nbme 1 block 1-4.doc

7/25/2019 NBME 1 Block 1-4.doc

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NBME Form 1 Step 2

Section 1:--

1. A 70-year-old woman has had increasin a!dominal pain o"er the past 2 days. She has renal#ail$re and has !een recei"in peritoneal dialysis #or 1% months& her last treatment was 2 ho$rs

ao. She appears to'ic. (er temperat$re is )* + ,102.2 F and !lood press$re is 1/0*0 mm (.(er a!domen is distended and di##$sely tender to deep palpation with re!o$nd tenderness.e$ocyte co$nt is 1%000mm). 3hich o# the #ollowin is the most appropriate ne't step4

A 5-ray #ilms o# the a!domen

B +omparison o# a!dominal #l$id amylase with ser$m amylase acti"ity

+ 6rams stain o# a!dominal #l$id

8 9ltrasonoraphy o# the a!domen

E + scan o# the a!domen and pel"is

2. A ;-year-old irl is !ro$ht to the physician !eca$se o# temperat$res to /0 + ,10/ F tachypnea

and a nonprod$cti"e co$h #or 12 ho$rs. Fo$r days ao she was treated with an oral anti!iotic #ors$spected pne$mococcal pne$monia. E'amination shows diminished !reath so$nds o"er the lower

riht l$n #ields and d$llness to perc$ssion at the riht costophrenic anle. 3hich o# the #ollowin isthe most liely dianosis4

A Bronchople$ral #ist$la

B Empyema

+ $n a!scess

8


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A Anemia secondary to in#ection

B Anti!iotic therapy

+ 6astrointestinal !lood loss

8 Sicle cell disease

E Geetarian diet

;. An %7-year-old n$rsin home resident with dementia AlDheimers type is admitted to the

hospital !eca$se o# proressi"e lethary and decreased appetite #or ) days. She had a #l$-lieillness #ollowed !y a deep co$h 1 wee ao. ="er the past 10 months she has !een hospitaliDedonce #or !acterial pne$monia. She is responsi"e only to pain#$l stim$li. (er temperat$re is )%.? +,101.; F !lood press$re is 110?0 mm ( p$lse is 12)min and re$lar and respirations are

2%min. E'amination shows dry m$co$s mem!ranes. here is no adenopathy. +racles are heard inthe riht l$n !ase. An '-ray #ilm o# the chest shows an in#iltrate at the riht l$n !ase. heremainder o# the e'amination shows no a!normalities. 3hich o# the #ollowin is the most lielypredisposin #actor #or this patients pne$monia4

A 8ecreased airway elasticity

B 8ecreased !arore#le'

+ 8ecreased a re#le'

8 8ecreased thyroid #$nction

E 8iastolic cardiac dys#$nction

F mpaired cardiac response to e'ercise

6 mpaired -lymphocyte #$nction

( mpaired thirst

ncreased l$n compliance

H >enal salt wastin

?. A 27-year-old woman comes to the physician !eca$se o# #eelins o# an'iety a!o$t attendin her

10-year hih school re$nion. She has a 2-year history o# pro#o$nd an'iety palpitations andsweatin associated with an $neasiness aro$nd people& she a"oids #amily atherins and "isitin

#riends !eca$se she is a#raid o# !ein em!arrassed. She acnowledes that this #ear is$nreasona!le. She does not $se illicit dr$s !$t says that alcohol maes her more com#orta!le

aro$nd people. (er !lood press$re is 1)0*0 mm ( and p$lse is %%min. =n physical e'aminationshe appears healthy and well no$rished. =ccasional wheeDin is heard o"er the le#t l$n #ield. he

remainder o# the e'amination shows no a!normalities. =n mental stat$s e'amination she appearsworried. (er le$ocyte co$nt is *000mm) with a normal di##erential. 3hich o# the #ollowin is themost liely dianosis4

A Alcohol a!$se

B An'iety disorder d$e to a eneral medical condition

+ Asthma

8 6eneraliDed an'iety disorder

E


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F Social pho!ia

he response options #or the ne't two items are the same. Io$ will !e reC$ired to select one answer#or each item in the set.

For each patient with $rinary incontinence select the most liely ca$se.

A 8etr$sor insta!ility

B nterstitial cystitis

+ ="er#low incontinence

8 Stress incontinence

E 9rethra di"ertic$l$m

F 9rinary #ist$la

7. A pre"io$sly healthy //-year-old woman ra"ida / para / comes to the physician !eca$se o# a*-month history o# proressi"e loss o# small amo$nts o# $rine while r$nnin& she now has to wear

an a!sor!ent pad. E'amination shows a second-deree cysto$rethrocele.

For each patient with $rinary incontinence select the most liely ca$se.

A 8etr$sor insta!ility

B nterstitial cystitis

+ ="er#low incontinence

8 Stress incontinence

E 9rethra di"ertic$l$m

F 9rinary #ist$la

%. =ne day a#ter an $ncomplicated spontaneo$s "ainal deli"ery a 2)-year-old woman ra"ida 1para 1 has the onset o# loss o# small amo$nts o# $rine. She recei"ed epid$ral anesthesia d$rinla!or and deli"ery. E'amination shows an episiotomy witho$t e"idence o# hematoma. She is "oidin

;0 to 7; m o# $rine at a time.


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For each patient with coniti"e impairment select the most liely dianosis.

A Ac$te stress disorder

B 8ementia AlDheimers type

+ 8issociati"e amnesia

8 6eneral paresis

E (ead tra$ma

F (epatolentic$lar deeneration ,3ilsons disease

6 (G encephalitis

( ($ntintons disease

MaJor depressi"e disorder

H M$lti-in#arct ,"asc$lar dementia

K Niacin de#iciency

Normal-press$re hydrocephal$s

M


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arm since he #ell while walin and holdin hands with his %-year-old sister 2 ho$rs ao. =ne'amination he holds his le#t $pper e'tremity at his side with his #orearm pronated. here is no

tenderness o# the le#t lower e'tremity !$t there is restricted mo"ement o# the el!ow. heremainder o# the e'amination shows no a!normalities. 3hich o# the #ollowin is the most

appropriate initial step in manaement4

A epeat meas$rement o# MSAF< le"el

B riple screenin #or MSAF


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+ 9ltrasonoraphy

8 Amniocentesis #or meas$rement o# L-#etoprotein le"el

E Amniocentesis #or chromosomal analysis

1;. A 2%-year-old man is !ro$ht to the emerency department !y police !eca$se o# se"ere pain inthe riht lower C$adrant o# the a!domen #or )? ho$rs. (e has !een incarcerated in the co$nty Jailand his co$rt hearin is sched$led in 12 ho$rs. (e taes no medications. A!dominal e'aminationshows no re!o$nd. +omplete !lood co$nt li"er tests and erythrocyte sedimentation rate are withinnormal limits. An '-ray #ilm o# the a!domen shows a normal as pattern. est o# the stool #or occ$lt

!lood is neati"e. 3hich o# the #ollowin is the most liely dianosis4

A AdJ$stment disorder

B +on"ersion disorder

+ 8epressi"e disorder not otherwise speci#ied

8 Factitio$s disorder

E (ypochondriasis

F Malinerin

6 SomatiDation disorder

1?. A ?-year-old irl is !ro$ht to the physician !eca$se o# a /-wee history o# headache #ati$eand decreased appetite. 8$rin this period she has had na$sea and "omitin. At the ae o# / years

she was dianosed with poststreptococcal lomer$lonephritis. She is at the 1;th percentile #orheiht and the 10th percentile #or weiht. E'amination shows no a!normalities. (er ser$m $reanitroen ,B9N le"el is ;0 md. 3hich o# the #ollowin is most liely to limit proression o# thispatients renal #ail$re4

A ncreased potassi$m and sodi$m !icar!onate intae

B 8ecreased sodi$m and daily calorie intae

+

ow-protein diet

8 Strict #l$id restriction

E

8ialysis

17. A pre"io$sly healthy ?2-year-old man comes to the emerency department !eca$se o#a!dominal pain #or /% ho$rs. (is temperat$re is )%.? + ,101.; F !lood press$re is 1)0%0 mm (

p$lse is 110min and respirations are 1;min. A!dominal e'amination shows di##$se le#t lowerC$adrant tenderness with no peritoneal sins. >ectal e'amination shows no a!normalities& test o#the stool #or occ$lt !lood is neati"e. (is le$ocyte co$nt is 1/700mm). 3hich o# the #ollowin isthe most appropriate ne't step in dianosis4

A Bari$m enema

B + scan o# the a!domen


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+

+olonoscopy

8 +ystoscopy

E E'ploratory laparotomy

1%. A pre"io$sly healthy )-month-old irl is !ro$ht to the emerency department !eca$se o# a )-day history o# r$ntin and increasin di##ic$lty !reathin. She appears ill. (er temperat$re is )?.7

+ ,*% F p$lse is 1?0min and respirations are 7?min. E'amination shows r$ntin nasal #larinand mared intercostal retractions. Bronchial !reath so$nds and occasional !ilateral cracles areheard on a$sc$ltation. Ser$m st$dies show:

+a2 ;.? md


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B Aspiration pne$monia

+

Fat em!olism

8

(emothora'

E


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22. A )-year-old irl is !ro$ht to the physician a#ter her mother noted !lood on her $nderpants.

E'amination shows enital condylomata ac$minata in the perineal peri-introital la!ial and analareas. Some o# the ped$nc$lated condylomata appear to ha"e ca$sed the !leedin. She has no

"isi!le intra"ainal condylomata or "ainal or anal tears. (er mother has a palmar wart on her hand!$t no history o# condylomata ac$minata. (er mother has a !oy#riend who does not li"e with themand who has ne"er !een le#t alone with the irl. hey li"e with the mothers 27-year-old !rother

who only !a!y-sits the children when they are asleep. 3hich o# the #ollowin is the mostappropriate ne't step in manaement4

A


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2;. A 2%-year-old woman at 2% wees estation reports e'cessi"e #atia!ility and dyspnea. (er

!lood press$re is 11%7/ mm ( p$lse is 110min and re$lar and l$ns are clear to a$sc$ltation.he cardiac ape' is not palpa!le. S1 is lo$d and there is a sharp so$nd a#ter S2. A low-#reC$ency

diastolic m$rm$r is heard at the ape' that increases in intensity !e#ore S1. 3hich o# the #ollowin isthe most liely dianosis4

A Aortic re$ritation

B E!steins anomaly

+ Mitral re$ritation

8 Mitral stenosis

E

ric$spid re$ritation

2?. A 27-year-old woman comes to the physician !eca$se o# a 2-year history o# intermittentdiarrhea and se"ere crampin a!dominal pain. he stools are watery occasionally #o$l-smellin and

non!loody. She is c$rrently pain-#ree and has not had diarrhea #or 2 days. She also has intermittentconstipation. She has not had #e"er or weiht loss. She ret$rned #rom a trip to Me'ico ) months

ao. She had an appendectomy at the ae o# 12 years and a cesarean deli"ery / years ao.E'amination shows no a!normalities. 3hich o# the #ollowin is the most liely dianosis4

A

Bacterial astroenteritis

B +rohns disease

+ ntermittent small-!owel o!str$ction

8 rrita!le !owel syndrome

E

a'ati"e a!$se

27. An asymptomatic 21-year-old woman is #o$nd to ha"e an adne'al mass on pel"ic e'amination.She $ses oral contracepti"es. A photoraph o# the mass is shown. 3hich o# the #ollowin is the most

liely dianosis4

A Benin cystic teratoma

B

+orp$s l$te$m cyst

+ 8yserminoma

8 Endometrioma

E M$cino$s cystoadenoma


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2%. A 1?-year-old irl is !ro$ht to the physician !eca$se o# episodes o# palpitations o"er the past ?

months. he episodes occ$r when she r$ns or plays !aset!all. She is otherwise asymptomatic. (er!lood press$re is 12//? mm ( p$lse is 7%min and respirations are 1%min. She weihs ;;

,121 l! and is 1%0 cm ,71 in tall. (er arm span is 1%% cm ,7/ in and the $pper sement to lowersement ratio is 0.%;. (er #iners appear lon and are hypere'tensi!le. A rade /? early diastolicm$rm$r is heard alon the $pper and middle le#t sternal !order with radiation to the ape'.


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e##ecti"e treatment4

A mmediate discontin$ation o# cyclosporine

B ncreased dosae o# corticosteroids

+ 8i$resis and alaliniDation o# the $rine

8

>enal dialysis #or 12 wees

E ransplant nephrectomy

)1. An 1%-year-old man comes to the physician 1 wee a#ter he had a !lood press$re o# 1/0110mm ( d$rin a ro$tine precollee e'amination. (is temperat$re is )7.1 + ,*%.7 F !lood press$reis 1/0100 mm ( p$lse is *2min and respirations are 12min. he $pper e'tremities appear to

!e more m$sc$lar than the lower e'tremities. >adial p$lses are normal& #emoral posterior ti!ialand dorsalis pedis p$lses are decreased. A rade 2? systolic m$rm$r is heard o"er the precordi$m

anterior chest and !ac. An E+6 shows le#t "entric$lar hypertrophy. 3hich o# the #ollowin is themost appropriate ne't step in manaement4

A imitin physical acti"ity

B >epeat !lood press$re meas$rement in 1 month

+ nitiate a low-sodi$m diet and e'ercise proram

8


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6 Small !owel lymphoma

)). Fo$r ho$rs a#ter $nderoin a cesarean deli"ery at term #ollowed !y t$!al liation a )7-year-old

woman ra"ida 2 para 2 has diDDiness and con#$sion. he operation was $ncomplicated and!lood loss is estimated to !e %00 m.


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E'cess prod$ction o# atrial natri$retic peptide

E H$'talomer$lar cell hypertrophy and sclerosis

);. A pre"io$sly healthy /-year-old irl is !ro$ht to the physician !eca$se o# #e"er and re#$sal towal #or 1 day. She appears mildly ill. (er temperat$re is )%.? + ,101.; F p$lse is 120min and

respirations are 22min. he riht nee is erythemato$s and swollen. She holds her riht nee in#le'ion and resists any attempted mo"ement o# her riht le. She cries when the riht nee ismo"ed. 3hich o# the #ollowin is the most appropriate ne't step in manaement4

A

Acetaminophen with codeine therapy

B Arthrocentesis

+ Bone marrow aspiration

8 Bone scan

E

mmo!iliDation and traction

F yme titer

6

M> o# the spine

( eass$rance

H Ser$m rhe$matoid #actor assay

K

Systemic anti!iotic therapy

)?. An 1%-year-old man comes #or an e'amination prior to participation in school sports. (e statesthat he has had a d$ll ache in the scrot$m since !ein hit in that area d$rin a !aset!all ame 2

months ao. E'amination shows a 2-cm hard nontender mass in the riht testicle. he mass doesnot transill$minate or chane in siDe when the patient is placed in the s$pine position. 3hich o# the

#ollowin is the most liely ca$se4

A +ystic dilations o# the e##erent d$ct$les

B 8ilated pampini#orm "eno$s ple'$s

+ Fl$id acc$m$lation within the t$nica "ainalis testis

8

6erminal cell t$mor


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E Gasc$lar tra$ma

)7. A 1/-year-old !oy is !ro$ht to the physician !y his parents !eca$se o# a 2-year history o#

increasin academic pro!lems. (is parents say that he has always !een hyperacti"e and distracti!le!$t now his academic per#ormance has deteriorated to the point that he is #ailin ninth rade. (isteachers say that his hyperacti"ity is disr$ptin the classroom. (e weihs ;/ ,120 l! and is 1;2

cm ,?0 in tall. Se'$al de"elopment is anner stae ;& e'amination shows macro-orchidism whichwas not shown on pre"io$s e'aminations. (e has a hih #orehead and lon protr$din ears. (ee'hi!its poor eye contact d$rin the e'amination.


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richomonas "ainalis

)*. A ;7-year-old woman with !reast cancer comes to the physician !eca$se o# increasin nec paino"er the past ) days. She has #allen #reC$ently !eca$se o# m$scle weaness. Gital sins are within

normal limits. E'amination shows hyperre#le'ia o# all e'tremities. here is tenderness o"er thecer"ical spine. Ser$m calci$m le"el is 11 md. 5-ray #ilms show metastases to the cer"ical spine.3hich o# the #ollowin is the most appropriate ne't step in manaement4

A Application o# a so#t cer"ical collar

B


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admission #etal heart tones cannot !e heard. 9ltrasonoraphy shows little amniotic #l$id #etaledema and no e"idence o# a #etal heart!eat. A#ter 1 ho$r she deli"ers a )17;- ,7-l! still!orn

in#ant& e'amination o# the in#ant shows no o!"io$s a!normalities e'cept #or mild edema. heplacenta and mem!ranes appear normal. 3hich o# the #ollowin is the most appropriate immediate

co$rse o# action4

A

Noti#y the hospital lia!ility department

B =!tain consent #or #etal oran donation #rom the parents

+ >ecommend a$topsy o# the in#ant

8

ell the mother not to worry since she can et prenant aain

E ell the parents that there is a 1 in / chance o# rec$rrence in #$t$re prenancies

/2. A pre"io$sly healthy 1?-year-old hih school wrestler comes to the physician !eca$se o# a rash

on his #orearms and the !ac o# his les #or 1 wee. (e is alleric to pollen and d$st. E'aminationshows patches o# erythema with mild licheni#ication o"er the antec$!ital and popliteal #ossae. here

are cl$sters o# pain#$l $m!ilicated "esicles at sites o# acti"e sin in#lammation. 3hich o# the#ollowin is the most liely dianosis4

A EcDema herpetic$m

B (erpes Doster

+

Keratosis pilaris

8

ichen plan$s

E


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ota"ir$s in#ection

//. A 2%-year-old woman is hospitaliDed a#ter tain a massi"e o"erdose o# acetaminophen ta!letsin a s$icide attempt. She has type 1 dia!etes mellit$s and maJor depressi"e disorder re#ractory to

tricyclic antidepressant therapy. 8espite appropriate therapy she de"elops rapidly proressi"ehepatic #ail$re and !ecomes proressi"ely encephalopathic. =n the ?th day o# hospitaliDation she iscomatose. A + scan o# the !rain shows mild di##$se swellin. An appropriately crossmatched siDe-appropriate donor li"er is a"aila!le. 3hich o# the #ollowin is the most appropriate co$rse o# actionreardin transplantation4

A 8o not proceed with the transplantation !eca$se dia!etes mellit$s is a contraindication

B 8o not proceed with the transplantation !eca$se hepatic #$nction is liely to ret$rn o"er the ne'twee

+ 8o not proceed with the transplantation !eca$se maJor depressi"e disorder places the patient at

ris #or another s$icide attempt

8 8o not proceed with the transplantation !eca$se the onset o# encephalopathy and + #indins

s$est !acterial meninitis

E


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/?. A 20-year-old man is !ro$ht to the emerency department on a s$mmer day 20 min$tes a#terde"elopin headache na$sea and $nsteady ait while r$nnin the last 2 miles o# a marathon. =n

arri"al he is con#$sed and disoriented. (is temperat$re is /0 + ,10/ F !lood press$re is 100?0mm ( and p$lse is 1;;min. (is sin is warm and dry. Ne$roloic e'amination shows no #ocal

#indins. 3hich o# the #ollowin is the most liely mechanism o# this patients condition4

A

8epletion o# total !ody potassi$m

B 8epletion o# total !ody sodi$m

+ (ih-o$tp$t cardiac #ail$re

8

nadeC$ate dissipation o# !ody heat

E >elease o# creatine inase #rom m$scle cells

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

Form 1--Section 2:--

1. A 77-year-old woman is !ro$ht to the physician !y her son #or a ro$tine health maintenancee'amination. She says that she #eels well. (er son reports that 1 month ao she ot lost whiledri"in home #rom the local s$permaret. wo wees ao she #orot to t$rn o## the sto"e a#ter

cooin dinner. She has !een wearin !ilateral hearin aids since a$diometry 2 years ao showed!ilateral hih-#reC$ency hearin loss. (er "is$al ac$ity corrected with lasses is 202; in !oth eyes.Ne$roloic e'amination shows mild #ine tremors o# the hands when the arms are o$tstretched& thetremor is not present at rest. M$scle strenth is ;; in all e'tremities. 8eep tendon re#le'es are

decreased at the anles and 2 elsewhere. (er ait is normal. Sensation to "i!ration is mildlydecreased o"er the toes. =n mental stat$s e'amination she is awae alert and con"ersant. (erlan$ae #$nction is normal. She is oriented to person place and time and recalls one o$t o# three

o!Jects a#ter 10 min$tes. 3hich o# the #ollowin #indins in this patient warrants #$rther e"al$ation4

A 8ecreased deep tendon re#le'es at the anles

B 8ecreased sensation to "i!ration o"er the toes

+

(ih-#reC$ency hearin loss

8 Memory loss

E

remor o# the o$tstretched hands

2. A 10-year-old irl is !ro$ht to the emerency department !eca$se o# di##$se achin a!dominalpain na$sea and rec$rrent "omitin o"er the past ; ho$rs. She has an %-year history o# type 1

dia!etes mellit$s treated with 20 9 o# N


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K ;.) mEC(+=) ? mEC

6l$cose 710 md

3hich o# the #ollowin la!oratory #indins is most liely to !e increased4

A Arterial p(

B Ser$m +-peptide le"el

+ Ser$m manesi$m le"el

8 Ser$m osmolality

E Ser$m phosphor$s le"el

). A healthy 2/-year-old woman comes #or a ro$tine health maintenance e'amination. Menses occ$rat re$lar 2%-day inter"als and last ; to ? days. (er last menstr$al period was ) wees ao. Shetaes no medications. Biman$al e'amination shows a ;-cm mildly tender le#t adne'a. A prenancytest is neati"e. 3hich o# the #ollowin is the most appropriate ne't step in manaement4

A

>epeat e'amination in 2 wees

B Meas$rement o# ser$m +A 12; le"el

+ Meas$rement o# ser$m L-#etoprotein le"el

8 + scan o# the pel"is

E

8ianostic laparoscopy

/. A 2/-year-old primira"id woman at 1% wees estation comes #or a ro$tine prenatal "isit. She

has had increased !owel mo"ements o"er the past * wees& the stools are sometimes co"ered withm$c$s and !lood. 9se o# o"er-the-co$nter antidiarrheal dr$s has not relie"ed her symptoms.ectal e'amination shows no hemorrhoids or #iss$res. Fetal heart tones are a$di!le !y 8oppler.3hich o# the #ollowin is the most liely dianosis4

A

Ame!iasis

B 8i"ertic$litis

+

(yperperistaltic diarrhea

8 n#lammatory !owel disease

E Giral astroenteritis

;. A )2-year-old woman at )% wees estation comes #or a ro$tine prenatal "isit. 8$rin ro$tinescreenin at 2% wees estation she tested positi"e #or hepatitis B s$r#ace antien. (er prenancy


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has !een otherwise $ncomplicated. E'amination shows a $ter$s consistent in siDe with a )%-weeestation. 3hich o# the #ollowin meas$res is most liely to decrease the ris #or hepatitis B

in#ection in her new!orn4

A >ecommendation o# !ottle-#eedin rather than !reast-#eedin

B Maternal administration o# hepatitis B imm$ne lo!$lin ,(B6 now

+ Neonatal administration o# (B6 a#ter deli"ery and hepatitis B "accine at ) months o# ae

8 Neonatal administration o# (B6 and hepatitis B "accine immediately a#ter deli"ery

E +esarean deli"ery

?. A )7-year-old woman comes to the physician !eca$se o# proressi"e shortness o# !reath o"er the

past ; years& she now has #ati$e and shortness o# !reath with mild e'ertion. She has a history o#mitral stenosis secondary to rhe$matic #e"er at the ae o# 1; years. She was asymptomatic $ntil ;

years ao when she de"eloped se"ere shortness o# !reath d$rin prenancy. She was treated withdi$retics low-sodi$m diet and !ed rest and she was a!le to deli"er the !a!y at term. (er only

medication is hydrochlorothiaDide. (er temperat$re is )7 + ,*%.? F !lood press$re is 110%0 mm( p$lse is 100min and re$lar and respirations are 2?min. +ardiac e'amination shows an

o!"io$s openin snap in S2. A rade )? late diastolic m$rm$r is heard at the ape'. A riht"entric$lar li#t is palpated alon the le#t sternal !order. 3hich o# the #ollowin is most lielyincreased in this patient4

A Blood #low to the lower l$n #ields

B

8iastolic #illin time

+

e#t-to-riht sh$nt o# !lood

8 e#t "entric$lar end-diastolic press$re

E


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rimethoprim-s$l#ametho'aDole

F No prophyla'is indicated

%. An %-year-old irl with type 1 dia!etes mellit$s is !ro$ht to the emerency department 10min$tes a#ter !ein in"ol"ed in a motor "ehicle collision. She was in the !ac seat o# a small

a$tomo!ile that was rear-ended. nitially she was alert d$rin transport and reported !ilateral thihpain !$t then she stopped talin closed her eyes and !ecame $nresponsi"e to "oice& on arri"alshe responds to no'io$s stim$li with !rie# rimaces and no withdrawal. (er !lood press$re is/0palpa!le mm ( p$lse is 1/%min and respirations are 2%min. Air entry is symmetric. hep$pils are eC$al and react to liht. No cardiac m$rm$r is heard. he a!domen is so#t. here is

swellin o# the $pper portions o# !oth thihs. (er hematocrit is )7. 3hich o# the #ollowin is themost appropriate ne't step in manaement4

A

Meas$rement o# arterial !lood ases

B 5-ray #ilm o# the chest

+

+ scan o# the head

8 Administration o# ;0 de'trose in water

E n#$sion o# 0.* saline

*. A pre"io$sly healthy 1?-year-old !oy is !ro$ht to the emerency department 20 min$tes a#teran episode o# le#t arm shain that lasted appro'imately ) min$tes. ="er the past 2 days he hashad #e"er and emotional la!ility. =n arri"al his temperat$re is )%.* + ,102 F. (e is somnolent and

disoriented to person place and time. (e responds poorly to pain. Ne$roloic e'amination showsno other a!normalities. a!oratory st$dies show:

(ematocrit )/e$ocyte co$nt ?000mm)Semented ne$trophils ;0ymphocytes ;0


23/89

+ F$nal in#ection

8

(emorrhae

E

mm$ne-mediated demyelination

F


24/89

to palpation o"er the le#t chee and no transill$mination o"er the le#t ma'illary sin$s. he tympanicmem!ranes are normal and there is no erythema o# the throat. E'amination shows no cer"ical

adenopathy. he l$ns are clear to a$sc$ltation. 3hich o# the #ollowin is the most liely ca$saloranism4

A (aemophil$s in#l$enDae type !

B Mora'ella catarrhalis

+

Staphylococc$s a$re$s

8 Streptococc$s pne$moniae

E Streptococc$s pyoenes ,ro$p A

1). A /2-year-old woman comes to the physician #or an ann$al pel"ic e'amination and


25/89

1/. Fi"e wees a#ter "ainal deli"ery o# a healthy #$ll-term new!orn a 22-year-old woman ra"ida1 para 1 is !ro$ht to the physician !y her mother !eca$se o# depressed mood #or 2 wees. (er

mother is concerned that her da$hter is not a!le to tae care o# her in#ant. eass$rance

B on-term o$tpatient co$nselin

+ Antipsychotic therapy

8 Selecti"e serotonin re$ptae inhi!itor therapy

E

Admission to the hospital #or treatment

1;. A 72-year-old man comes #or a ro$tine #ollow-$p e'amination. (e has chronic o!str$cti"ep$lmonary disease treated with -adreneric aonists and ipratropi$m !y metered-dose inhaler and

mild arterial ins$##iciency o# the lower e'tremities treated with aspirin. (is !lood press$re is 1?0?0mm ( p$lse is 70min and respirations are 12min. F$nd$scopic e'amination shows

arterio"eno$s nicin.


26/89

B +arotid sin$s hypersensiti"ity

+

+on"ersion reaction

8

(ypertrophic o!str$cti"e cardiomyopathy

E (ypolycemia

F Mitral "al"e prolapse

6

=rthostatic hypotension

(


27/89


28/89

A

Adenosine deaminase de#iciency

B +ons$mption o# complement

+ 8e#ecti"e opsoniDation

8 8estr$ction o# +8/ lymphocytes

E 8e"elopmental arrest o# mat$ration o# B lymphocytes

F 8ysmorphoenesis o# the third and #o$rth pharyneal po$ches

6

mpaired chemota'is

( mpaired phaocytic o'idati"e meta!olism

20. A ?7-year-old woman has !een int$!ated #or 1 wee a#ter $nderoin a le#t lo!ectomy #or l$n

cancer. She has chronic o!str$cti"e p$lmonary disease. (er preoperati"e #$nctional "ital capacitywas /0 o# predicted. She is awae and alert. (er !lood press$re is 1)07; mm ( and p$lse is72min. he "entilator settins are a synchroniDed intermittent mandatory "entilation o# %minF=2 o# /0 and positi"e-end e'piratory press$re o# ; cm (2=. Arterial !lood as analysis shows:

p( 7./2


29/89

ncrease F=2

H

ncrease inotropes

K

ncrease respiratory rate

ectal e'amination shows no masses& test o# the stool #or occ$lt !lood is positi"e. 3hicho# the #ollowin is the most liely ca$se o# these symptoms4

A Bleedin #rom erosi"e esophaitis

B Esophaeal per#oration

+

Mallory-3eiss syndrome

8

Myocardial in#arction

E


30/89

h-positi"e = >h-positi"e

B

A >h-positi"e = >h-neati"e

+

A >h-neati"e = >h-neati"e

8

= >h-positi"e = >h-neati"e

E

= >h-neati"e = >h-positi"e

2/. A#ter an $ncomplicated laparoscopic cholecystectomy a ?2-year-old man has not had any $rineo$tp$t since the Foley catheter was remo"ed 12 ho$rs ao. 8$rin the ho$r !e#ore the operationthe /0 min$tes o# operatin room time and the 2 ho$rs in the reco"ery room his #l$id inp$t was2.; and $rine o$tp$t was 1 . Since that time he has !een recei"in intra"eno$s ; de'trose inwater with 0./; saline and morphine. (e is awae and alert and has a moderate amo$nt o#

a!dominal pain.


31/89

ntra"eno$s administration o# #$rosemide

E >einsertion o# a Foley catheter

2;. A healthy ;;-year-old man comes #or an initial health maintenance e'amination. (is last "isit toa physician was o"er 10 years ao. (e does not smoe and drins only on social occasions.

E'amination shows no a!normalities. 3hich o# the #ollowin imm$niDations sho$ld !e administered4

A (epatitis A "accine

B n#l$enDa "ir$s "accine

+

Measles-m$mps-r$!ella "accine

8


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8

Selecti"e A de#iciency

E 5-lined aammalo!$linemia

2%.

A )7-year-old man is !ro$ht to the emerency department ? ho$rs a#ter the onset o# constantincreasinly se"ere a!dominal pain and na$sea. (is symptoms awoe him #rom sleep and he has"omited once since that time. (e has no history o# similar symptoms and he does not tae any

medications or $se alcohol or illicit dr$s. Family history is noncontri!$tory. (e is in ac$te distressand lyin in the #etal position. Any mo"ement e'acer!ates the pain. (is temperat$re is )7.% + ,100F !lood press$re is 10%?% mm ( p$lse is 112min and respirations are 2/min. he l$ns areclear to perc$ssion and a$sc$ltation. E'amination shows a riid a!domen& !owel so$nds are a!sent.

a!oratory st$dies show:

(emolo!in 1/ d

e$ocyte co$nt 1%200mm)


33/89

3hich o# the #ollowin is the most appropriate ne't step in manaement4

A

Alcohol cessation

B

Better control o# dia!etes

+ Switch #rom captopril to calci$m-channel !locin aent therapy

8 6em#i!roDil therapy

E

hyroid replacement therapy

)0. A 2)-year-old woman has pain crampin and swellin o# the riht cal# ) days a#ter an$ncomplicated la!or and deli"ery. he riht #oot is swollen and there is mared tenderness with

dorsi#le'ion and palpation o# the riht cal#. E'amination shows no other a!normalities. A complete!lood co$nt and ser$m electrolyte le"els are within normal limits. 3hich o# the #ollowin is the most

liely ca$se o# this condition4

A (ypercoa$la!le state o# prenancy

B (yper$ricemia

+


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normal

8

8elayeddelayed

)2. A pre"io$sly healthy 2/-year-old woman comes to the physician !eca$se o# a low-rade #e"erand a nonprod$cti"e co$h #or 7 days. She has !een a!le to contin$e her daily acti"ities. (ertemperat$re is )7.7 + ,**.* F. A #ew scattered inspiratory cracles are heard in the thora'. An '-ray #ilm o# the chest shows patchy in#iltrates in !oth l$ns. 3hich o# the #ollowin is the mostappropriate initial pharmacotherapy4

A Amo'icillin

B +e#aclor

+

+ipro#lo'acin

8 Erythromycin

E

rimethoprim-s$l#ametho'aDole

)). A /;-year-old woman comes to the emerency department !eca$se o# shortness o# !reathchest pain diDDiness and mild n$m!ness and tinlin aro$nd the lips #or 2 ho$rs. She says that she

#eels lie she is oin to die. She had three similar episodes last wee when she was "acationin atthe 6rand +anyon& the #irst episode occ$rred while crossin a narrow !ride on a doney. She taesa hypolycemic dr$ #or type 2 dia!etes mellit$s "erapamil #or hypertension and s$matriptan asneeded #or miraine. She is mildly diaphoretic and appears pale. (er !lood press$re is 1)0*0 mm

( p$lse is 120min and respirations are 2%min. Ser$m l$cose le"el is 120 md. An E+6shows sin$s tachycardia. S$!lin$al nitrolycerin therapy does not relie"e her symptoms and i"esher a headache. he most appropriate ne't step in manaement is administration o# which o# the

#ollowin4

A (aloperidol

B oraDepam

+

='yen

8 S$matriptan

E

Gerapamil

)/. A ?7-year-old man is !ro$ht to the emerency department / ho$rs a#ter the onset o# se"eremidl$m!ar !ac pain. (e is an'io$s pale and diaphoretic. (is temperat$re is )7.1 + ,*%.% F

!lood press$re is 10;?; mm ( and p$lse is 120min. E'amination shows no other a!normalities.5-ray #ilms o# the l$m!ar spine show deenerati"e disc disease with calci#ications anterior to the"erte!ral !odies. 3hich o# the #ollowin ishe most liely dianosis4

A


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Aortoiliac occl$sion

B (erniated n$cle$s p$lpos$s

+ $m!ar discitis

8 $m!ar strain

E

$pt$red aortic ane$rysm

6 Spinal stenosis

);. A 17-year-old !oy is !ro$ht to the emerency department !y his parents !eca$se o# !iDarre!eha"ior #or ? ho$rs. ast niht he was o$t with #riends and since ret$rnin he has !een con#$sed

and has RtrashedR his room. (is !lood press$re is 1?;*; mm (. (e is hyper"iilant has littlespontaneo$s speech and is disoriented to place and time. (e appears catatonic !$t a!r$ptly

!ecomes assa$lti"e two times and needs to !e restrained. 3hich o# the #ollowin is the most lielys$!stance taen4

A +ocaine

B Ecstasy

+

S8

8

MethaC$alone

E


36/89

F

Sacroiliitis

6 Spinal epid$ral a!scess

( Spondylolisthesis

)?. A ;7-year-old woman is !ro$ht to the physician 2 days a#ter the s$dden onset o# se"ere low!ac pain& the pain does not radiate to the lower e'tremities. he pain !ean when she was li#tin

her randson. She does not ha"e weaness or sensory loss in the les and has had no $rinaryincontinence. She has a 10-year history o# rhe$matoid arthritis treated with prednisone. (ertemperat$re is )7 + ,*%.? F !lood press$re is 1)0?0 mm ( and p$lse is ?/min. E'aminationshows de#ormities o# the interphalaneal Joints o# the hands and e'C$isite tenderness to perc$ssion

o"er the l$m!ar spine. Bilateral straiht-le raisin to %0 derees does not increase the pain. M$sclestrenth and sensation are intact in the lower e'tremities. 8eep tendon re#le'es are 2 !ilaterally.Ba!insis sin is a!sent !ilaterally.

For each patient with !ac pain select the most liely dianosis.

A

(erniated disc

B $m!ar spinal stenosis

+

Metastatic cancer

8 M$scle strain

E =steoporotic compression #ract$re

F Sacroiliitis

6

Spinal epid$ral a!scess

( Spondylolisthesis

)7. A pre"io$sly healthy )2-year-old pl$m!er comes to the physician !eca$se o# a )-wee history o#

constant d$ll low !ac pain that does not radiate to the e'tremities. he pain !ean a#ter he$nloaded hea"y eC$ipment #rom his "an. t increases with acti"ity and is temporarily relie"ed !y!ed rest and i!$pro#en. E'amination shows tenderness to palpation o"er the l$m!ar paraspinalreion !ilaterally. he pain increases with #orward or lateral mo"ements o# the spine. M$scle

strenth and sensation are intact in the lower e'tremities. Bilateral straiht-le raisin to %0derees does not increase the pain. 8eep tendon re#le'es are 2 !ilaterally. Ba!insis sin isa!sent !ilaterally.

)%. A 72-year-old man comes to the physician !eca$se o# a 2-month history o# $rination twicenihtly and occasional $rinary #reC$ency and $rency. (e has a 1;-year history o# type 2 dia!etesmellit$s now moderately well controlled with ly!$ride. (is #ather was dianosed with prostatecancer at the ae o# 70 years and his sister died o# complications #rom systemic l$p$s

erythematos$s. (is !lood press$re is 1);%? mm (. +ardiop$lmonary e'amination shows noa!normalities. A!dominal e'amination shows no s$prap$!ic #$llness or tenderness. here is mild


37/89

enlarement o# the prostate with no palpa!le nod$les. (is post"oid resid$al "ol$me is 10 m.Ser$m st$dies show a $rea nitroen ,B9N le"el o# /; md and creatinine le"el o# ).% md.

9rine dipstic shows ) protein. 3hich o# the #ollowin is most liely to ha"e pre"ented proressiono# this patients renal disease4

A ntermittent Foley catheteriDation

B ntra"eno$s mannitol therapy

+

=ral cyclophosphamide and prednisone therapy

8 =ral enalapril therapy

E =ral #inasteride therapy

F =ral prednisone therapy only

6

=ral teraDosin therapy

)*. wo ho$rs ao a 2/-year-old man had the s$dden onset o# pain in the riht side o# his chestthat has !ecome increasinly se"ere. (e is now ha"in di##ic$lty !reathin. (is temperat$re !loodpress$re and p$lse are normal. An '-ray #ilm o# the chest is shown. 3hich o# the #ollowin is themost appropriate ne't step in manaement4

A Bed rest and sedati"e therapy

B Anti!iotic therapy

+ Anticoa$lant therapy

8 $!e thoracostomy

E

mmediate thoracotomy

/0. A 21-year-old collee st$dent comes to the physician !eca$se o# acne that de"eloped / daysao while she was tain her medical collee admission test. She is concerned a!o$t her

appearance and plans to !e in a weddin in ) wees. She has had similar episodes that ha"eresol"ed completely witho$t treatment. E'amination shows ac$te acne o"er the #ace with apredominance o# comedones and p$st$les. here is no e"idence o# chronic scarrin. 3hich o# the#ollowin is the most appropriate initial step in treatment4

A 8ietary restriction o# chocolates and simple s$ars

B 8ietary restriction o# mil prod$cts

+

opical acyclo"ir


38/89

8 opical hydrocortisone cream

E

opical retinoic acid

/1. A ?7-year-old woman comes #or a ro$tine health maintenance e'amination. She e'ercises

re$larly. She is not se'$ally acti"e. At her last "isit 1 year ao her ser$m cholesterol le"el was 1%0md and #astin ser$m l$cose le"el was %0 md& a


39/89

B Fi!romyalia

+


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Medications incl$de amlodipine and do'aDosin. =n arri"al his temperat$re is )7.; + ,**.; F !loodpress$re is 1;0100 mm ( p$lse is *;min and re$lar and respirations are 2/min. (is !reathin

is rapid and deep. +racles are heard in the l$n !ases. E'amination shows a so#t a!domen. Bowelso$nds are normal. he le#t lower e'tremity is e'ternally rotated. a!oratory st$dies show:

Ser$mNa 1); mEC

+l 102 mECK 7.1 mEC(+=) 12 mEC

Arterial !lood as analysis on / min o# o'yen !y nasal cann$la:

p( 7.22ectal sodi$m polystyrene s$l#onate ,Kaye'alate

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

Section ):--

1. A 2?-year-old woman is !ro$ht to the emerency department !eca$se o# mared con#$sion #or2 ho$rs& she also has had a #l$-lie illness #or ) days. ="er the past ? wees she has had increased

#ati$e weaness and na$sea. She recently started thyroid hormone replacement therapy #ora$toimm$ne thyroiditis& 1 wee ao her ser$m thyroid-stim$latin hormone le"el was ) 9m.

(er temperat$re is )% + ,100./ F !lood press$re is %0/0 mm ( and p$lse is 1/0min. Sheappears con#$sed and letharic. E'amination shows cool mottled sin. here is eneraliDed

hyperpimentation especially in"ol"in the palmar creases. he l$ns are clear to a$sc$ltation.A!dominal e'amination shows di##$se mild tenderness and no re!o$nd. a!oratory st$dies show:

(emolo!in 10 d

e$ocyte co$nt *000mm)Semented ne$trophils ;;Eosinophils 20ymphocytes 2;

Ser$mNa 12/ mEC+l *2 mECK ?./ mEC

(+=) 1? mEC


41/89

An '-ray #ilm o# the chest and $rinalysis show normal #indins. An E+6 shows sin$s tachycardia withpeaed wa"es. 3hich o# the #ollowin is most liely to con#irm the primary ca$se o# this patients

condition4

A Meas$rement o# p$lmonary artery press$re

B Meas$rement o# riht atrial press$re

+ Meas$rement o# ser$m antithyrolo!$lin anti!ody le"el

8 Meas$rement o# ser$m lactate dehydroenase acti"ity

E Meas$rement o# ser$m thyroid-stim$latin hormone le"el

F

A+( stim$lation test

6 8e'amethasone s$ppression test

(

Blood c$lt$res

Echocardioraphy

2. A 27-year-old man comes to the physician !eca$se o# a 1-wee history o# shortness o# !reathwith e'ertion paro'ysmal noct$rnal dyspnea and swellin o# his #eet. (e has not had chest pain orpalpitations. (e has !een healthy e'cept #or a R!ad coldR 1 month ao that resol"ed spontaneo$sly

a#ter 10 days. (is temperat$re is )7 + ,*%.? F !lood press$re is *0?0 mm ( p$lse is 120minand respirations are 2/min. E'amination shows J$$lar "eno$s distention to % cm. Bilateral !asilarcracles are heard. +ardiac e'amination shows a di##$se laterally displaced point o# ma'imal

imp$lse. here is a normal S1 and S2 and an S). E'amination shows 2 preti!ial edema !ilaterally.An E+6 shows no a!normalities. Echocardioraphy is most liely to show which o# the #ollowin4

A Asymmetric septal hypertrophy

B

Bic$spid aortic "al"e with stenosis

+ 8i##$se hypoinesia and dilation o# the "entricles

8 8ysinesia o# the le#t "entric$lar ape'

E Mitral "al"e prolapse

).

A );-year-old man is !ro$ht to the emerency department !eca$se o# intracta!le na$sea and"omitin o# non!ilio$s #l$id o"er the past /% ho$rs. (e has a history o# d$odenal $lcer diseasetreated with (2-receptor !locin aents. (is temperat$re is )7 + ,*%.? F !lood press$re is *0?0

mm ( p$lse is 1)0min and respirations are 10min. E'amination shows mild epiastrictenderness. 3hich o# the #ollowin are the most liely ser$m electrolyte #indins4


42/89

Na +l K (+=),mEC ,mEC ,mEC ,mEC

A

11; %0 /.0 2;

B1/0 %0 2.; /0

+1/; 100 ;.0 1;

81;0 10; 2.; 2;

E

1?0 1); ;.0 2;

/. A )-year-old !oy is !ro$ht #or a #ollow-$p e'amination. (e J$st completed a 10-day co$rse o#

amo'icillin that has not resol"ed his riht ear pain. (e appears irrita!le. (is temperat$re is )%.* +,102 F. E'amination shows downward and lateral displacement o# the riht a$ricle with tendernessto palpation o# the posterior a$ric$lar area& his nec is s$pple. 3hich o# the #ollowin is the mostappropriate ne't step in dianosis4

A Bone scan

B + scan o# the head

+ ympanometry

8 $m!ar p$nct$re

E

ympanocentesis

;. A ?7-year-old man has had shortness o# !reath on e'ertion #or ) months& he has had an 11.)-,2;-l! weiht loss d$rin this period. (e has smoed two pacs o# ciarettes daily #or 2; years. (e

appears chronically ill. E'amination shows decreased !reath so$nds on the le#t& heart so$nds arenormal. An '-ray #ilm o# the chest shows a lare le#t-sided ple$ral e##$sion. 3hich o# the #ollowin isthe most appropriate ne't step in dianosis4

A Bronchoscopy

B

horacoscopy

+ +losed ple$ral !iopsy

8


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=pen ple$ral !iopsy

E horacentesis

?. A proram #or the primary pre"ention o# coronary artery disease is implemented in a comm$nityin the 9SA. Ass$min that dianostic proced$res and detection remain the same which o# the

#ollowin meas$res in"ol"in the disease is most e##ecti"e in monitorin the proram4

A +ase #atality

B (ospitaliDation

+

ncidence

8 Mortality

E


44/89

E

Streptococc$s pyoenes ,ro$p A

*. A )2-year-old woman comes to the physician !eca$se o# !riht red rectal !leedin and se"eresta!!in pain with each !owel mo"ement o"er the past 2 wees. She has !lood-streaed stoolsand there is !lood on the toilet paper. ="er the past 2 months she has had mild constipation with

no chane in the cali!er o# the stool. E'amination shows a small anal #iss$re at the posteriormidline. >ectal e'amination is pain#$l !$t no a!normalities are detected e'cept #or a small amo$nto# !riht red !lood #rom the #iss$re. 3hich o# the #ollowin is the most appropriate ne't step inmanaement4

A Anesthetic ointment and stool so#teners

B

Anal dilatation $nder anesthesia

+ 8e!ridement and clos$re o# the #iss$re $nder anesthesia

8

S$rical #laps

E ateral internal sphincterotomy

10. A 2%-year-old n$llira"id woman comes #or a ro$tine health maintenance e'amination. She hashad proressi"ely se"ere dysmenorrhea o"er the past ? months adeC$ately controlled !ynonsteroidal anti-in#lammatory aents.


45/89

nternal small-!owel herniation

B ntestinal ischemia #rom a cardiac em!ol$s

+ ntram$ral hematoma o# the pro'imal small !owel

8 nt$ss$sception o# the small !owel

E

Malrotation o# the small !owel

12. A )2-year-old man with alcoholism is !ro$ht to the emerency department !y #riends !eca$sehe has !een $na!le to stand witho$t s$pport and has had R#$nny eye mo"ementsR& they report that

he has !een drinin appro'imately 1% !eers daily o"er the past month and has !een increasinlycon#$sed o"er the past ; days. (e is awae and con#$sed !$t is noncom!ati"e. (is speech issl$rred and his !reath smells o# alcohol. (is temperat$re is )7.2 + ,** F !lood press$re is 1%0?0mm ( p$lse is 110min and respirations are 1%min.


46/89

1/.

A pre"io$sly healthy /7-year-old woman comes to the emerency department !eca$se o# a )?-ho$rhistory o# na$sea "omitin and a!dominal pain that radiates to her !ac. ="er the past ) years

she has had intermittent episodes o# crampin a!dominal pain 1 to 2 ho$rs a#ter meals& the painlasts #or se"eral ho$rs and resol"es spontaneo$sly. She does not smoe and drins one to twolasses o# wine each e"enin. here is a #amily history o# coronary artery disease and hypertension.

(er temperat$re is )7 + ,*%.? F !lood press$re is 100?0 mm ( p$lse is 120min andrespirations are 20min. A!dominal e'amination shows moderate epiastric and riht $pperC$adrant tenderness with no $ardin or re!o$nd& !owel so$nds are decreased. a!oratory st$diesshow:

(ematocrit /;e$ocyte co$nt *000mm) with a normal di##erentialSer$m

otal !ilir$!in 1.; mdAlaline phosphatase 120 9Aspartate aminotrans#erase ,AS 6= 7% 9Amylase )?; 9

ipase 122) 9 ,N@11?0rilycerides )00 md

3hich o# the #ollowin is the most liely dianosis4

A

Ac$te cholecystitis

B Alcoholic hepatitis

+ Alcoholic pancreatitis

8 Ascendin cholanitis

E 6allstone pancreatitis

F (epatitis A

6


47/89

B

(epatitis B

+ (G in#ection

8


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B

Meas$rement o# ser$m parathyroid hormone le"el

+ Meas$rement o# ser$m "itamin 8 le"el

8 Ser$m and $rine protein electrophoresis

E 5-ray #ilm o# the chest

F Seletal s$r"ey

6 Bone scan

he response options #or the ne't two items are the same. Io$ will !e reC$ired to select one answer

#or each item in the set.

For each patient with papilledema select the most liely dianosis.

A

Bacterial meninitis

B +ere!ral in#arction

+ +ryptococcal meninitis

8 6lio!lastoma m$lti#orme

E (erpes simple' encephalitis

F (ypertensi"e encephalopathy

6

diopathic intracranial hypertension

( ntracere!ral hemorrhae

St. o$is encephalitis

1%. A 2;-year-old woman comes to the emerency department !eca$se o# increasinly se"ere!i#rontal headaches o"er the past ? months. 8$rin this period she has had transient episodes o#!lindness lastin 1 to 2 seconds. She has not had na$sea or "omitin. She has a lon-standinhistory o# di##ic$lty losin weiht. She c$rrently weihs 11) ,2;0 l! and is 1;2 cm ,?0 in tall.

(er !lood press$re is 120%0 mm (. Gis$al #ield testin shows enlared !lind spots. he remaindero# the ne$roloic e'amination shows normal #indins. A + scan o# the head with and witho$tcontrast shows no a!normalities. E'amination o# the cere!rospinal #l$id shows:

=penin press$re )00 mm (2=6l$cose 70 md


49/89

B+ 0mm)

6rams stain and c$lt$res are neati"e.

For each patient with papilledema select the most liely dianosis.

A Bacterial meninitis

B +ere!ral in#arction

+

+ryptococcal meninitis

8 6lio!lastoma m$lti#orme

E

(erpes simple' encephalitis

F (ypertensi"e encephalopathy

6 diopathic intracranial hypertension

( ntracere!ral hemorrhae

St. o$is encephalitis

1*. A 2;-year-old man with a history o# intra"eno$s dr$ $se comes to the emerency department

!eca$se o# a proressi"e di##$se headache eneraliDed malaise and low-rade #e"er #or 2 months.8$rin this period he has had a poor appetite res$ltin in a ?.%- ,1;-l! weiht loss. (istemperat$re is )% + ,100./ F. E'amination shows UUnec sti##ness. Mental stat$s e'aminationshows no a!normalities. +ranial ner"e e'amination shows weaness o# the lateral rect$s m$scle onthe riht and !ilateral papilledema. A + scan o# the head with and witho$t contrast shows

moderate "entric$lar enlarement. E'amination o# cere!rospinal #l$id shows:

=penin press$re 220 mm (2=6l$cose ); md

B+ 1mm

20. An asymptomatic )2-year-old woman comes #or a ro$tine health maintenance e'amination. (er

mother and sister ha"e a history o# low !ac pain and disc herniation. he patient is a postal worer.She weihs %? ,1*0 l! and is 1?; cm ,?; in tall. (er !lood press$re is 1)07% mm ( p$lse is7/min and respirations are 1?min. >ane o# motion o# the spine is normal and witho$t pain.here is no scoliosis or e'cessi"e yphosis o# the !ac. 3hich o# the #ollowin is the most e##ecti"e

stratey to decrease this patients ris #or de"elopin low !ac pain4

A +hane in Jo!

B


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imit physical acti"ity

+ Stretchin e'ercises

8 3eiht-loss proram

E Nonsteroidal anti-in#lammatory dr$ therapy

F


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E =ral administration o# chlorpromaDine

2). A 17-year-old !oy s$stains a head inJ$ry and loses conscio$sness a#ter di"in into a #reshwaterlae #rom a plat#orm. A#ter !ein s$!mered #or ) min$tes he is resc$ed. (e is initially cyanotic !$tthen !eins to co$h and !reathe spontaneo$sly a#ter a ;-min$te res$scitation. ="er the ne't )?

ho$rs which o# the #ollowin complications is most liely4

A Ac$te respiratory distress syndrome

B Bacteremia

+

Bacterial pne$monia

8 (ypernatremia

E

Meta!olic alalosis

2/. A 1;-year-old !oy is !ro$ht to the emerency department )0 min$tes a#ter !ein in"ol"ed in amotor "ehicle collision. (e was the $nrestrained passener. =n arri"al he is disoriented. (is !lood

press$re is %0/0 mm ( p$lse is 112min and respirations are 2/min. here is no J$$lar "eno$sdistention. E'amination o# the chest shows d$llness to perc$ssion and decreased !reath so$ndso"er the riht hemithora'. 3hich o# the #ollowin is the most liely dianosis4

A 8iaphramatic r$pt$re

B

Flail chest

+

(emothora'

8 Massi"e aspiration

E


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8 As a!o$t tra"el history o"er the past ? months

E

=!tain a detailed e'ercise history

F

Meas$rement o# ser$m yme ,Borrelia !$rdor#eri anti!ody le"el

6 9rine to'icoloy screenin

2?. An %0-year-old woman has had !leedin $ms #or ) wees. (er diet has consisted o# only teaand toast #or 2 years. She appears thin and wea. Gital sins are normal. (er $ms arehypertrophied and e'$de !lood with press$re. here are ecchymoses o# the inner thihs and smallhemorrhaes aro$nd the hair #ollicles. he remainder o# the e'amination shows normal #indins.

S$pplementation with which o# the #ollowin "itamins is most liely to ha"e pre"ented thiscondition4

A

A

B B12 ,cyanoco!alamin

+

+

8 8

E E

27. A )0-year-old woman ra"ida 2 para 1 is !ro$ht to the emerency department in la!or. Anepisiotomy is per#ormed. Followin deli"ery o# the head the sho$lders do not #ollow with the $s$altraction and maternal p$shin. 3hich o# the #ollowin is the most appropriate ne't step in

manaement4

A Fle'in the womans nees toward her sho$lders

B More #orce#$l traction and #$ndal press$re

+

8eli"erin the posterior arm

8 >otatin the head 1%0 derees

E

Symphysiotomy

2%.

A )2-year-old man comes to the physician !eca$se o# a )-day history o# low !ac pain $rinaryhesitancy and pain with $rination. (e has had se"eral similar episodes o"er the past ) years. (ehas not had any $rethral dischare or recent se'$al contacts. (is temperat$re is )7.2 + ,*%.* Fand !lood press$re is 12?7? mm (. he l$ns are clear to a$sc$ltation& there is no costo"erte!ral

anle tenderness. A!dominal e'amination shows no tenderness or masses. here is no tendernessto palpation o# the lower !ac. Straiht-le raisin to *0 derees is neati"e. here are no motor or


53/89

sensory de#icits in the lower e'tremities. >ectal e'amination shows a di##$se minimally enlaredtender prostate with no masses. a!oratory st$dies show:

Ser$m prostate-speci#ic antien ? nm ,NV/9rineSpeci#ic ra"ity 1.020

Blood neati"e6l$cose neati"eKetones neati"ee$ocyte esterase neati"eNitrites neati"e

3hich o# the #ollowin is the most liely dianosis4

A

Benin prostatic hypertrophy

B +ystitis

+

Epididymitis

8


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tract in#ection 2 wees ao. She is listless e'cept #or intermittent episodes o# discom#ort. (ertemperat$re is )% + ,100./ F. A!dominal e'amination shows riht-sided tenderness witho$t

$ardin or re!o$nd& !owel so$nds are present. >ectal e'amination shows !riht red !lood andm$c$s. An '-ray #ilm o# the a!domen shows no a!normalities. 3hich o# the #ollowin is the most

appropriate ne't step in manaement4

A

5-ray #ilm o# the $pper astrointestinal tract with contrast

B 3ater-sol$!le contrast enema

+ +orticosteroid enemas

8

Admission to the hospital #or total parenteral n$trition

E mmediate laparotomy

)1. An asymptomatic /7-year-old man comes #or a preemployment e'amination. (e has ne"er !een

hospitaliDed. (e is a comp$ter prorammer and he plays hand!all once weely. (is maternalrandmother had type 2 dia!etes mellit$s and a paternal $ncle had heart disease. he patients

!lood press$re is 12?%0 mm (. E'amination shows no a!normalities. (is total ser$m cholesterolle"el is 22; md. 3hich o# the #ollowin is the most appropriate ne't step in manaement4

A Step 2 American (eart Association cardiac diet

B Ser$m lipid st$dies while #astin

+

E'ercise stress test

8

=ral cholestyramine and niacin therapy

E =ral pra"astatin therapy at !edtime

)2. A 2;-year-old woman comes to the physician !eca$se o# a )-month history o# the $ne'plained$re to eat a #ew ta!lespoons o# cornstarch daily. he amo$nt o# cornstarch inested has increased

rad$ally d$rin this time. She has leiomyomata $teri& she is otherwise healthy. (er weiht is$nchaned #rom her last "isit 1 year ao& she weihs ?1 ,1); l! and is 1?% cm ,?? in tall. (er

!lood press$re is 120%0 mm ( and p$lse is 100min.


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E

Admission to an eatin disorders clinic

F Antipsychotic therapy

6 Folic acid s$pplementation

( Selecti"e serotonin re$ptae inhi!itor therapy

)). A )0-year-old woman comes to the physician #or a #ollow-$p e'amination / months a#terstartin treatment with lithi$m car!onate& d$rin this period she has had a ).2- ,7-l! weihtain. (er medication was prescri!ed soon a#ter the !irth o# her son to treat racin tho$hts

increased spendin and o"ertalati"eness& she has had di##ic$lty sleepin #or more than 2 ho$rsnihtly. (er symptoms decreased a#ter 2 wees o# lithi$m car!onate therapy. She contin$es to taelithi$m car!onate ,)00 m three times daily. (er temperat$re is )7 + ,*%.? F !lood press$re is120%0 mm ( and p$lse is 70min. E'amination shows normal #indins. he most appropriate

ne't step is meas$rement o# which o# the #ollowin4

A Fastin ser$m l$cose le"el

B

e$ocyte co$nt

+ Ser$m alaline phosphatase acti"ity

8 Ser$m creatinine le"el

E Ser$m thyroid-stim$latin hormone le"el

)/. =n a ro$tine e'amination a 2-year-old !oy has a hemolo!in le"el o# 10.; d hematocrit o#)0 and mean corp$sc$lar "ol$me o# 72 m). (e drins #o$r to #i"e %-oD !ottles o# mil daily. (emaintains a re$lar diet !$t does not eat "eeta!les. 3hich o# the #ollowin is the most lielydianosis4

A Folic acid de#iciency

B

ron de#iciency

+ Sicle cell disease

8

halassemia

E Gitamin B? de#iciency

);. A ;7-year-old man is !ro$ht to the physician !y his wi#e !eca$se his sin has appeared yellow#or ) wees. E'amination shows Ja$ndice and scleral icter$s. (is total ser$m !ilir$!in le"el is %md with a direct component o# ?.2 md. A + scan o# the a!domen shows a lare lesion in the

head o# the pancreas. 3hen the res$lts are initially disc$ssed the patient says that he does notwant to hear the report and his wi#e arees to a!ide !y his wishes. 3hich o# the #ollowin is the


56/89

most appropriate co$rse o# action4

A 3ithhold the res$lts as the patient wishes

B +ontact the patients children to disc$ss the res$lts

+ +ons$lt with the hospital ethics committee

8

nsist on tellin the patient the res$lts

E >e#er him to another physician

)?. A pre"io$sly healthy ;2-year-old man comes to the physician !eca$se o# a )-month history o#increased $rinary "ol$me and increased $rinary #reC$ency at niht. (e has had a ?.%- ,1;-l!weiht loss d$rin this period despite no chane in appetite. (is #ather has hypertension and his

mother has hypertension and type 2 dia!etes mellit$s. (e c$rrently weihs *; ,210 l! and is17% cm ,70 in tall. (is !lood press$re is 1?0%; mm ( in !oth arms. E'amination shows no other

a!normalities. (is non#astin ser$m l$cose le"el is 2%0 md. 3hich o# the #ollowin ser$m le"elsis most liely to !e increased in this patient4

A

Bicar!onate

B 6l$caon

+ (8-cholesterol

8 ns$lin

E Ketones

)7. hree days a#ter hospitaliDation #or heparin treatment o# deep "eno$s throm!osis o# a le#ts$per#icial #emoral "ein a ;2-year-old woman has proloned !leedin #rom a "enip$nct$re site. She

had a p$lmonary em!ol$s 2 years ao. (er temperat$re is )7.; + ,**.; F. E'amination showsm$ltiple ecchymoses at the "enip$nct$re sites with ooDin o# #resh !lood. a!oratory st$dies show:

(emolo!in

10.; d


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B

8isseminated intra"asc$lar coa$lation

+ E'cessi"e !lood loss #rom anticoa$lation

8 Factor G de#iciency

E Factor 5 de#iciency

F mm$ne throm!ocytopenic p$rp$ra

6 hrom!otic throm!ocytopenic p$rp$ra

)%. A )7-year-old woman comes to the physician !eca$se o# an itchy rash o"er her tr$n #or 2

wees. She has not had #e"er chills shortness o# !reath chest pain or astrointestinal symptoms.She has a history o# rec$rrent $rinary tract in#ections and has !een tain trimethoprim-

s$l#ametho'aDole prophyla'is #or the past year. She is in mild distress. (er temperat$re is )7.; +,**.; F !lood press$re is *??2 mm ( p$lse is 7%min and respirations are 1/min.

E'amination shows a mac$lopap$lar erythemato$s rash o"er the tr$n. a!oratory st$dies show:

e$ocyte co$nt 10;00mm)Semented ne$trophils 72Bands 1Eosinophils 1;

ymphocytes /Monocytes %Ser$m9rea nitroen ,B9N 12 md

+reatinine 0.* md9rine3B+ 2hp#

>B+ 2hp#

3hich o# the #ollowin is the most liely ca$se o# these #indins4

A

EcDema

B Medication ad"erse e##ect

+

Staphylococcal sin in#ection

8 Streptococcal sin in#ection

E 9rinary tract in#ection

)*. A 1*-year-old primira"id woman at )/ wees estation comes to the physician #or a ro$tineprenatal "isit. (er prenancy has !een $ncomplicated. She has no history o# serio$s illness. Shetaes no medications and has no nown alleries. E'amination shows a $ter$s consistent in siDewith a )/-wee estation. A ro$tine clean-catch $rine c$lt$re rows reater than 100000

coloniesm o# Escherichia coli. 3hich o# the #ollowin is the most appropriate pharmacotherapy4


58/89

A Ampicillin

B

+ipro#lo'acin

+

+lindamycin

8 8o'ycycline

E rimethoprim-s$l#ametho'aDole

/0. A 1)-year-old irl is !ro$ht #or a well-child e'amination. Menses ha"e occ$rred e"ery other

month since menarche 10 months ao. (er last menstr$al period was 1 wee ao. She is notse'$ally acti"e. Se'$al de"elopment is anner stae ). E'amination shows no a!normalities. 3hicho# the #ollowin is the most appropriate ne't step in manaement4

A 8isc$ssion o# prenancy pre"ention

B

Meas$rement o# ser$m l$teiniDin and #ollicle-stim$latin hormone le"els

+ 9rine -h+6 test

8


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md (8-cholesterol le"el o# /0 md and trilyceride le"el o# 1;0 md. 3hich o# the#ollowin is the most appropriate ne't step in manaement4

A

>ecommend the Step 2 National +holesterol Ed$cation


60/89


For each child with #e"er and co$h select the most liely dianosis.

A L1-Antitrypsin de#iciency

B +ystic #i!rosis

+


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shallow respirations with decreased !reath so$nds at the riht l$n !ase. An '-ray #ilm o# the chestshows a riht ple$ral e##$sion and hilar adenopathy.

PPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPPP

Section /:--

1. A pre"io$sly healthy ;2-year-old man comes to the emerency department !eca$se o# hicc$ps#or 1 wee. (e has smoed two pacs o# ciarettes daily #or )0 years. (e does not drin alcohol. (eis alert and oriented. (is temperat$re is )7 + ,*%.? F !lood press$re is 1;0*; mm ( p$lse is70min and respirations are 12min.


62/89

e'ertion. (e has pernicio$s anemia treated with monthly "itamin B12 ,cyanoco!alamin inJectionsand a$toimm$ne thyroid disease c$rrently treated with thyroid replacement therapy. E'amination

shows !ilateral ptosis and disconJ$ate aDe. here is !ilateral #acial weaness and hypernasalspeech. he ton$e is wea and the a re#le' is red$ced. M$scle strenth is /; in the pro'imal

m$scles o# the $pper and lower e'tremities. 8eep tendon re#le'es are 2 di##$sely. Ba!insis sin isa!sent. Sensory e'amination shows no a!normalities. A + scan o# the chest is shown. 3hich o# the#ollowin is the most liely dianosis o# this patients intrathoracic lesion4

A Aspiration pne$monia

B

Bronchoenic carcinoma

+ $n metastasis

8 Sarcoidosis

E hymoma

F

hyroid carcinoma

). A )2-year-old man recei"in intensi"e chemotherapy #or (odins disease has a temperat$re o#)* + ,102.2 F. (is respirations are /0min. 3idespread cracles are heard in all l$n #ields. An '-ray #ilm o# the chest shows a di##$se al"eolar and interstitial pattern. 3hich o# the #ollowin is themost liely ca$sal oranism4

A Asperill$s species

B +andida al!icans

+ +occidioides immitis

8


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B

Atrophy o# astric m$cosa

+ Bacterial o"errowth in the small intestine

8 ncreased demand #or #olic acid

E ncreased demand #or "itamin B12 ,cyanoco!alamin

F Mala!sorption

6 Gitamin B1 ,thiamine de#iciency

;. A //-year-old woman comes to the emerency department 2 days a#ter !ein dischared #rom

the hospital #or a!dominal pain& an e'ploratory laparoscopy showed no a!normalities. ="er the past; years she had !een admitted to the hospital n$mero$s times #or the e"al$ation o# a "ariety o#

symptoms& all wor-$ps had !een neati"e. (er temperat$re is )*.2 + ,102.? F. E'aminationshows a reddened ind$rated laparoscopic wo$nd. She is admitted to the hospital and i"en

intra"eno$s anti!iotics. =n the second hospital day a n$rse witnesses the patient r$!!in sali"a intoher laparoscopy site. 3hich o# the #ollowin is the most liely dianosis4

A AdJ$stment disorder with dist$r!ance o# cond$ct

B +ond$ct disorder

+

+on"ersion disorder

8

Factitio$s disorder

E (ypochondriasis

F MaJor depressi"e disorder

6

=ppositional de#iant disorder

( SomatiDation disorder

?. A )7-year-old woman is !ro$ht to the emerency department !eca$se she has !een $na!le to

see o$t o# her riht eye since awaenin 2 ho$rs ao. She states that any mo"ement o# the eye ispain#$l. E'amination shows "is$al ac$ity o# 20200 in the riht eye and 2020 in the le#t eye. heoptic #$ndi are normal. he le#t p$pil reacts normally to liht. he riht p$pil is poorly reacti"e todirect liht. he remainder o# the eye e'amination shows no a!normalities. 3hich o# the #ollowin is

the most liely site o# the lesion4

A e#t optic ner"e

B


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e#t optic radiation

+ e#t optic tract

8 e#t "is$al corte'

E =ptic chiasm

F

>etina

6 >iht optic ner"e

( >iht optic radiation

>iht optic tract

H

>iht "is$al corte'

he response options #or the ne't two items are the same. Io$ will !e reC$ired to select one answer#or each item in the set.

For each patient with peripheral ner"e dys#$nction select the most liely site o# ner"e inJ$ry.

A A'illary ner"e

B +er"ical ner"e root at the cer"ical #oramen

+ on thoracic ner"e

8

Median ner"e a!o"e the el!ow

E Median ner"e at the el!ow

F

Median ner"e at the wrist

6 M$sc$loc$taneo$s ner"e a!o"e the el!ow

( M$sc$loc$taneo$s ner"e at the el!ow

M$sc$loc$taneo$s ner"e at the wrist

H >adial ner"e a!o"e the el!ow


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K

>adial ner"e at the el!ow

>adial ner"e at the wrist

M S$prascap$lar ner"e

N horacodorsal ner"e

= 9lnar ner"e a!o"e the el!ow

< 9lnar ner"e at the el!ow

O

9lnar ner"e at the wrist

7.

A pre"io$sly healthy /2-year-old carpenter comes to the physician !eca$se o# a ?-month history o#pain and n$m!ness in his dominant hand that awaens him at niht. (e descri!es n$m!ness in his

lon and inde' #iners a#ter dri"in #or e'tended periods o# time. E'amination shows minimalatrophy o# the thenar m$scles. here is normal sensation to liht to$ch on the little #iner and thepalm o# the riht hand. Sensation to liht to$ch is decreased at the tip o# the th$m! inde' #inerand lon #iner. 5-ray #ilms o# the riht el!ow and wrist show no a!normalities.

For each patient with peripheral ner"e dys#$nction select the most liely site o# ner"e inJ$ry.

A A'illary ner"e

B +er"ical ner"e root at the cer"ical #oramen

+ on thoracic ner"e

8

Median ner"e a!o"e the el!ow

E Median ner"e at the el!ow

F Median ner"e at the wrist

6 M$sc$loc$taneo$s ner"e a!o"e the el!ow

(

M$sc$loc$taneo$s ner"e at the el!ow

M$sc$loc$taneo$s ner"e at the wrist


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H >adial ner"e a!o"e the el!ow

K

>adial ner"e at the el!ow

>adial ner"e at the wrist

M S$prascap$lar ner"e

N horacodorsal ner"e

=

9lnar ner"e a!o"e the el!ow

< 9lnar ner"e at the el!ow

O

9lnar ner"e at the wrist

%. A pre"io$sly healthy )7-year-old man comes to the physician !eca$se o# a 2-month history o#pain in the #orearm and little #iner o# his dominant hand& he has !een worin as a receptionist #or

? months. (e descri!es n$m!ness in his little #iner and weaness o# his rip. here is decreasedsensation to liht to$ch at the tip o# the little #iner.


67/89

+ (eart

8

Kidney

E

hyroid land

11. A 1*-year-old man is !ro$ht to the emerency department /; min$tes a#ter s$stainin asinle lare sta! wo$nd to the riht $pper C$adrant o# the a!domen. (e is o!t$nded. (is !loodpress$re is ?0palpa!le mm ( and p$lse is 1/%min. Breath so$nds are eC$al !ilaterally.

E'amination shows a /-cm laceration in the riht $pper C$adrant in the midcla"ic$lar line. hea!domen is distended. 3hich o# the #ollowin is the most appropriate ne't step in manaement4

A

5-ray #ilms o# the a!domen and pel"is

B Anioraphy

+

+ontrast st$dy o# the wo$nd tract

8 + scan o# the a!domen

E + scan o# the chest

F aparoscopy

6


68/89

F

8ecreased prolactin

6 ncreased androens

( ncreased estroen

ncreased FS(

H ncreased (

K ncreased proesterone

ncreased prolactin

1).

A 7-day-old new!orn is !ro$ht #or a well-child e'amination. (e was !orn at home. (is mother hastaen acetaminophen #or perineal discom#ort. he new!orn is !reast-#eedin well. (e is at the 7;th

percentile #or lenth and weiht. E'amination shows no a!normalities. A#ter "accination withhepatitis B he has proloned !leedin at the inJection site. here is no #amily history o# e'cessi"e!leedin. a!oratory st$dies show:

(emolo!in 1? de$ocyte co$nt ?%00mm)Semented ne$trophils /%

Bands 2ymphocytes ;0


69/89

(

Giral to'ic e##ect

Gitamin de#iciency

H Tinc de#iciency

1/.

A ?7-year-old man with lon-standin sins and symptoms o# conesti"e heart #ail$re is admitted tothe hospital !eca$se o# proressi"e shortness o# !reath. E'amination shows no other a!normalities.An '-ray #ilm o# the chest shows cardiomealy cephaliDation o# !lood "essels and a riht-sidedple$ral e##$sion. 3hich o# the #ollowin sets o# ple$ral #l$id #indins is most liely in this patient4

e$ocyte Semented


70/89

/0

)0000

%0

20

8

/.;

?0

10000

20

%0

E

/.;

*0

2000

;0

;0

1;. For % wees a ;2-year-old man with a ;-year history o# type 2 dia!etes mellit$s has had deep

!$rnin pain in the !all o# his riht #oot and !i toe when the #oot is raised a!o"e chest le"el. (ealso has crampin in his riht cal# when he wals more than ;0 #eet. (e has smoed two pacs o#

ciarettes daily #or )0 years. Femoral p$lses are palpa!le& pedal p$lses are a!sent. 3hich o# the#ollowin is the most liely dianosis4

A

Aortoiliac stenosis

B Femoral popliteal stenosis

+ Monone$ropathy

8 Gasc$litis


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E

Geno$s stasis

1?. A 1-year st$dy o# a new dr$ to treat hypertension is cond$cted. =ne h$ndred patients withhypertension are enrolled& ;0 patients are i"en the new dr$ and another ;0 patients are i"enhydrochlorothiaDide. All patients completed the trial. =ne noted $ne'pected e##ect is increased

rowth o# scalp hair which occ$rred in those tain the new dr$ a nonstatistically sini#icantdi##erence ,pW0.10. his e##ect has also !een reported in st$dies o# other similar dr$s in the newtherape$tic class. he in"estiators o# the st$dy concl$ded that the new dr$ did not ca$se hairrowth. 3hich o# the #ollowin #eat$res o# this st$dy is most liely to a##ect the "alidity o# thisconcl$sion4

A 8i##erential #ollow-$p

B ead time !ias

+

enth o# the st$dy

8 Sample siDe

E

Sel#-selection

17. A )%-year-old woman ra"ida 2 para 1 at )% wees estation has had no #etal mo"ement #or)? ho$rs. (er prenatal co$rse prenatal tests and #etal rowth ha"e !een normal. Fetal heart tones

are heard !y 8oppler. 3hich o# the #ollowin is the most appropriate ne't step in manaement4

A >o$tine prenatal "isit in 1 wee

B Maternal hydration

+ Nonstress test

8

mmediate ind$ction o# la!or

E Amniocentesis

1%. A healthy 7-year-old !oy is !ro$ht to the physician 1 wee a#ter he was e'posed #or se"eral

ho$rs to a child with chicenpo'. he patient and his healthy sister ha"e not had chicenpo'. heyha"e not recei"ed "aricella "accine. 3hich o# the #ollowin is the most appropriate manaement #orthe patient and his sister at this time4

A Administer acyclo"ir as prophyla'is

B

Administer imm$ne lo!$lin intra"eno$sly

+ Administer aspirin therapy i# "esicles appear

8


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Ad"ise the parents to eep the si!lins home #rom school to pre"ent e'posin their classmates

E n#orm the parents that a "esic$lar rash may appear at any time o"er the ne't 2 wees

1*. A ?-year-old !oy is !ro$ht to the physician !y his mother !eca$se o# proressi"e "is$al losso"er the past year. ="er the past 2 years he has had deterioration o# his hearin speech writin

and intellect$al per#ormance. (is maternal $ncle had similar symptoms. Gis$al ac$ity is 20200!ilaterally. F$nd$scopic e'amination shows optic atrophy. (is hearin is maredly impaired. here isweaness and spasticity o# all e'tremities. 8eep tendon re#le'es are e'tremely hyperacti"e.Ba!insis sin is present !ilaterally. =n mental stat$s e'amination he is not oriented to place yearmonth or the names o# his si!lins. An M> o# the !rain shows mared symmetric white matter

disease in"ol"in all lo!es. 8ianostic st$dies are most liely to show which o# the #ollowin4

A A!normally decreased ser$m cholesterol le"el

B Acanthocytes on !lood smear

+ An e'cess o# "ery lon chain #atty acids

8

Normal ner"e cond$ction st$dies

E Gitamin E de#iciency

20. A 22-year-old primira"id woman at 1? wees estation is !ro$ht to the emerency

department !eca$se o# proressi"e shortness o# !reath o"er the past /% ho$rs. (er temperat$re is)7 + ,*%.? F !lood press$re is 12070 mm ( p$lse is 100min and respirations are 2/min.Scattered wheeDes are heard.


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increased central "eno$s press$re4

A +onstricti"e pericarditis

B +or p$lmonale

+ e#t-sided conesti"e heart #ail$re

8

Mitral stenosis

E ric$spid stenosis

22. A ;-year-old !oy is !ro$ht to the emerency department )0 min$tes a#ter he #ainted at homea#ter standin $p #rom a sittin position. (is symptoms !ean ) days ao with diarrhea and"omitin. (e has had no $rine o$tp$t #or 1% ho$rs. (e is alert !$t C$iet. (is temperat$re is )7.; +

,**.; F !lood press$re is 7;/; mm ( p$lse is 120min and respirations are 2%min.E'amination shows dry lips and tentin o# the sin. here is no a!dominal tenderness. Bowel so$nds

are hyperacti"e. he remainder o# the e'amination shows no a!normalities. (is capillary re#ill timeis ; seconds. ntra"eno$s !ol$s doses o# 0.* saline are administered. Bladder catheteriDation

yields ; m o# $rine. 9rinalysis is most liely to show which o# the #ollowin4

A Blood

B

Erythrocyte casts

+ (yaline casts

8 e$ocyte casts

E ='alate crystals

2).

A 2-year-old !oy is !ro$ht to the physician !eca$se o# #e"er and co$h #or 2 days. (e had

Streptococc$s pne$moniae meninitis at the ae o# 1 year S. pne$moniae !acteremia at the ae o#1% months and pne$monia at the ae o# 22 months. wo maternal $ncles died !e#ore the ae o# 2

years #rom Rin#ection.R (is temperat$re is )*.% + ,10).? F p$lse is 1;0min and respirations are?0min. E'amination shows s$!costal retractions on inspiration. a!oratory st$dies show:

(emolo!in 10 de$ocyte co$nt )?000mm)

Semented ne$trophils 70Bands 20ymphocytes %Monocytes 2


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An '-ray #ilm o# the chest shows an in#iltrate in the le#t $pper lo!e. 3hich o# the #ollowin is themost appropriate ne't step in manaement4

A

>ee'amination in 12 wees

B


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+

(2- receptor !locin aent therapy

8 e#le' "asodilation

2?. An otherwise healthy /-month-old irl is !ro$ht to the physician !eca$se o# a !irthmar on herarm that has increased in siDe o"er the past se"eral wees. E'amination shows a ) ' 2-cm !riht

red raised so#t nontender compressi!le patch o"er the le#t #orearm. 3hich o# the #ollowin is themost appropriate ne't step in manaement4

A opical corticosteroid therapy

B Biopsy

+

aser therapy

8 E'cision

E No inter"ention is necessary

27. A 7-year-old irl is !ro$ht to the physician in Septem!er !eca$se o# #e"er and sore throat #or 1day. She is in the third wee o# second rade. (er temperat$re is )%.? + ,101.; F. E'aminationshows an erythemato$s pharyn' and slihtly enlared tonsils witho$t e'$date. here is nosini#icant cer"ical lymphadenopathy. A rapid test #or ro$p A streptococc$s is neati"e. 3hich o#

the #ollowin is the most appropriate ne't step in manaement4

A Monospot test

B


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hroat c$lt$re

+ ntram$sc$lar penicillin therapy

8 =ral erythromycin therapy

E =ral penicillin therapy

he response options #or the ne't two items are the same. Io$ will !e reC$ired to select one answer


For each patient with weaness select the most appropriate test to esta!lish the ca$se o# thecondition.

A Brain stem a$ditory e"oed potentials

B

+arotid $ltrasonoraphy

+ +hromosomal analysis #or trin$cleotide repeat

8 Electroencephaloraphy

E Electromyoraphy and ner"e cond$ction st$dies

F

M> o# the spine

6 M$scle !iopsy

( >epetiti"e ner"e stim$lation

Somatosensory e"oed potentials

H S


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Sensory e'amination shows no a!normalities.

For each patient with weaness select the most appropriate test to esta!lish the ca$se o# thecondition.

A

Brain stem a$ditory e"oed potentials

B +arotid $ltrasonoraphy

+ +hromosomal analysis #or trin$cleotide repeat

8

Electroencephaloraphy

E Electromyoraphy and ner"e cond$ction st$dies

F

M> o# the spine

6

M$scle !iopsy

( >epetiti"e ner"e stim$lation

Somatosensory e"oed potentials

H S


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(e has an ata'ic ait. here are o$ty tophi on the dorsal aspect o# the le#t el!ow. a!oratoryst$dies show:

(ematocrit ))Mean corp$sc$lar "ol$me 70 m)Ser$m

9rea nitroen ,B9N 17 md6l$cose *0 md+reatinine 2 md9ric acid 1/ md

3hich o# the #ollowin is the most appropriate ne't step in manaement4

A Meas$rement o# !lood lead le"el

B Meas$rement o# ser$m porpho!ilinoen le"el

+ + scan o# the a!domen

8

M> o# the !rain

E +ar!idopa-le"odopa therapy

)1. A co$nty health o##icer in"estiates an o$t!rea o# illness amon persons attendin a ch$rch

picnic. he illness is characteriDed !y the onset o# na$sea and "omitin ) to / ho$rs a#ter attendinthe picnic. All a##ected persons reco"er witho$t speci#ic therapy. he in"estiation implicates esalad as the "ehicle o# transmission. his episode is consistent with a #ood!orne o$t!rea ca$sed !ywhich o# the #ollowin4

A +lostridi$m per#rinens

B 6iardia lam!lia

+

Salmonella species

8 Staphylococc$s a$re$s

)2. A ?2-year-old woman comes to the physician !eca$se o# eneraliDed weaness #or 2 wees. She

has a 20-year history o# arthritis o# the hands treated with aspirin and acetaminophen. She had twoepisodes o# $rinary tract in#ections ; and 11 years ao respecti"ely. E'amination shows noa!normalities e'cept #or (e!erdens nodes on the hands. a!oratory st$dies show:

Erythrocyte sedimentation rate1; mmhSer$m

Na1)? mEC+l100 mEC

K/.* mEC


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(+=)20 mEC

9rea nitroen ,B9N/1 md

+reatinine/ md9rine

B+noneBacterianone

SC$amo$s epithelial cellsoccasional6ran$lar castsoccasional

>enal $ltrasonoraphy shows no a!normalities. 3hich o# the #ollowin is most liely to ha"e

pre"ented this condition4

A


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E Smoin cessation

)/. A pre"io$sly healthy ?7-year-old man is admitted to the hospital !eca$se o# lethary con#$sion

m$scle cramps and decreased appetite #or 7 days. (e appears ill. (is temperat$re is )7 + ,*%.? F!lood press$re is 12070 mm ( p$lse is *%min and respirations are 20min. Breath so$nds arediminished at the riht l$n !ase. Ne$roloic e'amination shows no a!normalities e'cept #or

lethary. Ser$m st$dies show:

Na11/ mECK

/.) mEC+reatinine1 mdhyroid-stim$latin hormone

/.1 9m

An '-ray #ilm o# the chest shows a 2-cm nod$le in the riht lower lo!e and mediastinal adenopathy.A !iopsy specimen o# the nod$le is most liely to show which o# the #ollowin4

A

Adenocarcinoma

B +lear cell carcinoma

+ Mesothelioma

8 Small cell carcinoma

E

SC$amo$s cell carcinoma

);. A ?2-year-old woman comes to the physician !eca$se o# !loatin and crampin a!dominal pain

and intermittent diarrhea o"er the past ; years. (er symptoms ha"e increased o"er the past monthsince she started a new diet that emphasiDes yo$rt and cottae cheese as low-#at so$rces o#calci$m and protein. Gital sins are within normal limits. A!dominal e'amination shows di##$setenderness to palpation with no re!o$nd tenderness& there are no masses or oranomealy. Bowelso$nds are increased. est o# the stool #or occ$lt !lood is neati"e. 3hich o# the #ollowin is the !est

e'planation #or this patients diarrhea4

A mpaired intestinal motility

B

n#lammatory process

+ Mala!sorption

8 Secretory process

)?. A ;2-year-old woman comes to the physician !eca$se o# a )-month history o# intermittent!loody dischare #rom the riht !reast. She does not per#orm re$lar monthly !reast sel#-e'aminations. She has a )-year history o# maJor depressi"e disorder treated with #l$o'etine.E'amination o# the !reasts shows no a!normalities. No masses are noted on palpation.

Serosan$ineo$s #l$id can !e e'pressed #rom the nipple o# the riht !reast !y pressin on the le#tside o# the areola. 3hich o# the #ollowin is the most liely dianosis4


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A

+ystosarcoma phyllodes

B Fat necrosis

+ Fi!roadenoma

8 Fi!rocystic chanes o# the !reast

E 6alactorrhea

F (yperprolactinemia

6

ntrad$ctal papilloma

( Mastitis


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)%. A 70-year-old man comes to the physician !eca$se o# $rinary hesitancy and #reC$ency #or *

months. (is temperat$re is )7.; + ,**.; F. E'amination shows a circ$mcised penis with no $rethraldischare. estic$lar e'amination shows no a!normalities. >ectal e'amination shows an enlared

r$!!ery prostate that is nontender to palpation. 9rinalysis shows many le$ocytes and noerythrocytes. 6rams stain o# $rine shows ram-neati"e rods. 3hich o# the #ollowin is the mostliely ca$se o# this patients condition4

A n#ection o# the epididymis

B

n#ection o# the prostate

+ n#ection o# the $rethra

8 Ne$roenic !ladder

E =$t#low o!str$ction o# the !ladder

)*. A )2-year-old woman comes to the physician !eca$se o# lethary and !oredom since the !irth

o# her son ; months ao. She worries a!o$t her a!ility to care #or him and has had #reC$entpalpitations. She is $na!le to #all !ac asleep a#ter nihttime #eedins. She stopped !reast-#eedin 1

month ao. (er son is healthy and rowth and de"elopment are normal #or his ae. (er !loodpress$re is 122%0 mm ( p$lse is ;%min and respirations are 1%min.


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+ Sensiti"ity decreases

8

Speci#icity decreases

/1. A )2-year-old woman comes to the physician !eca$se o# a 1-year history o# increasinly se"ere

d$ll pain in her lower !ac and !$ttocs. She also has had mornin sti##ness o# the lower !ac thatlasts #or 1 to 2 ho$rs. here is no history o# tra$ma. (er Jo! does not reC$ire hea"y li#tin. (er!lood press$re is 11070 mm ( p$lse is ?%min and re$lar and respirations are 1?min.+ardiop$lmonary e'amination shows no a!normalities. here is tenderness to palpation o"er thesacroiliac Joints !ilaterally and decreased #le'ion and e'tension o# the l$m!ar spine. An '-ray #ilm o#

the l$m!osacral spine shows sclerosis o# the sacroiliac Joints. a!oratory st$dies are most liely toshow which o# the #ollowin #indins in this patient4

A

8ecreased erythrocyte sedimentation rate

B (istocompati!ility h$man le$ocyte antien B27

+

ncreased ser$m antin$clear anti!ody titer

8 ncreased ser$m carcinoem!ryonic antien ,+EA le"el

E


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starin spells that last 1 to 2 min$tes each. 8$rin episodes he also smacs his lips and pics at hisshirt collar. Fo$r years ao he was comatose #or 2 wees a#ter s$stainin a head inJ$ry in a

motorcycle collision& he reC$ired ? months o# reha!ilitation. (e reports that o"er the past year hehas had intermittent episodes o# smellin !$rnt r$!!er that occ$r appro'imately e"ery 2 wees. (e

hears an intense hissin so$nd d$rin these episodes. E'amination shows no a!normalities. 3hicho# the #ollowin is the most liely dianosis4

A A!sence seiD$res

B +omple' partial seiD$res

+ ransient ischemic attac

8 o$rettes disorder

E

im!ic encephalopathy

//.

A /7-year-old woman is admi

nbme 1 block 1-4.doc

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