) Optic neuritis
O H) Pituitary adenoma
O I) Pseudotumor cerebri
0 J) Temporal arteritis
I
23. A 32 yo man with 1-year history of
constant worries about his financial
situation and health despite his
success.
A. Buspirone
24. A 49-year-old man has had
progressive shortness of breath over
the past year. He now has dyspnea
after walking up one flight of stairs. He
has fine crackles bilaterally on
auscultation of the lungs. Spirometry
shows:
Vital capacity (VC) decreased
FEV1 decreased
Ratio of FEV, to VC increased
Arterial blood gas analysis on room
air:
pH 7.42
PCO2 60 mm Hg
PO2 34 mm Hg
Which of the following is the most
likely diagnosis?
0 A) Asthma

p
o
p
p

B) Bronchiectasis
C) Chronic bronchitis
D) Emphysema
E) Pulmonary fibrosis

E
25. A previously healthy 24-year-old
woman, gravida 3, para 3, is brought
to the emergency department because
of deep, sharp, intermittently severe
pain in the left lower quadrant of the
abdomen for 2 hours. Her last
menstrual period was 3 weeks ago.
She takes no medications. She is in
obvious distress and is lying on her left
side with her lower extremities drawn
up against her abdomen. Her
temperature is 37C (98.6F), blood
pressure is 140/70 mm Hg, and pulse
is 125/min. Abdominal examination
shows rigidity and tenderness. Pelvic
examination shows a 12-cm mass in
the left lower quadrant of the
abdomen. Which of the following is the
most appropriate next step in
management?
O
O
O
O

A) Ultrasound-guided aspiration
B) Dilatation and curettage
C) Exploratory laparotomy
D) Hysterectomy

C
26. Fourteen hours after admission to
the hospital for treatment of severe
hypertension, a 32-year-old woman
has stridor. On admission, she was
given captopril. She appears anxious.
Her blood pressure is 140/85 mm Hg,
pulse is 140/min, and respirations are
32/min. Examination shows swelling of
the lips and tongue. Diffuse stridorous
wheezes are heard on auscultation.
There is diminished air movement.
Which of the following is the most
appropriate next step in management?

p A) Observation only
p B) Measurement of serum captopril
level
O C) Measurement of serum IgE level
o D) X-ray film of the chest
0 E) Tracheal intubation
E
27. A 65-year-old woman has had
progressive irritability, palpitations,
and heat intolerance for 6 months. She
has had a 7-kg (15-Ib) weight loss
during this period. She has had a neck
mass for more than 10 years. 1311
scan shows an enlarged thyroid gland
with multiple areas of increased and
decreased uptake. Which of the
following is the most likely diagnosis?
O A) Graves' disease
O B) Multinodular goiter
O C) Thyroiditis
O D) Toxic adenoma
0 E) Triiodothyronine (T3)
thyrotoxicosis
B
28. 19 yo man has fever, headache,
sore throat, swelling of cervical
LNs for 5 days.
C. EBV
For each patient with chronic knee
pain, select the most appropriate next
step in management.
C A) Anterior cruciate ligament
reconstruction
C B) Arthroscopic partial meniscectomy
C C) Quadriceps strengthening
exercises
C D) Sympathetic blockade
C E) Total knee replacement
C F) Upper tibial osteotomy

29. 18 yo woman. Answer C

30. A 70-year-old man comes to the
physician because of knee pain that
has been present for 10 years. He is
unable to comfortably walk further
than one block and has difficulty
sleeping because of the pain. He has
pain on both medial and lateral sides
of the knee. Range of motion is from
15 to 100 degrees, there is a bowleg
deformity when he stands.
E
31. A 55-year-old man with alcoholic
cirrhosis is hospitalized for 2 weeks in
April for treatment of gastrointestinal
bleeding. His last immunization for
diphtheria-tetanus (Td) was 6 years
ago. Which of the following is the most
appropriate management prior to
discharge?
O A) Administration of immune
globulin
O B) Inactivated poliovirus vaccine
O C) Influenza virus vaccine
O D) Pneumococcal vaccine
0 E) Td toxoids
D
32. One week after cholecystectomy
for acute cholecystitis, a 57-year-old
woman comes to the physician
because of a 1-day history of
abdominal cramps and watery, green,
foul-smelling diarrhea. She finished a
7-day course of cefoxitin 3 days ago.
She appears dehydrated. Her
temperature is 39.8C (103.6F),
pulse is 115/min, and blood pressure
is 105/70 mm Hg. Abdominal
examination shows moderate
distention and diffuse tenderness,
there is no guarding. Test of the stool
for occult blood is positive, the stool

contains leukocytes. Her hemoglobin

level is 10.8 g/dL, and leukocyte count
is 39,000/mm3. The patient is
admitted to the hospital, and
administration of intravenous fluids is
begun. Which of the following is the
most appropriate next step in
pharmacotherapy?
O A) Intravenous amphotericin
O B) Intravenous ampicillin,
clindamycin, and gentamicin
O C) Intravenous corticosteroids
O D) Oral diphenoxylate and atropine
0 E) Oral metronidazole
E
A picture here
33. A 32-year-old comes to the
physician because of painless growths
around her anal region that she first
noticed 4 months ago. Over the past
10 years, she has had sexual
intercourse with multiple partners. She
has a 4-year history of Crohn's
disease. Medications include
sulfasalazine and metronidazole. Her
father has psoriasis. A photograph of
the lesions is shown. Examination
shows no other abnormalities. Which
of the following is the greatest risk
factor for this condition?
O A) Crohn's disease
O B) Family history of psoriasis
O C) Multiple sexual partners
O D) Treatment with metronidazole
0 E) Treatment with sulfasalazine
C
The response options for the next two
items are the same. You will be
required to select one answer for each
item in the set.
For each patient with dysphagia, select
the most likely diagnosis.

O A)Achalasia
O B)Adenocarcinoma of the esophagus
O C)Candidal esophagitis
O D) Diffuse esophageal spasm
O E) Polymyositis
0 F)Refluxesophagitis
0 G)Scleroderma (systemic sclerosis)
0 H)Squamous cell carcinoma of the
esophagus
0 I)Viral esophagitis
34. A 42-year-old man with an 8-year
history of intermittent difficulty
swallowing solids and liquids has had
increasingly severe exacerbations
because of stress over the past 6
months. He also has nocturnal
regurgitation and cough. Esophageal
motility studies show failure of
relaxation of the lower esophageal
sphincter.
A
For each patient with dysphagia, select
the most likely diagnosis.
A) Achalasia 0 F)Refluxesophagitis
Q B) Adenocarcinoma of the
esophagus 0 G)Scleroderma (systemic
sclerosis)
p C) Candidal esophagitis 0
H)Squamous cell carcinoma of the
esophagus
p D) Diffuse esophageal spasm 0
I)Viral esophagitis
0 E) Polymyositis
35. A 45-year-old woman has had
generalized weakness for 1 year,
increasing difficulty walking up stairs
over the past 6 months, and difficulty
swallowing for 1 month. Examination
shows weakness of the proximal
muscles of the extremities. Ear, nose,
and throat examinations and

manometry show decreased

contractions of the pharynx with
decreased upper esophageal tone.
E
36. A 42-year-old man with
hypertension is brought to the
emergency department 1 hour after
the onset of chest discomfort, severe
headache, irritability, and confusion.
His blood pressure is 2201148 mm Hg.
Examination shows papilledema.
Urinalysis shows blood. An ECG shows
ischemic changes with left ventricular
hypertrophy. A CT scan of the head
shows no abnormalities. Which of the
following is the most appropriate
pharmacotherapy?
O A) Atenolol
O B) Captopril
O C) Diltiazem
O D) Furosemide
O E) Guanethidine
O F) Hydralazine
O G) Losartan
O H) Methyldopa
O I) Nitroprusside
O J) Prazosin
0 K) Thiazide diuretic
I
37. A 2-year-old girl is found floating
facedown in a swimming pool. On
rescue, she immediately coughs and
breathes spontaneously. She is
conscious and oriented. Without
treatment, which of the following is the
most likely outcome for this child?
A) Complete recovery
B) Development of acute respiratory
distress syndrome
C) Hemolysis
D) Pulmonary hypertension
E) Severe neurologic deficit

A
38. A 25-year-old woman has had
daily cough and wheezing for 4
months. She has had difficulty sleeping
because of her symptoms. Inspiratory
and expiratory wheezes are heard with
a slightly prolonged exhalation phase.
Rz Adrenergic agonist therapy by
inhalation is begun. She is still mildly
symptomatic during the day with
bronchospastic episodes occurring
three times weekly at night. Which of
the following medications should be
added to the regimen?
O A) Inhaled glucocorticoids
O B) Inhaled ipratropium
O C) Oral erythromycin
O D) Oral furosemide
0 E) Oral theophylline
A
39. Five years after being shot in the
right thigh, a 21-year-old man comes
to the emergency department because
of a busing sensation adjacent to the
scar. At the time of the initial wound,
he was discharged after 6 hours of
observation with no fractures or softtissue
swelling. A loud murmur is heard on
auscultation, there is a thrill. He has
dilated varicose veins with
incompetent valves in the lower leg.
Which of the following is the most
likely diagnosis?
O A) Arterial spasm
O B) Arteriovenous fistula
O C) Deep venous thrombosis
O D) Occlusion of the superficial
femoral artery
O E) Pseudoaneurysm
B
40. A study is conducted to investigate
the prevalence of past infection with

genital herpes among students

attending a large coeducational
Midwestern university. After obtaining
informed consent, the study
participants undergo antibody testing
for herpes simplex virus 2 (HSV).
Which of the following is the most
important factor in determining the
validity of a positive test?
A) The number of sexual partners of
the student
B) The proportion of students infected
with HSV
C) The proportion of students with
negative tests
D) The proportion of students with
positive tests
E) The total number of students
screened
B
41. During a routine examination, a
20-year-old man is found to have a
firm, bilaterally enlarged thyroid gland
and lymphadenopathy. His father died
of thyroid cancer at the age of 40
years. Which of the following
hormones is most likely associated
with this patient's findings?
O A) ACTH
O B) ADH (vasopressin)
O C) Aldosterone
O D) Calcitonin
O E) Growth hormone
O F) G3-hCG
O G) Insulin
O H) Parathyroid hormone
O I) Thyroid-stimulating hormone
0 J) Thyroxine (T4)
D
42. Twelve days after sustaining a
cerebral infarction, a 72-year-old man
has fever and cough. Initial symptoms
included inability to move his right arm

and leg, swallow, speak, or respond to

questions. He has been receiving a diet
of pureed foods since he recovered his
ability to swallow 3 days ago. He is
wearing false teeth. His temperature
now is 38.8C (101.8F), blood
pressure is 135/85 mm Hg, pulse is
94/min, and respirations are 28/min.
Examination shows moderate
weakness of the facial muscles and
right extremities. Gag reflex is absent.
Breath sounds are decreased, and
there is dullness to percussion over the
right lung base posteriorly. An x-ray
film of the chest shows an infiltrate in
the posterior basal segment of the
right lung. Which of the following is
most likely to prevent recurrence of
this patient's lung condition?
O A) Removal of false teeth
O B) Suppression of gastric acid
production
O C) Chronic antibiotic prophylaxis
O D) Administration of metoclopramide
to increase gastrointestinal motility
O E) Insertion of a feeding
jejunostomy tube
E
43. A previously healthy 72-year-old
man is brought to the physician
because of two episodes of transient
paresis in the left arm during the past
2 days; each episode lasted for 3 to 4
minutes. No bruits are heard over the
carotid arteries, and there are no
cardiac murmurs. Carotid duplex
ultrasonography and confirmatory
arteriography show a 30% stenosis of
the internal carotid arteries bilaterally.
Which of the following is the most
appropriate next step in management?
A) Aspirin therapy
B) Heparin therapy
C) Nifedipine therapy
D) Placement of a carotid endovascular
stent

E) Carotid endarterectomy
A
44. A 35-year-old man with a 10-year
history of persistent hallucinations and
delusions comes for a follow-up
examination. He has been treated with
haloperidol, chlorpromazine, and
fluphenazine with minimal relief of
symptoms. He is currently taking
haloperidol. On
examination, he walks slowly with no
arm swing and has no facial
movements. Which of the following is
the most likely cause of his motor
behavior?
O A) Excess limbic y-aminobutyric acid
activity
O B) Increased serum prolactin level
O C) Nigrostriatal dopamine blockade
O D) Noradrenergic depletion in the
frontal lobe
O E) Ventral tegmental dopamine
blockade
C
45. An 82-year-old woman comes to
the physician because of a 2-month
history of progressive shortness of
breath with exertion and a 3-week
history of right upper quadrant
abdominal discomfort. She has chronic
obstructive pulmonary disease,
hypertension, and
rheumatoid arthritis. Medications
include methotrexate,
hydrochlorothiazide, naproxen,
albuterol metered-dose inhaler, and
aspirin. Examination shows pallor.
Breath sounds are decreased. The liver
is enlarged, firm, and mildly tender.
Test of the stool for occult blood is
positive. Her hematocrit is 27%, and
mean corpuscular volume is 76 pm3. A
CT scan of the abdomen shows
multiple hypodense lesions in the liver.

Which of the following is the most

likely diagnosis?
O A) Cholangiocarcinoma
O B) Hepatocellular carcinoma
O C) Lymphoma
O D) Metastatic colon cancer
O E) Metastatic lung cancer
O F) Metastatic pancreatic cancer
D
46. On routine health maintenance
examination, a 23-year-old man has a
systolic murmur. There is no family
history of heart disease. His blood
pressure is 110170 mm Hg, and pulse
is 601min. Cardiac examination shows
a point of maximal impulse in the fifth
intercostal
space at the midclavicular line, there is
a normal S1 and a split, fixed S2. A
grade 216, systolic ejection murmur is
heard at the left sternal border, there
is no change with inspiration,
Valsalva's maneuver, or hand grip. An
exercise stress test shows no
abnormalities. Which of the following is
the most likely cause of this patient's
cardiac murmur?
O A) Aortic stenosis
O B) Atrial septal defect
O C) Hypertrophic cardiomyopathy
O D) Mitral valve prolapse
O E) Ventricular septal defect
B
BLOCK 2
1. For the past 10 years, a 28-year-old
woman has followed a strict diet that
prohibits dairy products, meat, fish,
and fowl. On routine examination, her
hematocrit is 30%, and mean
corpuscular volume is 122 pm3. Which
of the following is the most
appropriate next step in diagnosis?

O A) Erythrocyte folate determination

O B) Serum iron and total iron-binding
capacity determinations
O C) Serum thyroid hormone
determination
O D) Serum urea nitrogen (BUN)
determination
O E) Serum vitamin B12
(cyanocobalamin) determination
E
2. A 47-year-old man comes to the
physician because of a persistent
nonproductive cough for 3 months. He
has not had fever, rhinorrhea, or nasal
congestion. He was seen by a
physician 3 months ago for the cough
and treated with amoxicillin and an
over-the-counter cough medication. He
has a 3-month history of hypertension
well controlled with lisinopril. He is in
no distress. He weighs 79 kg (175 lb)
and is 178 cm (70 in) tall. His
temperature is 37.1C (98.8F),
blood pressure is 130178 mm Hg,
pulse is 721min and regular, and
respirations are 161min. Examination
shows no abnormalities. A complete
blood count and x-ray films of the
chest show no abnormalities. Which of
the following is the most appropriate
next step in management?
O A) X-ray films of the sinuses
O B) Discontinue lisinopril therapy
O Q Add a beclomethasone inhaler to
the medication regimen
O D) Add ciprofloxacin to the
medication regimen
O E) Add hydrocodone to the
medication regimen
B
3. A 12-year-old girl is brought to the
physician by her mother because she
is concerned about her daughter's

difficulty making friends and

socializing. Her development and
adjustment had been normal until 6
months ago when she began to refuse
to use restrooms at school or eat in
the cafeteria. Her mother describes her
as a quiet, serious child who does not
readily interact with other people. Her
teachers report that her concentration
varies. at times, she appears to be
daydreaming. On examination, she is
reserved but pleasant and appears to
be of normal intelligence. Her speech
is normal in rate and rhythm. She says
that she is concerned that her voice
will fail her if she has to read aloud in
class. Which of the following is the
most likely diagnosis?
O A) Attention-deficitthyperactivity
disorder, inattentive type
O B) Autistic disorder
O C) Expressive language disorder
O D) Oppositional defiant disorder
O E) Selective mutism
O F) Social phobia
O G) Age-appropriate behavior
F
A picture here for q4
4. A 25-year-old woman is brought to
the emergency department 45 minutes
after being hit in the right eye with a
tennis ball. She has severe pain and
decreased vision in the injured eye.
Visual acuity is 201400 on the right. A
photograph of the eye is shown. Which
of the following is the most likely
diagnosis?
O A) Acute angle-closure glaucoma
O B) Anterior iritis
O C) Cataract
O D) Hyphema
O E) Hypopyon
D

5. A 44-year-old woman is brought to

the emergency department 40 minutes
after being stabbed in the left groin.
Her blood pressure is 128/84 mm Hg,
pulse is 100/min, and respirations are
16/min. Examination of the wound
shows a small hematoma and no
external bleeding. Popliteal and pedal
pulses are palpable in the left lower
extremity below the injury. Lacerations
of the femoral artery and vein are
found and repaired. Two days
postoperatively, she has progressively
severe pain of the left lower extremity
and swelling of the leg from the knee
down. Which of the following is the
most likely cause of her new
symptoms?
O A) Arterial embolism
O B) Compartment syndrome
O C) Lymphatic disruption from the
injury
O D) Thrombosis of the femoral vein
0 E) Wound hemorrhage
B
6. The crude mortality rate for
coronary artery disease in Community
A is twice the crude mortality rate for
coronary artery disease in Community
B. The age-standardized mortality
rates for coronary artery disease in the
two communities are the same. These
findings are most consistent with
which of the following inferences?
A) Coronary artery disease mortality in
the elderly is higher in Community A
than Community B
B) Coronary artery disease mortality in
young adults is higher in Community A
than Community B
C) The population of Community B is
younger than the population of
Community A

D) The proportionate mortality from

coronary artery disease is higher in
Community A than Community B
E) The two communities have similar
age distributions
C
7. An otherwise healthy 28-year-old
man comes to the physician because of
a dry hacking cough for 3 months. A
routine examination 6 months ago
showed no abnormalities. His paternal
grandfather had colon cancer.
Examination today shows normal
findings. An x-ray film of the chest
shows a large anterior mediastinal
mass. Which of the following is the
most likely origin of this neoplasm?
O A) Colon
O B) Kidney
O C) Prostate
O D) Stomach
0 E) Testicle
E
A testis tumor may become metastatic
and manifest with large retroperitoneal
and/or chest lesions, while the primary
tumor is nonpalpable. Scrotal
ultrasonography may locate the
primary tumor. Histopathology of the
primary testis often shows a focus of
tumor surrounded by fibrous scar,
termed burned-out testis cancer.
8. A 50-year-old man has a cardiac
arrest during sexual intercourse. He is
promptly resuscitated and recovers
uneventfully from an acute anterior
wall myocardial infarction. At discharge
from the hospital, he and his wife
inquire about the safety of future
sexual intercourse. Which of the
following is the most appropriate
advice?
O A) Psychiatric consultation is

necessary
O B) Sexual intercourse should be
performed while wearing an
ambulatory ECG monitor
O C) Sexual intercourse will be safe
when exercise tolerance improves
O D) They should wait 3 months before
having sexual intercourse
O E) They should have sexual
intercourse as soon as possible to
overcome the fear of another event
C
9. A 68-year-old woman with terminal
metastatic breast cancer is living at
home with her son. She has a living
will requesting that she be allowed to
"die in peace." She is unresponsive to
voice and has not had any food or
liquids for 3 days. Her son disagrees
with her decision not to accept further
therapy, including chemotherapy,
antibiotics, hospitalization, and enteral
or parenteral nutrition. Which of the
following is the most appropriate next
step in management?
p A) Abide by the decisions of the next
of kin
p B) Obtain a court order to allow
additional therapy to be given
O C) Start enteral feedings
p D) Admit her to the hospital
0 E) No further intervention
E
10. A 57-year-old woman comes to the
physician for a follow-up examination.
She has a 5-year history of
hypercalcemia, which was diagnosed
with routine laboratory studies, and
her serum calcium levels have ranged
from 10.8 mg/dL to 11.5 mg/dL. She
declined further evaluation in the past
because she "felt well." She takes no
medications. Her last menstrual period
was 7 years ago. She maintains a

weight of 67 kg (148 lb) and is 170 cm

(67 in) tall, BMI is 23 kg/m2. Her
blood pressure is 126/80 mm Hg, and
pulse is 66/min. Examination shows no
abnormalities. Which of the following is
the most appropriate next step to
assess her risk for fracture?
O A) 24-Hour urine collection for
measurement of collagen cross-links
excretion
O B) Bone densitometry
O C) Bone-specific measurement of
serum alkaline phosphatase activity
O D) Posteroanterior and lateral x-ray
films of the thoracic spine and hips
O E) Biopsy of the iliac crest
B
11. A 30-year-old woman, gravida 4,
para 3, is admitted to the hospital in
labor at 38 weeks' gestation. The
cervix is 4 cm dilated. Contractions
occur every4 minutes. The fundal
height is 40 cm. The membranes are
intact. The fetal lie cannot be
determined by abdominal examination,
and no presenting part is palpable in
the pelvis. Which of the following is the
most appropriate next step in
management?
O
O
O
O
O

A) Ultrasonography
B) Administration of oxytocin
C) Administration of tocolytic drugs
D) Amniotomy
E) Cesarean delivery

A
12. Six days after undergoing a
laparoscopic cholecystectomy for acute
cholecystitis, a 35-year-old woman
comes to the physician because of
fever and abdominal pain for 3 days.
She is jaundiced. Her temperature is
38C (100.4F). Abdominal

examination shows distention and

incisions that are healing normally.
Leukocyte count is 12,000/mm3, and
total serum bilirubin level is 7.9
mg/dL. Which of the following is the
most likely cause of the jaundice?
O A) Anesthetic-related hepatitis
O B) Common bile duct injury
O C) Fulminant hepatic failure
O D) Reaction to perioperative
antibiotics
O E) Subhepatic abscess
B
13. A 9-year-old boy is brought to the
physician because of progressive
weakness and a purple-red
discoloration over his cheeks and
upper eyelids over the past 8 weeks.
His symptoms began shortly after a
camping trip, and he now is unable to
climb stairs, walk long distances, comb
his hair, or dress himself. His mother
says that she was careful to apply his
sunscreen on the trip and can recall no
tick bites or exposure to poisonous
plants. His only medication is a topical
corticosteroid for several dry, scaly
patches of the skin. He appears weak
and lethargic. He is at the 75th
percentile for height and 25th
percentile for weight, he has had no
change in his weight since his last
examination 9 months ago. His
temperature is 37.7C (99.8F),
blood pressure is 110/68 mm Hg,
pulse is 105/min, and respirations are
28/min. Examination of the skin shows
a purple-red discoloration over the
cheeks and eyelids, periorbital edema,
erythematous plaques and scales over
the elbows and knees, and flat-topped
red papules over all knuckles. There is
generalized weakness and atrophy of
the proximal muscles. Which of the
following is the most likely diagnosis2

O A) Dermatomyositis
O B) Duchenne's muscular dystrophy
O C) Eczema
O D) Lyme disease
O E) Psoriasis
O F) Rocky Mountain spotted fever
O G) Seborrhea
0 H) Systemic lupus erythematosus
A
14. An 82-year-old man is brought to
the emergency department because of
the sudden onset of confusion 48
hours ago. His family says that he
previously had been functional and
independent. His temperature is
37.5C (99.5F), blood pressure is
110/70 mm Hg, pulse is 90/min, and
respirations are 12/min. The skin is
warm and clammy. Bowel sounds are
hypoactive, and there is guarding and
tenderness in the right lower quadrant
of the abdomen. Examination of the
heart, lungs, and extremities shows no
abnormalities. He is drowsy but
arousable and oriented to person but
not place or time. There are no focal
deficits. Which of the following is the
most likely
diagnosis?
O A) Appendicitis
O B) Colon cancer
O C) Meningitis
O D) Pneumonia
0 E) Urinary tract infection
A
15. Two hours after emergency
cholecystectomy, a 48-year-old woman
has an oxygen saturation of 84% and
a PO2 of 56 mm Hg on 2 Lfmin of
oxygen via nasal cannula. Her blood
pressure is 120180 mm Hg, and
respirations are 16/min. Decreased
breath sounds are heard on the right,

and there is decreased excursion on

inspiration bilaterally. There is minimal
dullness over the right base.
Examination shows no jugular venous
distention or pedal edema. An x-ray
film of the chest shows increased
density over the right lower lung field,
the tracheal, mediastinal, and cardiac
silhouettes are shifted to the right. The
right lung field appears considerably
smaller than the left lung field. Which
of the following is the most likely
cause of these findings?
O A) Atelectasis
O B) Pleural effusion
O C) Pneumonia
O D) Pneumothorax
0 E) Pulmonary embolism
A
16. A 47-year-old man comes to the
physician because of low-grade fever
and malaise for 3 months. He was
infected with hepatitis B 25 years ago.
He appears well nourished but ill. His
temperature is 37.7C (99.8F),
blood pressure is 110170 mm Hg,
pulse is 801min, and respirations are
121min. Examination shows slight
jaundice and hepatomegaly. The
spleen is not palpable, and there is no
ascites or dependent edema. Serum
studies show:
Total bilirubin 3 mg1dL
Alkaline phosphatase 160 U!L
Aspartate aminotransferase (AST, GOT)
230 U!L
Alanine aminotransferase (ALT, GPT)
275 U!L
Serum a-fetoprotein level is markedly
increased. Ultrasonography of the right
upper quadrant of the abdomen shows
a 5-cm, solid lesion in the right lobe of
the liver. Biopsy is most likely to show
which of the following?

O A) Focal nodular hyperplasia

O B) Hepatic adenoma
O C) Hepatocellular carcinoma
O D) Metastatic adenocarcinoma
0 E) Regenerating liver nodule
C
17. A previously healthy 30-year-old
woman has had a painless lump in her
neck for 2 days. Her mother was
treated for a thyroid tumor at the age
of 35 years. Her 28-year-old sister has
an increased serum calcitonin level but
no thyroid mass. Examination shows a
palpable thyroid nodule. Her serum
calcitonin level is increased. Which of
the following diagnoses should be
excluded prior to surgical treatment of
the thyroid gland?
O A) Adrenocortical carcinoma
O B) Lung carcinoma
O C) Ovarian carcinoma
O D) Parathyroid carcinoma
O E) Pheochromocytoma
E
18. A 67-year-old man comes to the
physician because of a 1-month history
of shortness of breath with exertion,
easy fatigability, and mild ankle
swelling. Five years ago, he underwent
successful chemotherapy with
doxorubicin for lymphoma. Moist
crackles are heard throughout both
lungs. An S3 is heard. The liver edge is
palpated 4 cm below the right costal
margin. There is 2+ pitting edema of
the pretibial region, ankles, and feet.
Which of the following is the most
likely underlying cause of this patient's
symptoms?
O A) Aortic sclerosis
O B) Cardiotoxicity
O C) Cirrhosis
O D) Mediastinal obstruction
0 E) Pneumonitis

B
The response options for the next two
items are the same. You will be
required to select one answer for each
item in the set.
For each patient with vaginal bleeding
during pregnancy, select the most
likely diagnosis.
O A)Abortion of a blighted twin
O B)Cervicitis
O C)Ectopic pregnancy
O D)Focal decidual necrosis
O E) Gestational trophoblastic disease
0 F) Incomplete abortion
0 G) Ovarian torsion
0 H) Ruptured ovarian cyst
0 I) Threatened abortion
19. A 23-year-old woman, gravida 2,
para 0, has had vaginal spotting and
abdominal cramps for 2 days. Her last
menstrual period was 8 weeks ago. A
home pregnancy test was positive 2
weeks ago. She underwent a
salpingectomy4 years ago following an
ectopic pregnancy. Examination shows
a closed cervix, an enlarged uterus,
and no adnexal masses. Transvaginal
ultrasonography shows an empty
uterus. Serum 3-hCG level is 8000
mIU1mL.
C
20. A 25-year-old woman has had
painless vaginal postcoital bleeding for
2 hours. Her last menstrual period was
10 weeks ago. A pregnancy test is
positive. There is a small amount of
dark blood in the vaginal canal. She
has a reddened, friable cervical os.
I

21. A previously healthy 62-year-old

man comes to the physician because of
a 1-year history of numbness and
weakness of the right hand. He is a
carpenter and has no history of injury
to his hand. Examination shows
wasting of muscle mass in the first
web space. Sensation to touch is
decreased along the ring and little
fingers. There is weakness of
abduction and adduction of the fingers.
Which of the following is the most
likely site of nerve injury?
O A) Axillary nerve
O B) Long thoracic nerve
O C) Median nerve above the elbow
O D) Median nerve at the elbow
O E) Median nerve at the wrist
O F) Musculocutaneous nerve above
the elbow O G) Musculocutaneous
nerve at the elbow
O H) Musculocutaneous nerve at the
wrist
O I) Radial nerve above the elbow
O J) Radial nerve at the elbow
O K) Radial nerve at the wrist
O L) Suprascapular nerve
O M) Thoracodorsal nerve
0 N) Ulnar nerve at the elbow
N
22. A 45-year-old man comes to the
physician for a follow-up visit. He has
had recurrent ulcer disease for 8
years, his symptoms are currently
relieved with antacid therapy. He had
one episode of bleeding 1 year ago
that required a blood transfusion. He
appears pale. His hemoglobin level is
10.6 g/dL, mean corpuscular volume is
78 pm3, and reticulocyte count is
0.8%. Which of the following additional
laboratory findings is most likely?
Serum Iron Iron-binding Capacity
(TIBC) Saturation of Serum Ferritin
(pg/dL) (pg/dL) (N=250-400) TIBC

(%) (ng/mL)
O A) 30 120 25 50
O B) 40 360 11 10
O C) 60 180 33 80
O D) 80 200 40 120
0 E) 100 150 67 600
B
23. A 6-year-old girl is brought to the
physician because of a 1-day history of
vomiting, headache, and weakness.
One month ago, she underwent
resection of an astrocytoma and
placement of a ventriculoatrial shunt
for residual hydrocephalus, her
postoperative course had been
uncomplicated. Currently, she is
drowsy and irritable. Her temperature
is 37.5C (99.5F), blood pressure
is 126/54 mm Hg, pulse is 82/min, and
respirations are 24/min. Funduscopic
examination shows papilledema.
Reflexes are brisk with hypertonia in
the lower extremities.
Which of the following is the most
likely underlying mechanism for these
symptoms?
O A) Carcinomatous infiltration of
cerebrospinal fluid
O B) Malfunction of ventriculoatrial
shunt
O C) Overproduction of cerebrospinal
fluid from a choroid plexus papilloma
O D) Recurrence and extension of the
astrocytoma
O E) Thrombosis of the superior
sagittal sinus
B
The response options for the next
three items are the same. You will be
required to select one answer for each
item in the set.

For each patient with a respiratory

problem, select the most appropriate
next step in management.
O A)Administration of BCG vaccine
O B)Administration of an inhaled
bronchodilator
O C)Administration of oxygen
O D)Arterial blood gas analysis
O E)Bronchoscopy
O F)Culture of the pharynx for bacteria
O G)Direct laryngoscopy
O H) Gastric washings for acid-fast
bacteria
O I) Intravenous infusion of saline
O J) Isoniazid and rifampin therapy O
K) Lumbar puncture
O L) Measurement of serum aspirin
level
O M) Subcutaneous administration of
epinephrine.
N) Viral culture of respiratory
secretions
00) X-ray films of the chest
O P) X-ray films of the neck
24. A previously healthy 8-year-old
boy is brought to the emergency
department because of swelling of the
lips and difficulty breathing for 20
minutes. The symptoms began when
he was helping his father clean the
gutters on their house. He appears
anxious. His temperature is 37.2C
(99F), pulse is 1201min, and
respirations are 50/min. Pulse
oximetry shows an oxygen saturation
of 96%. His lips and eyes appear puffy.
He has subcostal and intercostal
retractions. Auscultation of the chest
shows diffuse bilateral wheezing.
M
25. A 16-year-old girl is brought to the
emergency department because of
heavy breathing for 8 hours, and
vomiting and ringing in the ears for 1

hour. She recently broke up with her

boyfriend and has been threatening to
hurt herself. She appears somnolent
but is arousable and answers questions
appropriately. Her temperature is
37.5C (99.5F), pulse is 88/min,
and respirations are 50/min. Pulse
oximetry shows an oxygen saturation
of 96%. She has no retractions, nasal
flaring, or cough. The lungs are clear
to auscultation.
L
26. A previously healthy 6-year-old
boy is brought to the physician for a
follow-up examination after a PPD skin
test produced an induration greater
than 15 mm. He has had no cough or
fever. He has a good appetite and is at
the 50th percentile for height and
weight. He appears well. His
temperature is 37.2C (99F), pulse
is 88/min, and respirations are 18/min.
The lungs are clear to
auscultation.
O
27. A 25-year-old nulligravid woman
comes to the emergency department
because of severe pain in the right
lower quadrant of the abdomen for 4
hours. She has had no nausea,
vomiting, fever, or chills. Three weeks
ago, a right adnexal mass was found
on routine examination. Her last
menstrual period was 3 days ago. Her
temperature is 37.2C (99F), blood
pressure is 110/70 mm Hg, and pulse
is 92/min. Pelvic examination shows
right adnexal tenderness. Hemoglobin
level is 13 g/dL, and leukocyte count is
9000/mm3. Pelvic ultrasonography
shows a small amount of free fluid in
the cul-de-sac. Which of the following
is the most likely cause of the pain?
O A) Appendicitis

O B) Endometriosis
O C) Ovarian hemorrhage
O D) Ruptured ovarian cyst
O E) Torsion of the adnexa
0 F) Tubal obstruction
D
28. A 15-year-old boy comes to the
physician because of acne over his face
for 1 year. He prefers not to use any
oral medications. Examination shows
10 to 15 pustules. Which of the
following is the most effective
treatment for this patient's symptoms?
p A) Avoidance of chocolate, fatty
foods, and caffeine
p B) Use of benzoyl peroxide soap
O C) Vigorous scrubbing of affected
areas
p D) Application of vitamin A and
vitamin E to affected areas
p E) Ultraviolet light therapy
B
29. A 3-year-old boy with acute
lymphoblastic leukemia has had fever
for 3 days. He completed his last
course of chemotherapy 6 days ago.
He has had no malaise, rash, or
anorexia and has had no known
contact with sick children in preschool.
He appears well. His temperature is
38.6C (101.5F), blood pressure is
75160 mm Hg, pulse is 100/min, and
respirations are 22/min. Examination
shows normal findings. Laboratory
studies show:
Hemoglobin 10.1 g/dL (N=11.5-15.5)
Leukocyte count 2200/mm3
Segmented neutrophils 5%
Bands 1%
Lymphocytes 65%
Atypical lymphocytes 11%
Monocytes 18%
Platelet count 35,000/mm3

Which of the following is the most

appropriate next step in management?
O A) Schedule a follow-up visit and
discharge without medication
O B) Observe him in the office for 3
hours, discharge without medication if
examination remains unchanged
O C) Discharge him with oral broadspectrum antibiotic therapy
O D) Admit him to the hospital for
observation
O E) Admit him to the hospital for
intravenous broad-spectrum antibiotic
therapy
E
30. A 72-year-old woman is brought to
the emergency department 1 hour
after the sudden onset of right facial
droop and weakness of the right arm
and leg. She takes captopril for
hypertension and daily aspirin. Her
blood pressure is 150/90 mm Hg,
pulse is 80/min, and respirations are
161min. Examination shows a left
carotid bruit and right central facial
paralysis. There is moderate
expressive aphasia. A CT scan of the
head shows no abnormalities. Which of
the following is the most appropriate
initial pharmacotherapy?
O A) Oral ticlopidine
O B) Oral warfarin
O C) Sublingual nifedipine
O D) Intravenous nitroprusside
O E) Intravenous tissue plasminogen
activator
E
31. A previously healthy 37-year-old
woman comes to the physician
because of a 3-month history of
episodes of severe anxiety, shortness
of breath, palpitations, and numbness

in her hands and feet. Her vital signs

are within normal limits. Physical
examination shows no abnormalities.
Thyroid function studies and an ECG
show no abnormalities. Which of the
following is the most appropriate
pharmacotherapy?
A) Lithium carbonate
B) Methylphenidate
O C) Olanzapine
p D) Paroxetine
0 E) Valproic acid
D
BLOCK 3 ANSWERS
1. D. I think this is fibromyalgia.
2. E
3. A
4. E CF carrier state
5. C suspect malignant disease
6. E MVP causing mitral
regurgitation
7. D hypercalcaemia, likely due to
lung CA
8. D
9. D
10. E septic arthritis
11. A
12. B CRF due to DM
13. F spinal cord injury, with
possible bowel injury
14. F
15. E
16. E chronic pancreatitis
17. B
18. B
19. C organophosphate poisoning,
cholinergic intoxication
20. B maxillary sinusitis
21.
22.
23.
24.
25.
26.

C
D
E
E
B
B lumbar muscle strain (simple

back pain)
27. A In septic shock, cardiac
contractility is decreased because of
inflammatory cytokines and other toxic
stuff.
28. D
29. B
30. D
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

A
E
B
E
B
B
C
F
D
D

41. C
42. C
43. H
44. B
45. A
46. D
BLOCK 4 ANSWERS
1. A
2. D asymptomatic but multiple
cardiac risk factors
3. C pulmonary hypertension,
secondary to CF
4. E
5. B
6. D CRF, due to DM
7. A
8. B
9. D
10. C
11.
12.
13.
14.
15.
16.
17.

E
E
F
A
C
A
A

18. B AVMs can lead to

congestive cardiac failure due to high
volume of circulating blood
19. B
20. E
21. E
22. D
23. E
24. A
25. A Parkinsons disease
26. C
27. C
28. B Febrile neutropaenia needs
AP aminogycoside + (AP penicillin or
AP cephalosporin)
29. B
30. A
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.

C
D
A
C
B
D
M
G
C
C

41.
42.
43.
44.
45.
46.

A
B Polycystic Ovarian Syndrome
A
E
B
A